Therapist's Gender and Gender Roles: Impact on Attitudes toward Clients in Substance Abuse Treatment

The purpose of the present study was to investigate the impact of therapist's gender and gender roles on attitudes toward clients. Attitudes toward motivational interviewing were also a focus as MI can be hypothesized to be feminine rather than masculine in nature. The subjects (N = 246) were Finnish substance abuse therapists. Their attitudes toward clients were measured using a vignette task. Results indicated that female therapists were significantly more positive toward clients than were male therapists. Although females were significantly more feminine than males, they saw themselves as masculine as the males did. The more feminine the therapist was, the more s/he preferred MI. In the future, an examination of this kind should be combined with measurement of treatment processes and outcomes.


Introduction
e effects of various treatments on outcome have been studied extensively both in psychotherapy and substance abuse treatment [1,2]. e investigation of between-therapist variation in outcome has been infrequent, although it has proved an important factor in both disciplines [3,4].
Other little-studied factors are the gender and gender roles of the therapist and their impact on treatment effectiveness [5]. Gender role is a key concept in our study. It refers to the set of attitudes and behaviors socially expected of the members of a particular gender [6]. According to Bem's [7] theory, a traditionally gender-typed person is highly attuned to the cultural de�nitions of gender-appropriate behavior and uses such de�nitions as the ideal standard against which her or his own behavior is to be evaluated. Masculinity and femininity are gender roles of the traditional type. Androgyny, in turn, is considered to be a modern gender role. It means that a person is both masculine and feminine; these traits are not mutually exclusive.
Research on psychotherapy has indicated that therapy effectiveness may be predicted on the basis of gendered factors [8]. In the substance abuse �eld, there is evidence that therapist's attitudes toward clients vary according to the client's gender. DeJong et al. [9] demonstrated that therapists were more confrontational and critical with male clients, while female clients received more empathy and support. e male clients were seen by the therapists as threatening, in which case the attitudes became confrontational, while female clients were seen as submissive, which led to empathetic attitudes. ese attitudes were due to stereotypical gender roles common in society. e therapist's own gender had no impact on the attitudes toward clients in the study by DeJong et al.
By contrast, �ndings on mental health professionals have indicated that males generate more stereotypical attitudes toward clients than do females [10,11]. ese �ndings corroborate a study by Bernstein and Lecomte [12] reporting that psychotherapist's gender is an important factor for attitudes toward clients, males being more stereotypical than females.
A small study by Saarnio et al. [13] showed that the clients of male therapists dropped out of inpatient substance abuse treatment signi�cantly more frequently than did the clients of female therapists (20 versus 10%). Five therapists of each gender and 105 clients took part. Unfortunately, a more detailed examination of the �ndings was not possible because no in-session data were collected.
However, one possible explanation is that female therapists were more adept at avoiding alliance ruptures that easily lead to dropping out. is explanation is supported by a recent Finnish study which found that female therapists in substance abuse treatment were signi�cantly more empathetic and friendly toward clients than were their male colleagues [14]. Moreover, avoidance of excessive directiveness was considered more important by female therapists than by males.
ere is evidence that therapist empathy is an essential factor in substance abuse treatment [15]. Empathy is significant for the working alliance and thus for the continuity of treatment [16]. Miller et al. [17] demonstrated that therapist empathy explained as much as 67% of variance in treatment outcome; in other words, the more empathetic the therapist, the better the outcome.
Miller et al. [18] showed experimentally that the therapist's style affects the client's drinking aer treatment. From among two experimental groups, the therapists in one group were instructed to work in a directive-confrontational style and the therapists in the other group in a client-centered style. e therapists in the second group followed the principles of the motivational interviewing (MI) in which emphasis is placed on a positive attitude toward the client, especially empathy [19]. e directive-confrontational style caused signi�cantly more opposition than did the client-centered style. e treatment results can be summed up as follows: the more the therapist confronted, the more the client drank one year aer the treatment.
MI can be hypothesized to be feminine rather than masculine in nature as in it avoidance of confrontation and excessive directiveness play important roles. It would be interesting to �nd out whether there are between-therapist differences in attitudes toward MI due to gender or gender roles. e hypothesis is wholly explorative in nature.
e purpose of the present study was to investigate the impact of therapist's gender and gender roles on attitudes toward clients with different genders and sexual orientations. Attitudes toward MI were also a focus. ese were formulated as three questions: (1) are there differences in masculinity, femininity, or androgyny between male and female therapists?
(2) are there between-therapist differences due to gender or gender roles in attitudes toward clients? An electronic questionnaire was sent via the Internet to counselors, social workers, nurses, physicians, psychologists, and team leaders ( ). Regardless of job title, they all had the same task, therapy with clients. erefore, for simplicity, they are called as therapists. e response rate was 45.1%. Unfortunately, we did not get any information on nonrespondents. is was due to an anonymous procedure in data collection. Out of those participating in the study, 29.7% were men ( ) and 70.3% women ( ). e gender distribution was similar to that of the total personnel of the A-Clinic Foundation (22.2% men and 77.8% women). e age of the subjects varied between 24 and 63 years (M .0; SD 0.0), while the women (M .8; SD 9.9) were signi�cantly ( . ; 0.00 ) younger than the men (M . ; SD 9. ). On average, the female therapists had a higher level of professional education than the male therapists, even though the males had acquired university degrees more oen than their female colleagues (Table 1). Among therapists in team leader position, men were more common than women. Compared to men, the women more oen worked as nurses. Every tenth subject had a history of personal recovery of substance abuse.
Male therapists reported more oen being homosexual than did female therapists. According to a population-based Finnish study, the proportion of individuals with gay, lesbian, or bisexual identities has been estimated to be 2.5% of males and 1.9% of females in the year 2007 [20].

