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A Cluster Analytic Study of Clinical Orientations Among

Chemical Dependency Counselors
Dennis L. Thombs and Cynthia J. Osborn
Three distinct clinical orientations were identified in a sample of chemical dependency counselors (N = 406). Based on cluster
analysis, the largest group, identified and labeled as uniform counselors, endorsed a simple, moral-disease model with little
interest in psychosocial interventions. A 2nd group, identified as multiform counselors, embraced an incongruent moral-diseasepsychosocial model, and valued a myriad of treatment approaches. The smallest group, labeled client-directed counselors, did
not fully endorse Alcoholics Anonymous (AA) principles, valued non-coercive treatment, and recognized coexisting psychopathology in clients. Results from a discriminant function analysis provided evidence to support the 3-group cluster solution.

n the United States, the gap between practice and research in the addictions field has persisted or possibly
expanded during the 1990s (Backer, David, & Soucy,
1995; Lamb, Greenlick, & McCarty, 1998). Despite
calls for new views on the nature of addiction (Leshner,
1997), broad-spectrum approaches to treatment (Institute
of Medicine, 1990), and practice based on informed eclecticism (Miller & Hester, 1995), many frontline practitioners
are presumed to hold to experiential models acquired from
their own recovery (Lamb et al., 1998). Indeed, there is a
long history of association between Alcoholics Anonymous
(AA) and the U.S. treatment system (Yalisove, 1998), and,
as a result, the research literature commonly describes the
disease model as dominant (e.g., Morgenstern, Frey,
McCrady, Labouvie, & Neighbors, 1996) and widespread
(e.g., Ogborne, Wild, Braun, & Newton-Taylor, 1998). Although these assumptions may be accurate, they have not
been extensively studied in the 1990s. This seems to be a
research need given the rapid changes in the delivery of
addiction treatment services, many of which can be traced
to managed care pressures (Morey, 1996).
Brown (1995) contended there is little incentive for the
research and the service delivery communities to collaborate. Traditionally, funding agencies have supported treatment outcome research and placed little emphasis on
investigations seeking to diffuse treatment innovations. At
the same time, treatment programs have usually selected
practices based on personal recovery experiences rather
than on criteria based on data. Thus, the federal government has assumed responsibility for facilitating collaboration. The Center for Substance Abuse Treatment (1998a)

has primary responsibility for technology or information

transfer to the frontline practitioner. To date, however, there
remain many gaps in basic knowledge about how to facilitate treatment innovation (Backer et al., 1995). One
problem is the lack of data on the characteristics of chemical
dependency counselors. Deitch and Carleton (1997) have
noted that the development of counselor competencies in
the present treatment environment is dependent not only
on disseminating new information but also on tailoring
training experiences to the personal qualities of these adult
learners.
The fault for the gap between practice and research does
not rest entirely with chemical dependency counselors. The
research community has been slow to collaborate with practitioners and to make research findings more accessible
(Brown, 1998). This predicament is not unique to the
addictions field. Similar problems have been noted in other
professions and organizations (Rogers, 1995), and resistance
to change is a common characteristic of complex hierarchical organizations in many sectors of society (Kavanagh, 1995).
Nevertheless, many innovative practices have not diffused
rapidly into the U.S. addictions treatment system, even when
there are data to support their implementation. Some of
these practices include contingency management strategies
(e.g., Kidorf & Stitzer, 1996), motivation enhancement
therapy (Miller & Rollnick, 1991; Miller, Zweben,
DiClemente, & Rychtarik, 1992), problemservice matching (McLellan et al., 1997), and selected harm reduction
strategies (Erickson, Riley, Cheung, & OHare, 1997).
It is important to understand the views and valued treatment practices of chemical dependency counselors because

Dennis L. Thombs is an associate professor with academic appointments in Health Promotion, and Counseling and Human Development Services, and
Cynthia J. Osborn is an assistant professor in Counseling and Human Development Services, both in the Department of Adult, Counseling, Health, and
Vocational Education at Kent State University, Kent, Ohio. Financial assistance for this research was provided by a grant from the Kent State University
Research Council. The authors thank the Ohio Credentialing Board for Chemical Dependency Professionals for their help and Jonathan Richardson for his
assistance with data entry. Correspondence regarding this article should be sent to Dennis L. Thombs, 316 White Hall, Kent State University, Kent, OH 44242
(e-mail: dthombs@educ.kent.edu).

