Abstract
Substance use is a pervasive public health problem for which millions of Americans will access treatment. Training, practice, and research in substance use traditionally have not been a focus for counseling psychologists. Thus, many in our field do not feel adequately trained to work with clients who have substance use disorders. Counseling psychologists need to remain viable in a rapidly changing health care environment where treatment for substance use and mental health disorders have parity with other medical treatments. The goal of this article is a call to the profession to increase our presence in the field of substance use alongside other health care providers. We discuss how this objective can be accomplished through training, practice, and research that will not only enhance our competence, but further solidify our value in the health care marketplace.
The misuse of alcohol, tobacco, and other drugs (e.g., opioid-based pain medications) is among the leading preventable cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2015a, 2015b; Trust for America’s Health, 2015). Despite decades of research on substance use prevention, intervention, and delivery of evidence-based treatment by physicians, health psychologists, social workers, and public health professionals, problematic substance use remains a major public health problem. Traditionally, counseling psychologists have had less involvement in research and practice related to substance use despite the high rates of co-occurrence with other mental disorders such as depression, posttraumatic stress disorder, and anxiety (Flynn & Brown, 2008; Grant et al., 2004; Substance Abuse and Mental Health Services Administration [SAMHSA], 2015).
For years, scholars have encouraged psychologists to engage in more training, practical experience, and research in the treatment of substance use disorders (SUDs; W. R. Miller & Brown, 1997; Washton & Zweben, 2008), but psychologists typically report feeling unprepared to work with these presenting concerns (Aanavi, Taube, Ja, & Duran, 1999; Harwood, Kowalski, & Ameen; 2004; Madson, Bethea, Daniel, & Necaise, 2008). Madson et al. (2008) surveyed counseling and counseling psychology master’s and doctoral students and found 58% of them believed that counseling psychology students are not well trained to address substance abuse issues with clients. Indeed, only 34% of master’s and doctoral students surveyed completed a course in substance use. This is problematic because more than half of the respondents (54%) reported that they frequently work with clients who abuse substances, and 70% of the sample indicated that education and training in substance use should be a core component of graduate training.
The limited practice-related substance use training found in counseling psychology programs extends to research as well. A recent study indicated that of 130 faculty from 22 APA-accredited counseling psychology programs, two (1.5%) reported involvement in research related to substance use (Raque-Bogdan, Torrey, Lewis, & Borges, 2012). Only 26% of counseling or counseling psychology graduate students whom Madson et al. (2008) surveyed were involved with substance use research; 46% of those students worked with noncounseling faculty on substance use research. Our own review of counseling psychology faculty from APA-accredited programs conducted in preparation for this article found that 31 indicated substance use as an interest or expertise area. However, only 13 of these 31 faculty members had authored a publication on a substance use topic. We also found that over the past two decades, fewer than 15 articles related to substance use were published in The Counseling Psychologist and the Journal of Counseling Psychology combined. Despite the low level of substance use–related training and research in counseling psychology programs, a majority of training directors have indicated that their students have interest in health psychology, of which substance use is a major component (Raque-Bogdan et al., 2012). Furthermore, graduate students in counseling psychology have indicated a desire to receive training in substance use (Madson et al., 2008).
Given this reported lack of training, it is not surprising that, in general, counseling psychologists do not feel adequately trained to assess, conceptualize, and treat clients with SUDs (Madson et al., 2008). This state of affairs is problematic for our field. In this article we argue that counseling psychologists need to remain viable in a rapidly changing health care environment where treatments for substance abuse and mental health disorders have parity with other medical treatments (SAMHSA, 2016). The demand for substance abuse and mental health treatment services, as well as professionals who can competently provide such services, will continue to grow as more people in our country gain access to health care (SAMHSA, 2016). Hence, now is the time for counseling psychologists to expand their training, practice, and research to include the treatment of clients with SUDs. Neglecting substance use as an area of practice and research will place counseling psychologists at a disadvantage to meet the needs of an ever changing health care field, not to mention the fact that psychologists have an ethical responsibility to routinely screen and assess clients for substance use and SUDs (W. R. Miller & Brown, 1997). This article calls for professionals in counseling psychology to increase our presence in the field of SUDs alongside other health care providers. This can be accomplished through training, practice, and research that will not only enhance our competence but also further solidify our worth in the health care marketplace. To achieve the goal of this article, we discuss the relevance of SUDs for counseling psychologists in three major areas: (a) doctoral training, (b) professional practice, and (c) research. Prior to discussing these topics, we provide an overview of the substance use and abuse problem in the United States and the workforce demands it creates for psychologists. For the purposes of this article, the terms substances and drugs are used interchangeably to include alcohol, tobacco, and other drugs (e.g., marijuana, opioid-based pain medications, and cocaine) unless a distinction is made referring to a specific substance.
