Resistance to SUD Licensure: California Hypocrisy

California is famous for its beautiful coastlines, majestic mountains, vast deserts, and lush
agricultural regions that grow much of the world’s produce. California is also known for its
technological innovations and progressive attitudes in its pursuit of social equality. I believe the
positive aspects of the Golden State overshadow many of the negative realities and significant
social inequalities that have existed here for decades. Social inequality is particularly glaring
related to people who have Substance Use Disorder (SUD).
Historically, the state has mistreated this population, either through neglect or abusive practices,
including mass incarceration, or labeling people with substance use disorder as criminals, rather
than patients with a medical disease. The heavy-handed role of California in the “War on
Drugs,” with its disproportionate impact on minority communities is undeniable. In recent years
California has made some effort to mitigate the impacts caused by bad policies that led to the
mass incarnation of drug offenders, but it has not been enough. According to the Public Policy
Institute of California, “As of June 2014, the state’s incarceration rate had dropped by slightly
more than 8 percent, from 622 inmates per 100,000 residents to 570” (2021). Even an
incarceration rate of 570 per 100,000 people places California incarceration rates far above other
states and many developed nations.

The slight reduction in the state’s prison population did not come about due to a shift in its
attitude toward substance users who, historically and presently, constitute a huge percentage of
California’s incarcerated. Prison reductions were forced upon the state due to prison
overcrowding caused by excessive imprisonment of drug offenders. This in no way reflects the
progressive mindset that California is famous for. Our prisons are still full of individuals who
have a SUD and were convicted of committing more serious crimes under the influence or in
pursuit of substances driven by the disease of addiction. Progressive practices that might include
reduced sentencing for more serious crimes for people with SUD, or the implementation of
quality addiction treatment for incarcerated populations, not to mention evidenced-based and
culturally appropriate services, have moved at a snail’s pace.
This article is not about the “War on Drugs” and mass incarceration of those with a medical
diagnosis of SUD. I mention it only to highlight one of the more glaring aspects of obvious state
sponsored abuse and neglect of a population with a disability. Mass incarceration and labeling
people with SUD as criminals are deliberate acts driven by ignorance and bad policy. However,
it is vital that we take a deeper look at the less obvious examples of neglect that have resulted in
professional inequality, the perpetuation of stigma, and risk to the public. Continuous acts of
omission, by which our state government has failed to do everything in its power to provide
adequate care and protection to one of the most vulnerable segments of its population, those with
a SUD, must be considered from the lens of continuing stigma and outright discrimination.

There is a myriad of things that demonstrate the state’s failings with regard to the disease of
addiction. One glaring example is California’s continuous refusal to create and implement state
licensure for Substance Use Disorder counselors. It is very important to understand why
California lags far behind the nation in requiring a comprehensive set of standards for private
practitioners who can treat people at the earliest stage of disease. Equally important is
understanding why California should change course concerning this vital part of the continuum
of care. The first steps toward change would be to review California’s historic failure to adopt
SUD counselor licensure; determining reasons that SUD licensure is critically needed;
explaining the harms caused by not adopting it; and developing solutions to roadblocks for
licensure of SUD counselors.

California’s Failure to Adopt SUD Licensure

According to the California Senate Committee on Appropriations’ analysis of SB-1101 “Alcohol
and drug counselors: regulation” (2015-2016), “In recent years, there have been several bills
proposed to license drug and alcohol counselors, including SB 570 (DeSaulnier, 2013), AB 2007
(Williams, 2012), SB 1203 (DeSaulnier, 2010), SB 707 (DeSaulnier, 2009) and others. None of
those bills were enacted.” (2016). The state’s largest and most vocal advocacy organization for
addiction treatment and prevention, the California Consortium of Addiction Programs and
Professionals (CCAPP), been intimately involved in this multiple-year effort to create SUD
counselor licensure in California. CCAPP’s vision for SUD counselor development involves a
career ladder that begins with registered SUD counselor interns and progresses through levels
leading to state-issued licensure. The tiered system allows SUD counseling professionals to
advance according to specific education milestones and years of experience in the profession.
CCAPP supports a tiered advancement approach because it helps protect the public by ensuring
that SUD counselors advance only according to their level of education, experience, and
professional competency as evidenced by nationally recognized exams. It also provides SUD
counseling professionals with options to pursue their vocation; while not all SUD counselors will
wish to seek the advanced education and experience needed to operate at higher certification
levels or as independently licensed professionals. SUD counselors can essentially progress to the
level on the career ladder where they feel they can best serve their communities. Currently, all
levels of the SUD counselor career ladder are operational except for state licensure, which
California has refused to adopt.

