Abstract
Substance use disorders and the mortality rate associated with overdoses are well publicized health crises, yet practitioner biases and lack of experience present barriers to care. Student practicum experiences can assuage these concerns, yet specialized training to treat substance use disorders is lacking. Practicums for behavioral health students provide specialized, applied learning opportunities that are foundational to developing skills and perspectives on the obstacles and opportunities of working with substance use disorders. Understanding treatment needs and training gaps from the perspective of those entering the field contributes a unique perspective. This qualitative project applied thematic analysis to the responses of two focus groups of mental health trainees (N = 18) to elicit lessons learned following a two-semester practicum in substance misuse treatment settings. Three themes emerged: Organizational, Client, and Personal Lessons Learned, which identify actionable steps for training programs and treatment agencies to support new practitioners. Trainees articulated gains in knowledge, attitudes, and skills, and in understanding factors influencing client outcomes.
Keywords: training substance use disorder practitioners; substance use disorder trainees; SUD practitioners; SUD practicum
Overdose mortality in the United States remains in excess of 100,000 deaths annually (Centers for Disease Control and Prevention [CDC], 2023) with most states seeing at least a 30% rise in overdose mortality, and some communities doubling or tripling their rates of overdose deaths in the past three years (Ahmad et al., 2024; CDC, 2020). Overdose mortality remains an omnipresent threat as the number of individuals diagnosed with substance use disorder (SUD) continues to increase, affecting untold individuals, families, and communities (Burrow-Sanchez et al., 2020). The growing mortality and SUD rates have culminated in a public health crisis, exacerbating burdens for already overstretched systems such as foster care, health, and mental health settings (Burrow-Sanchez et al., 2020; Green et al., 2020). As the death toll rises, so do significant economic costs, with the National Institute on Drug Abuse (2020) estimating that $740 billion is lost annually due to substance use. Adding to the public health crisis is the disproportionate impact on rural communities, which typically have fewer resources and reduced access to care, yet have overdose rates comparable to better resourced urban areas (Stobbe, 2019).
Treatment providers are desperately needed, particularly for SUD (Dimoff et al., 2017; McCarty et al., 2020; Pederson & Sayette, 2020), yet providers often report being uncomfortable treating those experiencing substance use disorder (Burrow-Sanchez et al., 2020; Crowe et al., 2013; Gooding et al., 2021; Nash et al., 2017). Contributing factors include a lack of both didactic and experiential learning opportunities specific to substance use disorders, and the personal attitudes, biases, and stigmas of providers (Avery et al., 2017). This gap in service provider knowledge and skills widens even more in areas with already limited resources and reduced access to care, including rural and underserved areas (Green et al., 2020).
Literature identifying the impact of education and training specific to treating substance misuse indicates positive effects for those engaging in the training. For instance, Nash et al., (2017) found that nursing students, after completing a substance-related clinical internship, reported more positive attitudes toward patients with SUD, increasing their ability to form therapeutic relationships. Likewise, medical students indicated a greater likelihood of pursuing an addiction specialization following a rotation related to substance use disorder (Gooding et al., 2021), and counselors reported greater competence after completing an internship in an SUD setting (Crowe et al., 2013). These findings indicate the value of experiential learning with clients experiencing SUD, particularly related to attitudinal changes. Having these attitudinal changes as a student helps establish and develop practitioner expectations. Simply stated, provider attitudes affect client outcomes (Avery et al., 2017; Green et al., 2020) and clinical practicum experiences offer a method of mitigating providers’ negative attitudes and perception of stigma prior to entering professional practice.
This study sought to understand if practicum experiences in SUD-related agencies support trainee skill, knowledge, and attitudinal development in preparation for practice. Specifically, this study sought to address this research question: How does experiential learning through a practicum inform behavioral health student learning related to SUD?
Methods
Participants (N = 18) were members of the Opioid Workforce Expansion Program cohort funded by the Health Resources and Services Administration (HRSA) at a large Southeastern university. The Opioid Workforce Expansion Program designated funding to develop behavioral health students into practitioners with specialized knowledge and skill in SUD and opioid use disorder (OUD) serving HRSA-designated rural and underserved areas. Participants completed a two-semester practicum in SUD settings along with dedicated training in telebehavioral health, which can serve clients and communities with limited access to onsite providers.
