The Uphill Battle
Therapy is difficult on its own. Finding access can be even harder.
A burned-out health care workforce threatens the recovery of many substance users strapped for time and help.
It was right after his mother’s death when Gage Presgraves, still reeling from the loss, injected his first shot of heroin. He was only 13 years old.
Twelve years later, he doesn’t feel comfortable disclosing much about his addiction during the Narcotics Anonymous meetings at the recovery center where he is under probation.
Presgraves said he isn’t comfortable with people knowing his weaknesses. “That’s not how I was raised,” he said. But many recovering patients say going to therapy helped them address personal and social problems that were contributing to their addiction.
The American Society of Addiction Medicine considers counseling as the most important part of treatment, and most treatment facilities require it. But in Appalachian Ohio, finding a counselor can be a challenge.
As a behavioral health care worker shortage grips Ohio, some of those remaining in the workforce are burning out. In the midst of that, harm reduction services may be effective ways to lower overdose rates for people who desperately need help but aren’t ready for or don’t have access to treatment.
Addiction is difficult to talk about
Although therapy is known to be effective, those who misuse drugs often find it difficult to open up or continue with therapy. The involvement of role models – counselors who overcame addiction themselves – is often key.
Allison Hoover, a treatment navigator at Perry County Behavioral Health, said a shared history connects her with the patients. She has been in recovery for four years. Each time a new patient walks through her doors, she remembers the time when she was in their place.
“I know what life is like on the other side,” Hoover said. “It's hard for them to admit that they've messed up. It’s even harder to say, ‘Hey, I need help.’”
For Presgraves, the idea of seeking help felt next to impossible. He left home at 15, soon after his father remarried. Penniless, dreams of cars and girls chased him out of his hometown in Perry County. He moved to Columbus, where he realized selling drugs could earn him money fast.
Presgraves’ arms are covered in tattoos. He says that every time he steps out of the recovery house, he can feel all eyes on him.
“People see these tattoos and usually automatically know they are prison tattoos,” he said. “They look at you differently. They're either scared of you or intrigued by you.”
Those encounters have made him tight-lipped, he said. Yet, he was quick to agree to an interview. After the first interview, he sent the following message: “Your interest in my recovery makes me wanna keep doing good.”
The soft-board in the hallway of John W. Clem recovery house has listings of narcotics and alcoholics anonymous meetings on display for the residents.
Photo by Bharbi Hazarika
Lindsay Hall became a counselor at a methadone clinic in Portsmouth, Ohio, in late 2021. Hall said the difficulty of getting some patients to sit down and talk is often linked to a feeling of helplessness.
“But once you can get them to sit down and actually engage in counseling services, and then make a habit of it, then you start to break through that and get them to realize that there's a reason why we're using,” said Hall, who is in recovery herself. “And if we can figure out why we're using (drugs), we can learn coping skills to kind of build that up to where we don't get the thought of, ‘Hey, I need to use to deal with this.’”
Therapy is only successful when the counselor forms a sincere bond with the patients, allowing them to open up, according to Kim Hardin, a counselor for Integrated Services, a treatment team member affiliated with the Perry County New Direction Drug Court.
“I don't like cutting the apron strings, which means, you got to just let them go. I don't like that,” Hardin said. “Because I know what the end results can be. And that's not what I want for any of my clients. But again, it is also their choice.”
In December 2021, during a status review hearing, defendants updated the court about their remission. One of the participants, who was a few weeks into his recovery then, disclosed that his oldest daughter overdosed a few nights earlier. When Judge Dean Wilson asked if that triggered him to start using again, he promptly refused.
“It actually made me take a really close examination of myself,” the man said to Wilson. “And I've determined that I can't be an effective father if I'm screwed up. And I feel partially responsible for planting some of them seeds.”
The courtroom inside Perry County New Direction Drug Court.
