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Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 42.)
Mental health and addiction labor force problems directly affect treatment access, quality, and cost. Without addressing gaps in personnel and training, the behavioral health field will struggle to meet the needs of the growing numbers of people living with cooccurring disorders (CODs).
Although current workforce challenges may seem daunting, substance use disorder (SUD) treatment supervisors and administrators can help confront and overcome these difficulties by creating, implementing, and sustaining professional development and training opportunities within their organizations.
This in turn will help support the uptake and utilization of best practices.
Recruitment and retention priorities are urgently needed because of the challenging nature of the addiction and mental health service professions, which leads to high rates of staff burnout and turnover.
Professional education and accreditation, combined with mentoring and supervision, can help increase adoption of core and advanced clinical competencies, increase providers’ comfort with working with people who have CODs, reduce stigma surrounding the profession/field, and provide structured career development.
Availability, quality, and cost of SLID treatment and mental health services are intricately tied to the current state of the behavioral health workforce. Without a robust, sizeable labor force, how will people with mental disorders and addiction problems have their needs met? Without enough trainees entering the field or staff willing to stay in their jobs long term, how will addiction and mental health service organizations keep their doors open? What sort of ripple effects might an understaffed or ill-prepared workforce have on our healthcare system, economy, and society as a whole?
Rather than serve as a primer on labor difficulties in the mental health and addiction fields, this chapter—addressed primarily to supervisors and administrators—provides an informative update on the current state of mental health and addictions professions. The goal is to help supervisors, administrators, and other organizational leadership understand aspects of the workforce relevant to their organization's ability to provide high-quality, cost-effective, evidence-based services for CODs and help them feel better prepared to address workforce gaps in their own agency.
This chapter is divided into two main sections:
The first half addresses recruitment, hiring, and retention in the behavioral health workforce. Finding, getting, and keeping the right employees is critical to ensuring the long-term sustainability, viability, and effectiveness of the field. Toward that end, the chapter contains links to practical, web-based resources for programs and administrators, including toolkits and manuals.
The second half of this chapter focuses on ensuring the competency and professional development of program staff. This section includes detailed discussions about the role of training, supervision, and credentialing, all of which are necessary components of preparing the field to deliver evidence-based care and fostering increased service provision.
Note that general guidelines aimed at supervisors and administrators serving people with CODs are in Chapter 2 and information about implementing various treatment models and settings is in Chapter 7.
This chapter discusses training needs for addiction counselors working with clients who have CODs. However, any behavioral health service provider in any setting (e g., primary care, a social worker's office, SUD treatment, a psychologist's/psychiatrist's office) should have the skills and competencies to recognize CODs and provide at least a basic screening that encompasses CODs, with enough knowledge of community resources to refer for integrated COD treatment if the provider can't provide such treatment himself/herself.
As of March 2020, the Health Resources and Services Administration (HRSA) has identified approximately 5,537 mental health professional shortage areas in the United States, requiring 6,387 mental health practitioners to fill the shortage (HRSA, 2020). The behavioral health workforce is fraught with profession gaps and similar challenges that serve as barriers to treatment access for people with mental disorders and SUDs. For instance (Olfson, 2016; Weil, 2015):
Formal education in psychology and psychiatry is time consuming and costly, making it harder to recruit and retain trainees.
The number of medical trainees specializing in psychiatry is shrinking.
Within psychiatry, types of services provided are variable (e.g., medication management only vs. psychotherapy and pharmacotherapy).
Psychiatrists are less likely to accept Medicaid than other medical specialties, which is particularly damaging to individuals with serious mental illness (SMI), like schizophrenia, who often require public assistance. Psychologists also are unlikely to accept Medicaid given low reimbursement rates.
Psychologists and psychiatrists tend to be disproportionately clustered in certain geographic regions, leaving shortages in rural areas (vs. more affluent urban and suburban areas) and particular regions of the United States (e.g. Midwest, Deep South).
People with SMI are grossly underserved due in part to factors like lack of formal training opportunities in SMI and low provider comfort with working with these populations.
