Characteristics, beliefs, and practices of community clinicians trained to provide manual-guided therapy for substance abusers

Regular article

Characteristics, beliefs, and practices of community clinicians trained

to provide manual-guided therapy for substance abusers

Samuel Ball, Ph.D.a,*, Ken Bachrach, Ph.D.b, Jacqueline DeCarloc, Chris Farentinos, M.D.d,Melodie Keen, M.A., L.M.F.T.e, Terence McSherry, M.S.P.H., M.S.P.A.f,

Douglas Polcin, Ed.D.g, Ned Snead, M.S.h, Richard Sockriter, M.S., M.B.A.i,Paulen Wrigley, R.N., M.S.j, Lucy Zammarelli, M.A.k, Kathleen Carroll, Ph.D.a,l

aYale University School of Medicine, Division of Substance Abuse, VACT Healthcare Center (151D),

950 Campbell Avenue–Bldg. 35, New Haven, CT 06520, USAbTarzana Treatment Centers, 18646 Oxnard Street, Tarzana, CA 91356, USA

cLower East Side Service Center, 46 East Broadway, New York, NY 10002, USAdChangePoint Inc., P.O. Box 92067, Portland, OR 97292-2067, USA

eConnecticut Renaissance Inc., P.O. Box 1520, Norwalk, CT 06852, USAfNortheast Treatment Center Inc., 499 N 5th St., Philadelphia, PA 19123, USA

gHaight Ashbury Free Clinics Inc., 603 Clayton Street, San Francisco, CA 94117, USAhChesterfield Substance Abuse Services, P.O. Box 92, 6801 Lucy Court, Chesterfield, VA 23832, USA

iRehab After Work, 1440 Russell Road, Philadelphia, PA 19301, USAjADAPT Inc., P.O. Box 1121, Roseburg, OR 97470, USA

kWillamette Family Treatment Services Inc., 687 Cheshire St., Eugene, OR 97402, USAlNational Drug Abuse Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health,

6001 Executive Boulevard, Room 5213, Bethesda, MD 20892-9561, USA

Received 7 February 2002; received in revised form 24 May 2002; accepted 24 June 2002

Abstract

The successful dissemination of empirically supported addiction therapies to community providers requires an appreciation of the

characteristics of those practitioners who might be willing participants in this process of technology transfer. Clinicians (N = 66) from 11

community treatment programs associated with six research-clinic partnerships of the National Drug Abuse Clinical Trials Network

volunteered to be trained in Motivational Interviewing or Motivational Enhancement Therapy (MET/MI) and were assessed prior to

training. The sample of clinicians was heterogeneous in education and credentials, had a high level of counseling experience, reported using

a wide range of counseling techniques and orientations, but had limited prior exposure to MET/MI or to the use of treatment manuals of

empirically supported therapies. In general, many of the clinicians reported beliefs and techniques that were consistent with their stated

theoretical orientation and recovery status. Relatively few participants reported relying on one dominant orientation or set of techniques.

D 2002 Elsevier Science Inc. All rights reserved.

Keywords: Training; Technology transfer; Psychotherapy; Substance abuse

1. Introduction

The dissemination of empirically supported therapies

(EST) has become an important initiative in the substance

abuse treatment field with considerable attention and fund-

ing directed to the development, testing, training, and

transfer of efficacious treatments. As Morgenstern, Morgan,

McCrady, Keller, and Carroll (2001) articulated, changes in

health care policy and delivery have placed increasing value

on standardized treatment procedures, cost-effectiveness,

and outcome. In this environment, there is a growing

awareness on the part of community practitioners of the

importance of delivering EST and increasing attention to

0740-5472/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.

PII: S0740 -5472 (02 )00281 -7

* Corresponding author. Yale University School of Medicine, VA CT

Healthcare (151D), 950 Campbell Avenue – Bldg. 35, West Haven, CT

06516, USA. Tel.: +1-203-937-3486, ext. 7409; fax: +1-203-937-3472.

E-mail address: [email protected] (S. Ball).

Journal of Substance Abuse Treatment 23 (2002) 309–318

manual-guided approaches as funding sources begin to

emphasize best practice guidelines for treatment programs.

Although manual-guided EST may be a reasonable response

to the accountability expectations of a managed behavioral

healthcare system, providers have been slow to adopt them

in standard clinical practice. The dissemination of manual-

guided therapies into the provider community represents

one of several major efforts to ‘‘bridge the gap’’ between

scientists and practitioners (Lamb, Greenlick, & McCarty,

1998). An important preparatory step in successful bridging

efforts may be to evaluate and understand the experience,

training, and beliefs of community providers willing to

participate in this technology transfer process.