450

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Cluster Analytic Study

ideology influences clinical decision making (Brickman et

al., 1982; Shaffer & Robbins, 1991; Worthington & Atkinson,
1993), and treatment strategies are derived from differing
assumptions about the nature of addiction problems
(McCrady, 1991; Miller & Hester, 1995). Disease model
practitioners may not be receptive to, nor adequately prepared to adopt, new practices that deviate from their personal experience. Thus, there is a need for training programs
that prepare practitioners for change. This will require that
the characteristics of practitioners be factored into the planning of professional development activities. Such planning
may result in matching training to the needs and specific
characteristics (e.g., attitudes) of practitioner subgroups
(Gassman, 1997).
The current study investigated whether types of chemical dependency counselors could be discerned based on views
of the nature of addiction and ratings of various treatment
practices. Previous studies of chemical dependency counselors (Culbreth & Borders, 1999; Humphreys, Noke, &
Moos, 1996; Leavy, 1991; Morgenstern & McCrady, 1992;
Moyers & Miller, 1993; Mulligan, McCarty, Potter, &
Krakow, 1989; Osborn, 1997) have not used cluster analyses
to identify a counselor typology based on beliefs about
addiction and its treatment. Ogborne et al. (1998) reported
the emergence of two distinct groups of addiction counselors
in Ontario, Canada, based on their beliefs about specific
treatment processes. The construction and analysis of group
membership, however, was not the primary focus of the study,
and the methods used to create the typology were not well
specified to allow for replication.
The present study, therefore, represents an initial but systematic inquiry into chemical dependency counselor types,
based on their views of addiction and valued treatment practices. The research questions that guided this study were
the following:
1. What are the current and prevailing views of addiction and its treatment among chemical dependency
counselors?
2. Can distinct types of chemical dependency counselors be identified based on their views of addiction
and valued treatment practices?
3. If such a typology exists, what are the implications
for chemical dependency counselor training and the
adoption of innovation in treatment settings?

METHOD
Sample and Procedure
In Ohio, registered candidates are practitioners with varied
academic backgrounds who work under supervision in the
substance abuse field. Current state credentialing standards
stipulate that registered candidates must obtain their chemical dependency certification within 2 years. Three levels of
certified chemical dependency counselors (CCDC) are
recognized in the state. CCDC I requires a high school
degree, a minimum of 135 clock hours of training, at least 6

months of work experience, and successful completion of a

written exam. CCDC II has the same minimum academic
and written exam requirements as CCDC I but requires an
additional 135 hours of training, at least 1 year of work
experience, and successful completion of an oral exam. CCDC
III requires a masters degree in a behavioral science and
permits independent practice in the state.
We obtained names and addresses of registered candidates
and certified counselors from the Ohio Credentialing Board
(OCB) for Chemical Dependency Professionals. After eliminating those with incomplete and overseas addresses and those
living in states noncontiguous to Ohio, every fifth name in the
OCB directory was sent a survey packet. Two postcard reminders were mailed to nonrespondents. From the pool of 1,261
potential respondents, 406 surveys were returned, yielding a
response rate of 32.2%. In other mail surveys of this population, Moyers and Miller (1993) reported a response rate of
20%, and Morgenstern and McCrady (1992) obtained 28%. In
the current study, nonrespondents were primarily registered
candidates (53%), followed by CCDC IIIs (33%), and CCDC
I and IIs (14%). Investigator contact with a limited number of
nonrespondents (during data collection) as well as OCB officials (after data collection) suggested that the relatively high
rate of nonresponse (particularly among registered candidates)
was due to failure to purge names from the OCB directory
when counselors left the addictions treatment field.
The socio-demographic characteristics of the respondents
are comparable to those reported in other surveys of chemical dependency counselors. For instance, this sample was
62% female compared with 56% reported by Culbreth and
Borders (1999), 59% reported by Leavy (1991), and 60%
by both Moyers and Miller (1993) and Osborn (1997).
The proportion of the current sample in recovery (37%)
was similar to that reported by both Culbreth and Borders
and Leavy, 34% and 39%, respectively. The proportion in
recovery was somewhat lower than the 55% found by
Osborn in a national survey of chemical dependency counselors. The proportion of respondents holding a graduate
degree (53%) was comparable to both Osborn and Leavy,
50% and 52%, respectively.
Measures
Measures were selected to comprehensively assess the clinical
orientation of chemical dependency counselors. The domains
considered to be most germane to this assessment were (1)
counselors conceptions of the nature of addiction and (2) the
extent to which they value various treatment practices.
Understanding of Addiction Scale (UAS). Based on the
Understanding of Alcoholism Scale (Miller & Moyers, 1995),
the 70-item instrument used in this study was reworded
and hence, revised, to assess counselors conceptions of alcohol and drug addiction. The items were worded to refer to
both alcohol and drugs without changing the concepts being
measured by Miller and Moyerss alcoholism version. (A
similar alteration in wording was reported by Humphreys,
Greenbaum, Noke, & Finney, 1996).

