What Shapes Professional Practice: Judgement and Decision-Making in Danish Outpatient Alcohol Counselling

Study aim

The present qualitative vignette study explores professional judgement and decision-making among addiction counsellors working in outpatient treatment for alcohol use disorders in Denmark. The aim of the study was to examine what the counsellors base their professional judgements on and to explore the reasoning that informs their decisions. The findings will be discussed from a discourse theoretical perspective.

Terminology

In the research of judgement and decision-making, a variety of concepts are used. Here, we follow the terminology often used within social work (research). The term “professional judgement” is thus used to refer to an individual (counsellor) considering the evidence about a client or a situation and reaching a conclusion or recommendation. The term “decision-making” is used to refer to a conscious process of the individual (counsellor) leading the individual to select a course of action from among two or more alternatives (Taylor, 2023). As such, professionals form their judgements prior to or while engaging in decision processes (Killick & Taylor, 2024).

The vignette method

Vignettes are, like case stories, short fictional stories or descriptions of hypothetical contexts, actions, and individuals (Finch, 1987). Thus, a vignette can be seen as a “snapshot” of a given situation (Hughes, 1998). Vignettes are constructed according to the researcher's interests and study objectives and are therefore usually fictive. However, vignettes typically describe situations that are likely to occur in real-life because the vignettes are intended to constitute realistic descriptions of the situations concerned. When using the vignette method, respondents are presented to one or more vignettes and invited to respond to the situations, persons, events, etc., outlined in them. The vignette method is particularly suitable in exploring opinions, judgements, understandings, values and interpretations in relation to a specific phenomenon or a specific situation (Ejrnæs & Monrad, 2012).

Construction and content of the vignettes for the present study

Two vignettes were created by the researchers (KHV and ASN). When constructing the vignettes, the researchers drew upon their own professional experiences within the alcohol treatment field. Furthermore, available statistical data from the alcohol treatment field (e.g., gender, age, years of problematic/harmful alcohol use prior to applying for treatment, somatic and psychiatric conditions related to AUDs) were used to ensure that the clients in the vignettes resembled clients encountered by the counsellors in their daily practice. The vignettes were also read through by an experienced addiction counsellor who contributed with feedback on wording, inclusion and exclusion of information, and the realism and relevance of the vignettes, as well as the clarification of the practice context.

Both vignettes described a situation where a client sought treatment at the public alcohol treatment services and had shown up for the introductory interview with a counsellor in the outpatient treatment facility. The client's life situation and alcohol problem were described, primarily through information provided by the client himself. Selected information about family, employment, housing, mental health, etc., was also included in the vignette, albeit the information differed in the two vignettes. One of the vignettes was constructed to portray a typical client appearing at the outpatient treatment facilities. The other vignette was constructed to portray a client who was more strained and with more complex problems, including possible psychiatric comorbidity.

The vignettes are presented in Appendix 1 (in Danish). English translations of the vignettes are available upon request from the corresponding author.

Recruitment

A purposive sample of outpatient treatment facilities was invited to participate. The purposive sampling strategy was based on the size of the municipalities in which the treatment facilities were located, the capacity of the treatment facilities and on whether the treatment facilities offered treatment for AUD only or for all substance use disorders (alcohol as well as other substances). These criteria were considered to ensure that the sample of counsellors were representative of the diversity in the outpatient treatment facilities across Denmark. A sample of 29 treatment facilities, covering the spectrum on these variables, was selected.

The treatment facilities were contacted via email, which briefly presented the research objectives and advertised for addiction counsellors willing to participate in an interview. The only inclusion criterion was for the participants to provide psychosocial treatment for AUD as a substantial part of their daily job.

Sample

In total, 13 addiction counsellors volunteered to participate and all met the inclusion criterion. One counsellor dropped out due to illness, leaving completed interviews with a total of 12 counsellors from 10 treatment facilities. A detailed overview of the characteristics of the participating counsellors is presented in Appendix 2.

All participants received information about the study and gave their verbal consent to participate prior to conduction of the interviews.

