Why Understanding and Involving the Customer Matters in Behavioral Health

Mat Roosa, LCSW-R
NIATx Coach

Treatment organizations continue to face the challenge of improving access to and retention in treatment. NIATx (originally known as The Network for the Improvement of Addiction Treatment) was developed specifically to help treatment providers make simple, powerful changes that can improve service delivery.

NIATx is based on five principles. The first principle, Understand and Involve the Customer, is number one for a reason. According to the research that was foundational to NIATx, this principle has more impact on the success rates of change implementation than all of the other four principles combined!

Listening to the voice of the customer
Everyone has heard the old business adage, “the customer is always right.” Many of us struggle with this concept. While a shoe store might take back a pair of shoes with half the sole worn off, do we really think that the customer is “right” to ask for the refund? Principle #1 helps us to understand just how right the customer always is.

There is no more important vision and voice than that of the customer. The customer is the only one who can tell us what they feel and what they want. The customer is always right about their perceptions of their experience, and that perception is the most important concern when we are trying to engage and help them. The best product or service will not be successful unless it is embraced by the customer.

So, what steps can we take to engage and involve the customer better?
I recall being at a meeting during which a veteran administrator was asked how recipients of services would feel about a major change. As he waxed on about a number of variables, I could see a supervisor of peer services, a woman with a great deal of lived experience as a service recipient, growing more and more frustrated. When he took a breath, she simply said, “Why don’t you just ask them?”

Why don’t we spend more time “just asking them”? The asking of customers requires that we treat them as partners at the table of service development and service improvement. While most would say they are willing to ask, fewer are willing to invest the time and ready to relinquish the control that is required for genuine asking. The walk-through, the Empathy Map and the Nominal Group Technique are three tools that will help teams to build a culture that values customer input.

The walk-through
One essential NIATx tool is the walk-throughThis role play exercise in which staff walk through the client experience is typically conducted at the beginning of the change project and helps teams see treatment barriers and process problems that are often hiding in plain sight. Walk-through exercises have uncovered issues such as an incorrect phone number listed as the agency contact information, poor directions to the treatment location, confusing signage at the facility, unwelcoming waiting areas, and lengthy intake sessions that require excessive or duplicative paperwork.

Here are a few tips for ensuring a successful walk-through:

1. Inform your staff: The team should be prepared for the experience. You want to see the process at its best, and then consider how it can be improved.

2. Stay in your role: complete the process in an authentic fashion.

3. Note the details of the process, and your emotional experiences

4. With each step of the process ask two questions: Is this necessary? If yes, Is it the best that it can be?

The Empathy Map
What do your customers say, think, feel, and do? What are their goals? Draw a large version of the Empathy Map grid, and ask your team members to write single ideas on sticky notes to be placed in the five sections of the grid. This tool will cultivate empathy for your customers’ experiences. It can serve as a way to gather all of the wisdom that customers have shared with administrative and treatment staff over time, and can help to identify key themes that will lead toward improvements. These questions are also an excellent structure for asking customers for feedback through interviews or focus groups.

The Nominal Group Technique
Using the Nominal Group Technique (NGT), another essential NIATx tool, is an excellent way to brainstorm with a team that includes customers, The structure of the process is designed to create inclusive participation among the team members. The four steps of the NGT process are intended to ask a powerful question and encourage listening to all of the answers offered. It can empower customers, and teach staff members about the value of the customer voice.

Four steps of the NGT

The walk-through, Empathy Map, and the NGT: three critical tools for understanding and involving the customer, and understanding just how right the customer is.

About our guest blogger:
Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development and planning, evidence-based practice implementation, and also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration.

You can reach Mat at: matroosa@gmail.com

ECHO-CMU for ATTC 25th Anniversary: SEA-HATTC’s expansion of new learning strategies

Behavioral health is a major problem while ongoing health workforce shortage is global issue. SEA-HATTC signed MOU with Missouri Telehealth Network, University of Missouri for utilization of ECHO® model and software to conduct virtual clinics via multi-point videoconferencing also extend behavioral healthcare knowledge and tele-consultation to primary care and community hospitals in the upper northern Thailand.

To promote the expansion of new learning strategies, SEA-HATTC mapped out an implementation of behavioral health ECHO® (Extension for Community Healthcare Outcomes) model as a guided practice strategy for transforming medical education and increasing workforce capacity to teach best-practice specialty care.Having been endorsed as a highly innovative strategy that produces improvements in the quality and efficiency of integrated care, ECHO is a low-cost yet high-impact intervention linking expert inter-disciplinary teams of practitioners through tele-education.

