How can the mental health workforce be sustainably and successfully trained in an evidenced-based brief treatment approach all while meeting their own needs and the mental health needs of a client? How can this be accomplished? This article attempts to provide a framework for answering this very challenging question. Training clinicians within the mental health workforce is a critical component that impacts the quality, access, and cost of mental health care. Behavioral health workforce shortages and increased demand for services have required mental health professionals and organizations to devise innovative service delivery and training strategies.
Solution-focused brief therapy (SFBT) is an evidence-based practice (EBP) that can assist clinicians, and behavioral health organizations manage long waitlists and increase access to treatment for more clients. Solution-Focused Brief Therapy has been applied successfully across a wide range of professions and fields, in a transdisciplinary manner, for a broad range of mental health conditions (Beyebech, M. et al., 2021).
Solution-focused brief therapy can provide a solution to open up enrollments assisting clients in “graduating” from discrete treatment episodes. SFBT can help clinicians and mental health organizations manage surging caseloads, staff retention and burnout, and increasingly complex client needs that have only worsened with the mental health COVID pandemic.
One component of caring for the mental health workforce is providing high-quality training programs. Effective training includes equipping medical and mental health professionals with brief, practical tools that clinicians can apply right away. Despite the acute need for evidence-based brief and practical therapeutic approaches, often these are not extensively taught in training programs. Solution-focused brief therapy is an evidenced-based, hopeful, pragmatic approach that quickly engages with clients and assists them in developing a plan of action, harnessing a client’s often unrecognized resources both individually and within their social context. SFBT empowers clinicians and clients to navigate purposeful conversations to assist clients in reaching their targeted goals.
The Need for Mental Health Workforce Development
Workforce development and training must advance as an integral centerpiece of behavioral health policy and funding priorities for all policymakers to address the critical mental health needs of our nation. The COVID-19 pandemic has only worsened what were already significant challenges facing the mental health workforce. The Centers for Disease Control and Prevention (CDC) reported that the percentage of U.S. adults with recent symptoms of anxiety or a depressive disorder increased from 36.4% to 41.5% and the percentage reporting unmet mental health needs to be increased from 9.2% to 11.7%, with the largest increase seen among young adults (18-29) during August 2020 to February 2021 (Vahratian A. et al, 2021). In the early months of the pandemic, the nation saw an 18% increase in overdoses compared with the same months in 2019. The trend only continued throughout the rest of 2020. The American Medical Association recently reported that every state had seen increases in opioid-related mortality (Petterson, S. et al 2020). The United States Surgeon General Vivek H. Murthy came out with a 53-page advisory panel on December 7th, 2021, regarding the mental health challenges in children and stated the situation is dire (Protecting Youth Mental Health: The US Surgeon General’s Advisory, 2021). A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that need immediate awareness and action.
“Mental health challenges in children, adolescents, and young adults are real and widespread. Most importantly, they are treatable and often preventable. Combined with an uptick in gun violence, a reckoning on racial justice, a climate emergency, and a divisive political landscape, the coronavirus-related hardships have taken a toll on young Americans’ mental health at a time when it was already in decline. More people seeking help have strained the ability of practitioners to provide treatment, underscoring, experts say, the need to radically change how mental health is addressed in the United States. ” (Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory). Doctor Vivek Murphy further writes:
“Our obligation to act is not just medical—it’s moral. I believe that coming out of the COVID-19 pandemic, we have an unprecedented opportunity as a country to rebuild in a way that refocuses our identity and common values, puts people first, and strengthens our connections to each other. If we seize this moment, step up for our children and their families in their moment of need, and lead with inclusion, kindness, and respect, we can lay the foundation for a healthier, more resilient, and more fulfilled nation.”