In addition to understanding organizational/systemic fac-

tors and developing relevant training materials and proce-

dures, the successful dissemination of EST relies on a

sophisticated understanding of the audience of community

treatment providers willing to learn and adopt such

approaches in standard clinical practice (Addis, Hatgis,

Soysa, Zaslavsky, & Bourne, 1999; Strosahl, 1998). Treat-

ment manuals were developed initially to improve the

internal validity of clinical trials by reducing variability

associated with therapist effects (Crits-Christoph, Beebe, &

Connolly, 1990), and their use is now regarded as standard

practice in psychotherapy outcome trials (Carroll, 1997;

Dobson & Shaw, 1988; Luborsky & DeRubeis, 1984). In

general, research suggests that adherence to a manual-guided

treatment is associated with positive outcomes (DeRubeis &

Feeley, 1991; Foley et al., 1987; Frank et al., 1991; Wade,

Treat, & Stuart, 1998; Wilson, 1996). Nonetheless, several

practitioner concerns have been raised about technical flexi-

bility and individual case conceptualization (Addis, 1997;

Craighead & Craighead, 1998; Kendall, 1998; Strosahl,

1998). In addition, there are no standards for the best way

to train clinicians (Addis et al., 1999), little research on

organizational receptivity to training and dissemination

efforts (Strosahl, Hayes, Bergan, & Romano, 1998), and

no studies on client or therapist factors that may facilitate or

impede this dissemination process (Kendall, 1998).

The penetration of treatment manuals into standard clini-

cal practice remains a major issue (Strosahl, 1998), and

researchers have begun to evaluate the awareness and

attitudes of providers toward manuals. In a large national

survey of doctoral psychologists in clinical practice, Addis

and Krasnow (2000) found that over half reported never

using a treatment manual, and one third had a very poor

understanding of the nature of treatment manuals. Cognitive-

behavioral therapists (CBT) generally had more positive

views of treatment manuals than did psychodynamic thera-

pists. This was consistent with the survey by Najavits, Weiss,

Shaw, & Dierberger (2000) of 47 CBT therapists (two thirds

with doctoral degrees) who indicated few concerns, very

positive opinions, and reliance on manuals in clinical prac-

tice. Addis and Krasnow (2000) have identified the need for

more research on the thoughts and feelings about EST

manuals among a more diverse group of clinicians with less

extensive CBT and research training who may have different

attitudes about clinical research products.

Only very recently has a literature emerged character-

izing addiction counselors with regard to their theoretical

orientations to counseling, use of specific individual coun-

seling techniques, experience in using manual-guided ther-

apies, and their beliefs about treatment, clients, and the

recovery process. In a large multisite trial for alcohol use

disorders, Project MATCH (1998) evaluated the relation

between therapist differences, treatment conditions, and

outcomes. Twelve-step therapists tended to be in recovery,

endorsed a disease concept of alcoholism, and were

employed as certified counselors more often than were

CBT or motivational enhancement (MET) therapists. As is

true in most carefully conducted clinical trials involving

behavioral therapies, Project MATCH employed a com-

paratively select group of therapists chosen based on their

allegiance to or expertise in one of the three treatment

models being compared. Such studies may not have rel-

evance to training a broader group of front-line addiction

counselors in community programs. Sobell (1996) was the

first to study the dissemination of protocol-based substance

abuse treatments to addiction practitioners, but focused only

on the clinician’s response to the training. Building on this

work, Morgenstern et al. (2001) evaluated clinician’s sub-

jective response to training, the relation between beliefs

about treatment and substance abuse, and the ability to

deliver CBT after a training program modeled on Project

MATCH. Morgenstern et al. (2001) randomly assigned

29 community clinicians from two predominantly 12-step

oriented outpatient programs to receive either intensive CBT

training or no training. The counselors reported a high

degree of satisfaction with the CBT training and manual,

confidence in using these techniques, and ability to imple-

ment the techniques with competence.

The multisite Cannabis Youth Treatment Study is another

recent exception to the use of pre-selected therapists. This

study provided a qualitative analysis of therapist experi-

ences in conducting one of several manual guided therapies

(motivational, cognitive, behavioral, family systems) (God-

ley, White, Diamond, Passetti, & Titus, in press). Half of the

participating treatment sites were standard addiction treat-

ment programs and had never participated in a clinical trial,

and only 5 of 19 therapists had prior experience with a

manual-guided therapy. In general, most therapists appreci-

ated the structure, principles, and consistency provided by

the manual and felt it facilitated rather than hindered the

counseling process. However, several felt that it restricted

their ability to respond to individual client needs, and this

was felt more strongly for the CBT than for MET.

The Morgenstern et al. (2001) and Godley et al.

(in press) studies demonstrated the feasibility of training

community practitioners to deliver manual-guided EST and

began to describe some of the attitudes and beliefs of these

providers toward a treatment they were trained to provide.

The current study builds on this preliminary work by

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318310

characterizing a diverse group of providers from across the

country and lays the foundation for investigating therapist

factors that may facilitate or hinder the acceptance and

application of manual-guided treatment for substance abus-

ers. The funding and development by the National Institute

on Drug Abuse (NIDA) of the Clinical Trials Network

(CTN) provides a unique opportunity to evaluate tech-

nology transfer processes and training issues on a large

scale with a heterogeneous group of community providers.