Substance Use Is a Public Health Problem
The use and abuse of substances is a pervasive component of U.S. society. It is difficult to find a cultural group (e.g., ethnic, religious, geographical) in our country that does not have a practice or norm related to substances, even if that norm is abstinence (Vakalahi, 2001). Although variation does exist, in general the most widely used substances are alcohol, tobacco, and marijuana, where 52.7%, 25.2%, and 8.4% of people ages 12 and older, respectively, reported use within the past month (SAMHSA, 2015). Although the majority of individuals in the United States report consuming alcohol within the past 30 days, the majority do not drink at risky levels (SAMHSA, 2015). The National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2004) defines heavy episodic or binge drinking as four or more drinks for women and five or more drinks for men over a 2 hr period; this level of use is often associated with negative social, psychological, and health consequences (CDC, 2015a). Approximately 23% of individuals ages 12 and older are estimated to engage in heavy episodic drinking or binge drinking, and 6.4% of people 12 and older meet criteria for an alcohol use disorder (SAMHSA, 2015). Young adults between the ages of 18 and 25 represent the group with the highest prevalence rates of binge drinking: 37.7% report binge drinking within the past 30 days, and 16.3% meet criteria for an SUD (SAMHSA, 2015). In 2014, about 1 in 10 people ages 12 and older used an illicit drug in the past 30 days, and almost 3% met criteria for an illicit drug use disorder (SAMHSA, 2015). (Illicit drugs are those illegally sold in the United States for recreational purposes such as cocaine and heroin. Marijuana is legally sold in some states but is not legal at the federal level. For this reason, federal surveys typically consider marijuana an illicit drug.) The abuse of opioid-based prescription medication is now considered a national health epidemic, with overdose rates that have quadrupled in the past 15 years and overdoses related to prescription medications now outnumbering those from heroin and cocaine combined (see Trust for America’s Health, 2013).
As mentioned previously, many clients who present with a mental health disorder (e.g., depression, anxiety, PTSD) also have a co-occurring SUD (Quello, Brady, & Sonne, 2005). The high comorbidity rate of SUDs with other mental health disorders (i.e., 39.1%; SAMHSA, 2015), combined with the fact that most clients seek general outpatient treatment rather than specialty substance use services, makes it almost certain that trainees and practicing counseling psychologists will see clients with SUDs in practice (Grant et al., 2004; W. R. Miller & Carroll, 2006). Indeed, Aanavi et al. (1999) conducted a survey of 1,200 psychologists and found that more than 90% reported seeing clients for which substance use or abuse was a concern.
The passages of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act increased access to health care in an unprecedented fashion. In particular, these acts created a larger demand for psychologists who can provide mental health and substance use services to a range of clients and in a variety of treatment settings. An estimated 27 million more individuals in the United States will have access to substance use treatment, many of whom were previously uninsured and historically had high rates of SUDs but limited or no access to care (Beronio, Po, Skopec, & Glied, 2013; Humphreys & Frank, 2014). Consequently, the United States will see an increased demand for health care professionals, including psychologists, able to provide substance use treatment services in the coming years.
The overview has presented a context for the scope of the substance use problem and how the demand for trained professionals to provide treatment services is growing. As a field, we need to consider ways that counseling psychologists can increase substance use training, practice, and research so that we can be active participants and valuable contributors in contemporary integrative health care (see Buki, 2014). In the remainder of this article, we discuss ideas and provide examples of the ways substance use has relevance for counseling psychologists and how to incorporate substance use in our training programs, professional practice, and research. In the next section we focus on ways to enhance our doctoral training programs to increase student competencies in working with clients who have SUDs. We also discuss postdoctoral training opportunities in substance use.
Doctoral Training in Substance Use
Doctoral training programs in counseling psychology need to keep pace with the contemporary needs of the country’s workforce by training students in skill sets that have definitive value in the 21st century. As most training directors and practicum supervisors know, nearly all students will encounter clients who present with SUDs either as a primary or a secondary issue (Aanavi et al., 1999; Harwood et al., 2004; Madson et al., 2008). However, the doctoral curriculum in counseling psychology programs is largely dictated by the American Psychological Association (APA) accreditation standards, and there is no requirement for training in SUDs, nor will there be in the newest Standards of Accreditation (APA, 2015). Training directors and faculty will need to go beyond the Standards to integrate training in substance use treatment in doctoral curriculums, as well as to ensure that students develop competencies to work with clients experiencing SUDs and meet the skills sets necessary for contemporary health service psychologists (Raque-Bogdan et al., 2012).
Government agencies such as SAMHSA and the Health Resources and Services Administration (HRSA) anticipate future shortages in the number of substance use treatment professionals in our country (Hyde, 2013). Doctoral students who supplement the standard curriculum with training in substance use will be better equipped to fill the shortage of providers and meet the demands of our changing health care system (as integrated approaches to treatment become the norm; Hyde, 2013; Kelly & Coons, 2012). While we wait for accreditation standards to catch up to the current demands of the workforce, training directors, faculty administrators, and supervisors can look for creative ways to integrate training in the assessment, prevention, and treatment of SUDs into existing curricula.
