Competencies in Behavioral Health

Running head: COMPETENCIES IN BEHAVIORAL HEALTH

Workforce Competencies in Behavioral Health: An Overview
Michael A. Hoge, Manuel Paris, Jr., Hoover Adger, Jr., Frank L. Collins, Jr., Cherry V. Finn,
Larry Fricks, Kenneth J. Gill, Judith Haber, Marsali Hansen, D. J. Ida, Linda Kaplan,
William F. Northey, Jr., Maria J. O’Connell, Anita L. Rosen, Zebulon Taintor, Janis Tondora, &
Alexander S. Young
Michael A. Hoge, PhD is Professor of Psychology (in Psychiatry) at the Yale University School
of Medicine in New Haven, CT and Co-Chair of the Annapolis Coalition on Behavioral Health
Workforce Education. Manuel Paris, Jr., PsyD is an Assistant Professor of Psychology (in
Psychiatry) at the Yale University School of Medicine. Hoover Adger, MD, MPH is Associate
Professor of Pediatrics at the Johns Hopkins University School of Medicine and Director of
Adolescent Medicine at the Johns Hopkins Hospital in Baltimore, MD. Frank L. Collins, Jr., PhD
is Professor and Director of Clinical Training at Oklahoma State University in Stillwater, OK
and past member of the Board of Directors of the Council of University Directors of Clinical
Training & the American Psychological Association’s Committee on Accreditation.
Cherryl V. Finn is the Adult Mental Health Program Chief at the Georgia Department of Human
Resources, Division of Mental Health, Developmental Disabilities and Addictive Diseases in
Atlanta, GA. Larry Fricks is the Director of the Office of Consumer Relations for the Georgia
Division of Mental Health, Developmental Disabilities and Addictive Diseases in Atlanta, GA.
Kenneth J. Gill, PhD, CPRP is Professor and Founding Chair of Psychiatric Rehabilitation and
Behavioral Health Care at the University of Medicine & Dentistry of New Jersey – School of
Health Related Professions in Scotch Plains, NJ and Vice President of the Commission on
Certification of Psychiatric Rehabilitation Practitioners. Judith Haber, PhD, APRN, CS is
Professor and Director of the Master’s and Post-Master’s Programs in the Division of Nursing at
New York University in New York, NY and past Chair of the National Panel that developed the
Psychiatric-Mental Health Nurse Practitioner Competencies. Marsali Hansen, PhD, ABPP is the
Director of the Pennsylvania CASSP Training and Technical Assistance Institute in Harrisburg,
PA. D. J. Ida, PhD is Executive Director of the National Asian American Pacific Islander Mental
Health Association in Denver, CO and Fellow for the Asian Pacific American Women's
Leadership Institute. Linda Kaplan, MA is CEO of Global KL, LLC in Silver Springs, MD and
past Executive Director of the National Association of Alcoholism and Drug Abuse Counselors.
William F. Northey, Jr., PhD is a Research Specialist for the American Association for Marriage
and Family Therapy in Alexandria, VA and Principal Investigator of the CSAT sponsored
Practice Research Network. Maria J. O’Connell, PhD is an Associate Research Scientist in the
Department of Psychiatry at the Yale University School of Medicine. Anita L. Rosen, PhD,
MSW is Director of Special Projects at the Council on Social Work Education in Alexandria, VA
and Project Manager for the John A. Hartford Foundation of New York City’s SAGE-SW
Gerontology Initiative at CSWE. Zebulon Taintor, MD is Professor and Vice Chairman of
Psychiatry at New York University School of Medicine in New York, NY.
Janis Tondora, PsyD is an Assistant Clinical Professor of Psychology (in Psychiatry) at the Yale
University School of Medicine. Alexander S. Young, MD, MSHS is the Director of the VA