There are many nuanced reasons that SUD counselor licensure has not been created, but most are
rooted in the failure of the state to allocate resources to create a license program. However, per
the fiscal impacts section of the previously mentioned analysis of SB-1101, the initial startup
costs and annual maintenance costs provided were so minimal, given the immense wealth of
California, that not creating licensure due to the cost would be laughable if the issue of addiction
and widespread individual and community consequences were not so tragic. To create SUD
counselor licensure in California, a new board or bureau would need to be created within the
Department of Consumer Affairs (DCA), the department that oversees other state licenses, at a
cost to the state of roughly $750,000.00. Additional annual costs such as issuing licenses,
processing renewals, background checks, processing complaints, etc., are estimated to be
approximately 1.1 – 2.1 million. However, eventually the fees collected for initial licensing and
renewals would likely cover the expenses. In light of the devastation caused by addiction,
particularly considering the nation’s continuing opioid epidemic and California’s growing
stimulant epidemic, the importance of building California’s inadequate workforce could not be
more urgent. Considering the low budget impact to the state and consequently taxpayers, not
adopting SUD counselor licensure is utterly nonsensical. Given the positive result of a
costbenefit analysis of California’s potential to provide SUD patients with individual
practitioners early in their disease progression, there must be more to the state’s failure to adopt
licensure than purely financial implications.

Why California Must Adopt SUD Counselor Licensure

There are many reasons why adopting SUD counselor licensure in California is of critical
importance. But before addressing some of the most important reasons, it is important to begin
by speaking to those who are currently certified SUD counselors, registered interns, or plan on
entering the profession about the inequality among helping professionals. If you are reading this
as an SUD counselor, intern, or other addiction-focused professional, you may be asking, “If we
already have SUD counselor certification, why do we need a license?” That is a valid question.
Currently, in California, there is only SUD counselor certification. SUD counselor certification is
issued by private certifying organizations that are overseen by the California Department of
Healthcare Services (DHCS). The certifications are not issued by the state itself, in part because
we have always been viewed as “paraprofessionals.” Certified SUD counselors have a
designated scope of practice like other behavioral health professionals but are prohibited from
diagnosing clients/patients within that scope of practice because they are not licensed (though
some states do afford certified SUD counselors these privileges). Only physicians, physician
extenders (Physician Assistants, Nurse Practitioners), and other designated Licensed
Practitioners of the Healing Arts (LPHAs), including licensed psychologists, licensed marriage
and family therapists, licensed clinical social workers, and licensed professional clinical
counselors, can diagnose.
By virtue of a professional holding a designated license, even having received no training, little
education, and no competency testing specific to SUD, they are allowed to diagnose and treat
people with SUD. Diagnosing and treating SUD falls explicitly, or by implication, in the scopes
of practices for many licensed professionals, although few have the competency needed to
assess, diagnose and treat SUDs. How do I know this? I know this because I have spent the better
part of the last five years providing what I would consider entry-level SUD educational
presentations and training to LPHAs and other allied professionals in my local community and
throughout large portions of California at their request. I want to emphasize, entry-level SUD
education and training, not advanced, because entry level is where many licensed professionals
are in their understanding of SUD.

