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Addiction counselors today and the clients they encounter: comprehensive findings from latest NAADAC survey.

The workforce is one of the critical issues confronting the substance abuse field today. The Center for Substance Abuse Treatment's (CSAT's) National Treatment Plan highlighted the importance of the workforce as well as the deficit of knowledge about this backbone of the nation's substance abuse treatment system.

In the past several years, NAADAC, The Association for Addiction Professionals has worked with CSAT to attempt to close the deficit through operation of a Practitioner Services Network. The PSN has been used to learn more about members of the association and to examine issues that are increasingly critical to NAADAC and the field, such as the training and education needs of counselors and the needs of our clients.

In the most recent PSN study the primary focus was to characterize the client mix NAADAC members encounter, their diagnoses, the treatment they receive, and their current treatment needs. The study particularly offers insight into differences in treatment practice and clients encountered between counselors who work in private practice and counselors who work in organized behavioral health facilities.

A 53-question survey was given to a representative sample of about 300 NAADAC members. The overall response rate was 63 percent. The most novel aspect of this study was the collection of data about a sample of about 400 clients.

In addition to the survey, a small, qualitative study was conducted with three focus groups of experienced substance abuse counselors who had been in the field longer than five years. The purpose was to identify and highlight issues that these counselors consider to pose the greatest challenge to the field today. Twenty counselors participated.

Practitioner characteristics

The PSN survey obtained information on select practitioner characteristics, including work setting, years of experience, age and education. A highlight was the capture of data on the characteristics of counselors working in private practice and of the clients they treat. Surprisingly, close to half of the counselors surveyed work to some degree in private practice. In total, 26 percent of practitioners work solely in a private-practice setting, while 18 percent work in both a private-practice setting and an organizational setting.

Counselors were largely mid-career (i.e., between five and 15 years of experience) or late-career (i.e., more than 15 years of experience), rather than early-career (i.e., less than five years of experience) professionals. Regardless of career level, the majority of counselors were between the ages of 35 and 64. This trend in early- and mid-career counselors suggests that these counselors entered the field at a later point in their life, perhaps after having made a career change.

The survey also found that the majority of the substance abuse counselors were well-educated--a finding that may reflect a new emphasis on the importance of higher levels of education. Sixty-four percent of the counselors surveyed held a master's degree and/or doctorate degree. Eighteen percent of practitioners who work solely in private practice held a doctorate.

Client characteristics

Counselors provided individual client data for more than 400 clients. Slightly more than half of these clients (53 percent) were seen in an organized behavioral health facility (e.g., substance abuse and mental health ambulatory and residential clinics as well as public and private hospitals). A unique feature of the survey was that data were acquired on a representative sample of clients seen in a solo or group private practice. Very little has been known about clients who get substance abuse treatment from private practitioners.

The majority of clients were male, white, in their mid-30s, and single, and had attended and/or completed high school (see Table 1). There were notable differences in client characteristics across settings. Nearly two-thirds (64 percent) of clients seen in a private-practice setting were employed either full-time or part-time, compared to 37 percent of clients seen in an organizational setting.

While the average age of clients was similar across settings, adolescents and children ages 18 and younger were seen more often in organizational settings (15 percent) than in private practice (6 percent). Clients ages 55 and older were more often seen in private practice (8 percent) than in organizational settings (4 percent).

Primary diagnoses

The PSN study provides more detailed information about the actual primary and secondary DSM-IV diagnoses of clients seen by substance abuse counselors. As expected, the majority of clients (66 percent) across settings had a primary diagnosis of substance abuse or dependence. Fewer clients (16 percent) presented with a secondary diagnosis of substance abuse or dependence. More than half (54 percent) of all clients with a primary or secondary diagnosis of a substance abuse disorder were being treated for both an alcohol and drug disorder/problem (see Table 2).

Clients in private practice were also more likely to have an alcohol use-only disorder/problem compared to clients treated in organizational settings. Within practice settings, clients seen in private practice were twice as likely to be treated for alcohol use only than for drug use only. Within organizational settings, clients seen were equally likely to be treated for alcohol use only or drug use only.

The PSN study also found differences in primary diagnoses by treatment setting. While three-quarters of clients seen in organizational settings had a primary substance abuse or dependence diagnosis, a smaller percentage (59 percent) of clients seen in private practice were diagnosed with a primary substance abuse or dependence disorder (see Table 3).

