Building Competencies and Skills Among Service Providers Working with Young People who Experience Serious Mental Health Conditions: State of the Science
This paper explores what is currently known about the most promising strategies for increasing providers’ capacity to deliver effective behavioral health services and supports. The paper also describes how this information has been—or could be—applied to the design of cutting-edge approaches for building skills and competencies among providers that work with young people who experience serious mental health conditions.
Need for developmentally- appropriate service and support strategies
Evidence produced in recent years has drawn attention to the idea that the services and supports that are typ- ically available for emerging adults with serious mental health conditions (SMHCs) tend to be neither engaging nor developmentally optimal (Kessler, Demler, & Frank, 2005; Pottick, Bilder, & Vander Stoep, 2008; U. S. Government Accountability Office, 2008). In fact, while young people in this age range experience the highest rates of SMHCs, they are also the population group least likely to engage in behavioral health services, and this is particularly true for young people from racial and ethnic minorities (Substance Abuse and Mental Health Services Administration, 2015, 2017).
Recognizing this gap between need and uptake, researchers and service providers have responded by describing and developing promising new approaches specifically designed to meet the unique needs of emerging adults with SMHCs, and a small number of these approaches have been tested to the extent that they can be described as “empirically supported” (i.e., supported by evidence; Walker & Gowen, 2011, 2012; Walker et al., 2013). Many of these approaches share a core of key practice principles that are intended to promote engagement, good working relationships, and the activation of change processes. Typically, the principles encourage practitioners to work with young people in ways that are strengths-based and driven by the young person’s perspectives and priorities.
Additional shared principles stress the importance of helping the young person to acquire skills for increasing self-determination, as well as skills for building relationships and/or social capital, through connections to supportive adults and peers, and through connections to development-enhancing contexts (Walker 2015; Walker & Flower, 2015). “Studies have shown that providers using “treatment as usual” very rarely used element of either evidence-based or best practices, despite frequently believing that they were doing so.”
As a complement to efforts to design new approaches specifically for young/emerging adults, the field has also seen initial efforts to adapt and test evidence-based practices (EBPs) that have been shown to be effective for children, adolescents, or adults generally. Discussions of the processes for adapting EBPs so that they are optimal for emerging adults focus on ensuring that the adapted versions are engaging and developmentally appropriate, and compatible with young people’s cultures, values, and needs. A key theme in these discussions is that the adaptations should also include attention to enhancing young people’s self-determination and relationship-building skills (e.g., Ellison et al., 2015; Institute of Medicine & National Research Council, 2015).
The importance of developing and testing structured interventions and programs for young people is rein- forced by studies examining what happens when, as is typical in usual care, practitioners use an unstructured, eclectic approach. Studies of service providers working with adults (Carroll & Martino, 2010) or children (Gar- land et al., 2010; Garland, Bickman, & Chorpita, 2010) have shown that providers using “treatment as usual” very rarely used elements of either evidence-based or best practices, despite frequently believing that they were doing so. In fact, Carroll and Martino found that clinicians in their control condition spent large amounts of time with clients involved in clinician-initiated “chat” that was not connected to treatment and that predicted lower levels of engagement. In contrast, clinicians receiving training in the active condition— Motivational Interviewing, a structured approach—had very low levels of chat.
Training best practices
If developmentally-appropriate programs and interventions are to be implemented more widely, there is an obvious need for cost-effective training to create a workforce that is prepared to provide services to emerging adults in effective, engaging, and develop- mentally-appropriate ways (Clark & Unruh , 2009; Haber, Karpur, Deschênes, & Clark, 2008; Hoffman, Heflinger, Athay, & Davis, 2009; Stein, Connors, Chambers, Thomas, & Stephan, 2014). The broader research on training strategies and components provides guidance on how this can be accomplished.
Adhere to principles of adult learning.
Best practices for training are based on principles of adult learning. Specifically, adults learn best when they are self-directed, internally motivated, and actively engaged in examining their own attitudes and increasing their own knowledge and skills (Trotter, 2006). Ideally, training content builds upon what individual participants already know, is presented in meaningful ways, incorporates active learning processes, and includes a focus on how to apply learning to problems at hand (Kadushin & Harkness, 2002; Trotter, 2006).
