“The shortage of alcoholism and drug abuse counselors in the United States is equivalent in significance to the overall nursing staff shortage in medicine, in terms of its impact on the field.”
—Terry Gorski, internationally recognized behavioral health expert

At the beginning of the previous century, there was an alive and healthy indus- try for the treatment of alcohol and drug abuse, according to addictions historian and researcher William White. By the time of Prohibition, the industry virtually disappeared and did not reemerge for several decades. One of the factors contributing to the decline of addiction treatment systems was the lack of new leaders to take over the roles formerly held by aging leaders. A century later the behavioral health field, especially the substance abuse field, is facing a similar leadership crisis as current executives retire, die, and move aside.

The Problem—by the Numbers

Growth. The Department of Labor's Bureau of Labor Statistics lists mental health and substance abuse social workers as the 26th-fastest growing occupation, expected to increase by 29% from 83,000 in 2000 to 116,000 in 2010. Nearly 5,000 new counselors are needed annually for net replacement and growth.

Employment status and education level. According to the 2003 Center for Substance Abuse Treatment (CSAT) Environmental Scan, the substance abuse treatment workforce was estimated at 135,000 full-time staff; 45,000 part-time staff; and 22,300 contracted staff. Seventeen percent of medical staff at substance abuse treatment facilities worked full time, 31% part time, and 47% contracted (the status of 5% was unknown). Among the overall staff, 17% of full-time staff had graduate degrees, 17% of part-time staff, and 32% of contracted staff. Twenty-nine percent of full-time staff had bachelor's degrees or no degrees, 22% of part-time staff, and 11% of contracted staff. Studies have indicated that 60 to 80% of direct-service staff have at least a bachelor's degree, and almost 50% have a master's degree. Most substance abuse programs do not have full-time staff with medical degrees or other advanced graduate degrees.

In 2003, 47% of administrative/nonclinical substance abuse staff were full time, 43% part time, and 10% contracted. Among the administrative/nonclinical staff, 68% had bachelor's degrees and 77% had master's degrees.

The CSAT scan found that most academic education occurred at the community college level, with course and program quality highly variable. No accreditation standards exist for training in the substance abuse field. Most training was didactic with little to no management or leadership development programs available. Whereas most staff (90%) attend training annually, little is known about the quality of in-service education, clinical supervision, or academic courses in substance abuse.

Reasons for entering the field. People enter the substance abuse field for the challenge, to help others, because of personal concerns, or because they or family members had a substance abuse problem.

Tenure. Sixty-three percent of substance abuse staff have worked in the field six years or more, but 68% have been in their current jobs less than five years.

Gender. The majority of direct-service substance abuse staff are women (data range from 57 to 60%); more strikingly, 70% of new counselors are women. In contrast, the majority (65%) of management staff are men.

Age. Direct-service substance abuse staff's average age range is the mid-40s to 50 years old; 75% of the substance abuse workforce is over 40. Many people enter the field in their late 30s to early 40s. Most people enter the field in their mid-30s, often as a second or perhaps third career.

Race and ethnicity. The substance abuse workforce is 75 to 90% white; private agencies have fewer minority staff than public agencies.

Certification. Studies vary by region and modality, but most claim that 50 to 55% of direct-service staff are credentialed in substance abuse (licensed or certified addiction counselors).

Caseload and paperwork. The average substance abuse counselor's caseload is 29 clients; approximately 20% of a counselor's time (one day a week) is spent on paperwork. Many clinicians say that estimate is low. Interestingly, the United States spends $1,000 per capita per year on healthcare paperwork. Canada spends just $300 per person per year. We're drowning in paperwork and, as an old Soviet psychiatrist once said to me, “The only solution to reducing the amount of paperwork required is to kill the people producing the forms.”

Annual turnover. Annual management staff turnover in the substance abuse field is almost 50%, and substance abuse counselors have a two-year turnover rate. Behavioral healthcare's turnover rates are well above the national average, ranging from 17 to 33% per year. Most turnover is voluntary, with people moving from one agency to another.

Low salaries are the primary factor in turnover. Other factors include paperwork, long hours, and large caseloads. Up to 73% of substance abuse directors report difficulties in recruiting qualified staff, and 83% of directors say low salaries are the main reason for recruitment problems. According to the CSAT scan, management practices that can reduce turnover include:

improved, ongoing clinical supervision
greater job autonomy
better communication between management and staff
improved recognition and reward systems for performance
paperwork assistance
improved training programs

Salaries. Average starting salaries in the substance abuse field are in the low $30,000s. The majority of new counselors’ salaries range from $15,000 to $34,000. The majority of agency directors’ salaries range from $40,000 to $75,000. Higher salaries are associated with having a graduate degree.

