Human services professionals (HSPs) serve an almost indescribably broad range of clients needing assistance to function “in all major domains of living” (National Organization for Human Services, 2022), including mental health and addiction-related disorders, including both substance use disorders (SUDs) and process addictions (PAs). Thus, human services education programs must prepare students for a wide range of settings, problems, and populations. The inclusion of addiction education (about SUDs and PAs) in human services curricula is supported by the likelihood an HSP will encounter, not just people with mental health disorders, but also people with SUDs and PAs (NOHS, 2022). Statistics from the National Institute on Drug Abuse (2023) reported that 46.3 million people identified with a SUD in 2022 in the United States. In addition, unintentional overdose fatalities climbed from 92,000 in 2020 to over 100,000 in 2021 (Lombardi et al., 2023). A report from The National Alliance on Mental Illness (NAMI, 2023) indicated that 17 million people had a mental health diagnosis co-occurring with a SUD in 2020. HSPs can be on the front lines of the addiction field, addressing the multitude of people with both addictions and co-occurring disorders (CODs), filling the alarming gap which exists in effective treatment. In fact, there will be 75,000 new jobs for addiction professionals, a 23% increase within the next ten years (Bureau of Labor Statistics, 2020). Therefore, it is worthwhile to analyze human services addiction education and develop best practices to guide educators who teach those serving the growing population of people with SUDs and PAs.
This article outlines historical changes in theoretical treatment approaches and curriculum innovation using current research along with Transformative Learning Theory (TLT), which changes preconceived knowledge using critical reflection, experiential learning, and open dialogue to develop new reference points (Mezirow, 1991). Authors discuss curriculum related to learners’ attitudes and beliefs towards addiction and evidence-based treatment; exploring traditional, evidence-based, and holistic treatment practices; and experiential learning and reflection. We present didactic activities and recommendations to implement in a course/curriculum that uses TLT to teach about integrated care. The innovative goal, thus, of this article is to advocate for addictions education that expands learners’ belief systems so that they are more open to integrated care options that cater to each individual they treat.
Foundational Models in Addiction Education
It is important to acknowledge that the addiction treatment field has evolved over the past several decades, making many changes in how we perceive and treat individuals with SUD’s, PA’s, and COD’s. This article uses the terminology “addiction” to include both clients presenting with substance use disorders (SUDs) and process addictions (PAs) as this model is geared to all addiction-related disorders and is considered appropriate and accurate terminology that has moved away from terms like “substance abuse” (Saitz et al., 2021). We have also transitioned from the disease model to the biopsychosocial model (BPS) to assess and treat SUD’s, PA’s, and COD’s. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) suggests the use of the recovery model of care when defining recovery for the individual.
The biopsychosocial model has long been regarded as the gold standard for treating those with SUD’s, PA’s, and COD’s (Wiss, 2019). Introduced by Dr. George Engel, the core constructs based in systems theory support a multicausal view of addiction. Multicausal components of addiction include biological factors including physical health; genetic factors and medication effects; psychological factors such as mental health, personalities, and traumas; and social factors including cultural influences with family and social and environmental relationships (Wiss, 2019). The BPS model therefore supports integrated care as it views, assesses, and treats the individual from whole person or holistic lens and is highly compatible with the recovery model of care as will be defined based on the constructs of systemic thinking.
The recovery model of care (RMC) is based on the constructs that recovery is possible and must be patient driven (Cruwys et al., 2020; SAMHSA, 2019). The RMC takes a solution-focused approach by centering recovery on personal goals and strong interpersonal relationships. These goals are driven from SAMHSA’s definition of recovery suggesting it is a unique process of change of the individual to improve their overall functioning through personalized goal identification and achievement (Cruwys et al., 2020; SAMHSA, 2019). The RMC is a holistic, client-driven, and strength-based approach to recovery, yet has limitations. Primarily, it is not a consistent program, hindering the ability for the RMC to be effectively used without supporting approaches such as the BSM as a basis of addiction evaluation (Cruwys et al., 2020; Wiss, 2019). Although the BSM of treatment and the RMC may seem to support different ideologies, researchers support that the two can be used in tandem, as the former for assessment and treatment, and the latter to enhance the assessment model and to support client-focused care and personalized recovery (Burgess & Fonseca, 2019).
