Building a curriculum

The field of addiction counseling currently is without a nationally standardized curriculum. While a good number of certificate and degree programs in addiction exist at the community or junior college level, they vary with regard to hours and content—even within the same state. Very few degree programs or courses exist at the bachelor's or master's degree level. If this remains the case, the profession of addiction counseling will languish. Other helping professions, including social work, marriage and family therapy, and mental health, understand the need to establish national standards in higher education, and they have done so through approved, certified, or accredited degree programs.

Throughout most of the addiction profession's history, the work of counseling has been provided by lay individuals who themselves have battled an addiction.1 Many individuals in recovery relied upon “what worked for them” in helping others. The presence of counseling skills and the understanding of addictions was rare to nonexistent; the main goal was to keep an individual alive. Today, a number of forces have changed this approach. This article will review where addiction studies have come from and where they are going.

Research over the years has indicated that there indeed remains much room for progress. Several studies of clinical training programs approved by the American Psychological Association (APA) found “a low level of training in the evaluation, treatment and prevention of substance abuse.”2 A follow-up study five years later “found few changes in the quantity or nature of university training in substance abuse.”3 Lawson and Lawson concluded in a review that there was consensus toward a need for minimum training standards for human service professionals, yet they found little agreement on prerequisites, curriculum, or instructor qualifications.4

Organizational development

The profession of addiction counseling began to solidify in the early 1970s when Congress passed the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act. Adoption of this legislation provided substantial funding in the form of block grants to the states, both for treatment of patients with alcohol use problems and for training of individuals to work with this population.

During the same period, Congress established the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Banken and McGovern report that NIDA and NIAAA were the first organizations to establish specialized training focusing on counseling skills to meet the needs of addicted persons.5

States began to establish private substance abuse counselor certification boards at the time of the birth of two national organizations: the National Association of Alcoholism and Drug Abuse Counselors (now known as NAADAC, The Association for Addiction Professionals) and the International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse (ICandRC). Also during this time, the Association for Counselor Education and Supervision (ACES) developed academic minimum standards at the graduate level for professional counseling.

Following this effort was the formation of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the National Board for Certified Counselors (NBCC), both in the early 1980s. These organizations began to include within their mission standards for the certification of professional counseling. They eventually would play a role in the establishment of standards in addiction counseling as well.

Unfortunately during this time, states were given “the authority to determine acceptable professional credentials for individuals performing non-medical treatment services.”5 Horvatich and Wergin found in the field of addictions counseling that non-degreed individuals, or at the least high school graduates who were recovering addicts and alcoholics, were being recognized as qualified professionals to engage in counseling.6 Some states required counselors to have a certain number of years in the field before they could become state-certified. Only recently have some states required a bachelor's degree, yet others do not require certification if a counselor works in a state-certified facility. Any education that these individuals received was training provided by the state, state-certified institutions, and workshops and conferences, rather than academic institutions. Standards varied from state to state, with no established basis.

With the arrival of NAADAC and ICandRC, many counselors began to move toward the process of working on requirements for national certification. Certification standards here began to incorporate relevant courses in undergraduate education along with practicum hours directly associated with addicted clients, while verifying supervision with increasing clock hours for each level of certification. After educational and supervision hours were met, individuals would need to present an oral case presentation and pass a state or national exam. The exam tested individuals on what were identified as the “12 core functions” of addictions counseling: skills in screening, skills in intake procedures, orientation of clients, assessment, treatment planning, foundations of counseling, crisis intervention, client education, referral, reporting, record keeping and consultation with other professionals.7,8 These were viewed as the basic level of competency related to the practice of addiction counseling.

In the 1990s some states moved toward licensure of counselors in addiction counseling. Here, degree requirements and levels of certification varied, yet states began to see the need for academically prepared counselors who met addiction certification standards. In 1995, the counseling field took a major step through the joint efforts of the NBCC and NAADAC, when the Master Addiction Counselor (MAC) certification was introduced. The MAC certification required that candidates “have a graduate degree with emphasis on counseling, including course work in addictions as part of the qualifications,”9 along with postgraduate hours including supervision in addictions.

Theory and treatment

For some students currently in college, their introduction to the field of addictions comes while taking an introductory psychology or sociology class. A typical assignment is for students to attend one or more AA meetings and write a paper on their experience.10 Some colleges and universities might have one course on addictions, yet the course often does not address how to meet the treatment needs of substance users.