What Can Be Done

The CSAT scan offers a number of recommendations, including the following:

Develop career paths for all staff levels to encourage personnel to see substance abuse counseling as a profession.
Develop executive management curricula to train the next generation of supervisors, managers, and leaders.
Focus on clinical supervisors, using curricula that include clinical as well as management/supervision training.
Conduct a study on staff turnover's costs to agencies and the substance abuse treatment system.
Establish an accreditation process for substance abuse training and academic programs.
Establish standards for in-service training.
Develop standard guidelines for internships.

It is interesting to compare these results and recommendations with my 1974 study Manpower Needs in the Alcohol Field. The training priorities in 1974 were:

Clinical supervision training for managers and supervisors
Leadership development and succession planning for the next generation of leaders
A system to credential/accredit counselor training programs
Development of credentialing systems for counselors and a career path for personnel in the field

The question may well be asked, what progress have we made in the substance abuse field in the past 30 years?

In addition to research data indicating the field's needs, ample anecdotal information indicates the need for leadership development, clinical supervision systems, and succession planning for the next generation of personnel. By 2010, many of the major U.S. substance abuse and behavioral health treatment centers will undergo significant turnover of their long-term leaders, directors, CEOs, and executive management staff.

Unfortunately, the pool of resources is quite small, with many agencies vying for the same talent. The behavioral health field, and especially the alcoholism and drug abuse field, has not spent the time and effort to nurture the next generation of leaders, managers, and executives. A major leadership gap will occur within the field as the “old-timers,” now in their late 50s to 70s, retire or die, leaving a major shortfall in senior-level talent. Unless meaningful action is taken within the next five years, this leadership crisis could be a major blow to the field.

Furthermore, as the CSAT scan asks, who are the next generation of counselors, middle managers, and directors? A major gender gap remains in the next generation of counselors. Considering that 70 to 75% of the new entrants into the substance abuse field are women, and that 70% of clients are men, what are the issues regarding women counseling men?

A multifaceted approach is needed to address these concerns. A growing number of leadership development programs are starting in the behavioral health field. For example, the Fellows Program of the Carolinas Conference in North Carolina shows significant potential as a national model for leadership development (www.carolinasconference.com). The New England Institute of Addiction Studies Summer Leadership Development Program provides excellent didactic and classroom experiential training for managers and future leaders (www.neias.org/SATneias.html). The Addiction Technology Transfer Center Leadership Institute (www.nattc.org/leaderInst/index.htm) and the Community Health Leadership Program of the Robert Wood Johnson Foundation (www.communityhealthleaders.org) both show promising results.

Most of these programs, however, have a short duration. A long-term perspective and funding stream are needed to prepare future leaders. A related step is to survey the behavioral health field to determine what leadership and succession-planning programs exist and which programs have the greatest potential for addressing the above concerns.

The next step is for the behavioral health field to select one or two models and approaches based on this study and seek to replicate the models in several states. Currently, the most effective models seem to include these components:

mentorship with highly experienced leaders
ongoing communication over an extended period (one to two years)
peer assistance programs allowing participants to form a peer group for technical assistance, support, and guidance
specific activities that enhance and expand knowledge and skills (reading assignments, projects, reports, etc.)

These components need to be compiled into an ideal curriculum with the potential to be replicated in other locations. The Carolinas Conference's Fellows Program seems to have an ideal curriculum, tested and tried over the past five years with very positive results. This model needs to be replicated by many state mental health and addiction authorities, counselor and supervisor training programs, institutes on behavioral health studies, Addiction Technology Transfer Centers, academic institutes, and other training resources. Furthermore, the outcome of this project should be studied and the program modified as needed, based on outcome results. State and federal authorities need to support these models’ expansion at the local, state, regional, and national levels.

Finally, educational institutions need training in the recommended curriculum and program models. These programs need to be mainstreamed into academic institutions to lead toward credentialing, falling under training and educational accreditation standards.

Conclusion

The field has been slow to act because of a number of factors: economic pressures, constantly changing external demands, and lack of vision and foresightedness. Without prompt action to remedy the pending shortage of resources and personnel, the field is heading toward a problematic future. The window of opportunity to develop succession plans and leadership development programs is small. May it not be the case that the field is so busy tending to current clients that it fails to train personnel to treat future clients.

The Problem—by the Numbers

What Can Be Done

Conclusion

Bibliography

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