This study surveyed clinicians from different treatment

programs and orientations who had volunteered to be

trained in motivational interviewing or enhancement ther-

apy, the first psychotherapy protocol implemented within

the NIDA-funded CTN.

2. Method

2.1. Participants

Clinicians from eleven community treatment programs

(CTP) associated with six research-clinic partnerships of the

NIDA-funded CTN volunteered to learn manual-guided

Motivational Interviewing (MI; 1-session intervention) or

Motivational Enhancement Therapy (MET; 3-session inter-

vention) (Miller & Rollnick, 2002; Miller, Zweben, DiCle-

mente, & Rychtarik, 1995). To be eligible to participate,

clinicians needed to be currently employed (or an intern

approved by a supervisor) at a participating CTP and

demonstrate interest in participating in the psychosocial

treatment protocol through willingness to: (a) be trained

and follow a treatment manual for the duration of the

protocol; (b) be randomly assigned to either the MET/MI

or Standard Treatment condition; (c) have treatment sessions

audio-taped for review, attend regular supervision sessions,

and complete pre-training and process ratings. All clinicians

were approved for participation by CTP administrative/

supervisory staff.

Clinicians were ineligible for this study if they were

already credentialed as a MET/MI trainer, had formal

MET/MI training within the 3 months prior to protocol

training, or served as a MET/MI therapist in a prior

clinical trial. Less formalized or previous exposure to

MET or MI was not an exclusion criterion. All CTP

clinicians agreed to complete the study surveys before

being informed of the treatment condition (MET/MI vs.

Standard Care) to which they would be randomly assigned

and therefore before any protocol training. Clinician ran-

domization was used to ensure that the MET/MI condition

did not consist of only those clinicians who were highly

motivated for training and supervision or who differed on

level of education, credentials, or prior exposure to manual-

guided treatment.

A total of 75 staff members completed the surveys. Nine

of these (several of whom had no active caseloads) were

identified as staff that would be serving as MET/MI super-

visors for the protocol and so were excluded from the

analysis. The majority of the 66 primary clinicians (86%)

identified their job title as counselor, therapist, senior

counselor, or social worker. The remainder was either

practicum students (6%) or clinical coordinators (8%),

carrying active caseloads at the participating clinics.

2.2. Community treatment programs

The CTN MET/MI study is being conducted in out-

patient drug-free (i.e., non-methadone) community treat-

ment programs (CTP). All 11 CTPs are established,

licensed programs on the east and west coast of the

United States that have partnered with an academic

research center (together called a ‘‘Node’’) within the

CTN, and most provide an array of services for addicted

individuals. In the New England Node, Connecticut

Renaissance, Inc. (Norwalk, CT) provides outpatient and

intensive outpatient behavioral health treatment, residential

and half-way house services to individuals, groups, and

families throughout Connecticut. Integrated Behavioral

Health (New London, CT) consists of an outpatient mental

health, substance abuse, and co-occurring disorders pro-

gram providing individual and group counseling, case

management, medication monitoring, partial hospital, and

residential respite services.

In the Pacific Region Node, the Haight Ashbury Free

Clinics, Inc. (San Francisco, CA) provides outpatient coun-

seling, detoxification, medical care, residential treatment

and specialized programming for African American and

criminal justice referred men, HIV+ and homeless women,

families, and adolescents. Tarzana Treatment Centers (Tar-

zana, CA) is a large behavioral healthcare provider in five

locations in southern California providing detoxification,

residential, partial, intensive outpatient, primary care, and

sober living houses. Specialized programming is available

for women, parents and children, HIV, adolescent, and adult

drug court clients.

In the New York Node, Lower East Side Service Center

(New York, NY) provides inpatient and outpatient drug-free

and methadone integrated with mental health, medical, and

vocational services. In the Mid-Atlantic Node, Chesterfield

County CSB Substance Abuse Services (Chesterfield, VA)

provides a broad range of outpatient services including

assessment, counseling, primary care groups, outreach,

continuing care, and specialized adult, women, children

and youth services.

In the Oregon Node, ADAPT, Inc. (Roseburg, OR) is an

intensive prevention and treatment program, providing

comprehensive assessment and intervention services and

specialized programming for families, youth, dual diag-

nosis, corrections, and DUI offender populations. Change-

Point, Inc. (Portland, OR) is an outpatient treatment

program with six locations, providing intensive outpatient

and domestic violence intervention programs for English,

Spanish, and Russian speaking clients and gender specific

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318 311

programs. Willamette Family Treatment Services, Inc.

(Eugene, OR) is a large agency consisting of four facilities

offering a full range of services including detoxification,

men’s and women’s residential, women’s and co-ed inten-

sive outpatient, adolescent girls residential and outpatient,

aftercare, and a child development center.

In the Delaware Valley Node, NorthEast Treatment

Centers (Philadelphia, PA) is a large behavioral health

program, including outpatient, intensive outpatient, residen-

tial, inpatient and ambulatory detoxification programs. In

addition, specialized forensic, dual diagnosis, HIV, adoles-

cent, and mothers with children programming is provided.