Didactic Training
A mainstay of the curriculum for counseling psychology programs is didactic courses. Thus, to ensure that all counseling psychology doctoral students receive basic training in screening, prevention, and treatment for SUDs, training directors and faculty should consider incorporating relevant information into required courses related to the assessment, diagnosis, prevention, and treatment of other mental health disorders. This is one way to limit the proliferation of new courses in already full curricula. For example, assessment and diagnosis of SUDs can be incorporated into required clinical assessment and diagnostic courses, whereas theories for understanding the etiology of substance use and evidence-based treatment approaches can be included in psychological theories and intervention courses. For assistance developing content for coursework to enhance competency in substance use, faculty can consult the 12 core knowledge areas outlined in the standards for the Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders developed by the APA’s College of Professional Psychology (see http://www.apapracticecentral.org/ce/courses/). Developed in 1996, the Certificate of Proficiency in SUDs is the first and only area for which a Certificate of Proficiency is offered by APA (W. R. Miller, 2002). Psychologists may wish to obtain this certificate as official demonstration of quality training and competence in treating SUDs.
If programs wish to require a substance use course and one is not available in the home department of a counseling psychology training program, students will need to take such a course in departments of allied areas such as psychology, social work, public health, or health sciences. For example, we discovered through an informal survey of doctoral training directors that students in several APA-accredited counseling psychology programs may choose to take an elective course on substance use from affiliated master’s programs in mental health counseling or other psychology or health professional programs. In addition to elective coursework, there may be opportunities for students to take advantage of trainings that occur in the surrounding community. One place to look is the local psychological association’s website in the state or city where the doctoral program is located; typically, students can attend such trainings at reduced rates. A second resource is the preconference or regular workshops offered as part of regional or national conventions (e.g., APA, College on Problems of Drug Dependence, Research Society on Alcoholism) that doctoral students may already attend.
If students would like to receive advanced training in substance use, they may obtain certification as a substance use or addictions counselor. Many states offer certifications for substance use counselors that require completion of a specified curriculum comprised of coursework and supervised practice (SAMHSA, 2005). For example, New York State’s Office of Alcoholism and Substance Abuse Services offers the Credentialed Alcoholism and Substance Abuse Counselor certification (see https://www.oasas.ny.gov/sqa/credentialing/casacreq.cfm). It is likely that doctoral students in their second or third year will already have completed many of the educational requirements for state certification as a substance use counselor and may be lacking only a course in addictions or specialized practicum experience.
Another great resource for training in substance use that many counseling psychology training directors, faculty, and doctoral students may not be aware of is the network of Addiction Technology Transfer Centers funded by SAMHSA (see http://www.nattc.org), a network of 10 regional and four national centers that provide training in evidence-based practices for substance use. The Addiction Technology Transfer Centers network provides numerous local, regional, and national trainings each year on treatment approaches such as motivational interviewing, screening, brief intervention, and referral to treatment (SBIRT), and medication-assisted treatment. These trainings are especially appropriate for doctoral students because they are offered in different formats, including face-to-face, webinars, and online courses, and are free of charge. Our own experience has taught us that students will be more likely to take advantage of training opportunities with the support and guidance of their training directors, faculty, or advisors. Thus, we encourage training directors and faculty to support their students taking advantage of such training opportunities by requiring them as part of a practicum course or counting them as an elective requirement. In sum, there are innovative ways for training directors, program faculty, and doctoral students to integrate training in substance use into their curricula without undue burden on students. Didactic education in substance use will lay the groundwork for students to obtain specialized practicum placements that will assist them in developing applied skill sets.
