Embracing Change: Mapping Problems and Solutions in Troubled Times—The South Carolina Cognitive Behavior Therapy Training Initiative

By Pamela Woll, Southeast Addiction Technology Transfer Center

Like much of the substance use disorders (SUD) treatment field, South Carolina’s providers experienced the early impact of COVID-19 as a steep rise in the need for services combined with a steep decline in capacity to meet that need. In communities, fear, isolation, loneliness, and financial stress escalated, while social support diminished. Traditionally marginalized populations were disproportionately affected.

Many individuals were already deeply troubled long before the pandemic hit. For decades, more and more people had been: 

  • suffering the effects of early, chronic, intergenerational, historical, and/or racial trauma; 
  • deeply affected by inequities and disparities in the social determinants of health, diminishing their resilience and resources;
  • afflicted with multiple substance use disorders, mental health conditions, and chronic physical health conditions; and/or 
  • bearing the social, psychological, and financial burdens of years spent in the foster care, juvenile justice, and/or criminal justice systems, or on the street.

 Meanwhile, the pandemic made in-person services more dangerous, so the field experienced severe reductions in resources, treatment capacity, time to connect with clients, and face-to-face mentorship and peer support for staff. Clinicians needed training in interventions that would: 

  • be easily transferrable to Zoom and telehealth; allow practitioners to make more progress in shorter sessions; 
  • provide coping skills to help clients solve problems even with reduced clinical and social support;
  • and include clinical supervision, booster sessions, mentorship, training of trainers, and support for fidelity.

One category of interventions that fit all those criteria was Cognitive Behavior Therapy (CBT), a well-supported evidence-based approach that helps people learn to work with the thoughts, feelings, and actions that keep them stuck in counterproductive patterns (Carroll & Kulik, 2017, p. 847).


The South Carolina Cognitive Behavior Therapy Training Initiative

In 2020, Roberta Braneck, State Opioid Response Director for South Carolina’s Department of Alcohol and Other Drug Abuse Services (DAODAS), requested intensive training on CBT across the statewide system. The Southeast Addiction Technology Transfer Center (SATTC) responded through the efforts of James Campbell, LPC, LAC, MAC, AADC, Training and Technical Assistance Manager.

Together they identified a trainer for the series, R. Trent Codd, III, EdS, LCMHC, Executive Director, CBT Center of Western North Carolina. The team developed a strategic training plan, using implementation science principles to foster sustainability and maintain clinical gains far beyond the end of the formal initiative.

The series began in the first five months of 2021, with multiple sessions in each step of a process that included:

  • Initial Training (four hours), Skill-Building Sessions (six hours), 
  • Clinical Supervision Sessions (eight hours), 
  • Booster Sessions (four hours), and 
  • Training of Trainers (four hours).

 A total of 170 participants logged into the initial general content session, with subsequent sessions tailored to smaller groups to increase opportunities for discussion and skill practice. 

 A Focus on Conceptualization

The training subject might not be on the cutting edge, but the trainer’s approach has been innovative and well-tailored to our contemporary challenges. According to Codd, the series has focused, not on the activities that most people think of when they hear “CBT,” but on the conceptualizations that guide clinical decision making.

“I’m a big believer that the conceptualization is one of the biggest things that defines CBT,” Codd said. “The interventions are almost secondary to how people conceptualize what is maintaining the client’s problems, and how they use that conceptualization to develop their treatment targets. If you focus on the technique itself, that’s just the shiny object. Outcomes are really related to the conceptualization, not the interventions.”

The CBT conceptualization process helps clinicians encompass the many thoughts, feelings, and actions that clients disclose, allowing them to isolate those that offer the best opportunities for intervention. If clinicians work in teams, conceptualization can help the team create a shared “map” for more effective communication.

According to Codd, one of the most important reasons for a focus on conceptualization is the complexity of the internal, relational, and environmental challenges that many clients are facing. “Conceptualization tells the clinician how to modify the treatment based on all these factors,” he said. “It’s not a magic pill, but it gives clinicians a good working map that they can flexibly adapt across a wide range of factors.”

Participant evaluations and individual feedback showed strong positive responses to Phase One, though the most valuable data will not be available until the Initiative’s next phase. It starts with a six-hour CBT Fidelity Training in October 2022, with registration still open to South Carolina practitioners.

Reference

Carroll, K.M. and Kiluk, B.D. (2017). Cognitive behavioral interventions for alcohol and drug use disorders: Through the Stage Model and back again. Psychology of Addictive Behaviors, 31(8), 847-861.