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Thombs and Osborn

Previous studies using the UAS to assess the beliefs of

chemical dependency counselors have factor analyzed
the items to develop valid subscales. Both Moyers and
Miller (1993) and Humphreys, Greenbaum, et al. (1996)
found a two-factor structure representing Disease and
Psychosocial concepts. Cronbach alpha coefficients in
these studies are reported as .88 and .78 for the Disease subscale, and as .72 and .75 for the Psychosocial
subscale. Previous research has not used cluster analysis to determine whether the instrument can identify
distinct types of practitioners.
Treatment Processes Rating Questionnaire (TPRQ). In an
effort to move beyond the disease/behavioral model dichotomy,
Morgenstern and McCrady (1992) developed the TPRQ
to assess the degree to which various processes and therapeutic mechanisms are deemed essential by addictions
practitioners. Morgenstern and McCrady identified four
treatment process domains a priori: disease (10 items),
behavioral (17 items), general psychotherapy (6 items),
and pharmacological treatment (2 items). Morgenstern
and McCrady did not report internal reliability coefficients for each of these domains, but Ogborne et al. (1998)
reported that standardized alphas were high in all cases
(> .8) (p. 304).
Items were rewritten for the present study to encompass both alcohol and other drugs, similar to the alteration of wording reported by Ogborne et al. (1998). To
facilitate reader comprehension, relatively sophisticated
terms such as affective involvement and self-efficacy,
were reworded as emotional involvement and self-confidence, respectively. In addition, five items were added
to the TPRQ to assess respondents views regarding the
use of alternative medicine practices (e.g., acupuncture,
hypnosis, over-the-counter herbal remedies) and cigarette
smoking cessation. Ogborne et al. cluster analyzed a modified set of TPRQ items and found two distinct groups but
provided limited information about the characteristics of
each cluster.
Professional/demographic measures. Single-item measures
were used to assess a broad range of personal and professional characteristics of the respondents (e.g., recovery status, certifications and licenses, salary). Confidence in ones
knowledge of the DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders, fourth edition, American Psychiatric Association, 1994; above and beyond substance
use disorders) was assessed on a scale ranging from nonexistent (scored as 1) to excellentI am very confident in
my knowledge of mental disorders (scored as a 5). Respondents also rated five psychotherapies (cognitive-behavioral,
solution-focused, Adlerian, existential/humanistic, and
other) and the disease model on a 10-point scale. Scores
of 10 represented theories (or models) perceived to have
no influence on ones professional practice, whereas scores
of 1 represented theories with great influence. Other
represented a variety of psychotherapies, including psychodynamic, that were rated as having little influence on
practice by a majority of respondents.

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RESULTS
Principal Components Analyses
Principal components analyses were conducted separately on
the UAS items and the TPRQ items. These analyses were
deemed necessary because both instruments had been modified for the study. Our primary objective was not to identify
parsimonious factor structures but to produce a range of unique
factors that could serve as clustering variables in subsequent
cluster analyses. Thus, the criterion for extracting factors was
simply an eigenvalue greater than or equal to 1.00. This
approach included factors accounting for a small amount of
variance in the principal components analyses to allow for the
possibility that they could make substantial contributions to
cluster solutions in the ensuing data analytic stage.
The principal components analyses were conducted using
oblique and orthogonal rotations. Although the procedures
yielded nearly identical results for both the UAS and the
TPRQ analyses, the oblique rotations were selected because
they usually provide factor solutions that are more realistic
(Portney & Watkins, 1993). The criteria for determining the
significance of the factor loadings followed criteria outlined
by Hair, Anderson, Tatham, and Black (1998) in which items
were retained only if they loaded above .60 on the designated factor and less than .30 on all other factors (thereby
optimizing communality within factors and uniqueness
between them). The factors derived from these procedures
as well as their means and reliabilities are summarized in
Tables 1 and 2. An examination of the means and standard
deviations in these two tables reveals that the sample was
relatively heterogeneous regarding moral, disease, and psychosocial conceptions of addiction and its treatment.
Cluster Analyses
SPSS (1988) cluster procedures were used to group the
chemical dependency counselors according to their responses to the 28 extracted UAS and TPRQ factors. Three
of the most widely used cluster algorithms (k-means, Wards,
and complete linkage) were used to conduct the analyses
(Hair et al., 1998). In each analysis, squared Euclidean distance coefficients were used as the measure of proximity.
Because there was no theoretical rationale for assigning differential weights to the factor scores, the variables resulting from the different UAS and TPRQ measurement scales
were transformed to Z scores. This procedure standardized
the factor scores so that each was equally weighted in the
analyses (Hair et al., 1998).
Because there were 63 cases with missing values, 343 cases
were used in the three cluster analyses. There was correspondence between the cluster solutions generated by the k-means
and complete linkage methods; each analysis identified a
simple, two-group solution that differentiated disease model
practitioners from non-disease-model practitioners. In contrast, the agglomeration coefficients and dendrogram generated from the Wards algorithm clearly indicated that a
three-group solution accounted for clustering in the data.