Practicum Training
Doctoral students in nearly all practicum settings will encounter a proportion of clients who present with substance use concerns (Cellucci & Vik, 2001; Erdur-Baker, Aberson, Barrow, & Draper, 2006). In some cases, students may have opportunities to obtain in-service SUD training at the practicum site, but this is probably not the norm. More likely, program directors and faculty in counseling psychology training programs will need to be proactive in developing practicum experiences that provide specialized training in substance use. There is federal funding available, fortunately, to enhance the training of graduate students in addictions and co-occurring mental health concerns. For example, the American Psychological Association’s Minority Fellowship Program offers predoctoral and postdoctoral Mental Health and Substance Abuse Services Fellowships (see http://www.apa.org/pi/mfp/psychology/index.aspx). Individual clinical, counseling, and school psychology doctoral trainees may apply for the fellowships, which are designed to support the training of practitioners in behavioral health services and prevention. In addition, HRSA funds two programs to promote capacity of the behavioral health workforce to meet the health care needs of the country. The first is the Graduate Psychology Education program for graduate programs in psychology to train future health service providers (see http://bhpr.hrsa.gov/grants/mentalbehavioral/gpe.html). The goal of this program is to provide funding that will support the development of a behavioral workforce that can meet the needs of underserved populations. Especially relevant, this program has specific requirements that trainees gain clinical competency in the areas of mental health and substance use treatment service delivery. A second program funded by HRSA is titled Behavioral Health Workforce Education and Training (BHWET; see http://bhw.hrsa.gov/grants/mentalbehavioral/index.html). The focus of BHWET is on training master’s and doctoral students to meet the mental health and substance use needs of at-risk children and youth. For example, SAMHSA-HRSA recently released a call for a collaborative BHWET grant (see http://bhw.hrsa.gov/grants/mentalbehavioral/index.html) that focuses on increasing the substance use and mental health workforce and targets master’s-level students in counseling programs, including school counseling, as well as predoctoral internships in health service psychology. The goal of this grant is to train graduate students to meet the clinical needs of children, adolescents, and transitional-age youth with behavioral health disorders. SAMHSA also funds training grants for graduate students in behavioral health professions to expand their competence in SBIRT (http://www.samhsa.gov/sbirt). SBIRT is an evidence-based intervention that, to date, has mainly been used in public health and medical settings (Agerwala & McCance-Katz, 2012). Counseling psychologists are already trained, generally, to implement the major elements of the approach (e.g., evidence-based screening, brief psychological interventions, and making appropriate referrals) and need only learn how to fine-tune these skills to apply them to substance use.
External funding opportunities may not always be available. For this reason, we also encourage counseling psychology training directors and faculty to take advantage of existing practicum training opportunities in their local communities that can provide specialized training in substance use for students. For example, community-based substance use treatment centers or health care clinics are frequently in need of additional staff in the form of graduate-level practicum students. Another option is for training programs to partner with substance use treatment clinics housed in schools of medicine or hospitals where practicum students can be exposed to the delivery of integrated health care. If specialty practicums in substance use do not already exist, then it may take some effort on the part of training directors or practicum coordinators to establish them. However, the long-term training benefit for students and the program will likely outweigh any initial costs. In sum, there is external funding available for training graduate students to meet the clinical needs of clients with SUDs. Training directors also have options for increasing the availability of specialized practicums in substance use for their students.
Postdoctoral Training
Training directors and faculty can also encourage students to consider the numerous specialized training opportunities available immediately following graduation such as postdoctoral traineeships and fellowships. Recently graduated counseling psychologists who previously were not able to obtain training in substance use or are interested in obtaining advanced skills in this area can consider postdoctoral traineeships. Postdoctoral positions in substance use typically include training in clinical practice, as well as research. Suggestions for recent graduates who would like to obtain postdoctoral positions include the following: (a) connect with professional networks to learn about postdoctoral opportunities that are not formally advertised, (b) join departmental and professional association listservs (e.g., Divisions 17, 50) where advertisements for fellowships are often circulated, (c) attend conferences and scientific meetings attended by faculty and supervisors looking for new postdoctoral trainees (e.g., APA Convention, College on Problems of Drug Dependence, Research Society on Alcoholism), and (d) search the Internet for listings on sites such as PsycCareers and the Association of Psychology Postdoctoral and Internship Centers’ directory of postdoctoral fellowship opportunities (Kuo, 2012). Students trained to assess for, and intervene with, substance use will likely feel more competent providing substance use screening, prevention, and treatment services to clients in practice settings. Thus, counseling psychologists properly trained in substance use issues may be less likely to refer out clients who have SUDs and will be greater assets to integrative health care teams. Next, we present information helpful to those working with clients using or abusing substances and consider how counseling psychologists can integrate SUD screening and treatment into their practice.
Practice in Substance Use
Unfortunately, many psychologists rarely conduct substance use screenings and lack the skills to recognize clients who are at risk for SUDs or are experiencing problems related to substance use (Freimuth, 2008). Furthermore, many health care professionals, including psychologists, mistake the physical and psychological effects of substance use (e.g., stomach problems, sleep disturbance, low mood) for emotional disorders (Freimuth, 2008). When psychologists do detect a client who meets criteria for an SUD or when a client admits to substance use, they have an informal tradition of referring those clients to allied professionals or specialist treatment programs (W. R. Miller, 2002; Schneier et al., 2010). This may be due to psychologists’ lack of training in substance use treatment (Cellucci & Vik, 2001; Madson et al., 2008; W. R. Miller & Brown, 1997). Although referring out clients who use substances is commonplace among psychologists, there are several problems with this one-size-fits-all approach to referral. First, most addiction counselors and many other allied professionals are not well trained in the diagnosis and treatment of co-occurring mental disorders, particularly for more severe disorders (Brady, 2002). Second, traditional substance use treatment typically focuses solely on the substance use problem and excludes attention to co-occurring mental health concerns or related family, social, interpersonal, spiritual, or cultural issues (W. R. Miller & Carroll, 2006). Traditional substance use treatment is not as focused on developing the therapeutic relationship, empathy, and fostering the strengths and resilience that may be ideal for positive outcomes. Finally, traditional substance use treatment is not typically individualized for the client in a manner that meets his or her unique psychological, social, interpersonal, and cultural needs (Madson et al., 2008). Counseling psychologists, who take a strengths-based, developmental, culturally responsive approach to conceptualization and treatment (Gelso & Fretz, 2001; Packard, 2009) and are experts in the diagnosis and treatment of mental health concerns, could fill the gaps in traditional substance use treatment. Next, we discuss some ways in which counseling psychologists could better meet the needs of clients who use substances, thereby enhancing substance use treatment.
