Journal of Studies on Alcohol, Vol. 40• No. 5• 1979
Attitudesof Paraprofessionals Toward Alcoholism;SettingEffects VictoriaBerger-Gross 2 and StephenLisman SVMMaaY. Paraprofessionals working in a residentialalcoholismtreatment program had significantl•tmore "custodial"attitudes and attitudes of "humanism"toward alcoholicsand beliefs concerninga psychological etiologyof alcoholismthan did paraprofessionals at a sobering-upstation.
Paraprofessionals are becoming increasinglyimportant in the treatment of mental illnessand, particularly,of alcoholism(1). Sowa and Cutter (2) have pointed out that the paraprofessionals' attitudes can have great impact on patients and their treatment program. Sterne and Pittman (3), for example, found that therapistswith moralistic attitudes toward alcoholismwere more pessimisticregarding recovery and viewed alcoholicsas poorly motivated,while therapistsexpressing illness-oriented attitudestoward alcoholismwere more optimistic.Similarly, Pattison (4) has concludedthat the effects of a particular treatment are largely determinedby interpersonalrelationships. Most studiesof paraprofessionals' attitudes have been carried out immediatelyfollowing training programsdesignedto modify these beliefs and attitudes,although attitudes measuredat this time may not be valid indicatorsof long-term attitudes (5). Another weaknessof many of thesestudiesis that the nature of the treatmentenvironment the caregivinggroup is working in is not defined. In addition to population variablessuchas age, race and socialclass,varioussettingeffects may also critically affect the attitudes and behavior of staff-that is, the quiet, relatively well-ordered atmosphereof the traditional 60-day inpatient treatment ward is quite different from that of either a detoxicationunit of a generalhospitalor a "sobering-up"station. In the present study the experimentalgroups are drawn from two different populationsof paraprofessionals. The two groups are similar in sex, age range, educationalbackgroundand social class,but one works with abstinent alcoholicsin a 10-week inpatient treatment program of a state hospital and the other handlesa large volume of in• From the State University of New York at Binghamton. aNew York University,6 WashingtonPlace, New York, New York 10003. ACKNOWLEDGMENT.--We thank Paul Berger-Grossfor his assistancein the preparation of this article.
Received for publication: 10 January 1978. Revision: 18 August 1978. 514
BRIEF REPORTS
515
toxicatedpeople at a local 24-hour sobering-upfacility. Qualitative differencesin exposureto alcoholics'behaviorin the two facilitiesmay influenceattitudestoward alcoholicsand their treatment.We predicted that the paraprofessionals at the state hospital would exhibit more lenient or humanisticattitudesthan would the staff of the sobering-up station,and that the former would be more likely to expressa belief in a psychologicaletiology of alcoholism. METHOD
Subiects.There were 12 paraprofessionals from the state hospital (SH) and 9 from the sobering-upstation (su). All were men and high-schooleducated (mean years of education,s•, 12.4; su, 12.9). Both groupswere predominantlyof socioeconomic statusV (6). They were comparablein mean age (SH, 44.4, range, 26--61; Su, 34, range, 24--57) and similar in racial composition(1 su man was Black). All had been employed in their present occupationfor at least 8 months. Persistentfollow-upsyielded almost maximal subject participation-12 of 12 at the state hospitaland 9 of 11 at the sobering-upstation.It was estimated by the directorsof each facility that about 80 to 85% of each group were recoveredalcoholics.Due to the sensitivityof the issuein both organizations, it was impossibleto obtain more specific identification of these counselors.