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TABLE 1
Principal Components of the Understanding of Addiction ScaleRevised (UAS; Oblique Rotation)
Factor

Number of
Loadings

Range of
Scores

SD

1
1
3
2
1
1
1
1
2
1
1
1
1
2
1
1
2
1
1
3
28

14
14
312
28
14
14
14
14
28
14
14
14
14
28
14
14
28
14
14
312

2.5
2.8
4.7
4.4
2.9
3.0
3.1
2.8
5.8
2.3
2.1
2.3
2.1
5.6
3.4
2.3
5.8
3.0
2.8
7.7

0.7
0.7
1.5
1.2
0.8
0.5
0.6
0.5
1.2
0.7
0.6
0.8
0.7
1.2
0.6
0.7
1.2
0.7
0.6
1.8

Clients need humility in recovery

Best way to help clients is to listen
Clients are immoral
Lack of spirituality causes addiction
It is necessary to treat clients families
Abuse can be differentiated from dependence
Clients lie about their substance use
Most clients relapse after treatment
Addicts have a physiological susceptibleness
Blackouts indicate substance dependence
Client motivation depends on counselor skill
Recovering addicts are the best counselors
Some clients wind up using without problems
Social environment is a determinant of addiction
Co-existing psychological problems should be treated
Most clients recover and live normal lives
Greater use increases probability of dependence
Treatment should be individualized
Client compliance increases likelihood of recovery
There exists an addictive personality type
Total number of UAS factors

Percentage
of Variance
13.3
5.8
4.8
3.6
2.9
2.6
2.5
2.3
2.1
2.1
2.0
1.9
1.8
1.7
1.7
1.6
1.5
1.5
1.5
1.4
58.6

.71

.71

Note. UAS = Understanding of Addiction Scale. Factor names are abbreviated labels for questionnaire items or composite factor scores. Items
loaded > .60 of the designated factor and < .30 on all other factors. The UAS responses range from strongly disagree (scored as 1) to strongly
agree (scored as 4).

These conflicting results are generally consistent with research

on cluster analysis techniques (e.g., Morey, Blashfield, & Skinner, 1983; Wells-Parker, Anderson, Pang, & Timken, 1993).When
there are relatively few outliers (as in these data) and cluster
overlap (i.e., groups occupying the same space) is judged to be
a greater consideration, Wards method has been shown to outperform other clustering procedures (Aldenderfer & Blashfield,
1984). More specifically, Wards method has been shown to
yield interpretable, heuristically interesting cluster solutions
that can be validated by external criteria (Morey et al., 1983).
Thus, Wards three-cluster solution was selected for further
examination.
Variable profiles were created for the purpose of interpreting the nature of each cluster and assigning labels. The
profiles for the three-cluster solution appear in Table 3.

The variables are ordered by their F values (high to low),

where it can be seen that there were significant group differences on 24 of the UAS and TPRQ variables. The mean
Z scores represent the typical position of each group relative to that of the total sample.
The largest group consisted of 192 respondents (56% of the
cases in the analysis). They can be labeled uniform counselors. As shown in Table 3, the profile of this group includes
moderate support for moral and disease concepts (e.g.,
Clients lie about their substance use and Blackouts indicate
substance dependence), combined with a tendency to reject
psychosocial concepts and interventions (e.g., Cravings can
be reduced with conditioning strategies and Teaching coping skills is important). Overall, individual differences among
clients are minimized in this group. The uniform thinking