Social workers and primary care providers can help fill critical workforce and service gaps left by psychiatry and psychology (particularly in treating clients with SMI), but this will require additional training in behavioral health assessment, diagnosis, and treatment and better compensation.
A focus group of mental health and SUD treatment providers identified organizational and system-related factors they believed hindered their ability to adequately care for clients with CODs (Padwa, Guerrero, Braslow, & Fenwick, 2015):
Lack of support for COD services, such as low allocation of resources, discontinuing consultations with outside COD experts, discontinuing onsite drug testing of clients, and not implementing integrated care procedures even when already developed by staff
Lack of COD training opportunities
An inability to bill for CODs (e.g., certain organizations would only permit billing for mental health services and not SUD treatment)
Lack of local addiction services, which make coordinating care, referring clients to specialty services, and linking clients to needed resources more difficult. Even when these services are present, available slots are limited and wait-times are often long.
Large caseloads and limited time to work with clients
Difficulty Initiating and maintaining contact with outside SUD treatment providers, especially with providers in residential treatment settings
Fragmented, nonintegrated care that results In different providers using different (and sometimes opposing) treatment approaches with the same client. This Is particularly problematic when clients on pharmacotherapy attend mutual-support groups or treatment programs that strongly discourage psychotropic medication.
The documented workforce shortage in SUD treatment and mental health services underscores the need for aggressive, effective, and even creative recruitment and hiring strategies and policies. Extended vacancies in behavioral health service positions leave programs—and the clients they serve—vulnerable to negative outcomes like further turnover, high stress, low morale, and fragmented, ineffective care.
The ability to recruit and hire quality, long-term employees first requires attracting the right candidates. Job postings and advertisements in multiple outlets, such as websites, on social media, at job fairs, in newspapers, and within the community, can increase exposure and widen the potential pool of applications. Less traditional but nonetheless effective places to advertise include churches, synagogues, and other faith-based organizations; community welfare agencies and housing offices; shopping centers; and health clinics and senior centers. Staff referral incentives encourage current employees to act as recruiters and also help increase retention.
Exhibit 8.1 outlines steps from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Recruitment and Retention Toolkit, designed to aid behavioral health service organizations in building more effective recruitment, hiring, and retention practices. The toolkit offers a six-step approach and includes numerous resources (e.g., templates, samples, worksheets) to guide programs at each step (see “Resource Alert: Recruitment and Retention Resources for the Behavioral Health Workforce”).
EXHIBIT 8.1. Building an Effective Recruitment and Retention Plan for Behavioral Health Service Providers.
RESOURCE ALERT: RECRUITMENT AND RETENTION RESOURCES FOR THE BEHAVIORAL HEALTH WORKFORCE.
Behavioral health service provider turnover and burnout can strain organizational infrastructure, prevent clients from receiving much-needed services, and weaken the field as a whole. The Department of Labor's Bureau of Labor Statistics estimates a national turnover rate across all professions of around 3.7 percent (Bureau of Labor Statistics, February 11, 2020). By comparison, turnover in the behavioral health field is quite high. Among addiction counselors and supervisors, average annual turnover has been estimated to range between 23 percent and 33 percent (Eby, Burk, & Maher, 2010; Knight, Broome, Edwards, & Flynn, 2011; Laschober & Eby, 2013) and between approximately 17 percent and 26 percent among mental health therapists and supervisors (Beidas et al., 2016; Bukach, Ejaz, Dawson, & Gitter, 2017). In both sectors, turnover is usually voluntary—an additional cause for concern.
Reasons for behavioral health service providers to leave their jobs voluntarily include burnout (driven by factors like high workload and not having a clear understanding of job roles and duties), low levels of support from supervisors and coworkers, and job dissatisfaction (related to high workload and poor supervisory relationships) (Garner & Hunter, 2014; Yanchus, Periard, & Osatuke, 2017; Young, 2015). (Also see the section “Avoiding Burnout.”)
