Challenges abound in the substance use disorder workforce

There are many workforce issues that we experience as treatment professionals working in the substance use disorder field. When we analyze these issues, I think it is important for us to understand the history of our profession. If we look back 50 years into this profession, the behavioral health field was nonexistent. During that time, we had mental health, alcoholism, and drug addiction. These were three separate distinct professions and never the twain did they meet. In the mental health arena we had psychiatrists, psychologists, and licensed social workers. All were providing care to those that suffered from chronic and persistent mental illness. In the “alcoholism” category we had recovering alcoholics, a 12 Step movement, and the beginning of what we now call treatment. Through this, the Minnesota Model emerged. In 1958, the Synanon organization was birthed by Charles Dietrich and used by recovering addicts. Fifty years ago we saw alcoholism and drug addiction as two separate and distinct problems, not one in the same. Thirty-five years ago, in the 1970s, the alcoholism and drug addiction professions began to see the need for certifications.

Each state was a little bit different during this time. There were minimal standards for people working with those that suffered from chemical dependency. The profession eventually created what is known as the “12 Core Functions.” Our workforce began internationally acknowledging a system that recognized licensed chemical dependency counselors.

In years gone by, there were many people in recovery who were compassionately and lovingly helping others suffering from alcoholism. Yet little education was needed. In order to have a license today, the educational level has been increased from those who barely finished high school or who were holding GEDs. In both professions we have come full circle to a place where we are now using peer support.

The way that we reference addiction and alcoholism has changed in our profession. Within the last 15 years we have begun to identify what is now seen as the “behavioral health field.” Our profession went from “alcoholism and drug addiction” to “chemical dependency,” from “chemical dependency” to “substance abuse” and from “substance abuse” to “substance use disorders.” Currently we are looking at both “substance use disorders” and “persistent mental illness” under an umbrella called behavioral health. We are seeing a melting pot of professional credentials: from LPCs to MFTs to CIPs to CADCs and LCDCs to psychologists, psychiatrists and physicians, all of whom have all types of certifications in addiction medicine. They are studying different topics, and they come together in what we nicely like to call multidisciplinary teams. From one provider to the next, these teams vary dramatically and there is a lack of consistency. There is no Yale, Harvard, or Stanford to educate those that consider themselves substance use disorder professionals.

I believe providing information about the history of this workforce helps in understanding why individuals enter this profession. Here are some reasons why individuals choose to work in the substance use disorder field. According to a previous study:

• 95% of people indicated that they were drawn to this field because of the challenging and interesting work

• 91% have a desire to work in a helping profession

• 78% were motivated by the substance use disorder problems that they saw in their community

• 61% indicated that they, their family member, or their friend had a substance use disorder problem

In the United States today; more than half of the substance use disorder workforce is clinically trained or a mental health professional. The current overall education data from 2011 shows 98% of states require mental health professionals to have a master’s degree or better. Forty-five percent of states do not require a college degree in order to be qualified as a substance use disorder counselor. This does not mean that they do not require a certification. So again, there is still a need for a higher qualification in order to be in the mental health profession than there was 50 years ago.

Clinical directors working in the substance use disorder arena, on average, have about 17 years of experience. Fifty-seven percent of all clinical directors said that they have a master’s degree, while 8% hold doctoral degrees. Currently, 36% of direct care staff have a master’s degree, which still leaves the greatest portion of direct care staff without master’s degrees.

Let’s take a look at the gender of treatment professionals. The majority of the clinical workforce is female, while administrative and agency directors are more frequently male than female. The National Association of Addiction Treatment Providers (NAATP) has a current board makeup that seats CEOs and administrators of addiction treatment programs. Out of 25 board members, 80% of them are male. The average age of clinical directors in the United States is 52, while 51% of direct care staff are between the ages of 25 and 44.