The professionals that I have presented to include mental health therapists, pharmacists,
physicians, nurses, law enforcement officers, public health workers, attorneys, religious leaders,
child welfare social workers, and other human service professionals that do not understand the
disease of addiction yet interface with populations that have SUD almost on a daily basis. I
would also add that I have found that many licensed professionals don’t have an interest in or
passion for this population. Stigma and misunderstanding are prevalent even among those trained
to question their personal bias. Mental health therapists did not go into their profession with the
expectation of treating people with SUD typically. So, what does this mean for SUD counselor
or aspiring counselor? It means that you, as the non-licensed, certified counselor who works in
the treatment and recovery space, might be an expert on SUD and know far more than the LPHA
that works alongside you or supervises you. Yet you cannot diagnose . while they can, and
because they can, they earn a much larger salary than you. It is an ongoing frustration for many
certified SUD counselors that have to train licensed co-workers, or unlicensed therapist interns
on SUD only to have them make significantly higher rates of pay and sometimes even have to be
supervised by them. LPHAs have to diagnose because you, as the SUD counselor, cannot, per
regulation and for billing purposes. In the final analysis, from a business standpoint, not having
SUD licensure makes SUD counselors less valuable within our own profession even though we
have expertise and years of experience that many LPHAs do not. It also means that SUD could
be eventually be fully placed in the hands of the aforementioned LPHAs, making SUD
certification become obsolete. Before you say to yourself, “That can’t happen,” realize it can
happen, especially as SUD treatment becomes more medically focused.

Before I go any further, I want to say that there are some LPHAs that are incredibly
knowledgeable about SUD and have the interest, passion, and necessary competency. Some
LPHAs were certified SUD counselors first before they became licensed in a related discipline,
but most did not receive SUD specific education in their respective degree programs and I would
argue, based on my own experience and what other SUD focused trainers have told me, not
many are passionate about working with addicted populations. The point is that none of the
education programs that lead to the licensures listed above are inherently addiction-focused and
many programs only include SUD-related courses as electives if they offer any at all. SUD
counselor education is specific to SUD but counselors lose out on higher pay, prestige, and
professional respect by not having SUD counselor licensure available.

Someone might argue that a person who wants to diagnose and should just pursue one of the
licenses listed above. Well, I am all for it, if that person wants to be a physician, physician
extender, or mental health therapist, but many counselors who went into the profession want to
work specifically with people that have SUD. Many do not want to be licensed in another
discipline. Also, many SUD counselors that have sought other licensures only did so because
there is no path to licensure within their discipline. They were forced to step outside of the
profession to obtain some other type of licensure. I will use myself as an example. I am a
certified SUD counselor. I have been in the profession for over 10 years. I have a Master’s
Degree in Addiction Counseling from a regionally accredited university located in a state that
has SUD licensure. I had to go out of state to even get the degree. Since SUD counselor licensure
does not exist in California, universities, and colleges here are not incentivized to create bachelor
and master’s programs in addiction studies. In addition to my years in the profession; earning a
graduate degree in my discipline; working as a community SUD trainer and treatment program
auditor; having served as the Board President of CCAPP; surviving 20 years spent in the hell of
my own addiction; and 15 years of personal recovery, I still cannot diagnose clients/patients.
However, a licensed professional that I may have trained with no formal education related to
SUD can. What I find even more frustrating is that LPHAs in related helping professions are
enthusiastic to have me or others like me teach and train them because they know they lack the
knowledge and competency, but historically, many of the professional organizations that
advocate and support the LPHAs that I have trained are organizations that have actively opposed
CCAPP’s efforts for obtaining SUD licensure. I know that there are other certified SUD
counselors with high levels of education that can relate to my frustration. Though I am a strong
proponent of professional equality in the helping professions, professional equality is not even
the most important argument for SUD counselor licensure.

