Turnover, inadequate training continue to plague substance use disorder workforce

The substance use disorder profession suffers from what we call “The Graying Out of Leadership.” We currently have a great number of executive-level leaders who will be retired over the next five to ten years. Our profession has very few identified, effective leadership training programs that will take the workforce to the next level. Even though most recent studies show that there is an influx of young people coming through the clinical ranks, there is not enough capacity to compensate for those that are aging out of the profession.

So what are some of the critical issues and trends that impact the workforce? In large part, prevention and treatment services have been driven more by tradition than science over the last few decades. Most recently, this profession has talked more about evidence-based best practices. Oftentimes it can take more than a decade to get evidence-based best practices out into the general population. We found that it takes five years of a demonstration project to show what is qualified as a best practice, and it takes another five years to write it, document it, disseminate information, train people, and incorporate these practices into services. Because of this time frame, our field has begun to look at what are called “Promising Practices.” Here is how it works: While practices are being researched, clinicians have begun to implement the new models of care based on what we believe to be good results. These practices are not evidence-based but are in the process of being researched and documented. Why is this helpful? It allows for practices to be utilized in a more timely manner.

In part one of this blog, we explored how more people than ever are receiving higher degrees within the substance use disorder field. But what we haven’t answered yet is this: How many are still not required to have a degree? At present, the skill set needed to treat our populations is rapidly changing. People in need of care are experiencing more co-occurring disorders. Clinical staff in our profession are not trained well enough to deal with the severity of illness that the populations are presenting with. Let’s take, for example, the state of California. California’s facility licensing regulations only require that 30% of counseling staff be licensed or certified under the California Department of Health Care Services. All other counseling staff can be registered pursuant to Section 13015. In order to receive registrations it takes only a standing letter that says the individual is working in the substance use disorder field. After this registration, a person has two years in which they are supposed to get licensed or certified. It is within this time frame that people may or may not stay in the field, which causes attrition within work environments.

Lastly, our workforce faces recruitment and retention issues. The most recent study showed that there is an annual turnover of 18 to 25% within substance use disorder treatment organizations. Compare this to the average turnover rate of other occupations, which holds at 11%. The greatest amount of turnover is voluntary, with the number one contributing factor being low salaries. Another reason why this profession faces a higher turnover rate is little upward mobility. Most agency directors and treatment staff entered into the field in the roles that they currently hold. So there isn’t a lot of growing from the ground up through agencies. For most treatment facilities, inpatient or outpatient, one of the greatest difficulties is in having a qualified staff. Typically there are a lot of candidates for hire, but few of them meet the minimum job requirements. This is due in part to the lack of training/education available in the substance use disorder profession.

One study listed the top 10 retention problems being a lack of:

1. Living wage and healthcare benefits

2. Retirement plans

3. Opportunities to grow and advance

4. Clarity in job role

5. Autonomy or having input to decisions made

6. Manageable work loads

7. Having administrative support

8. Confident and cohesive team for coworkers

9. Lack of a supportive supervisor

10. Lack of rewards for exceptional performance

So what are some identified solutions for strengthening our profession?

First, we must recruit young professionals between the ages of 20 and 30. They should have diverse backgrounds so that our workforce better represents the populations they are serving. We must also take steps to improve student recruitment within educational institutions by focusing on underrepresented groups. We must push to have substance use disorder curricula within historical Black colleges, Hispanic-serving universities, and Tribal colleges. Let’s begin to look at loan forgiveness programs within higher education. As treatment professionals, it is our job to encourage the current workforce and practitioners to pursue higher credentials and degrees. This ensures that they too are better able to deal with the increasing needs and severity of illnesses represented in current populations. We need to have more clinical directors implement supervision that integrates observation methods. By utilizing role playing, and tape review, we can enhance the skills and techniques of direct clinical care teams. This will help us serve the influx of patients that will be potentially served under the Affordable Care Act (ACA). We need the creation of work competencies that are based on educational standards that are consistent nationwide. There needs to be an increase in computer literacy in the workforce so that more electronic medical records are instituted and are better used.

By implementing these changes, we will continue to bridge the gap between mental health professionals and substance use disorder professionals so that behavioral health truly becomes one umbrella. Let us challenge organizations to get better at creating professional development plans that are designed to strengthen the skill set of their current workforce. Let us create and design more mentorship programs to provide greater opportunity for upward mobility. And finally, we must fight for better payment for services in order to pay the workforce more significantly so that we can skillfully serve the addicts and families that still suffer.

References and suggested reading

Gallon SL, Gabriel RM, Knudsen JR. The toughest job you’ll ever love: a Pacific Northwest Treatment Workforce Survey. J Subst Abuse Treat 2003; 24 :183-96

Kaplan L. Substance Abuse Treatment Workforce Environmental Scan. Washington, D.C.: Abt Associates Inc. ; 2003.

U.S. Department of Health and Human Services. Strengthening Professional Identity: Challenges of the Addiction Treatment Workforce. Rockville, Md. : Department of Health and Human Services ; 2005.

Substance Abuse and Mental Health Services Administration. An Action Plan for Behavioral Health Workforce Development: Executive Summary. Rockville, Md: Department of Health and Human Services; 2005.

The Annapolis Coalition on Behavioral Health Workforce. Building a National Strategic Plan for Behavioral Health Workforce Development: Executive Summary. Cincinnati ; 2007.