Chapter 11





     The rates of drug use have waxed and waned over time; however, access to treatment remains elusive to many. For those who can access treatment, being able to work with highly skilled counselors and other health care providers is imperative. One such factor that can increase the likelihood of this occurrence is the clinical supervisor. Clinical supervision is considered essential in addictions work as they not only help trainees hone current skills and develop new ones, but they help to ensure that clients receive the support they need, which leads to increased treatment completion and sustained recovery. Clinical supervisors take on several roles that call for engagement in clinical work (e.g., administrative tasks such as billing, grant writing, and hiring and firing as well). Clinical supervisors are also tasked with operating from a theoretical framework or model of supervision, that best fits with their personalities, knowledge, and the needs of those they supervise. Developmental models of supervision have proven useful as they support the trainee and set the stage for the continual evolution of self-awareness, independence, and commitment to work. These factors are essential in addictions work as they also help trainees better understand how racial and gender disparities might impact their work and how they can engage in culturally appropriate action.






     Substance use disorders (SUDs) affect the lives of millions of individuals each day. In 2018 alone, approximately 53.2 million individuals age 12 or older used illicit drugs; the most commonly consumed substance was marijuana, which was used by 43.5 million people.29 In this same year, 139.8 million people 12 or older were current alcohol users, 67.1 million engaged in binge drinking (4 drinks for women and five drinks for men within a 2-hour timeframe), and 16.6 million were classified as heavy alcohol users. Rates of opioid use have decreased over the past few years, but still, 9.9 million individuals misused these substances. Tobacco is another commonly used substance and an estimated 27.3 million individuals were daily smokers, and 10.8 million of these regular smokers smoked a pack of cigarettes or more per day.

     The rates of substance use and misuse worldwide have remained consistent over the years, but a great need remains for effective, integrated treatment and skilled trainees. Competent clinical supervisors are crucial in the treatment process. Their knowledge, skills, and abilities help to increase treatment retention and completion among clients with SUDs. Clinical supervision is an essential factor in helping to increase the number of skilled and qualified trainees; it is the means through which trainees develop and learn to implement the skills and techniques necessary to effectively and efficiently assist clients during detox, treatment, and recovery. When clinical supervision is available, trainees are in a position to provide much-needed services to individuals entering into treatment. They are also better positioned to address racial and gender disparities that may thwart the developmental progress of both trainees and clients.


     While alcohol and mood-altering substances have been used or ages, it was not until the mid-1750s that steps to control problem drinking were noted. Sobriety or talking circles, which were created by and composed of Native American tribes, were organized.24 Shortly after that, Dr. Benjamin Rush created Sober Houses and published research on the association of alcoholism and chronic health and social problems. The term alcoholism was coined in 1849 by Magnus Huss,39 and Rush proposed the idea of alcoholism as a disease that should have a specific treatment regimen like all other diseases. Recognizing the success of Native American’s sobriety circles, Bill Wilson and Dr. Robert Smith founded Alcoholics Anonymous (AA) in 1935. AA provided a safe place for individuals to share their problems and concerns associated with drinking. Attention to the problematic use of other drugs such as opium and morphine began in the mid-1850s and inebriate asylums were built to treat individuals who presented with problems caused by these substances. Inebriate asylums served as the impetus for residential treatment and created the path toward residential type treatment options for men with substance use problems. “While a very brief period of abstinence is required to restore a patient of this kind to sanity, it takes a far longer time…before he is restored to that power of self-control on which his future welfare depends.”1,p.102 Residential treatment provided opportunities for clients to engage in a longer course of treatment while addressing multiple variables associated with drug use. It should be noted that initially, only men had access to treatment; it was not until 1867 that the Martha Washington Home in Chicago was open to treating women with SUDs. There are many other incidents and movements that led to the professionalization of addiction counseling and where we are today in terms of the support and services provided for those diagnosed with SUDs.

     Although there were incidents along the way that proved harmful and ineffective, there were many events that served to increase our understanding of addiction as a disease and the need to treat it as such. Some of these events include the following and many other events all led our current state of substance abuse treatment and the need for qualified trainees to help support and guide individuals into and through recovery.


Clinical supervisors are charged with helping trainees develop skills required for work in addictions. When clinical supervisors are privy to the history of substance abuse treatment, they are generally more sensitive to the plight of those diagnosed with these disorders and the need for quality treatment. Armed with this knowledge, clinical supervisors can work with trainees to help them hone specific clinical skills required to support clients in treatment and recovery. They are also able to model empathy and work with trainees to change negative beliefs and racial and gender stereotypes about individuals with substance use disorders, which is especially crucial as these negative beliefs and stereotypes lead to the continual perpetuation of disparities among those in treatment.

RACE    
     According to SAMHSA,29 the rates of lifetime illicit drug use slightly declined for most racial groups between 2017 and 2018; however, there was a slight increase for European Americans:
 

Although racial minorities consume lower rates of alcohol compared to European Americans, they generally experience more alcohol-related problems. According to Zapolsky,40 minorities are often subjected to higher rates of health problems such as liver damage and cirrhosis, cardiovascular disease and stroke, and gastrointestinal distress. The higher rates of alcohol use and the subsequent development of physical and chronic illnesses may be attributed to higher levels of stress, poor diet, and lack of exercise; lack of access to insurance and health care, and lower quality care for minorities.2 Heavy chronic drinking further increases the likelihood of developing mental health conditions that further complicate the client’s prognosis. Those of Asian descent generally have overall lower risks of alcohol due to genetic and environmental protective factors.

     There are a number of factors that contribute to the quagmire that perpetuates discrimination against minorities who abuse substances. One such factor is racism. While most minorities use less alcohol and drugs compared to European Americans, they are much more likely to suffer greater legal and social consequences because of racism and sexism. Stereotypes and attitudes have led to the creation of laws and other standards designed to prevent the initiation of drug use; they also make it challenging to fund and access intervention and treatment services. This legislation has led to how minorities with substance use disorders are treated, and they prevent minorities from seeking out and accessing much-needed treatment. A prime example of this is the crack and opioid epidemic.

     Clinical supervisors who are aware of this knowledge are better positioned  to relay to their trainees how these disparities impact racial minorities in terms of access to substance abuse treatment and the quality of treatment they may receive. Clinical supervisors can work with trainees to help them identify how these inequalities might impact their overall success and how they can best provide support for clients who are racial minorities. For example, clinical supervisors can educate trainees on the relationship between race, poverty, and alcohol use. From here, they can work with trainees by helping them to develop skills and techniques that address this trifecta of problems.

WOMEN AND SUBSTANCE USE
     Men engage in drug and alcohol use at higher levels than women; however, women are just as likely to develop a substance use disorder. In 2017, lifetime illicit drug use rates for females were 45.7% compared to 53.6% of men, marijuana lifetime use, 41.2% versus 49.5%, and alcohol lifetime use, 79% versus 82.9%.31 Because of varying physiologies, women respond to substances much more quickly and require much less to experience intoxication similar to that of males. Women who abuse substances are also more likely to have experienced chronic pain and trauma, be divorced, lose custody of their children, experience higher rates of psychiatric disabilities, as well as general health problems. Although women have lower rates of use when compared to men, they are more likely to experience higher rates of drug cravings, severe withdrawal, relapse, overdose, and death from overdose as well.16

     Women are much more likely to be isolated when it comes to substance use and because of varying circumstances, their experiences surrounding substance may be much more traumatic. Society holds women to different standards and those who use drugs may be viewed as lacking moral standards or even “unfit mothers” undeserving of their children and appropriate care. Finding a treatment facility that allows children is a unique challenge for women who abuse substances. These facilities are few and far between, and they generally have waitlists, which results in months before entry. When a decision has been made to seek treatment, it is essential to provide access immediately. Other factors that should be considered include co-ed treatment spaces. Many women in treatment have experienced violence at the hands of men. Women need space to process these issues. Even if the only option is co-ed, creating “women-only” spaces and activities can help to assuage this problem. Also of note, is the need to provide culturally responsive treatment. Minority women have experiences that slightly differ from those of European American women, particularly experiences related to racism. Considerations that address potential treatment disparities could help to increase access to treatment, treatment retention, and treatment completion.

     Recognizing the unique factors impacting women in substance abuse treatment programs is essential. Clinical supervisors are responsible for imparting knowledge to trainees that will better support their work with female clients. Women may require special services and the trainee may be required to implement these services or connect their female clients to said services. Clinical supervisors can assist by helping trainees develop specialized skills and obtain additional knowledge or training required so that they are prepared to address the needs of women whether they relate to the substance use disorder itself or to any of the other myriad issues (e.g., parenting, inter-partner violence, trauma) that specifically affect women.