Participants consisted of Master of Social Work (MSW; n = 15) and counseling psychology graduate students (MS, n = 2; PhD, n = 1) who were completing the specialized training program. Of those, the 61% (n = 11) identified as cis-female, 33% (n = 6) as cis-male, and 5% (n = 1) as nonbinary. The average age of participants was 30 (SD = 5.44), and 14 (77%) reported being from rural areas. The majority of trainees self-identified as Caucasian/White (83%, n = 15); other responses were African American (5.55%, n = 1), multiracial (5.55%, n = 1), and Latinx (5.55%, n = 1).
Following their two-semester practicum in OUD treatment settings, participants were invited to a voluntary (Institutional Review Board approval #54826) focus group held through Zoom. Focus groups were 60 minutes long and conducted by the first author, with specific questions consisting of:
- What draws you to working in the field of substance use disorder?
- What keeps you in the field when it gets tough?
- What are some of the most challenging aspects of working with SUD?
- What is the greatest lesson you’ve learned about working with SUD?
- What creates burnout in working with SUD? What can help prevent burnout?
- What suggestions do you have regarding cultural considerations for providing services (e.g., rural, Appalachia, poverty, etc.)?
Focus groups were recorded and subsequently transcribed using Rev.com, with pseudonyms replacing participant names during analysis.
Analysis
Following Terry et al.’s (2017) six-step process, this study employed inductive thematic analysis, within a constructivist paradigm, rather than imposing a priori theory. In step one, the first author conducted focus groups and wrote memos presenting potential themes. In step two, the second author coded the data to capture student representation of lessons learned. In step three, the first and second authors reviewed codes to determine which coalesced around categories, themes, and subthemes. In step four, this category initially included three themes with three subthemes that were then recorded, and relevant quotes were selected. In step five, the definition process for themes resulted in collapsing three subthemes from the first and second themes into two subthemes each. This manuscript represents the final step of Terry et al.’s (2017) process.
Results
Participants presented three themes related to the lessons they learned as behavioral health practicum students in SUD treatment facilities, with each explicated below: Organizational Lessons Learned, Client Lessons Learned, and Personal Lessons Learned. Subthemes detailed the lessons as well as how participants intended to apply the knowledge they had gained through the practicum experiences.
Organizational Lessons Learned
This theme reflects two subthemes focused on what students learned about SUD agencies, and included their observations on needed change, as well as what agencies did well during their practicum experiences.
Supporting Balance and Boundaries for Staff
Engaging in organization culture was an initial challenge for students who quickly felt overwhelmed. Related to caseload, Nora shared, “There was a point where I was seeing like 30 clients a week, plus doing an IOP [intensive outpatient], and I was just burning through all of my energy, and I told them that ‘I can’t keep this up, or I’m going to get compassion fatigue.’” Professional awareness of practitioner personal responses to workload and client needs is invaluable in experiential learning opportunities, and enables transitioning to practice in a manner that minimizes burnout.
Evelyn identified another lesson learned about structuring supportive environments for staff: “I also think the fact that we have these clinicians and supervisors of our programs who are wearing so many ‘hats’: they’re not only the clinician, they’re the supervisor, they’re the staffing person. That’s also creating so much burnout for these people.” Holding multiple positions adds an extra burden for the entire organization, leading to student awareness of role boundaries.
To navigate barriers effectively, students articulated they learned to find balance and set boundaries. Trainees indicated that organizational supports, such as reducing caseloads, providing high-quality supervision, and promoting or honoring staff self-care to prevent burnout, were well received. Organizational lessons learned reported by practicum students in SUD settings conveyed their concerns and recommendations for ways organizations could work more effectively to improve staff, and subsequently client, outcomes. From their perspective, these learning experiences allowed conversations with agency administration that led to aspects of support, allowing these emerging practitioners to better serve SUD clients.
Navigating Institutional Bias and Barriers
Students identified institutional bias that favored clients with privileged identities, benefitting predominantly White, as well as literate populations. For example, Deborah was in a residential facility, and said,
A total of two African Americans that actually participated in a program. And even when they came, we didn’t have the products that they use, and we weren’t able to really provide for them what we do for the other individuals because of their ethnicity, because we weren’t prepared to be able to care for them the same way. And that was so disappointing.