A regular monthly 60-minute tele medical education on ‘behavioral health’ under ECHO-CMU Project has been launched for doctors, nurses, psychologists and nutritionists.The goal is to manage and control of chronic disease through behavioral health interventions. ECHO-CMU has 4 sites in Chiang Mai, Chiang Rai, Lamphun and Lampang Provinces all are the provincial hospitals located in the upper northern region of Thailand. Hub is located at SEA-HATTC Office, Department of FamilyMedicine at Chiang Mai University. Spokes are residents of Family Medicine in in-service training program.

To date, there are 75 health professionals (excluding Hub team) participating. Sessions under behavioral health theme included ‘care for patients with EMCO stroke’; ‘multidisciplinary approach for self-management support’; ‘approach and management for delated development at child’; ‘MI and counseling’; ‘health behaviors and behavior change’; ‘caring past stroke patients’;‘depression’; ‘deconditioning’; ‘nutrition for patient with NCD’; ‘dealing with alcohol and smoking in chronic disease patient’; ‘ updating guideline for NCD’; ‘diet for DM’; ‘exercise for elderly with chronic disease’, and etc., as the model shown below.

The clinics are supported by basic, widely available teleconferencing technology. During teleECHO clinics, primary care clinicians from multiple sites present patient cases to the specialist teams and to each other, discuss new developments relating to their patients, and determine treatment. Specialists from Faculty of Medicine, Chiang Mai University and Mahidol University serve as mentors and colleagues, sharing their medical knowledge and expertise with primary care clinicians. Essentially, ECHO® creates ongoing learning communities where primary care clinicians receive support and develop the skills they need to treat a particular condition. As a result, they can provide comprehensive, best-practice care to patients with complex health conditions, right where they live.

Besides the behavioral health theme of the pilot ECHO-CMU, the upcoming theme will be provided on ‘Caregiver of NCDs Geriatric Patient’ targeted to primary care practitioners, co-health workers, village leaders and health volunteers.

Given the limited project budget and the vast geographic spread of the target countries, SEA-HATTC introduced ECHO model to the regional advisory board members as an effective multi-point videoconferencing platform in extending HIV/addiction technology transfer and tele-consultation to health and social workers in Tier 1 countries including Cambodia, Lao PDR, Myanmar plus India and Indonesia for workforce development within the Southeast Asia region.

Workplace Learning: Helping Practitioners Work Wiser

Nancy Roget, Joyce Hartje & Terra Hamblin 
CASAT, University of Nevada Reno 

After 25 years of conducting training workshops, translating research into bite-size pieces for curricula or stand-alone products, and creating opportunities for performance feedback to enhance skill development, the Addiction Technology Transfer Centers (ATTCs) are ‘upping their game’ to offer novel training/technical assistance (TA) options that include multiple learning components in new delivery formats focused on changing practices. 1, 2, 3 Leading these efforts in 2017-2018, the Pacific Southwest ATTC, which includes three partnering institutions: University of California at Los Angeles (UCLA); University of Nevada Reno (UNR); and Arizona State University (ASU), recently began implementing new training models for workforce development. Specifically, the Pacific Southwest ATTC based its new model on two of the principles derived from the work of Flexner4 and others 5:

  1. Learning is competency-based and embedded in the workplace
  2. All workers learn; all learners work
Typically, training for behavioral health professionals and recovery support specialists has been conducted offsite with staff traveling to the learning event (e.g., workshop or conference) rather than embedded within the workplace. While many behavioral health practitioners liked being out of the office to receive training, administrators frequently complained about loss of revenue (billable hours), which is a valid concern especially with many more complex EBPs requiring three- and four-day training events. Unfortunately, administrators used this rationale in some instances to decrease the amount of training practitioners could attend. However, limiting or eliminating training paid for by organizations in order to reduce costs and increase revenue is not a viable answer since training/TA can enhance the quality of service delivery and improve client-level outcomes. Workplace-embedded training is feasible and, like all ATTC-sponsored training, competency-based.

In 2018, the Pacific Southwest ATTC piloted several sequenced learning events delivered online during regular work hours over an extended period of time (4 to 8 weeks). Initial feedback showed that participants liked the format, although some still struggled with the technology. The Pacific Southwest ATTC is currently revising its sequenced workplace learning events to match lessons learned from the business and healthcare fields regarding increased team building and providing a context for the new skills.

Another significant contributor to this new method of delivering training/TA in the workplace is the work of Aaron and colleagues. 6, 7 These researchers found that administrators possessed significant influence (positive or negative) regarding the adoption of EBPs by their organizational staff. One concrete way administrators showed organizational support of workplace learning was by allowing employees to count the learning sessions as part of their work day schedule.