MENTAL ILLNESS
     The treatment of mental illnesses is also crucial in clinical supervision because there is a high co-occurrence rate between substance use disorders and psychiatric disabilities and both should be addressed while in treatment. Clinical supervisors are there to help trainees first recognize symptoms of each disorder, and possibly how to diagnose them, and also to help trainees understand how treating one disorder and not the other disorder serves to sabotage any work or progress made by the client. Care should be taken with diagnosing minorities to avoid a misdiagnosis. Clinical supervisors should point out that some behaviors are characteristic of many cultures, and they should not be pathologized. Health care professionals should also exercise caution when making mental health diagnoses for substance use disorders. Clinical supervisors should relay to trainees the importance of allowing clients an ample amount of time to detox as some symptoms of intoxication and withdrawal mimic psychiatric criteria (e.g., hallucinations or delusions).

     Disparities in addiction can lead to the problems that further hamper one’s ability to get appropriate care. Even though minorities are less likely to use drugs, the ramifications they experience are much different from and often more punitive than that of European Americans. Minorities are not getting the help they need in many instances, and this prevents treatment and recovery and their full integration back into their social worlds. Clinical supervisors who are mindful of these discriminatory practices are better prepared to guide health care professionals in developing clinical skills that support the specific needs of these clients. Clinical supervisors are charged with helping those they supervise identify blind spots and explore their own beliefs towards substance use. Clinical supervisors’ tasks in these situations are not just to help develop clinical awareness, but to also create opportunities for their trainees to become more culturally aware and sensitive towards those with substance use disorders especially as it relates to minorities.

TREATMENT DISPARITIES
     Understanding treatment disparities in addiction treatment are especially significant when supervising a trainee. Clinical supervisors should be familiar with how minorities, particularly racial minorities, are impacted by factors such as unfair policies, a lack of access to quality treatment, and a lack of culturally sensitive treatment. This awareness serves to make trainees more sensitive to the needs of their clients, and it also increases the likelihood of advocating for better treatment access and quality services. When clinical supervisors are knowledgeable and sensitive to these matters, they model culturally sensitive behaviors and techniques when working with their trainees. As a result, trainees are guided in the development of both skills and attitudes that support all of their clients during treatment and beyond.

     Data and outcomes reveal that racial minorities receive far less treatment than European Americans. African Americans have less access to treatment, and they generally have less supports–financial, familial, social–that could increase their likelihood of finding and completing treatment. Compared to other racial minority groups (e.g., African Americans, Hispanics, Asian Americans), American Indians and Alaska Natives were most likely to need treatment for illicit drugs and alcohol (17.5% versus 9.3%), and they were more likely to receive specialty treatment; however, they were still less likely to receive treatment when compared to other minority groups.32 African Americans are most likely to receive treatment compared to other racial minority groups because they were more likely to recognize a need for treatment, and they were more likely to seek out treatment as compared to other racial minority groups.32

     Even when treatment is available, minorities are more likely to drop out before completion due to factors that may be related to the cost of treatment, location of treatment facility, and lack of family support. African Americans, Hispanics, and Native Americans are less likely to complete treatment at rates of 4.7%, 3.5%, and 8.1%, respectively.26 These higher dropout rates may be attributed to treatment that is not culturally sensitive, poor clinical staff, location of treatment facility (e.g., too far away), lack of family support, or lack of commitment and motivation. A protective factor, factors that prevent or drastically reduce the use of a substance, for Native Americans in this instance is the culturally specific treatment programs funded by the federal government. These programs are located throughout the nation and incorporate both evidence-based treatment techniques and Native traditions into the treatment program. Not only are these programs Native specific, but they are also for Natives only.

     The higher treatment dropout rates for African Americans and Hispanics could be attributed to finances caused by unemployment or under-employment, a lack of engagement or culturally sensitive treatment or possibly psychosocial issues such as unstable housing and homelessness and broken or non-supportive family systems. The clinical supervisor can support their trainees and in turn, the clients they serve, by ensuring that trainees understand not only the disparities that play a role in treatment access and services but by helping trainees develop the clinical skills required to address these unique problems as well as the skills required for advocacy. When clinical supervisors and trainees align in their thoughts, attitudes, and skills related to advocating for minority clients with substance use disorders, clients are better served, and this may help to reduce (or even prevent altogether) what the US has experienced in terms of drug epidemics (i.e., crack and opioids) and the glaring racial disparities associated with both.

     The crack and opioid epidemic. Clinical supervisors who have worked in the field of addiction are aware of the inconsistencies present in treatment. The incongruencies may be base upon the race of a person, his or her gender, or several other arbitrary factors, such as the drug a person chooses to use. The treatment of individuals with substance use disorders is oftentimes based upon the substance an individual decides to use. There are “bad drugs,” like methamphetamine, and there are other drugs deemed more acceptable. There are also stereotypes about which substances are more likely used among specific subgroups of people. These stereotypes create space for disparities to materialize. The ensuing discrimination results in a lack of access to treatment and other safe places that support recovery. Ideas and beliefs about two substances in particular, provide the perfect example of this–crack and opioids. In recognizing the disparities experienced by those who use crack cocaine in particular, clinical supervisors can relay to trainees how these problems have uniquely impacted racial minorities and how they can shape their work with clients to ensure successful clinical outcomes.

     Crack is made by mixing cocaine, baking soda, or ammonia and adding heat, which results in a crystallized rock; it is much cheaper than cocaine and produces a quick intense high, making it more attractive, especially for those who have little money but are still looking to get high. As the United States declared war on drugs, the use of crack exploded and reached epidemic status in the mid-1980s. While crack use was considered as something that plagued minority communities, in reality, European Americans reported higher rates of crack use overall during this time. During the height of crack use, NIDA18 found that 75% of European Americans, 15% of African Americans, and 10% of Hispanics reported using crack amid the crisis. However, arrests and sentencing did not reflect this as African Americans, particularly African American men, were more likely to be charged and sentenced–79% of those convicted for crack offenses were African American, 10% Hispanic, and 10% European American9 during this same time. These inequalities led to high rates of imprisonment as well as a host of other social ills.

     Crack use is linked to many other health and psycho-social issues such as higher rates of blood-borne diseases (i.e., HIV/AIDS, Hepatitis B and C), homicide and suicide, other violent behaviors, other drug use, homelessness, and family dysfunction. In just recognizing that European Americans make up the majority of crack users, clinical supervisors and trainees can help reshape the narrative and address the racial disparities related to access to treatment, treatment outcomes, the negative repercussions (e.g., legal) associated with its use.

     Minorities who abuse crack were faced with harsh consequences. They generally were not offered treatment, and if they were, crucial elements were missing that should address the unique circumstances they experienced before and after use, such as high rates of unemployment, unstable housing, poverty, social and physical trauma, and abuse. Instead, minorities who used crack were met with extended prison sentences with little to no rehabilitation available.
The crack epidemic did not lead to a call for funding to expand treatment and prevention services; it was met with increased policing and laws that further restricted the rights and access to services. Decades later, minority communities are still recovering from the harm caused to themselves, their families, and their communities by crack.
Clinical supervisors can support their trainees who work with minorities who abuse crack by helping them first to understand the circumstances surrounding the initiation of their drug use. For example, what role did negative psycho social factors play in a person deciding to use crack for the first time and what role did they play in the continuation of drug use. Clinical supervisors can assist trainees by certifying that they have the skills required to address these issues, and when trainees do possess these skills, they are better positioned to address the most important factors, those that get at the heart of crack use among minorities. It is also important to note that crack is not the only substance that has reached an epidemic proportion. The substance now at the center of the new drug epidemic is opioids. The use of opioids is wreaking havoc in the US; however, a different population is primarily affected:

     European Americans. Once prescribed to treat acute pain only (cancer, post-operative/surgery), prescription opioid use, and subsequent abuse has increased exponentially over the years. One response has been to declare a national health emergency and work towards developing treatment options–including pharmacological treatment options–that address the needs of those addicted to these medications.

     Prescription opioid misuse reached epic proportions a few years ago, and while most people who use these medications take them as prescribed, 21-29% abuse them.15 In 2017, 1.7 million individuals met the criteria for an opioid use disorder and approximately 80% of individuals who use heroin used prescription opioids first.15 In 2018 alone, 10.3 million people over the age of 12 misused an opioid.24 While rates of opioid use have decreased (slight increase for African Americans), its use leaves in its wake devastated lives, particularly in poor minority communities.

     Disparities associated with opioids tend to fall into two categories: 1) who has access to the drug itself and 2) who have access to addiction treatment. It is well documented that minorities are less likely to have access to opioids. Minorities are less likely to have insurance and access to medical care overall, but when they do, health care providers are much less likely to prescribe these medications due to negative beliefs and attitudes. The notion that minorities can withstand more pain, that the black body is biologically ‘different’ from European Americans and actually ‘stronger,’ and the health care professionals doubting their experiences of pain has led to inappropriate care.27 Clinical supervisors and trainees should know that even though minorities have less access to prescription opioids, they still abuse them and they may resort to using other opioids, such as heroin. Heroin produces a similar high and is much cheaper and easier to access. Access to treatment for opioid abuse in minority communities is few and far between, and medications proven to treat these disorders effectively, are often not readily available within minority communities.