Work Force Shortage

For many years, there has been a very real workforce shortage problem in the SUD counseling
profession. Many people that go into this profession are in recovery themselves or they were
impacted personally in some way by a person that has a SUD. They have a passion for it because
they are connected to it personally. Few people outside the recovery community choose this as
their life’s work. This means that the SUD counseling interest pool is small to begin with. SUD
counseling, rewarding as it is, tends to be a high burnout profession in general. Typically, SUD
counselors do not make a lot of money and there is no pathway to licensure in the profession
they are passionate about, so they leave. They leave SUD counseling to other related professions
or they leave to other types of work out of financial necessity and/or burnout. This has a huge
impact on the workforce because the prevalence of SUD in society is growing, especially in this
season with the pandemic and social unrest. To make matters worse, older, more experienced
SUD counselors are retiring. This means there will be less quality mentorship and coaching for
incoming counselors and there will not be enough new counselors entering the profession to
replace those who are retiring. With low pay; high stress; and no pathway to licensure in their
profession, why would people stay? Passion and care for others is a powerful motivator but it
cannot pay bills. Licensure would lead to higher pay, greater mobility to help avoid burnout, and
the pursuit of professional licensure would likely keep people tied to the profession in pursuit of
that goal.
You would think that California would consider it worth spending a few million dollars for initial
startup and annual cost for new licensure that could help free mental health therapists to do what
they went into their professions to do, which is mental health therapy, where there is,
coincidentally, also a shortage of qualified therapists. Additionally, SUD cases and overdoses are
growing; we are in an opioid crisis (and a burgeoning stimulant crisis); experienced people are
leaving the profession, and not enough new counselors are replacing them; there are few
addiction studies programs available in California; low SUD competency and passion levels for
many LPHAs and not enough of them to fill the need. I would call that a crisis, but there is one
more important thing to point out.

Currently, California is a pilot state for SUD treatment expansion in the public sector under the
1115 or ODS – Waiver. SUD treatment under Medi-Cal has shifted to a true medical model
under this pilot program and is currently funding treatment levels of care and services not
previously covered or even available under the prior design. Counties that opted into the pilot
program, “Waiver Counties,” are expected to ensure network adequacy. The expansion of
programs and services is preferable, but at the very least, counties were required to create and
maintain a certain level of services based on estimates of the population that have a SUD in the
Medi-Cal eligible population. Network adequacy generally refers to programs and services, but it
is contingent upon having qualified staff necessary to deliver the services within the program.
While DHCS cannot advocate one way or another for or against licensure, it should be logical
for it to see that requiring network adequacy from counties that face impossible workforce
shortages can only lead to failure for the Drug Med-Cal Organized Delivery System now being
held out as a national success.

Public Safety

While much of this article has been focused on professional equality and workforce issues, there
is an even more important reason to adopt SUD licensure; public safety. As stated, LPHAs are
often not properly trained in SUD-specific competencies and best practices, which can pose a
safety risk to the public. However, there are other public safety concerns that people are unaware
of. For example, many people are unaware that many outpatient programs and those conducting
SUD-focused private practice are unregulated. Anyone can open an outpatient program or private
practice and offer services for cash to the public. People providing these services do not have to
be licensed or certified. Outpatient programs are not mandated to be certified (regulated) by the
state. DHCS only oversees SUD counselors working in programs which are licensed (impatient)
or who agree to become voluntarily certified (outpatient) in order to receive county funding.
Given the debilitating and potentially life-threatening nature of SUD, the vulnerability of the
population, as well as the skill and competency needed to be a SUD-focused professional, this
should terrify the public. Certified SUD counselors may privately practice without a license.
Certified SUD Counselors are allowed to do this as long as they inform clients that their
certification is not a state license. If they are certified with CCAPP, the public does have some
level of protection because CCAPP has its own ethics committee that investigates complaints.
CCAPP also has the authority to sanction counselors for ethical violations up to termination of a
credential, but if someone is uncertified there is no oversight. This being said, certification
requires that the consumer understands and can access certification lists and ethics statuses for
counselors which is highly unlikely.
For many years, people outside, and some inside of the SUD profession, have been outraged that
certified SUD counselors are allowed to practice privately without a license. Often, the lack of
license is not the main complaint. It is that certified counselors are viewed as paraprofessionals
and not considered on par with LPHAs. One of the strongest arguments against the creation of
SUD licensure has been the perception that SUD counselors only possess a low level of
education (this is not always the case). To become licensed as a mental health therapist, for example, aspiring licensees must obtain a master’s degree from an accepted university that
includes specific course work and practicum hours during their degree program. It also includes
the accumulation of a larger amount of practicum hours as an intern therapist, post-graduation,
and the passing of state exams. SUD counselor certification requires all the same components
with the exception of a mandatory master’s degree. 