Data collection

Data analysis

The transcribed interviews were analyzed using thematic analysis (Braun & Clarke, 2006). The coding of data was data-driven with no predefined codes or themes. Codes were developed concurrently with the thorough reading of the transcripts (Kvale & Brinkmann, 2015). Following the study objectives, particular attention was paid to passages where the counsellors clearly expressed their opinions or judgements regarding the topic in focus.

The analysis of the data consisted of the following steps: (a) thoroughly reading the transcripts of all 12 interviews; (b) making initial notes and explorative comments; (c) generating and applying initial codes; (d) developing emergent themes and collating the coded data extracts within these themes; (e) refining the themes; searching for patterns and connections across themes, thereupon forming superordinate themes and subthemes; (f) re-reading and elaborating on the most potent subthemes, resulting in a number of subcategories for each subtheme; and (g) searching for patterns and connections across superordinate themes, subthemes and subcategories.

When presented to an attitude object (a specific topic of matter), the counsellors expressed their opinions and argued for their judgements or decisions. As part of the analysis, themes were developed for both the specific judgements or decisions and for the arguments and reasons expressed by the counsellors. However, our analytical focus was on the latter because the study objective was to examine the basis of the professional judgements and decisions, and not the specific decisions and their content.

Theoretical approach

Laclau & Mouffe (Howarth, 2005) belong to a social constructionist tradition, in which knowledge is perceived not as a reflection of reality but rather as socially constructed. The discourse theory developed by Laclau & Mouffe (Howarth, 2005) emphasizes how nothing can have a meaning independent of the discourses it is placed within (Howarth, 2005). Social meaning is relational, contextual and contingent, and, in particular, social structures are conceived as incomplete and open meaning systems. Laclau & Mouffe (Howarth, 2005) focus on how social actors construct meanings within these social structures (Howarth, 2005).

Laclau & Mouffe (Phillips, 2020) relate to a distinct poststructuralist discourse-analytic approach (Phillips, 2020). This implies the view that there is no one general system of meaning, but rather a number of discourses where meanings change from discourse to discourse.

In the present study, specifically the concepts of “floating signifiers” and “subject positions” from Laclau & Mouffe's discourse theory (Howarth, 2005; Laclau & Mouffe, 2014; Phillips, 2020) will be used as analytical tools to discuss our findings. These concepts will thus constitute a lens through which the accounts of the counsellors (the social practices) can be understood by placing their meaning in a broader social and structural context (Howarth, 2005), thereby offering a perspective for understanding the results of the study.

The basis of professional judgements and decisions

In examining the basis of the professional judgements and decisions made by the participating counsellors, one superordinate theme, “The reasoning” was developed. This theme encompassed counsellor statements that justified, supported, or explained the judgements and decisions that were made. Within this superordinate theme, two subthemes were developed, with these being “Knowledge” and “Values”. Across the multiple attitude objects, judgements and decisions, the counsellors’ arguments and reasons were consistently based on knowledge and/or values: knowledge and values functioned as the reasoning behind the judgements and decisions.

Knowledge and values are not mutually exclusive concepts. Often, they are entangled, and, in practice, the distinction between the two are not unambiguous. Knowledge may inform a value-based approach, just as values may shape the understanding of knowledge. Hence, a differentiation between knowledge and values will to some extent be an analytical distinction. However, for the analysis of the interviews from the present study, the development of “Knowledge” and “Values” as distinctive subthemes were analytically sound.

The use of knowledge and values to justify judgements and decisions were, among others, seen in relation to the topic of the client's treatment goal. For example, in this excerpt from an interview with a counsellor: Interviewer:

Torben [the client] says himself that his goal is to reduce his alcohol consumption. He doesn't want to stop drinking completely. How should Henriette, the counsellor, deal with this?

The counsellor seemingly bases her professional judgement on knowledge about the brain and addiction and uses this knowledge as an explanation for accepting the client's goal.

Another counsellor, Ulla, on the other hand, responds to the questions about treatment goals from a value-based point of view: “We are not to be judges here. And we should not have a know-all attitude in many areas. It is people's lives, and it is their choice” (Ulla, counsellor). Here, the counsellor does not derive her arguments from factual knowledge. Instead, she justifies her judgement from a value-based standpoint, where the client's autonomy and humility as a professional are emphasized.

