“Do you think it’s easy to change? Alas, it is very hard to change and be different. It means passing through the waters of oblivion.” –DH Lawrence, “Change” (1971)
Much has been made of the Affordable Care Act (ACA), also known as Obamacare, which has recently become active. Perhaps you’re wondering how the ACA will affect you, an alcohol and other drug (AOD) counselor and our profession. As it turns out, it will affect us a lot! In fact, according to two experts, Dr. A. Thomas McLellan—the Director of the Treatment Research Institute and the former Deputy Director of the Office of National Drug Control Policy—and David Neilsen, from the California Department of Health Services, the ACA will likely affect California’s AOD counselors more than any other. This is because the United States’ healthcare budget is currently 25 percent of the overall US budget—more than any other single category—and California is still the largest state by population in the Union. Neilsen stated that the ACA will require some sixty thousand new AOD counselors in California alone to provide services (personal communication, September, 13, 2013). So, the better question might be: What kind of services will we need to provide under the ACA? We will get to that question a bit later; instead, let’s begin with how the ACA will affect us counselors professionally.
We were so excited when we heard this news recently in a conference, we think you might be too. According to Dr. McLellan, sixty thousand new jobs are coming to our profession, one that already needs new workers daily as many of us begin to look at retirement or perhaps are weary of working in a profession that generally gets little respect, even less pay, and has high turnover rates (personal communication, September, 13, 2013). Incidentally, those statistics are the same as the fast-food industry standard, according to a report done several years ago. In addition, perhaps some of us are unprepared—or even reluctant and/or resistant—to meet the challenges of a new culture of drug treatment rooted in science, like the ever-growing popularity of evidence-based treatments or practices. Another big change will be the necessary electronic health records (HER), which will be the only way agencies, individuals, and other practitioners will be paid. “No EHR, no payment,” said the State of California’s Deputy Director of Health Services recently (personal communication, September, 13, 2013).
So, what kinds of skills do these experts say are needed to work in this new Mental Health (MH) and Substance Use Disorders (SUD) treatment system? How will the culture change? Are we, individually and as a profession, ready? That last question is an important one, and we believe the answer is, “no, we’re not—but we can be!” How we get ready is the aim of both this article and the subsequent training we will be offering in the coming months.
“We are the servant of the patient not the master.” –Hippocrates
These experts believe that one of the biggest areas of change for us will be in the new general healthcare teams we will be working alongside—think doctors, nurses, physician’s assistants, nurse practitioners, not to mention social workers, nutritionists, and more. Along these same lines will be the need for more extensive education for us. How much education you will need and of what kind will likely be driven by decisions on how and with whom we may work. Many of us will likely need to make some important decisions about the area of our profession in which we desire to work, if at all, and come to see our work as a specialty area within healthcare come January 1, 2014, not as a stand-alone specialty anymore. For example, are we happy doing educational groups and providing peer support, or do we want to provide more direct consumer care? The latter will likely require more formal education.
Another major shift will be in how clients are viewed. According to Dr. McLellan especially, treatment providers will need to work within a model of helping consumer-clients to reduce the harmful effects of their drug use, not simply abstain from it, though certainly many of these consumer-clients will choose abstinence as their goal. Furthermore, Dr. McLellan states that treatment will no longer be seen as something one would do only once to be successful but rather, addiction would move into a chronic illness model. This means that we would treat addiction as a complex, chronic condition that cannot be cured, but which can be managed as other chronic diseases are, like diabetes, heart health, nutrition, and weight management. For some of us, this shift may also mean an extra dose of open-mindedness is in order.
One area of concern for us was Dr. McLellan’s comment regarding how many of us are lacking training in the very areas that will bring new life to our profession. How could that be, we said? According to Dr. McLellan, we could potentially need to rethink most of our professional world: Are we addiction counselors, or MH/SUD counselors? Are we only going to treat the addicted, or are we going to need to expand our role to become MH/SUD counselors in the new era of treatment via the ACA? This is a fundamental shift in who we are and have been since the 1970s. It means we would need to expand treatment services to include those consumer-clients who simply need a bit of help in the form of treatment for a chronic illness, not only an addiction, as we are currently trained. It also means that the kind of treatment that will be effective may also be different. How can we even tell if what we’re doing now is or isn’t what the ACA will be asking of us? “Lions and tigers and bears, oh my!” you may be saying. Hold on, there’s a simple way!
One brilliant way to view this shift was suggested by Dr. McLellan: “When you think of treatment for SUD’s, take out the word ‘addiction’ and replace it with ‘diabetes care.’ If what you’re about to do sounds silly for diabetes care, then stop; don’t do it!” One of his examples was around the traditional celebrations held for clients and patients when they complete an addiction treatment episode. You know the ones: consumer-clients share the stories of what their lives were like before treatment; the family is in attendance and usually in tears; a coin or stuffed animal goes around the room and everyone rubs good “juju” on the item, which is finally given to the consumer-client as a token of their commitment to (usually) abstinence and life, etc. Now, go back and read that section again only with “diabetes care” in place of addiction. Doesn’t sound the same, does it? One could say it even sounds a bit nonmedical. Yes, we’re talking a whole new world here!
The ACA is also unintentionally forcing us as a profession to ask some difficult questions about who needs treatment and what that treatment should look like if it’s not for addiction. As AOD counselors, we have traditionally focused our treatment efforts on those whose drug use led to abuse and/or dependence, using DSM-IV-TR terminology. Well, what about those consumers whose use does not lead them to become dependent or “addicted?” Should we care? We now know that there is a large percentage of the general population that may be able to use substances without that use ever becoming a problem for them. The question is what kind of help do they need if not to quit? If they’re not addicted, why would they seek help? Are we prepared to treat these consumers differently, as nonaddicted users, rather than like those who are addicted?