Embracing Change – Diversity and Connectivity in behavioral health

By Dr. Susie Villalobos, Director, National Hispanic and Latino Addiction & Prevention Technology Transfer Centers

The lives and livelihoods of many Hispanic and Latino Americans were deeply affected by the impact of COVID-19. The spotlight reminded us of the continued racial and ethnic inequalities in health and healthcare. The quality, experience, and access remain stagnant as the socio-economic vulnerability increased issues of substance use, mental health disorders, and overall negative outcomes (Goldman, N., 2018).

The National Hispanic and Latino ATTC and PTTC continue to collaborate with community agencies and Regional TTCs around the nation in serving the afflicted diverse communities. A common word used in the development of our products is "resiliency"!

Resiliency of the community. Courage of the individual. And pride in the culture.

Hispanic Heritage Month

The Hispanic population in the United States is the largest ethnic minority with over 60.6 million people (Ramirez, A.G., 2021). This year's theme for Hispanic Heritage Month, "Unidos: Inclusivity for a Stronger Nation" imparts the reinforcement of diverse voices and perspectives in building stronger connections.


From September 15 through October 15, we celebrate the Hispanic/Latino and Latinx culture, focusing on the heritage of our diverse citizens from the Latin American countries of Brazil, Spain, Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Colombia, Venezuela, Ecuador, Peru, Bolivia, Paraguay, Chile, Argentina, Uruguay, Cuba, Puerto Rico, and the Dominican Republic.

As the NHL-ATTC and PTTC and parent agency the National Latino Behavioral Association (NLBHA), we celebrate our culture during the month by promoting diversity and the success of the contributions Hispanic Americans have made throughout history. Our National Latino Behavioral Health Conference on September 15 and 16 at the Sahara Hotel in Las Vegas, Nevada, coincides with the beginning of Hispanic Heritage Month. The conference agenda highlights the innovative, culturally responsive, and linguistically appropriate workshops from across our networks. Our keynote speakers will highlight the theme of our conference focusing on Latino Behavioral Health Equity, and finish the two-day event in a charity celebration on 16 de Septiembre with a musical tribute to Selena and Vicente Fernandez, while raising money for students studying in the field of behavioral health.

Connecting with community

Collaborative efforts by the NHL-ATTC and PTTC have produced three exciting new learning series focused on the workforce development of behavioral health providers working with Hispanic/Latino/Latinx communities.

Our first series dug deep into Understanding, Going Through, and Managing Loss, Grief, and Bereavement: Life with the Covid-19 pandemic for Latinos with a view on Latino Men. The series was led by Elizabeth Robles, a certified thanatologist, and garnered over 200 attendees.

The second virtual learning series, “A Cultural Adaptation of Screening, Brief Intervention, and Referral to Treatment, (SBIRT) for Working with Hispanic and Latinx Communities” led by Diana Padilla, talks in depth about the foundational cultural principles of “Cultural Humility” and “Culturally Responsive Services” and the relevancy of beliefs, practices, and linguistic needs of diverse communities.

And finally, wrapping up with Dr. Marilyn Sampilo in a four-part series entitled: Accelerating Training in Behavioral Health Equity: A Learning Series for Trainees, designed to enhance education and training related to health equity for current behavioral health trainees.

Embracing equity

As we end Year 4 with a menu of services for our Hispanic/Latino/Latinx serving agencies, we are proud to move forward with new collaborations on the horizon.

We have plans for a national assessment in identifying the needs of our Spanish-speaking peer recovery specialists. Our podcast Latinos Con Voz, produced by our ATTC and PTTC team, created over six series, in English, Spanish and Portuguese, and will develop new episodes focused on Suicide Prevention, Stimulant use Treatment, and Trauma Informed Care in rural communities.

Our fifth issue of the Cultivating Wellness newsletter will be out in September. With the development of these products, we promote and advocate for a shift in understanding an intersectional approach among providers, that considers structural and impactful factors in bridging health advocacy and social equality.

Inequality of services plays a central role in determining one's mental health, opportunity, and well-being. 1 in only 10 Latino citizens in the U.S. seeks mental health services (Vahratian, A., 2021).

We heed the call to increase access and build a behavioral health workforce that mirrors its population. Only then do we facilitate equity, embrace change, and promote access to basic human rights including health. We look forward to our fifth year as a National Hispanic Latino ATTC and PTTC to continue our work for multilingual programming, influencing health advocacy, and impacting the experience of underserved groups to inspire large-scale systems change.