The reality is that individuals with mental health and substance use needs are facing challenges accessing adequate, timely, and affordable care in every state in the country. Often this leads to dire consequences such as the need for acute care services, engagement in the criminal justice system and in some cases, suicide or overdose. Furthermore, the current crisis is contributing to long documented health disparities, including significant (and avoidable) early mortality for those with behavioral health conditions (de Mooij et al, 2019). Prior to COVID -19, the addiction treatment workforce was experiencing annual turnover rates ranging from 13-52% with nearly half of all organizations operating with significant staff shortages, low recruitment, and retention success. Many workers are continuing to leave the field for higher-paying and less demanding work with young professionals often filling jobs until they are eligible for higher-paying private practice (National Council, HMA prepare recommendations for workforce crisis. Annapolis Coalition. (2022, March 30)
Access to behavioral health services is complex and impacted by systemic factors such as federal and state policy, payment, provider capacity, social determinants of health, historical disparities, and an individual’s capacity to engage in services. Limited funding streams for behavioral health contribute to non-competitive salaries for the nation’s behavioral health workforce. This forms the foundation of the workforce shortages that have developed over time and are now at a crisis point. (Behavioral Health Workforce is a National Crisis: Immediate Policy Actions for States, retrieved 2022). In addition, the economic, political, and social context in which an organization resides as well as the structure, leadership, and culture of an organization impacts the delivery of quality healthcare. The need for evidence-based training and treatment interventions that can be implemented effectively in a sustainable way within organizations is more critical than ever.
What are the Challenges Associated with Training the Mental Health Workforce in Evidence-Based Practices?
Strategies specifically designed to facilitate the training of mental health practitioners in evidence-based practices (EBPs) have lagged behind the development of the interventions themselves. A report by the United States Surgeon General (1999) suggests that the majority of clients with mental illness do not receive EBP. There are obstacles to the dissemination and implementation of EBP being translated into clinical practice (e.g., criticism of treatment manuals, inadequate training, and unsupportive organizational climates). Understanding how to best disseminate EBP is paramount to reducing the gap between research and practice (Beidas and Kendall 2010). This gap in training mental health practitioners has resulted in a shortage of treatment providers who are adequately trained and supported to provide EBPs and is a major contributor to the “research-to-practice gap”. (Kazdin, A. E. 2008).
General themes and definitions have emerged from the theoretical and empirical literature on training. In the adult education literature, teaching and initial education have been distinguished from training or “retraining” and “mastery of action”. (Thompson 1976). Two complementary processes have been identified as essential for effective implementation of training: the methods through which professionals learn new skills and techniques and systems of ongoing feedback and support to continue to develop the newly acquired skills (Welch et al., 2006).
It has been shown consistently that a “one and done”, or single-exposure training model is limited. “One and done” trainings are inadequate in their ability to produce sustainable results. In order to provide practice related behavioral change and have it be effective, previous training on the EBP seems to be required (Fixsen et al., 2005; Beidas & Kendall 2010).
What is known regarding the implementation and sustainability of training programs?
The ability to engage and train a large, multidisciplinary workforce in the use of EBPs is a necessary but not sufficient condition to demonstrate training effectiveness. It is also necessary for the workforce, once trained, to sustain the use of the EBP (Shapiro et al., 2012). When considering the efficacy and sustainability of effective training programs, it is essential to consider the organization, system, and unique context in which training occurs. Prior research has identified a diversity of elements that affect training implementation. These include the training program, provider characteristics, and the unique social context of organizations implementing training programs (Beidas and Kendall, 2010). Program factors include the quality of an evidence-based practice, training content, and methods of training. Active learning which includes interactive processes that focus on action and reflection within a clinical context is most helpful. Active learning includes modeling, practice opportunities, building self-efficacy, interaction among learners, and role-plays. In addition, ongoing supervision and feedback that builds confidence have been shown to improve therapist adherence and competence (Henggeler et al., 2002). A practitioner’s belief that a particular treatment is useful for their client population improves successful training outcomes. This includes having success with the treatment approach in a range of settings with “challenging cases”.
The following factors have been shown to promote sustainable transdisciplinary mental health workforce training programs (Lyon et al., 2011).