Attitude Scales.Three measurement deviceswere completedby eachsubject. The first, the Attitudes Toward Alcoholism Instrument (ATA) (7), is designedto measureattitudes about the etiology of alcoholismand treatment approachesand the degree of socialstigma or acceptance.It has six scales: "'PsychologicalEtiology,' which refers to statementsthat embracethe notion that the causeof alcoholismis psychological,i.e., emotionallybased, learned, etc.; 'Physical-GeneticEtiology' which applies to statementsthat propose the idea that alcoholismhas a physicalor inherited cause;'Moral Weakness' which consistsof assertionsembracingthe view that the alcoholichas weak morals or character;the 'Medical illness Model' categorywhich refers to propositionsarticulating the notion that the alcoholicis sick and that alcoholism should be treated as an illness; 'Humanism' which contains assertions supportinga kind, fair, and humanistictreatment of the alcoholic;and 'Social
Rejection'which refers to statementsthat support the view that alcoholics shouldbe avoided or rejected" (7, p. 224). The test-retestreliabilitiesof the instrumentover a period of 2 weeks ranged from .53 to .77 on the 6 component scales, the median Pearson product-momentcorrelationcoefficientbeing .71 (7). Social desirability,as measuredby the Marlowe-CrowneSocialDesirabilityScale (8), was found to have a negligibleeffect on mostresponses, especiallythosefrom men. The secondscale,the CustodialAttitude Inventory (cAt) (9), is designed to assessthe degree of "humanitarian" versus "custodial" attitudes toward alcoholicpatients. People who maintain a "custodial"attitude are defined
as thosewho feel that alcoholicsare incurableand shouldbe kept institu~ tionalized;the conceptof the "humanistic" attitudeis basedon the premise that alcoholismis a condition which requires treatment rather than moral sanction.The cAi has a significantlypositive correlationwith responses to
the F scaleof authoritarianism developedby Adorno et al. (10) and has been used with a variety of caretakinggroups.
516
JOURNALOF STUDIES ON ALCOHOL
The third measurewas designedto identify what treatmentsthe subjects would recommendfor alcoholics.Each subjectwas presentedwith 4 stories describingmale problemdrinkerswho vary along two dimensions: chronic vs acutedrinkinghistoryand low vs high socialclass.The subjectwas asked to select2 of 9 methods(11) that would be mostlikely to controlthis man's drinking behavior and whether an inpatient or outpatient treatment program would be preferable. ]•ESULTS
The SHgroupscoredsignificantly higheron two of the ATAscalesthan did the su group:the respective scoreson the "psychological etiology" scalewere 13.71vs 12.5 (t • 3.197, 19 dr, p • .05) and the scoreson the "humanism" scalewere 13.83vs 12.78 (t -- 2.636,19 dr, p • .05). The SHgroupalsohadhigherscoreson the CAI(59.25vs52.56;t --- 2.384, 19 dr, p • .05).
There were no significantdifferencesin the groups'responses to the casehistories.However,severaltrendsemerged.The sHgroupwasmore likely to recommendinpatientcare than was the sv group.Also,as was foundby Linsky (11) in his householdsurvey,"psychiatric or psychologicalhelp" and "medicaltreatment"were more frequentlychosenby both groupsthan were other treatmentapproaches. DISCUSSION
Severalaspectsof the paraprofessionals' attitude toward alcoholism appearto be relatedto situationalvariables.The differencein responses to the ATAhumanismscaleare consistentwith the hypothesisthat the staffof the sobering-up stationwouldhavelesstolerantattitudestoward alcoholicsthan would the paraprofessionals in the state hospital.The
latter alsoscoredhigheron the psychological etiologyscale,as would be expectedfrom the therapeuticsettingand purportedtreatmentphilosophy. The resultsof the CAIare not so easily explained.While Mendelson et al. assertthat the scaleis designedto assessthe degreeof "humanitarian" versus"custodial"therapeuticattitudes toward alcoholicpatients, the group from the state hospital scored significantlyhigher than did thosefrom the sobering-upstation.The scaleis a revisionof the Scale of Custodial Attitudes Toward Mental Illness, used with care-
taking groupsin an institutionalsetting,so that it is conceivablethat it is actuallytappingthe subjects'socialization into, and acceptance of, a generalstate hospitalphilosophyrather than basic interpersonalbe!iefs. Also, it is questionablewhether "humanitarian"and "custodial" attitudesare truly opposite endsof a unidimensional continuum. Further studyshouldbe madeof the CAIif it is to be profitablyutilized in any future
research
effort.
