“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
improved training programs