The argument against SUD licensure has been, “Why should SUD licensure be granted to
individuals who did not obtain a master’s degree, specific to addiction, or at least in a related
field?” It is a strong argument and one that I sympathize with. I do think people forget that the
scope of practice is limited for SUD and would not require a long graduate program, but the
argument is valid and one of professional equality. We, as the addiction profession, cannot
educate the public about the complexity and potentially life-threatening nature of SUD and then
say that vocational SUD training, with no advanced education, is enough to justify licensure that
would allow us to operate independently.
When SUD counselor certification (then referred to as alcohol and drug counseling certification)
first began, decades ago, there were a lot of ideas about causes of addiction. but not a lot of valid
research. It was not until fairly recently that substance addiction was accepted as a brain disease.
Some in the profession are still unconvinced, even in the face of mounting scientific research,
which is disturbing, but that is another article. The point is, that the addiction treatment
community grew up in isolation away from the other helping disciplines early on due to stigma.
Nobody wanted to deal with “addicts and alcoholics” so they embraced more spiritual solutions
which proved effective for many but not all. Spiritual 12-step programs eventually morphed into
social model treatment. While the treatment and recovery communities have retained many of its
early characteristics, SUD treatment has moved to a medical model of treatment that is grounded
in scientific research and evidence-based practices. These changes significantly raise the required
competency levels needed to be an effective SUD counselor in the new treatment environment,
especially if we wish to operate as state-licensed SUD treatment professionals. Since the research
on addiction has made significant advancements, increasing our understanding enough to justify
graduate-level addiction studies programs that are increasingly springing up nationwide, there is
no reason why a master’s degree should not be required for SUD licensure in any state including
California.
To be clear, the idea is not to replace certification with state licensure. As I mentioned earlier in
the article, SUD licensure should only be required for the SUD counselor who wishes to practice
independently, or who would like to be able to diagnose in the programs in which they work.
Various levels of certification which are based on education level and experience should remain
available on the SUD counselor career ladder. The various certification levels on the career
ladder would serve two main purposes. 1) It provides a space for everyone who wishes to work
as a SUD counselor to do so in accordance with their education and experience, 2) It serves to
allow SUD counselors to work and progress on the career ladder as they pursue state SUD
licensure. No other related, licensed profession that I can think of, has a career ladder like this
available. It provides excellent opportunity for advancement while elevating public safety in the process.
For certified counselors who are doing private practice in California at present, the current draft
of CCAPP’s licensure bill includes special fairness protections that would grant an exemption
from the license requirement, allowing those who are already practicing to continue practicing
for ten years during which time they will be monitored by the licensing authority as they work to
meet the educational requirements. To recap, SUD licensure does not replace certification, it
creates a path for higher pay within our discipline, and language in the bill provides a cushion for
certified counselors to continue in private practice as they work to achieve the educational
requirement of licensure. Nobody gets left out, and the public, as well as our profession is
protected. 

