counseling attaractiveness

1. 2013
http://informahealthcare.com/ada
ISSN: 0095-2990 (print), 1097-9891 (electronic)
Am J Drug Alcohol Abuse, 2013; 39(5): 298–303
! 2013 Informa Healthcare USA, Inc. DOI: 10.3109/00952990.2012.694522
REGULAR ARTICLE
The impact of twelve-step program familiarity and its in-session
discussion on counselor credibility
Cory B. Dennis, MSW, Brian D. Roland, PhD, and Barry Loneck, PhD
School of Social Welfare, University at Albany, State University of New York, Albany, NY, USA
Background and Objective: The therapeutic relationship is an important factor in substance
abuse treatment. Because Twelve-Step Program (TSP) concepts and principles are often
incorporated into substance abuse treatment, we investigated whether counselor familiarity
and time spent on TSPs impact counselor credibility. Method: A sample of 180 clients receiving
residential treatment in the capital region of a northeastern state in 2009 completed a Client
Demographic Questionnaire and the Counselor Rating Form - Short Version. Their counselors
(N ¼ 31) completed a corresponding Counselor Demographic Questionnaire. Results: The effect
of the estimated percentage of in-session time discussing TSPs (p ¼ .010) and the effect of TSP
familiarity for counselors in recovery (p ¼ .017) had significant effects on counselor credibility.
Conclusions and Scientific Significance: The credibility of counselors is important for a working
relationship with clients. These results highlight counselor influence stemming from a TSP
presence in treatment, indicating positive ramifications for the therapeutic relationship.
Keywords
Twelve-Step Programs, therapeutic
relationship, counselor credibility,
interpersonal influence theory, treatment,
History
Received 18 October 2011
Revised 21 March 2012
Accepted 21 March 2012
Published online 14 August 2013
INTRODUCTION
It is well established in the general treatment literature that
the therapeutic relationship is related to positive outcomes
(1) and this holds true when treating substance use disorders
(2–6). Although various therapeutic models may have
equivalent effects (7), it is common in the treatment of
substance use disorders for providers to incorporate Twelve-
Step Program (TSP) concepts and principles into their
approach (8), and several studies have found an association
between TSP participation and positive outcomes (9–14).
Because of the pervasiveness of TSPs in substance abuse
treatment, because of the link between TSP participation and
positive outcomes, and because of the link between the
therapeutic relationship and positive outcomes, it is important
to know what impact a counselor’s savvy with TSPs has on
the therapeutic relationship. Stated more specifically, it is
important to determine what effect counselor familiarity with
TSPs and time spent discussing TSPs has on client perception
of counselor credibility. This study explores that link.
Interpersonal Influence Theory
Counselor credibility is an important concept in the thera-
peutic relationship and one approach to understanding it is
Interpersonal Influence Theory (IIT) (15). This theory posits
that credibility gives counselors the power to influence the
change process with clients. Three elements are important to
understanding credibility: expertness, trustworthiness, and
attractiveness (i.e., similarity in background). Expertness is
evidence of a counselor’s ability to work with a client,
whether conveyed through the type of training the counselor
received, the counselor’s perceived amount of knowledge, or
simply his or her reputation. Similarly, trustworthiness is
conveyed through a counselor’s openness, honesty, role, and
genuineness. Finally, attractiveness is based on the likability
of a counselor, and can be shaped, in part, by the similarity in
background to a client.
Within the framework of IIT, credibility is the critical
concept by which counselors influence their clients in making
healthy changes. More specifically, counselors who are
perceived as credible have the power to influence their
clients, and this influence has important ramifications. Across
disciplines (e.g., psychiatry, social work, and psychology), the
level of a referral source’s credibility has a strong correlation
with the level of their effectiveness in making a referral (16).
Perceptions of counselor credibility can shape treatment
preferences (17) and affect therapeutic outcomes (17,18). An
initial study within substance abuse treatment found client
perceptions of counselor expertness and attractiveness (i.e.,
elements of credibility) influence their rating of the working
alliance (19). Thus, credibility is worthy of consideration.
