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Workforce Development and Organization 1
Running head: WORKFORCE DEVELOPMENTAND ORGANIZATION
Workforce Development and the Organization of Work: The Science we Need
Sonja K. Schoenwald
Kimberly E. Hoagwood
Marc S. Atkins
Mary E. Evans
Heather Ringeisen
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Abstract
The industrialization of health care, underway for several decades, offers instructive
guidance and models for speeding access of children and families to clinically and cost effective
preventive, treatment, and palliative interventions. This industrialization -- i.e., the systematized
production of goods or services in large-scale enterprises -- has the potential to create
efficiencies, in part because workforce responsibilities become more functional and
differentiated. To date, however, the models suggested by this industrialization have not been
applied to children’s mental health services. A combination of policy, regulatory, fiscal,
systemic, and organizational changes will be needed to fully penetrate the mental health and
substance abuse service sectors. In addition, problems with the availability, preparation,
functioning, and status of the mental health workforce decried for over a decade will need to be
addressed if consumers and payers are to gain access to effective interventions irrespective of
geographic location, ethnic background, or financial status. This paper suggests that critical
knowledge gaps exist regarding (a) the knowledge, skills, and competencies of a workforce
prepared to deliver effective interventions; (b) the efficient and effective organization of work;
and (c) the development and replication of effective workforce training and support strategies to
sustain effective services. Three sets of questions are identified for which evidence-based
answers are needed. Suggestions are provided to inform the development of a scientific agenda
to answer these questions.
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Workforce Development and the Organization of Work: The Science We Need
Introduction
Within the last decade, several government reports and independent reviews have
concluded that the development of a workforce adequately prepared to implement effective
mental health treatments and services is among key challenges to the larger scale dissemination
and implementation of evidence-based treatments (EBTs) (Hoge and Morris, 2002; Hoge,
Tondora, & Marelli, 2005; Institute of Medicine, 2001; U.S. Public Health Services, 2000).
These reports cite a combination of worker shortages, inadequate workforce training, and limited
post-professional education and quality assurance mechanisms as limiting the reach and benefit
of effective treatments and services to consumers. These reports suggest that to improve the
quality and effectiveness of care, “the burden clearly lies with researchers, educators, and the
administrators of healthcare organizations to identify the competencies required for effective
practice, to effectively teach these competencies, and to support their application in the daily
process of caring for those in need” (Hoge et al., p. 529).
Relatively little is known, however, about the knowledge, skills, competencies, and
attitudes needed to adequately implement one or more evidence-based treatments; and nothing is
known about the extent to which there is commonality or uniqueness among the knowledge,
skills, competencies and attitudes for implementing effective treatments targeted at either a
particular class of problems or across problem areas.
We propose that evidence-based answers to three sets of questions are needed to speed
progress toward the development and continuous renewal of an effective workforce in children’s
mental health. The first set pertains to what is known about individual learning and performance
on the job of effective interventions.
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1. To what extent are the knowledge, skills, competencies, and attitudes needed to
effectively implement one or more treatments for a particular class of problems
similar and distinct?
2. To what extent (and for which treatments of which conditions) does learning to
implement different treatment protocols have synergistic effects on the
implementation and outcomes of each protocol?
3. To what extent (and for which treatments of which conditions) does learning different
protocols interfere with the adequate performance of one or more of them?
That these questions are pertinent now points to the progress that has been made in
children’s mental health treatment and services research over the past three decades. It suggests
that the knowledge base on children’s mental health has reached a point where basic knowledge
about diagnostic accuracy, treatment efficacy, and effectiveness for some disorders exists and
where there is at least some consensus in the field to issue guidelines for practice. The scientific
and practical questions about workforce development that can now be posed are more refined,
nuanced, and precise. These issues are relevant to the delivery and the instantiation of treatments
within the service “system.” such as it is. Thirty years ago these kinds of questions would not
have been asked or, if asked, would have seemed irrelevant or premature.
