Exploring Burnout Among Behavioral Health Providers of Opioid Use Treatment in Rural Appalachia A dissertation presented to the faculty of The Patton College of Education of Ohio University In partial fulfillment of the requirements for the degree Doctor of Philosophy Gerard M. Grigsby May 2019 © 2019 Gerard M. Grigsby. All Rights Reserved. 2 This dissertation titled Exploring Burnout Among Behavioral Health Providers of Opioid Use Treatment in Rural Appalachia by GERARD M. GRIGSBY has been approved for the Department of Counseling and Higher Education and The Patton College of Education by Christine Suniti Bhat Professor of Counseling and Higher Education Renée A. Middleton Dean, The Patton College of Education 3 Abstract GRIGSBY, GERARD M., Ph.D., May 2019, Counselor Education Exploring Burnout Among Behavioral Health Providers of Opioid Use Treatment in Rural Appalachia Director of Dissertation: Christine Suniti Bhat I conducted a qualitative study of burnout among behavioral health providers who are treating opioid use disorders in rural Appalachia. The purpose of this study was to examine the factors contributing to burnout among behavioral health providers of opioid use treatment in rural Appalachia, as well as strategies used by these providers to manage burnout. I used interpretive description, a generic qualitative research approach, to explore burnout among behavioral health providers of opioid use treatment in rural Appalachia. I recruited 11 participants using convenience sampling, purposeful sampling, and snowball sampling strategies. I used semi-structured individual interviews as the primary method of data collection in my study. Guided by my conceptual framework, the multidimensional model of burnout, I used the constant comparative method to analyze my data. Data analysis yielded nine primary categories of factors that contribute to burnout, as well as 16 strategies (both helpful and unhelpful) used to manage burnout, among behavioral health providers of opioid use treatment in rural Appalachia. I discuss the implications of these findings for education and training, clinical practice, clinical supervision, leadership and advocacy, and future research within the behavioral health field. 4 Dedication I would like to dedicate this project to all the fighters… Fighters in recovery and fighters in the field I also want to dedicate this project to the greatest fighter I know, my beloved brother, Jamere 5 Acknowledgments I first want to acknowledge my chair, Dr. Christine Bhat, and the rest of my committee members, Drs. Yegan Pillay, Tamarine Foreman, and Dwan Robinson. Thank you for your guidance throughout this process. I also want to acknowledge all four of my parents, Anthony Grigsby, Brenda Johnson, Candace Grigsby, and Kevin Johnson. Thank you, Candace, for declaring in 2007 that I would “go all the way.” You saw the vision before I did and spoke this moment into existence when you and Dad dropped me off at Morehouse. To my mother, Brenda, thank you for your prayers and encouragement. Thank you for reminding me to stay on this path and challenging me to make the sacrifices that were necessary for me to get here. Thank you, Kevin, for your loyalty and unwavering support. You have been rooting for me since I went off to college, and you and mom have visited me in Athens more than anyone else. Thank you for reminding me of the importance of family, especially during some of the most trying times in my program. To my father, Anthony, thank you for being my greatest fan. Thank you for passing down your wisdom and teaching me the value of navigating this life with integrity. Thank you for instilling in me all that was needed for me to achieve what I once thought was unachievable. Thank you all. You have been my foundation. Without you, I would not be here. To my six older siblings, Kishauna H obby, Sharon Bocus, Tamieka Chavis, Eddie Lowe, Jarron Johnson, and Jamere Johnson, thank you for being examples to me. Thank you for uplifting me and calling, texting, or instant messaging me just to check on your baby brother. 6 To my best friend, Samantha Brooks, who is the best listener I know, thank you for being there when I needed you most. You always say that I inspire you, but you have been an inspiration to me as well. You have overcome so much, and you are doing things your mother could never have imagined for you. Keep your eyes on the prize, Samantha. Lori would be so proud! To the members of my chosen family, Trevor Burton, Shawn Crosby, Bruce Purvis, Lambert Rahming, Elijah Bell-Clarke, Danny Shelton, and Wsir Amen, thank you for your unwavering support. Thank you for encouraging me to apply to graduate school and believing in me when I sometimes did not believe in myself. Also, thank you for all the fun we have had that has allowed me to laugh and smile through the hard times. To my dear friend, Crystal Trout, thank you for being my rock throughout this process. We both know how arduous this journey has been. Soon and very soon, this will be over. To my former supervisor and mentor, Sheila Williams, thank you for taking me under your wing and giving me the opportunity to learn from one of the wisest and most skilled therapists I know. Who could have imagined that the frightened, doubtful trainee who showed up in your office five years ago would go on to complete a Ph.D. in Counselor Education and Supervision? I can never repay you for making room for me at my internship site and inviting me to show up authentically in all that I do as a professional counselor. Finally, to Mother Morehouse, thank you for challenging me to grow tall enough to wear the crown of excellence you placed over my head all those years ago. 7 Table of Contents Page Abstract ...........................................................................................................................3 Dedication .......................................................................................................................4 Acknowledgments ...........................................................................................................5 Chapter 1: Introduction ....................................................................................................9 Burnout in Appalachia ............................................................................................. 11 Burnout Management............................................................................................... 13 Context of the Study ................................................................................................ 15 The Problem ............................................................................................................ 22 Purpose .................................................................................................................... 26 Research Questions .................................................................................................. 27 Significance ............................................................................................................. 27 Conceptual Framework ............................................................................................ 28 Delimitations ........................................................................................................... 29 Definitions of Terms ................................................................................................ 30 Overview ................................................................................................................. 34 Chapter 2: Literature Review ......................................................................................... 35 Appalachia’s Opioid Problem .................................................................................. 35 Living with an Opioid Use Disorder......................................................................... 40 Changing Trends in AOD Treatment........................................................................ 50 Impact of Medicaid Expansion ................................................................................. 58 State of the Substance Use Treatment Workforce ..................................................... 61 Burnout.................................................................................................................... 63 Summary ............................................................................................................... 104 Chapter 3: Methodology .............................................................................................. 105 Disciplinary Positioning ......................................................................................... 105 Qualitative Methodology ....................................................................................... 107 Role of the Researcher ........................................................................................... 116 Research Design .................................................................................................... 118 Summary of Methodology ..................................................................................... 139 Chapter 4: Interview Summaries .................................................................................. 141 Suzie ...................................................................................................................... 141 8 Rachel ..................................................................................................................