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