Given the prevalence of TSP concepts and principles in the
treatment arena as well as their impact on treatment
outcomes, IIT indicates that substance abuse counselors’
Address correspondence to Cory B. Dennis, MSW, School of Social
Welfare, University at Albany, State University of New York, Albany,
NY, USA. E-mail: cbdnns@gmail.com

2. credibility is predicated upon expertness, trustworthiness, and
attractiveness with respect to TSPs. Here, expertness is
conveyed through knowledge of TSP concepts and principles,
trustworthiness is evident through a genuine valuing of TSP
concepts and principles, and attractiveness is based on either a
shared background with a counselor who participates in TSPs
or, more generally, likability based on an expressed enthusi-
asm for TSP concepts and principles.
However, counselor credibility with respect to TSP con-
cepts and principles may depend on two common-sense
notions: a counselor must be familiar with TSPs, and he or
she must spend time discussing TSPs during treatment
sessions. Thus, this investigation tested the following
hypotheses.
(1) Familiarity with the TSP approach is positively related to
the perceived credibility of counselors.
(2) The time spent discussing TSP-related information is
positively related to the perceived credibility of
counselors.
The independent variables were familiarity and time in
session, whereas the dependent variable was counselor
credibility. Counselors’ background such as education and
length of experience are important variables given their role
in client perceptions of addiction counselors (20). In addition,
counselor recovery status can be influential in the treatment
process (21), and with many counselors in recovery from a
substance use disorder, and by extension, having personal
experience in a TSP, recovery status is likely to have a
moderating effect on the hypotheses above. Therefore, a third
hypothesis was tested:
(1) Counselor recovery status moderates the effects of
familiarity and time spent on the perceived credibility
of counselors.
In summary, we posited that counselor TSP familiarity and
TSP time in-session is positively associated with counselor
credibility; in turn, research has established that credibility is
positively associated with working alliance, which, in turn, is
associated with positive treatment outcomes. This investiga-
tion tested that critical first link in this causal chain. It is
particularly important because counselors have direct control
over their familiarity with TSPs and over the amount of in-
session time spent on TSP concepts and principles; because
both, in turn, may be influenced by recovery status, its
moderating effect was also tested.
METHODS
Participants
The sample consisted of 180 clients and 31 counselors and
the distribution of demographic variables are presented in
Table 1. Client refusal rate was not collected in an effort to
reinforce the voluntary and anonymous nature of participation
(i.e., participation would be inconsequential to their treat-
ment); however, one counselor did refuse to participate. These
participants were recruited from eight residential treatment
facilities in upstate New York. Of the client-participants,
145 (80.6%) were male. The majority (22.8%) were between
18 and 24 years of age, followed by those who were 25–29
years (20.6%) and 30–34 years (18.9%). Most of the
participants were White (70%), followed by Black (17.8%)
and Hispanic (7.8%), with one (.6%) Asian-Pacific Islander
and (.6%) Native American; six (3.3%) responded as other.
Additional information was collected from 101 clients
who consented to the extraction of clinical information
(e.g., substance of choice) from their treatment files. Of these,
the mean number of substances abused was 2.12 (SD ¼ .87).
Alcohol was the most common primary substance of use at
48.5% (n ¼ 48), followed by heroin at 19.2% (n ¼ 19) and
marijuana/hashish and crack, each at 10% (n ¼ 10).
Marijuana/hashish was the most common secondary sub-
stance at 22.2% (n ¼ 16) and the most common tertiary
substance at 33.3% (n ¼ 15). Fifty-seven reported using
tobacco. The mean number of treatment episodes for clients
(n ¼ 101) was 3.1 (SD ¼ 1.52).
Of the 31 counselors, 20 (64.5%) were female. Nearly 23%
were between the ages of 30 and 34, whereas those between
the ages of 25 and 29 as well as between the ages of 45 and 49
both comprised approximately 19% of the sample. The
majority of the counselors were White (67.7%), followed by
Black (25.8%), with one (3.2%) Asian-Pacific Islander and
one (3.2%) Hispanic. Approximately 45% were Credentialed
Alcoholism and Substance Abuse Counselors (CASAC).
Of participants without a CASAC, one (7.1%) was a
detoxification therapist and one (7.1%) was a social worker,
and the rest are unknown. Approximately half (51.6%)
reported being in recovery. In terms of level of education,
nearly 36% of counselors had a master’s degree, about 23%
had a bachelor’s degree, approximately 19% had an
Table 1. Client and counselor characteristics.