Rehab After Work (Philadelphia, PA) is an outpatient and

intensive outpatient program providing group and individual

counseling for substance dependent adults and adolescents.

2.3. Assessment procedure

The clinician participants completed two surveys specif-

ically developed for this protocol prior to random assign-

ment to the treatment condition that they would be

providing in the protocol (MET/MI or standard care) and

to receive necessary training.

2.3.1. Clinician and supervisor survey

This 40-item self-report survey obtains information on:

(a) demographics; (b) levels of experience, education, and

credentials; (c) personal recovery; (d) counseling orienta-

tion; (e) previous MET/MI training; (f ) beliefs about treat-

ment, clients, and the recovery process. For counseling

orientation (d), clinicians were asked to rate each of seven

common addiction counseling approaches on a 5-point

Likert scale for the extent to which each described their

typical approach (Table 1). The text of the question was,

‘‘Listed below are some counseling/therapy approaches

used in alcohol and drug abuse treatment. Please rate each

one for how well it describes your own approach to

counseling/therapy.’’ For treatment beliefs (e), clinicians

were asked to estimate the percentage of clients they have

treated in the past 3 months on several dimensions (Table 2).

They also rated on a 5-point Likert scale their agreement

with several treatment-related beliefs. The text of the ques-

tion was, ‘‘Listed below are some statements about the

process of counseling individuals who have substance abuse

problems. Please rate each statement for how well it

describes your own beliefs.’’

2.3.2. Practitioner technique inventory

This 35-item self-report inventory asks clinicians to rate

the extent to which they use a variety of counseling

techniques with a typical current client they have been

treating for between 1 and 6 months. Items were rated on a

7-point Likert scale (not-at-all to extensively) and included

techniques from each of the following categories: (a) stan-

dard substance abuse counseling techniques (e.g., case

management; skills training); (b) MET/MI consistent tech-

niques (e.g., open-ended questions; reflective statements);

(c) techniques defined as antithetical to MET/MI (con-

frontation of denial; therapeutic authority). These items

will also be used to facilitate ongoing supervision of cases

and independent ratings of adherence and competence in

delivering protocol treatments.

Table 1

Counseling orientations endorsed by community clinicians

Counseling orientation (1) Not At All (2) A Little (3) Some What (4) Much (5) Very Much Mean (SD)

12-step/disease concept 8% 9% 29% 14% 41% 3.7 (1.3)

Relapse prevention/CBT 2% 6% 14% 42% 36% 4.1 (.9)

Reality therapy 18% 17% 26% 23% 17% 3.0 (1.4)

Motivational interviewing 24% 20% 23% 20% 14% 2.8 (1.4)

Rogerian/client centered 18% 15% 23% 33% 11% 3.0 (1.3)

Gestalt/experiential 33% 35% 21% 8% 3% 2.1 (1.1)

Psychodynamic/IPT 26% 27% 20% 15% 12% 2.6 (1.4)

Note: Response items are on a 5-point Likert scale with percentages above representing the proportion of counselors who responded to each item rating. Mean

rating is the average of the 1-5 Likert scale rating.

Table 2

Treatment beliefs endorsed by community clinicians

Clinician beliefs (1) Not At All (2) A Little (3) Some What (4) Much (5) Very Much Mean (SD)

Resistant clients are very difficult 8% 9% 29% 14% 41% 3.7 (1.3)

Abstinence is a necessary goal 2% 6% 14% 42% 36% 4.1 (.9)

Effective counseling involves struggle 18% 17% 26% 23% 17% 3.0 (1.4)

Clients need to accept powerlessness 24% 20% 23% 20% 14% 2.8 (1.4)

Treatment involves advice/suggestions 18% 15% 23% 33% 11% 3.0 (1.3)

Need to get through to unmotivated clients 18% 15% 23% 33% 11% 3.0 (1.3)

Note: Response items are on a 5-point Likert scale with percentages above representing the proportion of counselors who responded to each item rating. Mean

rating is the average of the 1-5 Likert scale rating.

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318312

2.4. Statistical analysis

Descriptive data is presented on clinician demographics,

experience, credentials, counseling orientation, beliefs, and

specific techniques. Pearson correlations and t-tests evalu-

ate the association between the degree of allegiance to

specific treatment orientations, clinician beliefs about

recovery or their clients, and the degree of endorsement

of specific techniques clinicians used in their treatment of a

typical client.

3. Results

3.1. Clinician demographics and experience

The 66 clinicians (Table 3) who volunteered to partici-

pate in this clinical trial were predominantly Caucasian

(77%), female (65%) and had an average age of 41.1

(SD = 10.7 years; range 22–63). The sample was an experi-

enced group of clinicians with a mean of 7.1 years (SD =

5.6) of counseling experience and a mean of 3.3 years (SD =

3.6) working for their current agency. Approximately half

of the sample (52%) had a master’s degree with the

remainder relatively evenly distributed among those with

high school, associate’s, or bachelor’s degrees. Most

degrees were in the fields of counseling (general or drug/

alcohol), social work, or psychology. Half of the sample

was certified in drug and alcohol counseling and 21% of the

sample was licensed in social work. Forty-six percent of

clinicians identified themselves as being in recovery (i.e.,

16% of sample preferred not to answer the question; 38%

answered ‘‘no’’).

