The Relationship Between the Clinical Orientation of Substance Abuse Professionals and Their Clinical Decisions

RCB 48:2 pp. 75–88 (2005) 75

The Relationship Between the ClinicalOrientation of Substance Abuse

Professionals and Their Clinical Decisions

In this study, the authors examined the relationship between the clinical orientations of substance abuse professionals (SAPs) and their clinical decisions. Cluster analysisgrouped a sample of 245 SAPs on two clinical orientations that differed in their relativeendorsement of traditional versus contemporary substance abuse counseling processesand beliefs. Logistic regression revealed that SAPs’ clinical orientations, labeled neo-traditional and precontemporary, could be predicted by their clinical decision-makingtendencies and education level. Implications for rehabilitation counselor education, su-pervision, and research are discussed.

Paul J. TorielloStephen J. LeiererLouisiana State UniversityHealth Sciences Center–New Orleans

Chris is unemployed. During a recent bar fight,Chris sustained a traumatic brain injury, whichnow causes significant barriers to daily func-tioning. Chris has a history of alcohol and drugabuse, as well as a mood disorder. Chris is onprobation for alcohol- and drug-related of-fenses and consequently has been ordered bythe court to receive substance abuse counsel-ing. Chris would primarily like to change byfinding a steady job. Chris is interested in quit-ting drugs but wants to continue drinking alco-hol. Chris is interested in taking medicationsfor the mood disorder.

Counselors working in substance abuse or vocationalcounseling settings are likely to face complex clinical deci-sions as they encounter clients like Chris. These decisionsmay include the following: Is Chris eligible for serviceseven with continued use of alcohol, or should abstinencefrom all drugs be required for services? Should the use ofmedications for a mood disorder be supported, or, again,should abstinence from all drugs be required for services?Should Chris’s probation officer be fully informed of Chris’s

treatment progress, or should Chris be allowed some levelof privacy? Toriello and Benshoff (2003) identified theseand other complex clinical decisions regarding clients likeChris as ethical dilemmas, in that counselors are often de-ciding between two mutually exclusive courses of action,where each course of action is supported by an ethicalprinciple (e.g., autonomy, beneficence). Encountering thesecomplex clinical decisions is more the norm than the ex-ception. For example, more than half of the clients pre-senting at substance abuse agencies have a co-occurringmental illness (Evans & Sullivan, 2001), and a third are involved with the criminal justice system (Office ofApplied Studies, 2001). Moreover, Drebing et al. (2002)recently found that out of the 27,917 vocational rehabili-tation clients served by the Veterans Health Administra-tion, 80% presented either a stand-alone substance abuseproblem or a co-occurring substance abuse problem andmental illness. If counselors are making frequent, complexclinical decisions that affect whether and how services areprovided to clients like Chris, an understanding of whatinfluences their decisions becomes a compelling question.

Of the possible influences, clinical orientation is animportant and underexplored variable. Clinical orienta-

76 Rehabilitation Counseling Bulletin

tions would seem varied due to the range of professionalsengaging in substance abuse counseling. Some substanceabuse professionals (SAPs) may only have graduated fromhigh school, whereas others may hold undergraduate orgraduate degrees (Mustaine, West, & Wyrick, 2003). De-grees may be in various disciplines, including rehabilitationcounseling, psychology, social work, ministry, corrections,and even fields that are not related to human services(e.g., political science; Toriello & Benshoff, 2003). Some-times, the credentials of SAPs are based solely on theirpersonal substance abuse history (West, Mustaine, &Wyrick, 2002). Finally, the current movement toward theadoption of “evidence-based” counseling interventionsmay affect clinical orientation, because some SAPs areadopting those interventions but others are not (Instituteof Medicine, 1998).

Consequently, one may postulate that such diverseclinical orientations would lead to diverse clinical deci-sions when serving clients such as Chris (McKinlay, Lin,Freund, & Moskowitz, 2002). The purpose of this studywas to conduct an initial examination of the relationshipbetween SAPs’ clinical orientations and their clinical de-cisions involving ethical dilemmas.

Researchers have been interested in examining SAPs’clinical orientations for more than a decade, largely in re-action to substance abuse counseling outcome studiesconducted during the 1970s and 1980s (Morgenstern &McCrady, 1992). These outcome studies were criticizedfor failing to address SAPs’ beliefs about substance abuseetiology and the accompanying counseling processes.Subsequently, the few studies that examined SAPs’ clini-cal orientations revealed complex results: SAPs’ clinicalorientations seemed to span a continuum, with traditionaland contemporary orientations at the extremes.

SAPs counseling a client like Chris from a tradi-tional orientation, which is widely regarded as the “dis-ease model” (Miller, 1995; Yalisove, 1998), would attemptto aggressively confront Chris’ denial about the drinkingproblem and convince Chris to accept that Chris has thedisease of addiction (Humphreys, Greenbaum, Noke, &Finney, 1996; Morgenstern & McCrady, 1992). In addi-tion, the SAP would persuade the client that he or she ispowerless not only over drugs but over alcohol, too, andcan never drink again. Counseling from a traditional ori-entation would also be influenced by beliefs that Chrishas special spiritual deficits and cannot be trusted becauseof a tendency to lie (Moyers & Miller, 1993; Thombs &Osborn, 2001).

At the other end of the continuum, SAPs counselingChris from a contemporary clinical orientation would tryto help Chris understand that problem drug use is alearned behavior and not a disease, by facilitating affec-tive involvement in treatment via client-centered ap-proaches (Morgenstern & McCrady, 1992; Moyers & Miller,1993; Thombs & Osborn, 2001). A contemporary orien-

tation would support the use of behavioral interventionssuch as coping skills and relaxation training.

SAPs counseling Chris from the middle of the clini-cal orientation continuum would operate from a mixtureof the two belief systems and interventions (Morgenstern& McCrady, 1992; Thombs & Osborn, 2001). For exam-ple, they might support Chris’s learning of coping andrelaxation skills but would also attempt to convince theclient that he or she has a disease. Additionally, theymight believe Chris has a disease but attempt to facilitateChris’ affective involvement in treatment via a client-centered approach, as opposed to a persuasive, aggres-sively confrontational approach.