Clients seen in private practice were more likely than clients seen in organizational settings to seek treatment for primary diagnoses other than substance abuse or dependence, including psychosocial and environmental problems (e.g., couples and family relationship problems) and other mental disorders (e.g., mood, anxiety and adjustment disorders).

Other than substance abuse or dependence, family relationship problems, couples relationship problems, mood disorders and anxiety disorders were most often reported as a primary diagnosis (see Table 4).

Secondary diagnoses

In addition to learning about clients' primary diagnoses, the PSN study provides an opportunity to gain insight on clients' secondary diagnoses, or co-occurring conditions (see Table 5). A small percentage of clients across settings reported substance abuse or dependence as a secondary diagnosis. Sixty percent of clients across settings had at least one co-occurring psychosocial or environmental problem, including more than half of clients seen in private practice and 65 percent of clients in organized health settings. Across settings, nearly half of all clients had at least one co-occurring mental disorder.

Among reported secondary diagnoses, family relationship problems were reported for over one-quarter of all clients with a secondary psychosocial or environmental problem. Couples relationship issues, career issues, parent/child/parenting issues, and other situationally precipitated problems were also reported for 14 percent or more of all clients. About one-fifth of all clients were reported as having a secondary diagnosis of mood disorders (see Table 6).

Treatment characteristics

Client information collected by the PSN survey is useful in learning more about the services received by clients as well as clients' treatment needs. More than half of all clients (59 percent) received prior treatment for substance abuse. Clients seen in an organized health facility were more likely than clients seen in private practice to have received prior treatment.

Forty-one percent of all clients received treatment mandated by the criminal justice system; 41 percent of these clients received treatment in a private-practice setting.

The majority of clients (75 percent) across settings had individual encounters with their counselors as opposed to a group encounter (23 percent) or family or couples encounters (2 percent). Clients seen in private practice were less likely to receive a group encounter than were clients in an organized health facility. Over one-quarter (28 percent) of clients in an organized health facility had a group encounter, compared to 17 percent of clients treated in private practice.

For 18 percent of all clients, the reported treatment encounter was their first visit. For the remaining 82 percent of clients, the median length of the treatment episode was four months. The majority of clients were expected to self-pay for treatment services; over two-thirds (68 percent) of expected self-pay clients were seen in private practice.

The majority of all clients (61 percent) were in extreme or considerable need of drug or alcohol abuse treatment, followed by family/social counseling (41 percent) and psychiatric/psychological treatment (37 percent). Less than 20 percent of all clients were in extreme need of medical treatment, employment counseling, or legal counseling. These findings appear to reflect the co-occurring diagnoses that were most often reported, including family and couples relationship problems and anxiety and mood disorders.


Focus group findings

The focus groups offered valuable firsthand accounts of counselors' experiences, challenges and issues of concern. Participants discussed how and why they entered the field. Entering the field after previously working in a different career was a main pattern that emerged. In addition, personal experience with addiction--either their own or that of a close friend or relative--was for most counselors a driving factor.

With regard to the proportion of substance abuse counselors that are recovering addicts themselves, the counselors noted that, unlike 10 years ago, there is currently more of a balance between counselors who enter the field because they are recovering addicts and those who enter the field through academic channels.

Many counselors expressed the sentiment that formal education is necessary to work in the field. This opinion is reflected in some of the counselors' own educational attainment, as most had a master's degree in either social work or counseling. In addition, the counselors highly valued on-the-job mentorship, both early in the career and throughout. For some counselors, their mentors were not their supervisors, but were people in the field who helped them along the way.

Some counselors stated that a personal history with addiction can be useful; however, they warned that counselors with a history of addiction should be aware of the differences between their own personal recovery and the recovery of others.

During the focus groups, counselors highlighted main challenges to their profession, such as high rates of staff turnover. Counselors felt that this occurs in part because of counselor burnout, low salaries, and the stigma associated with substance abuse. Another challenge--an increase in the certification and licensure requirements for practice--may drive some counselors out of the field; however, it was thought that the remaining counselors will be better qualified to practice.

Although the counselors tended to be highly educated, a majority of the clients of some counselors have mental health disorders as well as substance abuse disorders, and not all of these counselors felt they were sufficiently trained to treat them.

Further challenges include low salaries and frustration with managed care organizations. Low salaries have led some counselors to take on a second job and to be attracted to higher-paying management positions. However, a tradeoff is that management positions tend to lack a great amount of client interaction. With respect to managed care organizations, challenges in working with these groups include the denial or restriction of client treatment, varying policies, and difficulties in assisting clients to understand the policies of their individual managed care organizations.
Exhibit 1. Counselors by Treatment Setting

Private Practice Only 26%
Both Settings 18%
Organized Health Facility only 56%

Note: Table made from pie chart.

