The much- respected Columbia University Center on Addiction and Substance Abuse (CASA) released a major study recently entitled "Addiction Treatment in America - Not Based in Science Not Truly Medical." The 586-page report, as its name implies, is a critical analysis of the state of treatment, basing its findings on surveys of treatment providers, people suffering from addictions, a review of states' rules and procedures, and more than 7,000 publications on addiction. Some of the significant critiques include the fact that there are no national standards of practice for “addiction counselors,” and 14 states don’t require any education or licensing at all for addiction counselors, while just six states require addiction counselors to have a minimum of a bachelor’s degree.
We discuss these comments, along with treatment types, evidence-based approaches such as CBT, and the state of addiction education.
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. Today I'd like to talk about an interesting story that was just published in Time magazine from Columbia University’s Center on Addiction and Substance Abuse (CASA). This major study on addiction treatment in America, is not science based nor is it truly medical, but it makes some interesting statements that I hadn’t really considered before and they come from CASA, which is a well known authority on addiction. The article presents a critical but I think truthful assessment of our recognition of addiction as a disease, as a major social issue and the shortcomings that we’ve experienced in terms of treatment. We’re going to want to get this report and look at it in some great detail, but some of the things that it mentions - treatment of addiction is not based on any scientific evidence, and - it is often administered by people who are not required to have any kind of medical education. In fact, one of the primarily criteria for being an addiction counselor is having suffered an addiction disorder oneself. I thought that was very telling. Also, that there are 14 states that don’t require…. any kind of formal education on the topic at all, much less licensing, and …there are 6 states that do require addiction counselors to have a bachelor’s degree, 1 of them requires a master’s degree. So, those are some of the key things brought up early on in the report, Darryl, and I want to just toss it open to you and let you comment and we’ll go from there with the rest of it.
DARRYL: It actually struck me as very harsh and I wondered about the reporter on this and under what context it is being presented. CASA is very well respected even though there have been some glitches in the past but they've been called on them - but overall they do extremely good work. I would like to see the actual report because … what’s being reported is very harsh in terms of what is said to the treatment field. One thing that’s out of context here, is it wasn’t until 2008 that the federal Addiction Equity Act was passed - that finally recognized on a legal basis that addiction is a biological medical disorder rather than a matter of being weak-willed or bad or stupid, crazy, or immoral. It’s a matter of biology and how the brain of an addict or somebody vulnerable to the addiction is different. No state has fully implemented this act and it wasn't until July of last year, 2011, that 10 medical universities, began offering science of addiction with full residency programs. Now most of the medical schools are beginning to include addiction medicine as part of the formal training for physicians, so this is really new to the field. Looking back to the time when most addicts were viewed as criminals and those who provided services and counseling to addicts were also viewed as criminals - there was no science, no accepted credentialing. Having gone through that over the past 40 years, and watching this field develop, it was a difficult - we knew there had to be some sort of standard for our clinicians so they were properly trained to work with addicts. We wanted addiction counseling to be a true profession - requiring testing and credentialing. That was difficult at first because this field was viewed as a renegade field - outside the context or standard of anything, and it attracted people with a compassionate interest and a belief that addicts were of value and worth helping - helping them to get better and helping them to recover. A lot of ex-addicts who - after entering recovery and working 12-steps - that last step in the 12-step system is to give back ...to give back to your community…give back to those who are struggling with addiction and many found that for them, one of the best ways they could give back was by inspiring and helping others learn what they learned. The field was pretty much populated with recovering and compassionate people, some of them had medical educations, most of them did not. Some of them had clinical training…most of them did not and those were the people working in the field, working at absolutely bottom pay or no reimbursement, no rewards or whatever. And then we said, ok - we have to set some standards here. Then - those people who did not have any education or any kind of academic background and had been apart from academia for a long time, were faced with the daunting challenge of going back to school, training, getting certified and all the things that are now required to become an addiction