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Mental health counselors are facing increased challenges due to the impact of SARS-CoV2 Infection (COVID-19). Barriers, risk factors, and lack of resources have affected the profession. These include technology issues, access to necessary equipment, confidentiality, participation levels due to lax environment, and probation reporting requirements, and inconsistencies between state and federal guidelines. This past year, a large portion of mandated substance treatment was forced to an online format due to social distancing requirements (Watkins, 2020). Federal emergency measures allowed for telemental health counseling without certification, or even the necessary training (Federal Emergency Management Agency [FEMA], 2020). As a result, many agencies were left to solve these challenges on their own. Faced with ethical dilemmas and untrained staff, these agencies continue to struggle to maintain continuity of treatment. We discuss strategies on how to respond to these challenges, as well as implications in the counseling profession.
Substance abuse treatment; Addiction treatment; COVID-19; Mental health treatment
Current Challenges Impairing Health Care Facilities Due to the Impact of SARS-CoV2
Substance use is a growing public health concern. According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2017), “In 2017, approximately 19.7 million people aged 12 or older had a substance use disorder (SUD). In 2018, 67,367 drug overdose deaths occurred in the United States (Centers for Disease Control [CDC], 2020). Comprehensive evidence-based substance abuse treatment is more vital now than ever. Yet there have been significant challenges facing substance abuse treatment during the COVID-19 pandemic. This includes making sure that clients are able to access treatment, are receiving treatment via an evidence-based curriculum designed for the delivery format, and are ultimately receiving the appropriate level of care according to their diagnostic acuity.
The National Council for Behavioral Health  estimated that over half have had to reduce or close treatment programs and nearly 65% have had to turn away patients as a result. The National Association of Addiction Treatment Providers  estimated that nearly 20% of their providers have had to close or partially close facilities due to the impact of the COVID-19 pandemic.
These challenges are compounded by issues related to the stigma associated with a substance use disorder, the complexity of a broad range of treatment dynamics specific to each varying type of substance use disorder, and limitations surrounding substance abuse counselor training and education.
The Diagnostic & Statistical Manual (DSM-5  differentiates ten separate classes of substance-use disorders: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics, stimulants, tobacco, and other substances. The manual defines “all drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviours and the production of memories” (p. 481). Although many of these classes have overlap in diagnostic features and treatment strategies, there are still significant differentiating features within each class that would ideally warrant specific treatment protocols. For example, alcohol-related disorder diagnostic criteria according to the DSM-5  consist of the following:
A problematic pattern of alcohol use leading to clinically significant impairment for distress, as manifested by at least two of the following, occurring within a twelve-month period.
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent ore recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following: a need for markedly increased amounts of alcohol to achieve intoxication or desired effect, a markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for alcohol, alcohol is taken to relive or avoid withdrawal symptoms (American Psychiatric Association, 2013, pp. 490-491).
In addition to these distinct diagnostic features, the severity of the substance use disorder is also coded between mild, moderate, or severe. For example, in order to be considered a mild disorder the client would only present with 2-3 diagnostic criteria as listed above, a moderate disorder would present with 4-5 symptoms, and a severe disorder would exhibit 6 or more symptoms. Determining the level of severity is instrumental in assessing the level of treatment because more severe cases will require access to additional resources and support (e.g. home health care, additional support group or sponsors, and more frequent care; American Psychiatric Association, 2013).
Credentials of Substance Abuse Counselors
Historically, substance abuse counselors were those in recovery and who had little to no formal education in mental health treatment. They were considered paraprofessionals because they did not possess formal education surrounding mental health treatment and the application of evidenced-based theories. Treatment strategies were often based more on personal experiences rather than empirical findings . As Prochaska and Norcross (2014) suggest, “Without a guiding theory or system of psychotherapy, clinicians would be vulnerable, directionless creatures bombarded with literally hundreds of impressions and pieces of information in a single session” (p. 4). Untrained individuals may not be able to recognize common problems such as comorbid conditions or counter transference. They may also be unable to accurately assess risk of suicide or self-harm.