     Another noted difference is the amount of money the federal government and private entities have set aside to address the myriad problems caused by opioid use and misuse. These funds have been used to expand treatment and prevention services as well as increase research dedicated to developing a pharmacological treatment (e.g., methadone, buprenorphine, naltrexone). Research has focused on developing new medications and alternative ways to treat pain. Even as minority rates of opioid use among minorities have increased over the years, access to lifesaving medications used to treat this disorder is not widely available in these populations. Clinical supervisors who work in addictions should be aware of the racial disparities in terms of medication and treatment access and how this impacts the potential recovery of minority clients. Clinical supervisors are to inform trainees of the need for such access and how they might work with treatment providers to ensure minority clients have access to any treatments that increase their likelihood of treatment completion and sustained recovery.

     There are vast differences in how individuals who use crack-cocaine, particularly racial minorities, and those who abuse opioids are treated. While research notes that European Americans are more likely to use crack, other racial minorities are more likely penalized. For example, racial minorities are more likely to face harsher criminal sentences and have fewer treatment options than European Americans. There are also disparities as it relates to the amount of money and research dedicated to treating each disorder as well. Pharmaceutical companies and other entities have invested billions of dollars in the development of pharmacological treatment options for opioid use disorders. These medications have proven to be lifesaving; however, minorities do not have equal access to them. Clinical supervisors can play a vital role in addressing these treatment disparities during supervision. In these situations, clinical supervisors can work with trainees to first help them identify whether or not they hold attitudes that might be detrimental to client success. Clinical supervisors may also support their trainees in advocating for access to appropriate treatment, including pharmacological treatment for opioid use disorders.

     There are many disparities present in the criminal justice system. Racial minorities, women, and individuals with psychiatric disabilities face many harsh circumstances that complicate their treatment and recovery process when compared to European Americans. Clinical supervisors are to be mindful of these inequalities and how they have the potential to impact the ultimate client outcome–treatment completion and sustained recovery. In these instances, clinical supervisors can provide the support and guidance trainees need to make sound clinical decisions, employ culturally sensitive techniques, and advocate for changes that best reflect the unique needs of their diverse client base.


     In 2018, 21.2 million people age 12 and older needed treatment services; however, only 3.7 million (<2%) received any assistance.29 Finding a treatment program that provides any of the necessary services (e.g., detox, residential, in-patient, out-patient, behavioral therapy, case management, individual, group, family counseling) can prove challenging. One such way to improve some aspects of treatment, including the services offered, can be accomplished through clinical supervision.

     Clinical supervision has been deemed an essential element in substance abuse counseling, with one of the most critical aspects is protecting the welfare of clients.38 Clinical supervisors are tasked with supporting and encouraging counselor development, and trainees who receive “more sponsorship and greater acceptance-and-confirmation” by their clinical supervisor were significantly more likely to have more positive work experiences and outcomes. 25 This same study also found that trainees were scored significantly higher on their overall performance within the clinical supervisor-trainee relationship when they received adequate support and feedback.
The role of the clinical supervisor can frequently prove difficult because they are expected to take on several tasks, such as that of:


     Additional foci of clinical supervision include:


     “Clinical supervision enhances the quality of client care; improves the efficiency of counselors in direct and indirect services; increases workforce satisfaction, professionalization, and retention; and ensures that services provided to the public uphold legal mandates and ethical standards of the profession.”34,p.5 Clinical supervisors also help to implement evidence-based practices and even prevent the crossing of relationship barriers between trainee and client.8, 25
To address the unique factors associated with supervision in addiction, 11 fundamental principles were developed as guiding factors for those who work as clinical supervisors in this field:


Individuals who find themselves working in addictions come from varied backgrounds, which means that educational and work experiences vary. As such, some may not have received the requisite training and experiential opportunities to develop and hone their skills as clinical supervisors. Ideally, those who assume clinical supervisory roles have met the requirements deemed necessary to receive licensure and clinical supervisory status from their states’ licensing boards. However, even when this is accomplished, the application of clinical supervisory skills may still prove difficult or, at best, lacking. To further complicate matters, few studies have been conducted and little written on current models of supervision in addictions that can guide those in clinical supervisory roles. While this can be a challenge, it is not the only factor that complicates clinical supervision.


     Clinical supervision in addictions can be especially rewarding as it serves to increase the number of talented trainees, which translates into greater treatment success and, eventually, long-term recovery among clients. However, because of the diverse roles in which clinical supervisors are expected to engage and other challenges innate to working in addictions, proficient supervision can prove challenging, although not impossible. Some of the problems that clinical supervisors might experience include the inability to differentiate between their assigned tasks, a lack of training among counseling staff, high employee turnover and low job satisfaction, recovery beliefs, and medication-assisted treatment.

DIFFERENTIATION BETWEEN CLINICAL AND ADMINISTRATIVE TASKS
     In many settings, clinical supervisors are not only responsible for overseeing trainees, but they may still have a caseload of their own as well as other administrative tasks. Because each role requires clinical supervisors to utilize a different skill set, there may be difficulty in differentiating between or operating in these roles, especially for those who have not been adequately trained.34 While clinical supervisors may use many necessary counseling skills with both clients and trainees, they must still be able to distinguish between their roles, duties, and expectations for each group.34
Administrative tasks such as billing, grant writing, hiring, training, and firing all require time and attention from clinical supervisors; though, very few clinical supervisors have received adequate training in these areas either. Grant writing can take up excessive amounts of time with few dividends in most instances. Also, very few clinical supervisors have human resources experience. The time it takes to hire, fire, and replace staff can be time-consuming as well.  These responsibilities can hamper the clinical supervisor’s ability to focus on other areas of need such as the continual development of trainees.

TRAINING AND EDUCATION/PARAPROFESSIONALS
     When providing supervision for paraprofessionals, clinical supervisors may be required to assume additional responsibilities to accommodate the lack of skills and knowledge of those they supervise.10 Completing a formal education program and obtaining a license to practice was not always required in the field of addiction counseling. Addiction counseling is relatively new, as compared to other areas of counseling; therefore, it was much later before education, experiential activities, and work requirements were put into place. Before this, most counselors and clinical supervisors were usually in recovery themselves, often not far removed from their treatment. This led to concerns about the lack of knowledge and skill development among counselors and the quality of care clients received. CACREP currently outlines the knowledge and skills required for those obtaining a master’s degree in counseling with an emphasis on addiction. It is mandatory to complete courses that address common areas of counseling including human growth and development, social and cultural foundations, helping relationships, group, lifestyle and career development, appraisal, research and evaluation, and professional orientation. Within these courses, requirements for (a) foundational knowledge (e.g., history of addiction counseling; philosophies of treatment; neurological, biological, and psychological aspects of addiction), (b) contextual dimensions (e.g., role and function of addiction counselors, psychosocial factors that increase the likelihood of drug use and dependency; diagnostic criteria; ethical and legal considerations), and (c) practice (e.g., completion of practicum (100 hours) and internship (600 hours), intervention techniques; screening, assessment, treatment planning) are to be infused. However, there are still some certifications that can be obtained with a high school diploma/GED or an associate degree. A high school diploma or GED, coupled with work experience, may allow individuals to receive some certifications. For example, Arkansas offers a certificate as a peer recovery specialist and an alcohol drug counselor/alcohol and other drug abuse (ADC). It should be noted, however, that adequate clinical supervision can help offset limited education and training,25 but clinical supervisors themselves must be properly trained.

     While standards for those pursuing a counseling specialization in addictions were introduced in 2016, it should be noted that students pursuing other specialties in counseling (e.g., clinical mental health, rehabilitation, school) are generally not required to complete an addiction course. Graduates from these programs who take on positions in addiction may lack the basic knowledge necessary to provide adequate services. If these individuals go on to become clinical supervisors (often placed in this role because of an advanced degree), it can very well impact counselor development and ultimately client success. As such, the need for all graduate-level counseling programs to include some training and coursework in addiction is imperative.