Clients (N ¼ 180) Counselors (N ¼ 31)
Characteristic n % n %
Male 145 80.6 11 35.5
Age
18–24 41 22.8 2 6.5
25–29 37 20.6 6 19.4
30–34 34 18.9 7 22.6
35–39 19 10.6 1 3.2
40–44 24 13.3 3 9.7
45–49 17 9.4 6 19.4
50–54 7 3.9 2 6.5
55–59 1 .6 2 6.5
60–64 – – 2 6.5
Race
White 126 70 21 67.8
Black 32 17.8 8 25.8
Hispanic 14 7.8 1 3.2
Asian-Pacific Islander 1 0.6 1 3.2
Native American 1 0.6 – –
Other 6 3.3 – –
Recovery status
Yes – – 16 51.6
Education
Some high school 39 21.7 – –
High school 11811
65.61
6 19.4
Associates 21 11.7 6 19.4
Bachelor’s 2 1.1 7 22.6
Master’s – – 11 35.5
Doctorate – – 1 3.2
Experience in months
Mean (SD) – – 71.77 (68.04)
1
Includes General Equivalency Diploma (GED).
DOI: 10.3109/00952990.2012.694522 Twelve-Step Familiarity and Counselor Credibility 299

3. associate’s degree, and about 19% had a high school diploma,
with only one having a doctoral degree. Experience in
substance abuse treatment reported by counselors ranged
from 4 months to 20 years, with the middle 50% from
18 months to 11 years; the mean length of experience was just
under 6 years, and the median length was 4 years.
Measures
Three instruments were used to collect data. A Client
Demographic Questionnaire (ClDQ) and a Counselor
Demographic Questionnaire (CoDQ) were developed by the
authors. In addition to client demographic variables (e.g., race
and age), the CoDQ included perceived counselor familiarity
with TSPs and perceived time spent on TSPs. Likewise, in
addition to counselor demographic variables, the CoDQ
included recovery status, education, and experience. The
Counselor Rating Form - Short Version (CRF-S) (22) was
used to measure counselor credibility. The description of the
variables is given below.
Recovery Status
Counselors were asked whether they were in recovery from a
substance use disorder. This was scored on a binary scale.
In-Session Time on TSPs
Clients were asked to estimate the percentage of in-session
time, on average, they thought was spent discussing TSP-
related information.
Familiarity with TSPs
Clients were asked to rate counselor familiarity with TSP
concepts and principles using a Likert scale. Responses
ranged from not at all familiar (þ1) through somewhat
familiar (þ3) to very familiar (þ5).
Credibility
Clients completed the CRF-S (22). The CRF-S consists of
12 items, reduced from the 36 items in the long version
(23). Although there may be some inconsistency between
these versions, the CRF-S has the advantage of demanding
less time and a lower required comprehension level (24), and
was thus selected for this study. Confirmatory factor analysis
has been used to demonstrate the validity of the CRF-S
(22,25). This instrument measures clients’ perception of
counselor expertness, trustworthiness, and attractiveness as
factors of credibility, with total score indicating overall
credibility (25). Reliabilities measured with Cronbach’s alpha
for expertness, trustworthiness, attractiveness, and total score
for this sample were .92, .91, .89, and .92, respectively. These
levels are comparable to those reported by Tracey et al. (25)
of .93, .92, .92, and .95, respectively. Given the preliminary
nature of this investigation, we utilized only total score in our
analysis.
Education and Experience
Counselor education was assessed with a categorical variable
and ranged from Some High School to Ph.D./M.D.
With regard to experience, counselors were asked to
report the number of years and months of substance abuse
counseling experience.
Procedure
Upon approval of the institutional review board, agency
directors in the capital region of New York were contacted for
permission to recruit participants at their site. Once permis-
sion was granted, clients were gathered into a room, informed
of the study, made aware that participation was anonymous
and voluntary, and provided a survey packet if they consented
to participate. Those who chose to complete the survey were
offered five stamped envelopes as compensation. Counselors
were recruited separately from clients, and consented to
participate on a voluntary basis. They were not offered
compensation. All questionnaires and forms were distributed,
completed, and collected on-site. It should be noted that
counselors did not have access to client responses, clients did
not have access to counselor responses, and facility directors
did not have access to either counselor or client responses.