- Provider motivation
- Congruence with existing experience
- Trained personnel who meet with clinicians in their work settings to discuss the use of specific practices and techniques
- Encouraging learner participation through active, open-ended questioning
- Delivering a small number of key empirically-derived messages
- Distributing concise graphic reference materials
- Repeat key messages
- Developing specific plans for individual or group organizational behavioral change
- Ongoing case-based consultations
- Interprofessional learning (members of two or more professions learn together)
- Learning by bringing together multiple disciplines for multiple contacts and exercise
- A combination of didactics, role plays, case-based learning
- Small group discussion
- Web-based resources and facilitator support
- Formation of peer-to-peer group networks
- Coaching through direct feedback following observation
- Reminders to engage in clinical practice behaviors such as being displayed on the screen, stickers or printouts in clinical charts, and clinical checklists
- Self-regulated learning to help practitioners guide their own goal-setting Self-monitoring for skill acquisition
How does the Institute for Solution-Focused Therapy Develop and Provide Customized Training to Organizations and Their Staff?
The Institute for Solution-Focused Therapy provides diverse and flexible online training choices, including customized hybrid program options that combine live-interactive synchronous experiences with self-paced remote learning components maximizing training effectiveness. We offer a broad range of courses, from introductory to advanced in the practice of SFBT. We also provide ongoing enhancement programs which include solution-focused supervision. Most of our courses are eligible for continuing education credit. Our transdisciplinary approach engages with many professional disciplines, including physicians, mental health practitioners, educators, para-professionals, nurses, child protection services, EAP organizations, military, chaplains, probation officers, crisis clinicians, and in-home therapy teams, and others. We provide an initial one-hour free zoom consultation to learn about each unique organization and develop a customized program that meets their needs. Our customized live courses are also available as self-paced versions so staff who are new or unable to attend can be trained while also receiving continuing education credits. Our customized courses include recordings of all the training if desired, copies of slides, materials, and any customized materials that were utilized throughout the course. These customized courses can be purchased at a later date as a self-paced version for new staff or for staff who are unable to attend the entire training. The self-paced customized courses are available for continuing education and include an exam. We hope this will facilitate a sustainable training solution to workforce challenges given the high turnover of staff within many organizations.
During the past 18 months, we have had the privilege of training over 35 organizations. The following are a few training case examples to showcase how organizations have customized their training needs.
Training Case Examples
Integrative Health Care Organizations: CrescentCare
New Orleans, Louisiana
CrescentCare’s mission is to bring caregivers and the community together as partners in health and wellness for all. Their experience builds on more than 30 years of impact through their founding organization, NO/AIDS Task Force. Now, as a Federally Qualified Health Center, they are taking that expertise and expanding it! Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet stringent requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. CrescentCare offers a broad range of health and wellness services for anyone and everyone who is seeking healthcare services in Greater New Orleans and Southeastern Louisiana. https://www.crescentcare.org/
Mainstreaming of mental health services has led to an increase in the presentation and care of mental health patients in generalist health settings. There is a well-documented lack of adequate mental health educational preparation within healthcare. Many groups, including primary care physicians, nurse practitioners, and specialty health practitioners, have been identified as ill-equipped to meet the mental and physical health needs of clients.
There are broadly two groups of patients who require mental health services within medical settings: (i) clients with an existing diagnosis of mental illness who have physical conditions requiring ongoing care and (ii) clients who have physical health conditions who develop mental health conditions ( Brunero et al., 2012).
General and specialty practitioners have tremendously demanding workloads, leading to a lack of time, interest, and motivation to attend training. In addition, there is often a lack of organizational support that creates a barrier to the effective implementation of evidence-based practices. Cost and time constraints are also common barriers. To address these issues, CrescentCare reached out to train their Integrative Behavioral Health Team. After an initial Zoom consultation, the following customized training program was developed.