Evolution of Treatment
Likewise, treatment of addictions has evolved, and evidence-based treatments including cognitive behavior therapy (David et al., 2018), motivational interviewing (Doumas et al., 2019), medication-assisted therapies (Andrilla et al., 2018; Matteo, 2019), and other harm reduction approaches are used in addition to the traditional approaches, namely abstinence-based models socially known as 12-step, on which there is much less research (Hefner et al., 2022). Further, holistic approaches have come to the forefront of addiction treatment for those who have responded to homeopathic practices (Oliveira et al., 2022), acupuncture and Eastern-based practices, (Churtch et al., 2022), animal assisted therapies (Trujillo et al., 2019), and technology-based services provided through online applications (Schaub et al., 2018) in conglomeration with evidence-based and traditional interventions. Addiction education has, thus, continually evolved to provide up-to-date training to clinicians in all the above practices. As we continue to refine addiction education in the human services field, we must mobilize to update addiction education and send competent HSPs out into the field.
Integrated Care in Addictions
Integrated care is at the forefront of research in the helping and medical professions and is associated with improved client outcomes (Savic et al., 2017). It refers to the coordination of treatment modalities as well as treatment of, not just the addictive disorder, but the whole person, who has individualized needs for medical, mental health, and social support (Savic et al., 2017). Researchers investigating addiction treatment options have consistently found that integrated care leads to the most favorable outcomes for clients (Breuninger et al., 2020; Nikmanesh et al., 2016; Oliveira et al., 2022; Rasmus et al., 2019; Savic et al., 2017). Savic et al. (2017) state that integrated care is the preferred treatment modality in general for people with alcohol and other drug disorders. Further, Nikmanesh and colleagues (2016) concluded that adding treatment that includes the enhancement of self-efficacy, inclusion of cultural needs, and development of multi-dimensional social support to traditional and evidence-based interventions can be predictive of less relapse. This ideology encompasses both the BSP and RMC models of addiction treatment (Cruwys et al., 2020; Wiss, 2019). Breuninger and colleagues (2020) claim that capitalizing on the natural overlap of Alcoholics Anonymous and evidence-based Cognitive Behavioral Therapy produces integration of care that can support better outcomes for alcohol use disorder treatment. Further, the integration of CBT and homeopathic treatment has shown success for smoking cessation in clinical trials (Oliveira et al., 2022). Finally, Rasmus et al. (2019) found that evidence-based interventions used alongside holistic Indigenous peoples’ practices had optimal outcomes for Indigenous populations.
Most of these researchers call for addictions education that emphasizes the integration of treatment approaches. Educating HSPs about integrating treatment beyond just evidence-based interventions takes openness to various philosophies, perspectives, and theories about addictions. This openness to integrating evidence-based, traditional, and holistic interventions is founded on self-awareness and confrontation of biases, which Transformative Learning Theory (TLT) espouses.
Transformative Learning Theory
Transformative learning theory (TLT), created by Jack Mezirow (1991), postulates that adult learning occurs through the process of changing preconceived notions to develop new reference points using critical reflection, experiential learning, and open dialogue. TLT, as an adult pedagogical approach, supports the educator as a facilitator of learning and not simply the authority of knowledge (Mezirow, 1991, 1996, 2018; Nogueiras et al., 2019). This pedagogy promotes autonomous learning that allows free engagement in both dialectical discourse and experiences. The primary goal of TLT-based education is to promote learners’ abilities to either validate their points of view or transform them based on social experience (Mezirow, 1991, 1996, 2018; Nogueiras et al., 2019), and this research has been prolific. Although more limited inquiry, researchers have found that utilizing TLT as a theoretical orientation in studies on addiction can be successful. TLT can be used as an educational competency model in higher education and addictions education in human services (Barna, 2020; Fazio-Griffith & Ballard, 2016).
Transformative Learning Theory and Addiction Education
In addiction education, TLT can be used to address learners’ beliefs, their attitudes toward treatment options, and their biases about the populations they are serving. While strong, belief systems are not stagnant; rather, learners’ beliefs are transformed by their experiences. Through experiential learning (Mezirow, 2018), students have opportunities to engage with many addiction-related treatment practices, and through discourse (Barna, 2020; Fazio-Griffith & Ballard, 2016), they can evaluate their evolving beliefs about such practices. This framework can provide learners with a full array of addiction treatment practices, explore their attitudes towards addiction and treatment, and create an environment that fosters open discourse and self-reflection (Fazio-Griffith & Ballard, 2016). Addictions curricula containing emphasis on learners’ beliefs systems is an imperative starting point for their learning about and being open to any treatment option from which an individual might benefit.