CLINICAL SUPERVISOR SUPPORT IN REDUCING TURNOVER AND JOB DISSATISFACTION
     Turnover is expensive, can compromise the care clients receive, and may reduce the amount of time clinical supervisors can spend with trainees, particularly if they have to take on the cases of counselors who leave. Factors that increase turnover include job dissatisfaction and budget cuts, which impacts both pay and access to services for the client and trainee. Although there is a bright outlook in terms of employment for all areas of counseling, addiction counselors are oftentimes faced with lower overall salaries. In 2018, the average salary for mental health counselors was $44,630, marriage and family therapist $50,090, school counselors $56, 310, and for both vocational rehabilitation and addiction counselors, the salary average was $35,630.20 Another factor associated with job dissatisfaction is the nature of addiction itself. Addiction is a lapsing and relapsing condition, and it can be difficult for counselors working with clients who experience relapses.21 Clinical supervisors need to expose trainees to challenges they may encounter if seeking employment in addiction working environments.

     Clinical supervisors can affect the experiences of those they supervise and reduce the rates of burnout and resignation by establishing trust in their relationships, inspiring and motivating staff, communicating enthusiasm, and immediately responding to trainee needs and requests.23 Associations between clinical supervision and autonomy, disruptive justice (balance between job demands and rewards), and procedural justice (counselors having a voice in decision making) were noted to be essential factors in employee turnover.11 When efficient clinical supervision was provided, trainees experienced job autonomy, felt as if there was a balance between work and positive benefits, believed they could speak in making important decisions in the workplace, experienced less emotional exhaustion, and turnover intention was significantly reduced.11 Clinical supervisors help to define the culture that determines how well trainees connect to the work they perform, which impacts morale and job satisfaction. Clinical supervisors can advocate for pay raises for trainees who achieve well; if this is not feasible, clinical supervisors may look for other ways to reward trainees and recognize them for their work. When trainees are appreciated and have their needs met (e.g., development of clinical skills, supportive clinical supervisors, intrinsic and extrinsic rewards), the likelihood of turnover and low morale are drastically reduced.

THE RECOVERY BELIEF
     Early on, supervision in addictions was generally conducted by a “more senior helper telling another what to do.”10, para. 2 These researchers note that clinical directives often came from clinical supervisors who relied on their own recovery experiences as opposed to education, training, and practice. While our understanding of addiction treatment has evolved, some still believe the best counselors are those who are in recovery themselves because of shared experiences. In one study, recovering counselors felt as if they had some advantages over non-recovering counselors, including being able to better connect and empathize with clients, creating better boundaries in the counselor-client relationship, having a healthier attitude towards their clients, and being better prepared in general to provide treatment services.19 In this same study, non-recovering counselors felt they were more similar to their clients because of the universal “human struggle” and related to clients in this way; they did not feel as if not having a SUD negatively impacted their work.
While some recovering counselors report a higher level of commitment to their work and more motivation to continue working in the field,4 some counselors in recovery may find it difficult to “switch from self-to client-center approaches and possess rigid views of how to manage the recovery process.”35, p.126 Clinical supervisors working with these counselors can provide guidance on proper boundary setting and on identifying and addressing issues associated with transference and countertransference during clinical supervisory sessions.8 When supervising non-recovering counselors, clinical supervisors may work on developing and expressing empathy.

MEDICATION-ASSISTED TREATMENT
     Another factor that may complicate supervision in addiction is the use of medication-assisted treatment (MAT) for individuals with alcohol and opioid use disorders. MAT, coupled with behavioral interventions, has been found to increase treatment completion exponentially; reduce rates of lapse, relapse, and death; prevent the spread of blood-borne illnesses (e.g., hepatitis B, HIV/AIDS), improve overall functioning, and increase engagement in society.15,17,26
Medications such as methadone, buprenorphine, naltrexone, and naloxone have proven effective in treating these alcohol and opioid use disorders and preventing overdose deaths; however, these medications are underutilized. These medications work by reducing many of the symptoms associated with withdrawal and cravings. Some individuals take the stance of “no drug use” during treatment–including life-saving medications such as these–noting that these medications serve only as drug substitutes and can lead to their addiction.30 This argument has been made against the use of methadone in particular. When taken at treatment doses, methadone users do experience euphoria and symptoms of withdrawal and cravings are reduced. However, methadone can be addictive especially if not taken as prescribed.30 Higher doses can induce euphoria similar to that experienced while using opioids making its abuse and misuse attractive to some. Newer medications, such as buprenorphine and naltrexone, greatly reduce or altogether prevent the euphoric experience making their use more attractive.

     Less than one-half of privately funded treatment programs offered MAT and only one-third of these patients receive it.15 Most treatment centers in the US cannot provide these life-saving medications (NIDA). The problem in clinical supervision arises when this service is offered and there is a lack of clinically trained staff to assist in the monitoring and tracking of these medications. Most trainees and clinical supervisors have not received training in this area and are not prepared to address the myriad concerns that accompany the use of these medications.

     There are other factors unique to addiction counseling with which clinical supervisors must navigate, such as treating co-occurring disorders and addressing chronic pain among clients with SUDs. It should also be noted that clients in treatment often present with several health conditions and other psychosocial issues (e.g., lack of insurance, lack of safe housing, engagement with the legal system, breakdown of the family system) as well. However, supervision provided by trained professionals, those who meet the conditions mentioned above and understand how to operate within proven models of supervision, can offset potential problems that arise when working with trainees who serve this diverse population.


     “Together with some other disciplines, the substance abuse field often turns out clinical technicians with good counseling skills but no theoretical underpinning and little understanding of why they do what they do.”23, p.48 Models of supervision provide the framework from which clinical supervisors operate. These models provide structure for the clinical supervisor and trainee, which allows for the tracking of growth, the development of new skills, and the honing and expansion of previously held skills. Supervision is multilayered and includes a philosophical foundation (underlying ideas about how people change), descriptive dimensions (specific characteristics of practice-based upon one’s philosophical foundation), and stages of development (growth and development for both the trainee and clinical supervisor).23 While there are many models and theories of supervision, clinical supervisors employ the same necessary skills to foster relationships and support trainee growth. Models of supervision are only as good as the clinical supervisor’s ability to effectively operate within the framework and apply its views.

DEVELOPMENTAL MODEL
     To provide the most effective supervision, clinical supervisors must be able to identify the stage of development in which trainees are and then utilize supervisory techniques that move them along the continuum towards mastery. There are several developmental models of supervision in addiction and all focus on the trainee’s progression and development of skills all while being supported by trained clinical supervisors. There are a number of factors that lend to trainee’s level of skill; therefore, their development should always be viewed on a continual stage of growth and development.23 Stoltenberg et al.28 created one of the most prevalent developmental models of supervision used in addiction counseling in 1998. As such, clinical supervisors should be prepared to meet clients where they are in each stage by understanding the following levels of counseling development as proposed by their model:

LEVEL I: These trainees are entry-level and may have had few work experiences that allowed for the development of counseling skills. Trainees are usually enthusiastic about their new roles and are eager to help others. Unfortunately, trainees are soon hit with the realities of their new roles – not all aspects are glamorous and the work may seem difficult. If not processed in supervision, this could be viewed  as one of the first steps towards burnout.

     The following factors characterize this level of development:


     The primary goal at this level of supervision is to ensure that both trainees and clients remain safe. Clinical supervisors should focus on creating trainee autonomy and provide structure and feedback that is encouraging and fosters an environment for continual growth.23

LEVEL II: Characterized as the adolescent stage of trainee development, trainees may experience “trials and tribulations” during this most challenging stage.20 Trainees may be frustrated by their inability to solve problems and may experience conflict with their clinical supervisor as they vacillate between being dependent and exercising independence. During this level, trainees may experience stagnation and frustration, which are considered the second and third stages of burnout.

     This level of development includes the following aspects:


Supervision at this level should focus on promoting greater autonomy, which encourages trainees to employ the skills they are developing confidently. Trainees should have a caseload that provides a mixture of clients that challenges them, but also includes opportunities for success.23

LEVEL III: Trainees at this stage can operate from their theoretical orientation and provide “stable performance in all domains.” 23, p.76

     The following factors characterize this level of development:


When clinical supervisors can identify the level or stage of their trainees and can meet their developmental needs, they encourage the continual evolution of the trainee’s skills and abilities. They are also able to address factors that may lead to exhaustion, thus decreasing burnout and high turnover. It should be noted that as trainees are moving through these stages of development, clinical supervisors have similar experiences as they strive to become more competent in their work as well.

BLENDED MODEL
     The blended model is the only model specific to supervision in addiction settings.23, 34 Aspects of this model include:


     The blended model borrows aspects from the Minnesota Model of Recovery, or the abstinence model, and the 12 steps of Alcohol Anonymous (AA). The Minnesota Model of Recovery recognizes that alcoholism exists, that it is a disease, and that it waxes and wanes and affects all areas of a person’s life.8 This model emphasizes a collaborative working relationship between professionals and those in treatment as each group can help and support the other. This model relies heavily on the 12 steps developed as part of the AA treatment strategy. The 12 steps are:


There are many factors that underly the blended model including the belief that individuals with substance use disorders are capable of change mainly when they are offered guidance and support. When operating from this model of supervision, clinical supervisors focus on change–when it is appropriate and necessary and how to best implement strategies that support trainees through the changes they experience.