Some of the Underlying Reasons Why SUD Licensure Has Not Been Adopted

Given all the benefits of SUD licensure, as it relates to professional equality, the strengthening of
the workforce, public protection, and with minimal cost to the taxpayer, the reader may be
wondering why California has not adopted it. We all should be wondering why it has not been
adopted. To be blunt, I strongly suspect that the reasons primarily revolve around professional
competition and governmental preference rooted in stigma, coupled with professional snobbery
and money. Let me clarify what I mean by governmental preference. Years ago, when SUD
counseling began, the state allowed private certifying organizations to oversee and manage it.
The state provided oversight of the private certifying organizations (CCAPP, CAADE, and
CADTP). Early on, the state agency that regulated the private certifying organizations was the
Department of Alcohol and Drug Programs. This department also regulated many of the alcohol
and drug treatment programs in which certified counselors were employed. This Department was
eventually dissolved and its responsibilities were transferred to the Department of Healthcare
Services (DHCS). SUD counselor certifying organization oversight and treatment program
certification, licensure, and monitoring responsibilities are currently under DHCS.
In looking at other certified and licensed professions, it seems highly irregular for a
governmental body like DHCS to oversee SUD counselor certification in the first place, a
situation they inherited when, then Governor Brown, eliminated the Department of Alcohol and
Drug Programs. DHCS is the same organization that oversees the 1115 (ODS) Waiver pilot
program for Drug Medi-Cal expansion. And with the proposed Cal-AIM program, SUD and
mental health services are slated for greater and greater “integration.” Is DHCS aligned to
encourage licensed mental health therapists to take over all clinical responsibilities of SUD
treatment eventually? It’s worth considering, especially since many SUD counselors are in
recovery and people in recovery experience high levels of stigma and even professional abuse
working amongst other licensed helping professionals. Is there underlying bias toward our
profession that could be impacting regulation in general?
In addition to lack of support from former governors, SUD licensure has also been hindered
through active resistance by other professional advocacy organizations. Many of these
organizations represent the LPHAs listed earlier in the article. Being licensed to diagnose and
treat people with SUD, of course, comes with an ability to bill for these services. SUD licensure
would create competition for them. Marriage and Family Therapists and Licensed Clinical
Counselors met similar resistance from established LPHAs when they were up and coming but
not in the same way that SUD counselor licensure has met resistance. The perception that SUD
counselors do not have enough education persists. We are stilled viewed as paraprofessionals by
many. In the beginning stages of the SUD counseling profession that is what we were, but since
that time the profession has developed; many SUD counselors possess higher education levels,
including advanced degrees. Addiction science has advanced such that medical associations that
specialize in addiction now exist. The American Society of Addiction Medicine has extended
Associate Membership to addiction-focused professionals who possess certain graduate degrees
along with certification. The perception that SUD counselors are collectively undereducated
paraprofessionals is patently false, which is why several professional advocacy groups that once
opposed licensure are now actively supporting our efforts.

In the U.S., there is a lot of social change taking place. Change is taking place because people
that have been historically labeled, marginalized, abused, and intentionally oppressed refused to
continue to accept the status quo. People are raising their voices together and refusing to take
“no” for an answer. It is not a time for SUD-focused professionals to accept the things we think
we cannot change, but rather work to change the things we cannot accept. Historically,
individuals with SUD have been treated with contempt, and while it may not be as blatant as it
has been in the past, contempt can present in other forms, including professional exclusion.
People who dedicate their lives to this profession deserve the opportunity to pursue licensure in
their chosen discipline; licensure that will allow for the same level of professional autonomy
afforded to other licensed professionals. More importantly, California residents deserve
adequately staffed, safe, and competent care. 2021 is a turning point and I hope that all who read
this article will support CCAPP’s efforts to call on California to adopt SUD counselor licensure.

References:

Realignment, Incarceration, and Crime Trends in California. (2019, May 15). Retrieved January
21, 2021, from https://www.ppic.org/publication/realignment-incarceration-andcrimetrends-in-california/
CA SB-1011 Bill Analysis, (2016, May 15). Retrieved January 21, 2021, from
leginfo.legislature.ca.gov/faces/billAnalysisClient.xhtml?bill_id=201520160SB1101.