Turnover is destabilizing to an agency for numerous reasons (Young, 2015). Turnover often negatively affects an organization's capacity to serve clients, efficiency, profit-earning potential, operational spending, and staff morale and stress levels. The issue of staff turnover is especially important for professionals working with clients who have CODs because of the limited workforce pool and the high investment of time and effort involved in developing a trained workforce. It matters, too, because of the crucial importance of the treatment relationship to successful outcomes. Rapid turnover disrupts the context in which recovery occurs. Clients in such agencies may become discouraged about the possibility of being helped by others.
Turnover sometimes results from the unique professional and emotional demands of working with clients who have CODs. On the other hand, most providers in this area are very dedicated and find the work to be rewarding. Evidence suggests that turnover may be connected to providers’ feelings of preparedness to serve clients with CODs. SUD treatment providers who leave an organization but stay in the field (program turnover) are more likely to have formal education, training, and experience in SUDs than addiction counselors who leave an organization and withdraw from the field entirely (profession turnover) (Eby, Laschober, & Curtis, 2014). This suggests that programmatic training and professional development could help strengthen not only the individual agency but the workforce as a whole.
Turnover in the addiction field is linked to attitudinal and organizational predictors, including lower job satisfaction, lower job involvement, less support from supervisors or coworkers, and poor role manageability (Garner & Hunter, 2014). These factors are largely modifiable and are important targets for monitoring and implementing programmatic changes to help providers feel satisfied, supported, and competent on the job (Yanchus et al., 2017). Exhibit 8.2 offers methods for reducing staff turnover.
EXHIBIT 8.2. Reducing Staff Turnover in Programs for Clients With CODs.
A logical approach to reducing turnover is to prevent the occurrence of burnout. Burnout has been reported in as much as 67 percent of professionals in the mental health field (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). Reasons mirror those for turnover, including, but not limited to, demanding workloads and not feeling rewarded by one's work (Young, 2015). Often, mental health service and SUD treatment providers are expected to manage growing and more complex caseloads. “Compassion fatigue” may occur when the pressures of work erode a counselor's spirit and outlook and begin to interfere with the counselor's personal life; see also Treatment Improvement Protocol (TIP) 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (Center for Substance Abuse Treatment [CSAT], 2000c, p. 64). Assisting clients who have CODs is difficult and emotionally taxing; the danger of burnout is considerable. Program administrators must maintain awareness of the problem of burnout and the benefits of reducing turnover. Program administrators must demonstrate interest in staff well-being to sustain morale and team cohesion.
To lessen burnout among counselors working with a demanding caseload that includes clients with CODs, behavioral health service organizations should (Atkinson, Rodman, Thuras, Shiroma, & Lime, 2017; Oser, Biebel, Pullen, & Harp, 2013; Morse et al., 2012):
Create a collegial environment for staff, particularly by encouraging support between coworkers.
Increase the amount of supervision given to staff, not only for skill building but because supervision can serve as another outlet for emotional support and encouragement much needed by providers.
Advocate for and help staff cultivate self-care and self-compassion. For instance, provide staff with cognitive-behavioral interventions to improve their coping skills, foster positive attitudes, and increase relaxation, and promote mindfulness.
Decrease workloads, increase provider autonomy, and clarify roles and expectations.
RESOURCE ALERT: DEALING WITH STRESS IN BEHAVIORAL HEALTH SERVICE SETTINGS.
This section focuses on some key areas programs face in developing a workforce able to meet the needs of clients with CODs. These include:
The attitudes and values providers must have to work successfully with these clients.
Essential competencies for providers (basic, intermediate, and advanced).
Opportunities for continuing professional development as well as professional licensure.
Areas of weakness exist in many COD programs’ services, staff training/supervision, and staff competencies (Petrakis, Robinson, Myers, Kroes, & O'Connor, 2018). Of 256 U.S. addiction treatment and mental health service programs surveyed (McGovern et al., 2014), only 18 percent of SUD programs and 9 percent of mental disorder programs were COD capable. In a survey of 30 publicly funded COD programs (Padwa et al., 2013):
About 43 percent met or exceeded criteria for COD-capable programming.