INTEGRATED SPIRITUAL MODEL
     Possessing knowledge of spiritual models of supervision and how to operate within them is something unique in clinical supervision in addictions as well. The idea of incorporating spirituality in addictions treatment goes back to the introduction of Alcoholics Anonymous, where the concept of honoring a “higher power,” someone or something outside of self, as a way to successfully move through treatment and eventually sustained recovery. Other aspects of spirituality, such as the daily citing of the Serenity Prayer or the incorporation of scripture readings and prayers groups, are common among treatment facilities also. While several organizations offer curricula in the area of spirituality in addictions (e.g., American Counseling Association (ACA), CACREP), there are still some factors that have prevented its full integration into practice37 including a decline in religious connections and practice in the US.

     Over the years, reports have noted a decrease in religious affiliation in the United States, particularly among millennials and young adults. According to a recent Pew Research Center22 study, 9% of respondents reported that they do not believe in God, and of this group, 38% were between the ages of 18-29, and 34% of respondents were between the ages of 30-49. Sixty-three percent of their survey sample reported an absolute belief in God. This study also noted that Christianity is still the largest religious group (70.6%) with 25.4% of this group identifying as Evangelical Protestant and 20.8 % as Catholic. Approximately 6% identified as belonging to a non-Christian faith–Jewish, 1.9% and Muslim, 0.9%. Also of note is that 3.1% of participants identified as Atheist, 4% as Agnostic, and 15.8% as “nothing in particular.” The varying beliefs and religious practices are indicative of the range of views held by those in the counseling field, which can make the incorporation of this model more difficult than others.

     Researchers posit several barriers to the inclusion of spirituality into supervision including a lack of clinical supervisor training, diverse spiritual beliefs, and a lack of understanding of these differences, which may lead to an avoidance of supervision focused in this area.37 Because spiritual practices are an integral part of many treatment centers, those working in this field may benefit from developing their own understanding of spirituality. This does not mean that trainees are expected to engage in any spiritual practices but contemplating and coming to know one’s relationship to spirituality may enhance clinical supervisor-trainee and trainee-client relationships and the overall success of treatment.
The Integrated Spiritual Development Model (ISDM) is based on James Fowler’s Theory of Faith Development and Lawrence Kohlberg’s model of Moral Development. Fowler, who was a lecturer at Harvard Divinity School, studied the work of Kohlberg and found that his “work provided an impetus to try to operationalize a rich concept of faith and to begin to look more systematically at faith in a constructive-developmental perspective.”6, p.160

     Theory of Faith Development. Fowler posits that faith is not a set of beliefs or religious dogma, but a way of knowing, something that is common among all human beings, and forms out of necessary trust. For humans, faith underlies our beliefs, values, and meanings, which:


This theory is “designed to support the spiritual development of substance abuse counselors-in-training”37, p.86, and is designed to assist trainees in increasing their competency and incorporating spirituality into their practice. This theory is comprised of six stages that describe an increase in one’s growth and maturity in spiritual identity. The six stages described by Fowler and Dell7 and Weiss et al.37 are:


     Theory and Stages of Moral Development. Kohlberg’s theory is born out of his expansion of Piaget’s work on human developmental stages. The Theory of Moral Development focuses on one’s transformation in one’s form of thought, which determines how a person makes decisions or engages in the surrounding world.12 These authors note that moral judgment is a universal principle and can be applied regardless of one’s culture. This theory is comprised of three levels and six stages that demonstrate the gradual development of morality over time:

LEVEL 1: PRECONVENTIONAL MORALITY (individual-centered conception of morality)
         STAGE 2: INSTRUMENTAL PURPOSE AND EXCHANGE ORIENTATION

•     Equal exchange of favors

•     “An eye for an eye and a tooth for a tooth”

LEVEL 2: CONVENTIONAL MORALITY (socially centered conception of morality)


LEVEL 3: POSTCONVENTIONAL MORALITY (reason centered conception of moral norms)


     Towards an Integrated Model. The result of this model is to have trainees more comfortable in their integration of spirituality in their daily work with clients. When providing supervision using this model, the clinical supervisor and trainee are engaged in a way that supports the understanding and unfolding of the trainees’ spiritual knowledge, which is done through:



YOU HAVE SINNED AND I CANNOT WORK WITH YOU

     Sahara M. is an African American female who graduated with a master’s degree in mental health counseling and worked for a nonprofit agency in a small rural town that provided services to those who presented with general psychiatric disabilities. Sahara was raised in a two-parent home, and she and her parents regularly attended church several times each week. She attended “Bible camps” during the summer and was an active member of the youth group. She talked about going on mission trips with her family to help “spread the Word of God” and teach her children the real meaning of “being a missionary for God.” She was grateful for the opportunity to infuse her Christian beliefs into her work with some of her clients.

     Sahara’s caseload at the nonprofit consisted mostly of those with depression, generalized anxiety, and bipolar disorder. If an individual met the criteria for a substance use disorder, they were referred for treatment services as her agency could not address such complex cases. Because she had never come face to face with addiction in her immediate family, she had not spent much time thinking about this disorder and its ramifications, but she did hold some “beliefs that did not tolerate drunkenness.”

     After working at this agency for three years, grant funding was no longer available, and donations were few and far between, and as a result, Sahara was downsized. Because she had a family, she felt the need to find a job quickly and applied to several agencies in her town; she even applied to the treatment facility to whom she had frequently referred clients. She was immediately extended an opportunity to work in the treatment program and received praise for her history of working as a counselor. She enthusiastically accepted the position, but after a few months, she felt as if she was drowning and not especially effective with her clients.

     When meeting with her clinical supervisor, Sahara began to share her dismay at not being as productive as she was in her previous job and how she felt unprepared to provide the type of support her clients needed. She said, “I never leave this job; I take my clients with me wherever I go and this is exhausting. I never felt like this at my last job.” When asked by her clinical supervisor what she felt was contributing to her stress, she shared that she was “born and raised in the church” and that her beliefs clashed with these clients because she felt they had “greatly sinned” because of their “partying, drug use, and other ungodly behavior.” She also said, “I think one of my clients is gay and I not sure what to do with him.”
As the supervision session continued, she expressed that she could not leave this job because nothing else was available but that she wanted to become a better counselor because even though she felt these people “had sinned,” she still felt the need to stay and help them.




     Supervision in addiction settings can prove challenging for many reasons. There are some issues unique to supervision in this area – including differentiating between tasks, working with paraprofessionals or those with little training, high rates of turnover and job dissatisfaction, beliefs about recovery, and the use of MAT in treatment settings. However, when clinical supervisors are adequately trained and have the support they need, the ability to develop expert trainees is possible. To be effective, clinical supervisors should understand and operate from a model of supervision that best fits their personality, knowledge, and abilities. They should also recognize that just as one model or technique of counseling does not work for all clients, no one model of supervision works for all trainees. Being flexible and seeking out opportunities for additional training helps not only to increase their skills, but it increases the likelihood of developing more positive relationships with those they supervise, which is then translated into more positive work experiences and trainee/client success.


1Author. (1871). Asylums for inebriates. The British Journal and Foreign Medico-Chirurgial Review, 47, 102-116.

2Castañeda, S., Garcia, M., Lopez-Gurrola, M., Stoutenberg, M., Emory, K., …Talavera, G. (2019). Alcohol use, acculturation and socioeconomic status among Hispanic/Latino men and women. The Hispanic Community Heath Study/Study of Latinos. PLOS One. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214906

3Council for the Accreditation of Counseling and Related Educational Programs. (2019). Section 5: Entry-level specialty areas – addiction counseling. Retrieved from https://www.cacrep.org/section-5-entry-level-specialty-areas-a-addiction-counseling/

4Curtis, S., & Eby, L. (2010). Recovery at work. The relationship between social identity and commitment among substance abuse counselors. Journal of Substance Abuse Treatment, 39, 248-254.

5Derkas, E. (2012). The organization formerly known as Crack: Project prevention and the privatized assault on reproductive wellbeing. Race, Gender & Class, 19, 179-195.

6Fowler, J. (2001). Faith development theory and postmodern challenges. The International Journal for the Psychology of Religion, 11, 159-172.

7Fowler, J., & Dell, M. (2006). Stages of faith from infancy through adolescence: Reflections on three decades of Faith Development Theory. In E. Roehlkepartian, P. King, L. Wagener, & P. Benson (Eds.) The handbook of spiritual development in childhood and adolescence (pp. 34-46). Thousand Oaks, CA: Sage Publications.

8Glasner-Edwards, S., & Rawson, R. (2010). Evidence-based practices in addiction treatment: Review and recommendation for public policy. Health Policy, 97, 93-104.