Materials
. e �rst part of the questionnaire contained 18 items eliciting background information. e question on MI was formulated as follows: "In motivational interviewing one avoids directly telling the client what to do. How important do you consider this principle to be in substance abuse treatment?" e subjects were requested to use a �vepoint scale ( not so important⋯ very important). e different gender roles of the subjects, which in this study included masculinity, femininity, and androgyny, were measured by the Bem Sex-Role Inventory (BSRI) [21]. For this purpose, a short version of the BSRI consisting of 30 items was translated into Finnish by an expert translator. Backtranslation was not used as there were only single adjectives to translate.
Each item, such as "I am gentle" or "I am assertive, " was rated on a seven-point scale (1 = never or almost never true⋯7 = almost or almost always true). Both masculine and feminine traits were measured by ten items. In addition, ten neutral �llers were included. e androgyny score is the difference between an individual's femininity and masculinity. A high positive score indicates femininity and a high negative score indicates masculinity; the closer the score is to zero, the more androgynous the person is.
e alpha reliabilities of masculinity and femininity in the present study were of the same level as in the original study [7]: 0.78 (0.86) and 0.81 (0.81). It was not possible to calculate the alpha reliability for androgyny.
Despite having been developed over 30 years ago, the BSRI continues to be extensively used in both research and clinical work. In addition, its psychometric properties are considered valid [22]. However, recent studies have reanalyzed and questioned the BSRI's factor structure and validity [23,24]. e attitudes of the therapists toward clients were measured with a vignette task, in which the subject had to associate adjectives with three different �ctional client cases. e cases differed from each other only as regards the client's gender and sexual orientation. e �rst case was a heterosexual male with a substance use disorder. e second vignette had to do with a heterosexual female, and the third vignette concerned a homosexual male.
e vignette rating made use of 50 adjectives extracted from the Adjective Check List (ACL), which is commonly used to measure personality traits [25]. Half of adjectives were negative and half positive in meaning. e subjects selected six adjectives for each vignette.
Like the BSRI, the ACL has a wide range of uses and applications in both research and clinical work. In addition, the validity of the ACL has been found to be high [25].

Procedure. e study was approved by the A-Clinic
Foundation's Ethics Committee. e electronic questionnaire was sent to the therapists via the Internet. e participation of the therapists was voluntary and anonymous.
e statistical analyses were carried out using SPSS soware (version 16.0). e 2 test, -test, correlations, and analyses of variance (ANOVA, repeated measures, and MANOVA) were used. Effect sizes were calculated with Cohen's , de�ned as the difference between the means of female and male therapists, divided by the pooled standard deviation of these groups.

Gender and Gender Roles.
First, the results on gender roles measured by the BSRI were compared between male and female therapists. e raw scores were not converted to -scores because they were based on normative data over 30 years old. In addition, the results were not compared to those of other populations.
e male therapists received a slightly higher mean score for masculinity (M 4.9; SD 0.6) than the female therapists (M 4.8; SD 0.6). According to the -test, the difference was not statistically signi�cant ( 244 0. ; 0. ). Effect size was small ( 0. ). As for femininity, the means between males (M .2; SD 0.6) and females (M . ; SD 0.6) differed signi�cantly ( 244 2.6; 0.0 ) from each other. e male therapists were less feminine than the females. However, effect size was small ( 0. ). As regards the androgynous gender role, the male (M 0. ; SD 0.8) and female therapists (M 0.6; SD 0.8) differed signi�cantly ( 244 2. ; 0.0 ) from each other. Effect size was small ( 0. ). e mean score of female therapists deviated more from zero than that of men, so the male therapists were more androgynous than the women.