With regard to prior exposure to MI or MET, most

clinicians (68%) reported no prior formal workshop training

in these therapeutic approaches, 24% reported up to one full

day of prior workshop training, and only 8% had more than

one day of prior training (M = 1.9 days; SD = 4.1 hours).

Half of the sample reported no prior exposure whatsoever to

MET or MI, almost none (7%) reported ever using a

motivational therapy manual, and relatively few (26%)

had ever used any treatment manual in routine practice.

3.2. Counseling orientation and techniques

Clinicians reported using techniques from a range of

theoretical orientations common in the treatment of sub-

stance use disorders. In order of magnitude from most used

to least used, clinicians rated the following orientations from

the Clinician & Supervisor Survey: (a) relapse prevention/

cognitive-behavioral, (b) 12-step/disease concept; (c) Rog-

erian/client-centered; (d) reality therapy; (e) motivational

interviewing; (f ) psychodynamic/interpersonal; (g) gestalt/

experiential. However, on the Practitioner Technique Inven-

tory, clinicians scored highest on the use of MET/MI

consistent items when rating a typical client they had seen

in the prior 6 months. Relatively few clinicians reported

reliance on one dominant theoretical orientation in their

counseling approach (see Table 1).

3.3. Clinician beliefs

When asked to estimate the percent of clients on their

caseload along a number of dimensions, clinicians felt that

over half (53%) were currently in recovery. They thought

that approximately one third of their caseload could be rated

as being resistant (32%), having a recovery plan that

matched the clinician’s plan (39%), and as likely to achieve

stable recovery (38%). Clinicians reported having relatively

few clients on their caseload (9%) who were difficult-to-

like. In general, clinicians believed that abstinence was the

best goal for their clients and that treatment involved some

degree of advice and finding a way to ‘‘get through’’ client

resistance, although they did not endorse the belief that

treatment involved struggling with the client (see Table 2).

3.4. Demographics and clinician beliefs and techniques

Although not predicted, several gender effects emerged.

Male clinicians were more likely than females to view

effective counseling as involving advice, guidance, and

suggestions, t(64) = 2.6, p < .011, and ‘‘getting through’’

to unmotivated or resistant clients, t(64) = 2.3, p < .027. In

addition, males more strongly identified with a cognitive-

behavioral/relapse prevention approach than did female

clinicians, t(64) = 2.1, p < .036.

Masters-level clinicians reported higher allegiance to a

psychodynamic orientation, t(64) = 3.1, p < .003, and lower

allegiance to a 12-step/disease concept orientation,

Table 3

Clinician demographics and credentials

% (frequency)

Gender

Female 65% (43)

Male 35% (23)

Race

Caucasian 77% (51)

Hispanic/Mexican 9% (6)

African American 8% (5)

Middle Eastern 3% (2)

Native American 2% (1)

Asian American 2% (1)

Highest Degree

Masters 52% (34)

Bachelors 18% (12)

Associates 15% (10)

High School/GED 15% (10)

Certification/Licensure

Drug/Alcohol 50% (33)

Social Work 21% (14)

Other (education, marriage, family) 7% (5)

Note: N = 66.

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318 313

t(64) = 3.0, p < .003, than clinicians without a master’s

degree. Other than this, there were no significant differences

in clinician orientation, beliefs, or techniques between

clinicians related to their level of education or certifica-

tion/licensure. Clinicians who openly identified themselves

as ‘‘recovering’’ reported stronger allegiance to a 12-step/

disease concept approach to counseling than non-recovering

clinicians, t(53) = 4.4, p < .001. Other than this, there were

no significant differences in clinician orientation, beliefs, or

techniques between clinicians who identified themselves as

recovering in comparison to those who were not in personal

recovery from a substance use disorder. There were no

regional (east coast vs. west coast) program differences in

clinician orientation, beliefs, or techniques.

3.5. Association of clinician orientation with clinician

beliefs and techniques

Clinicians who reported commonly using a 12-step/

disease concept approach, t(64) = 3.8, p < .001, or being

in personal recovery, t(53) = 2.0, p < .046, reported

engaging in more counseling techniques that would be

considered antithetical to a MET/MI approach in compar-

ison to non-recovering clinicians or those who did not

commonly use a 12-step approach. Twelve-step/disease

concept oriented clinicians more strongly endorsed the

importance of an abstinence goal, t(64) = 2.2, p < .035,

the need to accept powerlessness, t(64) = 3.5, p < .001, and

to ‘‘get through’’ to unmotivated or resistant clients, t(64) =

2.2, p < .028, than did non-12 step oriented clinicians.