Page, Bailey, Barker, and Clawson found that while NAADAC and ICandRC saw the importance of academic preparation for the professional counselor, they did not require the completion of any academic program for the certification process.11 In 1993, the federal Center for Substance Abuse Treatment (CSAT) established the system of regional Addiction Technology Transfer Centers (ATTCs). Part of the task of the ATTCs was to “foster improvements in the preparation of addiction treatment professionals.”6 The ATTC network established a committee to review current addiction courses and programs. The committee found that the field of addiction counseling did not have a defined knowledge or skill set.

From there, the committee established four transdisciplinary foundations and eight practice dimensions, which incorporated 121 competencies. The transdisciplinary foundations for addictions counseling include Understanding Addiction, Treatment Knowledge, Application to Practice, and Professional Readiness.6 The practice dimensions are clinical evaluation, treatment planning, referral, case management, counseling of client and family, community education, documentation, and professional and ethical responsibilities.

In the 1980s, the addiction field began to evaluate the impact of the methods and techniques being used. Members of the field asked the question, “Is what we are doing actually helping clients?” This examination was brought about by the growth and influence of managed care and the move toward reimbursement of effective programs and therapies. No longer was the accepted standard going to be what worked for previous counselors, or exclusively a 12-Step approach to helping clients. Thombs and Osborn found that up to this point, counselors had held to experiential models that they encountered in their own recovery.12 Even treatment programs selected practices that were based on personal recovery rather than any kind of scientific data. But managed care was not going to expend funds on any methods, old or new, without proper study and data.13

Managed care began to move toward reimbursement of master's-level providers. Yet even with the presence of individuals with master's degrees who were certified in addictions, reimbursement for addiction services lagged behind that of mental healthcare, as the mental health field was seen as having stronger data to back up its approaches with clients.

At this point, greater ethical concerns were being talked about relative to addictions. No longer was addiction being viewed as limited just to alcohol and drugs. New behavior syndromes around gambling, eating, and sexual disorders were placed under the addiction umbrella. These syndromes further accentuated the need for competent professionals and a proven theoretical approach. It was soon discovered that some clients were getting treatment from individual therapists and programs that did not have training or certification in addictions. Scope of practice and standards of care were being evaluated and found lacking. Some forces in managed care were concluding that the treatment of addictions was costly and constituted a revolving door.14

Looking to the future

With all that has been done in various corners of the profession regarding certification standards, competencies, and knowledge and skill development, there still does not exist a broad consensus on a national academic standard or course of study. This can result in ethical concerns for the profession of addictions counseling. These concerns are related to some of the same ethical issues of which counselors in mental health are aware (e.g., confidentiality, abuse, dual relationships). Only 14 states currently require addiction counselors to have training or education in ethics. The challenge of achieving consistency is compounded by the presence of various certification levels based upon passing an exam, years in the field, and scope of job duties.15

There are some circumstances in which an individual might function above his/her level of certification, such as a counselor with a bachelor's degree formulating a treatment plan or giving an interpretation of an assessment to a client. Even with the presence of a code of ethics through NAADAC, and the fact that the national certification exam has an ethics domain, this does not ensure that ethical principles will always be practiced, applied properly, monitored, or remembered.

Klutschowski and Troth suggest that a lack of direction produces a lack of expectations of the addiction counselor regarding competency and knowledge.16 West and colleagues conclude that despite the various codes and state standards, there remains a need for a national educational standard for the profession.9 They conclude that without this, society will see the counselor as lacking professionalism—and the addict as a second-class citizen receiving second-class treatment.

Yet in other counseling-related disciplines such as marriage and family therapy, addiction counseling is being seen as a valued allied profession. CACREP is moving toward introducing addiction course criteria in all the programs it accredits.17 It is seen that the majority of students in CACREP programs receive little to no coursework in addictions, yet end up working with these clients after graduation. This is being viewed as a major ethical concern.

The profession of addiction counseling must now move forward and consolidate its body of knowledge, competencies, and skills into a cohesive nationally standardized academic course of study. Additional areas of focus must be added to bachelor's- and master's-level courses of study. These would include but not be limited to family dynamics, relapse prevention, dual disorders, and cultural issues. Given the influence of managed care, institutions of higher learning would do well to offer degrees of a crossover or hybrid nature with an emphasis on co-occurring disorders, quality control, utilization review, grants, policy, and clinical supervision.

As of this writing, NAADAC, The Association for Addiction Professionals is in consultation with other organizations to move forward with a review of current degree programs, courses, and course content relevant to counselors' scope of practice. The mission is to create a national standardization of addiction studies, from the associate to the doctoral level. We will keep the field apprised of our progress.

References

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