The entire primary care provider team: CrescentCare began by offering their entire primary care team the 2-hour live training “A Taste of Solution-Focused Skills and Practice”. All providers were invited to a 2-hour live interactive training program. The TASTE has unlimited participants, so the entire provider team could be introduced to the approach and learn how SFBT could help them in their practice across disciplines. This interactive introduction included an overview of the SFBT approach, video demonstrations, and interactive chat discussions with opportunities for questions. It can be used across an organization where executives, administrators, clinicians, case-workers, supervisors, and any staff interested can attend. This provided all staff with 2 hours of continuing education credits. This course can also be recorded as a customized version for new staff or staff unable to attend as a self-paced course that includes a short exam.
For supervisors and “champions” of this approach: A small group of 6 supervisors and integrative behavioral health clinicians choose a combination of more intense self-paced and synchronous training sessions to build their confidence and fluency in order to provide support for other clinicians in their organization. This group took the Foundations of Solution-Focused Online Intensive combined with a small-group BASIC Solution-Focused Skills and Practice interactive training. This small group received more intensive individualized training to support and sustain their staff and serve as “peer champions” of the SFBT approach within the organization. This hybrid intensive training approach provided clinicians with 19.5-course hours plus 12 hours of training for a total of 31.5 continuing education credits.
For the behavioral health clinical staff: A transdisciplinary group of behavioral health clinicians, nurse practitioners, and psychiatrists took the self-paced Solution-Focused Brief Therapy: An Introduction to Clinical Practice combined with the BASIC Solution-Focused Skills and Practice interactive training. This training helped build their confidence and skills in the SFBT approach.
The combination of the self-paced course with written and video demonstrations and the BASIC Solution-Focused Skills and Practice course provided hybrid training opportunities to solidify the foundations of the SFBT approach. The BASIC live course offers 12 hours of training divided into 2-hour sessions every other week. Offering continuing education training in group cohorts builds relationships. Further, it sustains a workforce while also providing a context for staff to continue practicing the skills they develop with each other. BASIC and ADVANCED small group sessions include some review of the material, an ongoing framework of the approach, role-plays, case discussions, interactive video demonstration discussions, breakout sessions, and recommended practice exercises discussed in the following session called “Success and Challenges” rounds. This hybrid training approach provided clinicians with 17 hours of training for a total of 17 continuing education credits.
A Current New Training cohort: Because of the success of the training, a new cohort of clinicians working with the homeless population is getting trained. This cohort includes a talented transdisciplinary staff of clinicians, case managers, and supervisors. They are also receiving a hybrid training approach, including Solution-Focused Brief Therapy: An Introduction to Clinical Practice combined with BASIC Solution-focused skills and practice for agencies.
Future Training options: In addition, there is the opportunity for further training, including ENHANCEMENT sessions to sustain the approach, ADVANCED Solution-focused skills further and practice online interactive sessions, and Solution-Focused SUPERVISION skills and practice. All of these offer further opportunities to sustain the approach within their organization.
Many organizations also pair the self-paced courses with the live cohort training of BASIC Solution-Focused Skills and Practice for agencies. Because we record these live interactive trainings, we now offer SELF-PACED CUSTOMIZED BASIC SKILLS AND PRACTICE versions for each organization that new staff can take at a later time or for staff who are unavailable for the training, all while obtaining continuing education credits. Providing continual professional development with colleagues and education credits are common reasons for staff satisfaction and can help sustain the workforce and may decrease staff turnover. A combination of Solution-Focused Brief Therapy: An Introduction to Clinical Practice paired with the live or self-paced customized interactive BASIC Skills and skills and practice (that can be offered to staff at later times in a self-paced format) provides 17 continuing education credits!