About half had mission statements, organizational certification and licensure, service coordination, and financial incentives focused on treating either mental illness or SUDs but not both.
24 of 30 programs could only bill for mental health services or SUD treatment but not both.
18 programs routinely used clinical interview assessment techniques adapted to CODs, but only 6 of those programs had formal standardized screening tools for CODs. Only five programs had formal procedures in place to conduct comprehensive assessments of clients who screen positive for CODs.
Most programs lacked stagewise treatments specifically for CODs, including a lack of psychoeducation about and recovery support for both mental disorders and SUDs.
18 programs had onsite prescribers.
23 programs used supervision and consultation to address mental conditions and substance use. However, most programs did not have licensed or otherwise competently trained staff to provide COD services other than pharmacotherapy management.
Over 80 percent of the sites offered direct staff training in basic competencies (e.g., prevalence, signs and symptoms, assessment procedures), but only about 57 percent of programs had staff with at least some advanced competency training in treating CODs.
The consensus panel underscores the importance of an investment in creating a supportive environment for staff that encourages professional development to include skill acquisition, values clarification, training, and competency attainment equal to an investment in new COD program development. An organizational commitment to both is necessary for successful implementation of programs. Examples of staff support may include standards of practice related to consistent high-quality supervision, favorable tuition reimbursement and release-time policies, helpful personnel policies related to bolstering staff wellness practices, and incentives or rewards for work-related achievement. Together these elements help create an environment in which high-quality service can thrive.
In support of all behavioral health service providers embodying the “no wrong door” policy for service readiness, the consensus panel strongly suggests all administrators consider providing COD training as part of their workforce development for staff, even if their program is not a specialty COD program.
Attitudes and values guide the way providers meet client needs and affect the overall treatment climate. They not only determine how the client is viewed by the provider (thereby generating assumptions that could either facilitate or deter achievement of the highest standard of care), but also profoundly influence how the client feels as he or she experiences a program. Attitudes and values are particularly important in working with clients who have CODs because the counselor is confronted with two disorders that require complex interventions.
Attitudes and values are important targets of professional development and training. Some research indicates that behavioral health service providers and trainees have more negative attitudes toward people with SMI and with SUDs—either separately or in combination—than they do toward people with medical or other mental disorders, and that attitudes toward individuals with comorbid SUDs and psychotic disorders in particular are among the most negative and worsen over time (Avery et al., 2016; Avery et al., 2017; Avery & Zerbo, 2015; Mundon, Anderson, & Najavits, 2015). Education-focused training and increased exposure to SMI, SUD, and COD populations could potentially help increase provider comfort, competency, and confidence while diluting personal biases that directly affect clinical care.
The essential attitudes and values for working with clients who have CODs shown in Exhibit 8.3 are adapted from Technical Assistance Publication 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (CSAT, 2006a). The consensus panel believes these attitudes and values also are consistent with the attitudes and values of the vast majority of those who commit themselves to the challenging fields of SUD treatment and mental health services.
EXHIBIT 8.3. Essential Attitudes and Values for Providers Serving Clients With CODs.
Several strategies can help reduce stigma and negative attitudes and opinions among behavioral health service providers about people with CODs. These include (Avery et al., 2016):
Increasing didactic and clinical exposure to clients with these disorders to improve provider knowledge and experience.
Providing education about commonly held negative attitudes and misperceptions about CODs, and encouraging trainees to reflect on and discuss their own experiences and beliefs (e.g., via journaling, writing reflection papers).
Offering supervision and mentorship by senior providers trained in addiction medicine with experience working with CODs.
Provider competencies are the specific and measurable skills providers must possess. Several states, university programs, and expert committees have defined the key competencies for working with clients who have CODs. Typically, these competencies are developed by training mental health and SUD treatment counselors together, often using a case-based approach that allows trainees to experience the insights each field affords the other.
