May is Mental Health Awareness Month, an initiative dedicated to improving the nation's understanding of mental health concerns and promoting access to quality behavioral health care. However, access to behavioral health services is one of the top challenges for the U.S. health care system, and this has been exacerbated by the COVID-19 pandemic. The shortage of mental health care providers has been documented, especially in rural communities. Barriers such as lack of insurance, providers who do not take insurance (PDF), or inflexible clinic hours also affect access to care, perhaps particularly in impoverished communities. In part, this reflects the shortage of licensed mental health providers (MHPs), including psychiatrists and psychologists.
There have been a number of efforts to address the gap in mental health care availability by expanding the mental health workforce. For example, task shifting is a model that focuses on training lay people to facilitate psychological interventions. Though this model is perhaps best known for its application in low-resourced nations, the task shifting model has also been applied in the United States. Inpatient or similar settings often employ psychiatric or mental technicians to ensure sufficient staffing, but training requirements vary widely (PDF) by state, formal mental health training is not always required, and specific tasks vary by facility. Social workers, Master's-level counselors, psychiatric nurse practitioners, and physician assistants also extend the reach of the mental health workforce, but these credentials still require two to three years of training. In fact, President Biden's new strategy to address the nation's mental health crisis specifically identifies new approaches to training paraprofessionals as one pathway to strengthening the nation's mental health system capacity.
Looking to the Military for a Workforce Extension Model
One potential solution to expanding the behavioral health workforce can be found in the U.S. military. In the military, the behavioral health workforce comprises licensed MHPs and behavioral health technicians (BHTs)—enlisted service members who are trained to work alongside licensed MHPs. BHTs provide support services under the supervision of licensed MHPs in an effort to improve the efficiency and effectiveness of the Military Health System (MHS). BHTs are trained to fulfill a variety of roles, including screening and assessment, outreach, psychosocial intervention, and case management tasks.
One potential solution to expanding the behavioral health workforce can be found in the U.S. military.Share on Twitter
RAND recently conducted a survey of military BHTs and MHPs, with over 1200 responding, to learn more about the tasks that BHTs perform most frequently, the tasks at which they are perceived to be most proficient, and potential opportunities to optimize their integration into clinical settings. Though this study was focused on the MHS context, the findings of this work might also provide insight into the ways that civilian BHTs could be most effectively integrated into behavioral health settings. Here, we highlight three recommendations that would facilitate the establishment of a civilian BHT role.
First, specialized training in behavioral health is essential and may be most effective when training integrates different training modalities and settings. For example, military BHTs complete an initial didactic training curriculum, which lasts about 10 to 12 weeks and covers topics ranging from psychopathology to interviewing skills; initial training culminates in a two- to five-week practicum. Based on our review of the curriculum and training process, this type of brief training curriculum may be optimized by focusing on the most common presenting problems BHTs are likely to encounter and includes interactive components (e.g., role playing essential skills). Importantly, training does not end with classroom education. Through on-the-job training, BHTs build upon their foundational knowledge and gain practical clinical experience. This type of on-the-job training is most effective when complemented by regular, structured clinical supervision and continuing education opportunities.
It would be worthwhile to develop a standardized scope of practice for civilian BHTs.Share on Twitter
Next, it would be worthwhile to develop a standardized scope of practice for civilian BHTs. Through our study, we asked military BHTs how frequently they performed each of 22 clinical tasks. Although screening tasks were performed most frequently, we found evidence that BHTs performed a wide range of tasks. To some extent, this is beneficial, as it allows the BHT role to be adapted to multiple types of clinical settings. However, this wide variation may also limit their proficiency across tasks. We found some evidence for this; BHTs typically rated their own proficiency more highly than MHPs rated BHTs on the same tasks. To maximize proficiency and efficiency, a set of core tasks should be identified that can be taught during a brief curriculum and that allow MHPs to focus on more-complex clinical tasks. This might include conducting intake interviews, administering symptom measures and assessing progress over time, or cofacilitating psychoeducational groups.
Finally, our survey provided some insight into the conditions that might make civilian MHPs more comfortable working alongside a BHT. One that might be especially relevant in a civilian context is creating a credential for BHTs, similar to the Certified Alcohol and Drug Counselor credential for substance use counselors. A credential helps signify that BHTs have completed required training and demonstrated knowledge related to the core BHT tasks. Moreover, this creates a mechanism to incentivize continuing education—for example, by requiring a certain number of hours to renew the credential annually.
Adapting the BHT Role for the Civilian Context
Certainly, there are differences between the MHS and the civilian health care system that should be considered. For example, the military is able to easily require all BHTs complete the same core curriculum, which happens through one centralized training center. To do this in the civilian context, there would likely need to be a professional organization responsible for developing standards for training and scope of practice. Establishing a common credentialing process at the national level could also be challenging, as individual states often have different licensure rules for health professions. That said, there are precedents for this type of role, such as the Psychological Wellbeing Practitioners who provide low-intensity interventions in the United Kingdom as part of the Improving Access to Psychological Therapies (IAPT) program. However, given increasing rates of depression, anxiety, and other mental health concerns in the community—especially since the onset of the COVID-19 pandemic—having a civilian analog to BHTs could help to expand access to and improve efficiency and effectiveness of civilian mental health care. Formal evaluation of implementation of this model would be necessary to demonstrate these potential gains.
Stephanie Brooks Holliday is a behavioral scientist and Kimberly Hepner is a senior behavioral scientist at the nonprofit, nonpartisan RAND Corporation. Harold Alan Pincus, M.D. is a professor in the Department of Psychiatry, codirector of the Irving Institute for Clinical and Translational Research at Columbia University, and director of quality and outcomes research at New York Presbyterian Hospital.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.