In the previously described studies, the researchersfound inconsistent results regarding SAPs’ characteristicsand clinical orientations. For example, some studies (i.e.,Morgenstern & McCrady, 1992; Moyers & Miller, 1993)found that recovering SAPs (i.e., those with a personalsubstance abuse history), in comparison to nonrecoveringSAPs (i.e., those without a personal substance abuse his-tory), endorsed significantly greater adherence to a tra-ditional clinical orientation, whereas other studies (i.e.,Humphreys et al., 1996; Thombs & Osborn, 2001) foundthat recovering SAPs did not significantly endorse oneparticular clinical orientation over another. Endorsementof contemporary orientations by SAPs with higher educa-tion levels seems to be the most consistent finding fromall of these studies. In all the referenced studies on SAPs’clinical orientations, the researchers discussed the poten-tial relationship of SAPs’ clinical orientations to theirclinical decisions as a concern needing further examination.

The research on clinical decision making is diverse.Researchers have studied mental health practitioners (Is-sakidis & Andrews, 2003; Jue & Lewis, 2001), nurses (Lauriet al., 2001; Watson, 1994), occupational therapists (Reich,Eastwood, Tilling, & Hopper, 1998), physicians (McKin-lay et al., 2002), and criminal justice professionals (Ride-nour, Treloar, & Dean, 2003), as well as SAPs (Lordan,Kelley, Peters, & Siegfried, 1997; Toriello & Benshoff,2003) and vocational rehabilitation counselors (Fischer,Wilson-Rollins, Rubin, & McGinn, 1993; Gade & Si-monson, 1978; Wong, 1990). Several of these studies ex-amined clinical orientation, but the clinical decisions didnot involve ethical dilemmas (e.g., Lauri et al., 2001;Watson, 1994). Most of the other studies examined clini-cal decisions involving ethical dilemmas but did not ex-amine the relationship between clinical orientation andthose decisions. For example, Toriello and Benshoff ex-amined the clinical decisions involving ethical dilemmasencountered by SAPs but did not examine the impact ofclinical orientation. Wong studied clinical decisions in-volving ethical dilemmas encountered by vocational re-habilitation counselors but, again, did not examine theimpact of clinical orientation. In both of those studies, ex-amples of the examined ethical dilemmas included coun-

Volume 48, No. 2 (Winter 2005) 77

selors making clinical decisions about (a) serving clientsor not, (b) conflicting clinical interventions, (c) conflict-ing postresidential treatment living environments, and(c) supporting clients’ choices or supporting agency phi-losophy.

Only the McKinlay et al. (2002) study approachedan examination of the relationship between clinical ori-entation and clinical decisions involving ethical dilem-mas. Researchers in that study found that physicians’clinical orientations predicted whether and how demo-graphically different patients (i.e., in gender, age, andrace) with the same medical conditions (i.e., chronic painand depression) would be treated. Thus, when SAPs aredealing with clients like Chris, their clinical orientationsmay also predict whether and how Chris would be treated.If this is accurate, then the orientation of the SAP thatChris encounters may predict whether he is even served,as well as the client’s ultimate satisfaction with the services.

If the substance abuse counseling environment re-quires SAPs to be adept at making frequent, complexclinical decisions involving ethical dilemmas, an under-standing of the relationship between their clinical orien-tations and their clinical decisions involving ethicaldilemmas seems important. Results from this study wouldsupport the belief that clinical supervisors should facili-tate their supervisees’ awareness of what influences theirclinical decisions in working with clients in either sub-stance abuse or vocational counseling settings. This un-derstanding would also be of benefit to rehabilitationeducators when exposing students to various clinical ori-entations. The research questions that guided this studywere the following:

1. How do the clinical orientations of a sam-ple of SAPs compare and contrast to thosefound in previous studies?

2. What is the relationship between SAPs’clinical orientations and their clinical deci-sions involving ethical dilemmas?

METHOD

Participants and Procedure

The 916 individuals certified by or working toward certi-fication by the Louisiana State Board of Certification forSubstance Abuse Counselors were surveyed for this study.Prior to the survey mailing, 20 undergraduate and gradu-ate rehabilitation students reviewed the survey materials,and comments regarding ambiguity in the items or in-structions were solicited. Consequently, we made severalwording changes in the survey’s instructions to increaseclarity. After the initial survey mailing, we mailed a follow-up postcard to participants who did not respond within 2 weeks. Four weeks after the initial mailing, we mailed a

second copy of the survey packet and a reminder letter tononrespondents. A total of 300 participants completedand returned surveys. However, 55 cases with missing datawere removed, leading to an overall usable response rateof 27% (245). In previous studies on SAPs’ clinical orien-tations, Morgenstern and McCrady (1992) reported a28% response rate, Moyers and Miller (1993) obtained a20% response rate, and Thombs and Osborn (2001) re-ported a 27% response rate.

Of the 245 respondents, 59% were women. Agesranged from 22 to 80 years, with a mean age of 46 (SD =12.05). A majority of the respondents (62%) were WhiteAmerican or European American, and the next largestself-described group was African American (32%). Forty-six percent of respondents had a master’s degree or higher;32% had a bachelor’s degree; and 22% had an associate’sdegree or high school diploma. The degree disciplines in-cluded but were not limited to rehabilitation counseling(1%), counseling (12%), psychology (9%), nursing (2%),criminal justice (2%), addiction studies (10%), social work(20%), public health (1%), history (.5%), fine arts (.5%),microbiology (.5%), and business administration (5%).Approximately 51% of the respondents considered them-selves to be recovering addicts or alcoholics. Sixty-threepercent of the respondents were certified by the state boardas substance abuse counselors, and 33% were recognized bythe state board as “counselors in training” for certification,whereas the remaining 4% were neither certified nor acounselor in training. Other professional credentials in-cluded but were not limited to certified rehabilitation coun-selor (1%), licensed counselor (8%), licensed social worker(12%), licensed nurse (2%), and physician (.5%).

