Workforce Retention in Addiction Treatment: Findings from the National Treatment Center Study

1. Workforce Retention in Addiction Treatment: Findings from the National Treatment Center Study Paul M. Roman, Principal Investigator Co-Investigators: Aaron Johnson, Hannah K. Knudsen, and Lori J. Ducharme This research is supported by NIDA Research Grants R01DA13110, R01DA14482, & R01DA14976 The University of Georgia

2. Goals of This Session • To briefly outline the research design of the National Treatment Center Study • To describe the addiction workforce, including counselors and program leaders • To present data and information on counselor turnover at the organizational-level • To discuss burnout and turnover intention among program leaders • To outline how programs may reduce counselor burnout and turnover intention The University of Georgia

3. The National Treatment Center Study:An Overview The University of Georgia

4. Key Goals of the NTCS • To document the range of treatment services available in the American substance abuse treatment system • Levels of care, use of medications, types of therapies, wraparound services • To understand issues related to workforce retention, including both counselors and program leaders The University of Georgia

5. Types of Treatment Organizations in the NTCS • This presentation focuses on: • Publicly funded programs • Privately funded programs • Therapeutic communities (TCs) • Centers affiliated with NIDA’s Clinical Trials Network • Recently we added methadone programs, but data are not yet available for analysis The University of Georgia

6. Public Centers • Nationally representative sample of 362 public centers • 80% response rate • Eligibility for study defined by funding sources: • > 50% of revenues from government grants/contracts • Includes government-owned facilities and non-profit programs that rely on public funding • Average center receives 84% of its funding from public sources The University of Georgia

7. Private Centers • Nationally representative sample of 403 private centers • 88% response rate • Eligibility for study defined by funding sources: • < 50% of revenues from government grants/contracts • Includes for-profit facilities and non-profit programs that rely on private funding (e.g. insurance, self-paying clients) • Average center receives less than 20% of its funding from public sources The University of Georgia

8. Therapeutic Communities • Nationally representative sample of 380 TCs • 83% response rate • Programs only required to identify themselves as TCs • Captures the spectrum of programs that report using this treatment model • Interviews include measures such as De Leon’s “Essential Elements” and membership in Therapeutic Communities of America to see how closely programs adhere to the classic TC models The University of Georgia

9. NIDA’s Clinical Trials Network • The CTN is a research network that links university-based researchers with community-based treatment programs in order to: • Conduct multi-site clinical trials of treatment techniques • Improve addiction treatment quality by moving evidence-based techniques into practice • 240 CTN-affiliated treatment programs participated in the NTCS • 92% response rate The University of Georgia

10. Types of Programs NOT in the NTCS • Programs based in correctional settings • VA programs • Halfway houses & transitional housing • DUI services • Counselors in private practice The University of Georgia

11. Basic Research Methods • Data collected from mid-2002 to early 2004 • Three levels of data collection • Organizations • Face-to-face interviews with administrators & clinical directors • Organizational structure, availability of services, staffing • Leaders • Mailback questionnaire • Leadership style, organizational strategy, burnout, turnover intention, demographic characteristics • Counselors • Mailback questionnaire • Job characteristics, attitudes toward innovations, burnout, turnover intention, demographic characteristics The University of Georgia

12. The Addiction Workforce:Characteristics of Leaders The University of Georgia

13. Average Leader Age & Tenure • The average leader is about 50 years old • Private center average = 49.9 years • Public center average = 49.7 years • In a recent survey of American full-time workers, the average age of managers was 42.6 years • The average leader has worked for their center for nearly 10 years • Private center average = 9.4 years • Public center average = 9.4 years • In a recent survey of American full-time workers, the average manager had worked for their organization for 10.9 years • On average, leaders have worked 18-19 years in the behavioral health field • Private center average = 19.5 years • Public center average = 18.8 years The University of Georgia

14. Leader Characteristics:Gender • Nearly half of program leaders are female. The University of Georgia

15. Leader Characteristics:Racial/Ethnic Minorities • Public centers are more likely than private centers to have a leader with minority background. The University of Georgia