Compared to addiction counselors and other allied professionals, counseling psychologists are highly trained in the assessment, diagnosis, and treatment of mild to severe mental disorders (W. R. Miller, 2002). Therefore, if better trained in treating SUDs, psychologists would be unique among allied professionals in their ability to offer clients comprehensive diagnostic and treatment services. Second, as opposed to the medical model of mental health treatment where clients’ disorders and deficits are the focus in session, the strengths-based model used by counseling psychologists would offer clients with SUDs a form of treatment that would foster the therapeutic alliance, embrace the client’s strengths, and empower client resiliency (Gelso & Fretz, 2001). Another crucial way in which counseling psychologists could enhance substance use prevention and intervention is by tailoring treatment to each client’s individual and cultural context. For example, treatment may be less stigmatizing and more effective for an unemployed Native American woman suffering from depression and mild alcohol use disorder, if the counseling psychologist tailored treatment to focus on reducing depressive symptoms and alcohol use by utilizing the woman’s strengths as a responsible leader in her community, involving a spiritual leader of importance to her, addressing employment concerns and vocational barriers, and scheduling sessions later in the evening so that the client could look for work during the day. Counseling psychologists’ multicultural competencies are a skill set that would set us apart from other substance use treatment providers in a way that would make us invaluable members of interprofessional health care teams in modern-day patient health homes and other integrative health care settings. Furthermore, providing high-quality, strengths-based, holistic preventative and intervention substance use services to all clients, including those traditionally underserved, would further our social justice mission.
To integrate substance abuse treatment into practice, one must learn how to quickly and effectively screen for substance use, and when to intervene or refer clients to another health care provider (e.g., when the client’s symptoms or problems are beyond one’s areas of expertise or require medical attention). SAMHSA’s empirically supported SBIRT approach to screening, brief intervention, and referral to treatment is an insurance-reimbursable service through commercial insurance companies, Medicare, and Medicaid (see http://www.samhsa.gov/sbirt/coding-reimbursement). SBIRT is delivered in a motivational interviewing framework; its primary goal is to identify and provide interventions to individuals at moderate or high risk for psychosocial or health care problems related to their substance use. SAMHSA recommends routine screening of people of all ages using screening tools with well-supported psychometrics such as the Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) and the Drug Abuse Screening Test (Skinner, 1982). A number of other valid substance use screening methods and instruments are available, many in the public domain (Zgierska, Amaza, Brown, Mundt, & Fleming, 2014).
Learning how to distinguish among low-, moderate-, and high-risk substance use is critical because the outcome of screening determines next steps in treatment. For individuals perceived to be at low or no risk for developing an SUD after screening, the provider reinforces their positive behavior choices (http://www.integration.samhsa.gov/clinical-practice/SBIRT). When comprehensive assessment indicates moderate- or high-risk substance use or presence of an SUD, counseling psychologists well versed in addressing drug and alcohol concerns can assess the client’s readiness to change (Connors, DiClemente, Velasquez, & Donovan, 2013), assist in increasing motivation for change (W. R. Miller & Rollnick, 2013), and collaboratively engage the client in an exploration of how to reduce or eliminate those aspects of the client’s substance use behaviors that are maladaptive. Counseling psychologists working with clients who use substances may (a) provide psychoeducation to clients about drug and alcohol and the impacts of their use, (b) motivate and empower clients to change problematic behavior patterns and prevent and cope with relapse, (c) address co-occurring disorders and symptoms, and (d) identify the necessity for referrals to specialty SUD treatment service (Glidden-Tracey, 2005). Training in SBIRT provides practitioners with skills in motivational interviewing and brief intervention to accomplish the aforementioned tasks in treatment. Research indicates that brief motivational interventions delivered in only one session and as little as 15 to 20 minutes are associated with reduced substance use (Cronce & Larimer, 2011; McCambridge & Strang, 2004; Samson & Tanner-Smith, 2015).