Photo by Bharbi Hazarika
Hardin watched the man confess from her seat in the courtroom. After the hearing, she rushed after him to show her support. She says she is invested in the people who come to her for help, whether they are just a couple weeks into the treatment or long after they complete it.
“I always let them know that they are more than welcome anytime,” Hardin said. “And I think that gives them a little bit of reassurance knowing that if they struggle, they have somewhere to go.”
Finding a therapist is the first hurdle toward recovery
Jamie Carnell, a resident at Summit Recovery center in Logan, Ohio, often found her individual counseling sessions were overbooked at the residential treatment center in Scioto County where she lived earlier. She would show up to find that she had to share her individual counseling slot with another patient. By the end of her stay at the previous facility, the only way she knew how to communicate with her overbooked counselor was with a wordless thumbs up.
“I can think of only two times where I actually sat in there and had a one-on-one session with the mental health counselor,” Carnell said. “There was no time to build that connection or rapport.”
Now, at Summit Recovery, Carnell said she feels comfortable to contact the staff at any time—a luxury she didn’t have at her previous facility. She credits the closeness that she shares with the counselors at Summit to the small group of participants and easy access to behavioral health workers.
“I know I can go up to anyone here and they’ll listen,” Carnell said. “I didn’t have that there.”
Travis Bookwalter picking out therapy workbooks for the residents at Summit Recovery Center.
Photo by Bharbi Hazarika
The demand for behavioral health workers in Ohio is predicted to increase 5.6% annually over the next decade, according to a 2019 report by Ohio Mental Health and Addiction Services. Across southeast Ohio, the demand for social workers and counselors is even higher. Over the next decade, the lagging supply and increasing need will create a growing deficit in those counties, especially in Scioto, Lawrence, and Knox, according to the Ohio Mental Health and Addiction Services report.
Infographic by Bharbi Hazarika
Source: Ohio Department of Mental Health and Addiction Services
Behavioral health worker supply/demand deficit in Ohio over the next eight years
*The forecasting analysis reported above are based on data available at the time of report compilation, April 16, 2021, according to Ohio Department of Mental Health and Addiction Services
Behavioral health care workers help patients in recovery through therapy, counseling and other reformative services. While the supply/demand deficit in 2019 for such workers was at 41%,
it is predicted to decrease to 15% by 2029.
The paucity of behavioral health workers has not just affected patients; those now working in the field are struggling with heavy workloads, increasing numbers of patients, and not enough time to do it all.
Finding enough time to meet with clients is just one struggle. Another is keeping up with paperwork. As the level of care for a patient rises, the health care providers’ responsibility for documentation also increases because insurance companies require more documentation for higher levels of care. For counselors, most of that documentation must be completed during the client’s counseling sessions, which takes time away from treatment.
Brittany Cornell, an addiction counselor in Portsmouth, Ohio, who is studying to become a social worker, said when she was working with her previous employer, she was unable to adequately counsel patients who required a higher level of care.
“A lot of that documentation, I had to do during my individual counseling sessions,” said Cornell, who is a recovering addict herself. “But, if I just worked on the documentation the whole time, then I wasn’t providing my client with the most sufficient care that they could get from me.”
Most days, Cornell arrived at her old workplace before 8 a.m. She spent much of her morning meeting with individuals for one-on-one counseling sessions. From noon till close, she led two group counseling sessions, filling out progress reports during the breaks. On average, she had to spend two to three hours on those reports each day – time she was not paid for.
“I ended up bringing that documentation work home with me,” she added. “It got to the point where it was not only taking time away from my family, but it was also starting to mess with me mentally.”
During treatment, some of those in the highest level of care need multiple one-hour sessions per week, Cornell said. As the intensity of care decreases, the frequency and duration of those scheduled sessions also reduces, but Cornell noted that not all interactions with clients are scheduled in advance.
