Some government estimates place the healthcare and other societal costs associated with the nation's alcohol and drug use problems in excess of $300 billion. Amid rising labor costs, a shrinking pool of job candidates, an aging workforce, and sporadic government leadership, it should come as no surprise that there is great angst over the effectiveness of the alcohol and drug abuse sector of the behavioral health workforce in addressing these problems.
There are fewer than 100,000 workers in this group, counting licensed and unlicensed staff as well as professionals from other disciplines with alcohol- and drug-related training. With difficult times ahead for many state and local governments, questions are bound to be raised about the use of limited resources to pay this workforce.
As drug and alcohol programs have moved from the margin to the mainstream, we have encountered significant workforce issues. This is not uncommon when the demand for trained workers exceeds the supply. But many also believe that problems in regulation, recruitment, retention, compensation, diversity, and rapidly changing treatment needs have compromised the present workforce's ability to deliver effective care.
The extent of the problem
This past year, while consulting for a new adolescent outpatient center in a metropolitan area, I learned that developing a program design to fulfill the needs of youths and their parents required a team of highly specialized workers able to do the job effectively and achieve state licensure based on new regulations.
Many states have specific regulations for providers of adolescent outpatient treatment. These require an enormous outlay of dollars before one can apply for licensure. The burden is compounded by other troubling issues in our industry, from low salaries to simply a shortage of qualified workers.
Recruiting licensed social workers, qualified health professionals, physicians, and family therapists with specific alcohol and drug experience was extremely difficult. Finding a certified alcohol and drug abuse counselor with specialization in adolescent treatment proved particularly daunting. Only access to private philanthropic dollars made it possible to hire and afford the staff needed for an effective program.
While attending to construction issues, our management team also needed to consider the staffing pattern up front. The specificity of state regulations required allocating far more resources than had been anticipated to address the recruitment problems before opening.
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Like most organizations, we followed the handbook. We developed a specific job description for each of the needed positions, set salary ranges, and began the process of all-out recruitment through newspaper advertising, Web site announcements, association announcements, and word of mouth. For certain positions we drew a large number of applicants, but many of the individuals lacked the requisite experience. For other positions, the well was dry. We received only two relatively appropriate applications for the adolescent counselor positions, and one of those individuals lacked adolescent treatment experience. We came to realize that the dearth of responses resulted from the simple fact that the necessary workforce is not there.
Who will do the work?
Government leaders must consider the ongoing challenges of training, recruitment, and retention of both new and experienced employees within our field. In human services, when government increases regulations or toughens certification requirements, it too often does not increase funding or raise allowable unit costs for services. In addition, it doesn't necessarily help to solve—or is slow to recognize—the problems it creates.
Working with another treatment agency in a state prison for men, in a region fairly close to two major cities, I found it almost impossible to identify experienced counselors, particularly males. We needed a staff of 21 to serve a population of 200 inmates. Ideally, the staff would be gender-balanced. But in practice, only one male staff member ended up working among female colleagues. Staff turnover was high as well, with much of this attributed to high stress and burnout.
The question is not only one of who will do the work, but of whether we can meet the demands of funding sources—and good practice—for staff diversity and effectiveness. In the example of the prison-based program, the problem was exacerbated by a state requirement that all group sessions be staffed by one male counselor or two females, because of rules surrounding female civilian workers and their safety. The lack of diversity in the program, coupled with the additional costs resulting from the inability to attract male counselors, cast some doubt on the efficacy of the overall program.
In a survey conducted by Therapeutic Communities of America in 2006, 81% of the association's member organizations reported that they had workforce shortages. The Annapolis Coalition, a group commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA) to look at this problem throughout the field, reported that workforce shortages would exist well into the future. The group cited a study finding that the industry experienced a 50% turnover in both directors and front-line staff of substance use treatment programs in any given year.1