Exhibit 2. Counselors by Career Level

Early Career 9%
Mid-Career 36%
Late Career 55%

Note: Table made from pie chart.

Table 1. Client Characteristics by Practice Setting

 Organized Health
 All Clients Private Practice Facility

Male 61% 57% 65%
Mean Age 34 36 33
Race/Ethnicity (1)
White 86% 88% 83%
Black 12% 11% 12%
Other 4% 2% 5%
Years of
 Education 12 13 11
Employed Full-
 time or 49% 64% 37%

(1) Respondents were asked to mark all that apply.

Table 2. Type of Client Substance Abuse Disorder by Treatment Setting

Substance Used All Clients Private Practice Organized Health Facility

Alcohol Only 27% 35% 21%
Drug Only 19% 17% 20%
Both Alcohol
 and Drug 54% 48% 59%

Table 3. Primary DSM-IV Diagnoses by Treatment Setting (1)

 Organized Health
Primary Diagnosis All Clients Private Practice Facility

Substance abuse
 or dependence 66% 59% 75%
 and Environmental
 Problems 28% 37% 20%
Other Mental
 Disorders 30% 35% 25%

(1) Some respondents marked more than one primary diagnosis.

Table 4. Top Primary DSM-IV Diagnoses Other than Substance Abuse or

 Organized Health
Primary Diagnosis All Clients Private Practice Facility

Psychosocial and Environmental Problems
Family relationship
 problems 8% 9% 7%
Couples relationship
 problems 7% 14% 2%
Health concerns,
 bereavement 3% 3% 3%
 issues 2% 3% 2%
Other situationally
 precipitated problems 8% 12% 6%

Other Mental Disorders
Mood disorders 11% 12% 10%
Anxiety disorders 7% 10% 4%
Schizophrenia and other
 psychotic disorders 3% 1% 5%
Adjustment disorders 3% 5% 1%

Table 5. Secondary DSM-IV Diagnoses by Treatment Setting (1)

Secondary Diagnosis All Clients Private Practice Facility

Substance abuse or
 dependence 16% 16% 15%
Psychosocial and
 Environmental Problems 60% 53% 65%
Other Mental Disorders 48% 47% 49%

(1) Respondents marked all secondary diagnoses that applied.

Table 6. Secondary DSM-IV Diagnoses by Treatment Setting (1)

 Organized Health
 All Clients Private Practice Facility
Secondary Diagnosis (%) (%) (%)

Substance abuse or
dependence 16 16 15

Psychosocial and Environmental Problems
Family relationship
problems 27 24 31
Couples relationship
problems 18 18 17
Career issues 16 15 16
issues 14 12 17
Health concerns,
bereavement 8 7 10
Child's behavior or
school performance 6 6 6
School-related problems 6 5 6
on food, shelter, etc. 6 3 8
Abuse, neglect (focus
on victim) 7 7 7
Abuse, neglect (focus
on perpetrator) 2 1 3
Other situationally
precipitated problems 18 13 22

Other Mental Disorders
Mood disorders 22 20 25
Anxiety disorders 14 16 13
Adjustment disorders 7 6 8
Personality disorders 7 6 7
Impulse control
disorders NEC 6 6 7
Sleep disorders 4 4 4
Eating disorders 3 3 3
Other mental
disorder(s) 3 4 2
Mental disorders due to
a general medical
condition 2 2 3
Schizophrenia and other
psychotic disorders 2 2 3
Dissociative disorders 2 3 1
Somatoform disorders 1 2 1
Delirium, dementias 1 2 1
Factitious disorders 1 2 <1
Sexual and gender
identity disorders <1 1 0

(1) Respondents were asked to mark all that apply.

By Gerard J. Schmidt, MA, LPC, MAC, Christel Villarivera and Christine Aguiar

Gerard J. Schmidt is a clinical affairs consultant for NAADAC, The Association for Addiction Professionals. Christel Villarivera and Christine Aguiar are with consulting firm The Lewin Group.
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Article Details
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Title Annotation:National Association of Alcoholism and Drug Abuse Counselors
Author:Schmidt, Gerard J.
Publication:Addiction Professional
Geographic Code:1USA
Date:May 1, 2005
Previous Article:Impulsivity, risk and recovery: help addicts manage situations and deal with consequences.
Next Article:Defining success in the treatment of adolescent substance users.

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