Attitudes toward Clients.
In the next section of the questionnaire, the therapists had to select six adjectives that best described the client in each of the three vignettes. Gender roles were not signi�cantly connected with the ratings. Instead, gender as such was a signi�cant factor: female therapists had a more positive attitude than the males toward all cases (Figure 1). A repeated analysis of variance indicated that the difference between the columns was signi�cant ( , 9.8; . ). On the basis of the -test, the difference between genders was greatest in attitudes toward the homosexual male client ( 5. ; . ) and smallest in attitudes toward the heterosexual female client ( . ; . ). e genders also differed signi�cantly ( . ; . ) from each other in their attitudes toward the heterosexual male client. Effect sizes for vignettes were medium to large ( .8; 0.6; 1.1). When controlling for background variables described in Table 1, the one-way analysis of variance revealed three variables on the basis of which the therapists differed sig-ni�cantly from each other as regards their attitudes toward the vignettes: professional education, job title, and technical eclecticism. When these variables and gender were used as independent variables and the combined score of the vignettes as a dependent variable in MANOVA, only technical eclecticism ( , 5 . ; . ) and gender ( , 5 . ; . ) remained signi�cant. Eclectic therapists were more positive toward vignettes when compared with singlemethod therapists.
In addition, ANOVA indicated that the therapist's marital status and length of therapy training interacted signi�cantly with gender on the attitudes toward the vignettes (Table 2). Single men had more positive attitudes toward all vignettes than men in pair relationships. For women the inverse was true: female therapists in a pair relationship had a more positive attitude than single women toward all cases. As for lengthy therapy training, the attitudes of the male therapists who had completed lengthy training were more positive, while among the female therapists such training weakened the positive client images.

Attitudes toward MI.
e study also focused on the connections between gender, gender roles, and attitude toward MI. Femininity had a signi�cant positive correlation ( . 8; . ) with attitude toward MI: as the therapist's femininity increased, so did the preference for MI. Masculinity and androgyny did not correlate signi�cantly with the attitude score.
MI was slightly more important for female therapists (M = 4.0; SD = 0.7) than in males (M = 3.8; SD = 0.7). However, they did not differ signi�cantly ( 244 = 1.3; = 0.2) from each other. Effect size was small ( = 0.2). When controlled for, MI usage per se was not signi�cantly connected with preference for MI.

Discussion
e present study investigated the impact of therapist's gender and gender roles on attitudes toward clients. Attitudes toward motivational interviewing were also a focus.
On average, the female therapists were signi�cantly more feminine than the male therapists. However, masculinity was at the same level in both genders. e degree of androgyny was higher among the male therapists than among the females.
Female therapists were signi�cantly more positive than male therapists in their attitudes toward all the cases in the vignette task. is �nding indirectly supports Saarnio's [14] conclusion: "On the grounds of personality and interpersonal functioning, female therapists were keener on working according to motivational interviewing" (page 1470).
Our �nding differs from the conclusion of DeJong et al. [9] that therapist's gender has no impact on attitudes toward clients. On the contrary, the vignette task result corroborates the �ndings for mental health professionals, indicating between-gender differences in attitudes toward clients [10][11][12].
Client's gender was not a relevant factor for therapist's attitudes: the vignette task scores were at the same level for both male and female cases. is �nding also differs from the result of DeJong et al. [9] that depending on the client's gender, substance abuse therapists will prefer different attitudinal stances.
As to why the female therapists had the most positive attitudes toward the homosexual male client, no answer can be given on the basis of the present study. However, in an international comparison, there were population-level differences between the genders in attitudes toward homosexuals, particularly in the Nordic countries [26]. Women were more positive toward homosexuals.
e topic is an important one, since some studies have indicated that homosexuals may have a higher risk of substance use disorders than heterosexuals [27]. In addition, it has been demonstrated that homosexuals have difficulties in entering substance abuse services [28]. ese �ndings could be taken into account in therapist training, especially for men.
We hypothesized MI to be feminine rather than masculine in nature as in it avoidance of confrontation and excessive directiveness play important roles. e results indicated that gender as such had no signi�cant association with the therapist's attitude toward MI, while a signi�cant correlation was found between femininity and the attitude score: the more feminine therapist was, the more s/he preferred MI. To the best of our knowledge, there are no studies available on this subject.
Our �ndings showed that eclectic therapists were more positive toward clients when compared with single-method therapists. is may be considered as an indication of more expertise among the eclectic therapists. We also found that therapist's marital status and length of therapy training interacted signi�cantly with gender on attitudes toward the vignettes. However, these interactions were explorative in nature, and no parallel information was available. It is therefore difficult to discuss them without the risk of speculation. A more detailed analysis of this topic is desirable.
ere were certain limitations in the present study. One of them was the modest response rate. Although the questionnaires sent via the Internet had a high degree of anonymity, more responses might have been obtained if data had been gathered through personal contacts. Second, while the BSRI has been used extensively, there are questions and limitations as to how valid its underlying factors currently are [23,24]. ird, the assessment of attitudes toward clients could partly have been confounded by socially desirable responding [29]. Tourangeau and Yan [30] concluded in their review that responses to questions on sexual orientation, in particular, are oen based on social expectations. Fourth, attitudes toward MI were only measured by a single item. Consequently, the measurement was not optimally reliable.
What the �ndings mean for practical substance abuse treatment remains open. In the future, an examination of this kind should be combined with the measurement of treatment processes and outcomes. Are there differences between female and male therapists in the continuity and outcome of substance abuse treatment? What do the gender roles matter for everyday treatment practice? ese are necessary steps before we can draw sound conclusions on gendered effects in this �eld.