Recent statutory changes affecting clinical providers in Minnesota continue to transform the traditional “Minnesota Model” of 12-Step treatment into a hybrid behavioral health/medical model quite unlike its predecessor. Minnesota's traditional chemical dependency treatment model has been dramatically affected by two major changes: the state's implementation of American Society of Addiction Medicine (ASAM) dimensional criteria for treatment planning in state-licensed facilities, and operationalizing of the Board of Behavioral Health and Therapy, a state board governing licensure of alcohol and drug counselors, or LADCs.

In the case of the ASAM criteria, Minnesota responded to national trends. On Jan. 1, 2005, the state implemented “Rule 31,” the latest regulation governing the licensing of chemical dependency programs. ASAM's six identified “dimensions” of recovery were deliberately written directly into the rule as part of an overall aim to change significantly the nature of traditional addiction treatment services.

The second change, involving the efforts of the Board of Behavioral Health and Therapy, addressed a latent need to professionalize further the addiction counseling degree, training, and licensure processes. The old saw about how one becomes a counselor (“All you need is an AA Big Book and a coffee cup”) quaintly obscured solid economic and clinical reasons for raising professional standards. Counselors required more clinical experience prior to employment, improved ethics training, and more comprehensive skill sets.

The state's new licensure rules will require would-be addiction counselors in Minnesota to complete a four-year degree program including five months of clinical internship and 2,000 hours of post-degree clinical supervision. Today's requirements for success in the addiction counseling market cannot be explained away by mere differences in treatment philosophies or generational gaps. They represent a significant shift in actual needs.

The new-look counselor

Amid an enrollment surge in counseling programs in our state, changes in student characteristics appear to be an even more dramatic development. Newer students differ from traditional addiction counseling students in that many have little or no “recovery experience,” which until recently was considered a benchmark of employability in the chemical dependency field. Conversely, today's graduates are demonstrating considerable skills that many earlier graduates did not possess. Traditional counselors entered the field predominantly in response to a calling and had to meet only minimal requirements (in relation to other licensed professionals) to become work-ready. Today's students are viewing the LADC as an alternative career choice to social work or education—similar tracks leading to comparable salary scales. More students today are choosing addiction counseling because it technically offers licensure-related income potential.

The model is changing from experience-based to competency-based, possibly crowding out some traditional students yet opening the door to a new generation. This dynamic is generating a vibrant dialogue at almost every level regarding a changed future for addiction counseling. Reviewing and understanding these skill sets required for success in an ASAM-based environment has helped our programs prepare for a period characterized by large-scale and lasting change:

Improved Organizational Skills. Current and future addiction counselors undoubtedly require strong organizational skills. Adaptation of the ASAM criteria has ushered in the development of an extraordinarily useful multidimensional, multidisciplinary addiction counseling model. For treatment program directors and counselors, the ASAM model's usefulness depends on organizing and tracking individual client, aggregate caseload, and milieu variables. Imagine even a simple scenario involving a counselor with a caseload of 15 clients presenting with “multiple complex problems.” Assessment and treatment planning over six dimensions for any length of time can generate literally hundreds of data pieces. This fact alone points out potential weaknesses of any ASAM-based model: information overload, increased paperwork, and decreased clinical time.

Our programs' own model recognizes a universe of 75 potential ASAM treatment problems and hundreds of goals and objectives, matched with potentially thousands of methods. Counselors need to develop effective organizational skills demonstrating how client needs are met by chosen methods to achieve treatment planning goals. We have come to find that counselors need these skills not only for effective case management, but also to counter an increasingly sophisticated utilization review system as payers require evidence based on ASAM levels of care.

Strong Technology Skills. Our next generation of counselors has the technological skills that link organization, communication, and programmatic support. Electronic charting combines technology and organization, but it is not universally available or affordable. Counselors working in programs lacking administrative support, those employing staff with advanced degrees, or programs utilizing sophisticated software packages require counselors with solid computer-based writing, spreadsheet, and presentation skills. These skills are increasingly required to maintain and enhance program quality, employee training, and the delivery of clinical material.