Counseling psychologists who routinely engage in screening and brief intervention for substance use and SUDs, and who facilitate collaborative referrals (i.e., SBIRT), will likely have more successful therapeutic outcomes for clients presenting with other mental health concerns. Indeed, integrated treatment focused on addressing co-occurring substance use and mental health concerns is more effective than treatment focused on either of the two concerns alone (Mangrum, Spence, & Lopez, 2006; Ziedonis, 2004). Developing skills in SBIRT will also provide a way for psychologists to bridge clinical work with medical providers by speaking the same language. Moreover, if we have the appropriate skills and credentials, we could become the providers to whom medical professionals refer clients, rather than to social workers or addiction counselors. In addition, increased training and practice assessing, preventing, and intervening with substance use will undoubtedly inspire more counseling psychologists to address this major public health concern on individual and systemic levels through innovative research. Next, we consider the unique ways in which counseling psychologists can contribute to substance use research to fill existing gaps and expand our scholarly scope of influence on public health concerns and health disparities.
Research in Substance Use
With our developmental and strengths-based emphases and extensive training in multicultural and social justice issues, we as counseling psychologists can bring a unique perspective to research on the development, prevention, and treatment of SUDs. Indeed, a few counseling psychologists have contributed to substance use research across the life span by investigating various risk and protective factors for alcohol use among adolescents (e.g., Burrow-Sánchez, Corrales, Ortiz Jensen, & Meyers, 2014), emerging adults and college students (e.g., Iwamoto, Grivel, Cheng, & Zamboanga, 2016; Martin, Groth, Buckner, Gale, & Kramer, 2013), and older adults (e.g., Vaughan, Robbins, & Escobar, 2014) as well as prevention and intervention efforts to reduce substance use among diverse populations (e.g., Burrow-Sánchez, Minami, & Hops, 2015; Martens, Smith, & Murphy, 2013; Santisteban, Mena, & McCabe, 2011). Perhaps our distinct contributions to substance use research can help make headway in reducing the mental, physical, emotional, and financial costs incurred from substance use. We discuss distinctive areas in which counseling psychologists can uniquely contribute to substance use research next.
Developmental and Vocational Perspectives
The trajectories of substance use are developmental in nature, with initiation generally taking place in adolescence and emerging adulthood (McCrory & Mayes, 2015; Sher & Gotham, 1999; Shulenberg & Maggs, 2002). Furthermore, peak prevalence and development of SUDs often occur in emerging adulthood (SAMHSA, 2015). The developmental nature of substance use and SUDs provides ample opportunity to conduct research that addresses substance use and other developmental transitions that are more commonly studied among counseling psychologists. For example, college students are transitioning out of their parents’ homes to college campuses that may be rife with alcohol and other drug use. These students are facing many developmental concerns typical of emerging adulthood such as identity exploration, academic and career exploration, and the forming of peer and romantic relationships (Arnett, 2005). Another example may be older adults who are transitioning out of the workplace and into retirement. Substance use may change during these transitions and influence the outcomes of the transitions. Counseling psychologists can bring their developmental, vocational, and strength-based lenses to better understand the role that alcohol and other substance use plays in life transitions to inform the development of empirically based prevention and intervention.
Multiculturalism and Social Justice
In addition to the developmental focus, counseling psychologists’ training in multiculturalism and social justice is also an avenue to further research on health disparities in substance use and SUDs. Racial disparity in health care is a major public health concern in the United States (U.S. Department of Health and Human Services, 2011). For example, when rates of specific substance use (e.g., alcohol use) of African Americans are compared to those of European Americans, several studies suggest that even though African American men consume less alcohol than European American men, they report greater numbers of drinking consequences, including physical symptoms (e.g., withdrawal) and personal consequences (family, work, and financial), even after controlling for socioeconomic status (Jones-Webb, Hsiao, & Hannan, 1995; Wallace, 1999). The so-called lower risk groups, such as Asian Americans, may also experience a higher burden related to their substance use. For instance, a recent investigation suggested that Asian American young adult men experience equal amounts of alcohol-related problems as European Americans, despite Asian Americans’ lower alcohol use (Iwamoto et al., 2016).
Given these concerns, the U.S. Department of Health and Human Services (2010) included the elimination of health disparities in the strategic plan for Healthy People 2020. With our training aimed at the development of multicultural competence and social justice issues, counseling psychologists are the “perfect fit” for contributing to the reduction of health disparities (Buki, 2007). Considering the broad scope of topics involved with substance use treatment, mental health utilization, and health disparities, and using the framework of Tucker et al. (2007), the following section illustrates one example of how counseling psychologists can reduce health disparities through research and the development of effective interventions. In addition to the multicultural focus of the example, we also integrate other core counseling psychology values (e.g., developmental and strengths-based foci).
Health Disparities
Counseling psychology has a strong tradition of recognizing and studying the intersection of sociocultural factors and mental health problems and health disparities, as well as culturally specific prevention (Reese & Vera, 2007). As a result, counseling psychologists often take a culturally responsive and client-centered approach to working with diverse clients and are well positioned to conduct research that reduces health disparities (Buki & Selem, 2012; Tucker et al., 2007). There is a substantial literature on the role of culture and substance use behaviors across a variety of substances, among different populations, and in different developmental stages (e.g., Iwamoto, Takamatsu, & Castellanos, 2012; Le, Goebert, & Wallen, 2009; Vaughan, Wong, & Middendorf, 2014; Zapolski, Pederson, McCarthy, & Smith, 2014). Counseling psychologists could draw on this literature to study how culturally and developmentally relevant factors, such as racial and ethnic identity development, acculturation, and gender socialization, may influence substance use treatment and treatment outcomes (Kaya, Iwamoto, Clinton, & Grivel, 2016), as well as health disparities as they relate to substance use and SUDs.