The answers to these questions have implications for research on the development,
testing, and dissemination of effective and efficient strategies to train and support a workforce
that can deliver effective treatments and services as the evidence base on effectiveness changes
over time. They also have immediate relevance to the organization of the components of the
service system, and vice versa.
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Service System Organization and Structure
The mission, structure, and organization of health care affect the definition, nature, and
organization of children’s mental health care; and, accordingly, the work and workforce
providing that care. We propose that a public health model of mental health and emerging
models of health care reform are particularly important to redefining and reorganizing children’s
mental health care, and accordingly, the development and support of the workforce providing
that care.
A Public Health Model for Children’s Mental Health
A public health model for children's mental health services would expand the mental
health workforce from a limited number of trained professionals to incorporate the range of
persons and settings important to children’s development. Acknowledging the importance of key
ecological settings to children’s development would encourage an alignment of mental health
research, programs, and resources to the key predictors that promote successful adaptation, thus
enhancing the benefits for all children. The functions of settings (e.g., childrearing in families,
learning and social development in schools) and their structure (i.e. family homes, school
classrooms, playgrounds) would guide the target, content, and form of services. Thus, the goals
of mental health care would be to support the adaptive functioning and positive outcomes across
settings in which children and their families live. A second implication of a public health
framework for children's mental health is the identification and support of indigenous resources
within these settings as targets for activating change processes. This follows logically from
prioritizing the goals of the setting (e.g., school, clinic, healthcare center) rather than a
predetermined goal. It is also important to insure the sustainability of program goals and
processes, as well as to reconcile the workforce imbalance relative to regional disparities and the
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high need for services. The identification of indigenous resources involves both the selection of
primary change agents (i.e. who in the natural and service ecology does the work of intervention)
and those factors involved in the successful performance of their roles. Thus, the functions and
roles of the more traditional mental health workforce would be expected to shift (e.g., office-
based individual counseling of a youth might be replaced with consultation with the teacher) and
the diversity of individuals working to support mental health in children and families would be
expected to expand (e.g., a teacher coaching a colleague in use of a classroom based behavior
management strategy; parents coaching one another in academic support strategies to use at
home).
Structural and Financing Changes in Health Care
Structural changes in health care will likely influence the workforce, organization of
work units, and training models needed to deliver effective treatments efficiently. Emerging
models of health care delivery and financing, such as the patient-focused medical home model,
focus on a combination of efficiency, effectiveness, continuity, and accountability. The current
medical home model (in the future, an integrated health – not just medical -- home) may be
particularly instructive for the deployment of effective mental health treatments and services for
children and their families. Chronic illness management in pediatric care has embodied elements
of this model for decades, and its application and adaptation to children’s mental health is
consistent with the public mental health model described above. For example, the course of
chronic illnesses such as cystic fibrosis and Type II diabetes is somewhat predictable, as is the
impact of specific habits, events, and the biological and psychosocial changes that unfold during
particular times in the life of the child (for example, onset of puberty). A primary care physician
aware of the research on the life course of the illness and general health of the child may be well
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equipped to monitor the health and illness, provide medications, while a nurse practitioner or
patient educator provides health behavior instructions to the child and parent. Essentially, a
health care team is accountable for having the information, competencies, and tools needed to
promote an individual’s health and effectively manage illness over time, and consequently
throughout a child’s development. A specialist may be needed when developmental or
unexpected events exacerbate the illness; and, when this is the case, the specialist can and should
(with permission of the youth and caregiver, of course), obtain the information on the life course
of the illness and child’s general health needed to effectively tailor the specialty and/or crisis
care to the patient and family. The primary care provider or group, in turn, obtains information
about the specialty care provided, and implications for managing the illness on a routine basis
following that care. Increasingly, the hope is that electronic health records will aid this
communication process. An advantage of this organizational structure is that both generalist and
specialist care can be coordinated, individualized, and delivered across geographic regions, thus
increasing the potential reach of effective care for larger populations.