For each of the two subthemes, knowledge and values, we further identified several subcategories, presenting in more detail the reasoning that informed the counsellors’ judgements and decisions. Figure 1 provides an overview of the superordinate theme, the subthemes and the subcategories within.

OPEN IN VIEWER

Figure 1.

Overview of main theme, subthemes and subcategories identified through the analysis of interview data.

The two subthemes and the subcategories are elaborated below.

Knowledge

Overall, the factual and methodological knowledge articulated was very similar among the counsellors. This applied when explaining alcohol problems as well as choosing and describing needed interventions. We also found widespread similarities regarding the language used by the counsellors when discussing the vignettes and the related questions.

Three subcategories were developed, representing the different forms of knowledge referred to by the counsellors. The factual knowledge (“Facts”) primarily covered knowledge about addiction, biology and genetic/environmental predispositions to the development of alcohol problems. For example, one counsellor, Tove, mentioned the relevance of providing “… education on the biochemical. You know, why is it you are drinking? What it [alcohol] does in your brain, the dopamine-releasing and such things”. Several counsellors also referred to knowledge about the brain and addiction, e.g., the counsellor, Lone, who referred to “… the new knowledge that we have about addiction. That the brain is plastic and that you can always develop new paths and such things”, and the counsellor, Tanja, who described having experienced a shift in the approach to a treatment goal of moderate drinking:

I remember, many years ago it was something like this when a client came in … that “if you drink like that, you will never [emphasis added] be able to drink again. You have to say no to alcohol for the rest of your life”. And I know that has scared many away [from treatment].

The factual knowledge also entailed known consequences related to harmful use of alcohol, such as cognitive impairments, sleep problems etc. Additionally, several counsellors referred to the National Health Authorities’ recommendations regarding alcohol consumption. The methodological knowledge (“Methods”) covered a number of different treatment methods. The methods most often referred to were cognitive behavioral therapy and motivational interviewing. However, other approaches and methods were also mentioned (e.g., family-oriented treatment, compassion focused therapy and meta-cognitive therapy). In addition to factual and methodological knowledge, experience-based knowledge (“Experience”) was applied by almost all of the counsellors. These were experiences gained through the counsellors’ clinical work. The experience-based knowledge related to experiences regarding similar cases as the two described in the vignettes and were typically mentioned in connection to the other two forms of knowledge. Counsellors often used their experiences to either substantiate or exemplify the factual knowledge, to justify their choice of method, or to support their judgements regarding the clients in the vignettes (problem severity, treatment goals, etc.).

Values

From all data extracts collated under the subtheme “values”, we identified several values and ideals consistently recurring through the 12 interviews. These included: recognition, autonomy, responsibility, empathy, to help, honesty, humility, respect, professional obligations, non-judgmental, care and uniform treatment. The identified ideals were not merely words or expressions often used by the counsellors. Rather, they were a summary of several words and statements, whose meaning was interpreted and condensed in the values ​​mentioned. An example of this was seen in a statement by the counsellor, Tanja: “Who likes to have others pointing their fingers at them? And being told that you are flawed or wrong? Then you won't come back. So, I think it's important to meet the client. And be inclusive and understanding”. This excerpt shows how values such as showing empathy and being non-judgmental were expressed.

In identifying the values underpinning the interviewees’ reasoning, we thus moved from the semantic level to an interpretive level (Braun & Clarke, 2006). A (not exhaustive) overview of data extracts (words and phrases) used in interpreting and condensing values is presented in Appendix 4 (in Danish). An English translation is available upon request from the corresponding author.

Differences among the counsellors regarding the use of values

While the knowledge used by the counsellors when justifying their judgements and decisions was rather uniform, there was a diversity regarding the specific values referred to by the counsellors. We identified a variation in how counsellors defined and applied particular values in their argumentation. Certain values showed not to have one clear definition but appeared in various versions or with subtle distinctions; for example, the values “recognition” and “responsibility”. Below, the value “recognition” will serve as an example to unfold this finding.

Recognition

Among the counsellors, the value “recognition” was brought up both explicitly and implicitly. However, the meaning of the value varied, and through the counsellors’ statements we saw how the concept of “recognition” was assigned with different content from counsellor to counsellor.

