Low Pay Makes Addiction Counseling Unattractive For Youth, An Aging Counselor Base

Gateway Foundation, based in Chicago, is one of the leading publicly funded treatment providers in the nation. The non-profit has annual revenues of almost $65 million and operations in seven states, as well as a superb reputation for delivering high quality treatment in both community and correctional settings. With its great reputation, financial and institutional stability, as well as excellent opportunities for advancement in a high growth environment, you would think that Gateway would have no trouble recruiting top quality counseling talent to join its 1,200 strong workforce. Think again."In the past two years, the length of time that a typical vacant counselor position here remains open has doubled to 60 days," says CEO Michael Darcy, adding that for more highly qualified staff - masters degree counselors with more than five years experience, for example - the recruitment time can stretch quite a bit longer. According to Darcy, Gateway Foundation is already in a crisis mode when it comes to recruitment and staffing. And he says that if something is not done soon to attract large numbers of youthful and better educated people into the addiction treatment counseling field, the treatment industry could soon be in big trouble. "Within five years time, if policy makers do not make progress on counselor workforce issues, we will start to see the labor shortages put a very serious strain on the public treatment system's capacity to carry out its mission."Over the past year or so, a growing sense of urgency hassettled over the treatment industry as a slew of studies and statistics have been released showing that not only is the existing counselor workforce base aging very rapidly, but also that youthful replacements are few and far between.

About three quarters of the treatment industry workforce - which is about 45 percent counselors - are over the age of 40, according to studies. And the Ohio Alcohol and Drug Addiction Workforce Development Project, a SAMSHA funded task force the agency hopes will become a national model for efforts to develop industry staffing solutions, estimates that 43 percent of counselors in that state are over 50 years of age. "The results of our study here in Ohio are broadly indicative of the national trends," says John Lisy, who is heading up the Ohio workforce project and who, in his day job, is executive director of the Shaker Heights Youth Center outside of Cleveland. It would not be a matter of much alarm if the quickly aging counselor workforce - the average age of a new counselor entering the field is almost 40 - were being replaced by a growing pool of qualified, youthful workers interested in becoming addiction counselors. Unfortunately, this is far from the case. "There certainly is no rush by young people wanting to enter the addiction counseling profession ," says Cynthia Moreno Tuohy, executive director of NAADAC, the nation's leading trade group representing addiction treatment counseling professionals. "In fact, it's just the opposite." According to the Lewin Group, a Maryland-based consulting company, the treatment industry needs 5,000 new addiction counselors every year just to replace the aging counselors who are retiring, as well as the younger counselors who are leaving the field. But that 5,000 figure may significantly understate the future need for new bodies, mainly because SAMHSA estimates that if current drug and alcohol use uptake rates continue, demand for treatment services will double by the year 2020. Since there are now at least 90,000 full-time and part-time counselors employed at treatment centers nationwide, SAMHSA's growth forecast implies the need for about 6,500 new professionals every year - in addition to the 5,000 replacement counselors - between now and the year 2020. This, of course, assumes that the growth in demand predicted by SAMHSA is met by an increase in capacity and not an increase in the nation's already scandalously large "treatment gap," which is the gap between the amount people deemed to need treatment every year and the amount of people who actually get it, currently estimated to be 20 million people nationwide. More than anything else, behind the counselor crisis that the addiction treatment industry now faces is low wages. "This is clearly the number one issue, getting the counselor salaries up," says Bob Neri, chief clinical officer at WestCare Foundat ion, which employs hundreds of counselors throughout its locations in seven states. Neri is certainly not alone in his assessment that low salaries are the leading cause of the looming counselor workforce crisis. According to RMC Research Corporation, whose Portland, OR, office does extensive treatment industry consulting, and the New York State Office of Alcoholism and Substance Abuse Services, the top reason for counselor recruitment difficulties is inadequate salaries, cited by 84 percent of hiring managers.

There is no question that addiction counselor salaries are indeed very low. Bearing in mind that the official poverty level for a family of four in the U.S. is $20,000 and that the nation's median household income was $44,000 in 2004, a starting addiction counselor with a BA can usually expect a salary of perhaps $25,000, and in some cases much less. In its 2004 bi-annual salary survey, the National Association of Addiction Treatment Providers, Naatp, says that out of the 152 member respondents to the survey, median salaries of $32,000 for BA counselors and $36,000 for graduate level counselors were reported. But the median numbers masked wide disparities in salary levels, with the survey showing that as little as $17,000 was paid for some BA counselors and as little as $24,000 for graduate level counselors. Neri says that he has not seen much of an increase in the time it takes to hire a counselor, but that's mainly because he has devoted vastly increased resources to recruitment activities over the past two years. "Our expenses in this area have gone up by 50 percent in that time," says Neri. According to Naatp's salary survey, the average addiction treatment program recruitment expense was almost $12,000 per year in 2004. In speaking to many treatment center CEOs for this report, from both the public and private side, Treatment Magazine found that most reported significantly higher recruitment expense over the past two years. Naatp's next salary survey, due out in next year's first quarter, will have updated recruitment expense numbers, which, based on the recent anecdotal evidence, should be quite a bit higher than in the 2004 survey. Part of what is driving the higher recruitment expenses is the massive, and rising, employee turnover rates that the the addiction treatment industry is now facing, which in turn are being mostly driven by low salaries and, in many cases, even more meagre benefits. "I have recently visited some smaller agencies that have given up offering health insurance altogether," says Gateway's Darcy, adding that one center told him that they were instead doling out $3,000 a year in cash payments to employees. "That's maybe enough for counselors to buy a high deductible plan that offers protection against catastrophic health risk," says Darcy. "But it still leaves the counselor liable for potentially very large payments to cover ongoing health- care costs." And most insurers refuse to write individual healthcare risk at all outside of group plans if someone has been to treatment within the last 10 years. As most counselors have been through treatment, this means that many of the 40 percent of addiction counselors who have no health benefits may be uninsurable without a group plan. There is no doubt that high staff turnover rates are a very serious and ongoing problem for treatment providers of all types. The clinical staff turnover rate for the respondents to the Naatp Salary Survey, which covered nearly 3,000 clinical staffers, was 22 percent in 2004, twice the national turnover rate for all disciplines. Other studies have put addiction treatment industry workforce turnover as high as 33 percent a year. "We need to get the salaries up to reduce the turnover and get new people into the addiction counseling profession," says WestCare's Neri. Westcare and Gateway both report that they have been somewhat successful in getting state policy makers to allow for funding to support a rise counselor salaries in recent years, with WestCare reporting pay for both BA and masters level counselors rising by about 10 percent to 20 percent over the past two years or so, with Gateway also resorting to paying one-time annual bonuses of 3 percent of salary.