TABLE 2
Principal Components of the Treatment Processes Rating Questionnaire (TPRQ; Oblique Rotation)
Factor
Clients need help developing better relationships
Some clients benefit from alternative therapies
Cravings can be reduced with conditioning strategies
Counseling should increase client self-efficacy
Client must accept disease concept and commit to AA/NA
Clients are responsible for change and maintenance of
recovery
Psychotropic medication is useful
Teaching coping skills is important
Total number of TPRQ factors

Number of
Loadings

Range of
Scores

SD

Percentage
of Variance

1
3
2
1
2

17
321
214
17
214

5.6
9.7
8.3
6.5
12.0

1.2
3.8
3.5
1.0
2.0

21.4
9.1
6.2
5.2
4.1

2
1
2
14

214
17
214

12.8
5.2
12.4

1.6
1.7
1.6

3.5
3.0
2.6
55.1

.80

Note. See Table 2 Note. The TPRQ responses range from detrimental (scored as 1) to essential (scored as 7).

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TABLE 3
Variable Profiles for a Three-Cluster Solution
Mean Z Scores

Cluster Variable
Cravings can be reduced with conditioning strategies
There exists an addictive personality type
Clients need humility in recovery
Clients lie about their substance use
Clients must accept disease concept and commit to AA/NA
Teaching coping skills is important
It is necessary to treat clients families
Clients need help developing better relationships
Recovering addicts are the best counselors
Some clients wind up using without problems
Best way to help clients is to listen
Coexisting psychological problems should be treated
Clients are immoral
Lack of spirituality causes addiction
Greater use increases probability of dependence
Client compliance increases likelihood of recovery
Social environment is a determinant of addiction
Counseling should increase client self-efficacy
Clients are responsible for change and maintenance of recovery
Blackouts indicate substance dependence
Psychotropic medication is useful
Abuse can be differentiated from dependence
Some clients benefit from alternative therapies
Addicts have a physiological susceptibility
Most clients relapse after treatment
Client motivation depends on counselor skill
Most clients recover and live normal lives
Treatment should be individualized

F Test

Uniform
Counselors
(n = 192)

Multiform
Counselors
(n = 100)

Client-Directed
Counselors
(n = 51)

F Value

0.30
0.09
0.02
0.13
0.02
0.22
0.23
0.26
0.10
0.18
0.18
0.12
0.04
0.10
0.04
0.01
0.13
0.20
0.14
0.15
0.02
0.07
0.02
0.14
0.09
0.06
0.09
0.04

0.73
0.46
0.36
0.23
0.33
0.55
0.49
0.43
0.06
0.03
0.03
0.05
0.34
0.16
0.33
0.24
0.36
0.26
0.27
0.02
0.16
0.31
0.20
0.01
0.16
0.18
0.09
0.11

0.20
0.73
0.87
0.88
0.80
0.13
0.05
0.21
0.70
0.65
0.57
0.62
0.39
0.56
0.41
0.52
0.18
0.17
0.03
0.40
0.41
0.11
0.31
0.29
0.00
0.01
0.16
0.17

49.38
31.65
29.66
27.96
26.81
26.07
19.71
17.98
14.90
14.63
12.51
12.37
10.94
10.84
10.83
10.61
10.14
8.74
6.70
6.37
6.16
5.14
4.78
4.41
1.99
1.96
1.87
1.36

.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.0001
.001
.002
.002
.003
.01
.01
.02
ns
ns
ns
ns

Note. Positive Z scores indicate values above the total sample mean. Variable names are abbreviated labels for questionnaire items or composite
factor scores.

about addiction was revealed by relatively low scores on such

variables as (1) Some clients wind up using without problems, (2) Best way to help clients is to listen, and (3) Coexisting psychological problems should be treated.
A second group, comprising 100 respondents (29%), was
labeled multiform counselors. They are characterized by
endorsement of a broad range of beliefs about the nature of
addiction and its treatment (see Table 3). They seem
enthusiastic about both disease model and psychosocial
concepts. They strongly support the use of conditioning
strategies to reduce cravings, teaching coping skills, treating
families, offering assistance with improving relationships, and
enhancing self-efficacy. Yet, of the three groups, multiform
counselors were also the most likely to agree that Clients lie
about their substance use and Clients are immoral. These
incongruencies suggest a lack of critical thinking about the
problems they see in their work with clients.
The third group, labeled client-directed (n = 51 or 15%),
shows numerous extreme positive and negative views on
the nature of addiction and its treatment. Their profile suggests that compared with the other groups, they are the
most likely to recognize heterogeneity among clients and
consider counselor listening to be an essential aspect of treatment. As seen in Table 3, the client-directed counselors tend

