Elements
The certification process involves assessing and determining clinical expertise within the established domains. Much of this determination is based on a review of experiential learning and information derived from portfolios. Applicants must demonstrate a predetermined amount of healthcare experience, provide superior clinical supervisor ratings and recommendations, have achieved established education levels, meet the clinical training requirements and pass a written examination. Additional factors taken into consideration are the credentials of clinical supervisors to determine whether they are qualified to make recommendations.

Licensure
The current debate surrounding the difference between certification and licensure is an arena that deserves attention. There is a trend toward licensing of healthcare professionals who treat alcohol and drug addiction. Unlike certification, licensure confers a legal status to those receiving it. Such a process implies that the treatment of substance abuse is a profession in its own right, not an expertise within another discipline. It also disregards the fact that substance abuse difficulties often involve other mental health problems and often co-exist with other addictive behaviors such as eating disorders, compulsive gambling and sexual addiction. Many of the associations involved in the debate declare that such a license is too narrow and would unnecessarily restrict or bar other qualified professionals who may have a background in mental health, marriage and family counseling, social work or psychology, for example, from practicing addiction counseling. Individuals from any of these disciplines may possess expertise in the treatment of addictive disorders and may, therefore, wish to acquire a specialty certification in recognition of excellence and proficiency. I believe that addiction treatment does not constitute a discipline in and of itself but is rather a specialty area within existing healthcare professions. A license to practice implies an established discipline or profession, one in which a uniform curriculum exists. State legislators should not be asked to develop a license for every possible disorder but should examine whether licensure reflects a recognized profession. A more reasonable and responsible solution would be to mandate certification at the regulatory level.

State Regulations and Managed Care
State licensed facilities and contracted programs must comply with established guidelines and staffing requirements that apply to directors, clinical supervisors, counselors, and assistant counselors. The guidelines outline the qualifications for each position and stipulate the necessary experience, education, certification and/or licensure as well as approved training hours in the appropriate areas or topics. In addition, managed care organizations have developed their own privilege criteria for reimbursement purposes — often requiring that providers be master's level and licensed. This has created a barrier since the majority of substance abuse counselors in this country have not attained certification.

To rectify the inconsistency, a national certification standard and a core curriculum would have to be adopted by academic institutions, state authorities governing practice as well as insurance companies. State certification boards should not be allowed to influence curriculum development due to the fact that they are limited to only one area of the field, oftentimes exhibiting bias and a narrow scope or definition of "addiction" and dictating who should be allowed to treat the disorder. Basic education for an addiction counselor should focus on clinical skills specific to counseling, but the curriculum would also have to include courses pertaining to other disciplines.

National Contributions
Academy Vice-President, Janice F. Kauffman, RN, MPH, CAS, served on a national panel organized by the Center for Substance Abuse Treatment, involving government and other experts in the substance-abuse-treatment field. They explored the current state of knowledge, resources, needs, services and capacity to recommend action priorities. Their plan to improve treatment is titled "Changing the Conversation" and focuses on the goals of the National Drug Abuse Strategy. They identified professional associations that foster training and appropriate credentialing in treatment settings. The Academy supports treatment organizations as they develop appropriate policies for clinical training and certification.

Upon the request of the Committee on the Social and Economic Impact of Pathological Gambling, National Research Council of the National Academy of Sciences, the Academy contributed to the topic of provider certification in pathological gambling treatment. The publication titled Pathological Gambling: A Critical Review is available through the National Academy Press at www.nap.edu.

Examinations
Based on a "training needs assessment" research project conducted by the ATTC/NE, Brown University and Harvard Medical School in 1995, the American Academy developed a comprehensive examination designed to test applicants' knowledge in the essential areas of addiction treatment. With the assistance of advisory board members, the examination items were composed according to 20 practice domains:

• Administrative, interpersonal and intervention skills;
• Assessment and diagnostic skills;
• Substance abuse concepts;
• Training activities that lead to credentials;
• Detoxification and dual diagnosis:;
• Ethical issues;
• Developing diagnostic and treatment formulations;
• Marriage and family therapy;
• Theoretical models of substance abuse;
• Therapy organization and movement skills;
• Referral and treatment process skills;
• Relationship between substance abuse and other problems (e.g., suicide, AIDS);
• Screening instruments and techniques;
• Treating special populations;
• Treatment techniques;
• Signs and symptoms of substance abuse and withdrawal.

Shaffer, Hall and Vander Bilt (1995) computed Cronbach alpha reliability coefficients for each of the subscales, and all but two of these indices were above 0.90. The two lower alphas also yielded satisfactory reliability estimates: 0.83 and 0.87. These reliability coefficients indicate that the subscales demonstrate high internal consistency. In addition, a factor analysis by Shaffer et al. revealed that these 20 areas loaded into three distinct factors: Clinical Practice Skills, Treatment Guides and Procedures and Specialized Training. Factor loadings for each of the areas were 0.50 or greater, and the Eigenvalues of the three factors were all 0.92 or greater. This strategy accounted for 66 percent of the total variance among the 20 areas, which indicates that an effective factor analysis had been accomplished. Finally, Shaffer et al. performed a separate factor analysis on each factor. None of the factors subdivided in these analyes, suggesting that each of the three factors is stable.

Expanding on the core exam, the Academy developed a specialty exam for Certified Addictions Specialists who specialize in the treatment of compulsive gambling. The content of the exam is based on contemporary knowledge as evidenced by the extant scientific and clinical literature (e.g., professional journal articles, scholarly reports and clinical research in the field of pathological gambling). The following domains have been established to measure one's clinical knowledge, skill and competency in the treatment of problem or pathological gambling:

• Screening and referral;
• Assessment and diagnosis;
• Formulation of a treatment plan;
• Theoretical models of treatment;
• Ethical issues;
• Interpersonal, intervention and administrative skills;
• Co-occurring disorders.

In addition to the performance domains, items on the examination also focus on the etiology of pathological gambling, requiring understanding of reasons for the onset and addiction cycles. Candidates should also be familiar with current research indicating the prevalence rate for specific groups and populations.

A specialty certification exam for the treatment of sexual addiction/compulsivity is under development in conjunction with the National Council on Sexual Addiction and Compulsivity. All examinations are administered electronically via the Academy's website at www.americanacademy.org.

Janet Mann is the Associate Director of the American Academy of Health Care Providers in the Addictive Disorders. She has many years of experience working with certification, credentialing and educational issues pertaining to the addictions field. Ms. Mann is a member of the American Society of Association Executives, the New England Society of Association Executives and the Massachusetts Organization of Addiction Recovery. She has also served on the National Steering Committee on Addiction Counseling Standards and the Editorial Advisory Board of the 2000 Behavioral Healthcare Sourcebook. For more information call 617/661-6248 or visit their website at www.americanacademy.org.

Reference Shaffer, H.J., Hall, M.N. and Vander Bilt, J. Training Needs Among New England Substance Abuse Treatment Providers (Technical Report #040395-NA100). Providence, RI; Addiction Technology Transfer Center of New England, Brown University, (1995).