MeasuresFollowing the work of Thombs and Osborn (2001) to“comprehensively assess the clinical orientations” of SAPs(p. 451), we used the same measures: (a) the Treatment Pro-cesses Rating Questionnaire (TPRQ; Morganstern & Mc-Crady, 1992) and (b) the Understanding Addiction Scale(UAS). To build upon their work, we also measured par-ticipants’ clinical decision-making tendencies with theComplex Clinical Decisions Survey (CCDS; an instrumentdeveloped for this study). Finally, we developed a demo-graphic questionnaire to measure participants’ key demo-graphics.

Treatment Processes Rating Questionnaire. Inresponse to the lack of studies of substance abuse counsel-ing processes, Morgenstern and McCrady (1992) devel-oped the TPRQ to assess the substance abuse counselingprocesses that SAPs deemed essential. To move beyondthe disease/behavioral model dichotomy, they culled theliterature for a comprehensive list of processes. The TPRQconsists of 35 items, including processes from the disease

78 Rehabilitation Counseling Bulletin

model, behavioral interventions, general psychotherapy,and pharmacological interventions. Although Morgen-stern and McCrady did not report on internal reliabilityfor these domains, Ogborne, Wild, Braun, and Newton-Taylor (1998) reported alphas of .8 or higher on all do-mains. For our study, and similar to Thombs and Osborn(2001), we rewrote TPRQ items to address both alcoholand drug abuse counseling processes without changing theoriginal content. For example, we changed “drinking be-havior” to “drinking/drug use behavior.” We also replacedoverly complex words to facilitate reader comprehension.For example, we changed affective to emotional and provi-sional to temporary. The resulting TPRQ asked partici-pants to respond from −3 (harmful) to +3 (helpful) on howhelpful they considered each process.

Understanding Addiction Scale. As did Thombsand Osborn (2001), we revised the Understanding of Alco-holism Scale (Miller & Moyers, 1995), a 40-item instru-ment to measure beliefs about alcoholism, to address bothalcohol and drug addiction without changing the con-cepts being measured in the scale. For example, we changedalcoholism to addiction. Factor analyses of the UAS re-sulted in a two-factor structure representing disease andpsychosocial beliefs (Humphreys et al., 1996; Miller andMoyers, 1995). Moreover, these studies reported Cron-bach alpha coefficients of .78 and .88 for the disease sub-scale, and .75 and .72 for the psychosocial subscale. Theresulting UAS asked participants to respond from 1 (stronglydisagree) to 5 (strongly agree) on the extent to which theyagree with a particular belief about addiction.

Complex Clinical Decisions Survey. We adaptedthe work of Toriello and Benshoff (2003) to develop theCCDS (see the appendix) to examine the relationship be-tween SAPs’ clinical orientations and their clinical deci-sions involving ethical dilemmas. The clinical dilemmasgenerated by Toriello and Benshoff made up the items forthe CCDS. For content validation, Toriello and Benshoffgenerated items via literature review and focus group in-terviews with SAPs. A group of experts made the finaldetermination of items that constitute components ofclinical decisions involving ethical dilemmas. Specifically,the experts determined which clinical decisions consistedof two mutually exclusive courses of action, with eachcourse of action supported by an ethical principle andthus deemed a potentially valuable course of action duringsubstance abuse counseling.

The CCDS consisted of 26 items. Participants re-sponded to each item by selecting the course of actionthey would most likely choose if faced with the decision.We directed participants to base their decisions on theirphilosophy of substance abuse counseling, even if theiremploying agency’s philosophy was different. We scoredthe CCDS at item level: We scored selection of a course

of action that was conceptually consistent with a contem-porary clinical orientation as 1 and selection of the tradi-tional course of action as 0. Toriello and Benshoff did notreport reliability coefficients for their instrument; how-ever, we found a Cronbach alpha coefficient of .50 for theCCDS. We expected a low coefficient due to forcedchoice responses as well as the conceptual distinctivenessof the items, even though all items represent clinical de-cisions involving ethical dilemmas.

Demographics Questionnaire. Variables exam-ined by the demographics questionnaire included age, cre-dentials, education level and major, ethnicity, gender,recovery status, and years of experience.

RESULTS

Principal Components Analyses

First, we conducted principal components analyses sepa-rately on the 35 TPRQ items and the 40 UAS items usingSPSS version 12.0 (2003b).We considered these analysesnecessary because both instruments had been modified forthe study and we sought to reduce the number of variablesfrom 75 observed questionnaire items. Like Thombs andOsborn (2001), our primary objective was not to identifythe most parsimonious factor structures for our data, butto produce several unique factors that could be used asclustering variables in subsequent two-step cluster analy-ses. Thus, our criterion for extracting factors was simplyan eigenvalue greater than or equal to 1.00. Althoughsome of the factors developed in the analysis accountedfor less than 3% of the variance, the principal compo-nents analyses allowed for the possibility of these factorsto make substantial contributions to cluster solutions inthe next stage of our analytic process.

We conducted the principal components analysesusing both oblique and varimax rotations. Although theprocedures yielded nearly identical results for both theTPRQ and UAS analyses, we selected the oblique rota-tions because they usually provide factor solutions that are more realistic (Gorsuch, 1983; Portney & Watkins,1993); that is, having uncorrelated factors developed fromthe factor analysis is highly unlikely. To optimize commu-nality within factors and uniqueness between them, we se-lected only those items with loadings above .60 on thedesignated factor and less than .30 on all other factors(Hair, Anderson, Tatham, & Black, 1998). We extracted19 total factors: 12 from the UAS and 7 from the TPRQ.We calculated scores for each of these factors by addingeach participant’s scores on the items within these factors.The means and reliabilities of the TPRQ and the UASfactors derived from these procedures are summarized inTables 1 and 2, respectively.

