By Steve Martino, Yale University
David Gustafson deserves much credit for stretching our imaginations about what is needed to redesign the addiction treatment system in the United States. It brings to mind a similarly stimulating series of chapters in Rethinking Substance Abuse, edited by William Miller and Kathleen Carroll in 2006, in which leaders in the addiction field challenged long held assumptions about substance abuse and proposed fresh new ideas about how to better approach addiction care. In the featured article, Dr. Gustafson identifies 11 essential ingredients to meet the needs of the various customers involved in the addiction treatment service system:
In most cases, he recognizes highly successful industry leaders that have maximally leveraged these essential ingredients (e.g., Apple, Microsoft, Panera Bread, Disney, National Football League, NASCAR, Amazon.com) and then rhetorically asks the question, "What can we learn from them?" The reader is left to ponder potential answers and is promised that forthcoming publications will provide some suggestions from Dr. Gustafson's multi-industrial research group. I very much look forward to their proposals.
As I read the article, however, Liza Minnelli singing "Money" from the classic 1972 musical film Cabaret began to play within me. In most cases, the institution of the essential ingredients as key components of a redesigned addiction treatment system would require a substantial societal investment, similar to the level of expenditures provided for other debilitating and deadly diseases that have greater public support (e.g., cardiac disease treatment as experienced by Dr. Gustafson at the Cleveland Clinic). The referencing of major multi-million and billion dollar industry leaders throughout the article kept the chorus ringing in my head: "Money, money, money, money, money…"
One area of investment critical to the success in pursuing the essential ingredients is the addiction treatment workforce. The training, workload, and compensation of addiction counselors need much more attention if the addiction treatment system is to improve. It is very clear that particular qualities of counselors can affect the engagement and participation of patients in their care and that the degree and duration of patient involvement in care affects their post-treatment outcomes. For example, patients treated by empathic counselors fare better than those treated by confrontational ones (Miller, Benefield, & Tonigan, 1993). Counselors who use evidence-based approaches are more likely to be more helpful to their patients than those who adhere to ineffective practices that have permeated the addiction treatment field (Miller, Zweben, & Johnson, 2005). Developing both general relational counseling skills and specific techniques unique to particular evidence-based practices requires an investment in counselor training. This typically involves targeted workshop training or seminars followed by supervised practice cases in which counselors who have their clinical care directly observed and then receive feedback and coaching to improve their practice (Beidas & Kendall, 2010; Herschell, Kolko, Baumann, & Davis, 2010; Martino, 2010; Rakovshik & McManus, 2010). Unfortunately, even when agencies purport to offer evidence-base practices to patients, few of them are providing their counselors training and even fewer offer closely supervised experiences to help counselors become proficient in the services they are trying to deliver (Olmstead, Abraham, Martino, & Roman, in press). While it is not clear why this is the case, in part it may be due to the lack of funding and financial incentives to provide sufficient training and supervision in the best available addiction treatment services.
Another area with financial ramifications is the excessive supervisor and counselor workloads in the field. Typical outpatient counselors carry active caseloads of 150-500 patients, often with very little medical backup available to them to manage the multitude of physical symptoms and co-morbid medical conditions that accompany addictions (McLellan, 2006). In large part, these caseloads are driven by rates of reimbursement and restricted funding for services. Agencies simply have to treat more patients with fewer counselors to stay financially afloat. Moreover, these caseloads have resulted in group treatment being the dominant approach implemented in addiction treatment settings (McLellan, 2006), even though adaptations of 1:1 evidence-based practices for use in group formats often are more complex to deliver and very few of them have been empirically validated in efficacy or effectiveness trials. Add to this the case management issues (financial and legal problems, unemployment, unstable housing or homelessness, dual psychiatric conditions) and one can easily wonder how it is even possible for counselors to help patients recover. Related fields have come up with evidence-based service system solutions to these problems, such as the use of Assertive Community Treatment (ACT) teams for patients with co-occurring serious mental illness and substance use disorders (Essock et al, 2006), but these modes of service delivery rely upon rich resourcing and will require more financial investment in the addiction service system if they are to be used within it.
Counselor workload burden has been further impacted by documentation demands. State and accreditation commission (Commission on Accreditation of Rehabilitation Facilities, Joint Commission on Accreditation of Healthcare Organizations) documentation requirements, inaccessible records, and redundant information gathering procedures all add to the burden. The field is reaching a point in which the time required to complete "paperwork" may be diminishing the ability of counselors to deliver the very services they are documenting. Furthermore, time that might have been spent on clinical supervision to promote evidence-based practices often gets shifted to administrative oversight to ensure that counselors are compliant with their documentation requirements. These problems are well recognized in the field and many efforts are underway to develop an electronic medical record appropriate for the addictions treatment field (Ghitza, Sparenborg, & Tai, 2011); this will require money, money, money, money, money.
Another area with financial implications is the turnover of addiction counselors in addiction treatment programs. Annual turnover rates are as high as 50% in some agencies, as McLellan (2006, p. 288) puts it, "approximately the same as in the fast-food industry". The time and effort spent on rehiring, orienting, training and supervising staff is substantial. Part of the problem may be due to the limited compensation counselors get for the work they do. The 2011 pay rate for addition counselors in the United States was $20,011 – 46,423.00 per year (http://www.payscale.com/research/US/Job=Addiction_Counselor/Salary; accessed December 9, 2011). It is not surprising that counselors may look around for better employment opportunities both within and outside of the field to make ends meet.
Finally, we need to invest more money in implementation research. While we may know which treatments work and in some cases how they work (Miller & Rose, 2009; Kulik, Nich, Babuscio, & Carroll, 2010), we lack some very basic information about what the best and most cost-effective strategies are for preparing the workforce to delivery evidence-based practices. For example, a train-the-trainer approach is often used to disseminate and implement evidence-based treatments in mental health and addiction community programs (Hawkins & Sinha, 1998; Hein, Litt, Cohen, Miele, & Campbell, 2009; Rogers, Cohen, Danley, Hutchinson, & Anthony, 1986). In this approach, an expert trains practitioners how to teach a designated treatment to others. Subsequently, the practitioners return to their settings and then train, supervise, and monitor staff members' treatment implementation. The idea is to establish program-based advocates who first become knowledgeable and committed to a treatment, and then actively champion its use within their agencies (Addis, Wade, & Hatgis, 1999; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Simpson & Flynn, 2007; Squires, Gumbley, & Storti, 2008). The belief is that this would permit in-house, ongoing supervision and consultation to the implementation effort and the capacity for just-in-time training given the expected counselor turnover within agencies, thereby making it more cost-effective than a solely expert driven training approach. In a randomized controlled trial, we found the opposite. Namely, the expert approach was more cost-effective than the train-the-trainer one, in comparison to a self-study control condition, even in the hypothetical condition in which the train-the-trainer approach was repeated 25 times within one year! What we believed to be true and has been widely practiced turned out to be wrong, at least in this case. As we move to redesign the U.S. addiction treatment system (e.g., by addressing needs and assets of the counselor workforce), close attention will be needed to ensure the best bang for the buck as changes are instituted.
Just for the moment, however, let us suppose these kinds of investments will be made by federal, state, local, and private groups. Dr. Gustafson has invited us to imagine a service system that provides high quality, integrated, collaborative, monitored, continuing care anytime and anywhere. The return on this type of investment in terms of reduced health and legal problems and service system costs, improved personal and family functioning, employment, and quality of life would be huge. It seems well worth it to me, and I would imagine that all the potential customers of addiction services would come to the cabaret.