BRIEF REPORTS
517
REFERENCES
1. STARR,G. E. and KENT, L. M., eds. The paraprofessionalin the treatment of alcoholism;a new profession.Springfield, Ill.; Thomas; 1973. 2. SOWA,P. A. and CVTTER,H. S. Attitudes of hospital staff toward alcoholics and drug addicts. Q. J. Stud. Alcohol 35: 210-214, 1974. 3. STERNE,M. W. and PITTMAN, D. J. The concept of motivation; a source of institutionaland professionalblockagein the treatment of alcoholics.Q. J. Stud. Alcohol 26: 41-57, 1965. 4. PATT•SON,E. M. A critique of alcoholism treatment concepts; with special reference to abstinence.Q. J. Stud. Alcohol 27: 49-71, 1966. 5. Coo•a•, G., WE•-IMER,G. and GRtmER,J. Training paraprofessionalsin the treatmentof alcoholism;effectson knowledge,attitudesand therapeutictechnique. Q. J. Stud. Alcohol 36: 938-948, 1975. 6. HOLL•NGSnEAD, A. B. Two factor index of social position.New Haven, Conn.; 1957. [Mimeographed.] 7. TOLOR,A. and TAMEraN,J. S. The Attitudes toward AlcoholismInstrument; a measure of attitudes toward alcoholics and the nature and causes of al-
coholism.Br. J. Addiction 70: 223-231, 1975. 8. CROWNE,D. P. and MAimOWE,D. A new scaleof socialdesirabilityindependent of psychopathology. J. Consult. Psychol.24: 349-354, 1960. 9. MENDELSON,J. H., WEXLER, D., KUBANSKY,P. E., HARRISON,R., LEIDERMAN,
C. and SOLOMON, P. Physicians'attitudes toward alcoholicpatients. Archs Cen. Psychiat. 11: 392-399, 1964. 10. ADOR•O, T. W., FRENKEL-BRUNSWIK, E., LEViNSON,D. J. and SANFORD,R. N. The authoritarianpersonality.New York; Harper & Row; 1950. 11. L•NSK¾,A. S. Theories of behavior and the social control of alcoholism.Soc. Psychiat.,Ber]. 7: 47-52, 1972.
Attitudesof Paraprofessionals Toward Alcoholism;SettingEffects VictoriaBerger-Gross 2 and StephenLisman SVMMaaY. Paraprofessionals working in a residentialalcoholismtreatment program had significantl•tmore "custodial"attitudes and attitudes of "humanism"toward alcoholicsand beliefs concerninga psychological etiologyof alcoholismthan did paraprofessionals at a sobering-upstation.
Paraprofessionals are becoming increasinglyimportant in the treatment of mental illnessand, particularly,of alcoholism(1). Sowa and Cutter (2) have pointed out that the paraprofessionals' attitudes can have great impact on patients and their treatment program. Sterne and Pittman (3), for example, found that therapistswith moralistic attitudes toward alcoholismwere more pessimisticregarding recovery and viewed alcoholicsas poorly motivated,while therapistsexpressing illness-oriented attitudestoward alcoholismwere more optimistic.Similarly, Pattison (4) has concludedthat the effects of a particular treatment are largely determinedby interpersonalrelationships. Most studiesof paraprofessionals' attitudes have been carried out immediatelyfollowing training programsdesignedto modify these beliefs and attitudes,although attitudes measuredat this time may not be valid indicatorsof long-term attitudes (5). Another weaknessof many of thesestudiesis that the nature of the treatmentenvironment the caregivinggroup is working in is not defined. In addition to population variablessuchas age, race and socialclass,varioussettingeffects may also critically affect the attitudes and behavior of staff-that is, the quiet, relatively well-ordered atmosphereof the traditional 60-day inpatient treatment ward is quite different from that of either a detoxicationunit of a generalhospitalor a "sobering-up"station. In the present study the experimentalgroups are drawn from two different populationsof paraprofessionals. The two groups are similar in sex, age range, educationalbackgroundand social class,but one works with abstinent alcoholicsin a 10-week inpatient treatment program of a state hospital and the other handlesa large volume of in• From the State University of New York at Binghamton. aNew York University,6 WashingtonPlace, New York, New York 10003. ACKNOWLEDGMENT.--We thank Paul Berger-Grossfor his assistancein the preparation of this article.