454

to agree that (1) Some clients wind up using without problems, (2) The best way to help clients is to listen, and (3)
Coexisting psychological problems should be treated. This
group strongly rejects the addictive personality concept and
moralistic notions (e.g., Clients lie about substance use).
Client-directed counselors also reported that they do not
insist that clients accept the disease concept and commit to
AA. Overall, client-directed counselors seemed more focused
on clients needs than on specific treatment modalities.
Validation of the Three-Cluster Solution
According to Aldenderfer and Blashfield (1984), a sound
method for validating a cluster solution is to conduct significance tests that compare clusters on variables not used in
the clustering procedure. Thus, we performed a multiple
discriminant function analysis of the three cluster groups to
determine how these groups differed on a variety of measures assessing professional credentials, employment, reliance
on specific psychotherapies, and demographic characteristics.
After a listwise deletion of 114 cases with missing values,
292 cases were used in the analysis. A total of 27 discriminating variables were entered simultaneously into the analysis.
As Table 4 shows, two statistically significant functions

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TABLE 4
Multiple Discriminant Analysis of Three Chemical Dependency Counselor Groups
Means and Structure Coefficients
Discriminating Variable (Range)
CCDC certification level (13)
Caucasian (versus other)
Confidence in DSM-IV knowledge (15)
African American (versus other)
Academic attainment (15)
Provider of outpatient services (no/yes)
Intention to seek degree or working on degree (no/yes)
Counselor license/certification (no/yes)
Reliance on existential/humanistic concepts (110)
Work exclusively with dual diagnosis clients (no/yes)

Uniform M

Multiform M

Client-Directed M

Function 1

Function 2

2.36

1.94

2.66

3.77

3.46

4.34

3.26

3.03

3.85

7.16

6.39

5.57

.543
.506
.477
.474
.452
.362
.346
.324
.111
.025

.141
.203
.106
.081
.181
.014
.173
.052
.509
.332

10.29
64.98
0.47
0.67
110.72
54
.001

20.16
35.02
0.37
0.86
40.22
26
.04

Function Characteristics
Eigenvalue
Canonical correlation
Wilkss lambda
Percentage of variance
Chi-square
df
p

Note. CCDC = certified chemical dependency counselor. The following discriminating variables had structure coefficients < .248 on both functions: 1 = years of work experience in the field; 2 = status as clinical supervisor or director/administrator; 3 = employed in nonmedical residential
setting; 4 = employed in medical residential setting; 5 = employed in corrections setting; 6 = employed in other settings; 7 = age; 8 = sex; 9 =
recovery status; 10 = annual salary; 11 = licensed as a social worker; 12 = licensed as a psychologist; 13 = reliance on Adlerian concepts; 14
= reliance on disease and model concepts; 15 = reliance on cognitive-behavioral concepts; 16 = reliance on solution-focused concepts; 17 =
reliance on other therapy concepts.

emerged from the analysis. An examination of the group centroids (not shown) revealed that Function 1 clearly separated
the multiform counselors from the client-directed counselors, whereas Function 2 distinguished the uniform counselors from the client-directed counselors.
The cluster group means and structure coefficients of the
10 effective discriminating variables appear in Table 4. The
remaining 17 variables had structure coefficients less than
.248 and thus were judged to be relatively unimportant to
the discriminant solution (a list of these variables appears
in Table 4). An examination of the structure coefficients
shows that 8 variables accounted for a substantial amount
of the variance in Function 1. Thus, compared with the
multiform counselors, the client-directed counselors (1)
were more likely to possess a higher CCDC certification,
(2) were more likely to be Caucasian, (3) had greater confidence in their knowledge of DSM-IV criteria, (4) were
less likely to be African American, (5) were more likely to
hold a higher academic degree, (6) were more likely to provide outpatient services, (7) were less likely to intend to
seek a higher degree or to be working on a degree, and (8)
were more likely to be a state licensed or nationally certified
counselor. There were only 2 variables that had substantial
associations with Function 2. These structure coefficients
indicated that client-directed counselors were (1) more likely
to rely on existential and humanistic concepts and (2) less
likely to work exclusively with dual diagnosis clients, compared with the uniform counselors.
Overall, the 27 discriminating variables correctly classified 64.4% of the respondents into the three cluster groups.