Data Analysis
Because clients are clustered within counselors and the
group difference by recovery status was highlighted, a
population-averaged model was used to test the effects of
TSP familiarity and in-session time on counselor credibility.
The moderating effect of counselor recovery status was also
included in the model.
RESULTS
The number of clients per counselor ranged from 1 to 13, with
an average of 5.6. However, given the statistical model and
assuming independent observations, counselors with only one
client participating (n ¼ 3) were combined to form a pseudo-
counselor, resulting in an average of six clients per counselor,
ranging from 2 to 13. Among all clients (N ¼ 180), the
majority perceived their counselors as familiar with TSPs.
In fact, 42% indicated very familiar, 29% mostly familiar (the
median), and 22% as somewhat familiar. Of the 11 (6.1%)
clients (one did not respond) who perceived their counselor as
unfamiliar, all but one was male and all but one of the
corresponding counselors was female. From the clients’
perspective, the mean percentage of time spent in-session
discussing TSP-related content was 28% (SD ¼ 26.04), with
an interquartile range of 10–50%. Five participants did not
respond to this item. The mean CRF-S total score was 70.23
(SD ¼ 11.99), with scores ranging from 26 to 84. Client and
counselor reports were not found to be statistically different
on levels of familiarity (2
¼ 14.69, df ¼ 8; p5.066) or the
percentage of time spent in-session discussing TSP material
(t ¼ À1.93; p5.056). However, the lack of statistical differ-
ence was marginal.
The coefficients in Table 2 show the effect offamiliarity
and time spent in-session on the extent to which counselors
were perceived as credible. For the model under investigation,
the average within-counselor correlation was À.0031.
Controlling for counselor characteristics (e.g., recovery
status, education, and experience), the effect of TSP
300 C. B. Dennis et al. Am J Drug Alcohol Abuse, 2013; 39(5): 298–303

4. familiarity on average was not significant for counselors not
in recovery; however, there was a significant interaction
effect, meaning that the effect of familiarity depended on
recovery status. Thus, the effect of perceived familiarity with
TSPs is on average 4.76 points (p ¼ .004) higher on the CRF-
S for counselors in recovery compared with those not in
recovery. Therefore, the CRF-S total score is on average 3.12
points (p ¼ .017) higher when familiarity increases by one
point for counselors in recovery. Time spent in-session
discussing TSP concepts and principles significantly effects
the credibility score by an average of .09 additional points
for each 1% increase (p ¼ .010) when controlling for coun-
selor characteristics. The interaction between recovery status
and time spent did not add to the model, and was therefore
dropped.
DISCUSSION
Familiarity with TSPs and in-session time devoted to them
were considered for their role in the perception of counselor
credibility, an important variable in the therapeutic relation-
ship. With the effect of familiarity with TSPs depending on
the recovery status of a counselor, clients expect recovering
counselors to have a higher level of familiarity, which, from
an IIT perspective, can lend to an attractiveness based on
similar backgrounds and to trustworthiness by demonstrating
congruence with TSP-related recommendations made to
clients. Similarly, non-recovering counselors may be held to
a different standard in that they may not be expected to be as
familiar, given they do not share this background with the
clients. Some familiarity may be important however, regard-
less ofrecov-ery status, given the statistically significant effect
of perceived time spent in-session. As such, counselors may
profit in making efforts to include TSP-related information in
their sessions regardless of recovery status, particularly if
clients are expected to attend TSP meetings as part of their
treatment plan. Doing this can lend additional credibility to
counselors, thereby increasing their extent of influence (15).
However, this is likely more pertinent for counselors working
in more orless TSP-orientedfacilities, as was the case in this
study, where a lack of in-session time devoted to TSP-related
material may conflict with clients’ experience of treatment as
a whole. Regardless, many clients naturally hold counselors to
different standards based on recovery status. Research con-
trasting how clients perceive nonrecovering counselors who
are clearly familiar with TSPs to those who clearly are not
familiar with such programs may be helpful for understanding
different expectations. Culbreth (21) found that recovery
status has a strong correlation with the process of treatment,
and the moderating role of recovery status in this study
provides more insight into the dynamics of the client-
counselor relationship.