counselor. This was especially hard for those in California, which was one of the states with no requirements and allowed people to be counselors with no education in counseling or medicine. California had a huge community of providers who revolted, asking - "how can you now make us do all this when before you treated us like second class citizens and said we shouldn’t even be doing this type of work?" And because of that, in California to this day, there are 9 different certification organizations, unlike Oregon and many other states that have only 1. Six states don’t have any requirements. There is also a national certification for drug and alcohol counselors. Some places have grandfather clauses for those who have been in the field for 20 years and provided good services for 20 years - they are grandfathered in with the basic credentials to be a counselor. And some places said "absolutely not" and require people to go back to school. You have to do so many unit credits in community college. You have to take a test and you have to pass these tests. The majority of states have full credentialing programs that require certain core courses and then testing, and there are different levels - in Oregon level 1 requires an associate degree, usually from a community college and passing a test to be certified for basic counseling. Level 2 allows you to be a supervisor, which requires at least a bachelor’s degree and special testing, level 3 requires a master’s or a PhD and it allows you to be an educator. There are special certificates for specific aspects of addiction, like pain addiction specialist/counselor, or trauma certification. Most of the states do require some sort of validation. The other thing I want to quickly point out about this article is from a national level, you aren’t allow to just do your own therapy - it must be an evidence-based practice. The interventions must be from the list of accepted programs from the national registry of evidence-based programs and practices. Those have undergone federal scrutiny and have a lot of empirical research and data that qualifies it as valid. But even with those - the states then have their own priorities as well or their own belief systems. In Oregon, they have their own registry of what they recognize as evidence-based or research-based interventions and practices and they don’t accept some of the national ones. You know, they select the ones they want you to use and there is a mandate now that every program has to employ something called “trauma informed care” in their practice of counseling. So, there’s a lot more going on credentially in a field that was viewed as a non-field just a few years ago. Everyone is playing catch-up - there are some states, I guess, that allow counselors to do some work without any education or without any certification, but I’ll point out quickly - having been both in academia as well as in the clinical field - that just because somebody goes to school and gets a bachelor’s degree and passes a test or something, that doesn't guarantee they are going to be an ethical or a viable counselor. It's important to have some sort of policing and some self-scrutiny of what’s going on, what’s effective and what’s happening in order for this to be a true discipline and a viable discipline… some states mandate reporting of unethical practices or unwise practice by a fellow clinician, you must report them to the licensing authority who then scrutinize whether or not this person should be allowed to continue or not continue. So, I was surprised, really at this report from CASA, but I think it’s the reporter's slant on the report. Knowing CASA's work I believe they’re trying to advocate for better resources in order to provide professional care and to bring more professionalism into the field of addiction treatment. I think the field is becoming more professional and it should be applauded for how far it has come from the belief that it was an irrelevant field a short time ago. But, I encourage the field to continue to expand and grow. There are now PhD programs in addiction counseling…I wanted to start PhD programs in addiction counseling because the degree of neuroscience and medicine, genetics and epigenetics today, you really have to know what PhD’s know in order to be on top of all of the developments in this field. And those who educate and teach about that, I think they should have a PhD. There should be multiple PhD programs for the clinical aspects just like there are for a medical practice - with residence programs in addiction medication.
HOWARD: It is good that many who are studying to be physicians have some background at least and some exposure to addiction medicine and the issues involved here. The article in the Huffington Post about this study says that this is part of a 5 year study under the direction of Dr. Drew Altman, the president and CEO of Kaiser Family Foundation, just to answer your earlier question. A wide range of scientific literature and surveys were analyzed, they went to different states and talked to leading researchers and experts about this. And, the definition of treatment that it talks about are the various psychological and social therapies like motivation interviewing, motivational enhancement therapy, cognitive behavior therapy – CBT, but what it does not include is detox and religious based counseling, which would be 12-steps.