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Cluster Analyses

To understand the contribution of these 19 factors to par-ticipants’ clinical orientations, we conducted a two-stepcluster analysis (SPSS, 2003b) to construct groups (i.e.,clusters for interpretation as clinical orientations) as dif-

ferent as statistically possible and as internally homoge-neous as statistically possible. With the first step, we ex-amined the agglomerative hierarchical clustering of thepreclusters formed in the first (precluster) step with fourcriteria (SPSS, 2003a). The Schwartz Bayesian criterion(BIC) is a goodness-of-fit measure that decreases (smaller

TABLE 1. Principal Components of the Treatment Process Rating Questionnaire (TPRQ)

Factor # of loadings Range of scores M SD % of variance α

Teaching coping skills is important 2 2–14 12.73 1.55 27.9%

Help clients accept disease and commit to 3 3–21 18.98 2.63 8.4 .75AA/NA

Help clients use behavioral modification 3 3–21 8.72 3.87 5.0 .65techniques

Psychotropic medications are helpful 2 2–14 5.86 2.90 4.5

Increase clients’ confidence for change 2 2–14 3.12 1.48 4.2

Help clients commit to treatment 1 1–7 6.17 1.11 3.3

Reduced substance abuse is a possible 1 1–7 2.02 1.34 3.0treatment goal

Total number of TPRQ items 14 56.3

Note. TPRG (Morgenstern & McCrady, 1992). AA = Alcoholics Anonymous; NA = Narcotics Anonymous. Factor names are abbreviated labelsfor questionnaire items or composite factor scores. Items loaded >.60 of the specified factor and <.30 on all other factors. The TPRQ responsesrange from harmful (scored as 1) to helpful (scored as 7).

TABLE 2. Principal Components of the Understanding Addiction Scale (UAS)

Factor # of loadings Range of scores M SD % of variance α

Addiction is a disease 2 2–10 7.33 2.19 16.3

Clients are weak in moral character 3 3–15 9.02 3.72 8.6 .78

Addiction is largely a spiritual issue 3 3–15 10.81 2.90 6.5 .70

Addiction is partially caused by one’s 3 3–15 7.80 2.57 4.5 .63environment

Relapse is common 2 2–10 6.90 1.69 3.9

Genetics play a role in addiction 2 2–10 7.26 2.12 3.7

Addicts lie about their use 1 1–5 4.26 .84 3.3

Clients who experience “blackouts” are addicts 1 1–5 2.41 1.25 3.0

Underlying psychological issues can cause 2 2–10 4.78 1.60 2.8addiction

Addiction is not caused by substance use 1 1–5 2.74 1.29 2.7

Addiction is caused by substance use 2 2–10 8.14 1.77 2.6

Clients can recover without treatment or 1 1–5 2.10 .98 2.5AA/NA

Total number of UAS items 23 60.4

Note. UAS (adapted from Thombs & Osborn, 2001). AA = Alcoholics Anonymous; NA = Narcotics Anonymous. Factor names are abbreviatedlabels for questionnaire items or composite factor scores. Items loaded >.60 of the specified factor and <.30 on all other factors. UAS responsesrange from strongly disagree (scored as 1) to strongly agree (scored as 5).

80 Rehabilitation Counseling Bulletin

values indicate improved fit) up through the optimal so-lution and then increases with additional clusters. Next,the BIC change value evaluates the change in BIC fromthe previous cluster step. Third, the Ratio of BIC Changespresents the ratio of the BIC change found moving from aone-cluster to a two-cluster solution, from a two-cluster toa three-cluster solution, and so on until the experimenter-specified number of clusters is reached (SPSS, 2003a). Fi-nally, the Ratio of Distance Measures evaluates for eachcluster solution the distance measure for that number ofclusters divided by the distance measure from the previoussolution.

With these four fit measures, we determined that atwo-cluster solution was optimal. We selected the two-cluster solution because: (1) the BIC was the lowest(10073.23); (2) the reduction in BIC was the largest (−101.53); (3) the movement of BIC ratio values from thethree-cluster solution to the two-cluster solution was thelargest (1.00); and (4) the Ratio of Distance Measureswas the greatest (2.54). Thus, the two-cluster solutionprovided the best solution for maximizing the statisticaldifferences between participants’ cluster scores while min-imizing statistical difference within each cluster.

In the second step of the cluster analysis, we exam-ined the characteristics of the two clusters. Cluster 1 iscomposed of 137 (56%) participants, whose scores on thefollowing factors were significantly higher than those ofthe participants not in Cluster 1. The participants inCluster 1 scored higher on more traditional interventionsthan on contemporary interventions. Specifically, partici-pants in Cluster 1 were more likely to agree with the fol-lowing statements (the number in parentheses is the rankof the factor in defining the cluster): “Help clients com-mit to treatment” (1); “Help clients accept disease andcommit to AA/NA” [Alcoholics Anonymous/NarcoticsAnonymous] (3); “Teaching coping skills is important”(5); “Addiction is caused by substance use” (8); “Addic-tion is largely a spiritual issue” (9); “Addicts lie abouttheir use” (10); “Addiction is a disease” (11). Likewise,participants in Cluster 1 were less likely to support the fol-lowing statements, which reflected a more contemporaryorientation: “Reduced substance abuse is a possible treat-ment goal” (2); “Help clients use behavioral modificationtechniques” (4); “Increase clients’ confidence for change”(6); “Psychotropic medications are helpful” (7).

Cluster 2 is composed of 105 (44%) of the partici-pants, whose scores on the following factors were signifi-cantly different than those of participants not in thecluster. The participants in Cluster 2 scored higher onmore contemporary interventions than on traditional in-terventions. Specifically, participants in Cluster 2 weremore likely to agree with the following statements: “Helpclients use behavioral modification techniques” (1); “Re-duced substance abuse is a possible treatment goal” (2);“Psychotropic medications are helpful” (5); “Increase

clients’ confidence for change” (7); and “Underlying psy-chological issues can cause addiction” (12). In addition,participants in Cluster 2 were less likely to agree with thefollowing statements, which reflect a more traditionalclinical orientation: “Help clients commit to treatment”(3); “Help clients accept disease and commit to AA/NA”(6); “Addiction is caused by substance use” (8); “Clientsare weak in moral character” (9); and “Addiction is largelya spiritual issue” (10).