Learners’ Belief Systems
The debate about the efficiency of treatment from practitioners in recovery and those not in recovery is ongoing (Stokes, 2018; Williams & Mee-Lee, 2019). However, researchers have found that practitioners hold different beliefs about which addictions treatments to use based on their personal recovery status (Edmond et al., 2015; Smith & Liu, 2014). The authors of this paper do not propose specific beliefs students and practitioners should have; rather, we propose a process of growth and transformation in the belief systems of students that makes room for an integrated approach instead of one (e.g., traditional 12-step) or the other (e.g., evidence-based).
Evidence-based treatments are a crux in addictions pedagogy (Amodeo et al., 2013) However, addictions practitioners may be hesitant to use them because of their beliefs that 12-step treatment is most effective (Edmond et al., 2015). Smith and Liu (2014) found that practitioners in recovery hold strong beliefs favoring traditional 12-step treatment approaches, and they are likely to use them hand in hand with evidence-based treatment. Those without recovery status did not demonstrate strong beliefs about traditional treatment like 12-step meetings, and use them less frequently, instead favoring evidence-based models (Stokes, 2018; Williams & Mee-Lee, 2019). Fundamentally, positive treatment outcomes and increased quality of life are reported when practices integrate evidence-based, traditional, and holistic treatments and emphasize client autonomy (Breuninger et al., 2020; Nikmanesh et al., 2016; Oliveira et al., 2022; Rasmus et al., 2019; Savic et al., 2017). Thus, addictions curricula should address the learners’ beliefs and the sources of those beliefs before any formal pedagogy about treatment and integration of evidence-based, traditional, and holistic, is introduced. All didactic recommendations in this article are based on the cited literature and are the original ideas of the authors except where noted or obvious to be common practice and often/traditionally used.
Didactic Recommendation. Introductory addictions coursework traditionally asks students to examine themselves and increase their self-awareness, e.g., through an abstinence exercise and various reflection papers. However, to examine their core beliefs and potentially engage in a transformative process, educators can provide activities and assignments that go into deeper reflection and use the dialogue and discourse of TLT. The following series of an in-class activity is an example of TLT-infused didactic practice that prepares students to examine their own beliefs and open them to more possibilities through critical reflection, experiential learning, and open dialogue.
In-Class Activity. Stage 1. The educator asks students to reflect on their core beliefs about addictions treatment. They provide them with the materials to create a poster with visual and verbal components to represent their reflections. Students draw and write what they fundamentally believe about a) addictions in general, b) people with addictions, and c) addictions treatment, to include stereotypes, personal experiences, personal biases, media representation, and systems that influence the addictions epidemic, e.g., legislation, penal systems, race and socioeconomic status, poverty, pharmaceutical industries, medical professionals, etc. The educator can post the posters around the room and allow students to peruse. As part of critical reflection, students should a) compare and contrast their core belief systems, b) identify new beliefs they find intriguing, and c) identify an area of growth.
The next step in this TLT process involves discourse (discussion) and Socratic questioning (thoughtful, curious questioning used to examine complex and challenging topics). Following the stage 1 exercise, educators should engage students in a group discussion about the commonly held beliefs amongst students in the class about addictions, people with addictions, and addictions treatment. The educator can visually present the common beliefs on a whiteboard or smart board. As exhaustively as possible, the educator should provide the students with a list of treatment interventions with brief descriptions. Through Socratic questioning, the educator and class should identify which treatments align with each core belief shared and discuss why. The discourse should examine what philosophies, perspectives, and theories support certain treatment options.
Next, the educator presents students with a case scenario of an addiction client. They ask them to apply their core belief system to the treatment of the client (written), i.e., which treatments align with their core beliefs. In small groups, students share their core belief systems with each other. The ultimate goal of the group activity is to create a treatment scenario that integrates all the group members’ beliefs. The educator can use Socratic questioning to help students examine the process that occurred in their group to create the integrated treatment. This series of activities can help educators transition into the importance of integrated treatment as they present the treatment modalities used in the field in depth.
These TLT activities support learners’ free engagement in dialectical discourse to explore their beliefs, validate their points of view, or transform them based on the social experience of the activities. Specifically, they scaffold the student toward a case scenario that requires integrating approaches and caters to the individual in the case.
