The opening lines of Charles Dickens' A Tale of Two Cities come to mind when I think about human resources in the mental health and substance use fields: “It was the best of times, it was the worst of times….” We spend about 80 cents of every treatment dollar on our human resources (according to information collected by SAMHSA), yet our staffs have important training needs that are not being met. Current providers are undoubtedly the best educated of any generation, yet they have received very little training in evidence-based practices and almost no training in leadership or information technology.
Reports from the field indicate that newly graduated clinicians are unprepared to work in an organizational context. Furthermore, they have not been fully trained to work in teams, especially those that span specialty and primary care. Major universities have been very delinquent in updating graduate clinical training programs to fit modern realities. This situation needs to change.
For the past two years, the Annapolis Coalition on the Behavioral Health Workforce has been working with SAMHSA's Center for Mental Health Services (CMHS) to develop a strategic plan to address our major human resource training needs. The results are not likely to surprise you:
Initial clinical training and continuing education need to improve dramatically. Revisions to provider organizations' training programs must incorporate service quality improvement and the tools necessary to affect it: evidence-based practices, clinical performance measures, related benchmarks, and IT.
Widespread leadership training needs to be initiated. This training must include interorganizational partnering and specific training in how to become a transformational leader.
Training needs to directly address several critical topics that have divided the mental health and substance use fields in the past: co-occurring disorders, prevention and early intervention, integration with primary care, and effective inclusion of psychopharmacology into a broader array of care.
Training needs to address the core goals of recovery and resiliency in all types of care, along with a strong consumer and family focus.
Although these needs are relatively easy to enumerate, operational solutions are more difficult to identify and implement. There are some national efforts taking place, though. CMHS currently supports four small awards to promote clinical training of minorities. SAMHSA's Center for Substance Abuse Treatment (CSAT) has initiated mentoring for substance abuse leaders through the Addiction Technology Transfer Center (ATTC) Network. CMHS has partnered with CSAT to offer leadership training through the ATTC mentoring program to ten state transformation leaders.
Yet the federal government used to be much more involved in training staff. In 1949, the National Institute of Mental Health (NIMH) created a clinical training program with an annual budget of about $4 million. By 1972, this annual investment had grown to about $117 million, after which the annual investment began to decline. The program was transferred in 1992 to CMHS. In 1993, the annual investment was about $4 million ($4 million certainly had more of an impact in 1949 than in 1993). In 1994 and succeeding years, the only federal investment was CMHS's small awards for clinical training of minorities.
And more than 25 years have elapsed since NIMH offered leadership training through its Staff College. Most of those who received this training are entering retirement age. No federal program has undertaken behavioral health leadership training since 1981.
Experiencing more than a quarter century without a national leadership training program and more than a decade without a national clinical training program has taken a considerable toll. Our leaders are aging toward retirement without any clear replacement strategy, and our clinicians lack modern treatment and organizational skills. Therefore, we need to come together to demand the creation of a national program to support leadership and clinical training.
To be successful, a national program will require a support center to identify and transfer training models, best practices, and demonstration projects. It will require a national grant program with an annual national investment of at least $50 million to compensate for the years of neglect. Clearly, leadership and clinical training grants should not be designed as handouts. Awards must include a payback provision, with a formula for forgiving the debt based on future service in the public or not-for-profit sectors.
As we move forward, we will be confronted with the emerging mental health and substance use care needs of our returning vets, and we also may be confronted with major care needs as a result of a potential avian flu pandemic. Future crises will demand our very best response, including high-quality care based in evidence, together with appropriate measures to assess effects. Our very best response will only be possible if we confront our staffs' training needs now.
Ronald W. Manderscheid, PhD, is Director of Mental Health and Substance Use Programs at the consulting firm Constella Group, LLC.