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Desert Pacific MIRECC Health Services Unit and Associate Professor of Psychiatry at UCLA in
Los Angeles, CA.
This work was supported in part by Contract No. 03M00013801D from the Substance Abuse and
Mental Health Services Administration and is in the public domain.
Address correspondence to: Michael A. Hoge, Ph.D., Yale Department of Psychiatry, 25 Park
Street, 6th Floor, New Haven, CT 06519. Phone: (203) 785-5629. Email: [email protected]

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ABSTRACT
Competency-based training approaches are increasingly being used in healthcare to guide
curriculum content and to ensure accountability and outcomes in the educational process. This
article provides a comprehensive overview of the state of competency development in the field
of behavioral health. Specifically, it identifies the groups and organizations that have conducted
and supported this work, summarizes their progress in defining and assessing competencies, and
discusses both the obstacles and future directions for such initiatives. A major purpose of this
article is to provide a compendium of current competency efforts, so that these might inform and
enhance ongoing competency development in the varied behavioral health disciplines and
specialties. These varied resources may also be useful in identifying the core competencies that
are common to the multiple disciplines and specialties.

Key Words: competencies, training, assessment, behavioral health

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INTRODUCTION
There have been growing concerns about the quality of heath care in America. As the
Institute of Medicine (2001) has focused its attention on potential strategies for improving the
safety and effectiveness of services, it has called for a vigorous effort to develop a workforce that
possesses a well-defined set of core competencies (Institute of Medicine, 2003a). In a similar
vein, the organization that accredits medical residency programs has mandated that such
programs demonstrate the knowledge and skill of their students on a specific set of common
competencies (Accreditation Council for Graduate Medical Education [ACGME], 1999).
There are parallels to these trends in the field of behavioral health. For example, in its
report to the President, the New Freedom Commission on Mental Health (2003) raised major
concerns about the quality of mental health care in the United States. It identified a “workforce
crisis” and called on training and education programs to offer a curriculum that “…incorporates
the competencies that are essential to practice in contemporary health systems” (pg. 75). With
respect to substance use disorders, the Strategic Plan for Interdisciplinary Faculty Development
(Haack & Adger, 2002) noted the historic lack of attention on addictions issues in the training of
the healthcare workforce, and called for four core competencies on substance use disorders to be
incorporated into all health professions education.
Over the past decade, major efforts to identify and assess competencies in behavioral
health have, in fact, begun. This article provides a review of the current status of those efforts. A
total of 13 topic areas or initiatives in competency development are examined. These are
organized into four categories: (1) substance use disorders (addiction counseling;
interdisciplinary health professionals); (2) disciplines (marriage and family therapy, professional
psychology, psychiatric-mental health nurse practitioners, psychiatric rehabilitation, psychiatry,

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social work); (3) populations (children; serious and persistent mental illness); and (4) special
approaches to care (recovery, cultural competency, peer specialists). While not exhaustive of all
activities, this review captures some of the most prominent initiatives in the field.
Competency development in behavioral health can be described as a patchwork quilt of
initiatives that have been conducted independently. We have asked a series of experts who have
played a major role in these initiatives to each contribute an overview, identifying the segment of
the workforce for which their competencies were intended, the organization(s) that sponsored the
work, the progress that has been made in both competency development and assessment, future
directions for the initiative, and instructions on how to access the competency models that were
produced. While the resulting sections of this article each provide such information, if available,
the sections are somewhat variable in content, reflecting the unique history, purpose, and
processes employed in these diverse efforts.
SUBSTANCE USE DISORDERS
Addiction Counseling
Linda Kaplan
Addiction counseling is relatively young as professions go. Certification processes started
in the late 1970’s and in 1981 three states in the Mid-west established a small consortium to
develop some common standards for certification. A report by Birch and Davis (1984) delineated
the first set of national competencies for alcoholism and drug abuse counselors, which laid the
foundation for the twelve core functions that were then used as the basis for certification
standards.
The number of state credentialing boards for alcoholism and drug abuse counselors
increased rapidly and by 1989 almost all states had voluntary certification boards. The National
Certification Reciprocity Consortium (today known as the International Certification and

