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The Mental Health Field Fails at Addiction Treatment

We don't want addicts as clients. We have little knowledge of, and less training in, addiction issues. We also have the same stigmatizing attitude toward addicts as the rest of society.

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Yvona Pabian via author

By Yvona Pabian

07/24/13

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On the road to becoming a psychologist, I noticed a troubling inconsistency between my clinical experience and academic training: Despite the fact that I regularly encountered clients with addiction-related issues, I received little addiction training in graduate school. The prevailing message was that treating addiction issues fell outside of the work of psychologists and other mental health professionals. I have come to understand that this serious failure must be addressed in order to assure that clients with addiction are treated competently.

Substance Use Disorder (SUD) is the most prevalent mental health diagnosis among the general population. It is the nation’s leading cause of death, disability and disease and is implicated in many social problems, according to the National Institute on Drug Abuse.

Traditionally, addiction counselors who are in recovery have played the leading role in SUD treatment. But mental health providers are increasingly well placed to implement most aspects of addiction prevention, early intervention and treatment for people with both emotional disorders and SUD.

Yet many graduating students in mental health fields simply do not want to work with substance abusers. (For example, one study found that 70% of graduates did not find addiction work satisfying.) Once in practice, they are slow to respond to the addiction field’s demand for their services. It is possible to be a licensed psychologist having only very limited knowledge of SUDs. Critics have concluded that the lack of graduate addiction training can only be described as institutional denial or minimization of the significance of addictive disorders.

In her distinguished 2001 paper, “Helping 'Difficult' Clients,” Lisa Najavits, an addiction specialist, discussed her own initial reaction to addiction treatment: “If I had any prior impression, it was likely negative (an impression I have since realized is fairly typical in the mental health field): ‘They can’t get better,’ ‘I don’t understand that area of work,’ and ‘Alcoholics Anonymous is the main treatment for that.’"

My initial reaction as a psychology graduate student toward SUDs was no different.

I became interested in the treatment of SUDs when I realized that I lacked skills in diagnosing and treating addiction issues. I lacked knowledge of addiction theory, the biological basis of addiction, screening instruments and evidence-based treatments. I did not know how to manage people with a dual diagnosis. And I mainly focused on treating clients’ emotional problems, which I felt more confident in addressing. My deficits at times resulted in less than optimal client care.

The lack of graduate addiction training can only be described as institutional denial or minimization of the significance of addictive disorders.

I decided to pursue a clinical volunteer position at an outpatient addiction treatment facility in order to build confidence and gain skills in addiction counseling. Addiction counselors taught me invaluable skills in addiction treatment and shifted and corrected my flawed thinking about addiction. But I was puzzled that no treating psychologists were on staff. As a result, clients with SUDs—many of whom had multiple and complex problems—were receiving treatment only for their addiction. 

The ugly truth is that people with SUDs are often viewed by mental health providers as morally weak, self-indulgent, unpredictable, dangerous and blameworthy.  I, too, felt somewhat judgmental of addiction clients’ predicament, frustrated with clients who relapsed, and skeptical about their prognosis. Not surprisingly, Illicit drug users report that they experience addiction treatment as filled with judgment. Addiction expert John Imhof even says, “The addiction treatment provider may possess such a significant amount of negative feelings or attitudes toward the addicted client that any hope for objective and effective diagnosis, treatment, and rehabilitation becomes diminished, if not completely eliminated.”

It is crucial that the mental health field critically examine its attitudes toward addiction work and its competencies to treat SUDs. Experts recommend that the field take a number of steps to improve psychologists’ and other mental health providers’ work with SUDs—both in academic training and in clinical practice.

As long as the addiction field and the mental health field remain artificially separated, we will, at best, continue to provide compartmentalized treatment that does not meet the needs of the whole client; at worst, clients will receive incompetent and harmful care.

1. The two fields must be integrated so that both professions work together for the good of the client.

2. Mental health providers need to be routinely trained in addiction issues.

3. They need to shift their thinking to viewing addiction treatment as a part of traditional mental health services.

4. They need to establish partnerships with addiction organizations to build their capacity to respond to addiction issues.

5. Addiction training needs to be included as a prerequisite for the accreditation of mental health training programs, the licensing of mental health professionals, and license renewal.

In addition, universities are not taking responsibility for guiding mental health field students to intervene with addiction cases.

6. Faculty need to be trained to provide education in addiction assessment and treatment as a part of the mental health program's core curriculum.

7. They must increase their awareness of their own attitudes toward SUDs and challenge these attitudes’ negative effect on their instructional practices. 

8. In order to advance innovative thinking about mental health providers’ role in addiction treatment, the profession must encourage students to be “torchbearers” of new ideas.

“First do no harm” is a pillar principle of medical ethics. If the mental health field takes these recommendations seriously, it can go a long way toward doing no harm to clean with addiction—and even doing them much good.

Yvona Pabian is a doctoral candidate in counseling psychology at Cleveland State University. Her clinical interests include addiction issues, co-morbid disorders, crisis intervention and diversity. Her research interests include the study of clinical judgment, addiction competencies and ethics.

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