For counselors who refer their clients to TSPs, being
familiar with and spending some in-session time on TSPs
would be important to the effectiveness of the referral. From
an IIT standpoint, counselors demonstrating this can exude a
sense of expertness and trustworthiness and thereby increase
their credibility and influence in making a referral. This is
important because research has indicated that treatment
providers can influence client participation in TSPs
(12,26,27), yet many clients do not follow through with
such referrals. One reason may be that some counselors lack
important information related to TSP participation (28). Thus,
by increasing their influence through TSP-based credibility,
counselors may be able to help clients participate in TSP soon
enough and long enough to realize the associated benefits
(29). As such, the possible connections between TSP famil-
iarity, time in-session allotted to TSPs, and TSP referrals are
important to consider in future studies.
The results of this study underscore the importance and
value of Twelve-Step Facilitation (TSF) therapy as a means
for counselors to establish TSP-based credibility in their work
with clients. The TSF approach is officially recognized as an
evidence-based practice (30). It is an active way to facilitate
client participation in TSPs (31) by integrating the 12-step
approach into treatment plans with the primary goals of
acceptance of powerlessness over addiction and surrender to a
power greater than self (e.g., the group, a deity) that will
support recovery, as contained in the first three steps of TSPs
(32,33). This approach is associated with improved drinking
outcomes (34), and because TSF leads to TSP participation
(12,34), it can counteract the influence of networks that
support drinking (12,35). Thus, making use of TSF is a
sensible approach for gaining familiarity with TSPs and
provides guidance for effectively discussing TSPs in-session
and for making referrals.
The results of this study are limited by the structure of the
sample as clients were mostly male and white, and were
receiving treatment in facilities that incorporate TSPs on at
least some level. Beyond the CASAC, licensure was not
captured for many counselors, and for those without a
CASAC, 11 did not have a graduate degree. Thus, counselors
in the study may have functioned in differing capacities. In
addition, the self-reported nature of participant responses may
introduce bias into the results. Although participation was
voluntary, some client-participants may also have haphazardly
completed the questionnaires in order to obtain the promised
compensation. Finally, the effect of counselor TSP familiarity
on counselor credibility was somewhat limited by the small
number of participants ranking their counselors low on the
familiarity scale. Furthermore, although TSP familiarity and
percentage of time were statistically similar between
Table 2. Recovery status, education, experience, TSP familiarity,
percent of in-session time, and the interaction between recovery status
and familiarity on the CRF-S using a population averaged model
(N ¼ 175).
Coefficients
b SE t
Constant 60.02 2.31 25.97 .000
Recovery status 1.10 1.86 .59 .553
Associates or bachelor’s 1.63 2.19 .74 .456
Master’ s or doctorate 7.26 2.36 3.08 .002
Experience (months) .07 .01 4.69 .000
Counselor TSP
familiarity, centered
À1.64 1.15 À1.43 .153
% of in-session time
on TSPs, centered
.09 .03 2.57 .010
Interaction between
recovery status and
familiarity, centered
4.76 1.66 2.87 .004
DOI: 10.3109/00952990.2012.694522 Twelve-Step Familiarity and Counselor Credibility 301

5. counselors and clients, their measurement was limited to
single items. Thus, developing sensitive measures of
counselor TSP familiarity and the amount of in-session time
would be beneficial.
CONCLUSION
The findings of the study highlight a beneficial way in which
TSP content can be integrated with substance abuse
treatment. Generally, clients have certain expectations of
counselors and the extent to which counselors meet these
expectations can affect their perceived level of credibility and,
thus, their level of influence. Including TSP material
in-session may have positive ramifications for the client-
counselor relationship, which would speak to the expectation
clients have of the role of TSPs in treatment. Consequently,
counselors, regardless of recovery status, should be prepared
to incorporate some of this material into sessions, as it can be
useful for establishing credibility with clients. Furthermore, it
is particularly important that counselors who are in recovery
demonstrate adequate familiarity with TSPs. TSF was
identified as an established approach for acquiring
TSP-based credibility. The influence obtained through
being perceived as credible was discussed in the context of
TSP referrals, which was identified as an important area for
future research.
Declaration of Interest
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of this
article.
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DOI: 10.3109/00952990.2012.694522 Twelve-Step Familiarity and Counselor Credibility 303

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