Volume 1, Issue 3

The Devil Will Be in the DetailsSteve Martino
By Steve Martino, Ph.D.
Yale University School of Medicine and VA Connecticut Health System

The expert panel members for the ATTC National Office report, Understanding America’s Substance Use Disorders Treatment Workforce, should be commended for their initial efforts to develop a survey that will systematically evaluate the development needs of the addiction treatment and recovery services professional workforce. As noted in the report, the workforce is aging out and there is an insufficient number of adequately prepared professionals coming into the field and/or remaining there to meet the treatment needs of people who have substance use disorders. Reliable and valid information is needed in three areas that detail: 1) the workforce’s demography; 2) anticipated workforce development needs for the next five years; and 3) strategies that might best prepare, retain, and maintain professionals in the field.

Needs identified by the survey likely will drive future Substance Abuse and Mental Health Services Administration (SAMHSA) workforce development initiatives. The report presents a review of the extant literature and summarizes what is known and needs to be known in each of the three areas as the first step in developing the survey. My commentary addresses additional issues absent in the report that need to be known and methodological suggestions to sharpen the capacity of the survey to answer the expert panel’s key questions.

Basic demographics of the workforce

The report details standardized individual and organizational demographics and retention indicators that will be used in the survey. The evaluation of professional demographics (e.g., sex, ethnicity, educational level, certification status, etc.) is straightforward. The assessment of major structural organizational characteristics (e.g., treatment modality, urban/rural, size, private versus public, etc.) is logical. The inclusion of retention indicators (e.g., staff turnover) is critical to understanding what factors are associated with professionals’ decisions to leave their jobs.

However, because the survey will be administered only to agency directors, it will not directly tap the experiences of other professionals (e.g., their perception of the program’s motivation to change, institutional resources, staff attributes, and organizational climate) (Simpson & Flynn, 2007), which might influence treatment center staffs’ work satisfaction and job turnover. For example Knudsen and colleagues (2003, 2006) found that counselors who perceived their managers as 1) empowering them to make decisions about how to perform their jobs, 2) being fair in their distribution of work and rewards, and 3) seeking staff input in decision-making had less job-related emotional exhaustion and intention to quit.

The survey’s apparent absence of assessing professionals’ experiences at the individual level may significantly limit the degree to which it can identify workforce development needs and related future initiatives. If, for example, the experiences that professionals have where they work significantly contribute to their intention to stay in or leave their jobs (a likely proposition), then the survey, as currently designed, would be inadequate in its capacity to evaluate job turnover and how to effectively address it.

It would be prudent to add to the survey’s methodology a procedure in which directors identify professionals that work within their agencies and to survey these individuals directly. While efforts will be made to include counselor and clinical supervisor input through focus groups for the purposes of developing the survey, their immediate experiences of their work lives at their employment settings do not appear to be part of what will be formally evaluated in the survey. The workforce survey may be excluding the perspective of the largest segment of the very workforce it aims to understand.

Anticipated workforce development needs

The report recommends that the survey collect current staffing needs (e.g., open positions) and the previous year’s staff turnover rates as well as information about client demographics and treatment outcomes (program retention, treatment completion) to determine in which areas the workforce may need development. It is unclear to what extent the survey will evaluate access to computer- and internet-based technologies and the comfort professionals have in using them. Given the aging workforce, many addiction service professionals might not be familiar and facile with technologies that have become a routine part of younger adults’ lives. The push for electronic medical records, multiple communication avenues (e-mail, texting, Facebook, Twitter), and growing distance learning opportunities for developing professional skills suggests that assessment of this area should be part of a survey that aims to anticipate potentially important workforce development needs.

Also unclear is the extent to which the perspective of clients who receive services within the agencies will be included in the survey’s development. The primary aim of any addiction treatment setting is to serve its clients. Client observations of addiction service settings and professionals likely would be quite informative in identifying where the workforce needs to develop. As one example in a meta-analytic review of therapeutic alliance research, Martin, Garske, and Davis (2000) found that clients tend to view alliance as more stable than counselors. Thus, the first impressions of clients about their relationships with their counselors (and perhaps the agency) are likely to stick. This finding suggests that counselors need to have the skill to quickly establish positive alliances with their clients, especially because the clients’ experience of the therapeutic alliance appears to be a consistent predictor of engagement and retention in addiction treatment (Meier, Barrowclough, & Donmail, 2005). At the very least methodologically, client focus groups could be conducted to get their opinions about what is included in the draft version of the survey and to determine if additional information might be needed.

Strategies to prepare, retain and maintain the workforce

The report is most comprehensive in its detailing of infrastructure needs (e.g., loan repayment programs, accreditation processes for addiction training programs), education and training needs (e.g., curricula development for supervisors and managers, identifying and disseminating best practices), factors impacting retention (e.g., salary, workload), and the importance of cataloging workforce development efforts within and across states. The report, however, does not explicitly mention if the survey will assess strategies professionals use to learn empirically supported substance abuse treatments. This area is of tremendous importance to the field given that these treatments typically are seen as the best interventions counselors have to offer clients, SAMHSA advocates for their implementation (e.g., National Registry of Evidence-based Programs and Practices; http://www.nrepp.samhsa.gov/), and many Single State Authorities and managed care systems are beginning to mandate counselors to use them (e.g., http://www.oregon.gov/DHS/mentalhealth/ebp/main.shtml).

Traditional training strategies for empirically supported treatments include reading manuals, attending workshops, and receiving clinical supervision (Baer et al., 2007). Distance learning strategies include computer-assisted, Web-based, and simulation programs (Weingardt, 2004). In particular, distance learning strategies are likely to become more prevalent and popular in that they can make training more available to professionals from geographically diverse areas, easier to schedule, individualized and self-paced, standardized in quality, and lower in cost. Understanding how professionals view these different training strategies and what training options are available to them within agencies might better inform the field how to develop future training initiatives and could play a critical role in the preparation, retention, and maintenance of the workforce. Knudsen, Ducharme, and Roman (2008) learned this firsthand when they found that the perceived quality of clinical supervision was strongly associated with counselors’ feeling they had more autonomy at work, were permitted input in decision-making, and were treated fairly, which in turn related to less emotional exhaustion and intention to leave their jobs. A survey about workforce development should evaluate these kinds of training issues.

Final thoughts

The ATTC National Office report on the initial effort to develop an addiction workforce survey through literature review and expert panel consensus provides a comprehensive account of the multiple factors that may influence the recruitment, preparation, and retention of professionals in the addiction treatment field. The planned stepwise procedure for developing the survey with targeted stakeholder input and conducting it across agencies in all 14 ATTC Regional Centers, with methods to ensure adequate sampling and high response rates, suggest the survey will produce data that will be very useful in understanding important workforce development needs and strategies for addressing them. In the meanwhile, the field awaits the final version of the survey to see if it will address all the major areas of workforce development that need to be known for the purposes of enhancing the workforce and improving addiction services. The devil will be in the details.

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