About the author:

Dr. Susie Villalobos is the Director for the National Latino Hispanic Addiction and Prevention Technology Transfer Centers. Before joining NLBHA, Dr. Villalobos had worked with academic institutions and non-profits as a public advocate and researcher by implementing and managing clinical and socio-behavioral studies/programs. Her expertise in working with local, State and Federal agencies stems from her associations with CBO’s focused on activities committed to focusing on health disparities among Latino populations living and working on the U.S. – Mexico Border. Dr. Villalobos in her capacity as Regional Evaluator for the State of Texas, in Public Health Region 10 provided leadership in data analysis, data optimization, policy analysis and forecasting. She is a 2020-2021 graduate from the National Hispanic Latino and National Latino Behavioral Health Leadership Academy. She is particularly passionate about tackling issues faced by Latino populations across, age, race, gender, and biographical location.

Dr. Villalobos received her doctorate degree in Educational Administration and Leadership from the Department of Education at the University of Texas at El Paso and a master’s degree in Educational Psychology/focused on Community Counseling from the Department of Education at the University of Texas at El Paso.

Read this article in Spanish.

Read this article in Portuguese. 

References:

Goldman, N., Glei, D. A., & Weinstein, M. (2018). Declining mental health among disadvantaged Americans. Proceedings of the National Academy of Sciences, 115(28), 7290-7295.

Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino population from obscurity to the forefront of health care, public health intervention, and societal presence. JAMA, 326(7), 597-598.

Vahratian, A., Blumberg, S. J., Terlizzi, E. P., & Schiller, J. S. (2021). Symptoms of anxiety or depressive disorder and use of mental health care among adults during the COVID-19 pandemic—United States, August 2020–February 2021. Morbidity and Mortality Weekly Report, 70(13), 490.

Embracing Change: This Recovery Month, BHPs should take steps to recover from burnout

By Alexander Waitt, co-project director, Central East ATTC 

As we recognize Recovery Month, let’s take a moment to talk about burnout in the helping profession, and what we can do to help Behavioral Health Professionals “recover” from the pandemic and its fallout.

People are leaving the helping profession left and right, and there isn’t a consensus as to why. Nor, more importantly, what is needed to close the floodgates. Is it higher pay? Better work conditions? More training? 

 

While COVID-19 was responsible for added burnout and compassion fatigue leading to individuals leaving the helping profession (Elsevier, 2022). The healthcare sector has been at a breaking point for many years. COVID-19 was the straw that broke the camel’s back, leaving community leaders, stakeholders, and organizational administrators wondering how we get back to a place of retaining and developing a solid workforce. 

A black man's hands are in a meditative pose.

 

My response to the question, “What can be done to keep professionals in the field?” involves the follow-up question, “What is your organization currently doing to help your workforce establish a healthy relationship with their work?”

 

In my years of working in the healthcare sector, as a counselor, consultant, and administrator, what I believe to be true is that people long for their work to be meaningful and for their work contribution to be noticed and acknowledged. The tangible things like a competitive wage, a supportive and safe work environment, and the tools to be successful at one’s job are of utmost importance. And, if the environment around them doesn’t allow professionals to connect and continuously reconnect with the why that brought them to the field, people will become burnt out, exhausted, and leave that much faster.

 

I don’t offer a simple answer because the problem is multi-faceted. It requires a solution as dynamic as the problem itself. 

 

I would never advocate for anyone to stay in a profession that isn’t healthy for them. But perhaps what is needed for a struggling behavioral health professional is a different type of support, not an exit.

 

For the last 10 years of my career, I’ve had my professional ups and downs. What’s helped me get through my hard times is developing a healthier relationship with self-care. Self-care is a topic that is talked about a lot, identified as needing to be taken seriously, and that many professionals struggle to engage. I’ve spent a lot of time figuring out what taking care of myself truly means and it’s something that is always evolving. 


Taking care of myself in my twenties is different than taking care of myself now. 


If you’re in the healthcare profession, examine these resources that have the potential to build a healthier relationship with your self-care practices.

 

While better pay and safer work conditions are not just band-aids and will serve to keep some frontline workers in the field, it leaves me wondering: what else is contributing to the mass exodus of individuals leaving the helping profession?

      

I wish I had the opportunity to ask anyone leaving the helping profession, “What drove you to decide to have a career in this field, to begin with?” I feel confident that most responses to the above question do not include financial compensation and safe work conditions. Why? Because what drives most people to the helping profession is personal. It’s as simple for most as a desire to help. Many in the field are driven by their own experiences of being helped. 

 

Professional wages and safe working conditions are not things that drive people to this vocation. They are the things that ensure a quality of life that allows a helper the opportunity to continue to give to others without having to worry about themselves.  

 

If you could go back and do the last 10 years of your professional career again, would you? 


At times, I think it is natural in one’s career to explore where you are. To reflect on both the work you’ve done and how you feel about the work you’ve done. 