When the two-cluster solution is optimal for pro-ducing classifications from the unclassified data to de-velop a model of participants’ clinical orientations, eachcase would fall in either Cluster 1 or Cluster 2. (In the“Discussion” section, Clusters 1 and 2 are labeled “neotra-ditional” and “precontemporary,” respectively, for inter-pretation purposes.) One might assume, therefore, thatCluster 1 is the opposite of Cluster 2. However, it is im-portant to note that each factor utility in defining a clus-ter is unique from cluster to cluster. In addition, thefactors making up each cluster were different; the ordinalranking factors used to define Cluster 1 were not the sameas the ordinal ranking of variables used to define Cluster2. At this point, the t values (see Table 3) indicate theutility of a particular variable in identifying a cluster; the factors of Cluster 1 are not the statistical inverse ofthe factors of Cluster 2. For example, the factor “Helpclients use behavior modification techniques” was signifi-cant for both clusters. Participants in Cluster 1 were morelikely to be supportive of the interventions represented inthat factor; whereas participants in Cluster 2 were lesslikely to be supportive of those interventions. However,the ordinal rank and the t value for that factor were not ofthe same ordinal rank or t value between clusters. Thatfactor was the most important variable in describing Clus-ter 1 (t = 8.72, p < .001), yet it ranked fourth in definingCluster 2 (t = −8.82, p < .001).

Of the participants in Cluster 1, 59.4% were women;63.2% were White and 34% were Black; 36.4% possesseda graduate degree; and 54.1% were in recovery from ad-diction. The average age of the participants in Cluster 1was 47.6 years; and the average number of years of experi-ence was 8.6. Of the participants in Cluster 2, 58% werewomen; 63% were White and 30% were Black; 52% pos-sessed a graduate degree; and 50.2% were in recovery fromaddiction. The average age of the participants in Cluster2 was 45.9 years, and the average number of years of ex-perience were 9.2.

Logistic Regression

Although Thombs and Osborn (2001) used a discrimi-nant analysis to determine how the clusters differed on avariety of measures assessing professional credentials, em-ployment, reliance on specific psychotherapies, and de-

Volume 48, No. 2 (Winter 2005) 81

mographic characteristics, we used logistic regression forseveral reasons: (a) participants were not normally dis-tributed among the two clusters, (b) the independent va-riables were categorical and not interval, (c) there was nota linear relationship between the clusters and the inde-pendent variables, (d) the two clusters were not normallydistributed in each of the independent variables, (e) thecluster outcome was not homoscedastic for each level ofthe independent variables, and (f) the error terms werenot normally distributed (Garson, 2001).

Results from the logistic regression revealed that fourcourses of action from items on the CCDS combined withgraduation from college significantly predicted partici-

pants’ cluster membership. From the CCDS, participantswho would: (a) “withhold information in order to preventthe client from being removed from treatment” were overthree times more likely to be in Cluster 2 (Wald χ2 =11.15, p = .0008, odds ratio = 3.18, CI 1.61 – 6.26); (b) “not mandate that the client be abstinent from alldrugs in order to receive treatment” were almost twotimes more likely to be in Cluster 2 (Wald χ2 = 3.54, p =.06, odds ratio = 1.84, CI .98 – 3.48); and (c) “use a coun-seling intervention that research has shown to be effec-tive” were over three times more likely to be in Cluster 2(Wald χ2 = 5.116, p = .023, odds ratio = 3.32, CI 1.18 –9.34). Finally, participants were more likely to be in Clus-

TABLE 3. Cluster Profiles

Cluster 1: Cluster 2:Neotraditional Precontemporary

Factor Range M SD t value M SD t value

Help clients commit to treatment 1–7 6.69 .50 13.01*** 5.50 1.31 –5.58***

Reduced substance abuse is a possible 1–7 1.42 .66 –12.44*** 2.80 1.58 5.88***treatment goal

Help clients accept disease and commit to 3–21 19.99 1.32 9.54*** 17.67 3.27 –4.45***AA/NA

Help clients use behavioral modification 3–21 6.75 3.01 –8.82*** 11.28 3.33 8.72***techniques

Teaching coping skills is important 2–14 13.34 1.04 8.70*** 11.94 1.75 –5.49***

Increase clients’ confidence for change 2–10 2.61 .93 –6.42*** 3.79 1.77 3.88***

Psychotropic medications are helpful 2–14 5.05 2.71 –4.18*** 6.91 2.80 4.54***

Addiction is caused by substance use 2–10 8.59 1.54 3.42*** 7.54 1.87 –3.24***

Addiction is largely a spiritual issue 3–15 11.36 2.61 2.85** 10.10 3.10 –2.77**

Addicts lie about their use 1–5 4.44 .64 2.56** 4.02 1.00 –2.17

Addiction is a disease 2–10 7.74 1.88 2.32* 6.80 2.44 –2.12

Clients are weak in moral character 3–15 9.67 3.81 2.19 8.17 3.43 –2.83**

Underlying psychological issues can cause 2–10 4.47 1.61 –2.09 5.19 1.52 2.60**addiction

Relapse is common 2–10 6.67 1.76 –2.07 7.19 1.55 2.71**

Addiction is partially caused by one’s 3–15 7.50 2.56 –1.99 8.20 2.55 2.22environment

Addiction is not caused by substance use 1–5 2.54 1.23 –1.62 3.01 1.33 1.73

Genetics play a role in addiction 2–10 7.59 2.04 1.51 6.84 2.16 –1.47

Clients who experience “blackouts” are 1–5 2.54 1.30 1.32 2.24 1.16 –1.68addicts

Clients can recover without treatment or 1–5 2.10 .99 –.29 2.10 .98 .32AA/NA

Note. AA = Alcoholics Anonymous; NA = Narcotics Anonymous. Factor names are abbreviated labels for questionnaire items from the Treat-ment Process Rating Questionnaire (Morgenstern & McCrady, 1992) or the Understanding Addiction Scale (Thombs & Osborn, 2001) or compositefactor scores. Items loaded > .60 of the specified factor and < .30 on all other factors. *p < .05. **p < .01. ***p < .001.