Effective training that builds on past experiences takes account of stages of professional development (novice to expert), learning processes, individual learning modality preferences (auditory, visual, sensory, practical), and learning styles (Kolb & Kolb, 2005).
Promote understanding of service contexts and users.
For service providers to be effective, training initiatives need to prepare them to function in community settings and with the service users that they are likely to encounter in practice (Hoge, Huey, & O’Connell, 2004). Training content and strategies should therefore include a focus on having participants apply their learning to situations and problems they encounter as providers, with support and feedback provided when they implement new practices or techniques (Kadushin & Harkness, 2002; Trotter, 2006). Inclusion of community and service user voices in training initiatives can also help to increase providers’ understanding of service contexts and users. For example, communities of color and advocacy organizations such as Youth MOVE National and the Federation of Families for Children’s Mental Health have advocated for members of the focal community and service users to be involved in the development and implementation of training initiatives to provide “insider” perspectives. To be well prepared to serve youth, service providers are increasingly asking for young adults with service experiences to provide training, as reported in the recent Pathways Transition Training Partnership/ Youth MOVE training needs survey, Supporting You in Supporting Youth (Jivanjee, Brennan, Grover, & Thorpe, 2018).
Incorporate high-quality coaching.
Training providers to work with young people in new ways typically requires substantial time and investment. Less resource-intensive strategies such as training work- shops and self-paced online trainings have shown some effectiveness in increasing provider knowledge and changing their attitudes. When workshops are enhanced with opportunities to observe and practice new skills, practitioners are in some cases able to replicate these skills within the controlled context of the training (Lyon, Stirman, Kerns, & Bruns, 2011; Olmstead, Carroll, Canning-Ball, & Martino, 2011). While increased knowledge, favorable attitudes, and the ability to demonstrate key skills in a controlled environment are important precursors to practice change, these kinds of lower-resource strategies are generally acknowledged to be insufficient to create and sustain practice change in real-world settings. (Beidas & Kendall, 2010; Carroll & Rounsaville, 2007; Lyon et al., 2011; Sholomskas et al., 2005). For practitioners to become adept in new ways of working with clients, initial training needs to be followed by high-quality, practice-focused coaching over a period of at least several months.
There is a growing consensus that, in order for practitioners to become adept in new ways of working with clients, initial training needs to be followed by high-quality, practice-focused coaching over a period of at least several months (Edmunds, Beidas, & Kendall, 2013; Goense, Boendermaker, & van Yperen, 2016; Martino et al., 2016). Coaching is often understood to be a function of regular supervision, but can also be provided by consultants, expert peers, or other individuals in a dedicated coaching role. High-quality coaching incorporates “gold standard” elements (Dorsey et al., 2013), including observation of practice (either live or via audio- or video recording) and provision of feedback in a manner that is connected to the intervention theory and based on objective criteria (Garland et al., 2013; Herschell, Kolko, Baumann, & Davis, 2010; Milne, Sheikh, Pattison, & Wilkinson, 2011). It is also important that ongoing coaching/supervision incorporate observation, since people generally (Kruger & Dunning, 1999), and clinicians specifically (Martino, Ball, Nich, Frankforter, & Carroll, 2009; Olmstead, Abraham, Martino, & Roman, 2012), tend to be very poor reporters on their own level of skill.
Ensure a supportive organizational context.
The organizational context is also important since organizational structures and systems, management practices, and supervisor, and peer support have been found to impact the extent to which new learning is applied in practice (Beidas & Kendall, 2010; Gray, Sharland, Heinsch, & Schubert, 2015). Team-based learning with others in supportive environments allows opportunities to receive coaching, feedback, and reinforcement (Gururaja, Yang, Paige, & Chauvin, 2008; Lick, 2005; Senge, 1990). In a recent qualitative study of social workers’ and social work students’ experiences and perspectives on lifelong learning (Jivanjee, Pendell, Nissen, & Goodluck, 2015), participants described examples of workplace cultures that either promoted or inhibited learning and the application of new learning on the job. For example, heavy caseloads, overwork, and fears of making a mistake were described as barriers to ongoing learning, while having a supervisor who supports learning was described as essential. For knowledge transfer to occur, training goals and content must be consistent with organizational goals and be reinforced on the job through management and supervisory support for practice changes, and training efforts must be accompanied by relevant changes in structures for accountability and reporting, as evidenced in a study of staff training to improve practice in child welfare organizations (van Zyl, Antle, & Barbee, 2011).