"But what we really need to do is get counselor salary and benefit levels up to what the states and municipalities pay at the treatment centers they own and operate," says Neri. According to the Naatp Salary Survey, BA counselors at addiction treatment centers owned by either state or local government entities had an annual median salary of almost $40,000, about 25 percent more than the overall survey median for BA counselors. But equally important, perhaps even more so, are the outstanding benefits at the government owned centers, where counselors enjoy the best health coverages, not to mention pension and retirement perquisites that are often not offered at all at many treatment centers.But while large and small publicly funded addiction agencies are already in crisis mode when it comes to their counselor workforces, the private side of the business is not nearly as much so. "We have certainly heard about the big problems some addiction treatment centers are having retaining and attracting counseling staff," says Mike Slinskey, COO of Behavioral Health of the Palm Beaches, BHOPB, based in South Florida. "But we have not seen an increase in the amount of time its takes to hire a new counselor and we do not have high staff turnover rates." Mike Slinskey's experience at BHOPB was echoed by many private, for-profit and non-profit addiction treatment facilities, some of which are able to offer very attractive salaries and benefit packages other centers cannot. Challenges founder Dale Redlich says that finding entry level and BA counselors is relatively easy, but that finding experienced clinical supervisory talent is a different matter. "For this type of staffer, our searches have sometimes been quite lengthy and time consuming," says Redlich, whose center specializes in relapse treatment and prevention. And if it's in the right location, counselors will often beat a path to a treatment center's door. When Jaywalker Lodge - located in Colorado amid the pristine Rocky Mountains - opened a new facility and expanded the number of its beds to 30 from 18, Executive Director and founder Bob Ferguson says he had 10 applications for every new counselor position available. "We are fortunate that there is a very high quality of life here in Colorado, which means many counselors want to work here," says Ferguson, adding that Jaywalker pays its counselors "way above" industry norms, largely to offset the area's high cost of living. But there are some on the for-profit side of the addiction treatment business who are indeed being squeezed by the deepening counselor shortage. The Right Step, based in Houston, delivers very affordable care - $8,500 for 30 days - and is almost totally reliant on payments from insurance carriers, who like CEO George Joseph's low cost, high quality model of care. "My recruitment costs have risen at least 50 percent over the past two years," says Joseph. "For a low cost center like ours, where we watch every penny, this puts added pressure on us." Early this year, The Right Step raised its cash pay prices by 25 percent, which Joseph says was in large part due to increased staffing costs. And Joseph agrees that a center's geographic location can have a critical impact on its ability to stay adequately staffed. "We are lucky to be based in Houston," says Joseph. "It's the fourth largest metropolitan area in the country and there is a large pool of qualified counselors. But in other, smaller places it's much more difficult."

The Right Step has run exactly into this problem in the wake of its recent acquisition of Focused Recovery Inc., which has outpatient facilities in Taos, Santa Fe, Las Cruces and Albuquerque New Mexico. "We have not been able to find a male counselor for the Albuquerque facility, period," Joseph says.

But the extent to which addiction treatment providers like The Right Step -those that rely on commercial insurance payments for most of their revenues - will be able to pass along higher counselor salary, benefit and recruitment costs to carriers is highly opened to question. Between 1991 and 2001, aggregate payments from insurance carriers to addiction treatment providers declined by 15 percent to $2.4 billion. The Right Step, which charges insurance carriers per diems that are often half those of some of its competitors, has been able to pass along some compensation cost increases to payors. Other, higher cost facilities may find it increasingly difficult to do this as counselor compensation costs rise in the coming years, perhaps resulting in a squeeze on operating margins. "It's indeed very possible that a margin squeeze is on the horizon for many treatment providers," says Joseph.

This is likely to be especially true for the outpatient sector of the treatment market, which relies far more on insurance carriers than any other and also has the highest counselor personnel costs as a percentage of total personnel costs, 71 percent according to SAMHSA. And the latest quarterly reports from big managed care providers show that the profit gravy train these companies have been on for years may have come to an abrupt halt due to rising payments to hospitals, which means that the historically trod upon addiction treatment sector may be even less successful pushing through per diem increases going forward. How addiction treatment providers address the counselor shortage will be critical to the future health of the industry. In the meantime, though, many centers will continue to fill counselor jobs the way so many have been filled over the past 40 years. While proudly announcing it had received a prestigious NAADAC award recently, Berkeley, CA-based Options Recovery Services also proudly pointed out that 24 out of its 56 staff members were program graduates.