Understanding the Landscape of Behavioral Health Pre-service Training to Inform Evidence-Based Intervention Implementation

Equipping the behavioral health workforce to deliver evidence-based interventions (EBIs; i.e., interventions with empirical support for their efficacy) is a critical public health need (1). EBIs are often not delivered with high fidelity in community mental health settings (2), and treatment often fails to promote meaningful symptom reduction (3). To date, most efforts to increase rates of EBI use target clinicians after they enter the service sector (4), and significant gaps remain (1). Given the challenges faced in training providers to deliver EBIs after they enter the workforce, reports on the needs of the behavioral health workforce highlight the importance of incorporating EBI training into pre-service graduate curricula (coursework and practicum) to achieve the goal of enhancing the quality of mental health care in the community (5–7).

Pre-service training, particularly in terminal master’s degree programs, is an ideal intervention point for improving EBI use in clinical care settings. Master’s degrees represent the typical level needed to practice independently, and graduates of these programs (e.g., marriage and family therapy, social work, and counseling) are most representative of usual care settings (5). However, master’s-level providers come from diverse educational backgrounds and theoretical orientations (5), which complicates translating broad calls to improve pre-service training into practice. Graduate curricula exist within large educational systems that have competing forces exerting pressure on curriculum content (e.g., faculty philosophies and training, accreditation standards, licensure, and state regulatory requirements). Improving or changing educational practices across these diverse settings requires the understanding of and careful attention to these contextual factors. Furthermore, virtually no systematic research exists on what kind of pre-service education strategies best prepares trainees to enter the behavioral health workforce equipped to deliver high-quality care. Nonetheless, trainees are entering work settings that increasingly expect them to do so.

Changing educational practices requires identifying and addressing contextual barriers to system change; therefore, these efforts might borrow from principles of implementation science (IS), which is the scientific study of how to disseminate and integrate EBIs into routine clinical settings. Reforming pre-service education to improve clinicians’ use of EBIs after workforce entry is also aligned with the goal of IS to increase EBI use in community settings. We demonstrate how IS principles can be applied to the pre-service context and propose an agenda for future research at the intersection of workforce development and IS in behavioral health.

Understanding the Pre-service Context

Implementation theories underscore the need to understand the settings in which change is to take place across ecological levels (8). Current understanding of facilitators and barriers to EBI inclusion in master’s degree programs comes from large surveys that provide broad contextual overviews but little nuanced detail (9, 10). While research suggests that master’s program directors recognize the advantages of EBI training (9–11), EBIs are inconsistently incorporated into curricula (9). Pre-service education typically includes a combination of didactic instruction and experiential learning via classwork and clinical “fieldwork.” Ideal skill acquisition is theorized to occur when classroom learning about EBIs is reinforced by supervised clinical field experiences (12). However, little is known regarding the nature of EBIs taught across different programs in classrooms and fieldwork or the educational strategies used to deliver this content (e.g., didactic or experiential learning, or both). For example, while cognitive–behavioral therapy is the most common EBI taught in social work programs (9), we do not know which intervention protocols are taught or for what presenting concerns.

Furthermore, contextual factors both within and external to individual graduate institutions influence curricula. Within institutions, faculty and fieldwork supervisors vary in their knowledge of, attitudes toward, and experience with EBIs (10). Lack of faculty to lead course development is a primary barrier to EBI training (10), and programs vary in how faculty make decisions about which intervention models are taught (13). Teaching is also influenced by structural factors (e.g., proportion of coursework taught by adjunct faculty and courses required for graduation) and institutional culture and climate (e.g., perceived value of EBI and/or research within departments and faculty development priorities).

Key external factors in graduate programs include accrediting and licensure bodies for each discipline (7), which exert powerful influences on pre-service educational content. Published accreditation standards show that graduate programs must satisfy many requirements to attain and maintain accreditation, including substantial course content and 500 to 900 hours of fieldwork experience, to be accomplished in only two years, on average. Consistent with this, program directors cite the challenge of providing EBI training alongside other requirements (10). Furthermore, fieldwork supervision may need to be conducted by a discipline-specific supervisor or be demonstrably consistent with the overarching discipline’s philosophy (e.g., marriage and family therapy trainees must receive relationally oriented fieldwork supervision). This leaves little space to provide training in multiple EBIs within the confines of course and practica requirements.

Efforts to increase EBI-based curricula in pre-service settings must consider these contextual influences. There are two interrelated questions that should guide work in this area: how IS can inform EBI integration into pre-service settings and how programs should prioritize which EBIs are taught.