The variables were most effective in correctly classifying

the uniform counselors (83.1%) and least effective in classifying the client-directed counselors (34.0%). Both the
multiform and the client-directed counselors were most
likely to be misclassified as uniform counselors, indicating
that these two groups were not well defined by the discriminating variables assessed in the study.
Cross-Tabulation of Cluster Groups by CCDC
Certification Level
To closely inspect the relationship between cluster group
membership and CCDC certification level, the 343 cluster
analyzed cases were cross-tabulated (2 = 29.55, df = 4, p <
.00001). In the uniform counselor group, 116 of 192 cases
(60.4%) were CCDC IIIs. The multiform counselors were
overrepresented by registered candidates (42 of 100 cases),
and in the client-directed group, 40 of 51 counselors (78.4%)
were CCDC IIIs.

DISCUSSION
Interpretation of the findings must be qualified by the limitations of the data collection procedures. The investigation
relied on a self-report mail survey in one state that yielded
a 32.2% response rate. Therefore, there is some uncertainty
about the representativeness of the sample. However, as
noted earlier, the rate of response compares favorably with
other mail surveys of this population (Morgenstern &
McCrady, 1992; Moyers & Miller, 1993), and the demo-

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Thombs and Osborn

graphic characteristics of the sample are similar to those

reported in other published studies (Culbreth & Borders,
1999; Leavy, 1991; Moyers & Miller, 1993; Osborn, 1997).
Furthermore, a recent review of survey sampling methods
suggests that low response rate does not necessarily introduce nonresponse bias (Krosnick, 1999). Among the general public, major reasons for nonresponse have become
lack of free time and long work hours. These reasons do not
necessarily produce sampling errors (Krosnick, 1999).
The findings of this study challenge the description, or
perhaps stereotype, of chemical dependency counselors as a
monolithic group strident in its advocacy for the disease
model and closed to other treatment options. It is noteworthy that counselors in recovery were not concentrated in
any particular cluster group. The present study does find that
the largest cluster group within the sample, the uniform counselors (56% of the total sample), comes close to fitting formulaic descriptions. However, there were other groups that
seemed to be more invested in processes that deviate from
the traditional disease conception of treatment. Although
not rejecting the disease model, the smallest group, the client-directed counselors (15%), indicated that they did not
insist that clients work within this framework.
The cluster variable profiles, combined with the discriminant analysis results, indicate that a chemical dependency
counselor typology can be constructed based on clinical orientation. The responses of uniform and multiform counselors suggest that they analyze client information in opposite
ways. On the basis of a few addiction counseling concepts,
uniform counselors seemed to reduce clinical information.
For example, even though the uniform counselors were the
cluster group most likely to work exclusively with dual diagnosis clients, they were less likely than client-directed counselors to rate the treatment of coexisting psychopathology as
essential. In contrast, counselors in the multiform group
seemed willing to accept large amounts of client information
to formulate clinical impressions based on concepts that
sometimes seemed incongruous. For example, multiform
counselors were likely to endorse the use of conditioning
strategies to reduce cravings and the teaching of coping skills
but also tended to believe in the existence of an addictive
personality type, that clients lie about their use, and that
clients are immoral. In addition, multiform counselors
endorsed the statement that Addiction is a bad habit as well
as the concept that Clients need to accept the disease concept of addiction and commit to a self-help program. Their
strong endorsement of moral, disease, and psychosocial concepts could be construed to represent a less than thoughtful
or a laypersons understanding of addiction and its treatment.
Such views may be partially attributed to inexperience; the
multiform clinical orientation was most concentrated
among those registered as candidates for chemical dependency counselor certification. However, the majority (58%)
were certified at the CCDC I/II and III levels.
The responses of the client-directed counselors suggest that
they apply a higher level of critical thinking to the
conceptualization of client problems. In general, features that