Implications for Organization of the Children’s Mental Health Workforce
A parallel scenario for children’s mental health might involve the cultivation of a cadre of
practitioners who are generalists and provide the equivalent of a “mental health home” for a
child and family, able to diagnose, activate preventive strategies in the natural ecology (e.g., at
home, in school, at pediatric care visits), and provide episodes of treatment for a range of
commonly-occurring problems that can be effectively treated using outpatient based (i.e., clinic,
school, home) models of service delivery. Specialists or specialty teams may be needed to
effectively treat particularly chronic or severe conditions. For children with chronic problems,
the specialty team may be the “mental health home,” as happens often in the early years of the
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diagnosis of a chronic pediatric medical condition. Accountability for the child’s well being
throughout childhood and adolescence could reside with the “mental health home” whether that
is a generalist team or a specialist team (depending on the youth’s conditions). In the future, an
integrated health home would house needed medical and mental health expertise.
Consideration of specialist and generalist functions. Of the evidence-based treatments for
youth thus far transported and sustained in a number of communities and states, several were
developed, tested, and delivered in usual care by specialty teams. For example, Multisystemic
Therapy (MST) therapists are organized into teams with a clinical supervisor, work flexible
hours to conduct assessment and intervention activities when and where needed, have caseloads
of 4-6 families, and so forth. Similarly, a team of staff with differentiated roles and functions
implements Multidimensional Treatment Foster Care (MTFC; Chamberlain, 2003). And, both
models were designed, tested, and transported as alternatives not to standard outpatient care, but
to restrictive, out-of-home placements (incarceration, residential treatment, group home) for
adolescents whose serious antisocial behavior was chronic and often violent.
This specialty model stands in contrast to the majority of efficacious treatments for
childhood anxiety, depression, and disruptive behavior disorders increasingly being evaluated in
effectiveness and usual care implementation studies (including state-wide initiatives) in which a
single clinician is expected to learn multiple distinct treatments. Not yet known is how well
therapists are able to implement an evidence-based treatment with some children while
continuing to treat others with the mix of techniques that characterize common practice. Nor is it
clear how well therapists are able to implement more than one evidence-based treatment with
more than one set of problems at a time. Anticipating the problems in clinician learning and
performance of multiple models of this approach to the generalist model nearly a decade ago,
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John Weisz suggested, “One could imagine new strategies for case assignment, with a generalist
model replaced by specialty teams, such that therapists are not required to treat all types of youth
seen in the clinic, and thus not expected to learn all treatments for all child conditions” (Weisz,
2000, p. 4.). Another alternative to this scenario, not yet empirically examined, is that the
deployment of treatment elements common across classes of evidence-based treatments for
classes of conditions and target populations (children, adolescents, adults) is found to be
effective for at least some conditions and target population (see, e.g., Chorpita & Daleiden,
2009). If this were the case, then the generalist clinician could be one trained to effectively
implement the common elements for the pertinent conditions and target populations.
Localized, population-based organization. The decision as to whether the constellation of
individuals serving generalist and specialist functions is formally organized as a team (i.e., a
group of individuals – generalists and specialists - operating as a unit within a single service
organization) or as coalitions (i.e., groups of generalists and specialists, operating either within
or across service organizations or even regions, who access one another and client information as
needed) will most likely be determined on the basis of several factors. These may include the
size and needs of the populations to be served; the contours of the treatments known to be
effective for identified problems; and the costs and effects on clients of organizing and deploying
the services in different ways. For example, a medium sized city that locks up (or sends to
residential treatment) a certain proportion of youth with chronic serious antisocial behavior
would likely need a single specialty team (MTFC, MST), and the organization hosting that team
could well also host (as many do) a variety of outpatient programs for youth, which in the near
future would include evidence-based approaches to the treatment of child and adolescent
depression, anxiety, disruptive behavior disorders, and co-occurrence among these conditions.