9Hazelden Betty Ford Foundation. (2016). The Minnesota Model. Retrieved from https://www.hazeldenbettyford.org/articles/the-minnesota-model

10Juhnke, G., & Culbreth, J. (1994). Clinical supervision in addictions counseling: Special challenges and solutions. ERIC Digest. Greensboro, NC: ERIC Clearinghouse on Counseling and Student Services. (ERIC Document Reproduction Services No. ED372355)

11Knudsen, H., Ducharme, L., & Roman, P. (2008). Clinical supervision, emotional exhaustion, and turnover intention. A study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse. Journal of Substance Abuse Treatment, 35, 387-395.

12Kohlberg, L., & Hersh, R. (1977). Moral development: A review of the theory. Theory into Practice, 16, 53-59. doi:10.1080/00405847709542675

13Kohlberg, L., Levine, C., & Hewer, A. (1983). Moral stages: A current formulation and a response to critics. Contributions to Human Development, 10, 167-174.

14Maxwell, B. (2014). Moral development: Lawrence Kohlberg and Carol Gilligan. In D. Phillips Encyclopedia of educational theory and philosophy. Los Angeles, CA: Sage Reference.

15National Institutes of Health. (2019). Behavioral research to improve medication assisted treatment (BRIM). Retrieved from https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative/behavioral-research-improve-medication-assisted-treatment-brim

16National Institute on Drug Abuse. (2019b). Sex and gender differences in substance use. Retrieved from https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women

17National Institute on Drug Abuse. (2016). Effective treatments for opioid addiction. Retrieved from https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction

18National Institute on Drug Abuse. (1991). The epidemiology of cocaine use and abuse. Retrieved from https://archives.drugabuse.gov/sites/default/files/monograph110.pdf

19Nielson, E. (2016). Substance abuse counselors’ recovery status and self-schemas: Preliminary implications for empirically supported treatment implementation. Journal of Drug and Alcohol Research, 5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473661/

20O*Net. (2019). Occupational search. Retrieved from https://www.onetonline.org/

21Oser, C., Biebel, E., Pullen, E., & Harp, K. (2013). Causes, consequences, and prevention of burnout among substance abuse treatment counselors. A rural versus urban comparison. Journal of Psychoactive Drugs, 45, 17-27.

22Pew Research Center. (2019). Religious landscape study: Belief in God. Retrieved from https://www.pewforum.org/religious-landscape-study/belief-in-god/#demographic-information

23Powell, D., & Brodsky, A. (1993). Clinical supervision in alcohol and drug abuse counseling: Principles, models, methods. New York: Lexington Books.

24Prosky, R. (2015). Who started the first sobriety program? Retrieved from https://www.bocahouse.com/blog/started-sobriety-program/

25Rothrauff-Laschober, T., Eby, L., & Sauer, J. (2013). Effective clinical supervision in substance use disorder treatment: Programs and counselor job performance. Journal of Mental Health Counseling, 35, 76-94.

26Saloner, B. & Lê Cook, B. (2013). Blacks and Hispanice are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff (Millwood), 32, 135-145.

27Santoro, T., & Santoro, J. (2018). Racial bias in the US opioid epidemic. A review of the history of systemic bias and implications of care. Cureus, 10, e3733. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6384031/pdf/cureus-0010-00000003733.pdf

28Stoltenberg, C. (1997). The integrated developmental model of supervision. Psychotherapy in private practice, 16, 59-69.

29Substance Abuse and Mental Health Services Administration. (2019a). Key substance use and mental health indicators in the United States. Results from the 2018 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf

30Substance Abuse and Mental Health Services Administration. (2019b). Methadone. Retrieved from https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone

31Substance Abuse and Mental Health Services Administration. (2018). 2017 Nation Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf

32Substance Abuse and Mental Health Services Administration. (2017a). Need for and receipt of substance use treatment among American Indians and Alaska Natives. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH120/NSDUH120/SR120-treatment-need-AIAN.htm

33Substance Abuse and Mental Health Services Administration. (2017b). Trends in the use of methadone, buprenorphine, and extended-release naltrexone at substance abuse treatment facilities: 2003-2015 (update). Retrieved from https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.html

34Substance Abuse and Mental Health Services Administration. (2009). Clinical supervision and professional development of the substance abuse counselor. A treatment improvement protocol (TIP) 52. Retrieved from https://store.samhsa.gov/system/files/sma14-4435.pdf

35Substance Abuse and Mental Health Services Administration. (2005). Substance abuse treatment: Group therapy. A treatment improvement protocol (TIP) 41. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64220/pdf/Bookshelf_NBK64220.pdf

36W. B. (1939). Alcoholics anonymous: The big book. Mineola, NY: Ixia Press.

37Weiss Ogden, K., & Sias, S. (2011). An integrative spiritual development model for supervision for substance abuse counselors-in-training. Journal of Addictions & Offender Counseling, 32, 84-96.

38West, P., & Hamm, T. (2012). A study of clinical supervision techniques and training in substance abuse treatment. Journal of Addictions & Offender Counseling, 33, 66-81.

39World Health Organization. (n.d.). Lexicon of alcohol and drug terms published by the World Health Organization. Retrieved from https://www.who.int/substance_abuse/terminology/who_lexicon/en/

40Zapolski, T., Pedersen, S, McCarthy, D., & Smith, G. (2013). Less drinking, yet more problems. Understanding African American drinking and related problems. Psychology Bulletin, 140. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3758406/pdf/nihms456621.pdf

CHAPTER 12











     As can be noted so far in the book, a variety of service providers deliver case management services to a diverse set of clients. In this chapter, we will look at what case management services look like in the mental health and substance abuse field. When a person is referred for mental health or substance abuse treatment (in some cases a person is referred to both), he or she will have a level of care assessment completed. The purpose of the level of care assessment is to determine if mental health and substance abuse services are appropriate for the client and, if so, what type of treatment is the most appropriate for the client. We will also examine the multidimensional approach to mental health and substance abuse services, discuss the concept of least restrictive level of care, examine the various types of mental health and substance abuse services, and discuss how ignoring multicultural considerations can lead to misdiagnoses and invalidation. It must be noted that the interventions highlighted in this chapter can be used to facilitate services for ALL populations, including those who might be part of underrepresented groups in this country.






     Mental health and substance abuse treatment services are services that help clients learn ways to improve their overall health and wellbeing. There are several types of mental health and substance abuse services (which we will discuss later), but first, it is important for the healthcare practitioner to understand the systems and structure of mental health and substance abuse services as these systems and structures guide the types of treatment services that an agency can provide. In order for an agency to provide mental health and substance abuse services, the agency has to be accredited. Accreditation refers to a set of rules, policies, and guidelines that the agency must follow to be considered “qualified” to provide services. These sets of rules, policies, and guidelines are referred to as accreditation standards.
      Each state has their own mental health administration and substance abuse administration where the rules and regulations of providing each service is determined. While each state has similar rules and regulations, the rules and regulations vary from state to state. To illustrate the impact of having two systems, the systems in the state of Illinois will be used as an example (with the understanding that other states will be similar to Illinois, yet different).
      Why is this important to know? First, it is to ensure that appropriate services are being provided and to monitor the client’s progress in treatment. Second, if the provider does not meet the review dates (e.g., once per year for assessments and every six months for treatment plans), the agency will not get paid for any services that are provided until the assessment or treatment plan are updated and reviewed. Many health and human service providers are not taught in their higher education training about the nuances of providing services and, therefore, struggle when they enter the field.
The Department of Alcoholism and Substance Abuse (DASA) is the agency that regulates substance abuse treatment services in Illinois. DASA’s regulating law is referred to as Rule 2060. Much like Rule 132 on the mental health end of services, Rule 2060 details:      For example, to provide substance abuse services in Illinois, the practitioner must be eligible to obtain their Certified Alcohol and Drug Certification (CADC) within two years of their start date. There are several ways that a provider can become a CADC with a combination of education and experience. That is, a person with a high school diploma can become a CADC if he or she has two years of paid experience, 150 hours of clinical supervision, and 225 hours of addiction counseling specific education. If a person has a bachelor’s degree or higher, the degree can substitute for the work experience requirements.

      Another time when a client might not access the appropriate treatment service is when the service is not available. For example, suppose that a client needs hospitalization for mental health issues, there are several instances (especially in rural areas) when the hospital is full and cannot admit any more clients. When the service type is full, it is often said that “the agency has no beds” or “all of the beds were full.” When an agency’s beds are full, the health and human service provider can put the client on the agency’s waiting list, look for other agencies that provide similar treatment services, or make a referral to a lower level of care. The concept of “level of care” is discussed next.