In 1972, the National Association of Alcoholism Counselors and Trainers (NAACT) was founded. A decade later, this organization evolved into the National Association for Alcoholism and Drug Counselors (NAADAC). In 2001, it became the Association for Addiction Professionals, preserving the same acronym. Today NAADAC provides education, clinical training, and certification for substance abuse on a national level. NAADAC establishes and monitors the credentials for National Certified Addiction Counselor (NCAC), Nicotine Dependence Specialist (NDS), and Master Addiction Counselor (MAC). Other state specific organizations have established substance abuse credentials based upon the same model. Although substance abuse treatment models have improved as a result of this credentialing path, there are still many individuals administering substance abuse treatment who are not credentialed .
Kerwin et al. Found a statistically significant difference in training requirements between drug and alcohol certification versus mental health counselling . When comparing these two fields, the study demonstrated that minimum state requirements to qualify as a substance abuse counselor are quite different from the requirements to qualify as a mental health counselor. The study revealed that only 50% the states even required a substance abuse counseling credential to work in treatment centers, whereas 86% of the states required credentials for mental health counseling . In addition, some mental health counselors are required to obtain telehealth training as part of the credentialing process. However, substance abuse counselors are often not required to receive such training (Georgia Addiction Counselors Association [GACA], 2020; NAADAC, 2020) .
Substance-Abuse Treatment Prior to COVID-19
Prior to the COVID-19 pandemic, mandated treatment centers offered substance abuse clinical evaluations and outpatient mandated substance abuse treatment to clients in coordination with agencies such as the Department of Behavioral Health and the court system. The majority of these centers are approved for outpatient level 1 treatment and clinical evaluations as specified by the American Society of Addiction Medicine (ASAM) . The treatment options include either short-term or long-term level 1 ASAM treatment courses. Long-term treatment is defined as a minimum of 17 weeks and a maximum of 52 weeks. Short-term treatment is defined as a minimum of 6 weeks and a maximum of 17 weeks. The curriculum was developed as a face-to-face format with substance abuse groups meeting at least three hours per week. The curriculum is delivered in an open group format mixed with individuals from various age groups, genders, cultural backgrounds, race, and economic status.
Individuals in these types of treatment programs are mandated by the court system to attend treatment, which is often monitored by probation. Non-compliance with treatment could result in serious consequences, including revocation of probation status. However, with the onset of the COVID-19 Pandemic, many treatment centers were unable to provide in-person treatment services and the programs that were being utilized had not been developed for distance-based or remote delivery. For example, Prime Solutions is a popular outpatient substance-abuse treatment program that is currently being used in 36 states. The Prime Solutions curriculum was not designed for the delivery of telemental health substance abuse treatment and has been largely utilized in-person . Therefore, the program may lack the resources necessary for monitoring compliance, engagement, and effective outcome when applied in a distance-based format.
Challenges, Barriers, and Risk Factors During COVID-19
The overall impact from the COVID-19 epidemic has not only been devastating to substance abuse clinics, but also to their clients. Treatment continuity suffered as a result of sudden discontinuation of treatment due to job loss, courts and state agencies temporary closures made it difficult to meet mandated obligations, and reduction in agency staff often limited treatment capacity. On top of those challenges, clients may have been confused by discrepancies between state and federal authorities, as well as agency delays in transitioning to alternative treatment formats. As a result, many clients withdrew from treatment (GDBHDD, 2020), which was particularly harmful for substance abuse clients who rely on treatment to prevent relapse.