16. Leader Characteristics:Educational Attainment • The majority of leaders have at least a Master’s-level degree. The University of Georgia

17. Leader Characteristics:Personal Recovery Status • About one-third of leaders are personally in recovery from substance abuse. The University of Georgia

18. Average Leader Salary • The average leader earns between $55,000 and $65,000 per year • Leaders of private centers earn more ($64,496) than leaders of public centers ($56,010) The University of Georgia

19. Workforce Retention “At the Top”:Turnover Intention and Emotional Exhaustion Among Program Leaders The University of Georgia

20. Turnover in the Context of Leadership • There has been growing concern about high rates of turnover among counselors at treatment programs • Relatively little is known about turnover among program leaders • Turnover of leaders may be even more disruptive to centers • High costs to recruit new leaders • Increases uncertainties for program staff • Disrupts inter-organizational linkages The University of Georgia

21. Past-Year Change in Center Administrators • About 24.0% of centers reported a change in the administration of their center within one year. The University of Georgia

22. The Concept of Turnover Intention • Studies of turnover are challenging to conduct • Most surveys of employees are done just once, so researchers can’t measure actual turnover • But turnover intention has been identified as the best predictor of actual turnover over time • “I am seriously thinking about quitting my job.” • “I am actively looking for a job at another center.” The University of Georgia

23. Burnout & Emotional Exhaustion • Emotional exhaustion as central concept of burnout • “I feel emotionally drained from my work.” • “I feel frustrated by my job.” • Certain jobs are at higher risk of burnout, particularly those that involve “constantly dealing with other people and their problems” (Cordes & Dougherty, 1993) • Doesn’t that sound like the central task of management? • They have to deal with funding agencies, coordinate with other agencies, manage employees, etc. The University of Georgia

24. Greater emotional exhaustion and greater turnover intention is linked to greater odds of turnover one year later. Emotional Exhaustion Change in Administrator One Year Later + Turnover Intention Change in Administrator One Year Later + The University of Georgia

25. What are the sources of turnover intention & emotional exhaustion for program leaders? The University of Georgia

26. Organizational Strategy • Long tradition of studying how perceptions of being “in control” can enhance employee well-being • Control over making the “big decisions” • Control over uncertainties • Two aspects of organizational strategy are linked to this idea of “control”: • Bold decision-making orientation • Long-term strategic planning The University of Georgia

27. Bold Decision-Making Orientation • “When confronted with decision-making situations, this center typically adopts a bold, aggressive posture in order to maximize the probability of exploiting opportunities.” • In other words…managers have the power to take risks • Leaders were less likely to be planning to quit when this orientation towards bold decision-making was higher The University of Georgia

28. Long-Term Strategic Planning • Long-term strategic planning may help managers anticipate future challenges & plan solutions in advance • Includes financial planning, market research and anticipating where clients will be coming from in the long-term • Enhances sense of control over the many uncertainties of program management • Results show that long-term strategic planning reduces emotional exhaustion The University of Georgia

29. Performance Pressures as a Stressor • Another common theme in job stress studies is that work-related pressure increases burnout and turnover intention • For managers, pressures may be related to the financial performance of the organization • Generating high revenues, minimizing costs, high patient census • Greater emphasis on these types of performance increases both emotional exhaustion and turnover intention The University of Georgia

30. Participative Management of Staff • Long line of research shows that participative management is good for staff • Allowing employees to make decisions about how to perform their jobs • Providing information to employees about management’s decisions & asking for their input • But is it good for managers too? The University of Georgia

31. Centralized Decision-Making • Centralized decision-making as the opposite of participative management • “There can be little action taken here until a supervisor approves a decision.” • “Even small matters have to be referred to someone higher up for approval.” • While control over “big decisions” may be good, not letting employees have control over the “small decisions” may increase stress: • Higher emotional exhaustion • Higher turnover intention The University of Georgia