How IS Can Inform EBI Integration Into Pre-service Settings

Leverage IS frameworks to understand the pre-service context and guide change.

Many implementation frameworks are available to identify and organize key contextual factors influencing EBI curricula and guide change processes. We offer two that are well suited for implementation efforts in the pre-service context. First, the Consolidated Framework for Implementation Research (CFIR) model synthesizes contextual factors that may influence EBI curriculum interventions (8); many of the contextual factors thought to influence EBI curricula fit clearly into the CFIR model (e.g., accreditation standards represent an “outer setting” factor influencing EBI curricula). Second, the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework delineates four phases of change that should occur within implementation efforts (14).

Partner with pre-service stakeholders and learn from champion programs.

Process models of implementation, such as the EPIS framework, highlight the importance of partnered approaches to understanding context and implementing innovations (14). Successful integration of EBI content into curricula will depend on an in-depth understanding of how well an EBI aligns with a program’s philosophy, and how complementary fieldwork can reinforce students’ experiential learning of that intervention. Efforts should include partnering among training directors, academic faculty, community fieldwork supervisors, and representatives from accreditation/licensure boards. Mixed-methods research to identify and learn from champion programs that successfully integrate EBIs in their curricula could provide insight into factors that will facilitate scale-up across other programs.

Develop and evaluate education implementation strategies for the pre-service setting.

Emerging work suggests the benefit of shaping trainees’ attitudes toward EBIs in graduate fieldwork (12). More research is needed to develop and systematically evaluate novel education strategies (classroom and fieldwork based) that best prepare clinicians for successful EBI delivery (e.g., flipped classroom models, standardized patients, technology-assisted trainings, standardized fieldwork supervision). Ultimately, comparative effectiveness studies, conducted with input from adult learning theory and education experts, should examine the effects of a range of educational strategies on clinician EBI knowledge and skill acquisition to determine which strategies best prepare clinicians for sustainable EBI use after workforce entry.

Develop and evaluate multilevel implementation strategies to sustain and scale up effective educational implementation strategies.

Once effective educational strategies are identified, identifying factors that facilitate or impede their sustainability and developing plans to continually refine, evaluate, disseminate, and implement proven educational strategies across behavioral health pre-service settings will be important next steps.

Identify outcomes of successful implementation.

Short-term evaluation of efforts to integrate EBIs should include outcomes across contextual levels. Studies of educational strategies to improve clinician EBI use should examine outcomes in both classroom and fieldwork settings, as well as EBI attitudes, knowledge, and self-efficacy of key stakeholders (e.g., trainees, faculty, fieldwork supervisors). Long-term outcomes should address the sustainability of curricular changes, the impact on clinician EBI use after workforce entry, student perceptions of their level of EBI preparedness for entering practice, and faculty and fieldwork supervisors’ perceptions of EBI educational strategies.

Deciding Which EBIs Should Be Prioritized for Implementation in Pre-service Settings

Programs seeking to include EBIs in their curricula have an overwhelming number of interventions from which to choose (15). Most psychosocial EBIs are complex and require access to an expert supervisor to optimally support trainee knowledge and skill acquisition. No single EBI addresses all the clinical concerns a trainee will treat over their career. Furthermore, clinical interventions that are evidence-based today will likely be supplanted by new treatment approaches in the future. Encouraging graduate programs to teach EBIs that achieve current standards of evidence is important, but the longer term challenge is to ensure that curricula keep pace with scientific progress.

To ensure that graduates are equipped to deliver EBIs sustainably over the course of their career, pre-service education must provide fundamental skills to learn about and practice new interventions throughout their careers. This is the “hardware” a clinician needs to effectively deliver new EBIs (update his or her “software”) as science advances. Given the proliferation of treatment manuals in existence, some have argued for teaching a “common elements” therapeutic approach in graduate programs (6). However, alternative EBI models and frameworks exist, including transdiagnostic interventions, evidence-based principles, and measurement-based care (15). While empirical work is ultimately needed to determine which approach best prepares clinicians for evidence-based practice, we argue that interventions that best approximate the idea of a clinician “hardware”—such as intervention strategies that can support a variety of specific EBIs, like measurement-based care—should be prioritized for pre-service implementation, rather than specific treatments.

Conclusions

Improving EBI training in pre-service settings is an area ripe with potential to yield a powerful public health impact. While these benefits cannot be understated, efforts in this area are unlikely to succeed without effective partnerships among key stakeholders in graduate education. IS offers strategies to approach research in this area to maximize the likelihood of success.