This chapter will discuss which clients are appropriate for re-
ferral to a 12-step program, at what point in therapy to make
the referral, and why these need to be considered together. In
addition, the therapist's attitude toward 12-step programs
and its effect on making a referral will be discussed.

While the majority of clients dealing with issues related to
an addiction will benefit from involvement in a 12-step pro-
gram, there are some clients who will not. Obviously the first
step is to assess for addictive patterns. Once these have been
identified there are several factors which affect the clinician's
decision about whether to refer a client to a 12-step program,
and the timing of the referral.

The most significant factor to consider is the client's ability
to form a therapeutic alliance or attachment. While all clients
vary in their ability to form an alliance with the therapist,
some have extreme difficulty. Theoretical orientations con-
ceptualize the reasons for a client's difficulty in forming the
therapeutic alliance differently. In psychodynamic terms this
difficulty is primarily based on the lack of the ability to attach
and the use of a distancing defense. The etiology of the inabil-

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