I had a wonderful mentor in my career express to me that people who find personal meaning in their professional work tend to do it better, get more fulfillment out of it, and experience joy when working. Can you imagine that; on a daily basis, experiencing joy while working!? Those of us who can say yes to that question consider ourselves fortunate.

 

We owe it to ourselves to engage in self-reflection and exploration, even more so if we’re struggling. For those considering leaving the helping profession but haven’t yet, please reconsider. Take some time away to think through your change. 

 

I would encourage you to reflect on and reconnect with the personal experiences you had during your formative years that contributed to your decision to take this career path. Spend time reflecting on or connecting with the mentors who inspired you to keep going early on in your career. Remember those you’ve helped and think of those you’ll help in the future. 

 

While we advocate for the value of our profession to be reflected in certain tangible things, we must also never lose touch with what brought us and has kept us here. It will serve the well-being of all of us and our professions to remember what brought us here, to reconnect with your passion.


Editor's note: SAMHSA just released a new product, "Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies."


 

References:


Elsevier, March 15, 2022. Doctors and nurses worldwide point to a roadmap to future-proof healthcare, [Press release] https://www.elsevier.com/about/press-releases/corporate/doctors-and-nurses-worldwide-point-to-roadmap-to-future-proof-healthcare

Embracing Change: Leading Through Change - Essential Skills for Managers in Behavioral Health Settings

 By Beth Rutkowski, MPH, and Michael Shafer, Ph.D.

Behavioral health and recovery support professionals operate within interdisciplinary, multi-professional teams of providers. Behavioral health professionals frequently find themselves serving as site managers, team leaders, shift leads, clinical supervisors, and other middle-management positions. In these positions, behavioral health professionals are often called upon to perform tasks and functions for which their clinical training program did not provide adequate preparation. 

 

Among these roles is that of team leader. In these capacities, team leaders serve as facilitators of team development, cohesion, and action, including the implementation of new practice routines. Facilitators help others get things done. Effective team leaders work best by promoting inclusive engagement in team decision-making and team responsibilities among all members of the team.

 

The PSATTC developed and pilot tested an intensive technical assistance model designed to enhance internal change capacity within substance use disorder treatment and recovery support organizations. 


A bunch of white arrows pointing to the right, while a single red arrow in the middle points to the left.


 

For the past three years and amid the COVID-19 pandemic, 77 individuals representing 32 agencies participated in intensive training on change management facilitation and effective facilitation skills. Participating agencies launched change teams and engaged in a series of actions designed to identify and prioritize issues in need of improvement. The teams then designed and carried out a series of implementation steps while ensuring executive sponsor engagement and support. 

 

Drawing upon traditions of group work and systems theories, while integrating elements of process improvement, including NIATx, the Organizational Process Improvement Initiative (OPII) was designed to develop internal change facilitator(s) and internal change capacity within organizational units or teams, as opposed to deploying an external facilitator/consultant technical assistance model. In this approach and as we emphasized to our participants, we were "change agnostic." In contrast to more narrowly focused process improvement or EBP implementation-focused technical assistance approaches, the OPII provided teams with the skills and a structure for launching and sustaining changes they had prioritized with executive leadership endorsement.

 

The beginnings of the COVID-19 pandemic occurred a month after launching our second cohort as 37 individuals completed three days of in-person training on the OPII and change facilitation. Learning lessons from our first-cohort experiences, teams left with PSATTC faculty site visits scheduled within the next 45 days to ensure the launch of local agency change teams and the beginning of a 9-12-month structured change plan process.

 

Remarkably, most of these participating agencies ultimately returned to their change efforts and engaged in the OPII change model to varying degrees of success. 


For the next two years, our PSATTC team made radical changes in our approach and the platforms and tools available to us to provide intensive technical assistance.

 

As we approached the launch of our third cohort, we did so with a recognition that everything that the PSATTC provided had to be delivered virtually and that every agency participating in the cohort would be doing their local change facilitation work virtually, as well. We threw out our tried and true "three-day, in-person, intensive training workshop," and replaced it with a five-week, eight-session, 21-hour virtual training Academy. We planned for local agency change teams to be convening virtually, with some agency personnel working from home while others were in the clinic. We required participating agencies to purchase (a cost of ~$200) and utilize MIRO, a virtual collaboration application, for local change team meetings. We utilized MIRO as our instructional delivery platform and pre-populated numerous pages and templates for use during the training that change facilitators could copy and use with their team.