Training modalities
A range of training modalities is used to prepare service providers and to sustain and enhance their skills, each with strengths and limitations. Face-to-face training through workshops and presentations is widely used for continuing education and to support professional licensure (Nissen, Pendell, Jivanjee, & Goodluck, 2014). Face-to-face training has the advantage of being tailored to local conditions, and it tends to be popular with service providers (Jivanjee et al., 2018). Face-to-face training can be helpful for communicating new knowledge and for changing provider attitudes toward new ideas and practices. However, as noted previously there is little evidence Web-based training has grown in popularity as a cost-effective training approach that can reach wide audiences.that such training leads to knowledge transfer in the absence of follow-up coaching. Further, such trainings are expensive to provide and limited in the numbers of participants. While trainer characteristics and content delivery matter, the most frequently reported best practice strategies for supporting knowledge transfer have been supervisory support and reinforcement, coaching and opportunities to practice, use of inter- active activities, post-training evaluation, and correspondence of training content and job responsibilities (Burke & Hutchins, 2008; Lyon et al., 2011; Shapiro & Kazemi, 2017).
In recent years, web-based training has grown in popularity as a cost-effective training approach that can reach wide audiences, with additional advantages of being self-paced, convenient, engaging, and transportable across locations (Khanna, Carper, Harris, & Kendall, 2017). Positive outcomes of online training programs for service providers in mental health ser- vices have also been reported (e.g., Westbrook, McManus, Clark, & Bennett-Levy, 2012), although participants voiced concerns about inadequate accountability for completion of self-paced online training (McMillen, Hawley, & Proctor, 2016). Other studies suggest that there are further benefits from adding components to online training programs, such as treatment manuals, workshops, consultation, taped review of practice sessions, supervisor training, booster sessions, and/or completion of case reviews (Harned et al., 2014; McCay et al., 2017; Morris & Stuart, 2002; Reeves et al., 2006; Ruzek et al., 2014).
Barriers to the use of training best practices
Despite the consensus that effective training is necessary to improve the practice of service providers work- ing with young people with mental health difficulties, significant obstacles have been identified that stand in the way of the use of training best practices. In the Supporting You in Supporting Youth survey (Jivanjee et al., 2018), most transition service providers working with young people with mental health challenges endorsed five major barriers to receiving needed training: expense, heavy workload, shortage of travel funds, distance to training, and limited time off. Nearly half of participants also reported that lack of organizational support was at least moderately affecting their training access. About a quarter of respondents also noted that inadequate access to technology for online training and lack of supervisor support had an impact on their ability to get the training they needed. Each of the obstacles endorsed by service providers in the Supporting You in Supporting Youth survey will be discussed.
Cost, distance, and time.
The costs of providing the type of “gold standard” training that will lead to practice change can be a major barrier to the implementation of new programs or interventions. For example, the training that is required as part of EBP implementation is typically consistent with most aspects of the gold standard. Recent studies of implementation of various types of cognitive-behavioral therapy (CBT), one of the most frequently implemented EBPs, provide estimates of these EBP implementation costs are seen as one of the top barriers to implementation and were cited as the top reason for discontinuation of an EBP.costs. A recent investigation by Lang and Connell (2017) found that, across ten clinics, initial 10-month implementation costs averaged USD $89,575 per agency, $11,659 per participating staff member, and $2,745 per child treated with trauma-focused CBT. Roundfield and Lang (2017) studied ongoing costs to sustain the same intervention across 14 clinics, and found yearly costs of $65,192 per clinic, $4,461 per staff member trained, and $1,896 per child treated. EBP implementation costs are seen as one of the top barriers to implementation (Aarons, Wells, Zagursky, Fettes, & Palinkas, 2009) and were cited as the top reason for discontinuation of an EBP in a study that found that fewer than half of community agencies sustained an EBP over six years (Bond et al., 2014). A likely contributor to the lack of EBP sustainment is that while agencies bear the costs of the training, they typically do not reap the benefits, as payment for services is rarely predicated on client outcomes and other types of benefits (e.g., fewer out-of-home placements or emergency room visits) accrue to other system entities (Roundfield & Lang, 2017).