Click here to see an interview with Lucy Cordts: https://solutionfocused.net/lucy-cordts-crescentcare-health-centers-success-solution-focused-brief-therapy/
Lenape Valley Foundation, Pennsylvania
The mission of Lenape Valley Foundation is to partner with members of their community encountering mental health, substance use, and intellectual or developmental challenges as they pursue their personal aspirations and an enhanced quality of life. For over 60 years, Lenape Valley Foundation has served adults in the community with a variety of behavioral health needs. Their qualified staff work to provide individuals in our mental health programs, services for individuals with intellectual disabilities, and crisis services with the best possible care to meet their unique needs so that each person can work toward achieving their individual treatment goals. Lenape Valley Foundation also offers a full spectrum of services, dependent on the needs of the individual child and family assisting children and their families to reach their full potential by providing individualized, compassionate care. https://www.lenapevf.org/
Lenape Valley Foundation reached out for training during the COVID-19 pandemic hoping a brief evidence based treatment approach could help to manage the increased demand for mental health services and long waitlists. Their best hopes were to provide comprehensive training within their organization for their dedicated support staff, agency leaders, and full-time staff and clinicians serving on the front lines of the mental health pandemic. After an initial Zoom consultation, the following customized training program was developed.
All of the support staff and agency leaders took the self-paced course: Solution-Focused Brief Therapy: An Introduction to Clinical Practice. All of their full-time staff and therapists took the self-paced course: Foundations of Solution-Focused Practice Online Intensive. In addition, all of their full-time staff and therapists took the live synchronous BASIC Solution-focused skills and practice course.
In our final session on graduation day, we scaled how confident they are in their solution-focused skills as well as how confident they are that they will sustain their skills within their organization. All of the staff rated their confidence between 7-9 and all stated that this is “good enough”. I am summarizing a few of the comments from this dedicated and talented group of clinicians regarding what they have found most helpful from the training and what they know will help them sustain their skills.
- Having written reminders of the “four-square” guide to the overall approach available to use as needed
- Maintaining the “yes-set” and incorporating the client’s language within the formulation of questions
- Incorporating scaling questions to develop a plan
- Incorporating VIPs – including spiritual VIPs
- Asking coping questions and “what have you tried?”
- Consciously incorporating solution-focused language and questions in conversations
- Appreciating the solution-focused framework with their other skill sets
- Listening differently while hearing the same things and choosing to ask different questions
- Appreciating the client’s progress seeing more hope and actions
- Having greater skills to manage clients who are “stuck”
- Asking what do you know questions
- Having more skills to help clients focus on their goals
- Starting sessions with “What’s better” or “what’s been happening that you want to continue to happen?
- Appreciating how useful the approach is with families and couples
- Helpful in reducing vicarious trauma and increasing vicarious resilience
- Using “for you” statements paired with coping questions to minimize power struggles and take the pressure off needing to find a solution for clients
- Seeing the effectiveness of the approach inspires them to do more
- Incorporating solution-focused approaches within supervision and monthly group meetings
- Reviewing success and challenges rounds
- Taking small steps to practice each of the skills
- Learning the fundamentals and then taking a “deep dive” into more of the skills
The Alzheimer’s Association leads the way to end Alzheimer’s and all other dementia — by accelerating global research, driving risk reduction and early detection, and maximizing quality care and support. The Alzheimer’s Association 24/7 Helpline (800.272.3900) is available around the clock, 365 days a year. Through this free service, specialists and master’s-level clinicians offer confidential support and information to people living with dementia, caregivers, families, and the public. https://www.alz.org/
The Institute for Solution-Focused Therapy has had the privilege to provide training for the Alzheimer’s Association’s 24/7 crisis call line. Their goal was to provide skills for their staff so that one 30-minute call would make a difference for those living with or caring for someone with Alzheimer’s or other forms of dementia. During the pandemic, they experienced the all too common challenges associated with managing an increase in demand for their crisis call hotline services.
The organization had received prior solution-focused training through the Institute of Solution Focused Therapy and was now interested in providing enhancement training for their staff. New staff were offered the self-paced Solution-Focused Brief Therapy: An Introduction to Clinical Practice. Several different cohorts were put into courses based on their prior training experience. The trainings included a review of cases, role-plays, didactics, video demonstrations, and opportunities for practice and questions. All of the sessions were recorded so the organization could use these sessions for future staff training.