One challenge of training is to include culturally sensitive methods and materials that reflect consideration for the varying levels of expertise and background of participants. The consensus panel recommends viewing competencies as basic, intermediate, and advanced to foster continuing professional development of all counselors and clinicians in the field of CODs. Clearly, the sample competencies listed within each category cannot be completely separated from each other (e.g., competencies in the “basic” category may require some competency in the “intermediate” category). Still, the groupings within each category reflect, on the whole, different levels of provider competency.
Providers in the field face unusual challenges and often provide effective treatment while working within their established frameworks. In fact, research studies previously cited have established the effectiveness of SUD treatment approaches in working with people who have low-to moderate-severity mental disorders. Still, the classification of competencies supports continued professional development and promotes training opportunities.
Basic, intermediate, and advanced competencies are discussed further in the following sections. See also “Resource Alert: Oregon Health Authority's Competency Checklists for COD Providers” and Technical Assistance Publication (TAP) 21, Addiction Counseling Competencies (CSAT, 2006a) for more examples of provider skills within these competency categories.
Every SUD treatment and mental health service program should require counselors to have certain basic skills. Basic COD competencies include having a perfunctory understanding and working knowledge of the prevalence of CODs, screening and assessment procedures, common signs and symptoms, how to triage clients appropriately (e.g., referring for specialty care, engaging in treatment), how to provide brief interventions, and how to engage clients in treatment decision making (SAMHSA, 2011b). In keeping with the principle that there is “no wrong door,” the consensus panel recommends that clinicians working in SUD treatment settings be able to carry out the mental health-related activities shown in Exhibit 8.4.
EXHIBIT 8.4. Examples of Basic Competencies Needed To Treat People With CODs.
Intermediate competencies encompass skills in engaging SUD treatment clients with CODs, screening, obtaining and using mental health assessment data, treatment planning, discharge planning, mental health system linkage, supporting medication, running basic mental disorder education groups, and implementing routine and emergent mental disorder referral procedures. In a mental health unit, mental health providers would exhibit similar competencies related to SUDs. The consensus panel recommends the intermediate level competencies shown in Exhibit 8.5, developed jointly by the New York State Office of Mental Health and the New York State Office of Alcohol and Substance Abuse Services.
EXHIBIT 8.5. Six Intermediate Competencies for Treating People With CODs.
RESOURCE ALERT: OREGON HEALTH AUTHORITY'S COMPETENCY CHECKLISTS FOR COD PROVIDERS.
At the advanced level, the practitioner goes beyond an awareness of the addiction and mental health fields as individual disciplines to a more sophisticated appreciation for how CODs interact. This enhanced awareness leads to an improved ability to provide appropriate integrated treatment. At a minimum, advanced competencies in CODs should include possessing an indepth knowledge of specific therapies and treatment interventions, assessment and diagnosis procedures, and basic knowledge of pharmacotherapies (SAMHSA, 2011b). Exhibit 8.6 gives examples of advanced skills.
EXHIBIT 8.6. Examples of Advanced Competencies for Treatment of People With CODs.
Staff working in COD programs need relational skills (Petrakis et al., 2018), skills that are best learned through clinical supervision. A lack of high-quality supervision can hinder the ability of individual providers and programs as a whole to provide effective, evidence-based treatments for clients with COD (Petrakis et al., 2018; Sacks et al., 2013). To feel capable and confident in delivering appropriate treatments, providers need regular, ongoing, structured supervision that not only addresses specific aspects of individual caseloads but broad didactics about COD populations as a whole. Active listening, interviewing techniques, the ability to summarize, and the capacity to provide feedback are all skills that can be best modeled by a supervisor. Strong, active supervision of ongoing cases is a key element in assisting staff to develop, maintain, and enhance relational skills. (See also “Resource Alert: Competencies and Training for SLID Treatment Supervisors.”) Leadership efforts among supervisors, administrators, management, and senior staff help improve the uptake and provision of evidence-based COD services by providers and help processes for treating clients with CODs become part of the culture of the organization, leading to better outcomes for clients. Such efforts include actively championing and encouraging COD-specific clinical training and supervision practices and securing resources to support integrated care (Guerrero, Padwa, Lengnick-Hall, Kong, & Perrigo, 2015).