The Pacific Southwest ATTC is committed to making workplace learning a reality in the region by designing learning events that: are delivered online using easy and inexpensive or free learning platforms; include instruction/support on how to use the online learning platforms; are conducted during work hours; include team building exercises/assignments; use workplace-specific real life scenarios in case studies; include near-peer performance feedback; and ensure there is administrator support. Making workplace learning a routine practice for delivering competency-based training similar to other Fortune 500 businesses is the goal, culminating in the creation of innovative delivery of training events that increase access, decrease costs, and help practitioners and recovery support specialists work wiser.


  1. Edmunds, J.M. et al. (2013). Dissemination & implementation of evidence-based practices: Training & consultation as implementation strategies. Clinical Psychology: Science and Practice, 20, 152–165.
  2. Powell, B.J. et al. (2014). A systematic review of strategies for implementing empirically supported mental health interventions. Research on Social Work Practice, 24, 192–212.
  3. Herschell, A. D. et al. (2010). The role of therapist training in the implementation of psychosocial treatments: A review & critique with recommendations. Clinical Psychology Review, 30, 448–466.
  4. Flexner, A. (1910). Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston, MA: Ubdyke.
  5. Miller, B.M. et al. (2010). Beyond Flexner: A new model for continuous learning in the health professions. Academic Medicine, 85(2), 266-272.
  6. Aarons, G.A. et al. (2014). The Implementation Leadership Scale (ILS): Development of a brief measure of unit level implementation leadership. Implementation Science, 9(1), 45.
  7. Aarons, G.A. et al. (2016). The roles of system & organizational leadership in system-wide evidence-based intervention sustaniment: A mixed-method study. Administration and Policy in Mental Health, 43, 991-1008.

Trainer Development Efforts to Build a Competent Behavioral Health Treatment and Recovery Workforce in the Pacific Jurisdictions

Beth A. Rutkowski, MPH

In the 2012-17 funding cycle, the Pacific Southwest Addiction Technology Transfer Center (Pacific Southwest ATTC) region was expanded to encompass HHS Region 9. Formerly serving only California and Arizona, the Pacific Southwest ATTC now also serves Nevada, Hawaii, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Republic of the Marshall Islands, and Republic of Palau.

One strategy employed to service the unique and varied needs of the Pacific Jurisdictions was to join forces with the SAMHSA-funded Pacific Jurisdictions Workforce Development Initiative. This initiative began in 2011 to develop local expert trainers, grooming to provide the on-the-ground training and technical assistance to local behavioral health providers.

Topics were determined by each jurisdiction to address local needs (e.g., Matrix Model treatment, SBIRT, adolescent treatment, culturally responsive treatment and prevention). During the first year of the project, participants visited host sites in the mainland United States to gain experience from organizations providing services in their chosen focus area.

In March 2013, the Pacific Southwest ATTC, in partnership with the Pacific Behavioral Health Collaborating Council (PBHCC), conducted a conference attended by 27 individuals from the six Pacific Jurisdictions, along with representatives from the SAMHSA’s CSAT, CSAP, CMHS, and the Regional Administrator, HHS Region 9 (Dr. Jon Perez).

Participants engaged in meetings that focused on developing participants' skills in training and technical assistance. Each participant provided training on their focus area to peers and invited guests, and received individual coaching to improve skills. Participants heard from Drs. Thomas Freese (UCLA ISAP) and Steve Gallon (Oregon Health & Science University) on effective training and technical assistance strategies. Participants were also invited to UCLA ISAP to hear from ISAP's principal investigators about domestic and international research activities. The four-day conference ended with a recognition ceremony.

Access to local training and technical assistance experts is essential for the Pacific Jurisdictions. These island nations span an area of ocean larger than the continental United States. Their total land mass (669 islands and atolls spread across 5 million square miles of ocean) is smaller than the five states of New England. The total population of the Pacific Jurisdictions is approximately 451,000, and 19 languages are spoken. The island populations self-identify predominantly as native to their island, although segments of the populations are Filipino (5%-26%), Chinese (2%–5%), "other" Pacific Island background (2%–8%), and 2%–6% Whites or “other.”

Since 2013, the Pacific Southwest ATTC has visited Hawai’i and five of the six Jurisdictions on more than 15 occasions. The days are long, but the relationships developed and impact made is most satisfying. Recently, with supplemental funding from the PBHCC, Drs. Thomas Freese and Chris Rocchio and Mr. Alex Ngiraingas, an expert trainer from Palau, traveled to Pohnpei, FSM, to conduct a weeklong Alcohol and Drug Certification (ADC) Academy, to prepare providers to challenge the IC&RC certification exam. Because of this intensive weeklong training experience, eight people achieved regional certification, and one person achieved international certification. This increase in certified counselors represents a huge improvement in building a larger, more competent behavioral health workforce in the Pacific.