Cornell has an open-door policy at her office, so patients might drop in to chat with her, even if they had already attended an individual session with her earlier that week. Those drop ins can be helpful to the patients, but can cut into the limited time Cornell has for patients on that day's schedule. She explained that the problem lies in the heavy caseload thrust upon behavioral health professionals.
Many counselors and clinicians are leaving their jobs. Some leave burned out by stress; for others, the on-going COVID-19 pandemic, unconventional work hours, and rigid credentialing requirements are making such employment less attractive, according to a 2021 Ohio Council report on Ohio’s behavioral health workforce crisis. The same report discovered that “clinical staff are proving difficult to find, easy to lose, and costly to replace.”
For some, the healthcare worker-to-patient ratio at treatment facilities is partly to blame. Although there is a government mandated recommendation for clinician to patient ratio (1 to 12) in group therapy settings, the state largely doesn’t have any limitations set on the number of cases for one behavioral health care worker.
“Providers will set caseloads of staff based on worker supply and service needs,” Eric Waldersleben, director of media relations at Ohio Department of Mental Health and Addiction Services, wrote in an email. “The (group therapy ratio) requirement was established during Ohio’s Medicaid redesign process for the purpose of helping to ensure a group size that provides the opportunity for participants/patients/clients to fully participate — so that groups do not get so large that the needs of the participants cannot be met.”
But the number of individual patients that a clinician has varies. While Cornell had 12 patients requiring high intensity care, Hall, who works at an outpatient treatment facility, has almost 50 patients in her caseload. Hall said a majority of the patients that she sees at the methadone clinic require high levels of care.
“Now, if we have patients needing lower level of care that we only have to meet with once a month, that’s manageable,” Hall said. “But it's difficult to get a patient to that place.”
Even with that recommendation, Cornell said, she would sometimes end up with 14 or 15 clients in her groups, piling more work on her shoulders. Still, she feels if the recommended ratio for group therapy is lowered to six or eight patients per counselor, that would compel some treatment centers to hire more employees, improving the quality and availability of care. But the shortage means treatment centers do not have enough people to hire, even if that recommendation were to be lowered.
With a shrinking pool of staff available to treat patients and deadlier drugs on the streets, the symptoms of some patients worsen, escalating what was otherwise a routine appointment into crisis support, Cornell said.
Former patients work to build a community around recovery
Despite the shortage of staff, many counselors and social workers are committed to the work because of their ties with the affected communities and, for many, their own personal struggles with addiction.
Many recovery treatment centers recruit their former patients to become counselors because they are promptly accessible, according to Travis Bookwalter, co-founder of Summit Recovery center in Logan. Bookwalter, who himself has been in recovery for seven years, sees the benefit of recruiting from the patient population, but he thinks the responsibility may be too much to bear for some who are just starting recovery.
“You're getting people who are 90 days clean, and they want to give back," Bookwalter said. "So, they take up a job with the treatment center. But at 90 days, there is no human being that is ready for that kind of responsibility.”
The women at Summit Recovery Home pose for a picture after a group counseling session.
Photo by Bharbi Hazarika
Several of the women at Summit Recovery are studying to be counselors or social workers with the intention to help others. Many of them have been at the center for months. The women say that not rushing the recovery process and uncovering their trauma were the most important steps in their recovery.
“It took a lot of learning to get here, and now, the idea of helping someone just gives me purpose from all the pain I've been through in my life,” Maci Nicole, a resident at Summit who wants to become a peer support specialist, said. “Being able to turn that pain into a purpose is what gives me motivation to get up and go a little harder each day.”
Seeking help in the shadows
Steve Caruthers, a family mentor for Integrated Services in Hocking County, Ohio, decided to move into John W. Clem Recovery House in Athens eight years ago, after being pushed to do so by his family. He didn’t intend on spending more than a couple months there, adding: “I had already decided that I was gonna leave after two months and start using (heroin) again.”
That was before he met Richard Briggs, his house manager then. Briggs died in 2021, and since then Caruthers has been stewarding the residents at Clem Recovery House.
