Behavioral health technicians (BHTs), enlisted service members with the technical training to work alongside licensed mental health providers (MHPs), are an important part of the Military Health System (MHS) mental health care workforce. They serve as care extenders, helping the MHS improve the efficiency and effectiveness of the behavioral health care that it provides. However, each service branch has different training requirements for BHTs, making it difficult to identify common qualifications across the BHT workforce and ensure that the MHS is making the best use of their skills. The U.S. Department of Defense's (DoD's) Psychological Health Center of Excellence asked the RAND Corporation to assess the current functional operation and utilization of BHTs and to develop actionable recommendations for optimizing their engagement across the MHS.
Previous RAND research examined the selection criteria for the BHT career field and the training available to these personnel. It found inconsistencies in how BHTs were integrated across the force, recommending greater standardization in selection criteria, curriculum, on-the-job training (OJT), and professional development opportunities (Holliday et al., 2019). This follow-on study presents the results of what might be the largest survey of BHTs and MHPs in the MHS ever conducted.
The goal of this project was to assess current practice patterns, BHTs’ training needs, barriers and facilitators to better integrating BHTs into clinical practice, and potential steps that the MHS can take to optimize BHTs’ contributions to the health and readiness of the force. We developed separate but largely parallel surveys for BHTs and MHPs on BHT roles, responsibilities, and training. The parallel sets of questions we posed to these groups provided useful insights and allowed us to compare perspectives on BHTs’ roles and responsibilities, the frequency with which BHTs performed clinical tasks, the training and supervision they received, barriers to their effective integration into clinical settings, BHTs’ satisfaction with their work and fit with the career field, and MHPs’ satisfaction with BHTs’ work. The survey also elicited perceptions on a series of potential changes to BHT practice that could improve how BHTs are integrated into clinical settings.
We drew eligible survey participants from the Health Manpower Personnel Data System and sent our survey to active-duty BHTs in the Army, Navy, and Air Force, as well as to active-duty and DoD government civilian MHPs who had worked with a BHT in the previous 12 months, including licensed psychiatrists, mental health nurse practitioners, doctoral-level psychologists, and master's-level providers (i.e., social workers and master's-level psychologists). In total, we surveyed 538 BHTs and 685 MHPs (adjusted response rate: 42 percent for BHTs; 37 percent for MHPs).
Nearly 70 percent of BHTs were assigned to in-garrison military treatment facilities, with about 16 percent assigned to in-garrison operational units. Few BHTs were deployed at the time of the survey, and relatively few BHTs or MHPs reported having deployed in the previous 12 months. It was most common for BHTs and MHPs to be working in outpatient mental health and substance use treatment settings. Relatively fewer BHTs and MHPs were serving in other clinical settings or specialty programs. About half of BHTs and MHPs reported interacting with patients across multiple settings. BHTs tended to work with multiple MHPs, and it was common for them to support psychiatrists, psychiatric nurse practitioners, doctoral-level psychologists, and social workers. However, slightly fewer than half of the MHPs surveyed indicated that they were supervising a BHT at the time of the survey, with doctoral-level psychologists and prescribing providers being more likely to indicate that they did so.
Across the MHS, BHTs Varied in Their Responsibilities and How They Applied Their Skills
BHTs engage in a wide variety of tasks, including screening and assessment, psychosocial interventions, treatment planning and monitoring, and outreach and resilience activities. Both BHTs and MHPs reported that BHTs perform screening and assessment activities most often, but there was variation in the amount of time they spent on other clinical tasks, depending on their branch of service and current assignment. About half of BHTs who had deployed in the previous 12 months indicated that they performed more screening and assessment tasks, psychosocial interventions, and outreach and resilience tasks and fewer treatment planning/monitoring activities while serving in a deployed setting. Furthermore, about 90 percent of BHTs and MHPs reported substantial variability in BHT skills, even within the same rank. This finding aligns with our previous research finding that BHTs have a broad range of skills, but not all of these personnel have the same opportunity for ongoing training to maintain and develop their skills.
BHTs reported spending about one-third of their time on patient care activities in a typical week—but also an equivalent amount of time on administrative clinic responsibilities and nearly one-quarter of their time on nonclinical responsibilities. Previous research has suggested that BHTs might not spend a substantial portion of their duty hours on clinical tasks, given other competing demands (Nielson, 2016), and our results support that conclusion. Findings also suggest that BHTs across the force are not getting consistent opportunities to practice some clinical skills and may find themselves unprepared to perform certain patient care tasks when they change settings or assignments. BHTs who spent more time on patient care reported greater satisfaction, so more time spent on administrative tasks could affect their engagement with their work or longevity in the career field.