Paris also noted that her training facility was “predominantly White” and recognized that the inability to provide adequate treatment for racially marginalized clients meant that some clients may have a better chance at recovery than others.
Literacy inequity was also present, as facilities struggled to attend to varying literacy levels of clients. Fallon said, “We get quite a number of clients who read at an elementary level, if that, so the accessibility of the resources in group, for instance, if you give them a worksheet, they are not able to read it.” Fallon suggested that although many clients may be illiterate, organizations can adjust their resources and interventions to accommodate diverse reading abilities.
In addition to the lessons learned related to institutional impacts in SUD treatment facilities, students also shared recommendations for potential enhancement of services. Additionally, trainees indicated that outdated or limited policies serve as barriers to provision of quality services to their clients. They were required to navigate the policies and practices, which was challenging. Mark shared,
You get bogged down in administrative dilemmas and policy issues, because basically, I mean what we do and don’t is dictated by our clinical director, and we’re not really free to practice the way we feel might be best. I think it causes a lot of conflict in the work environment. I see how we can improve, but getting the people who can make change to actually listen to how to improve it has been a struggle.
As trainees, students have not been providers in the organizations long enough to have power to change systems, so navigating those dynamics was challenging. Current policy may be problematic, but lack of policy was as well, as Deborah identified:
There’s not really a [supervisory] board set up or policies to protect the individuals that are participating in these programs. There are very shady, sober living homes, and there are programs that are being run in ways that are very unprofessional and not serving their clients the best that they possibly could. But they get away with it because there’s a lack of policy.
This absence of policy, and lack of accountability around policy, resulted in poorer services for clients recovering from SUD. In sum, students learned about navigating macro barriers and how those barriers create obstacles to providing the best quality services, leading to potentially poorer outcomes for the clients they served.
Client Lessons Learned
Client lessons learned included trainee realizations about clients’ lived experiences and how they impact treatment. Two subthemes, Surviving in Stigma and Recognizing Client Resilience, emerged.
Surviving in Stigma
Although participants had been aware of stigma related to substance misuse, students experienced how mental health and substance use stigma compound for many clients. When the stigma of substance use disorder is internalized or imposed by support systems, clients experience guilt or shame, seeing themselves as failures and leaving little optimism for change. Verbalizing how essential hope was to the therapy process, Olivia said, “I’ve really learned how impactful that stigma is and how it could just defeat someone’s hope in a matter of minutes.” Nora added, “In rural Appalachia, it’s still considered a moral issue, rather than a disease model,” as she indicated that clients feel “useless” when they internalize the stigma imposed by their communities. For some, the burden of stigma on clients was surprising, serving as a key lesson learned in their practicum. Deborah said, “I think mine is realizing just how incorrect the stigma is of addiction. Because the more that I work in this field, the more I realize that any person is one or two decisions away from sitting in that exact same seat.” Acknowledging the negative effect of stigma suggests that the imposition of stigma was a significant barrier to treatment.
Recognizing Client Resilience
Another significant lesson was that resilience is an asset to the treatment process, highlighting the importance of seeing client strengths, harnessing the internal resources clients have, and observing what clients must overcome to reach recovery. This lesson was an important counternarrative to the stereotypes and stigmas clients face. Lena said, “They do recover and…their strength is amazing.” Lena’s observations helped her realize that the stigmas imposed upon and occurring within clients were inaccurate representations of their lived experiences and true goals.
Mark noted that even when clients may not present as ostensibly resilient, “as long as there’s breath in someone’s body, there is hope that they can recover.” Complementing this assertion, Olivia indicated that despite the organizational, policy, community, and personal barriers clients face, many continue to use their strengths to stay in recovery. “Listening to them and emphasizing their strengths…as a tool in their recovery in whatever way we can.” The utilization of client resilience and strengths in treatment aligned well with the final theme of Personal Lessons Learned.
Personal Lessons Learned
Personal lessons learned included Respecting Client Self-Determination, Addressing Personal Biases, and Setting Work Boundaries. Within these lessons, trainees acknowledged their role and responsibilities in facilitating the treatment process with clients.
Respecting Client Self-Determination
This subtheme included giving clients tools and allowing them autonomy to use them, including navigating client choices that may be harmful to their treatment and recovery. Lena noted, “Sometimes…it’s so clear to you what they need to do, the path that they need to take, but you got to let them do it on their own. They have to make their decision. You can’t do it for them. So that’s kind of the hardest part for me.” Being able to balance the client’s right to agency and self-determination with the student’s sense of what was needed for treatment efficacy is an important lesson for the transition of learner to practitioner.