Clinicians commonly using a reality therapy approach

reported engaging in more standard addiction counseling

techniques than those who do not follow this approach,

t(64) = 2.6, p < .011.

Clinicians commonly using motivational interviewing,

t(64) = 2.1, p < .039, Rogerian/client centered, t(64) = 2.1,

p < .044, or gestalt/experiential, t(64) = 2.2, p < .030,

approaches endorsed greater use of specific MET/MI coun-

seling techniques on the Practitioner Technique Inventory.

Clinicians commonly using a motivational interviewing

approach viewed resistant clients as less difficult than did

clinicians who less often used this approach, t(64) = 2.5,

p < .014. In addition, clinicians who reported having

received formal MET/MI training in the past reported using

fewer techniques that would be antithetical with MET/MI,

t(64) = 2.7, p < .010. These clinicians exposed to MET/MI

training also did not subscribe to the belief that recovery

involved admitting powerlessness, t(64) = 2.7, p < .010, or

that treatment required advice, guidance, and suggestions,

t(64) = 2.0, p < .045. MET/MI exposed clinicians reported

a lower allegiance to a 12-step/disease concept approach

than did clinicians with no prior MI training, t(64) = 2.4,

p < .021. Clinicians who reported commonly using a Roger-

ian, t(63) = 2.6, p < .013, or psychodynamic, t(63) = 2.5,

p < .014, approach also estimated that a higher percentage of

their caseloads would sustain recovery over a 1-year period.

The self-reported frequency and extensiveness of MET/

MI counseling techniques used for a typical client was

associated with the number of years of counseling experi-

ence, r(66) = .30, p < .015, and the degree of endorsement of

gestalt/experiential, r(66) = .41, p < .001, and reality therapy,

r(66) = .28, p < .024, orientations. The use of standard

counseling techniques was associated with years of coun-

seling experience, r(66) = .25, p < .045, and the degree of

endorsement of relapse prevention/cognitive-behavioral,

r(66) = .25, p < .044, and reality therapy orientations,

r(66) = .35, p < .004. The use of techniques that were con-

ceptualized as being antithetical to MET/MI was associated

with the degree of endorsement of 12-step/disease concept,

r(66) = .47, p < .001, and reality therapy orientations,

r(66) = .35, p < .007. Years of counseling experience also

was associated with higher endorsement of relapse preven-

tion/cognitive-behavioral, r(66) = .26, p < .035, and gestalt/

experiential orientations, r(66) = .27, p < .026.

4. Discussion

The evaluation of addiction treatment efficacy, effective-

ness, and dissemination has been greatly facilitated by the

development of sophisticated treatment manuals (Carroll,

1997; Carroll, Kadden, Donovan, Zweben, & Rounsaville,

1994; Carroll & Nuro, in press; Luborsky & DeRubeis,

1984). Twenty years ago, Weissman, Rounsaville, and

Chevron (1982) described some of the challenges of training

psychotherapists to use manual-guided treatment in clinical

trials. Today, many practitioners may be more open to

providing clinical services in a manner approximating

research because managed behavioral healthcare has

increasingly emphasized the importance of time-limited

treatments, external monitoring, targeted outcomes, and

treatment manuals as components of quality care and

evidenced-based practice (Addis, 1997; Strosahl, 1998). In

addition, through the dissemination activities of NIDA, the

National Institute on Alcohol Abuse and Alcoholism, and

the Substance Abuse and Mental Health Services Adminis-

tration, many addiction counselors have become familiar

with highly specified manual-guided therapeutic approaches.

However, whether wide distribution of treatment manuals

alone will improve the quality of care remains a matter

of some debate (see Addis, 1997; Kendall, 1998; Morgen-

stern et al., 2001; Wilson, 1996). An important, unexplored

area of research is the identification of which therapist

characteristics may facilitate or hinder learning manual-

guided approaches.

For the purposes of conducting carefully controlled

efficacy studies, the common recommendation is to use

experienced, skilled therapists with some a priori allegiance

to the treatment (often documented by sample taped session)

on which they are to be trained and supervised (Weissman

et al., 1982). As the goals of clinical studies shift from

evaluating treatment efficacy (primary focus on internal

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318314

validity) toward evaluating effectiveness (primary focus on

external validity), an important generalizability dimension

becomes the clinicians themselves. As the emphasis shifts

more broadly to dissemination research, it becomes even

more relevant to train therapists who are heterogeneous in

their experience, skill, and treatment orientation. Once

trained, this group of clinicians can be evaluated regarding

their willingness and ability to adhere to the manual during

the protocol and sustain changes in routine practice once the

protocol is completed (Carroll & Rounsaville, in press).

Although the ability to successfully train experienced

research therapists has been documented in several con-

trolled outcome studies in the addictions (Carroll, Connors,

Cooney, et al. 1998; Carroll et al., under review; Crits-

Christoph et al., 1998), the ability to train a more heter-

ogeneous group (more variable education, training, and

research experience) of substance abuse counselors who

are employed in community treatment programs is a rel-

atively unexplored area of research (Lamb, Greenlick, &

McCarty, 1998; Morgenstern et al., 2001). Demographi-

cally, our sample was quite similar to those of Project

MATCH (1998), the Cannabis Youth Treatment Study

(Godley et al., in press), and the Morgenstern et al. (2001)

CBT study in terms of age, gender, and years of experience.