      A “level of care” refers to the characteristics of the service. Characteristics of services include: treatment setting,      In mental health and substance abuse services, there are several levels of care. Services that are provided in a controlled environment (e.g., in a hospital setting or rehabilitation center) are said to be “higher levels of care” when compared to services such as outpatient treatment (e.g., services when the client goes to an agency for a number of sessions each week). The concept of levels of care is directly related to the concept of restrictiveness.       Understanding least restrictive level of care is also important when helping the client access follow up services. For example, a client might initially be referred to a rehabilitation facility where he or she receives services for two to three weeks, but will need additional supports and services after completion of the treatment at the rehabilitation facility. The provider would make a determination about what lower level of care would best meet the client’s needs. The movement through the different levels of care (in this case from a higher level of care to a lower level of care) is referred to as the continuum of care.

CONTINUUM OF CARE
      The continuum of care is similar between mental health and substance abuse treatment services, even though these services are often provided separately. The next section details the various types of treatment services in mental health and substance abuse. However, it is important to understand that the names and characteristics of each service can vary by state. The following is to be used as a general guideline for understanding the various types of treatment services. There are two main categories of services: Inpatient and Outpatient.

INPATIENT TREATMENT SERVICES
      Individualization of services means that each client’s treatment plan is unique to his or her needs and that no one approach to providing services is appropriate for all clients. Below are descriptions of the various types of residential mental health and substance abuse treatment services. As a general rule, unless specifically stated, the descriptions of the treatment types can be generalized to both the mental health and the substance abuse field.

      Withdrawal from certain substances can be life-threatening if the client does not receive detoxification treatment. For example, a client presented to the LOC assessment and stated that he or she had been drinking alcohol for the past six months on a daily basis. The client would likely be at risk of serious withdrawal symptoms if he or she stopped drinking alcohol without medical treatment. Alcohol withdrawal is life-threatening and should be taken seriously. Early signs of withdrawal from alcohol can be sweating, shakiness, goosebumps, nausea, diarrhea to more serious symptoms such as seizures, delirium tremens (i.e., the “DTs” which are a series of hallucinations and delusions), and major organ failure.
      Homicidal ideation, in contrast to suicidal ideation, is when an individual has thoughts or a plan to harm someone else. Much like suicidal ideation, individuals with homicidal ideation may present with only thoughts, but no active plan, to harm someone, or an individual may present with thoughts, an active plan, and the means necessary to harm another person.
      Medically-managed residential treatment services. Medically-managed residential treatment services are very similar to medically-monitored residential treatment services, but the service setting and staff is slightly different. The key distinction between the two types of residential treatment services is that in medically-managed residential treatment, there must be a physician on staff 24-7. Medically-managed residential treatment services are typically provided in a hospital-based setting. Clients who seek these services typically present with a mental health or substance use disorder or both; and a medical condition that can only be safely treated and monitored in a medical setting. For example, a client would likely be appropriate for this LOC if he or she presented with depression, anxiety, an alcohol use disorder, and cirrhosis (i.e., inflammation of the liver usually caused by alcohol that impairs the liver’s ability to filter out toxins in the body). The primary aim of this LOC is to not only to stabilize the client’s mental health or substance use disorders, but to also gain medical stabilization for his or her medical condition.

SUMMARY OF RESIDENTIAL TREATMENT SERVICES
     There are several types of residential treatment services. Detoxification is a substance abuse treatment service that helps the individual safely come off of substances. Crisis stabilization is a service for individuals that present with suicidal or homicidal ideation with the primary goal of helping the individual to phase out of the crisis.
      Medically-managed residential treatment services are often in a hospital-based setting where there is an attending physician on staff 24-7. Not every client will begin in a residential treatment setting after a LOC is completed, but some do. After the client is discharged from residential treatment services, he or she is typically referred to a lower LOC that is outpatient rather than residential. Much like residential treatment services, there are several different types of outpatient treatment services that vary in terms of service setting, length of stay, and intensity (i.e., how many hours per week the client is receiving treatment services). The human service professional that is providing case management services plays a key role in the client’s movement through the various LOCs.

OUTPATIENT TREATMENT SERVICES
     Outpatient treatment refers to counseling services that are provided at the agency, but do not involve the client staying overnight. The number of hours that the client receives services depends on the type of outpatient treatment. The types of outpatient treatment services that will be discussed in this section are:Medically monitored non-residential services;      Medically monitored non-residential services. Medically monitored non-residential services are often provided in the community to provide support for the client in his or her home setting. One of the most common medically monitored non-residential service that is provided is called Assertive Community Treatment (ACT). ACT is an evidence-based comprehensive treatment program that was developed to help provide community support for individuals with psychiatric disorders who were transitioning out of a hospital-based treatment program.8 ACT is a team-oriented approach of 10-12 practitioners that can include counselors, psychiatrists, psychologists, and nursing staff. The ACT team works with clients’ in their home and community setting to help them move toward their recovery. There is no maximum length of stay in ACT services. In other words, a client can be involved in ACT for as long as it is appropriate for this level of care. The team-approach in ACT services means that each practitioner (whether it be a case manager or a therapist) does not have his or her own caseload. In other types of treatment, it is common that the practitioner has a list of clients that is “assigned” to him or her. In ACT, the team shares the caseload and rotates which clients they see and when.
      Outpatient. Outpatient treatment is one of the lowest levels of care. A client who is involved in outpatient treatment can typically receive up to (but usually not exceeding) 8 hours of care per week. The client can be involved in both individual and group therapy. The number of hours that a client is seen in outpatient treatment is based on his or her individual needs. It might be that a client is only involved in individual therapy and is seen for one hour a week, or it could that the client is involved in both individual and group therapy and is seen weekly for individual therapy and goes to group twice per week. Outpatient is like IOP except the hours of care the client receives is different. Much like IOP, the client can address multiple issues in outpatient treatment which may include (but is not limited to) relapse prevention, anger management, healthy coping, developing healthy supports, family relationships, money management, time management, etc. The primary purpose of outpatient treatment is to provide therapeutic support while the client works on his or her recovery.

SUMMARY OF OUTPATIENT TREATMENT SERVICES
     The variety of the different types of mental health and substance abuse outpatient treatment services is vast. These outpatient services can range from highly intensive (e.g., medically-monitored non-residential services and partial hospitalization) to less intensive (e.g., intensive outpatient and outpatient treatment). The treatment teams in each type of outpatient service setting tend to be very similar (e.g., psychiatrist, psychologist, counselors, case managers, other support staff), but the philosophy and purpose of each type of outpatient treatment can vary. Nonetheless, it may be that a client is transitioning from residential care to outpatient treatment, but it may also be that the client only needs outpatient treatment service. Remember, a guiding philosophy on determining which LOC is the most appropriate for the client is the least restrictive level of care that can adequately meet the client’s needs. You might be asking yourself how the appropriate LOC is determined. We will look at the different assessment tools that are used to help the healthcare practitioner determine the appropriate LOC.


     There is no standard set of criteria in the U.S. that is used to determine which LOC is the most appropriate. The criteria that is used to determine LOC varies from state to state and is usually guided by state law. While the criteria vary from state to state, there are very common similarities that can be found in each state. One similarity is using the criteria to examine a multidimensional approach to determining LOC. The multidimensional approach includes criteria that assesses multiple aspects of the client’s life, (e.g., acute intoxication and withdrawal; biomedical conditions; mental health symptoms; willingness to participate in treatment and treatment engagement; relapse potential; and recovery environmental support). Below, we will look at each of these dimensions and the general criteria that is examined under each dimension. It is important to note that these criteria are subjective, meaning that they are up to the interpretation of the human service practitioner. When determining LOC, there is a lot of interpretation and assessment from the human service practitioner to arrive at what services would be most appropriate for the client. The case study at the end of this section will provide an illustration of what assessment might look like in a clinical setting.