DARRYL: That’s the real problem with the evidence-based movement - they are practice-based, practice evidence-based programs that have been effective in motivating people toward recovery …for 50 years - 12-step is one of them. And today there is money being generated to make them evidence-based. Because to make them evidence-based, you have to bring in research systems. You have to bring in a set up of variables…dependent, independent variables. There is scrutiny. You have to randomly assign things - have crossover system. You have to do it the way science wants you to do it and that usually costs a lot of money and there isn’t a lot of money to do much in this field. What becomes evidence-based might be somebody’s favorite rather than what has worked in the field for a long time. And with that, there are a lot of things out there that I think are effective, programs that warrant conducting the science on it and somebody should be financing it. If it’s not funded by individual professionals trying to establish their name to get grants or something - maybe the government should fund the research to determine if certain things are evidence based. You know, in saying all of this, I am aware that there are programs that are still performing what we call “haircuts” - this is when a program attempts to break people down and totally destroy their ego and destroy their sense of self in order to build them back as a recovering person. This is not evidence-based in any way and is probably oppressive and probably very wrong and probably ends up hurting a lot of people. And I agree that those programs and people that practice those sorts of things should be shut down and should not be allowed to practice. But by and large, most of this is moving toward evidence-based treatment programs in which your interventions and your counseling, your clinical counseling and your medical interventions are all established in their registry of acceptable practices and procedures. In Oregon they also are mandating motivational enhancement therapy because somebody in this state has - through personal research - found that to be the most beneficial, just like they came out with trauma informed care, which we practice through a trauma informed care mechanism.
This study cites programs that are just inappropriate. They cite one practitioner, I think in California, who was a sexual predator who managed to get into the field…I don’t know how that could have happened because in many states, like Oregon, you are fingerprinted when you apply for your certificate and for your license and you’re scrutinized, you know. And those who are offenders and a perpetrator of heinous crimes, are not allowed to practice. One of the difficult things that we were facing just last year in Oregon was something passed by the state legislature saying that if you …have ever been incarcerated or convicted of a felony, you couldn't be a counselor. We had to say, wait a minute, wait a minute - almost everybody coming into this field, by virtue of the fact that they were probably first an addict and then went back to school to earn credentials -probably did some jail time for drinking and driving, or use of drugs ….we understand we have to protect clients, so let’s make sure we prevent those people who have been offenders and done jail time for violent crimes or for sexual offences - but just to say anybody who’s done jail time is excluded, is incorrect. In Oregon, anyway….they look at the actual crimes committed and decide whether or not a person is qualified to become a certified counselor. So, a lot of what I see in many states is the exact opposite of what’s being reported here….a level of scrutiny that wasn't done in medicine or any other field until much later - in the addiction professional field they’re actually incorporating it a lot sooner.
HOWARD: Well, perhaps this is like many things - looking back, and analyzing….because it’s hard, to look forward. It certainly is still in a very evolutionary state.
DARRYL: Another thing that I think we need to look at is why….one of the problems in this field….well, it’s not a problem…recovery is such a wonderful thing and people’s lives are so touched and so affected by it that when people finally address their addiction, participate strongly in treatment and then gain recovery, the first thing they think about is giving back by becoming an addiction counselor, addiction therapist, or addiction professional. And I’m not sure that’s always a healthy thing to do. It seems like keeping your foot into a place that’s dangerous and I think there should be healthy alternatives in this field, but I haven’t seen that change in the 40 years I’ve been in this field. The majority of people who actually do well in recovery - want to become an addiction counselor.
HOWARD: That’s interesting. Well, we will see how it evolves. This was an interesting article and I’m glad we spent some time talking about it. And it looks like we’ve run out of time for now, so thanks for listening. And if you have comments, questions, or suggestions, we’d love to hear them. Stop by the CNS website, cnsproductions.com. Drop us a note there. Darryl, thanks.
DARRYL: Hey Howard, thanks for bringing this up. I thought it was an important thing to bring up, so I’m glad you did.
HOWARD: That wraps our pod for today. Please check back soon for the next in the series and visit our website, www.cnsproductions.com