Similar to the counselors in those studies, approximately

half of our sample had master’s degrees, half were licensed

or certified, and half self-identified as being in recovery.

Although we analyzed recovery status and educational level

separately, it is important to note that these were not

mutually exclusive categories. The addiction field has

increasingly embraced the importance of higher educational

and credentialing levels regardless of recovery status. Only

20% of the entire sample lacked any level of credentialing.

Most clinicians (68%) reported having no or minimal pre-

vious formal MET or MI workshop training or having used

therapy manuals in clinical practice. Cognitive-behavioral

and 12-step approaches were the most common theoretical

orientations endorsed, but clinicians also reported common

use of techniques that would be consistent with a motiva-

tional interviewing approach. Relatively few participants

reported relying on one dominant orientation or set of

techniques and instead appeared to use an eclectic or

integrative approach to addiction counseling.

Clinicians in our study appeared to be generally opti-

mistic about the ultimate success of their clients, believed

that abstinence was the best treatment goal, and that a

counselor’s advice, guidance, and handling of resistance

were important in facilitating the recovery process. Alle-

giance to particular schools of therapy was related to level of

education and recovery status. Recovering counselors inte-

grated more 12-step principles while masters-level coun-

selors integrated more psychodynamic work into their

treatment. Otherwise, there were very few differences in

theoretical orientation, utilization of techniques, or treatment

beliefs as a function of demographics, education, credential-

ing, or recovery status. Perhaps most worthy of note was the

finding that the number of years of counseling experience

was related to higher endorsement of a range of counseling

techniques from different theoretical orientations. This sug-

gests that more experienced addiction counselors (at least

those willing to participate in a clinical trial involving a

manual-guided therapy) were more flexible, eclectic, or

integrative in their conceptualization and treatment of

addiction. Stoffelmayr, Mavis, Sherry, and Chiu (1999)

found that counselor recovery status was a more powerful

predictor of flexibility in treatment techniques and goals

than was counselor education.

The study has several limitations. Although the therapist

sample may be considered more heterogeneous than typ-

ically found in clinical trials, it may not adequately represent

the broader range of clinicians providing counseling in

different addiction treatment programs in this country.

Specifically, the sample consisted of predominantly white,

middle-aged women with several years of experience who

were employed on the east and west coast in outpatient

drug-free programs that have become affiliated with major

medical school addiction research centers in metropolitan

areas. Furthermore, these clinicians were willing to be

trained to follow a treatment manual, be randomly assigned

to a treatment training condition, have sessions audio-taped,

attend regular supervision sessions, and complete rating

forms. Another study limitation included the use of self-

report measures that were developed for this study and do

not yet have independent evidence for their reliability or

validity. These self-reports may not adequately capture the

actual behavior of clinicians working with substance abuse

or dependent clients.

Nonetheless, our ongoing CTN investigation on the

effectiveness of MET/MI in community-based treatment

programs does address several design limitations noted in

the Najavits and Weiss (1994) review of therapist effec-

tiveness studies. We will be evaluating changes in clinical

practice prospectively among a group of therapists ran-

domly assigned to one of two conditions for training,

irrespective of prior theoretical orientation. The evaluation

of a heterogeneous group of community clinicians should

permit better analysis of individual differences than a

more restricted group of practitioners already skilled in

the treatment being evaluated. We will be able to evaluate

changes in orientation, techniques, and beliefs as a

function of clinician participation in this treatment pro-

tocol. Specifically, we plan to evaluate whether any

clinician characteristics are associated with the ability to

learn and sustain practice of a manual-guided EST. At the

baseline assessment reported here, we did find that those

clinicians who reported greater use of motivational inter-

viewing, Rogerian/client centered, and gestalt/experiential

techniques before training tended to view resistant clients

as less difficult, and those who reported prior formal

MET/MI training did endorse fewer techniques antithetical

to the approach. They also reported lower allegiance to a

12-step approach and did not subscribe to beliefs that

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318 315

recovery involved admitting powerlessness or that treat-

ment required advice, guidance, and suggestions.

In this regard, one important question is whether thera-

pists skilled in a particular approach are at an advantage or

disadvantage when it comes to learning a different ap-

proach. Twelve-step oriented and recovering clinicians

reported engaging in more counseling techniques that were

antithetical with MET/MI and more strongly endorsed an

abstinence goal, the importance of the client’s acceptance of

powerlessness, and the need to ‘‘get through’’ to unmoti-

vated clients. Morgenstern et al. (2001) observed that,

although their sample of counselors identified with a

12-step model, they were quite open to learning another

approach and acknowledged the limits of their current

treatment approach. Those trained in CBT experienced some

reduction in disease concept beliefs after training, and 90%

of the counselors were rated as adequate or better by

independent raters of adherence and competence.