To achieve COD capability, SAMHSA (2011b) recommends that programs ideally offer supervision that:
Is provided by professionals with licensure/certification in the addiction field, such as licensed/certified addiction counselors, clinical psychologists, psychiatrists, clinical social workers, psychological counselors, marriage and family therapists, and specialty practice nurse practitioners (psychiatric and mental health nurses).
Is provided formally and routinely, preferably onsite. Otherwise, supervision should at least be available as needed and offered on a semistructured basis.
Includes a focus on assessment and treatment skill development and, at the very least, should cover topics of case disposition and crisis management.
Is performed individually, in groups, or both.
Uses multiple methods of oversight, such as reviewing provider-supervisor rating forms, reviewing audio/video recordings of client sessions, direct observation, or a combination thereof.
RESOURCE ALERT: COMPETENCIES AND TRAINING FOR SUD TREATMENT SUPERVISORS.
The consensus panel is aware that many providers in the SUD treatment and mental health services fields have effectively performed the difficult task of providing services for clients with CODs, often without much guidance from established research and knowledge or systematized approaches. The landscape has changed, and a solid knowledge base is now available to the counselor. However, that knowledge typically is scattered through many journals and reports. This TIP makes an effort to integrate the available information. Counselors reading this TIP can review their own knowledge and determine what they need to continue their professional development.
Counselors should check with their states’ certification bodies to determine whether training leading to formal credentials in counseling people with CODs is available (also see the Section “COD/Addiction Certification in Health Disciplines” for links to websites that offer such information). Appendix B also lists some resources counselors can use to enhance their professional knowledge and development.
Although many program staff who treat clients with CODs possess basic skills, advanced provider skills and specialized training in CODs are frequently lacking (Padwa et al., 2013; Petrakis et al., 2018; Sacks et al., 2013). Training (along with supervision) in mental health service and SLID treatment can be effective in improving providers’ competence and treatment fidelity, which in turn have been associated with reductions in the severity of clients’ mental illness symptoms and substance use (Meier et al., 2015). Inadequate staff training is a barrier to people with CODs receiving needed treatment (Padwa et al., 2015). Rather than focusing on staff performance, like managing large caseloads and increasing billable hours, providers may benefit more from COD-specific training to enhance their knowledge of and comfort with treating clients who have co-occurring SUDs (Padwa et al., 2015).
Staff in integrated primary care and behavioral health service settings report desiring more education, training, and support related to SLID treatment services (Zubkoff, Shiner, & Watts, 2016), including:
Hiring more staff, especially professionals with previous knowledge and experience in SUDs.
Additional tangible resources (e.g., more therapy rooms).
More guidance in providing brief addiction interventions, such as motivational interviewing.
Training on how to address clients with complex SUD-related needs.
Education about the availability of different SUD treatment options.
Quick and easy access to as-needed consultations (e.g., phone-based consultations with peers with experience in treating SUDs).
The scope of practice that addiction counselors must follow legally and under which they can be reimbursed varies from state to state (University of Michigan Behavioral Health Workforce Research Center, 2018). In some states, practice privileges are broad, and in others they are quite restrictive. For instance, certain states mandate that addiction counselors can only conduct assessments and provide treatments for SUDs, limiting their ability to serve clients with CODs. Certification requirements and authorized services also are inconsistent. The lack of standardized training, credentialing, and practices makes it difficult for the behavioral health field as a whole to effectively respond to gaps in COD treatment access and provision.
Staff education and training are fundamental to all SUD treatment programs. Few university-based programs offer a formal curriculum on CODs, despite some improvement during the past decade. Many professional organizations are promoting the development of competencies and practice standards for intervening with substance use problems, including the American Psychiatric Association, American Psychological Association, American Society of Addiction Medicine, National Association of Social Workers, and American Counseling Association. They are also specifically encouraging faculty members to enhance their knowledge in this area so they can better prepare their students to meet the needs of clients with CODs. The consensus panel encourages all such organizations to identify standards and competencies for their membership related to CODs and to encourage the development of training for specific disciplines.