BHTs and MHPs Differed in Their Perceptions of BHT Proficiency and the Frequency with Which BHTs Performed Various Tasks
Although BHTs and MHPs generally agreed that BHTs were most proficient at screening and assessment-related tasks, they differed in their perceptions of BHTs’ level of proficiency. Specifically, 97 percent of BHTs indicated that they could conduct risk assessments with no assistance or conduct them with no assistance and train someone else on the task. However, only 43 percent of MHPs agreed. There were similar significant discrepancies in reported proficiency across all the clinical tasks in our survey. A reason for this variation could be unrealistic expectations on the part of MHPs, or BHTs might be unaware of their weaknesses on certain tasks or the expected skill level for these tasks. The survey results also indicated that MHPs might lack familiarity with the range of tasks BHTs can perform. Indeed, BHTs and MHPs varied in their reports of the frequency with which BHTs performed certain tasks, and more than three-quarters of MHPs indicated that further education on how best to utilize BHTs’ skills could improve the effectiveness of BHTs in the MHS. Efforts to address this mismatch in perceptions will be important. MHPs who perceived BHTs as more proficient were more satisfied with BHTs’ performance, and MHPs who have had a positive experience with BHTs might be likelier to integrate them more meaningfully into clinical tasks.
BHTs’ Satisfaction with Their Work Was Associated with Increased Time on Patient Care and Receiving Adequate Supervision
About two-thirds of BHTs reported satisfaction with their military job and the quality of their supervisor. Our findings suggest that the nature of BHT responsibilities contributes to their satisfaction. BHTs who reported spending more time on clinical tasks—rather than administrative or unit responsibilities—were more satisfied with their work. Relatedly, BHTs who felt more proficient completing clinical tasks were also more satisfied. We also found that BHTs who reported that they were a good fit for their job were more satisfied.
BHTs and MHPs reported that classroom instruction for BHTs was generally adequate, but many suggested that time spent on continuing education and supervision was inadequate. In turn, we found that BHTs who reported receiving adequate supervision had higher levels of satisfaction, and MHPs who perceived supervision to be adequate were more satisfied with BHTs’ performance.
BHTs Encountered Barriers to Developing and Using Their Skills
To gain a better understanding of the factors that could affect the types of roles that BHTs fulfill, including the extent to which they are integrated into clinical responsibilities, we asked BHTs and MHPs about barriers to effective BHT practice. Among both BHTs and MHPs, the most commonly endorsed barrier was variability in BHT skills, even among those with the same rank. Other frequently cited barriers related to MHP expectations and familiarity with BHT skills, as well as how BHTs’ responsibilities were allocated and the level of supervision they received. The majority of BHTs and MHPs agreed that providers would be more comfortable sharing clinical tasks with BHTs if BHTs had a credential.
Nearly 80 percent of MHPs saw a need for more-systematic supervision for BHTs to effectively provide clinical care. In comparison, only 45 percent of BHTs saw a need for more-systematic supervision. However, many BHTs indicated that MHPs do not have enough time to invest in ongoing supervision and training. This suggests that while MHPs see supervision as key to BHT skill development, finding time to provide this supervision may still be an issue.
Some barriers were endorsed less frequently. Only a modest proportion of BHTs and MHPs indicated that BHTs might feel more comfortable receiving OJT from a senior enlisted BHT than from an MHP. This suggests that it is not who provides the supervision that matters but, rather, that intentional time is set aside to provide supervision. In addition, relatively fewer BHTs and MHPs indicated that MHPs were concerned that they would not receive credit for care provided alongside a BHT.
There Are Opportunities to Improve BHT Training, Including Through Continuing Education and Supervision
Our survey asked about potential changes to BHT practice and how MHPs integrate these personnel into clinical settings. Our goal was to identify how BHTs could contribute more effectively to providing high-quality behavioral health care to service members across the MHS. The vast majority of BHTs (90 percent) agreed that they should be provided with ongoing professional development opportunities. Such a change could address the perceived variability in BHT skills that our survey highlighted. BHTs also indicated that they could be more effective if they received training to implement approaches that are effective across multiple psychiatric diagnoses and to provide evidence-based psychotherapies (EBPs) to lower-risk patients. MHPs similarly saw a need for more professional development opportunities for BHTs, more education for MHPs on how to integrate BHTs into clinical practice, and improved policies defining BHTs’ responsibilities.
There were several differences between BHTs and MHPs in their perceptions of which changes could be most beneficial, however. The largest difference pertained to the possibility of training BHTs to implement EBPs with clinically complex patients; BHTs overall found this option to be more promising than MHPs. This difference and others echoed differences in perceptions of BHTs’ training and skills. For example, both BHTs and MHPs reported that BHTs do not currently administer EBPs very often, so this could help explain why fewer MHPs found this change in BHT practice less essential than BHTs, who might want further training in this area.
These perspectives on potential changes to BHT practice point to several solutions that could improve opportunities for BHTs to apply their skills. For example, a structured approach to supervising BHTs could have benefits in addressing MHPs’ reservations about sharing clinical tasks with uncredentialed BHTs. One such approach is a tiered supervision model, in which newer MHPs supervise BHTs. In turn, a more-established MHP provides supervision to the newer MHP, including guidance on how to effectively supervise a BHT, resulting in skill development for both the new MHP and the BHT.