When funding is limited, organizations may have to balance the need for training against the requirement to have staff provide billable services during working hours (Sigel, Benton, Lynch, & Kramer, 2013). The logistics of training may include traveling considerable distances for live face-to-face training opportunities, which involve both travel costs and lost time from work, resulting in reduced revenue (Roundfield & Lang, 2017). Organizations must also insure that supervisory duties are covered, when supervisors attend trainings (Martino et al., 2016). In agencies requiring staff to carry heavy workloads, service providers may have to engage in training opportunities outside of regular working hours, adding to already demanding schedules and workplace stress (Reding et al, in press).
Organizational factors.
Issues arising in organizations that can delay or derail training efforts include resistance to change in the face of limited resources, and the absence of champions in the organization who promote the presentation of new approaches based on evidence, and support their eventual adoption by service providers (Gray & Schubert, 2012). Turnover within organizations, as key staff members take on new roles, or leave altogether and are replaced, can also interfere with the process of planning and executing training programs associated with the adoption of promising, empirically-supported, and evidence-based practices (Beidas et al., 2016).Providing “live” trainings partially or fully via web conference can eliminate the often substantial costs associated with travel for both trainees and trainers.
Technology barriers.
With the development of online training resources for transition service providers, such as self-paced modules and webinar presentations and archives, potential trainees have encountered obstacles to their participation. Their organization may have specific policies that limit access to their preferred technological devices or channels, or the technology-based training programs may not be accessible on the devices that they use most, including mobile phones (Storey, 2017). They may also have difficulty adapting to training delivered through technology, or lack the time and motivation to complete self-paced, or self-directed online train- ing programs (Brennan, Sellmaier, Jivanjee & Grover, 2018; Harned et al., 2014; McMillen et al., 2016).
Lack of supervisor support.
Although some attention has been paid to the importance of reducing supervisor stress and its associated turnover (Tebes et al., 2011), the lack of a consistent and supportive supervisor who fosters the implementation of knowledge and skills derived from training is a key organizational problem (Martino et al., 2016). Supervisors can also experience challenges working with service providers on training issues if they themselves are unfamiliar with the new practice and/or the theory base for the change they are promoting (Regan et al., 2017; Walker & Matarese, 2011).
Emerging approaches to managing barriers
Creative use of training modalities.
One set of strategies for addressing barriers to the use of training best practices involves creatively combining training modalities and/or incorporating technology to reduce costs and to allow for training experiences that are more in tune with principles of adult learning. For example, providing “live” trainings partially or fully via web conference can eliminate the often substantial costs associated with travel for both trainees and trainers. What is more, when travel costs are eliminated through online delivery of content, training can be spread out over time and skills introduced sequentially, starting with more basic skills and moving to more advanced skills, with time to practice and consolidate gains in between.
Similarly, allowing trainees to “observe” real practice by accessing a library of video recordings online can eliminate the costs related to bringing in experts to demonstrate good practice and the costs related to time and travel to observation of real sessions with service users. When trainees can access library material as needed, training can be more self-paced and better matched to individual needs. Another example is the use of audio or video recordings as the basis for consultation on trainees’ practice, which can eliminate costs related to having experts shadow trainees in the field.
Specialization.
One of the drivers of costs for implementation of new practices is the fact that most providers in community settings see clients that are diverse in terms of needs and, often, age, culture, or other treatment-relevant characteristics. So, for example, per-client costs for an empirically-sup- ported practice are driven up when the treatment— such as a treatment designed for emerging adults or a treatment focused on trauma—is only relevant for a subset of a providers’ clients. Strategies involving technology can be helpful in this situation as well, through the use of tele-mental health strategies that allow providers to specialize and provide a single type of service to more homogeneous clients across a wider geographic area (Hilty et al., 2013). Costs are reduced since fewer total providers would need training in order to serve the client population. This strategy would also address the “jack of all trades, master of none” problem, i.e., the need for providers to be trained in multiple interventions or practices in order to meet the needs of diverse clients. Even if agencies have the funding to comprehensively support multiple practices, it is not clear that providers can fully master a sufficient number of relevant practices such that at least one of those will be relevant to meeting the needs of any given client.
