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fense (DOD) and the U.S. Department of Veterans Affairs (VA) share characteristics of both the private- and public-sector systems of care but represent separate and distinct service systems. Finally, service systems for distinct populations are examined: children, the elderly, Native Americans, and consumers in rural areas.

PRACTITIONER ISSUES

In the field of mental health, training tends to follow a professional, medical model, and state licensing, formal advanced education, and other credentials are typically required for reimbursement. The field consists of several types of professionals, including psychiatrists, psychiatric nurses, psychologists, clinical social workers, and marriage and family counselors. Many mental health treatments (e.g., marital and family counseling, treatment of eating disorders or depression, and group therapy) are offered by more than one type of professional. Medication can only be prescribed by psychiatrists and other physicians, so they sometimes provide medication management while other practitioners provide therapy and counseling. Relatively few health professionals are cross-trained as substance abuse treatment professionals, although this is beginning to change (Josiah Macy Jr. Foundation, 1995).

Substance abuse practitioners include individuals in all of the mental health practitioner categories, as well as substance abuse counselors. Originally, most substance abuse counselors were former substance abusers, because counseling others was seen as an integral part of the recovery model and process. Over the years, many people who are not in recovery have also entered the field. Currently, there is a growing emphasis on credentialing for all substance abuse counselors, and the number of hospital-based treatment units has increased substantially (SAMHSA, 1993). In general, the counseling approach relies on a recovery model and community-based self-help. Counselors are discussed further in a later section of this chapter, Drug Treatment.

Table 4.1 provides an overview of the credentialing involved for all practitioners involved with mental health and substance abuse problems. In managed care networks, an estimated 20 percent of practitioners are psychiatrists, 40 percent are psychologists, and 40 percent are social workers (Iglehart, 1996). The committee is aware of competition and tension among these types of practitioners for philosophical reasons that are largely beyond the scope of this report. However, the committee is not aware of any evidence from outcomes research that any one category of behavioral health practitioner is more or less effective than any other type of practitioner. Moreover, treatment philosophies and strategies vary substantially within professions, as well as across practitioner types, so research would need to take these differences into account.



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