What do the majority of substance use disorder professionals look like? According to a 2012 report from the Addiction Technology Transfer Center Network, 86% of clinical staff, and 64% percent of direct care staff, are Caucasian. A 2010 SAMHSA report found that racial and ethnic minorities account for 30% of the population that we treat. Only 19.2% of psychiatrists, 5.1% of psychologists, 17.5% of social workers, 10.3% of counselors, and 7.8% of marriage and family therapists are minorities. This tells us that there is little racial or ethnic diversity, which makes it very difficult to be representative of the patients the workforce is seeing.

One of the biggest challenges that plagues the substance use disorder profession is salary. Salary is known for being notoriously low. A behavioral health chief medical officer’s salary ranges between $100,000 and $150,000, vs. their counterparts in general healthcare organizations who make between $180,000 and $300,000. A 2011 study found that direct care workers providing 24-hour care in a residential treatment setting make on average $23,000 a year. Compare this to the median salary of an assistant manager at Burger King who makes about $25,000 per year. In sum, higher salaries are correlated to having a higher degree status, a management role, more years in the profession, or holding a job in an urban setting.

Let’s look at demand vs. capacity. Data from a 2010-11 report indicated that approximately 21.6 million persons in the United States, 12 years or older, needed treatment for substance use disorders. A survey on counselors in 2012 indicated that nationwide there are 89,000 substance use disorder counselors. By 2022, they estimate that only an additional 28,000 counselors will join the ranks, and some of those 89,000 persons will be retired by then. With the onslaught of the Affordable Care Act (ACA), it is anticipated that an additional 6 to 10 million Americans who were previously untreated for chemical dependency will now have access to care. This shows us that there is a great disparity between how many professionals there are to provide care vs. the number of people that are already in need. As treatment professionals, we will now have a greater number who will need to access our services.

This profession sees real challenges in the rural and remote areas of the country. Populations living in these areas have limited access to care and transportation. People working in these parts of the country also have limited access to the education that they need in order to provide adequate care to those suffering from chemical dependency. In general, our country has a critical shortage of clinically trained professionals. There is also a need for those who treat children, youth, and older adults who suffer from substance use disorders.

Stay tuned for my next blog entry, which will cover some of the suggested solutions for these workforce issues. Also, feel free to leave a comment with your thoughts and suggested solutions!

Resources

• The Annapolis Coalition on Behavioral Health Workforce. Building a National Strategic Plan for Behavioral Health Workforce Development: Executive Summary. (Cincinnati, OH, 2007).

• Behavioral health salary survey. National Council for Community Behavioral Healthcare. (2011).

• Dilonardo, J. Workforce Issues in Integrated Behavioral Healthcare: A Background Paper. Unpublished Paper, National Council for Community Behavioral Healthcare. (2011).

• Gallon, S.R, Gabriel and J. Knudsen.  ″The Toughest Job You’ll Ever Love: A Pacific Northwest Treatment Workforce Survey,″   Journal of Substance Abuse Treatment 24(3). (2003).

• Kaplan, L. Substance Abuse Treatment Workforce Environmental Scan, (Washington, DC: Abt Associates Inc., 2003).

• Ryan, O., Murphy, D., Krom, L. Vital Signs: Taking the Pulse of the Addiction Treatment Workforce, A National Report - Executive Summary. (Kansas City, MO: Addiction Technology Transfer Center National Office in residence at the University of Missouri-Kansas City, 2012).

• Substance Abuse and Mental Health Services Administration. Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues. (2013).

• Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of national findings. (NSDUH Series H-41, HHS Publication No. (SMA) 11-4658). (Rockville, MD: Substance Abuse and Mental Health Services Administration. 2011).

• Substance Abuse and Mental Health Services Administration (2012a). Mental Health, United States, 2010. (HHS Publication No. (SMA) 12-4681). (Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2010).

• Substance Abuse and Mental Health Services Administration. An Action Plan for Behavioral Health Workforce Development: Executive Summary. (Rockville, MD: DHHS, 2005).

• U.S. Department of Health and Human Services. Strengthening professional identity: Challenges of the addiction treatment workforce. (Rockville, MD, 2005).