Click here to see an interview with David Parris, Clinical Director of the Alzheimer’s Association 24/7 Helpline: https://solutionfocused.net/solution-focused-brief-therapy-alzheimer/
Seacoast Mental Health Center, New Hampshire
Seacoast Mental Health Center’s mission is to provide a broad, comprehensive array of high-quality, effective and accessible mental health services to residents of the eastern half of Rockingham County in New Hampshire. They are a federally qualified health center (FQHC). Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. Services are available to all individuals in their large service region throughout every stage of life. Services can be accessed in a variety of ways: in their two offices and various community settings, including schools, primary care offices, and telehealth in your own home. https://smhc-nh.org/
Seacoast Mental Health Center reached out for training during the COVID-19 pandemic hoping a brief evidenced treatment approach could help to manage the increased demand for mental health services and long waitlists. Their best hopes were to provide comprehensive training within their organization for their dedicated support staff, agency leaders, and full-time staff and clinicians serving on the front lines of the mental health pandemic. After an initial Zoom consultation, the following customized training program was developed.
Seacoast Mental Health Center invested in training their entire clinical staff of approximately 125 clinicians. Clinicians were provided a hybrid training approach including a combination of the self-paced course Solution-Focused Brief Therapy: An Introduction to Clinical Practice with the live interactive course BASIC Skills and Practice for Agencies. They invested in 5 separate cohorts so clinicians could experience more personalized training including role-plays, breakout sessions, case discussions, opportunities for consultation with challenging cases, video observation discussions, and between-session practice exercises. All the synchronous training sessions were recorded and available for new hires as a self-paced course with options to earn continuing education credits.
Northwest Human Services, Salem Oregon
Northwest Human Services has been providing residents of Marion and Polk counties with comprehensive medical, dental, mental health, and social services for 50 years. They are a federally qualified health center (FQHC). Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. Their programs are integrated and designed to help support those in our community who need it most. They offer medical, dental, and mental health services on a sliding fee scale based on family size and income. No one is turned away due to their inability to pay. Homeless youth and adults at our HOST and HOAP Programs access basic needs services, case management, peer support, and health care at our Community Health Centers. Their Crisis & Information Hotline provides 24-hour crisis support and suicide intervention as well as limited emergency financial assistance for rent, utilities, and prescription medications. As long as there is a need, Northwest Human Services will continue to be a safety net providing health care and social services in our community. http://www.northwesthumanservices.org/
Northwest Human Services reached out for training during the COVID-19 pandemic hoping a brief evidenced treatment approach could help to manage the increased demand for mental health services within their integrated behavioral health organization. In particular, they were interested in learning how solution-focused brief therapy could be applied with clients who have experienced trauma. After an initial Zoom consultation, the following customized training program was developed.
They choose to provide their 16 staff with the self-paced cours:e Solution-focused therapy for the treatment of trauma. They found this helpful and then, a few months later, provided both current and new staff with the self-paced course: Solution-Focused Brief Therapy: An Introduction to Clinical Practice. They also added our self paced introductory course as part of the onboarding process for newly hired staff. Providing faculty with consistent training that can be offered at different times can help to cement an equitable and fluent education to this specific approach of therapy within an organization.
Training with a one-shot method is largely ineffective. The use of traditional workshop models or any single strategy is unlikely to be successful. Instead, a combination of approaches that comprise overlapping techniques and interventions such as interactive didactics, goal identification, small group discussion, critical thinking, self-reflection, peer collaboration, independent access to information, direct feedback, and follow-up have been found to be the most effective. Successful training is complex and involves attention to clinician engagement, active methods of promoting skill acquisition and providing ongoing support to solidify skills and build confidence. Transdisciplinary training emphasizing real-world clinical examples in practice and promoting self-regulated learning is essential. Of course, there is a need for implementation training to be studied including intervention fidelity, client outcomes, provider confidence, and the mechanisms for training effectiveness. Comprehensive training programs are essential to achieve implementation. Providers will need time and resource allocation to solidify their skills and acquisition. We invite all clinicians to complete evaluations and post-training feedback surveys to continue to improve and develop engaging, evidence-based, cost- and time-effective training.
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Click here for the full report: Surgeon General Youth Mental Health Advisory 2021
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