The Workforce Crisis: SAMHSA's Response

By Rebecca A. Clay

The shortage of adequately trained personnel to provide services for substance abuse and mental health—also known as behavioral health care—is of major concern within the field. For SAMHSA, creating strategies to solve this problem is a top priority.

This article is the first of two that will examine the nature of the workforce crisis and discuss SAMHSA efforts to address the problem. This article focuses primarily on mental health; the next will focus more on substance abuse.

Prestigious organizations across the field—including the Institute of Medicine (IOM), the President's New Freedom Commission on Mental Health, and the U.S. Surgeon General—all agree that the health care system needs to do a much better job applying evidence-based practices, serving rural areas, including consumers and families in decision-making, eliminating racial and ethnic disparities, and more. But none of these goals can be achieved without solving one underlying problem: the need for a bigger, better workforce.

"Some people don't have access to any services at all," said SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "Others don't have access to the right services—services provided by workers who are knowledgeable about evidence-based practices, experienced in the latest treatment methods, and sensitive to cultural nuances and issues."

How bad is the workforce crisis? The IOM's definitive report, Crossing the Quality Chasm: A New Health System for the 21st Century, cites workforce preparation as one of four critical areas demanding immediate action.

One problem is the simple shortage of providers. "We don't have a workforce that's adequate in terms of numbers, much less a workforce that's adequate in terms of training," emphasized SAMHSA Chief of Staff Gail P. Hutchings, M.P.A. "We have big hurdles to face in terms of recruitment and retention." These hurdles include low salaries, poor benefits, and the hassles of third-party reimbursement.

Simply put, there aren't enough providers to meet the Nation's needs. Take graduate-level personnel, for example. An influential study, Can the National Addiction Treatment Infrastructure Support the Public's Demand for Quality Care?, co-authored by A. Thomas McLellan, Ph.D., University of Pennsylvania Center for Studies of Addiction, found that few addiction treatment programs employ psychiatrists, psychologists, social workers, or nurses. This shortage of key clinical personnel compromises the field's ability to adopt effective new therapies and medications, the study warned.

In rural areas, shortages of behavioral health providers are critical. Consider psychiatrists, for instance. According to a report from SAMHSA's Center for Mental Health Services (CMHS), Mental Health, United States, 2002, Idaho and Mississippi have only 6 active psychiatrists per 100,000 residents compared to 57 per 100,000 in Washington, DC.

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In addition, service providers and administrators need training in areas other than clinical skills, said Ronald W. Manderscheid, Ph.D., chief of the Survey and Analysis Branch at CMHS. For example, the behavioral health workforce especially needs training in information technology and data analysis.

Persuading people to stay in the behavioral health field is another problem, fueled by the same concerns that make it difficult to recruit people in the first place. "Turnover is a key issue in both the substance abuse treatment and prevention system and in the mental health delivery system," said SAMHSA Center for Substance Abuse Treatment (CSAT) Director H. Westley Clark, M.D., J.D., M.P.H. "Just when I get you trained, you leave."

The McLellan study found that more than half of the substance abuse treatment program directors and a similar proportion of counselors surveyed were in their current jobs less than a year.

"We have a huge succession problem," said Dr. Manderscheid. He noted that the current generation of leaders is approaching retirement age, and their replacements aren't being recruited or retained.

Karl White, Ed.D., CSAT's Team Leader for Workforce Development, cited another problem. "There is a dire need for more clinical supervision," he said. "Supervisors carrying full caseloads of clients don't have time to oversee and mentor the people working under them or supervise the implementation of evidence-based practices."

CMHS Director A. Kathryn Power, M.Ed., emphasized the connection between improving the workforce and SAMHSA's initiative for Mental Health Transformation. "SAMHSA is seeking to introduce a fundamental change in the way mental health services are perceived, accessed, delivered, and financed," she explained. "Care should focus on facilitating recovery and building resilience—not just managing symptoms. To do this, we must ensure that service providers are taught the skills they need to facilitate change."

The Director of SAMHSA's Center for Substance Abuse Prevention, Beverly Watts Davis, sees a place for prevention in educating the workforce also. "Prevention is a continuum that extends from deterring diseases and behaviors, to changing community conditions to support a healthy and safe community and support recovery, to slowing the onset and severity of illnesses after they occur," she said. "Furthermore, after treatment, efforts are still needed to prevent relapse. We want to encourage service providers to include prevention in their thinking and planning and in all of their health promotion initiatives."