A discourse theoretical perspective on the identified differences in meaning

The results of our study showed that while similarities were found regarding the counsellors’ accounts of knowledge, diversity was found regarding the meaning of values used by the counsellors. Laclau & Mouffe's discourse theory (Howarth, 2005; Laclau & Mouffe, 2014) offers a framework for broadening our understanding of this finding. Specifically, the concepts of “floating signifiers” and “subject positions” will be applied in the following.

Laclau & Mouffe (Hein Jessen & Hansen, 2021; Phillips, 2020) describe how “floating signifiers” (i.e., signifiers referring to concepts within language that lack a fixed meaning) are contingent on the discursive context in which they are used. Thus, different discourses will compete to fix the meaning of the signifiers in different ways, and the same signifier may thus have several different meanings (Phillips, 2020). This corresponds to our finding that different counsellors may refer to the same value, but for different reasons, when arguing for their judgements and decisions regarding a specific topic. The value “recognition”, used in the present study as an example, showed not to have one fixed meaning. The meaning of the concept varied among the counsellors. Within the different discourses in which the value was used, “recognition” was assigned with content in different ways. From the perspective of Laclau & Mouffe (Phillips, 2020), this value/concept can be regarded a floating signifier; lacking a fixed, specific meaning. Each discourse competed to fix the meaning of “recognition” in its own specific way. This fight for “recognition” as, respectively, a moral/ethical demand, (necessary) acceptance or human recognizability showed how, in a discourse theoretical perspective, the value was a floating signifier. The same applied to other ideals and guiding principles that appeared through the analysis of the interviews. Thus, our analysis of these values as floating signifiers offers a perspective for understanding how one value can be used in different ways and for different purposes when counsellors argue for their judgements and decisions.

Subject positions refer to the positioning of subjects within a discursive structure. Different discourses constitute different subject positions with which the social actors – in this case the counsellors – can identify (Howarth, 2005). As the meaning of concepts (values) is contingent on the discursive context in which they are used, according to Laclau & Mouffe (2014), different discourses also open up to different subject positions. The subject positions influence which options for action or decision the counsellors experience having (Howarth, 2005). In a discourse theoretical perspective, the different versions of the value “recognition” can thus be linked to different competing discourses and subject positions. Recognition as a moral/ethical demand can be understood as linked to a subject position of “the humble social worker” for whom it comes naturally (as the available option for action) to see the client as the expert and to act based on joint responsibility. Recognition as necessary acceptance can be understood as linked to a subject position of “the practical facilitator”, constituted by a discourse within which the client's autonomy and responsibility are emphasized. For example, when the counsellor, Linda, explains that a moderate drinking goal will be challenging given the client's alcohol dependence, but accepts the client's wish to try anyway, because he must realize this himself. As a facilitator, the natural (available) action is to make treatment available, yet accepting and insisting on the client's responsibility. Recognition as human recognizability can be understood as linked to a subject position of “the authentic human being”, constituted by a discourse within which humanity and brotherliness are focal points, and the relation to the client is high priority. Thus, as an “authentic human being”, providing care and expressing empathy may be perceived by the counsellors as the obvious (available) option for action. A discourse within which emphasis is on factual, evidence-based knowledge and professional expertise, will likely open to a subject position of “the expert” for the counsellor to identify with. Accordingly, decisions and judgements within this discourse and from this subject position will likely be based on knowledge, and the communication of factual knowledge and expert guidance will be perceived as the proper action and a professional obligation (the available options for action within the discourse).

Consequently, different subject positions will result in different judgements and decisions and/or in different ways of arguing for and justifying the judgements and decisions. While similarities in the factual and methodological knowledge might be a result of training, dissemination of knowledge and implementation of clinical guidelines, the differences in meaning of values and in the use of values and/or knowledge can be understood as an expression of different subject positions made available through different competing discourses within the alcohol treatment context.

Diversity is a condition

The results of the present study are in line with previous research on professional judgement and decision-making in social work practice. Our finding of differences regarding counsellors’ understandings of specific values supports the findings of Blomqvist & Wallander (2004). Their study indicated a lack of professional consensus regarding the meaning of both different interventions and different concepts and terms. Blomqvist & Wallander (2004) also point out that there appear to be more fundamental differences in the social workers’ approach to clients. Their analyses indicated the existence of conflicting views or “styles” within the social work profession. This applied to, among other things, the importance of considering the individual client's point of view. Blomqvist & Wallander (2004) concludes that the differences identified were not to be explained by the variables included in their study. By applying the concept of “subject positions”, drawn from Laclau & Mouffe's discourse theory (Howarth, 2005; Laclau & Mouffe, 2014), our study offers a perspective for understanding this.