Trainees reported they realized that despite having training on how to reduce or abstain from substance use, clients have to make decisions for themselves. Mark noted, “At the end of the day…it’s their life, and they’re able to make whatever choice they see fit.” This lesson served as a protective posture to prevent trainees from adopting an overdeveloped sense of responsibility for clients while acknowledging the stigma and difficulties many clients face.
Allowing clients to provide feedback on the treatment process also reflects self-determination. Evelyn stated, “I think that’s a big part of giving the clients that power to say, ‘Hey, this is not the fit for me.’” The willingness to accept when clients do not want a specific treatment, without attributing it solely to treatment resistance, was an important lesson learned. Building on this point, Kenneth articulated that individualizing treatment was another way to respect self-determination: “I think my biggest takeaway was that treatment…[has] got to be adaptive, it’s got to be tailored to the individual. And it’s got to work with that individual.” Trainees believe the ability to tailor treatment based on client preference and needs facilitates better outcomes, as a function of respecting self-determination.
Addressing Personal Biases
Trainees also identified areas of personal bias that needed to be addressed in order to provide the best treatment for clients with SUD. Their biases often aligned with stigmas about people experiencing SUD, or were based in their lived experiences of people they knew with SUD. To address them, trainees learned to identify and challenge their previous assumptions, understand client contexts better, and value personal experiences without relying on them.
Mark noted that he continues to work on learning not to impose “my own opinion and bias in the treatment setting,” because he realized that although he has personal experience in recovery, it differs from his clients’ experiences. Additionally, Evelyn noted her previously held biases, based on stereotypes about people experiencing SUD, were prevalent in her community: “A lot of the messages I received growing up were really negative about the substance use community. And so, I had really challenged myself to tackle some of those biases I’ve had while I’ve been in my master’s program.” Her continued work on this represented a common acknowledgement by the trainees that identifying and addressing personal biases is an ongoing endeavor.
Setting Work Boundaries
Finally, the trainees learned lessons about the importance of setting work boundaries to prevent burnout and enhance their capacity to provide quality treatment. They also set emotional and practical work boundaries to reduce the impact of countertransference and dual relationships, as many of them returned to their home communities to provide treatment as trainees. Olivia shared, “I’m a really empathetic person, and sometimes I fear…letting my emotions get the best of me. Then especially in situations where like the emotions are high, and you can’t fix their problems.” Her perspective on holding empathy, while avoiding being overwhelmed emotionally, was a common context in which trainees learned to set necessary boundaries.
Although setting boundaries is essential to providing clients with optimal treatment, it is not an easy process, given numerous organizational and personal demands. Supervision was identified as key in providing an avenue for seeking help. Nora acknowledged, “I learned…that sometimes it can be hard, like you can try to set those boundaries all you want, but there are instances where you may struggle with that and need to ask for help.”
As it relates to dual relationships, Lena stated that setting boundaries is necessary:
I have a client in drug court right now who…I went to high school with. I’ve known her for 25 years. It’s really hard to separate myself from the relationship that we had before, because we were really close once upon a time. Then, like, just to see where she is now, it’s heartbreaking. That’s something I struggled with a lot of clients, because it’s like, I relate somehow.
Returning to work in her home community, Lena experienced a number of dual relationships common to treatment providers in rural areas. The “heartbreak” of seeing former friends suffer with substance misuse presented an emotional toll that required intentional boundary setting. Similar to Lena, Nora shared that working with people from her hometown presented a challenge in establishing work boundaries to navigate dual relationships, “So many people from high school were clients within my agency…It made it hard because, you want to remain professional, but this is home.”
Overall, the personal lessons trainees learned were informed by the unique contexts observed and confronted in SUD facilities, as well as the varied contexts and hardships their clients faced. Further, with many of them working in rural or hometown communities, they realized the ethical requirements of addressing biases and maintaining boundaries to provide optimal treatment.
Discussion
Trainees articulated gains in knowledge, attitudes, and skills from their practicum experiences in SUD settings, all factors influencing client outcomes, especially for stigmatized groups such as those with a diagnosed opioid or substance use disorder (Avery et al., 2017; Green et al., 2020). The lessons learned by the participants add to a body of knowledge in facilitating actionable steps for training programs and treatment agencies to better support trainees and new practitioners.