Technology today is not only about organizational needs. Trends indicate a rapid escalation in attempts by younger clients to challenge the physical boundaries of treatment via technology. Our experience has shown that new counselors need to be as technologically savvy as their clients; many communication technologies can be used in ways adversarial to the treatment process. Clients are communicating from within treatment environments via text messaging, Internet sites, and cell phones in ways that were impossible five years ago. Clients also are posting information about their treatment experiences on public and private web pages. Few clinical policies controlling such technological variables are in place. Our newest counselors seem well-versed in the many ways in which technology can enhance therapeutic as well as anti-therapeutic communication. This is an area we all need to watch as technology rapidly evolves.

Increased Training in Behavioral Health. ASAM is a medical/behavioral health model. Many traditional 12-Step programs have had great difficulty in adapting their traditional material to ASAM's psychological and psychiatric terminology. In some cases, ASAM assessment tools resemble generic mental health tools. Counselors are responsible for symptom identification, management, and communication of progress in this area to multiple parties, including medical and psychiatric providers and third-party reviewers.

Doing this effectively requires higher-level training than what traditional counselors received. In our academic programs, new students are taught how to assess, diagnose, and conduct treatment planning within the ASAM model. This may be more difficult than teaching in the traditional framework, but it appears to produce qualified and effective counselors. Research on “process addictions” such as gambling and shoplifting is already appearing in student textbooks, and our next counselors will be the ones expanding our offerings in these areas.

Expanded Cultural Competency. A common axiom in the addiction field is that addiction distorts perception. Many of our newest students understand cultural variables in ways that lead to more effective treatment planning. Largely because of the Internet, students today have more flexible concepts of cultural competency that expand beyond the elements of sex, race, and gender to include other cultural and sub-cultural factors relevant to the treatment process. Students today are exposed to a much more diverse campus population and are educated on topics such as women's issues, interpersonal violence, and multiculturalism in ways that did not exist a decade ago. Understanding how our entire culture influences perception, not only about race and gender but about respect, cultural status, interpersonal violence, and self-image, is essential to understanding client behavior and establishing rapport independent of any politically defined cultural variables.

One illustration of this involves the transformation of the traditional concept of respect based on accomplishment and how it has been replaced with an idea of respect generated by fear depending on how much “street cred” a person has accumulated. This idea has filtered into almost every area of treatment, yet has little to do with race, gender, or sexuality. We experience it as evolving across all cultural and socioeconomic backgrounds as a variable reinforced in music, television, and advertising. Our newest counselors seem to understand these intricacies better, and they represent our key to establishing rapport across broader and more subtle cultural connections.

Effective Communication Skills. Communi-cation skills are used by counselors to address difficult people and handle difficult information effectively. Today's interns appear to be sensitive to a wider range of socioeconomic and interpersonal dynamics. This may be a result of their broadened cultural exposure via the Internet. These qualities are necessary in an increasingly diverse “boutique” treatment market offering opportunities for specialization far beyond the traditional chemical dependency model. Counselors capable of understanding and synthesizing these trends effectively will best promote program strengths and improve client retention and satisfaction.

Conclusion

These are dynamic times for addiction counseling graduates and interns. The shift in the addiction counseling field from an experience-based model to a competency-based model reflects larger trends in health care and human services. A broadening cultural awareness of health and well-being is drawing us all into uncharted territory. Recruiting and training today's interns and graduates possessing many of the above-mentioned professional competencies will have a great impact on programs' viability.

While current changes at the clinical and licensing levels in Minnesota have highlighted the prevalent differences in counselor attributes, the changes have been largely beneficial. We are experiencing a renewed energy and new perspective, and we are learning new skills. While it is true that many addiction counseling graduates today are not in recovery, our experience shows that they possess skills of equal importance and can be as effective and valuable to any clinical team as their predecessors have been.