The workforce development themes and approaches reviewed above represent an illustrative subset of options for consideration as the mental health field endeavors to improve professional competence and the adoption of EBPs. It appears unlikely that the use of traditional workshop models or any single strategy will result in success. As described above and displayed in , the specific approaches actually comprise multiple overlapping techniques. Based on our review, we identified nine techniques (interactive didactics, goal identification, small group discussion, critical thinking, self-reflection, peer collaboration, independent access to information, direct feedback, and follow-up) that were shared by at least two of the selected approaches. Additionally, multiple approaches reviewed above (e.g., AD, Reminders) have been found to be most effective when combined with other approaches. In their classic study, Oxman et al. (1995)
reviewed 102 training studies and found that individual approaches typically demonstrate modest effects, but that the effects increase when they are used in combination. In developing training programs, combinations of approaches and techniques should be carefully selected in order to match the content of the intervention or practice being trained, the individual practitioner, and the service setting (including organizational context and the client population served; Beidas and Kendall 2010
). Issues of trainee motivation and engagement should also be carefully considered.
With these overarching recommendations in hand, the primary question becomes: which
approaches should be considered when developing a training and workforce development plan? As stated previously, the concepts discussed demonstrate a wide range of research support with regard to their effects on provider behavior. Further, the studies themselves display a wide range of methodological rigor. Some studies, particularly those within the medical field, provide relatively convincing results that substantiate the use of particular approaches (e.g., academic detailing, reminders) to support the acquisition and application of new behaviors. Simultaneously, other approaches (e.g., SRL) have received little rigorous study. Very few studies have been conducted that provide “head-to-head” comparisons of different approaches, making it difficult to lay out clear recommendations for use. Furthermore, because each of the training approaches reviewed combines several techniques (e.g., assessment, feedback, discussion of specific cases), tightly controlled comparisons are difficult to implement and no outcome data are available at the technique level. Meta-analyses of training components help to fill this gap, but the lack of direct comparisons limits conclusions that can be drawn about the most effective training models (Grimshaw et al. 2001
). Future research should begin to “unpack” and systematically vary the use of different techniques in training studies.
In addition, most evidence has been generated in contexts and settings that are quite distinct from those in which mental health practitioners are asked to implement EBPs. Nonetheless, certain approaches have been relatively well-established and should be considered. For example, despite the significant demand on the consultant (and resulting high costs), intensive coaching or mentoring of some form will likely be necessary to bring about the complex behavior change required when implementing new therapies. Coaching could be augmented by the use of reminders or checklists, which are moderately effective and can be implemented at a low cost. As expert coaching is gradually tapered, a transition to peer coaching and reminders could continue to support sustained provider implementation of new practices.
Even the approaches with less of an empirical foundation may have utility. This is especially true given the consistent finding that “training-as-usual” (i.e., single-shot training methods) is largely ineffective. In light of this, existing methods could likely be replaced with little risk of reducing the impact of training-as-usual. Depending on the context and the EBP, the approaches with stronger support may be enhanced by making the training interdisciplinary (i.e., IPE), emphasizing real-world clinical examples (i.e., PBL), and promoting self-regulated learning as a means of monitoring and facilitating fidelity and effectiveness.
Looking beyond the level of research support for different training approaches, the mental health service delivery field must also consider the question of fit and how those approaches function in the context of different trainees, EBPs, settings, and client populations.
For example, although academic detailing may not be very appropriate as a first-line method to reinforce a large number of complex skills that are expected of a practitioner learning a new EBP, it may be highly effective at reinforcing some key decisions that must be made in the process of evidence-based service delivery, such as considering placement options for an individual child or youth, encouraging staff and supervisors to look carefully at assessment data, or ensuring that an individual consumer is matched to an appropriate EBP. Academic detailing may also be highly important during the exploration and initial installation stages of EBP implementation (Fixsen et al. 2005
), when opinion leaders must be mobilized to support practitioners to be motivated to apply new techniques. Similarly, interprofessional or team-based training approaches may be most effective for complex, multicomponent interventions that involve team-based implementation or otherwise require contributions from collaborators across many disciplines and/or systems, such as Assertive Community Treatment (Stein and Santos 1998
), or the wraparound process (Bruns et al. 2008
). As described in vivid terms in the Haynes et al. (2009)
study on reducing surgical complications and deaths, reminders and checklists also have been found to be highly effective at reinforcing both practitioner competence as well as team functioning in complex interventions, and should be considered in behavioral health interventions that share these characteristics. As a final example, problem-based learning may be a highly appropriate training component to include in the new array of modularized intervention approaches that, rather than demanding a standardized sequence of steps or activities, ask practitioners to link a complex set of concepts, principles, and clinical techniques to a diverse range of clinical presentations (e.g., Chorpita et al. 2009
A surprisingly consistent aspect of the different literatures reviewed here is that studies have largely neglected to include outcome data for service recipients (Garet et al. 2001
; Muijs and Lindsay 2008
), a point that is reflected in . Although intervention fidelity represents an essential outcome for training and implementation studies, more research in the mental health field should include client-level variables (i.e., symptom change) as additional outcome data. Not surprisingly, effects of provider training on service recipients are typically smaller than their effects on provider behavior (Forsetlund et al. 2009
). Transfer of training or implementation fidelity could be included as key mediator variables when examining the relationship between training and client outcome.
Finally, even with mounting evidence to support the use of various training approaches, virtually no research has attended to the mechanisms responsible for the documented links between their use and observed professional outcomes. In much the same way that the field of psychotherapy has become increasingly focused on identifying mediators of treatment outcome, it will be important for training research to identify its own set of mediating variables. Potential training mediators may include improved team functioning as a result of IPE, use of deductive reasoning following PBL and SRL, or increased self-awareness after coaching.