Building on these findings and the data we collected on BHT selection, curriculum, and training in the first phase of this study, we identified four primary opportunities to improve how BHTs are integrated into clinical settings and how the MHS can help them maintain and make the best use of their skills.
Recommendation 1. Standardize Expectations for BHTs’ Scope of Practice and Educate Providers on BHT Roles
Our findings make it clear that BHTs can play a wide variety of roles. In many ways, this is by design: BHT technical training covers a broad range of clinical topics and skills, and service branch policy documents outline a similarly broad range of BHT responsibilities. However, this also means that BHTs’ skills may be applied in various ways across settings and supervisors, potentially leading to uneven skill development.
One way to reverse this trend would be to standardize expectations for BHTs’ scope of practice, including issuing specific guidelines regarding the skills that BHTs are expected to maintain regardless of setting, with a focus on high-frequency tasks, such as risk assessments, intake interviews, and administering and scoring behavioral health symptom measures. This could be articulated in formal policy or guidance documents, but it should nonetheless also address low-frequency or out-of-scope BHT tasks, such as those related to the provision of psychotherapy or working with high-acuity patients. Ongoing education for MHPs in supervisory roles would promote greater consistency in how BHTs’ skills are applied across the MHS. Finally, there is a need to examine how BHT time is allocated between administrative and clinical tasks, with the goal of providing adequate opportunities to exercise clinical skills. Our survey results suggest that providing adequate time for clinical activities could enhance BHTs’ job satisfaction.
Recommendation 2. Provide Clinical Support Tools to Structure BHT Tasks
BHTs and MHPs had vastly different perspectives on BHT proficiency in performing certain clinical tasks. This highlights a potential need for more clinical support tools, with our survey respondents recommending the use of templates, checklists, or forms to structure clinical tasks. These tools could target, for example, the most frequently performed BHT tasks or support BHTs’ training in treatment approaches that can be used across multiple psychiatric diagnoses. Standardized tools would have the added benefit of aligning expectations for BHT performance across settings and supervisors.
As suggested in our prior study, manualized or structured interventions that have been adapted for non-MHP mental health personnel could be adapted for use by BHTs, such as interventions that incorporate problem-solving therapy or motivational enhancement therapy (Holliday et al., 2019). Our findings suggest that MHPs would be receptive to training to support BHTs in implementing transdiagnostic approaches or EBPs with low-risk patients.
Recommendation 3. Standardize and Communicate Expectations for Supervision Through Policy Guidance
Seventy-eight percent of MHPs indicated that there is a need for more-structured supervision of BHTs, while 66 percent of BHTs indicated that MHPs had limited time to invest in supervision and training. Inadequate supervision can deprive BHTs of opportunities to develop and practice their clinical skills. As part of efforts to promote standardized expectations for BHTs’ skills and performance, it would be helpful to specify expectations or requirements for MHPs who supervise BHTs. Supervision can include a wide range of activities, from direct observation to cofacilitating sessions and staffing cases after BHTs provide one-on-one services. There has also been little specificity about the amount of time BHTs should spend in supervision with MHPs.
As health care services become integrated under the Defense Health Agency, there are opportunities to create policies related to supervision. Proposed standards address the amount of time that should be allocated to supervision each week and what modalities qualify as formal supervision (versus informal consultation). Such documents should also account for necessary adaptations for deployed environments, where BHTs may be expected to operate more autonomously and sometimes while geographically separated from their supervising provider.
Recommendation 4. Expand Continuing Education for BHTs, Such as Through the Development of a BHT-Specific Continuing Education Curriculum
The initial BHT technical training curriculum prioritizes breadth over depth. This makes continuing education and on-the-job skill development critical components of successful progression along the BHT career path. Indeed, the BHTs and MHPs we surveyed indicated that time spent on initial BHT training was adequate, but they also indicated that there was a need for more ongoing training opportunities. Notably, Air Force BHTs and MHPs were less likely to indicate that too little time was allocated to BHT continuing education, likely reflecting the fact that the Air Force has the most standardized continuing education curriculum for BHTs. It is possible that the Air Force could serve as a model for the other services.
Our survey results indicated that, across the MHS, there was significant variation in BHTs’ responsibilities and the tasks they performed, as well as how they were integrated into clinical settings. Importantly, BHTs reported greater job satisfaction when engaging in activities related to patient care, so more opportunities to perform these types of tasks—combined with adequate supervision and greater standardization in continuing education opportunities—could increase engagement and retention among BHTs. These personnel reported that only about a third of their time was spent on patient care responsibilities, indicating that BHTs might not be getting practice in these important skills and highlighting opportunities to better use their skills and training. Greater standardization of the BHT role and requirements related to supervision and continuing education might also increase MHPs’ comfort integrating BHTs into clinical tasks. By addressing these factors, BHTs will be better prepared to support the mission of the MHS and to enhance behavioral health support for service members.