 

The pandemic served as a major innovation disruptor to our team, causing us to pivot to the new realities that COVID-19 brought, not only in how we engaged with agencies to deliver intensive technical assistance but also how change was occurring within these agencies and the types of changes that they prioritized to address. Recognizing that the participating agency-based teams, like our PSATTC team, were living and breathing Zoom, we came up with a whole suite of no- and low-cost options for facilitating team meetings virtually. Jamboards, Mentimeter, Zoom polling, Google Docs, and Sheets replaced Flipcharts, masking tape, and Sharpies.

 

We discovered as a team and with our participating agencies that these virtual-mediated team facilitation tools provided, in many instances, more effective, inclusive, and efficient platforms than traditional and in-person devices.

 

As we emerge from the pandemic, we find ourselves challenged with integrating our newfound tools and experiences in virtually mediated technical assistance with some of our more traditional tools and devices. Supplementing our technical assistance “toolbox” with Jamboards and Zoom are perfect compliments to flipcharts and Sharpies in this post-COVID hybrid world within which we live!

 

Beth Rutkowski, MPH, has been associated with UCLA Integrated Substance Abuse Programs (ISAP) since December 2000, and currently serves as the Director of Training and Co-Director of the SAMHSA-funded Pacific Southwest Addiction Technology Training Center. In addition, she organizes and conducts conferences and trainings throughout the Pacific Southwest region, and has co-authored and edited several peer-reviewed research articles, book chapters, special issues, and technical reports on a variety of topics related to the treatment of substance use disorders.

 

Michael S. Shafer, Ph.D., is a Professor of Social Work at Arizona State University. Dr. Shafer has been associated with the Pacific Southwest ATTC for over 20 years, in addition to serving as Principal Investigator on multiple federally- and state-funded studies of implementation and inter-organizational collaboration. Shafer has published extensively in peer-reviewed journals, book chapters, asynchronous learning modules, and curricula.

NIATx Model Featured in Newly Released Classroom WISE Training Discussion Guide

By: Kristina Spannbauer, Great Lakes ATTC, MHTTC, and PTTC Communications Specialist

The Great Lakes Mental Health Technology Transfer Center School-based Supplement (SB-MHTTC) recently published a companion discussion guide for the Classroom WISE training program. Classroom WISE is a free, self-paced online course for educators and school staff that focuses on increasing mental health literacy in schools and developing robust and sustainable supports for students experiencing mental health distress and adversity. The Classroom WISE Discussion Guide is a supplemental training resource based on NIATx principles. The guide offers users a framework for integrating the Classroom WISE strategies in schools by applying evidence-based process improvement methods such as the nominal group technique (NGT) and PDSA (Plan, Do, Study, Act) rapid-cycle testing.

CLassroom WISE instructional material cover.
Recently, the Great Lakes SB-MHTTC also utilized the NIATx model as part of a school-based intensive technical assistance program (ITA) aimed at improving youth suicide prevention efforts. The educators who participated in the ITA reported how valuable NIATx was to the success of their initiatives. This positive feedback was, in part, the inspiration for creating the Classroom WISE Discussion Guide. The Great Lakes SB-MHTTC team recognized a unique opportunity to pair the NIATx model with the Classroom WISE curriculum to enhance the outcomes of the Classroom WISE strategies for educators and their students. 

The blending of both models provides more specific instruction on the steps required to successfully implement the training and how to measure change accurately and effectively over time as users complete the Classroom WISE training modules.

The NIATx model relies on implementation science and uses evidence-based practices to assist organizations through times of change in a collaborative manner that supports the organization’s goals and strengthens its infrastructure throughout the process. Furthermore, NIATx offers guidance on creating and facilitating work groups using nominal group technique—an approach emphasizing the equal representation of ideas, prioritizing organizational needs, and using data-driven decision-making to effect positive change. The inclusivity and equitable participation promoted by the nominal group technique is a vital component of successful process improvement as it explicitly includes the thoughts and opinions of everyone in the group—from the “executive” or those in leadership to the on-the-ground workers.

The Classroom WISE Discussion Guide is available for download on the Great Lakes Mental Health Technology Transfer Center’s products and resources website.  

The Classroom WISE training program was developed by the Mental Health Technology Transfer Center (MHTTC) Network and the National Center for School Mental Health (NCSMH) with funding from cooperative agreements with the Substance Abuse and Mental Health Services Administration (SAMHSA).

For more information about Classroom WISE, and to access the brand new Cultural Inclusiveness and Equity (CIE) WISE companion training series, please visit classroomwise.org.

Related Content:

Check out the June 2022 ATTC/NIATX Service Improvement Blog, “SUD and Beyond: Schools Use NIATx To Improve Youth Suicide Prevention Efforts” to read more about applying the NIATx model to school-based programs and services.