Evidence-Based, Traditional, and Holistic Treatment
Once learners have the opportunity to explore their beliefs and are allowed room for transformed beliefs to be adopted, educators can expose them to the myriad of evidence-based, traditional, and holistic treatments available and the research behind them, thus educating practitioners to provide integrated addiction care. Researchers including Golubovic et al. (2021) identified increased exposure to integrated addiction treatment practices through didactic and constructivist pedagogical approaches, increased practitioners’ application of multiple approaches in all areas of mental health treatment. Researchers support that multiple approaches improve outcomes with client with addictions (Breuninger et al., 2020; Nikmanesh et al., 2016; Oliveira et al., 2022; Savic et al., 2017; Wright et al., 2011).
Addictions care that integrates treatments requires high level critical thinking, since evidence-based, traditional, and holistic treatments can be viewed as conflicting when the addictions practitioner is not familiar with all (Breuninger et al., 2020). For example, fundamentally evidence-based practices emphasize client empowerment while traditional approaches start with surrender to a higher power. When viewed alone, students may believe the surrender in traditional 12-step treatment disempowers the client because it admits powerlessness over a substance or behavior. By delving into both forms of treatments and learning them side by side, it is enlightening to show students that, in surrendering to the substance or behavior in step three, the client is empowering themself to take action in all other aspects of their lives, including self-awareness, interpersonal relationships, and service through completion of the next nine steps.
With effective TLT instruction, students can examine and reflect upon these apparent conflicts and expand their beliefs about how the treatments can also complement one another, opening them to using integrated treatment instead of one or the other (Barna, 2020). TLT instruction also allows for the strengthening of viewpoints through discourse. In fact, the 12-steps mirror CBT philosophy in their fundamental goal to address cognitive processes and maladaptive thinking (Breuninger et al., 2020). Step four is an in-depth process of identifying maladaptive thinking and behavior, and step ten is a reminder to regularly check the way one is thinking or behaving so as not to return to the previously maladaptive and destructive way. Similarly, mindfulness-based holistic approaches complement both the coping skill development in CBT and the 11th step emphasis on meditation (Alcoholics Anonymous, 2002; Temme et al., 2012). Further, the concepts of acceptance, serenity, and service are core to both mindfulness and traditional 12-step programs (Alcoholics Anonymous, 2002). Addiction education that allows students to explore such conflict and alignment and have the openness to transform their thinking about it sets them up to consider integrated care options.
Didactic Recommendation. Many addiction education programs ask students to produce a treatment plan with a case scenario as part of their course requirements. Students are often required to explain their evidence-based theoretical approach in the assignment for a client presenting with a particular problem, with certain risk and protective factors, and with a history of success and failure in addictions treatment.
Assignment Alternative. The alternative task of this assignment would ask students to use integrated treatment interventions centered on the individual’s needs, not just evidence-based, in their treatment plans. Students would provide rationale for using traditional and holistic methods, while still presenting research on evidence-based practice. The assignment should ask students to explain how different treatment interventions would support each other and potentially conflict. They should explain why the integrated treatment they suggest is the best individualized treatment for the case scenario client by considering their medical, psychological, and social needs, as well as their backgrounds, cultures, and life experiences.
Researchers have confirmed that integrated individualized treatment has increased positive outcomes for clients with addictions (Breuninger et al., 2020; Nikmanesh et al., 2016; Oliveira et al., 2022; Savic et al., 2017: Wright et al., 2011). The alternative to this assignment builds upon the foundation of that research and on the reflection students have already done on their belief systems about addictions treatment options.
Whether online or face-to-face, providing learners with experiential opportunities to be exposed to many addiction-related treatment practices creates space to engage in discourse to evaluate their beliefs on traditional, holistic, and integrated treatment practices (Winfield & Rehfuss, 2020). When possible, learners should visit different types of addiction treatment facilities, attend social support groups including 12-step or other abstinence-based meetings, and reflect on how these experiences impact their belief systems about different strategies to implement in providing integrated care.
Didactic Recommendation. This curriculum alternative suggests adding a course into the curriculum: Addiction Field Observation. The sole focus on the course would be, appropriate to its name, observing and reflecting on the experience working in an addiction treatment setting. Assignments could focus on practical skills such as basic counseling, writing documentation, and, of course, their reflections on the observation experience.