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The implications of a regionalized restructuring of healthcare for workforce development
are that greater diversification and coordination of the workforce will be needed. Service
components may be disaggregated into job functions assigned to different providers depending
on the individual needs of the children and their caregivers. For example, a trained
paraprofessional or parent support specialist in a primary care or community health center might
conduct intake screening using standardized measures. The intake may be followed by facilitated
referral to a multi-family group therapy or a specific, 12-16 session treatment with or without
medication management provided by trained clinical staff; with discharge planning and ongoing
monitoring by a parent support specialist, and coordination to a school support specialist at the
child’s local school. This is but one of numerous potential examples. The point is that the
opportunities afforded by the current impetus of healthcare restructuring for mental health
workforce development and for the organization of clinical care suggest strategic expansion
coupled with greater functional specificity and diversification of roles. These roles are likely to
target both trained clinical providers as well as a range of facilitative service support staff, with
job functions dictated by functional competencies centered on the components of effective
clinical treatments. Functional criteria, rather than degree or licensure based criteria (unless they
are functionally driven), would be used to determine who serves in these capacities.
The set of research questions most pertinent to supporting the functional organization
(rather than profession, setting, or service category based organization) of a diversified
workforce to support a public health model of children’s mental health is as follows.
1. Will specialty teams be needed to effectively treat some kinds or classes of problems
because evidence indicates therapists are more effective with those problems when they
are relatively more specialized rather than operating as generalists?
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2. For what types of problems, and functions, could generalists be effective for some
functions (screening, prevention, education, referral, skill training, some types of
evidence-based treatments)?
3. What are the most efficient and effective ways to organize individuals with general and
specialized expertise?
4. To what extent can efficiencies in delivery of effective treatment be achieved through
diversification of the workforce?
In addition, workforce competency models developed in business and government may
be instructive to the functional organization of the mental health workforce. Such models
typically organize the details of required competencies into groups needed for effective
performance of particular jobs that are executed in the context of particular teams or
organizations, and thus take into account the information, tools, organizational support, and
motivational enhancements (recognition, advancement, compensation) in that context (Marelli,
2001). One competency model for the behavioral healthcare workforce (Hoge et al., 2005),
suggests three clusters of competencies: (1) Core competencies are applicable to everyone in the
organization providing service, such as ensuring client rights; (2) job family competencies are
applicable to everyone providing a particular type of service, such as outpatient treatment or case
management; and (3) “level competencies” reflect job levels within a job family (e.g., unlicensed
versus licensed staff providing case management).
Pursuit of the research agenda proposed in this paper could provide some of the evidence
needed to redefine clusters of competencies on functional grounds. “Core” competencies might
be those shown across diverse roles and functions (family advocate, skill builder, therapist,
psychiatrist) to contribute to client attendance and receipt of adequate doses of desired
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interventions, and such competencies might be those facilitating “common factors” explored in
psychotherapy process research (e.g., alliance, expectations, satisfaction). “Job family
competencies” may be the cluster associated with the effective performance of elements of a
particular class of treatments subsumed within in effective treatments for certain conditions (e.g.,
Chorpita & Daleiden, 2009), assuming deployment of these elements is demonstrated
empirically to improve outcomes for the targeted client populations. “Levels” might be reframed
to reflect the combination of competencies needed to execute one or more specific treatment
models for particular conditions, if evidence continues to indicate that such models constitute the
most effective treatment approach for these conditions. The extent to which these clusters of
competencies are demonstrated to be discrete and related would inform the design and testing of
training and support strategies used to develop and sustain them in practice. The National Action
Plan for Workforce Development proposed by the Annapolis Coalition on the Behavioral
Healthcare Workforce, explicitly calls for research and evaluation of the organizational, training,
and workplace based support strategies it proposes to expand the availability, diversity, and
effectiveness of the behavioral healthcare workforce. (www.annapoliscoalition.org).
If we can begin to answer the questions about individual learning and performance in the
workplace context of effective interventions, and functional organization of the workforce, then
we will be better equipped to develop and evaluate efficient and effective training and workplace
based support strategies. Basic research on learning, cognition, and performance; and, research in
other fields and industries on the organizational context of performance (Marelli, 2001) and
innovation implementation (Klein & Sorra, 1996; Real & Poole, 2005) are pertinent to this
effort.