Received for publication: 10 January 1978. Revision: 18 August 1978. 514
BRIEF REPORTS
515
toxicatedpeople at a local 24-hour sobering-upfacility. Qualitative differencesin exposureto alcoholics'behaviorin the two facilitiesmay influenceattitudestoward alcoholicsand their treatment.We predicted that the paraprofessionals at the state hospital would exhibit more lenient or humanisticattitudesthan would the staff of the sobering-up station,and that the former would be more likely to expressa belief in a psychologicaletiology of alcoholism. METHOD
Subiects.There were 12 paraprofessionals from the state hospital (SH) and 9 from the sobering-upstation (su). All were men and high-schooleducated (mean years of education,s•, 12.4; su, 12.9). Both groupswere predominantlyof socioeconomic statusV (6). They were comparablein mean age (SH, 44.4, range, 26--61; Su, 34, range, 24--57) and similar in racial composition(1 su man was Black). All had been employed in their present occupationfor at least 8 months. Persistentfollow-upsyielded almost maximal subject participation-12 of 12 at the state hospitaland 9 of 11 at the sobering-upstation.It was estimated by the directorsof each facility that about 80 to 85% of each group were recoveredalcoholics.Due to the sensitivityof the issuein both organizations, it was impossibleto obtain more specific identification of these counselors.
Attitude Scales.Three measurement deviceswere completedby eachsubject. The first, the Attitudes Toward Alcoholism Instrument (ATA) (7), is designedto measureattitudes about the etiology of alcoholismand treatment approachesand the degree of socialstigma or acceptance.It has six scales: "'PsychologicalEtiology,' which refers to statementsthat embracethe notion that the causeof alcoholismis psychological,i.e., emotionallybased, learned, etc.; 'Physical-GeneticEtiology' which applies to statementsthat propose the idea that alcoholismhas a physicalor inherited cause;'Moral Weakness' which consistsof assertionsembracingthe view that the alcoholichas weak morals or character;the 'Medical illness Model' categorywhich refers to propositionsarticulating the notion that the alcoholicis sick and that alcoholism should be treated as an illness; 'Humanism' which contains assertions supportinga kind, fair, and humanistictreatment of the alcoholic;and 'Social
Rejection'which refers to statementsthat support the view that alcoholics shouldbe avoided or rejected" (7, p. 224). The test-retestreliabilitiesof the instrumentover a period of 2 weeks ranged from .53 to .77 on the 6 component scales, the median Pearson product-momentcorrelationcoefficientbeing .71 (7). Social desirability,as measuredby the Marlowe-CrowneSocialDesirabilityScale (8), was found to have a negligibleeffect on mostresponses, especiallythosefrom men. The secondscale,the CustodialAttitude Inventory (cAt) (9), is designed to assessthe degree of "humanitarian" versus "custodial" attitudes toward alcoholicpatients. People who maintain a "custodial"attitude are defined
as thosewho feel that alcoholicsare incurableand shouldbe kept institu~ tionalized;the conceptof the "humanistic" attitudeis basedon the premise that alcoholismis a condition which requires treatment rather than moral sanction.The cAi has a significantlypositive correlationwith responses to
the F scaleof authoritarianism developedby Adorno et al. (10) and has been used with a variety of caretakinggroups.
516
JOURNALOF STUDIES ON ALCOHOL
The third measurewas designedto identify what treatmentsthe subjects would recommendfor alcoholics.Each subjectwas presentedwith 4 stories describingmale problemdrinkerswho vary along two dimensions: chronic vs acutedrinkinghistoryand low vs high socialclass.The subjectwas asked to select2 of 9 methods(11) that would be mostlikely to controlthis man's drinking behavior and whether an inpatient or outpatient treatment program would be preferable. ]•ESULTS
The SHgroupscoredsignificantly higheron two of the ATAscalesthan did the su group:the respective scoreson the "psychological etiology" scalewere 13.71vs 12.5 (t • 3.197, 19 dr, p • .05) and the scoreson the "humanism" scalewere 13.83vs 12.78 (t -- 2.636,19 dr, p • .05). The SHgroupalsohadhigherscoreson the CAI(59.25vs52.56;t --- 2.384, 19 dr, p • .05).