Curriculum Alternative. Programs could consider adding a Field Observation course entailing a 50-hour shadowing experience at an addiction treatment facility. The observation would include observing groups, intakes, phone calls, discharge planning, and meetings. Through course assignments, students would reflect on their beliefs before entering the experience. During the observation, they would reflect on their beliefs and assumptions, attitudes toward clinicians, reactions to clients, thoughts on treatments provided, and multicultural considerations. Their reflection would culminate by explaining how they reacted internally and externally and how their beliefs changed during the course. They would deeply reflect on what changes they notice in themselves regarding biases about clients, their belief systems, and their points of reference.
Experiential learning and reflection to solidify meaning in the learning process is a pillar of modern education, and we already engage in these evidence-based educational practices in human services education. Through these didactic recommendations, we are suggesting taking the concept of experiential learning further by combining it with the TLT process of evaluating students’ beliefs about addictions, people with addictions, and the many options in addiction treatment so that they may be more dynamic practitioners of integrated and individualized care.
Beyond the possibility for improved treatment outcomes, engaging in a TLT educational experience and learning about the effective integration of evidence-based, traditional, and holistic approaches also opens spaces for multiculturally-relevant treatment options. Competent human services practitioners in the field can implement treatment options tailored not just to the individual with an addictive disorder, but to the individual as a cultural being. For example, Rasmus et al. (2019) asserted that the backbone of substance use disorder treatment with Canada’s Indigenous populations was integrating culture and cultural methods (e.g., ceremonial healing, talking circles, and storytelling) alongside evidence-based and traditional practices (e.g., individual and group counseling, motivational interviewing). Called Holistic System of Care, it integrates evidence-based science with Indigenous Peoples’ ceremonial healing by focusing on the similar core values of using strengths-based interventions to heal historical trauma and to build solidarity through community. This kind of cultural congruence in addiction treatment is not common practice. Transformation and, thus TLT in education and practice, would be a central part of developing openness to providing this kind of integrated care centered around the individual with medical, mental health, social, and cultural areas of need.
The didactic recommendations in this paper are suggestions to enrich addiction education curricula by offering specific ways to address and transform students’ beliefs in the classroom, to practice integrated care in the commonly used treatment plan assignment, and to expand experiential learning. These recommendations are also presented in a way to scaffold the TLT process of discourse (Barna, 2020; Fazio-Griffith & Ballard, 2016) educators can use to fully engage with each step TLT recommends for transforming and expanding beliefs (Mezirow, 1991, 1996, 2018; Nogueiras et al., 2019). The series of activities in the first recommendation set the stage for a growth mindset and openness to integrated approaches; the second recommendation engages them in practicing integrated care in a specific case; and the third recommendation proposes an overarching curriculum addition that would hone in on the field experience students need for learning about addiction prevention and treatment.
The curriculum innovations we suggest use current research along with TLT. We propose recommendations that use critical reflection (Mezirow, 1991, 1996, 2018; Nogueiras et al., 2019), experiential learning (Mezirow, 2018), and open dialogue (Mezirow, 1991, 1996, 2018) to develop new reference points, change preconceived notions or validate and strengthen already held beliefs. Fundamentally, we suggest addictions education that expands learners’ attitudes and beliefs towards addiction and traditional, evidence-based, and holistic treatment to open them to learning about integrated care, which is associated with improved client outcomes (Breuninger et al., 2020; Nikmanesh et al., 2016; Oliveira et al., 2022; Rasmus et al., 2019; Savic et al., 2017).
As educators, we hear many of our colleagues remarking on how much they learned by teaching their students. While the students are engaging in TLT didactics offered by their instructors and examining their belief systems, the educator has the opportunity to reflect as well, with potentially exponential possibilities for growth and transformation. We cannot help but notice the parallel process: The human services practitioners who are transformed by their educational experiences in their addictions programs are serving clients with addictions in recovery who may have also just experienced one of the most profound transformations of their lives. Whether in recovery or not, students have the opportunity to validate, examine, and transform their beliefs, perspectives, and worldviews. Excellent addictions education in human services can be enhanced by tapping into the TLT learning process, as well as this natural process of transformation through the phenomenon of recovery. Emphasizing these areas in addiction curricula in human services programs can positively affect how students learn to provide comprehensive, integrated, and individualized care for improved client outcomes.