“Richard is probably the reason, I stayed,” Caruthers said. “I stayed because he cared.”
House manager Steve Caruthers leans on a door frame in the dinning hall at Clem house
A framed picture of Richard Briggs hung on a wall at Clem house.
House manager Steve Caruthers leans on a door frame in the dinning hall at Clem house
Photo 1: Steve Caruthers in the dinning hall of John Clems Recovery home.
Photo 2: A picture of Richard Briggs, former house manager, hung on a wall at the recovery home.
Photos by Bharbi Hazarika
People who battle addiction are often viewed as “less than,” Bookwalter said. He also suggested that perception thrusts many into living in the shadows, where they forgo healthy eating, hygiene and taking care of themselves. Poor hygiene especially can lead to even more health problems.
“When they use drugs, they’ll use the same needle and pass it along,” Bookwalter said. “And you’ll find that most of them have hep C or some other contagious diseases or they end up dead. And they don’t think about it because at some point they started believing that they don’t matter.”
Harm reduction facilities like syringe exchange services, fentanyl testing kits, among others, emerge as another reminder that the lives of those with addiction matter, said Shae Dalrymple, communication director and naloxone distribution specialist for Harm Reduction Ohio. Although harm reduction services keep people from overdosing and spreading contagious diseases, it should not be substituted for addiction treatment. Instead, those services bridge the expanding gap to treatment, according to Dalrymple.
“They often provide a trustworthy person who you can talk to about this really shameful – it shouldn't be shameful – but the shameful thing that other people may not know you're struggling with,” said Dalrymple, who has dealt with addiction herself. “They care, like how you're using; they care if you're doing it safely or not; and they try to help you understand how to do that.”
Jamie Decker, a harm reduction coordinator in Hancock County, Ohio, had no such conversation when he was using drugs. He had to teach himself how to clean syringes to avoid contracting diseases. He used to soak the limited needles he had in bleach, he said, and hope that would get rid of any pathogens.
The rejection targeted at people with substance use disorder ends up stonewalling access to services that help to keep them alive, said Decker, who has been in recovery for seven years. He said there are effective harm reduction facilities available, but they are not enough, adding: “We need more. We need better. We need more locations to make it easier for people to access those services,” he said. “That's really where the problem kind of lies.”
In Athens, Ohio, the county health department’s harm reduction clinic offers not only safe needles and syringes, Gaskell said, but other reformative services. Hidden from plain sight, the harm reduction office is located inside the county health department. Drivers, looking for the syringe exchange service, pull into the driveway at the rear of the Athens City-County Health Department. Without a sign in view, visitors must make out which door leads to the clinic – another example of the discreet nature of seeking help as an addict.
However, the opacity outside contrasts the openness to discuss those topics inside. Behind the door of the clinic, the room is lined with tables offering fresh needles, naloxone, information about counselors, treatment navigators, even fresh vegetables for visitors to take home. The staffers banter with some of the recurring faces at the clinic like old friends. Gaskell said the goal is to create a “safe haven, where they're treated with respect and kindness.”
Boxes of Narcan nasal spray set on a table in Athens Harm Reduction Clinic.
Photo by Bharbi Hazarika
When Dalrymple was using substances, she didn’t have access to any harm reduction services. At the time, she was living in South Carolina. She said she would often use the same needle to inject heroin for weeks.
“That's another testament to the fact that you're not going to stop someone from using,” she said. "The best you can do is make it safer.”
After moving to Columbus in 2019, she heard about Safe Point, a syringe exchange service located downtown. Standing at the doors of Safe Point that summer, she felt hesitant. Afterall, Dalrymple knows stigma all too well. But she is glad she walked in. She said, right from her first visit, the workers at the harm reduction facility treated her with care; treated her as a “person.”
“People who are in the throes of addiction, they're fighting isolation. It's dangerous,” Dalrymple said. “The opposite of addiction is connection to other people.”