Credentialing Is Not The Answer
Last week's post was about mental health struggles and moral degradation among "behavioral health" workers. Particularly in substance use treatment, poor quality care and abuse of patients is often blamed on minimal requirements for employment in the field. For example, Inside Rehab made lack of staff credentials a key point in its expose, warning patients to avoid providers who lack certain licenses and calling out the industry as a whole for low professional standards. (Rehab: An American Scandal looks to be a companion book, published this year, which I'll review in a future post. You know the topic when you see that circle of chairs!)
If unqualified staff are the problem, credentialing becomes the solution. But this is the wrong way to think about it.
First, I'll share my own credentials in context for readers who may not be familiar. In Maine, I'm a "licensed professional clinical counselor" (LCPC), a master's-level credential known in other states as a "licensed mental health counselor" or "licensed professional counselor." I am authorized to diagnose and treat people, and can bill insurers, independently. "Above" me in the credentialing hierarchy are psychiatrists and other medication prescribers, as well as clinical psychologists. "Below" are alcohol and other drug counselors, who must work under a certified supervisor (of which I am one), then various "aide," "tech," or "specialist" positions, who theoretically only assist in care.
Many patients will indeed spend most of their time with the lowest-ranking staff at a treatment center, seeing medical providers or clinicians like me on a weekly basis at most. They have every right to complain about this--especially in residential treatment, which can be wildly expensive. But it does not follow that they would automatically have better experiences with higher-credentialed staff. The same goes for credentialing at the organizational level: patients do not necessarily receive better care at facilities holding accreditation or certification.
Why isn't credentialing a reliable proxy for quality in addiction treatment?
- Front-line employment in this field is rarely competitive. This is demanding, stigmatized, low-paying work that most professionals do not want to do! Whatever credential someone may hold, they may well be the only person who applied for their job...after it sat open for a year. And this person may have settled for substance use work only after they found they couldn't get hired to do anything more desirable. Is the least competent clinician necessarily better than the most competent aide? By the same token:
- Providers are valued for billing services reliably, not for quality care. Substance use treatment facilities are lucky when they can retain a provider at all. So it is nearly impossible to be fired from one of these jobs unless your performance somehow impedes your function. And that function is bringing money in the door, not delivering satisfactory care (since so many patients are coerced or mandated, their evaluations don't matter) or ensuring particular treatment outcomes (which are not even tracked).
- High status and long-term experience in the field may just mean deeper indoctrination. Here's an earlier post on what I call addiction essentialism, a rigid understanding that is common among the public and constantly reified in the treatment industry:
Rosalie Genova
This understanding is not wrong, but it is incomplete. And when a provider is too confident in their experience, they lose curiosity. Curiosity is critical to meeting each patient as a unique individual and figuring out how to work with them– which may be totally different from working with anyone else, no matter how long we've been at it.
- Credentialing becomes an end in itself. English therapist Farhad Dalal has written that credentialing is about "the paperwork, not the actual work." The actual work, to be clear, is patient care, but literally no one monitors or assesses that. Both individual workers and treatment organizations are evaluated (if we can call it that) through box-checking exercises alone.
The real solution to lousy care and staff misconduct is nothing less than to start valuing the lives of drug users and people with addictions. If these patients mattered in our politics or economy, they would be entitled to appropriate care of their choice. Substance use jobs would be well-paying and competitive. And all eyes would be on our actual work.
In the current paradigm, I do have one suggestion for how to evaluate people working in this field. When I interviewed for one of my agency jobs, the interviewers asked me, "What is your understanding of addiction?" I believe you will get a good sense of someone's skill and commitment by asking them this question. There is no one right answer, but there certainly are some wrong ones. And I suspect the people who would give the most thoughtful, generative answers have all levels of credentialing, including none at all.