A significant focus of our future research will be on

understanding therapist factors associated with ease vs.

difficulty of learning and adopting manual-guided treatment

practices. However, the ultimate question is whether effect-

ive training is associated with improved substance abuse

and psychosocial outcomes for the client. Luborsky, McLel-

lan, Diguer, Woody, and Seligman (1997) found very wide

variability in client outcomes among different therapists

trained to provide the same treatment condition (see also

Gottheil, Sterling, Weinstein, & Kurtz, 1994; Rosenberg,

Gerrein, Manohar, & Liftik, 1976), and therapist effects are

often more powerful predictors of client drop-out and

outcome than are types of treatment provided or client

characteristics (Luborsky et al., 1986; Miller, 1985; Najavits

& Weiss, 1994). However, the addiction literature is sparse

and inconsistent in finding a relation between client out-

come and specific therapist variables such as personality

(Project MATCH Research Group, 1998), recovery status

(Machell, 1991; McLellan, Woody, Luborsky, & Goehl,

1988), level of professional education, training, or experi-

ence (Christensen & Jacobson, 1994; Gottheil et al., 1994;

Najavits & Weiss, 1994; Peterson, 1995; Sanchez-Craig,

Spivak, & Davila, 1991), or positive counselor expectations

for clients (Leake & King, 1977). Project MATCH (1998)

found several therapist effects on retention and outcome, but

most were accounted for by the behavior of a small number

of outlier therapists. Nonetheless, at this early stage of

investigation, there is evidence to suggest that a strong

therapeutic alliance and interpersonal skills (warmth, accur-

ate empathy, genuineness, support, affirmation, supporting

autonomy) appear to be related to better outcome, and that

therapist negative emotions (depression, hostility, feeling

overwhelmed) or behaviors (controlling, blaming, rejecting,

withdrawal) are associated with worse outcome (Najavits &

Weiss, 1994).

As Morgenstern and colleagues (2001) have described,

the gap between research (EST) and practice (traditional

counseling approaches) may be wider in the addiction

field than for any other psychiatric disorder given the

differences between the training, professional identifica-

tion, and treatment philosophies of researchers and clini-

cians in the field. In addition, we suggest that this gap is

even more complicated because of the significant hetero-

geneity within the group of addiction clinicians. These

individual differences in professional (education, training,

years of experience, treatment orientation) and personal

(recovery status) background may greatly influence the

success of any one approach to technology transfer. The

best method for disseminating EST to the addiction

provider community remains an open area of investigation

(Gordis, 1991). As such, this study may provide a starting

point for research attempting to understand clinician indi-

vidual difference variables that may be associated with

willingness to learn manual-guided psychosocial treat-

ments and to adopt their use in clinical practice. This

area of research may facilitate the development of alter-

native training procedures through a process of matching

specific types of training to specific types of clinicians. It

very well may be that certain types of training only

succeed for certain types of clinicians.

Acknowledgments

Authorship order is alphabetical except for the first and

senior authors. Funding for this study was provided from the

National Institute on Drug Abuse (grant numbers for each

Node listed in parentheses). From the New England Node

(Kathleen Carroll, PI; U10 DA13038), Samuel Ball is

Director of Substance Abuse Training and Kathleen Carroll

is Director of Psychosocial Research at Yale University

School of Medicine (West Haven, CT) and Melodie Keen is

Director of Adult Outpatient Behavioral Services at CT

Renaissance (Norwalk, CT). From the Delaware Valley

Node (George Woody, PI; U10 DA13043), Terence

McSherry is President of Northeast Treatment Center and

Richard Sockriter is Executive/Clinical Director of Rehab

After Work (Philadelphia, PA). From the Mid-Atlantic Node

(Robert Brooner, PI; U10 DA13034), Ned Snead is Director

at Chesterfield County CSB Substance Abuse Services

(Chesterfield, VA). From the New York Node (John

Rotrosen, PI; U10 DA13046), Jacqueline DeCarlo is

Director of Outpatient at Lower East Side Service Center

(New York, NY). From the Oregon Node (Merwyn

Greenlick, PI; U10 DA13036), Paulen Wrigley was

Research Coordinator at ADAPT (Roseburg, OR), Chris

Farentinos is Clinical Director at ChangePoint (Portland,

OR), and Lucy Zammarelli is Senior Manager at Willamette

Family Treatment Services (Eugene, OR). From the Pacific

Region Node (Walter Ling, PI; U10 DA13045), Douglas

Polcin is Research Psychologist at the Haight Ashbury Free

Clinics (San Francisco, CA) and Ken Bachrach is Clinical

Director at the Tarzana Treatment Centers (Tarzana, CA).

We also thank each of MET/MI project coordinators from

S. Ball et al. / Journal of Substance Abuse Treatment 23 (2002) 309–318316

these nodes (Bryce Libby, Charlotte Royers-Malvastuto,

Gena Britt, Erin Conner, Lynn Kunkel, Jeanne Obert).

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