The good news is that there are treatment answers for both of these consumer groups though they are indeed different. One group would include individuals who cannot drink because of a recent health issue and who may require education or guidance in making this change or adjustment—think a patient with a recent hepatitis C diagnosis, or a woman who discovers she is pregnant. This group could also include someone who simply wants to reduce their drinking as part of an overall healthier living plan. The second group would include those who have reoccurring problems as a result of their alcohol or other drug use, such as consumers with multiple driving under the influence offenses or those who have yet to reach their stated goals after several treatment episodes. These consumers would be seen to have a chronic substance use disorder and would likely do well to receive some more traditional, yet still evidence-based, treatment.
In traditional addiction treatment the goal is usually abstinence. In this new world of SUDs, the counselor may not be working with someone with an addiction problem. Both of us have worked with cases in which our consumer-clients wanted to drink more responsibly but realized they did not know what that really meant. As a culture, we don’t generally teach this information to young people in the same way we don’t educate counselors in such. These were consumers who did not want abstinence, though many times we’ve both worked with consumers who simply decide to quit, and said that it’s easier than counting drinks, and they do—they just quit! SUDs counselors may be asked to work with a consumer with substance abuse only or perhaps merely someone with a current problem using drugs, including alcohol. Since most addiction professionals are only trained to promote abstinence, it may be difficult for them to meet these consumer-clients where they are. Again, in our experiences, a moderation plan sometimes fits consumer-clients’ needs and their diagnostic criteria better than abstinence. Sometimes it helps to remember that just 20 percent of all substance abusers become dependent and no one knows who the 20 percent will be. Also, ASAM Patient Placement Criteria states that, “you start with the least restrictive environment” then increase services and treatment, as needed. Maybe the consumer-client just needs a moderation plan or a bit of guidance to help them determine how a substance is impacting their quality of their life, both the positive and the less positive. This new SUDs world will have counselors helping individuals discover for themselves whether or not they have a problem, rather than spending precious time and energy demanding that client-consumers see that they have a problem or risk being viewed as being in denial.
“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” –Arthur Schopenhauer
To conclude this conversation, let’s return to the discussion on who our consumer-clients will be, now that the ACA is in full effect, since Dr. McLellan discussed this topic at length at the conference, and what kind of treatment they will expect. Remember, the ACA also provides for parity of all conditions. First of all, the DSM-5 has done away with the binary dependence and abuse terminology. Instead, drug and alcohol use is now seen as on a continuum, which we believe better reflects how real people move in and out of patterns of drug use. The movement is rarely in a linear fashion; for example, from no use or little use, to moderate use, to harmful use, to problem use, to chaotic use, but not necessarily always in that direction or order. Let’s use the pyramid model that Dr. McLellan used to show use patterns in the United States for all potentially harmful drugs, except tobacco.
The tip of the pyramid represented those with very serious use patterns, whom previously we would have termed “dependent,” which is about 2.3 million people. “These are the consumers that we, including me, traditionally work with and that we are experts at working with,” Dr. McLellan said, “this is not the problem.” The bottom of the pyramid represented people who use a little or not at all, which is a surprisingly large number of Americans—some 250 million people. The middle section, or the “problem-for-us-current-AOD-counselors area,” signified the number of people whose use patterns would now be termed “medically harmful use.” These are people who are not abusing, and certainly not dependent, yet still need some assistance; a category of forty million people. That’s right, forty million! These are consumers that are willing to get some help but they will generally not be interested or willing to go somewhere that isn’t convenient, with few or untrained staff, to buildings that are falling apart, who only treat addiction with a Twelve Step and abstinence-only model. Did we mention that Dr. McLellan also states some of these consumers will need short-term residential treatment—two weeks at most—and again, they are not going to be willing to call themselves an alcoholic or addict, recite prayers, or be served less than nutritionally balanced foods (personal communication, September, 13, 2013)? They will want gyms and swimming pools, their electronic equipment, communication with the outside world when they need it, and regular, scheduled appointments with their medical team, including us, so that we can all work collaboratively with the goal of effective care for this, and every, consumer. They will not simply do what we say. Dr. McLellan’s concern is that most SUDs counselors are not trained to work in this way since there is no requirement for training in moderation strategies. In fact, many of the MH/SUDs counselors we talk to state they still feel undertrained in co-occurring disorders and motivational strategies, both of which will be critical skills necessary to provide effective treatment and change strategies to these forty million consumers. Our profession needs to see these consumers as new clients who want a menu of options for treatment that they could see might work for them, which is perfect since Dr. William Miller—the author of Motivational Interviewing; Controlling Your Drinking—and other researchers have found that this menu of options is exactly what works in any effective treatment.
Finally, we would suggest that if some currently certified AOD counselors, without proper education, training and/or consultation, were to work with a consumer wanting moderation or temporary abstinence, that counselor could be working outside their scope of practice (some certifications have a boarder scope of practice than others) and/or competence—a serious ethical violation of our profession’s Code of Conduct.* So the ACA is giving us a real opportunity to increase the consumer-clients we can connect with treatment, a chance to increase the service options we currently provide, and a reason to expand our knowledge of what works.
“Treat people as if they are who they can be and you help them to become who they’re capable of being.” –Johann Wolfgang von Goethe
The bottom line is that the ACA is bringing us lots of opportunity for change, both individually and to our profession. We see this is an amazing opportunity even though change is always a bit scary. So, let’s take advantage of this opportunity by taking that leap of faith together. Jump in—you’re not alone!
*We are not suggesting that all AOD counselors will now be working with moderation, nor that all those working in moderation are/will be working out of their scope of competence. As with any specialty area, one’s scope of competence—unlike one’s scope of practice—depends on specialized training/education. For more, please contact either of us.