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Feasibility, effects, and efficiency questions. Clearly, research is needed to determine the
feasibility, effects, and efficiency of the kind of organization and flow of mental health care
proposed here, the aim of which is to support continuity of effective care throughout the life
cycle of a particular condition or set of problems, and of the child and family, in the relevant
contexts (e.g., home, school, health care clinic). Among the potential limitations of this proposed
reorganization of work is that it does not represent a “health home” that integrates the prevention
and intervention of all medical, substance abuse, and behavioral and mental health needs under
one umbrella. The implications of such a comprehensive integration for the organization and
financing of the continuum of preventive to palliative services, and for the workforce currently
employed in medical, mental health and substance abuse services, is beyond the scope of the
current discussion. The modest proposal offered here is as follows: To replace the current guild
and cottage industry based approach to children’s mental health services -- which is largely
reactive and discontinuous -- with an approach in which the workforce is (a) organized
functionally and paid to anticipate and respond to both predictable and sentinel events in the life
and natural ecology of the child and family over time with (b) effective screening, assessment,
preventive, treatment, and palliative strategies that (c) take into account the strengths, needs,
and preferences of the child and family and (d) are communicated, along with intervention
outcomes and maintenance activities needed to sustain them, to the family and to those in the
natural and service ecology involved in future episodes of care.
Taking Workforce Development and Renewal to Scale
As evidence accrues regarding the boundary conditions of: (a) treatment effectiveness
(for which problems in which populations are specific treatments needed; for which problems is
deployment of select treatment components effective); (b) individual learning and performance
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in the practice context of the putative interventions; and (c) re-organization of the workforce
along functional lines, then strategies can be developed and tested to facilitate, sustain, and
refresh (as the evidence base is refreshed) the knowledge, skills, and competencies of the
workforce. The extent to which master’s or doctoral level training will contribute to the
effectiveness of a mental health workforce engaged in the deployment of evidence-based
interventions is an open question (Hayes, 1998). And, as noted previously, some aspects of client
care may be effectively deployed by individuals whose pertinent qualifications come in the form
of experience with a particular mental illness, service system, or advocacy effort, rather than in
the form of a particular degree. Post-bachelor’s university training may still turn out to be a
necessary step toward the effective deployment of effective treatments and services – particularly
if training in evidence-based thinking and treatments are part of the curriculum and practicum or
internship experience. This is, however, an empirical question. We propose that somewhere
between two workforce extremes – the combination of “professionalism added to immunity from
market and price effects” that hobbles policy efforts to mandate change in practice (Rossi, 1978,
p. 81), and relegation to technician status of practitioners -- lies a range and combination of
training, support, organizational, and policy (including standard setting, now accomplished via
educational and professional credentials and licensing) strategies that can be shown empirically
to sustain and renew the capacity of the workforce to provide effective care.
Taking workforce development and support strategies to scale suggests another set of
research questions.
1. For which treatments is ongoing support (i.e., regular supervision, peer supervision, work
sample review, implementation and outcomes data review, other mechanisms of support)
necessary to sustain adequate implementation and outcomes?
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2. For which treatments is providing such support feasible in community settings?
3. What kinds of training strategies can be used to help individuals deliver more than one
distinct treatment for more than one condition?
4. What strategies can be used to effectively and efficiently update knowledge, skills, and
competencies as the science on evidence-based treatments change? Do these strategies
have to differ for clinicians implementing multiple evidence-based treatments at a time?
The scant evidence base on training clinicians to implement evidence-based treatments
provides some guidance with respect to the first two questions, and suggests methods used to
train and supervise clinicians in randomized trials can be used effectively in usual care settings,
to the desired effect (i.e., usual care clinicians are able to implement the treatment as specified
and achieve the intended outcomes) (see, e.g., Sholomskas, Syracuse-Siewert, Rounsaville, Ball,
Nuro, & Carroll, 2005). In addition, several studies have manipulated workplace-based support
(inclusion or exclusion of ongoing supervision, or continued coaching following initial training)
in community care settings and found such is likely to be needed to sustain effective
implementation of effective treatments (see, e.g., Bradshaw, Butterworth, & Mairs, 2007). But,
there is much to be learned about which assessment, preventive, and treatment approaches
require what kinds of training and/or workplace support to ensure effective implementation and
desired client outcomes, and how to most efficiently and effectively provide that training and
support.