Specialization for the role of trainer and practice consultant/coach can also be facilitated technologically to improve cost-effectiveness. For example, significant expense is often incurred training local supervisors and practice coaches to support a new intervention or program. Typically, these staff will not have knowledge or experience using the new practice themselves (and often they do not carry a caseload anyway), so training them to a sufficient level of expertise requires substantial investment of both time and funds. And of course, this investment is lost if the supervisor/ coach leaves the job. Many training efforts rely on train-the-trainer models to develop local expertise, but available research indicates that trainer competence drops off with each step of remove from the purveyor (Olmstead et al., 2011). Additionally, on-site coaches and supervisors typically experience competition for their time, which makes it difficult for them to provide ongoing training support that matches best practice. However, if it is not necessary to be on site (i.e., training takes place using tele- and web-based strategies) training and coaching can be provided indefinitely by specialists with expert knowledge, resulting in higher quality at reduced cost.
Modularization.
A third set of strategies capitalizes on the fact that evidence-based and empirically-sup- ported interventions often share core elements, components or modules with one another (e.g., Weisz et al., 2012; Walker, 2015). One specific strat- egy proposes that providers can be trained in the elements that appear frequently as constituents of larger evidence-based and empirically-supported interventions. Once trained, the providers can then apply these elements flexibly to meet individual client needs. This approach has been explored for component elements of psychotherapy for children (e.g., behavioral contracting, goal setting, guided imagery; Chorpita & Daleiden, 2009) and holds promise for reducing the costs of training providers to work effectively with children. A slightly different strategy involves creating and testing structured enhancements—e.g., engagement or communication enhancements—that can be used to improve practice elements that are shared across interventions (e.g., Walker, Seibel, & Jackson, 2017).
Current work at Pathways RTC
As noted previously, in collaboration with Youth MOVE National, Pathways Research and Training Center has undertaken the Supporting You in Supporting Youth survey as a means of better understanding providers’ perceptions of training needs and their preferences regarding training modalities (Jivanjee et al., 2017). This information can help move the field forward in responding to the needs, opportunities and challenges described here. Additionally, Pathways RTC is developing and testing several competency-building approaches that incorporate a variety of cutting edge strategies, described in this document. Further details about each of these training projects can be found in the linked documents. Pathways RTC is developing and testing several competency- building approaches that incorporate a variety of cutting edge strategies.
- Achieve My Plan (AMP; Walker et al., 2017), is an enhancement for existing interventions and programs that build providers’ competence in working with young people in ways that promote their acquisition of self-determination skills, ensure that care/treatment is based on their perspectives and priorities, and promote strengths in meaningful ways. Current AMP training is completely delivered via “remote” training and coaching (i.e., via webconference and the internet) in a way that conforms to best practices outlined here.
- AMP+ is an adaptation of “original AMP,” and is also an enhancement to existing interventions or programs (Walker, Baird, & Welch, 2018). AMP+ aims to build skills for young adult peer support providers who work in a peer role that is focused on support- ing young people to carry out activities and plans in the community. AMP+ training is also delivered remotely in a manner that is similar to the training for “original” AMP.
- Promoting Positive Pathways to Adulthood (PPPA; Brennan, Jivanjee, Sellmaier, & Grover, 2018) is a 10-module online training program with an accom- panying toolkit of practice activities based on core competencies identified through literature searches and stakeholder consultation. A recent study tested the outcomes of PPPA and found that participants receiving either online training only or online training plus team-based practice exercises made significant gains in transition-related knowledge and self-rated transition competencies, with those participating in team-based exercises achieving greater knowledge gains.
- Technology-Enhanced Coaching focuses on helping supervisors to perform more effectively in the role of coaching their providers in skills for working more effectively using TIP (the Transition to Independence Program, a widely implemented intervention for working with older youth and young adults who experience serious mental health conditions). Super- visors are coached by Pathways staff in the efficient use of a reliable feedback system that incorporates video of providers’ work.
Conclusion
Walker, J., Jivanjee, P., Brennan, E., & Grover, L. (2018). Building Competencies and Skills among Service Providers Working with Young People who Experience Serious Mental Health Conditions: State of the Science. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.
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