Our findings are also in line with the findings of Mosteiro et al. (2018). They found that the professionals used the same argument categories and criteria when making decisions, but that the weighting and interpretation of these criteria differed significantly when justifying the decisions. This corresponds with our finding that the interpretation and attribution of meaning play a substantial role when making professional judgements and decisions. In the present study, we showed how counsellors referred to the same values when justifying their decisions, but that these values were understood and applied in different ways. This adds to the understanding of differences derived by Mosteiro et al. (2018), who conclude that the argument variability primarily can be explained by different perceptions of the facts presented to the professionals, different decision thresholds and a diversity in the judgements of the situation described in the vignette. Our analysis suggests that differences among counsellors also reflect different interpretations and applications of values in decision-making, which in turn are connected to different discourses and subject positions.

Differences in the definition and meaning of values among counsellors are to be expected, especially from a constructionist perspective highlighting the incompleteness and openness of the social structures. However, this attribution of meaning was left implicit and unreflected upon in the interviews with counsellors. The identified differences seem to remain “latent” or hidden from the very professionals whose judgements and decisions are guided by the particular values.

Implications for practice

Methodological considerations, limitations and strengths

The vignettes developed and used for the present study have formed the context for our data and analysis. Our results must therefore be viewed in the light of these very vignettes. On that basis, we must be cautious about generalizing beyond the specific contexts described in the vignettes. However, the vignettes were used with the purpose of exploring what the counsellors more generally base their professional judgements on and how they more generally reason. The interviews and analysis did therefore focus on reasons for judgements and decisions rather than the specific judgements and decisions themselves. This makes it likely that the knowledge and values informing the counsellors’ professional judgement will also apply in relation to other situations or patients within the broader context of outpatient treatment for AUD.

A limitation also exists regarding the predictive validity of our results and analysis. By using the vignette method, we are not able to conclude on the actual actions of the counsellors; only their opinions and judgements regarding what should be done. Thus, the responses of the counsellors cannot be used to predict what these counsellors would actually do in a similar situation (Finch, 1987). The vignette method only conveys tendencies to act in certain ways. However, this aspect is more an empirical question of the correlation between two different phenomena (tendencies to act vis-à-vis actual actions) than of the validity of the method itself. In relation to our study objectives, we consider this aspect not to be of critical importance because our aim was to investigate differences in the reasons for a practice rather than differences in practice per se. Supplementing our data with observations from practice would, however, add an extra and interesting perspective to our findings.

The present study combines the vignette method with individual interviews to explore professional judgement and decision-making. Following this objective, we consider the two techniques to be complimentary and well suited for the study. The vignette method has several advantages. It allows the researcher to specify the context and certain features related to this in detail in a systematic way. Accordingly, the normative statements of the respondents are related to a specified context rather than more abstract ideas or generalized situations (Finch, 1987). This enabled us to compare the counsellors’ answers and judgements regarding the situations described and made it possible to highlight the nuances and the diversity that appeared.

The vignette method also has the advantage of distancing the respondent's judgement of the situations described from his/her personal circumstances. This is partly due to the hypothetical character of the situations outlined and partly due to the researcher's opportunity to ask the questions in third-person (Finch, 1987). This makes it less personal and therefore less threatening and vulnerable for the counsellors to share their opinions and judgements (Hughes, 1998). By using the vignette method, we thus supported honest reflection and reduced the risk of response bias.

Conclusions

The present study demonstrated how addiction counsellors working in outpatient treatment for AUD in Denmark base their professional judgements and decisions on knowledge and values. Of particular relevance, certain values showed to lack a clear definition when applied by the counsellors. Values influence whether and how knowledge is used, making their clarification essential for a practice built on evidence-based knowledge. Without such clarity, value-based practice becomes meaningless and values cannot effectively guide the professionals. At least not in the same direction.