New challenges, barriers, and risk factors have emerged for both clients and counselors working with mandated substance abuse clients as a result of the COVID-19 pandemic. These challenges include: technology issues, inability to access necessary equipment, confidentiality issues pertaining to informed consent, decreased participation levels, lack of a structured treatment environment, and probation reporting problems. While in some instances telemental health services improved access to treatment , it oftentimes made accessibility to treatment more complicated. Challenges for substance abuse clients in particular are: limited access to technology, unreliable or non-existent Internet service, challenges reinstating driving privileges due to agency closures, and inability to pay for services due to job loss or lack of non-cash paying ability, such as credit cards or bank accounts .
Technology issues are one of the largest challenges facing clients. Many of them have never used an online platform for treatment and social distancing protocols have limited most agencies ability to provide training or assistance (GDBHDD, 2020) . Many clients may have discontinued or avoided treatment due to the inability to access or operate a particular telemental health platform. Others, especially those in rural areas, simply lack the necessary equipment, such as computers or cell phones, to access treatment remotely .
Even when a client is able to gain access, confidentiality and personal boundaries have become a significant concern, as clinicians are unable to control the client’s therapeutic environment . This also limits the clinician’s ability to monitor whether a client is currently under the influence of substance or alcohol. In addition, several clients are challenged with the inability to access technology in a private area or may lack situational awareness to determine whether or not a roommate or family member could be listening. This results in risks to informed consent and the client’s diminished capacity for attention .
Addressing Counselor Challenges
In terms of technology issues, both staff and clinicians need adequate telemental health training. Clients need assistance in operating technological platforms, including guidance in operating a computer, navigating software or the Internet platform, and challenges operating hardware, such as camera, microphone, and speakers . Clients in rural areas may need additional assistance, as they oftentimes have limited or no Internet services. Many are unable to afford the infrastructure required for telemental health, such as computer, hardware, and Internet service.
To combat issues relating to payment, some agencies have offered randomized lottery for pro-bono services; guidance in seeking state and federal assistance such as food stamps and unemployment benefits; other payment or technology options such as family members or temporary treatment hiatus; accommodations such as drop-box payment options, third-party payment options such as credit card release for family members and electronic cash applications (i.e. Venmo). For many, driving privileges were the primary motivating factor in seeking treatment. However, there was little that could be done regarding challenges with reinstating driving privileges due to state closures. This resulted in treatment attrition and premature drop-out. Therefore it will be helpful to find other novel incentives for treatment compliance.
Several studies found that counselors have a harder time keeping participants engaged, present, and on-focus in an online format versus in-person [9,11]. To address these challenges, clients need to be reminded to remove any distraction from the room such as television, radio, cell phones, etc. Clients need to be trained during the first online session regarding online etiquette, general procedures, and guidelines for the treatment sessions . Treatment goals may need to be broken up into smaller more accessible segments with more structured evaluative components. Participation also needs to be monitored via other methods, such as a co-facilitator or assistant, telemental health analytics, and attendance monitoring.
Addressing Agency Challenges
Agency challenges include: loss of client motivating factors resulting in decreased attendance, complexity regarding procuring client payments, limited telemental health employee training, lack of experienced telemental health providers, staffing issues due to quarantine or social distancing protocols, and discontinuation of care due to dismissal of charges as a result of the expiration of statute of limitations for DUI charges (Watkins, 2020). It is estimated that these challenges have contributed to lost revenue, higher overhead, and in some cases facility closures (Watkins, 2020).
During COVID-19, many court-systems were delayed, and probation officers were working under limited hours (GDBHDD, 2020). Social distancing may not allow for drug testing, which could create an obstacle in determining if a client is abstaining from alcohol and drugs. This phenomenon created a decrease in motivation with clients, less oversight of those on probation, and less communication with center directors. As a result, many clients either dropped out or delayed treatment, causing a significant decrease in census, which directly impacted the financial status of many treatment centers (Watkins, 2020).
To address motivating factors, clinicians should stress to clients the importance of treatment compliance and probation requirements. Center directors could also provide the state a reasonable explanation for lack of client treatment compliance (oftentimes limited to one-time 30-day period). This could be employed as a strategy to prevent probation violations or other negative repercussions, such as: license revocation, voluntary court compliance, and offender recidivism.