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Reciprocity Consortium/Alcohol and Other Drug Abuse [IC&RC]) had about 43 member states
by the late 1980’s. Common standards were developed that included both written and oral
exams, supervised work experience and a set number of education/training hours. In 1990 the
National Association of Alcoholism and Drug Abuse Counselors (NAADAC), concerned about
the lack of a national standard and the multitude of acronyms used by the many state certification
boards, developed a national certification process that required applicants to be state certified,
pass a national exam, and have an academic degree. This was the first time in the addiction
treatment field that academic degrees were paired with competencies as a basis for certification.
Traditionally, the addiction counseling field, which was developed by recovering counselors, had
relied on assessing competencies as a basis for certification, rather than on academic preparation.
In 1993 the Addiction Technology Transfer Center (ATTC) Network was created by the
Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health
Services Administration (SAMHSA) to improve the preparation of addiction treatment
professionals. Soon the ATTC National Curriculum Committee (Curriculum Committee) was
formed to evaluate curricula and establish priorities for curriculum development. The Curriculum
Committee developed the Addiction Counseling Competencies (ATTC, 1995), which contained
121 competencies. A national study was conducted validating the competencies as necessary for
addiction counseling (Adams & Gallon, 1997). These competencies were developed without
regard to education level.
The next step in the process was to articulate the knowledge, skills and attitudes (KSA)
under each of the competencies. Input from many stakeholder groups in the field was sought and
the competencies were sent to addiction experts for a field review. In 1996, a National Steering
Committee was formed which cross-walked the Addiction Counseling Competencies: The

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Knowledge, Skills and Attitudes of Professional Practice (ACC) (ATTC, 1995) and the
International Certification & Reciprocity Consortium (IC&RC) Role Delineation Study (IC&RC,
1996). This Steering Committee found that the ACC included the knowledge, skills and attitudes
that were required for effective practice, and endorsed the ACC as the bases for education and
training of staff that work with people with substance use disorders.
In 1998 SAMHSA published the ACC as a Technical Assistance Publication (U.S.
Department of Health and Human Services [DHHS], 1998). The ACC is divided into two
sections. The first contains the Transdisciplinary Foundations organized in four dimensions,
which cover the basic knowledge and attitudes for all disciplines working in the addiction field:
•

Understanding Addictions: Current models and theories; the context within which
addiction exists; behavioral, psychological, physical health and social effects of
psychoactive substances.

•

Treatment Knowledge: Continuum of care; importance of social, family and other
support systems; understanding and application of research; interdisciplinary
approach to treatment.

•

Application to Practice: Understanding of diagnostic and placement criteria;
understanding of a variety of helping strategies.

•

Professional Readiness: Understanding diverse cultures and people with disabilities;
importance of self-awareness; professional ethics and standards of behavior; the need
for clinical supervision and ongoing education.

There are eight dimensions in the second section, which focus on The Professional
Practice of Addiction Counseling:
•

Clinical Evaluation: Screening - to determine the most appropriate initial course of
action; and Assessment - the ongoing process of gathering and interpreting all
necessary information to evaluate the client and make treatment recommendations.

•

Treatment Planning: A collaborative process whereby the counselor and client
develop treatment outcomes and strategies.

•

Referral: A process that facilitates the client’s use of needed support systems and
community resources.

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•

Service Coordination: Encompasses case management, client advocacy and
implementing the treatment plan.

•

Counseling: A collaborative process that facilitates the client’s progress toward
mutually determined treatment goals and objectives through individual, group,
couples, and family counseling.

•

Client, Family and Community Education: Process of providing clients, families and
community groups information on the risks related to psychoactive substance use, as
well as treatment, prevention and recovery resources.

•

Documentation: Recording intake, treatment and clinical reports, clinical progress
notes and discharge notes in an acceptable, accurate manner.

•

Professional and Ethical Responsibilities: Includes responsibilities to adhere to
accepted ethical standards and professional code of conduct and for continuing
professional development; knowing and adhering to all federal and state
confidentiality regulations, abiding by the Code of Ethics for addiction counselors,
and obtaining clinical supervision and developing methods for personal wellness.