There were no significantdifferencesin the groups'responses to the casehistories.However,severaltrendsemerged.The sHgroupwasmore likely to recommendinpatientcare than was the sv group.Also,as was foundby Linsky (11) in his householdsurvey,"psychiatric or psychologicalhelp" and "medicaltreatment"were more frequentlychosenby both groupsthan were other treatmentapproaches. DISCUSSION
Severalaspectsof the paraprofessionals' attitude toward alcoholism appearto be relatedto situationalvariables.The differencein responses to the ATAhumanismscaleare consistentwith the hypothesisthat the staffof the sobering-up stationwouldhavelesstolerantattitudestoward alcoholicsthan would the paraprofessionals in the state hospital.The
latter alsoscoredhigheron the psychological etiologyscale,as would be expectedfrom the therapeuticsettingand purportedtreatmentphilosophy. The resultsof the CAIare not so easily explained.While Mendelson et al. assertthat the scaleis designedto assessthe degreeof "humanitarian" versus"custodial"therapeuticattitudes toward alcoholicpatients, the group from the state hospital scored significantlyhigher than did thosefrom the sobering-upstation.The scaleis a revisionof the Scale of Custodial Attitudes Toward Mental Illness, used with care-
taking groupsin an institutionalsetting,so that it is conceivablethat it is actuallytappingthe subjects'socialization into, and acceptance of, a generalstate hospitalphilosophyrather than basic interpersonalbe!iefs. Also, it is questionablewhether "humanitarian"and "custodial" attitudesare truly opposite endsof a unidimensional continuum. Further studyshouldbe madeof the CAIif it is to be profitablyutilized in any future
research
effort.
BRIEF REPORTS
517
REFERENCES
1. STARR,G. E. and KENT, L. M., eds. The paraprofessionalin the treatment of alcoholism;a new profession.Springfield, Ill.; Thomas; 1973. 2. SOWA,P. A. and CVTTER,H. S. Attitudes of hospital staff toward alcoholics and drug addicts. Q. J. Stud. Alcohol 35: 210-214, 1974. 3. STERNE,M. W. and PITTMAN, D. J. The concept of motivation; a source of institutionaland professionalblockagein the treatment of alcoholics.Q. J. Stud. Alcohol 26: 41-57, 1965. 4. PATT•SON,E. M. A critique of alcoholism treatment concepts; with special reference to abstinence.Q. J. Stud. Alcohol 27: 49-71, 1966. 5. Coo•a•, G., WE•-IMER,G. and GRtmER,J. Training paraprofessionalsin the treatmentof alcoholism;effectson knowledge,attitudesand therapeutictechnique. Q. J. Stud. Alcohol 36: 938-948, 1975. 6. HOLL•NGSnEAD, A. B. Two factor index of social position.New Haven, Conn.; 1957. [Mimeographed.] 7. TOLOR,A. and TAMEraN,J. S. The Attitudes toward AlcoholismInstrument; a measure of attitudes toward alcoholics and the nature and causes of al-
coholism.Br. J. Addiction 70: 223-231, 1975. 8. CROWNE,D. P. and MAimOWE,D. A new scaleof socialdesirabilityindependent of psychopathology. J. Consult. Psychol.24: 349-354, 1960. 9. MENDELSON,J. H., WEXLER, D., KUBANSKY,P. E., HARRISON,R., LEIDERMAN,
C. and SOLOMON, P. Physicians'attitudes toward alcoholicpatients. Archs Cen. Psychiat. 11: 392-399, 1964. 10. ADOR•O, T. W., FRENKEL-BRUNSWIK, E., LEViNSON,D. J. and SANFORD,R. N. The authoritarianpersonality.New York; Harper & Row; 1950. 11. L•NSK¾,A. S. Theories of behavior and the social control of alcoholism.Soc. Psychiat.,Ber]. 7: 47-52, 1972.