Ethical Issues for Counselors and Agencies
According to Barsky (2020), “Extraordinary times call for extraordinary measures” (p. 1). As many organizations have temporarily closed or been forced to replace in-person meeting with clients via telephone and digital communication, the standard delivery of care in accordance with our codes and manuals is not possible. Counselors are in a time of uncharted territory and clients are in time extreme need. Ethical concerns as a result of the revised agency plan include monitoring effectiveness, impairment, addressing personal concerns, confidentiality of information, electronic links, technology-assisted services, and communication differences in electronic media.
As noted previously, many clients have limitations accessing Internet, appropriate hardware, and software. Clients may also lack the necessary skills to effectively participate in an online format . ACA Code H.4.c.states that counselors must ensure that clients are able to effectively access and utilize technology . This needs to be a part of a clinician’s telemental health directive included within their written informed consent. Clients need to engage in a new informed consent process that explains the differences in risk and limitations prior to transitioning to an online format.
Many substance abuse counselors lack appropriate training and experience in telemental health platforms. Continuum of treatment may suffer as a result of a lack in core telemental health-competency, which in turn affects our number one responsibility to protect client welfare. The ACA Code of Ethics of Ethics C.2.a. and H.1.a. states that counselors need to have appropriate training and experience related to how they convey treatment . Therefore, counselors have an ethical responsibility to seek telemental health training through local, state, or national organizations. This includes local continuing education, state counseling association conferences, and other national training opportunities.
Many substance-abuse clients withdrew from treatment due to limitations in telemental health delivery. This included limitations in how to monitor compliance, such as whether or not they remained abstinent, and limited ability in communicating with partners in the managed care process. The ACA Code of Ethics C.2.d. and H.4.d.states that counselors need to monitor and evaluate the effectiveness of treatment . Center directors need to employ new strategies for monitoring the effectiveness of online treatment, such as reviewing recorded sessions, evaluating post-session satisfaction, and overall treatment completion/drop-out.
In general substance-abuse counselors are already lower paid and at high risk for burnout . Risk factors associated in working with substance abuse clients in the current situation include risk of contracting COVID-19, burnout due to higher stress rates, and decreased participation from the clients. Clinical directors need to provide resources that promote self-care strategies, so that clinicians feel protected by their employers.
Employee Wellness and Safety Plan
To address employee retention issues, centre directors should implement employee safety plans and employee wellness toolkits. One such tool is the Practitioner’s Guide to Ethical Decision- Making (2014), which could help agency directors identify primary needs. An Employee Safety plan could be developed in conjunction with local, state, and federal agencies. One example is COVID-19 Safety Guide by Colton Redlands Yucaipa Regional Occupational Program , which included the Occupational Safety and Health Administration (OSHA) standards for COVID-19 workplace guidelines .
OSHA has recommended a specific set of guidelines in order to ensure safety in the workplace during this pandemic specific to jobsite protocols in the areas of testing and hygiene . These guidelines also provide a template for agencies who may want to modify operating procedures and better manage continuum of treatment. Recommendations include: purchasing hand-sanitizer and personal equipment in the event the agency is able to reopen for face to face counseling; self-monitoring tools for employees and clients; workstation sanitation protocols, and common area protocols for safe use [15,16].