82 Rehabilitation Counseling Bulletin

ter 2 if they were college graduates (Wald χ2 = 4.33, p =.037, odds ratio = 2.01, CI 1.04 – 3.89).

Overall, this four-variable model correctly predictedthe cluster membership of 60% of the participants. Weused the Hosmer and Lemeshow (2000) statistic to assessthe goodness of fit between the model and the observedresponses to the four variables. We found no significantdifference between cluster membership and the observeddata (χ2 = 4.14 p = 0.388). Therefore, we concluded thatthe participants’ responses on the four variables were sig-nificantly associated with cluster membership.

DISCUSSION

Clinical Orientations

The two-step cluster analysis yielded a two-cluster solu-tion, thus clustering our sample on two clinical orientations.Referring to the substance abuse clinical orientation con-tinuum with traditional and contemporary orientations atthe extremes, we labeled the clinical orientations found inour study based on where they fell on the continuum“neotraditional” (Cluster 1) and “precontemporary” (Clus-ter 2). Both neotraditional and precontemporary orienta-tions fell between the traditional extreme and the middleof the continuum. In comparison to the clinical orientationsdescribed by Thombs and Osborn (2001), neotraditionaland precontemporary SAPs seem to be less traditionalthan “uniform” SAPs and less contemporary than “multi-form” SAPs, the latter of which operate from the middleof the continuum. Thus, neotraditional and precontem-porary SAPs have moved away from an extreme tradi-tional or “pure” disease model approach; however, they donot exhibit any particular favor for a nondisease model orcontemporary interventions.

The difference between neotraditional and precon-temporary SAPs seems to be their respective amounts ofmovement away from a traditional orientation, as well astheir amounts of movement toward a contemporary ori-entation. (The following interpretive comparisons are ref-erenced to “Chris,” our hypothetical client describedearlier, and are based on the Likert anchors for the coun-seling processes listed on the TPRQ [i.e., harmful to help-ful ] and the beliefs listed on the UAS [i.e., strongly disagreeto strongly agree].) For example, both groups endorsed dis-ease model interventions as helpful. Thus, in workingwith a client like Chris, both would try to help the clientaccept having the disease of addiction and commit to Al-coholics Anonymous or Narcotics Anonymous. However,the neotraditional SAPs endorsed this traditional inter-vention as more helpful. Both groups were unsure aboutthe accuracy of moralistic beliefs about substance abuse(e.g., Chris is weak in moral character), but precontem-

porary SAPs disagreed more with such beliefs. This pat-tern is consistent with beliefs about substance abuse beinga spiritual matter (e.g., Chris’s problem is largely a spiri-tual problem). SAPs from both orientations agreed withthese traditional beliefs, but the neotraditional SAPsagreed more.

Based on these differences, neotraditional and pre-contemporary SAPs seemed to have moved beyond rigidadherence to the traditional, pure disease model clinicalorientation that has dominated the field (Morgenstern,Frey, McCrady, Labouvie, & Neighbors, 1996) and aremoving toward contemporary interventions. Our findingsseem to support Morgenstern and McCrady’s (1992) con-clusion that the traditional clinical orientation towardsubstance abuse and substance abuse counseling was evolv-ing into a more contemporary yet complex orientation. Ifthis is the case, then the difference between neotradi-tional and precontemporary SAPs is that the precontem-porary SAPs have moved farther. For example, regardingcontemporary processes and beliefs, SAPs from both ori-entations endorsed behavior modification processes (e.g.,help Chris use behavioral modification techniques) as harm-ful, yet precontemporary SAPs endorsed those processesas less harmful than neotraditional SAPs did. SAPs fromboth orientations endorsed nonabstinence treatment goals(e.g., reduced drinking is a possible treatment goal forChris) as harmful, yet precontemporary SAPs endorsedthem as less harmful than neotraditional SAPs did.Again, this pattern was consistent with providing clientswith medications to augment their treatment (e.g., pro-vide Chris with medication to alleviate symptoms of themood disorder); SAPs from both orientations endorsedthose processes as harmful, but precontemporary SAPs en-dorsed the processes as less harmful.

Thus, neotraditional and precontemporary clinicalorientations seem different from the substance abuse clin-ical orientations described in previous studies. Several ofthe previous studies’ results revealed SAPs with contem-porary clinical orientations. For example, having a purercontemporary clinical orientation made up 17% of theMorgenstern and McCrady (1992) sample and 15% of theThombs and Osborn (2001) sample, while our results didnot reveal SAPs with such an orientation. This may re-flect regional differences, in that our southern sample ofSAPs may be reflecting conservative southern values asopposed to the northern sample of Thombs and Osborn.The differences may also reflect training standards andcontent of the regions. Moreover, clinical orientations de-scribed in previous studies tended to be extreme or in themiddle. Neotraditional and precontemporary SAPs aredifferent in that they are between an extreme traditionalorientation and the middle of the orientation continuum.Neotraditional and precontemporary SAPs differ from eachother significantly on their relative distance from thesepoints.

