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Stem the Progression of SUDs With Better Use of Our Existing Workforce
Clinical specialties are double-edged swords. They are valuable in promoting dedication to unique problems but can create a sense of turf. As generalists avoid specialty domains, the available workforce can be reduced to the point of inadequacy. Many therapists consider substance use disorders (SUDs) to be outside their competency. They avoid such clients and can be inattentive to early warning signs.
This needs to be rectified because SUDs are highly prevalent and non-specialized therapists could be extremely helpful. The behavioral workforce should be helping people face signs of SUD impairment at every stage of its development. The tiny minority getting SUD care today are generally accessing at a very late stage. Clinicians can be quite effective with basic therapy skills, without specialized training.
Recruiting All Licensed Therapists
There is widespread confusion about the importance of clinical techniques in our field. While we have many empirically validated techniques, their contribution to outcome is generally less than the impact of the person delivering care. Results vary by clinician, and some clinicians excel by relating well to a wide range of people.
Our field needs to focus on translating research into practice, especially the gems of meta-analysis. By summarizing multiple studies statistically, these analyses have shown our major treatment approaches achieve similar levels of effectiveness. They do not minimize techniques so much as highlight “therapist effects.” Therapists are key drivers of change. They should cast a wide net for people to help.
Too many people miss having therapy at the optimal time in their lives. They need not wait for a clinician skilled in motivational interviewing or relapse prevention. A motivated client should not reject an engaging, non-judgmental therapist in order to wait for someone with specialized SUD training.
Many clinicians avoid substance use issues because they are not sure what to say or do. It is the same discomfort leading many to avoid a client’s suicidal thoughts. The most important thing to do is listen carefully, and every clinician can do this. Clients respond to subtle cues to not discuss topics.
It is time to move “upstream” to help people in earlier stages of trouble. Specialty treatment and addiction support groups are often not a good fit for them. They fundamentally need someone who can discuss their warning signs without judgment. Stigma reinforces a reluctance to explore growing problems, and good therapists know how to work with that reluctance.
Reforming Our Care Delivery System
The ASAM criteria were monumental in 1991. We lacked a clear way to select the right level of care for people with late-stage SUDs. We need a similar watershed moment for screening and early interventions. Efforts have been made, but we have barely scratched the surface. It is a critical need.
What is the best location for early detection and intervention? While screening at many care sites has value (e.g., ERs), the most natural locus for this work is primary care. Visits are routine, continuous, and focused on prevention. The problem is that PCPs are swamped with recommended screenings.
A recent study determined PCPs would need 27 hours per day (sic) to provide the full range of guideline-driven services that are recommended. Screening for signs of SUD seems easy until understood in this context. Yet the need for behavioral work in primary care extends well beyond SUDs.
Behavior drives chronic diseases like diabetes and hypertension, and they comprise 75% of primary care costs. Behavior change is an essential part of primary care work. Our services are vital clinically and financially. The call for behavioral clinicians in this setting is getting louder.
Behavioral care is fundamentally a frontline service. Our field was not sufficiently developed when primary care was first instituted, but today our clinicians are prepared to reach a high percentage of primary care patients with brief and effective interventions. SUDs are just one part of this work.
It is time to use the entire behavioral workforce to stem the progression of SUDs. We can enhance the comfort level of all licensed therapists to work with these issues routinely. A subset of clients with advanced addiction need specialized care, but many others will respond to an empathic therapist.
Therapists will be practicing in both private and primary care offices for the indefinite future, and this is the sort of multi-lane action plan we need. Licensed therapists do not need elaborate training in SUD-focused techniques. They need encouragement to use their core skills for a common problem.
There is a time for risk management, ASAM guidelines, and specialized care, but we should be reducing those occasions. The best way to get there is by fully utilizing our existing workforce. It is a solution hiding in plain sight, but it will only happen if specialists both endorse and promote such a plan.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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