456

distinguished the client-directed counselors from the other

groups were (a) recognition of heterogeneity in their clients,
(b) viewing listening as important to the therapeutic relationship, (c) lessened emphasis on disease and AA concepts,
(d) recognition of psychopathology, (e) a higher level of professional certification and academic preparation, (f) being a
provider of outpatient services, and (g) racial status. The
independent influence of racial status was not anticipated
and cannot be explained within the parameters of the present
study. Before drawing conclusions about race and clinical
orientation, this particular finding must be replicated.
It is interesting that the client-directed counselor profile is
consistent with the depiction of the typical outpatient alcoholism professional that Yalisove (1998) described in a
historical review of the disease conception of treatment. From
the 1940s through the 1960s, practitioners in outpatient
settings were mental health professionals (rather than recovering paraprofessionals) whose primary treatment modality
was psychotherapy and who regarded alcoholism as a symptom of a psychiatric disorder. Similar to the client-directed
counselors identified in this study, these practitioners were
not strongly committed to the disease conception of treatment but were willing to collaborate with AA. Furthermore,
they were graduate trained and used a variety of treatment
processes.
During the 1970s and 1980s, Yalisove (1998) noted that
two developments led to the supplanting of the psychiatric
model in outpatient alcoholism treatment settings. First, in
the 1970s, state regulatory agencies began exerting control
over treatment agencies. Then, in the 1980s, the enhancement of counselor certification processes further solidified
the dominance of the disease concept. Ironically, current
managed care pressures to increase standards for counselor
certification and licensure (see Deitch & Carleton, 1997)
may encourage a return to models that are in some ways
similar to those of the 1960s. An expansion in the number
of client-directed counselors may be expected because most
treatment is provided on an outpatient basis by graduatetrained (and licensed) practitioners.
The discriminant functions that distinguished among
types of chemical dependency counselors were most strongly
associated with certification and licensure, academic attainment, race, and confidence in ones DSM-IV knowledge. It is
important to note that many professional and personal variables did not effectively distinguish among the counselor
groups, including their recovery status, number years of work
experience in the field, status as a supervisor, age, and sex.
Thus, clinical orientation is not related to these variables.
If it is assumed that client-directed counselors are more likely
to engage in best practices than other types of counselors,
then these data strongly support strengthening graduate-level
academic programming for counselors (see Stein & Lambert,
1995) and further development of credentialing requirements
(Page, Bailey, Barker, & Clawson, 1995). Unfortunately, a
recent review of counseling programs accredited by the
Council for Accreditation of Counseling and Related Educational Programs (CACREP) indicates that only 30% of

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programs require a course in substance abuse counseling,

with 77% offering an elective in this area (Morgan, Toloczko,
& Comly, 1997). This level of academic programming seems
inadequate when juxtaposed with the costs associated with
alcohol and drug abuse. In 1992, the estimated economic
costs of alcohol and other drug abuse in the U.S. reached
$249 billion (Center for Substance Abuse Treatment, 1998b).
Furthermore, there is considerable evidence that substance
abuse treatment not only produces a variety of positive
client outcomes but is cost-effective as well (Center for
Substance Abuse Treatment, 1997).
The methods used in this study preclude interpreting the
counselor types as stages of professional development. However, the findings do raise provocative questions for chemical dependency counselor training initiatives. The most basic question may be, Do the counselor types represent stages
or are they simply static states? More needs to be known
about the conditions that might influence movement from
one type to another and the timing of such a change (preservice education vs. in-service training). For instance, is the
multiform orientation usually an initial, transitory state upon
entering the field? If so, does shifting to a uniform orientation represent an attempt to manage the conflicting views
and ambiguous information that are generated in complex
organizations (see Glassman, 1995)?
Although more research is needed to confirm the cluster
pattern identified in this investigation, the typology of
chemical dependency counselors could contribute to emerging models that seek to explain innovation in the addictions treatment system (see Backer et al., 1995). Counselor
types may vary in their openness to new clinical practices,
especially those that are psychosocial in nature and those
that deal with coexisting psychopathology in clients.
Rogerss (1995) diffusion model characterizes early innovators as coping better with uncertainty, able to deal with
abstractions, and applying new information to their own
setting. Innovators also are likely to have more formal education and be exposed to other change agents. In this study,
the profile of uniform counselors suggests they may be the
least likely group to adopt new clinical strategies, whereas
multiform counselors could be prone to being overly enthusiastic about any new, and possibly untested, modality.
The processes by which client-directed counselors incorporate change in their practice may be more complicated.
Future research should track a cohort of counselors over
time, beginning with their entry into the field, to examine
these hypotheses.
The results of this study seem to support intensive inservice training of substance abuse counselors. These professionals practice in an increasingly challenging clinical environment. Training that specifically introduces alternative perspectives to traditional understandings of addiction and offers
a menu of appropriate treatment interventions will encourage
critical thinking and will equip practitioners to work effectively with a diverse clientele presenting complex issues.
Educational initiatives based on a readiness for change model
(Prochaska, DiClemente, & Norcross, 1992) that include a

motivation enhancement approach (Center for Substance Abuse

Treatment, 1999; Miller & Rollnick, 1991) provide practical,
client-focused strategies for assisting individuals with substance
abuse problems.

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