Volume 48, No. 2 (Winter 2005) 83

Relationship Between Orientationand Decisions

To build on previous substance abuse clinical orientationresearch, we examined the relationship between SAPs’clinical orientations and their clinical decisions involvingethical dilemmas. Results revealed that three clinical de-cisions from the CCDS significantly predicted clinicalorientation. Continuing our reference to Chris, results re-vealed that those SAPs who would not inform Chris’sprobation officer that the client had relapsed because ofconcern that the officer would remove the client from treat-ment were three times more likely to be precontemporary.Those SAPs who would not require Chris to abstain fromall drugs to receive treatment were two times more likelyto be precontemporary. And those SAPs who would use acounseling intervention that research has shown to be ef-fective were three times more likely to be precontempo-rary. Perhaps neotraditional and precontemporary SAPsare sensing the managed care pressures for movement towardcontemporary or evidence-based interventions (Thombs& Osborn, 2001) but have yet to be adequately exposedto specific interventions. The precontemporary SAPsseem more prone to choose a nontraditional course of ac-tion, which makes sense considering their placement onthe clinical orientation continuum described previously.The clinical decision differences between neotraditionaland precontemporary SAPs may also be influenced by thedynamics involved in the specific decisions. For example,regarding nonabstinence treatment goals, with precon-temporary SAPs being less traditional than neotraditionalSAPs, one might expect they would be more likely tochoose this nontraditional course of action.

From these results, one may postulate that a neotra-ditional SAP who is counseling Chris would (a) not sup-port Chris’s desire to continue drinking, (b) inform Chris’sprobation officer that he is still drinking, and (c) would beless likely than a precontemporary SAP to use an evidence-based counseling intervention. The opposite would char-acterize a precontemporary SAP counseling Chris; thiscounselor would be more likely to (a) support Chris’s de-sire to continue drinking, (b) not inform Chris’s probationofficer of the drinking, and (c) use an evidence-basedcounseling intervention. Of final interest is the fact that23 clinical decisions were not predictive of clinical orien-tations. This may be due to the closeness of neotraditionaland precontemporary SAPs on the clinical orientationcontinuum. This relative similarity may be reflected intheir similarity on the nondiscriminating clinical decisions.

The final variable that significantly predicted clini-cal orientation may add to our interpretation: educationlevel. The logistic regression revealed that college gradu-ates were more likely to be precontemporary. This findingsupports all of the previous substance abuse clinical orien-tation studies that higher education levels relate to more

contemporary clinical orientations. Thus, precontempo-rary SAPs, as a result of more education, may have hadmore exposure to contemporary or evidence-based inter-ventions and are therefore more apt to choose to usethem, a conclusion reached by Thombs and Osborn(2001). In fact, Thombs and Osborn alluded to an as-sumption that, because of lower education levels, tradi-tional SAPs are less likely to engage in evidence-basedpractices. This seems consistent with our findings. In con-clusion, there seems to be a relationship between SAPs’clinical orientations and their clinical decisions involvingethical dilemmas, a finding similar to the McKinlay et al.(2002) study of physicians. Additionally, education levelseems to play a significant and consistent role in the clin-ical orientation of SAPs.

Study LimitationsInterpreting the results must be done with caution be-cause of the limitations of our study. Most notably, gener-alizing interpretations beyond our sample is a concern forseveral reasons. First, our self-report mail survey was con-ducted in one state. Second, even though the entire pop-ulation of Louisiana SAPs possessing or working towardcertification was surveyed, the response rate of 27% maynot be entirely representative of the population. This re-sponse rate is comparable, however, to other mail surveysexamining SAPs’ clinical orientations (Morgenstern &McCrady, 1992; Moyers & Miller, 1993; Thombs & Os-born, 2001). Moreover, the demographic characteristicsof our respondents are similar to those found in otherstudies (Culbreth, 1999; Toriello & Benshoff, 2003). Wealso have concerns about the forced-choice aspect of theCCDS. This dynamic may have pressured participants torespond in a socially desirable manner (Anastasi, 1982).Thus, adding a Likert-type scale may be prudent for futureiterations of the CCDS.

Implications for RehabilitationCounselorsThe results of this study suggest several interesting impli-cations for the education, supervision, and research of fu-ture rehabilitation counselors (RCs). Assuming that thecontinuum described earlier is a valid mechanism for alsodescribing rehabilitation counselors’ substance abuse clin-ical orientations, it may serve as a useful heuristic for RCeducators, supervisors, and researchers. Replicating ourstudy with a sample of RCs would be important for at leastthree reasons: First, the number of vocational rehabilita-tion clients with substance abuse issues is considerable. Asstated earlier, Drebing et al. (2002) found that 80% ofclients served by the Veterans Health Administration pre-sented substance abuse issues. Second, there are no stan-dard guidelines that RCs follow in working with clients

84 Rehabilitation Counseling Bulletin

with substance abuse issues. For example, the decision toaccept such a client into vocational counseling is oftenleft to the clinical judgment of the RC (Drebing, Rosen-heck, Schutt, Kasprow, & Penk, 2003). Our results suggestthat this decision may be impacted by the RC’s clinicalorientation, which may not necessarily be a problem, con-sidering that Drebing et al. (2003) did not find evidenceof bias toward the acceptance of clients with substanceabuse issues. Third, we would postulate that the definitionof a rehabilitation counseling clinical orientation towardsubstance abuse may be a model for the general substanceabuse counselor to consider.

Across clinical orientation studies, including the cur-rent study, substance abuse clinical orientations can seem-ingly be classified along this traditional-to-contemporarycontinuum, and our results suggest that placement on thecontinuum relates to one’s clinical decisions in ethicaldilemmas. Thus, if decision making is a critical skill re-quired of RCs, then RC educators and supervisors need tobe mindful of this, particularly as they train and superviseRCs on substance abuse clinical decision making. Educa-tors and supervisors may want to monitor (via the TPRQand UAS) the substance abuse clinical orientation devel-opment of RCs and the connection of that developmentto clinical decision making. They could potentially mon-itor whether clinical orientation leads to suboptimal orbiased clinical decisions (Bornstein & Emler, 2001; Wat-son, 1994), and whether decision-making skills maturealong with clinical orientation maturity. Moreover, as ed-ucators and supervisors facilitate the substance abuse clin-ical decision-making development of RCs, researchersmay want to collaborate with them to further examine therelationship of substance abuse clinical orientation andclinical decision making. This examination could be aug-mented with previously researched decision-making mod-els (e.g., Carroll, 2000; Noseworthy, 1999; Wilson-Rollins,Rubin, & Fischer, 1993)