Conceptual and theoretical development. Guidance regarding the development and
larger-scale deployment of training and support strategies that effectively and efficiently
facilitate workforce implementation of effective treatments (as those treatments and the
workforce change) may require making forays into basic psychological research as well as into
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the training and performance literature from other fields. With respect to more basic research, we
might look to studies applying theory on behavior learning and performance to understand
normative beliefs, expectancies, attitudes and intentions that influence the adoption of
innovation. For example, several hundred studies of health-related behaviors, including
substance use, risk-taking, and sexual behavior, have relied on a small group of theories,
including the Theory of Planned Behavior, other decision-making and cognitive theories, and
basic learning theory (Ajzen & Fishbein, 1981; Jaccard, Litardo, & Wan, 999; Jaccard, Dodge, &
Dittus, 2002) to identify core elements that influence individual behavior and behavior change
(Fishbein, Triandis, Kanfer, Becker, Middlestadt, & Eichler, 2001; NIMH Workshop Report,
1991). A general framework distilling and synthesizing all of these elements, known as the
Unified Theory of Behavior (UTB), has been applied to participation in community partnerships
(McKay, Jensen, CHAMP Board, in press), adolescent-parent communication (Jaccard et al.,
2002) and physician adoption of guidelines (Perkins et al., 2007). The UTB conceptualizes a
person’s behaviors along two dimensions: those pertaining to the immediate determinants of
behavior and those pertaining to the determinants of the willingness to engage in a given
behavior. The UTB suggests that the expected values beliefs and self-efficacy are likely to
influence intention to act.
The UTB framework could be used to identify the determinants at the individual level of
the adoption of effective intervention approaches and extent to which these determinants vary
across the stakeholders in children’s mental health, thereby informing the extent to which the
targets of strategies to promote adoption of new practices, and the strategies themselves, should
vary across these stakeholder groups. For example, research guided by the framework could
identify the expectancies and attitudes (beliefs about the advantages and disadvantages of
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adoption of an innovation by agency directors vs. middle management vs. clinical staff);
normative beliefs (perceived frequency of EBP participation by families vs administrative staff);
subjective norms (perceptions of what important others think about decisions regarding adoption
of innovation); and self-efficacy (degree to which various respondents believe they possess the
skills needed for implementing innovations). These different determinants would point to
different intervention targets to facilitate ease of adoption or implementation of new practices.
Indeed, a number of approaches to the dissemination and implementation of effective medical
and substance abuse treatment practices evaluated over the last decade, such as social marketing,
employ several, but not all, of these elements (Grol & Grimshaw, 1999; Martin, Herie, Turner, &
Cunningham, 1998). This framework, as well as research on adult learning, and on the role of
computer assisted learning and decision support in the acquisition and performance of clinical
skills and competencies may help inform strategies to enhance the uptake and execution of new
strategies among seasoned professionals, as described subsequently.
Infrastructure support for workforce development. The current infrastructure for
workforce development consists largely of colleges and universities that supply educational and
pre-professional training, and guild and licensure-based post-professional education and training
requirements. Most community-based clinics serving children and families facilitate staff
attendance (and, in some cases, financial support for) the required training, and provide training
on a variety of topics themselves (Schoenwald, et al., 2008). Thus, norms supporting some
ongoing professional training and a modicum of institutional support for such training,
characterize mental health practice today. Alignment is needed, however, of norms and
institutional support with the demand characteristics of effective interventions and effective
methods of training individuals at the front line to provide and support these interventions.