The addiction counseling competencies are in the process of being revised by the ATTC. In
addition, competencies are being developed for clinical supervisors in addiction treatment.
The development of the ACC followed many of the seven steps outlined by Marrelli,
Hoge and Tondora (in press). However there were lessons learned along the way:
•

Communication and Education Plan: An important lesson learned was that
involving key stakeholders in the process did not lead to the adoption of the
competencies as the basis for certification, education or staff development. Though
stakeholders were involved and key groups did endorse the competencies, this did not
lead to changes in practice. Only a few state certification boards are using the ACC as
the basis for their education and training requirements. Many certification boards
have not yet realigned their processes to conform to the ACC and most academic
institutions have not based their curricula on the ACC. A thorough plan that includes
educating the field about the competencies and how they are to be used is necessary
in order for them to be adopted.

•

Evaluate the Competency Model and Plan for Updates: Though the intent has
always been to make the competencies dynamic and incorporate new technologies,
regular updates are difficult to plan and conduct. They are time consuming and
expensive.

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Though old processes and traditions are hard to supplant, the addiction field is making
significant progress toward the implementation of the addiction counseling competencies as the
basis for professional knowledge, skills and attitudes.
Interdisciplinary Health Professionals
Hoover Adger
There have been numerous federal and non-federal initiatives to define alcohol and other
drug specific knowledge, attitudes and skills, as well as core competencies for health
professionals encountering individuals with substance use disorders (Davis, Cotter, &
Czechowicz, 1988; Fleming, Barry, Davis, Kahn, & Rivo, 1994; Lewis, Niven, Czechowicz, &
Trumble, 1987). These programs have played a major role in bringing about change in the
curricula in schools of medicine, nursing, social work, psychology and other disciplines. While
many of the initial faculty development and educational efforts included primarily disciplinespecific activities, a recent focus has been expanded to a much broader and richer
interdisciplinary approach. This shift away from discipline-specific education and training has
been facilitated by the growing interdisciplinary membership and influence of the Association
for Medical Education and Research in Substance Abuse (AMERSA).
Since 1976, AMERSA has been working to expand education in substance use disorders
for health care professionals. AMERSA has achieved national recognition for its role in
supporting faculty development, curriculum design, implementation and evaluation and the
promulgation of an interdisciplinary approach to substance use disorder education and clinical
services. Moreover, the organization has played an important role in providing leadership for
improved training for health care professionals in the management of problems related to
alcohol, tobacco and other drugs.

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In 1999, AMERSA entered into a cooperative agreement with the Health Resources and
Services Administration’s Bureau of Health Professions and the Substance Abuse and Mental
Health Services Administration’s Center for Substance Abuse Treatment. This agreement
supported the initiation of a national interdisciplinary training program to improve health
professional education in substance use disorders. This interdisciplinary project has three
objectives, which include publishing a strategic plan on ways to improve health profession
education in substance abuse, establishing a faculty development program to enhance curricula
on this topic in professional schools and universities, and build an infrastructure to support
expansion of faculty development across health professions.
A Strategic Planning Advisory Committee was convened with nationally recognized
experts representing each of the disciplines involved in the project - dentists, dietitians, nursemidwives, nurses, nurse practitioners, occupational therapists, pharmacists, physical therapists,
physicians, physician assistants, psychologists, public health professionals, rehabilitation
counselors, social workers, speech pathologists, and audiologists. Using a modified consensus
development approach, the committee defined a set of core competencies for health
professionals, irrespective of discipline. A resulting statement, “Core Knowledge, Skills, and
Attitudes in Substance Use Disorders for Health Professionals,” broadly describes the minimum
knowledge and skills related to substance use disorders for all health professionals. Its four
elements are as follows:
•

All health professionals should receive education in their basic core curricula to
enable them to understand and accept alcohol and other drug abuse and dependence
as disorders that, if appropriately treated, can lead to improved health and well-being.

