Volume 4, Issue 3

Counseling without Training?
Elizabeth Wells, PhD
University of Washington School of Social Work

Dr. Junig advocates for wider availability of buprenorphine/Suboxone for both opioid dependence treatment and reduction of harm from opioid overdose. His comments in this regard are right on, even though they most certainly will raise the hackles of those in (and outside) the recovery field who see opioid agonist or opioid agonist-antagonist treatment as unacceptable or who do not agree with harm reduction goals. Unfortunately, the stigma associated with opioid addiction and with medication-assisted treatment keep sensible and science-based options from being followed in many cases. I also agree with Dr. Junig’s position on advising patients toward long term maintenance, as the data are clear regarding relapse following stopping use of this medication or methadone. Again, this is a hard pill to swallow for many who view this type of treatment as undesirable.

My only area of disagreement with Dr. Junig relates to his answer to Question 5: “Simply on the basis of their skills as physicians, and assuming they were willing to spend the time, do you think the majority of physicians could successfully deliver this psychosocial counseling?” Having spent my career as a researcher experimentally testing psychosocial treatments in community-based addiction treatment settings, I know how difficult it is to train intelligent people to provide evidence-based psychosocial treatments. I also believe that any psychosocial intervention ought to be based on research evidence, as is the provision of buprenorphine/Suboxone. I disagree that a physician who has not received specialized training in psychosocial treatment would, by virtue of being an MD, demonstrate fidelity or competence in delivery of effective “counseling.”  Yes, the surgeon knows what organ to remove (Dr. Junig’s example), but the surgeon is not trained to plan and deliver radiation therapy to a cancer patient or diagnose and treat a rare infectious disease. I have heard the assumption made, that MDs are intelligent and can certainly figure out how to do “counseling.” The latter is not the case, and we should not be encouraging them to deliver psychosocial treatments for which they have not been specifically trained.

The best outcomes arise from a combination of science-based medications and psychosocial treatments, and both should be delivered by professionals with competence in the selected treatment.

 



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