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The current process of designing, and deploying and evaluating training and support
strategies in usual care settings is, however, essentially undertaken anew by each group of
treatment model developers and the early adopters of the treatment – the service provider
organizations (and clinicians they employ) and service systems keen to introduce the new
treatment into the mix of services they provide (Becker, Nakamura, Young, & Chorpita, 2009;
Chorpita & Bernstein, & Miranda, in press). Taking any particular training and support process
to scale also requires enabling others to replicate it (that is, others have to be able to provide the
training and support needed for front line staff to achieve adequate implementation and
outcomes). Furthermore, such replication must be sufficiently robust to succeed in communities
and service systems with widely varying levels of individual expertise, training requirements for
practitioners, salary structures, working conditions (hours, unionization, liability issues), and
professional and service system norms for the workforce.
Chorpita and colleagues have suggested that the large-scale replication and installation of
training and on-the-job support to develop and sustain workforce capacity for implementing
effective interventions may require the development of additional infrastructure, if not an
entirely new industry. They note such an industry could be analogous to the Information
Technology (IT) enterprise now commonly found in most government and privately held
organizations with more than a few employees. Although the developers and manufacturers of
software programs provide the instructions for installation and problem-solving directly to
consumers (organizations and individuals purchasing the products), individuals in local IT
departments provide the installation and trouble shooting services to their colleagues. The
Network Partner model developed to cultivate and sustain local expertise in MST training and
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quality assurance could be construed as an iteration of this concept. Details of this model are
presented elsewhere (Schoenwald, 2008).
Technological support of the workforce. Examples of the effective use of technology in
the training and supervision of individuals providing evidence-based interventions can be found
in strategies used by colleges and universities to facilitate distance learning. Online synchronous
systems enable learners and teachers to engage in online discussion, and are supported by several
commercially available software systems, including, for example, those developed by
Elluminate, Inc. Web cams are used to enable participants to see who is talking, and instructors
can present all types of media in such forums, including streaming video and Power Point Voice
Over (ProVoice USA.com). In instructional settings, some of the content is typically presented
by instructors asynchronously via a website or learning management system using commercially
available systems such as BlackBoard (Blackboard, Inc. 1997), with online meetings occurring
after students or trainees have reviewed and interacted with the content. Content can also be
delivered over time, such as two hours per day, until all material is covered. With software such
as BlackBoard, trainees can upload examples of their interactions with clients, engage in chat
rooms and submit assignments. Trainees can use headsets with microphones or use computers
with built in microphones. Learners can be separated into groups, take exams, be polled for their
opinions and many other activities. With this kind of technology, learners can be in their offices
or at their home computer and interact individually, in contrast with systems that require
participants in a conference call to gather in a common room.
The use of data to inform clinical decision-making (including but not limited to
monitoring treatment progress and outcomes) and a reliance upon computers or other
technologies to facilitate care is among competencies likely to require further development in the
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future workforce. The conventional mechanism by which a typical clinician judges his or her
own performance or client progress remains prior experience and clinical supervision;
meanwhile, there is no consensus as to whether or not either positively affects clinical outcomes
(Beutler et al., 2004). Studies have demonstrated the positive impact of feedback about client
mental health status on outcomes, particularly for clients who may require a change in their
current treatment (Lambert, 2001). Other studies suggest the helpfulness of both client outcomes
and therapeutic process indicators (e.g., alliance) to clinical decision-making (Anker, Duncan, &
Sparks, 2009). This research is complimented by a growing evidence base around effective
interventions for promoting the adoption of information and communication technologies by
healthcare professionals (see review by Gagnon et al., 2009). Many practitioners may feel that
the dynamic nature of a therapeutic relationship or client change cannot be captured by
standardized measures or via computer technology. But with a growing federal and state
government emphasis on outcomes accountability, clinicians are increasingly being asked to
administer standardized clinical assessments to their clients and to interact with computerized
data systems for more than billing purposes. Therefore, the onus is upon the research community
to demonstrate the value of data to practitioners and discover data presentations that will be
considered helpful to everyday clinical practice (Kelly & Bickman, 2009). Such efforts are
likely to increase the appeal to consumers of technology-based clinical decision making tools
and enhance clinician data literacy.