Agency directors may want to provide resources that can assist in addressing self-care. An example is an employee wellness toolkit designed specifically for COVID-19 from the Wellness Council of America (WELCOA) . Through this online platform, employees are sent an access code and can review any of the twenty different wellness webinars. They can also independently access these modules at any time . The WELCOA (2020, pp. 3-4) Wellness plan toolkit includes:
1. Establishing a New Normal for Home
2. Establishing a New Normal for Work
3. Managing Anxiety
4. Social Distancing and Connection Care
5. Physical Activity at Home
6. Nutritious Food
7. Rest and Play
8. Leveraging Your Sphere of Influence in a Pandemic
9. Financial Well Being
10. Managing Expectations
11. Finding Balance
12. Connections, Empathy, and Compassion
13. Setting Up Your Home Office
14. Being an Influencer for Good
16. What’s Going Well?
17. It’s Okay Not To Be Okay
18. Boosting Your Immune System
19. Medical Consumerism During a Pandemic
20. Mindful Mini Breaks
It is important to monitor employee effectiveness and telemental health competence in accordance with the ACA Code of Ethics Standard H.4.c. stating, “When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client” [13,19]. In addition to the wellness toolkit, we recommend that directors hold weekly staff meetings via teleconferencing. Employees are encouraged to talk about fears, anxieties, and any other issues in relationship to employment [20-24]. The focus should be on encouraging wellness and checking in with the staff to ensure quality services are being delivered to the client .
In the wake of the COVID-19 pandemic many counselors were caught off-guard in the use of telemental health platforms. This was particularly challenging for substance abuse counselors who have not been previously trained in this type of distance-based counseling. In order to continue services to clients, local and federal governments issued a temporary order for the use of non- HIPAA compliant telehealth platforms. This presented challenges for both clinicians and clients. Challenges for clinicians included issues pertaining to logistics of delivery, such as lack of telehealth training and HIPAA-compliant telehealth platforms; monitoring treatment compliance, such as the inability to drug test clients; monitoring effectiveness, such as whether or not clients were engaged during the treatment protocols; and ensuring patient confidentiality, such as the inability to control the client’s telehealth environment. Challenges for clients included limitations in treatment accessibility, such as inability to attend in person or lack of Internet and telehealth equipment; struggles to remain engaged, such as a disconnection from sponsors, peer-support meetings, and case managers; and inability to pay for treatment due to financial hardships resulting from lay-offs and loss of supportive-income.
Short-term efforts have been helpful in addressing some client needs. However, there are still challenges in providing effective long-term distance-based treatment, maintaining continuum of care, and helping clients access telehealth technological resources. Clients need basic training in telemental health counseling protocols and need to understand the risks and benefits associated with this mode of therapy. They also need technological access points or assistance in procuring safe and reliable venues for distance-based treatment. The unique dynamics of telemental health treatment require additional follow-up care, such as: post-session check-ins, monitoring session attendance and engagement, and other novel ways to motivate program compliance.
To ensure the highest quality of care we must also tend to clinician mental health. Employee wellness toolkits provide structured modules for independent self-care and strategies for navigating the stressors associated with a COVID-19 environment. Now more than ever, clinicians need to rely on a professional network for consultation and support. This includes: weekly treatment consultation, staff support and collaboration groups, an increased level of oversight, and ongoing telemental health training.
Even after we have learned how to deal with the COVID-19 pandemic itself, the impact will likely be felt for many years in terms of a shift in the counseling paradigm towards a larger utilization of telemental health counseling. Uncertain times dictate greater flexibility in how we approach mental health treatment. We need to continue to develop best practices for utilizing telemental health counseling and the technology needed to provide effective services.
We have also been given the opportunity to see our client more holistically. Perhaps we better understand the need to advocate for basic client needs, such as technology, transportation, and finances. We also need to re-evaluate how we measure and monitor compliance in a virtual format. In times of crisis people look to those in the helping professions to provide guidance and support, as well as instill hope. As we continue to navigate this new normal in the age of COVID-19 and potential future crises, strategies for improving counselor resilience is more important than ever before.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Interests
Citation: Hicks A, Peterson J, Reed D (2021) Current Challenges Impairing Health Care Facilities Due to the Impact of SARS-CoV2. J Alcohol Drug Depend 9: 339.
Received: 01-Feb-2021 Accepted: 19-Feb-2021 Published: 26-Feb-2021
Copyright: © 2021 Hicks A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.