32. Involving Employees in Decision-Making • Managers can actively involve employees in the decision-making process • “I make sure all employee concerns are heard before job decisions are made.” • “I try to clarify decisions and provide additional information when requested by employees.” • Managers that involve employees more in the decision-making process reported: • Lower emotional exhaustion • Lower turnover intention The University of Georgia

33. Summary • Organizational strategy matters in terms of the well-being of program managers • They need control over big decisions • Long-term planning can help • Too much emphasis on (financial) performance may be detrimental • Participative management strategies—where employees are more involved in decision-making process—may have important benefits for the well-being of program leaders The University of Georgia

34. The Addiction Workforce:Characteristics of Counselors The University of Georgia

35. Key Questions about the Counseling Workforce • Is there substantial “graying” of the counseling workforce? • Is counseling becoming a “female occupation”? • To what extent are racial and ethnic minorities represented in the counseling workforce? • Is there evidence of greater workforce professionalism? The University of Georgia

36. Average Counselor Age & Tenure • The average counselor is in their mid-40s • Private center average = 46.4 years • Public center average = 44.6 years • TC average = 43.5 years • The average American full-time worker is about 40.4 years old • The average counselor has worked for their center for about 4-5 years • Private center average = 5.3 years • Public center average = 4.8 years • TC average = 4.3 years • The average American full-time worker has worked for their current employer for 8.4 years The University of Georgia

37. Counselor Characteristics:Gender • The majority of counselors are female. The University of Georgia

38. Counselor Characteristics:Racial/Ethnic Minorities • Private centers employ a significantly smaller percentage of minority counselors. The University of Georgia

39. Counselor Characteristics:Educational Attainment • Private center counselors are more likely to have a Master’s-level degree than counselors in public centers & TCs. The University of Georgia

40. Counselor Characteristics:Certification in Addictions Counseling • About half of the workforce is certified in addictions counseling, but TC counselors are less likely to have this credential. The University of Georgia

41. Counselor Characteristics:Personal Recovery Status • About half of the workforce is personally in recovery from substance abuse. The University of Georgia

42. Counselor Turnover:Associations with Organizational Characteristics The University of Georgia

43. Counselor Turnover in Addiction Treatment Programs • Previous research shows annual turnover rates range from 18% to 50% (Gallon et al., 2003; Johnson et al, 2002; McLellan et al, 2003). • Current data shows range between 13% and 21% depending on type of program • Significantly higher than national average across all occupations (11%) • Higher than teachers (13%) and nurses (12%) – occupations known for high turnover The University of Georgia

44. Comparing Voluntary Turnover • Public centers and TCs have significantly higher turnover than private centers (p<.001) The University of Georgia

45. What do we know about the differences between these types of programs that might explain differences in counselor turnover? The University of Georgia

46. Private Centers vs. Public Centers and Therapeutic Communities (TCs) Private centers • Higher % with primary alcoholism diagnosis • Higher % counselors with Master’s degree • Higher average salaries Public centers and TCs • Higher % relapsers and CJ referrals • Higher % minority clients • Higher % with primary cocaine diagnosis • Higher % minority counselors The University of Georgia

47. Results • Analysis using data from private centers • Higher levels of turnover associated with: • For profit status • Larger capacity • Composition of workforce • Prior Turnover Rate • Lower levels of turnover associated with: • Counselor-management relations The University of Georgia

48. Explanation of Results – Workforce Composition • Aspects of workforce affecting turnover • Higher percentage of female counselors = higher turnover • Higher percentage of counselors in recovery = higher turnover • Higher percentage of minority counselors and counselors certified in addictions = lower turnover The University of Georgia

49. Explanation of Results – Counselor-management relations • Participatory management • Center hears employee concerns before making decision • Receive sufficient notice of changes affecting work • Effective channels of communication between employees/management • Organizational commitment • Willing to put in extra effort to help center succeed • Proud to tell others I am part of this center • This is best of all possible centers for which to work The University of Georgia

50. What doesn’t impact turnover? • The diversity of services offered • Counselor education level • Counselor salaries • The types of patients being treated • Relapsers, CJ Clients, Indigent, Specific drugs The University of Georgia