Trainees reported gaining knowledge in navigating institutional barriers related to policy and staffing concerns, such as employees having multiple roles and large caseloads. Trainees believed that quality supervision, opportunities for consultation, and organizational support for self-care could mitigate the burnout associated with these barriers. Reactions and responses from trainees demonstrate the power of socialization into the professional setting, as they may feel able to question organizational policies and procedures in a way that employees (who are dependent on a paycheck from the agency) may not. As Nora articulates in advocating for manageable caseloads and balanced responsibilities, trainees are uniquely poised to bring fresh perspectives in challenging current practitioners and administrators to critically engage with current policies and procedures within their organization. These possible changes at the organizational level hold potential to improve conditions not only for staff, but also for clients. By experiencing less burnout and higher job satisfaction, staff are better able to provide quality services (Dattilio, 2015; Luther et al., 2017; Pakenham & Stafford-Brown, 2012; Steel et al., 2015).
Trainees identified shifts in attitude as they confronted personal biases about those living with substance use disorders. Each of the trainees had identified practice interest with this population, yet the clinical experiences still exposed deep-seated biases. Witnessing the impact of stigma on individuals trying to recover despite internalized societal messages was powerful for trainees. Further, witnessing clients’ resilience and hope for recovery helped challenge biases about SUD, bringing awareness of the role of hope in treatment and recognition of how bias and stigma diminish that hope. In challenging stigma, trainees were able to see clients as humans who shared similar goals as themselves, rather than the reductionist societal messages about moral failings. The pervasive impact of stigma helped students realize those stigmas experienced and internalized by clients inaccurately portrayed abilities, desires, and outcomes.
Improvement in clinical skill was another benefit. Through engaging with clients, trainees gained skill in setting emotional boundaries and navigating dilemmas, such as respecting self-determination—skills that are challenging even for experienced practitioners. The unique challenges associated with a rural setting were highlighted; emotional boundaries become more critical as dual relationships experienced in smaller, more rural areas represent additional stressors. From their practicum experiences, trainees realized their role and responsibility in providing optimal services in a SUD setting and are better prepared to enter these settings as practitioners.
The lessons learned from these experiences underscore the need for current providers to reflect on their own biases and boundaries. Personal attitudes and interpersonal skills affect clients even when a strong didactic foundation is present. Implementing experiential learning provides opportunities to develop the knowledge, skills, and attitudes essential for efficacious practice in substance misuse.
Limitations
These participants were located in rural and underserved communities, and so their experiences may not be representative of practice in more urban settings. The number of participants was limited, as was the diversity of the sample. Additionally, all participants were students in the process of transitioning to practice, so may not reflect the experiences of current practitioners. Finally, some of the participants were in recovery themselves, which may have impacted their perceptions and experiences. These limitations present opportunities for future research in understanding how practicum experiences can help prepare students for practice as SUD care providers.
Conclusion
Substance use disorders, along with the high mortality associated with overdose, are a public health crisis. Developing practitioners to meet the needs of those experiencing SUD is challenging due to lack of practice experience with the identified populations and practitioner biases related to substance misuse (Avery et al., 2017). However, student clinical experiences have the ability to address many of these concerns (Avery et al., 2017; Crowe et al., 2013; Gooding et al., 2021; Nash et al., 2017) and can better prepare practitioners for client care, particularly because provider attitudes affect client outcomes (Avery et al., 2017; Green et al., 2020). Practicum experiences offer a method of mitigating provider attitudes and stigmas prior to entering professional practice.
Immersion in SUD treatment settings helped students learn to navigate numerous challenges associated with organizations and the clients they serve, as well as to examine personal responses to client situations. Experiential learning in these settings gave trainees valuable insights that would have been difficult to convey meaningfully in a classroom. Trainees can have a much-needed role in public health literature and research, as their didactic learning, coupled with their practical experience and training status, provide a unique perspective. Lessons learned from these experiences can be translated into actionable steps for SUD treatment facilities and training programs. The trainees’ reflections on the development of their knowledge, skills, and attitudes within treatment settings highlight the critical role of the practicum experience in preparing SUD practitioners.
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