Policy support. Numerous authors have proposed changes in policy needed to facilitate
the broader deployment of effective services (see, e.g., Raghavan, Bright, & Shadoin, 2008; Isett
et al.; Rossi, 1978). The ostensible and actual functions of professional licensure and certification
policies are among those to be reconsidered when taking effective workforce development to
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scale. The purpose of licensure was originally legal: to protect the public from individuals who
lack the knowledge and skills to perform certain activities. For instance, a license is defined as
permission by the government or a regulating body to perform certain activities and is required if
some activity is prohibited (Gostin, 2000, p. 254). Examples of prohibited activities might
include the administration of prescribed medications, the prescription of controlled substances,
or the diagnosis and treatment of disease. Licensing authorities include professional boards,
boards of regents or state educational boards, health departments or other governmental agencies.
In addition to licensing, some professional organizations also have credentialing systems that
designate special qualifications of their occupation’s members, for example Advanced Practice
Registered Nurses or the American Board of Professional Psychology (ABPP). Certain states
also have specialty certifications, such as South Carolina’s certification in substance abuse
treatment. These professional associations and organizations have the authority not only to limit
entry into practice, but also to monitor practice and revoke the license of those considered unsafe
to practice under that license. These organizations also control licensure and certification through
continuing education requirements, which often rely on passive approaches to training that are
generally ineffective at changing provider behavior (Grimshaw et al., 2001).
The extent to which changes in licensure, certification or continuing education
requirements may impact client outcomes is an empirical question. Currently, there is little
evidence to suggest that the licensure or certification process has an impact on either client
outcomes or the effectiveness of care, possibly because they are established with little reference
to evidence about the safety or effectiveness for the target population. For children’s services, for
example, a very limited number of measures identified by the National Committee for Quality
Assurance specifically target youth. Furthermore, they represent only a fraction of those likely to
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receive services (i.e., follow up after hospitalization and follow-up for children prescribed
medication for Attention-deficit/Hyperactivity Disorder; http://www.ncqa.org/).
The limitations of licensure and continuing education in promoting effective mental
health services have been described before (see Bickman, 1999); however, these practices have
gone largely unchanged in the last decade and the noted limitations largely unchallenged.
Licensure and certification may not only have a limited impact on effective service delivery but
they may also limit workforce flexibility by reinforcing the use of specialists, rather than
generalists, whether or not they are needed. They do, however, represent one potential platform
for change. A research and professional challenge will be to determine what skills and
knowledge are needed to provide safe and effective services, how the practice of therapy and
other services can be monitored, if and how the workforce should be required to update skills
and knowledge, and how unsafe or ineffective members of the workforce should be managed.
This will be particularly challenging because of guild issues, which may have little to do with
safe and effective practice.
Conclusion
The advances made over the last two decades with respect to the validation of effective
treatments for a variety (but certainly not all) problems in youth mental health; the fledgling
success of efforts to transport and sustain such treatments in usual care settings; and the nascent
science on factors affecting the dissemination, implementation, and outcomes of effective
treatments in usual care have combined to render children’s mental health better able to take
advantage of the industrialization of health care delivery. The implications for strategic
expansion of the workforce centered on increased specificity of the components of quality care
are significant. The industrialization of health care delivery -- the systematized production of
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goods or services in large-scale enterprises– has the potential to create efficiencies in
technologies and in productivity, in part because tasks become more functional and systematic,
as does the workforce training to support effective implementation of such tasks (Cummings &
Hayes, 1996). In health care, this industrialization process has been underway for over two
decades, and is now being revisited with an eye toward greater access, comparative effectiveness
and efficiency. Because children’s mental health now has at least some effective interventions to
offer in usual care contexts, pressures to systematize the implementation of effective treatments
and training of the workforce to deliver them are building, and research is needed to respond to
that pressure with evidence-based strategies.
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