One specific way in which counseling psychologists might contribute their unique knowledge to reduce substance use disparities is through the application of research on social stigma and mental health treatment outcomes to the area of substance use. This is a critically important area of research because social stigma is linked to treatment underutilization (Vogel, Wade, & Hackler, 2007) and can therefore perpetuate health disparities (W. D. Miller, Pollack, Williams, 2011). Counseling psychologists might also use their knowledge about cultural strengths and culturally based sources of support, such as religion or spirituality (Boyd-Franklin, 2010; Herman et al., 2007), to study ways to reduce substance use and facilitate treatment utilization and retention among clients abusing substances.
Another way that counseling psychologists can contribute to health promotion, reduce stigma, and increase health-seeking behaviors among individuals who use substances is to develop broad, innovative interventions that focus on substance use treatment stigma. Many scholars recommend community-based outreach that incorporates technology (e.g., Internet or web-based videos) and media (television) in multiple languages (Alegría, Carson, Gonçalves, & Keefe, 2011; Tucker et al., 2007). These interventions could integrate psychoeducational services such as providing individuals with general knowledge of the substance use services they are eligible for, informing the clients about their rights (e.g., services that they are entitled to), and improving communications with practitioners (i.e., expressing needs). These types of interventions may also target misperceptions of substance use treatments (e.g., “seeking help is a sign of weakness”; Jang, Chiriboga, & Okazaki, 2009) and address the holistic benefits of substance use and mental health treatment (e.g., improved social and family relationships, physical health, work performance, and long-term financial benefits).
A third area in which counseling psychologists can offer their unique perspectives and skills to reduce substance use and related health disparities is through the development of culturally sensitive substance use prevention and intervention programs. Given the role of cultural identity factors (e.g., acculturation) in substance use treatment outcomes, culturally tailored interventions may offer more robust treatment effects for ethnic minority groups (Burrow-Sánchez & Wrona, 2012). Such interventions are not only culturally tailored, but also developmentally focused. For example, they address the needs of adolescents who are experiencing multiple developmental transitions. Furthermore, they are strengths based in that they draw on the cultural values of the population they aim to serve.
Therapeutic Process and Outcomes
Given counseling psychologists’ strong tradition of examining the factors that are associated with the therapeutic alliance, transference configuration, and real relationships through their understanding of the counseling process (Gelso, 2009), they can play an instrumental role as principal investigators or coinvestigators in funded randomized controlled trials. An understanding of the therapeutic processes, client factors, or types of interventions that are effective in fostering positive client outcomes can and has enhanced substance use prevention and intervention studies. Examples of some work in this area that has been done by counseling psychologists include examination of the mutual influence of therapist competence and adherence to treatment protocols (e.g., Imel, Baer, Martino, Ball, & Carroll, 2011) and how cultural variables related to the therapist, client, or the intervention (e.g., Burrow-Sánchez et al., 2015; Imel, Baldwin, et al., 2011) can influence treatment outcomes. More of this work is needed as it is not currently an emphasis among allied professionals conducting substance use research. In sum, counseling psychologists are well positioned to make unique contributions to existing substance use research that has the potential to not only improve the efficacy of substance use prevention and intervention efforts but also increase client retention in treatment and decrease health disparities. As counseling psychologists, we should make certain that our ideas and values are part of the interdisciplinary, multisystem force shaping the future of substance use treatment (see Buki, 2014).
Substance Use Research Funding Opportunities
Given the costly social, physical, mental, and public health problems resulting from substance use, the federal government devotes hundreds of millions of dollars annually to research aimed at better understanding, preventing, and treating substance use (National Institutes of Health, 2015). A thorough discussion of the vast array of sources of funding for substance use research (e.g., foundations, state agencies, university funding) and how counseling psychologists can locate and secure funding is beyond the scope of this article (see Burrow-Sánchez, Martin, & Imel, 2016). However, we want to draw readers’ attention to federal agencies that offer funding opportunities to support substance use research and training.