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Change Is Underway

Currently, SAMHSA is taking action to increase the number of behavioral health care providers and improve their training.

The SAMHSA-funded Annapolis Coalition is one of the Agency's most recent efforts in this regard. Founded by the American College of Mental Health Administration and the Academic Behavioral Health Consortium, the coalition and participants in SAMHSA's Partners for Recovery workforce initiative are building a national consensus on the nature of the workforce crisis and promoting improvements in both education and training.

At the 2001 conference in Annapolis that gave the group its name, the coalition began by identifying and describing some major problems.

First, the training offered in many graduate programs doesn't reflect the dramatic changes that occurred in behavioral health care in recent years. Despite the fact that the majority of behavioral health care is delivered through managed care arrangements, for example, students typically receive little formal training about how to work in such systems.

Second, nearly all continuing education programs use a passive, didactic model of instruction that has proven ineffective in influencing the way practitioners provide services or in improving health care outcomes.

Third, people working in this field with a bachelor's degree or no degree at all receive very little training. These care providers are the ones that consumers are likely to have the most contact with in public sector systems of care.

"We know that a large proportion of care is delivered by people who have very little information about mental illness and very little formal training in treatment," said Michael A. Hoge, Ph.D., a professor of psychology in the department of psychiatry at Yale University School of Medicine and Co-Chair of the Annapolis Coalition.

And fourth, consumers of services and family members who provide the bulk of support to individuals with behavioral health problems usually receive no training at all. "Particularly on the mental health side, there's been a very heavy emphasis on professional training and professional care," said Dr. Hoge. "We need to build much better educational support to teach individuals and families about disorders and how to navigate systems of care. We also need to engage them as educators of the workforce, teaching about the lived experience of illness, treatment, and recovery."

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A National Strategy

The CSAT publication, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, Technical Assistance Publication 21 (TAP 21) has been endorsed and is currently being used by several professional organizations as the basis for developing certification requirements for addiction counselors.

In addition, CSAT has been working for 3 years on a national workforce plan to guide SAMHSA in providing leadership on workforce issues in the substance abuse field. The internal guidance document draws on input from a series of focus groups with representatives from training programs, accrediting bodies, managed care plans, and others as well as currently available research and data from addiction workforce surveys conducted by CSAT's Addiction Technology Transfer Centers Network and others.

The Annapolis Coalition is also helping SAMHSA put together a national strategic plan for behavioral health workforce development. In May 2004, the coalition came together at a CMHS-funded conference to promote the use of core competencies as a foundation for training and education in behavioral health.

While SAMHSA staff members expect to craft a coordinated response to the workforce crisis, there are significant differences between the substance abuse and mental health service provider workforces. For example, the mental health field tends to emphasize providers with graduate-level training, whereas the substance abuse field embraces the use of peers who draw on their own experience of addiction and recovery to help others in addition to graduate-level professionals.

"SAMHSA is adamant about respecting the separate identities of the two fields, but we need to learn from each other and share resources," Ms. Hutchings said. "Especially given the number of people with co-occurring disorders, it's imperative that we put out a strategy that integrates both fields."

CSAT Division of Services Improvement Director Mady Chalk, Ph.D., further noted the importance of integrating behavioral health services with primary care medicine. "Much of what we do in the substance abuse treatment field depends on having health care providers with adequate education in addiction in primary care settings, clinics, and emergency rooms," she said.

In September 2004, several members of the Annapolis Coalition and nationally recognized substance abuse provider associates testified on their recommendations before the IOM. The Institute is producing a companion piece to its Crossing the Quality Chasm report that will focus specifically on mental health and substance abuse disorders. SAMHSA is helping to fund this IOM project.

The expert panel suggested that the IOM identify "levers of change" that could spur workforce development, such as regulation, accreditation processes, or financing. The panel also recommended the launch of a major recruitment and retention initiative that would involve such strategies as increased recruitment of culturally and linguistically diverse individuals, greater use of student loan repayment programs, and the enhancement of salary-and-benefit packages. Another suggestion outlines steps for building a more consumer- and family-centered workforce in the mental health field, recognizing the tradition of peer support that has characterized the substance abuse field.

For SAMHSA resources on workforce development, see Workforce Development: Related Resources. 

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