Substance abuse clinical orientation “development”or “evolution” assumes that clinical orientation is not astatic state. Future research is also needed to unequivo-cally determine whether clinical orientations do representdevelopmental stages. We think clinical orientations areindeed developmental. We base this hypothesis largely onthe SAP characteristic that has most consistently dis-criminated clinical orientation across studies: educationlevel. Across all studies, SAPs who were more contempo-rary in their clinical orientation tended to possess highereducation levels; as SAPs increase in education level,their clinical orientation becomes more contemporary. AsRCs operate from a master’s degree, one would expecttheir substance abuse clinical orientation to be more con-temporary, therefore. One question of interest may be:Does a contemporary clinical orientation lead an RC toobtain a higher education level, or does education impacta RC’s clinical orientation? Again, using the traditional-

to-contemporary continuum as a heuristic may help de-scribe the stages as well as movement across stages (Thombs& Osborn, 2001). For example, our results suggest thatoperating from a precontemporary orientation may bemore predictive of adopting more contemporary or inno-vative counseling interventions than operating from aneotraditional orientation. This hypothesis suggests a de-velopmental study or repeated-measures design, where re-searchers can work with educators and supervisors toexamine the developmental nature of RCs’ substanceabuse clinical orientations.

ABOUT THE AUTHORS

Paul J. Toriello, RhD, is an assistant professor and StephenJ. Leierer, PhD, is an associate professor in the Departmentof Rehabilitation Counseling at the Louisiana State UniversityHealth Sciences Center in New Orleans. Address: Paul J. To-riello, Department of Rehabilitation Counseling, LSUHSC,1900 Gravier St., Box G6-2, Rm 8C-1, New Orleans, LA70112; e-mail: [email protected]

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APPENDIX: CCDS

Part 3 Instructions: Each item below contains a decision you may make as a Substance Abuse Counselor. The twooptions of each decision are noted by the letters “A” and “B.” Next to each item, please write the letter of the optionyou would most likely choose if faced with the decision. Please base your answers on your philosophy of substance abusecounseling, even if your employing agency’s philosophy is different.

When deciding between . . . You would choose . . .

Ex. (A) Completing this survey of substance abuse counselors or

(B) taking a break from work to rest your mind.

1. (A) Continuing to serve a client who relapses or

(B) discharging that client for non-compliance.

2. (A) Serving an insured client, who can pay for services or

(B) serving an uninsured client who has a greater need for treatment.

3. (A) Providing services that are compatible with a client’s cultureor

(B) providing services that reflect your treatment approach.

4. (A) Informing a probation officer that a client relapsedor

(B) withholding this information in order to prevent the client from being removed from treatment.

5. (A) Taking time to complete required reports and case notes on timeor

(B) using the time to provide more comprehensive services to a client.

6. (A) Supporting a client’s choice of a post-treatment living environmentor

(B) recommending a more intrusive, but safe environment.

7. (A) Supporting a client’s choice to smoke marijuana to deal with a secondary pain symptom of being paralyzed

or(B) mandating the client be abstinent from all drugs in order to receive

services.

8. (A) Counseling a client in a group format because group counseling is cost-effective

or(B) providing more individual counseling to that client because he/she

needs it.

A

(Appendix continues)

Volume 48, No. 2 (Winter 2005) 87

When deciding between . . . You would choose . . .

9. (A) Providing suggestions to a client that reflect your personal understanding of the 12-Step model of treatment

or(B) providing suggestions to the client that reflect your agency’s treatment

philosophy.

10. (A) Addressing specific issues of a client at his/her probation officer’s requestor

(B) respecting the client’s request for privacy on those issues.

11. (A) Assisting a client who wants help to reduce their drinking/usingor

(B) mandating that the client become abstinent to receive services.

12. (A) Continuing to serve a client who chooses not to attend 12-Step meetingsor

(B) discharging that client for non-compliance to mandatory 12-Step meeting attendance.

13. (A) Using a counseling intervention that reflects traditional philosophy about substance abuse counseling

or (B) using an intervention supported by research.

14. (A) Mandating a client with anxiety problems to be abstinent from all drugs to receive counseling

or(B) supporting the client’s use of a prescribed mood-altering drug to cope with

the anxiety.

15. (A) Building rapport by disclosing to a client your personal experiences and consequences with drugs

or(B) adhering to a philosophy of minimal self-disclosures to clients.

16. (A) Recommending abstinence as a goal in a client’s treatment plan or

(B) developing a treatment plan which supports a client’s desire to find ways to cut back on using without becoming totally abstinent.

17. (A) Discharging a client for being disruptive in the residential treatment community

or(B) continuing to provide needed services to that client.

(Appendix continued)

(Appendix continues)

88 Rehabilitation Counseling Bulletin

When deciding between . . . You would choose . . .

18. (A) Providing the amount of treatment requested by a client who is court mandated to treatment

or(B) providing the amount of treatment indicated by the clinical assessment

of that client.

19. (A) Maintaining the credibility of a treatment agency by covering for an incompetent colleague

or(B) “blowing the whistle” on that colleague to ensure quality services.

20. (A) Discharging a client after the publicly funded, allotted length of treatmentor

(B) providing additional services to that client who has a need for more treatment.

21. (A) Assigning an immediate residential treatment entry date to a clientor

(B) allowing that client to enter treatment after certain family issues are resolved.

22. (A) Placing a client in residential services because he/she has no means of transportation to outpatient services

or(B) placing the client in the needed intensity of services indicated from a clinical

assessment.

23. (A) Supporting a client’s choice to smoke marijuana to deal with symptoms of schizophrenia

or(B) mandating the client be abstinent from all drugs in order to receive services.

24. (A) Using a counseling intervention that research has shown to be effectiveor

(B) using a popular approach supported by your peers.

25. (A) Giving a client a more severe diagnosis so they are eligible to receive servicesor

(B) giving the less severe, but accurate, diagnosis.

26. (A) Supporting a client’s desire to try a methadone maintenance programor

(B) discouraging the client’s desire to try a methadone maintenance program.

(Appendix continued)