THE MULTIDIMENSIONAL APPROACH TO DETERMINING LOC IN MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
      Dimension 4: Willingness to participate in treatment. It is important for the human service practitioner to understand that not all clients are self-referred to treatment. Self-referral means that the client expressed a desire on their own terms to access mental health or substance abuse treatment services. There are times when the client is referred by external sources such as physicians, probation or parole officers, friends, or family members. In mental health and substance abuse treatment, the human service practitioner assesses the client’s willingness to participate and engage in treatment by using the transtheoretical model of the stages of change.6 The transtheoretical model of stages of change consists of six levels: precontemplation;       A client who minimizes the severity of symptoms tends to take a situation that, to others, is problematic and make it seem like it is not a big deal. An example of rationalizing is if a client says “my depression is not as bad as people will say it is. I mean, sure I get a little sad, but it is not a big deal.” A client who justifies his or her symptoms provides excuses for why the symptoms are present or why there is a certain behavior. With reference to substance use as an example, a client may say “Even though my family says I have a drinking problem, I only drink because they are the ones who are stressing me out.” These are both examples of what a person who is in the precontemplation stage of change may say or do.
      Preparation. The preparation stage of change is characterized by the person preparing the needed resources and tools to act on making the change happen. For an individual who may need residential treatment, this might include preparation by informing family and friends of the decision to enter residential treatment or by packing clothing that will be needed during their stay. An individual in the preparation stage of change has made the commitment to making the change and is working toward engaging in behaviors that will allow the person to make the change.
      Maintenance. The maintenance stage of change is characterized by the individual’s ability to maintain the skills and tools that he or she has learned and implemented in his or her daily living. The key feature of the maintenance stage of change is that the person no longer requires intensive therapeutic assistance in implementing skills and tools on a routine basis. However, this is not to say that an individual in the maintenance stage of change is no longer in need of therapeutic supports and services, it simply means that the person is able to carry out his or her activities of daily living (e.g., money management, time management, bathing, working, cooking, etc.). However, if the individual starts to show signs or symptoms that could be problematic, he or she may move into the relapse stage of change.
      A client who is in the relapse stage of change might exhibit signs of denial (e.g., believing that their behaviors, thoughts, and actions are not problematic), minimization (e.g., “downplaying” the severity of a problem), or justification (e.g., providing excuses for one’s behavior). A client who is in the relapse stage of change is no longer maintaining the positive changes that they may have previously made. The stages of change model provide a general guideline of how people go through changes in their lives. This movement through the stage of change is not always a linear process, discussed next.

     Now that the various levels of mental health and substance abuse treatment have been discussed and the multidimensional approach to determining the appropriate LOC has been introduced, let’s look at how determining the appropriate LOC looks like in a practical setting. Keep in mind that each health and human services agency will have similar, yet varying, criteria to guide the provider in determining what type of mental health or substance abuse treatment (or both) is the most appropriate for the client. Although each agency will have varying criteria for determining the appropriate LOC, there are unique issues that members of underrepresented groups experience in mental health and substance abuse treatment. A theme that cannot be dismissed when examining the outcomes of many of the following underrepresented groups is discrimination, be it unintentional or not. Here, we will explore the unique issues experienced by women, people with disabilities, and people of color, (to name a few).

WOMEN IN MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
     According to SAMHSA,9 women have a higher rate of mental health and substance use disorders when compared to their male counterparts. More specifically, women tend to have higher rates of depression, anxiety disorders, eating disorders, bipolar disorders, and schizophrenic-related disorders than males. Further, SAMHSA9 asserted that the presence of a mental health disorder increases the likelihood that there is a co-occurring substance use disorder. Why is the presence of mental health symptoms more common in women when compared to men? The answer is fairly straight forward. In the U. S., there is a general expectation that women are to be the “caretakers” of the household (e.g., making sure the household is clean, taking care of the children, assuring laundry is done). However, what is oftentimes overlooked is that the number of women who are working is increasing. Thus, there is a paradigm shift from women being the “housekeepers” to being members of the workforce. This paradigm shift creates a conflict when it comes to an assumption about the roles of women in the U.S. Further, women experience higher levels of stress when compared to men. This stress is experienced both inside the home and in the workplace. An example, it is well known that women are paid less than men for performing the same job. Thus, women are expected to perform equally, if not better, than men for less pay. Factors such as higher stress and low pay contribute to the higher rates of co-occurring disorders in women. Understanding the unique issues faced by women can help the case manager use effective interventions, such as validating the life experiences of women.

PEOPLE WITH DISABILITIES
      Last, an agency that does not provide interpreter services (i.e., a person who can translate spoken language to sign language) would be a barrier for a person who is Deaf or hard of hearing. It is important that the case manager is aware of the unique barriers faced by people with disabilities so that resources can be coordinated to facilitate the treatment process and reduce the barriers that create unequal access for people with disabilities.

PEOPLE OF COLOR
     The number of people with color (e.g., African Americans, Latino Americans) who are diagnosed with a mental health disorder is disproportionate to the number of European-Americans with mental health disorders. According to Schwartz and Blankenship,7 African American’s are three to four times more likely than their European-American counterparts to be diagnosed with a psychiatric disorder while Latino Americans/Hispanics are three times as likely to be diagnosed with a psychiatric disorder when compared to European Americans.
      Another way that the case manager may cause harm is by invalidating the client’s lived experiences. For example, people of color tend to report that they do not feel like they are heard, believed, or understood by providers. This invalidation can discourage the client from engaging in, or returning to, services.1 Acklin and Wilson1 define validation as providing truth to one’s story. When a client feels that he or she has been validated, the quality and effectiveness of services increases when compared to clients who are not validated by the provider. Therefore, it is essential that the case manager has a working knowledge, awareness, and understanding of the unique issues experienced by people of color and the impact that these unique issues have on service quality and engagement.


      The provider that was completing Carter’s LOC assessment was a European American female in her late 50s named Karen. Throughout the assessment, Karen was having a difficult time determining what type of treatment would be the most appropriate for Carter. She also felt uncomfortable talking about Carter’s situation with his ex-wife’s boyfriend as she could not tell if Carter was telling the truth or exaggerating. Yes, many times, people who are part of underrepresented groups tend not to be believed by European American case managers (is there a study to highlight this point?) Carter noticed that Karen was uncomfortable during the LOC assessment, which made him feel as though he should stop talking because he was worried that Karen (much like his past counselor) would make him go to inpatient mental health treatment. As the LOC assessment progressed, Carter told Karen “You know, everything is fine. I am sure that I am just misunderstanding the situation with my ex-wife’s boyfriend. I shouldn’t have even brought it up.” To which Karen responded, “It is okay to bring it up, I am just concerned about your perception of the situation and possible delusions that you might be having that we might want to look into getting treated.” Further, Karen was unsure about Carter’s honesty about his current marijuana use. Karen believed that it is unlikely that people only use marijuana, and no other substances, therefore, she determined that she cannot rule out the possibility that Carter is underreporting his use. She expressed to Carter, “I know that it is sometimes difficult to disclose personal information, especially to someone that you just met, but it is very important for me to know all of the details of your substance use so that I can make sure that you can get the help that you need.” Carter started to feel even more guarded and replied, “What use do I have to come in here and lie to you, especially since my probation officer drug screens me all of the time?” Karen stated “Carter, I am going to need you to not be so defensive. I am just trying to help.” Karen proceeded with the LOC assessment, but found it increasingly difficult to get Carter to disclose the information that she was seeking.

DISCUSSION QUESTIONS



     Many clients present with symptoms of both mental health and substance abuse. Since the mental health and substance abuse service system is fragmented, many clients may feel confused about what type of service they need. To determine what type of treatment is most appropriate for the client, they will have a LOC assessment completed. The LOC assessment assists the practitioner in determining whether services are needed, and what type of services are the most appropriate. A common approach to determining the appropriate LOC is the multidimensional approach that examines the client’s risk of withdrawal, biomedical complications, mental health symptoms, willingness to engage in treatment, recovery environment support, and relapse potential. While the LOC assessment and multidimensional approach are comprehensive, complications in determining the appropriate LOC arise when the practitioner lacks awareness, knowledge, and skills for attending to multicultural considerations. As we saw in this chapter, ignoring multicultural considerations can lead to misdiagnosis and invalidation–two factors that can be very harmful to the client. Human service practitioners must have a working knowledge of how to apply multicultural considerations to prevent harm to ALL of the clients they serve, including people who may be part of underrepresented groups in the United States.

1. Acklin, C. L., & Wilson, K. B. (2017). Barriers to substance abuse treatment: Why validation plays a crucial role. SciFed Journal of Addiction Therapy, 1(1), 1-7.2American Association of Community Psychiatrists. (2000). Level of care utilization system for psychiatric and addiction services: Adult version 2000. Pittsburgh, PA: Author.
   
2. American Association of Community Psychiatrists (2000). Levels of care utilization system for psychiatric and addiction services: Adult version 2000. Pittsburgh, PA: Author
3. Bureau of Drug and Alcohol Programs. (2000). The Pennsylvania client placement criteria.
4. Laudet, A. B., Morgen, K., & White, W. L. (2006). The role of social supports, spirituality, religiousness, life meaning, and affiliation with 12-step fellowships in quality of life satisfaction among individuals in recovery from alcohol and drug problems. Alcohol Treatment Quarterly, 24(1-2), 33-73.
5. Mee-Lee, D. E. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Rockville, MD: American Society of Addiction Medicine.
6. Prochaska, J., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin.
7. Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133-140.
8. Substance Abuse and Mental Health Services Administration. (2008). Assertive community treatment: Building your program. DHHS Pub. No. SMA-08-4344. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
9. Substance Abuse and Mental Health Services Administration. (2015). Women matter! Retrieved from https://www.samhsa.gov/women-children-families/trainings/women-matter