Because the consequences of both addiction and mental disorders can present with physical or psychiatric manifestations, medical students, internal medicine and general practice residents, and general psychiatry residents all need to be educated in the problems of CODs. Too few hours of medical education are devoted to the problems of addiction and mental disorders. Medication can play a critical role in the treatment of CODs, so having adequately trained physicians who can manage medication therapies for clients with CODs is important.
MEETING THE GROWING DEMAND FOR ADDICTION COUNSELORS IN THE FUTURE: FARING WELL OR FALLING SHORT?
Many SUD treatment counselors learn through continuing education and facility-sponsored training. Continuing education and training involves participation in a variety of courses and workshops from basic to advanced level offered by a number of training entities. The strength of continuing education and training courses and workshops is that they provide the counselor with the opportunity to review and process written material with a qualified instructor and other practitioners.
Continuing education is useful because it can respond rapidly to the needs of a workforce that has diverse educational backgrounds and experience. To have practical utility, competency training must address the day-to-day concerns that counselors face in working with clients who have CODs. The educational context must be rich with information, culturally sensitive, designed for adult students, and must include examples and role models. Ideally, the instructors have extensive experience as practitioners in the field.
A recent survey (SAMHSA, 2018e) that asked approximately 13,600 SUD treatment facilities nationwide about their quality assurance practices found that almost 98 percent Included continuing education among their standard operating procedures. Nearly all facilities (almost 94 percent) regularly conducted case reviews between providers and supervisors. About 92 percent conducted client satisfaction surveys.
Continuing education is essential for effective provision of services to people with CODs, but it is not sufficient in and of itself. Counselors must have ongoing support, supervision, and opportunity to practice new skills if they are to truly integrate COD content into their practice.
Cross-training is the simultaneous provision of material and training to more than one discipline at a time (e.g., addiction and social work counselors; addiction counselors and corrections officers). Counselors who have primary expertise in either addiction or mental health will be able to work far more effectively with clients who have CODs if they have some degree of cross-training in the other field. The consensus panel recommends that counselors of either field receive at least basic level cross-training in the other field to better assess, refer, understand, and work effectively with the large number of clients with CODs. Cross-trained individuals who know their primary field of training well and also have an appreciation for the other field, provide a richness of capacity that cannot be attained using any combination of personnel familiar with one system alone.
Cross-training facilitates interaction and communication between the counselors from each discipline. This helps to remove barriers, increase understanding, and promote integrated work. Cross-training is particularly valuable for staff members who will work together in the same program. Consensus panel members have found cross-training very valuable in mental health services, SUD treatment, and criminal justice work.
Curriculums and other educational materials are available through ATTCs, universities, state entities, and private consultants. These materials can help enhance the ability of SUD treatment counselors to work with clients who have mental disorders, as well as to enable mental health personnel to improve their efforts with people who have SUDs. ATTCs offer workshops, courses, and online remote location courses. (See Appendix B for training sources.)
The disciplines of medicine and psychology have recognized subspecialties in CODs with a defined process for achieving a certificate in this area. Exhibit 8.7 summarizes current information on certification by discipline. Drug and alcohol certification requirements vary by state (review at https://addictionstraininginstitute.com/certifications-in-florida/) as do addiction counselor requirements (www.addiction-counselors.com/).
EXHIBIT 8.7. Certification for Health Professions.
The consensus panel strongly encourages counselors to acquire competencies specific to working effectively with clients who have CODs. Juggling a high-stress, demanding workload with continuing professional development is difficult. The panel urges agency and program administrators, including line-level and clinical supervisors, to develop COD competencies themselves and to support and encourage continuing workforce education and training. To the extent possible, they should customize education and training efforts—in content, schedule, and location—to meet the needs of counselors in the field. That is, bring the training to the counselor. Rewards can include salary and advancement tied to counselors’ efforts to increase effectiveness in serving clients with CODs, shown via job performance. Clinicians in primary care settings, community mental health centers, or private mental health offices also should enhance their knowledge of alcohol and drug use in clients with mental difficulties.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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