At the federal level, the National Institute on Drug Abuse (NIDA) funds research related to the etiology of drug use as well as prevention and treatment of drug use, whereas the NIAAA funds research related to the etiology, prevention, and treatment of alcohol use and alcohol use disorders, and the National Cancer Institute (NCI) funds tobacco-related research. In addition to these specific centers that focus on substances of abuse, institutes such as the National Institute of Mental Health may fund research related to the etiology, prevention, and treatment of comorbid SUD and mental health disorders. The National Institute on Minority Health and Health Disparities funds projects aimed at reducing and eliminating health disparities, including disparities related to substance use and substance use treatment. Counseling psychologists will find that a major focus of institutes such as NIDA and NIAAA is to fund rigorous research studies that maximize internal validity and are aimed at understanding how and why interventions work. Pursuing funding to support a broader and deeper understanding of the etiology of substance use, the psychological and social impact of substance use, or to develop substance use prevention and intervention efforts will allow counseling psychologists to expand the reach of our research and join other health care professionals in impacting the health of the nation. To provide readers with guidance in launching a program of research in substance use, we next discuss postdoctoral fellowship opportunities in substance research.
Postdoctoral Fellowship Devoted to Substance Use Research
Recent graduates who intend to pursue a career in research or as a faculty member and who wish to contribute to substance use scholarship may be interested in postdoctoral research fellowships. Individuals with some research experience in the area may be most competitive for fellowships devoted to substance use research, yet individuals with other research experience whose skills and experience could be applied to the area of substance use will also be competitive. Research fellowships are most often found within academic departments (e.g., schools or colleges of medicine, public health, or psychology) or research institutes (e.g., Group Health Research Institute [see GroupHealthResearch.org], Research Institute on Addictions—University at Buffalo [see www.buffalo.edu/ria.html]), which are collaborations among investigators from various settings including different academic departments, universities, health care centers, and hospitals. Research fellowships are most often funded by grants (e.g., T32 or F32) from federal agencies such as NIAAA, NIDA, or the National Institute of Mental Health. Such grants are typically awarded to a principal investigator or investigators to fund a specific project over a specific length of time (e.g., a 5-year longitudinal study on alcohol and drug use trajectories among adolescents) and allow for funding of postdoctoral fellows to assist with or manage the project. Research institutes typically possess multiple grants for multiple projects and hire numerous postdoctoral fellows each year. Research fellowships are usually 2- to 3-year commitments that provide individuals with time and experience to develop an independent program of research. Not only do postdoctoral fellows receive hands-on experience managing grant-funded projects, but they also receive intensive research training and ample opportunities to publish with senior colleagues and to write grants of their own.
Individuals can find research-oriented postdoctoral fellowships in many of the same ways they would find practice-oriented fellowships. It is especially important for those interested in research fellowships to demonstrate the strong potential for an independent research career. Furthermore, those interested in substance use research fellowships will likely not find such opportunities listed on the Association of Psychology Postdoctoral and Internship Centers website or listserv. Instead, most opportunities are found by networking with substance use researchers at scientific and professional organization meetings and conventions such as APA, the Association for Behavioral and Cognitive Therapies, College on Problems of Drug Dependence, or Research Society on Alcoholism, and via advertisements on listservs associated with the aforementioned professional organizations as well as Division 50 of the APA, the Society of Addiction Psychology (Kuo, 2012).
In sum, there are numerous postdoctoral fellowship opportunities in substance use research for counseling psychologists who may not have been exposed to substance use research at the predoctoral level or who want more advanced training in substance use research. These opportunities assist fellows in advancing their research methodology knowledge and skills, contributing to the scholarly literature on substance use, applying for grant funding to support their work, and initiating an independent line of substance use research. As more counseling psychology departments and health care settings seek faculty and staff who contribute to health psychology research, counseling psychologists who have training in substance use and an established track record of substance use scholarship and practice will likely be more competitive job candidates.
Conclusion
The health care landscape in the United States is rapidly changing, and consequently more people will have access to behavioral health treatment than ever before. In particular, individuals will have greater access to treatments for mental and substance use disorders. To meet the needs of health care consumers, the workforce will require additional well-trained, competent professionals to provide substance use services (Center for Substance Abuse Treatment, 2006). Substance use has not traditionally been a focus for counseling psychologists. Perhaps, as a result, many in our field do not feel adequately trained to work with clients who have SUDs (Madson et al., 2008). In this article, we argued that it is time for us, as counseling psychologists, to expand our training, practice, and research to include SUDs because, as the health care field changes, continuing to overlook this area will place us at a disadvantage relative to allied professionals, as well as place us at risk of not fulfilling our ethical responsibilities (W. R. Miller & Brown, 1997). First, we provided recommendations and examples of ways to integrate didactic and practicum training in substance use into doctoral programs in counseling psychology and raised awareness of postdoctoral training opportunities. Second, we discussed important clinical areas that practicing counseling psychologists need to consider when working with clients who present with SUDs. We suggested SBIRT as a framework for identifying and effectively intervening with clients at moderate-to-high risk of SUDs because it is an evidence-based, insurance-reimbursable approach to substance use prevention and treatment. Last, we reviewed some areas of research in substance use in which counseling psychologists can make important contributions. Our hope is that this article will promote conversation among counseling psychologists that will lead to action and increase our competence in substance use training, practice, and research.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.