•

All health professionals should have a basic knowledge of substance use disorders
and an understanding of their effect on the patient, the family, and the community.
Each practitioner should have an understanding of the evidence-based principles of

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universal, selected, and indicated substance abuse prevention as defined by the
Institute of Medicine.
•

All health professionals should be aware of the benefits of screening for potential or
existing substance-related problems, as well as of appropriate methods for
intervention.

•

All health professionals should have core knowledge of treatment and be able to
initiate treatment or refer patients for further evaluation and management. At a
minimum, all health professionals should have the ability to communicate an
appropriate level of concern and the requisite skills to offer information, support,
follow-up, or referral to an appropriate level of services.

In addition, cross-disciplinary core knowledge, skill, and attitude competencies for health
professionals in substance use disorders were identified by the Strategic Planning Advisory
Committee. As one example, the skill competencies are as follows:
All health care professionals should be able to:
•

Recognize early the signs and symptoms of substance use disorders.

•

Screen effectively for substance use disorders in the patient or family.

•

Provide prevention and motivational enhancement to assist the patient in moving
toward a healthier lifestyle, or referral for further evaluation or treatment.

The entire report (Haack & Adger, 2002), which details the Strategic Plan for
Interdisciplinary Faculty Development recommendations and supporting evidence, is available
online at www.amersa.org or www.projectmainstream.net. In addition to the interdisciplinary
core competencies for all health professionals, each of the disciplines involved has outlined prior
activities and competencies that are specific to that discipline. Project curriculum and resource
materials are also available from the website.

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DISCIPLINE SPECIFIC COMPETENCIES
Marriage and Family Therapy
William F. Northey, Jr.
The American Association for Marriage and Family Therapy (AAMFT) began its
development of core competencies for the field of marriage and family therapy (MFT) in January
of 2003. The AAMFT Board of Directors charged the executive director with convening a task
force that would define the domains of knowledge and requisite skills in each domain that
comprise the practice of marriage and family therapy. The product was to be relevant to
accreditors, trainers, and regulators (Northey, 2004). The model outlining these competencies
would define knowledge and skill levels, the areas in which such knowledge and skills would be
obtained, and characteristics that might predispose one for success as a marriage and family
therapist. Competencies as defined would be based, to the extent possible, on a task analysis of
clinical practice, clinical research, evidence based family therapies, and emerging trends in
family therapy. Attention would also be paid to the interface between MFT and the broader
mental health delivery system, including the bridge between biological and/or genetic issues and
pharmacological treatment, and the knowledge and skills marriage and family therapists (MFTs)
would acquire and maintain in relation to these domains.
The AAMFT created a 50-member taskforce, a 5-member steering committee, and
assigned one primary staff member to develop the competencies. All of the members of the
taskforce had published or presented on MFT education, training, or supervision. The steering
committee was made up of progenitors of MFT evidence-based models, as well as regulators,
educators, and researchers. The steering committee began its process by discussing ways to
structure the core competencies. The committee reviewed extant models of competencies

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developed in a variety of fields (e.g., substance abuse, psychiatry, mediation, nursing) and
reviewed research related to the development of exams used by regulatory bodies.
The structure decided upon by the committee had two levels. The primary domains
identified focused on the practice of MFT:
•

Admission to Treatment: All interactions between client and therapist up to the point
when a therapeutic contract is established.

•

Clinical Assessment and Diagnosis: Activities focused on the identification of the
issues to be addressed in therapy.

•

Treatment Planning and Case Management: All activities focused on directing the
course of therapy and extra-therapeutic activities.

•

Therapeutic Interventions: All activities designed to ameliorate the clinical issues
identified.

•

Legal Issues, Ethics, and Standards: All aspects of therapy that involve statutes,
regulations, principles, values, and the mores of MFTs.

•

Research and Program Evaluation: All aspects of therapy that involve the
systematic analysis of therapy and how it is conducted effectively.

The subsidiary domains focused on types of skills or knowledge. These were: 1) conceptual, 2)
perceptual, 3) executive, 4) evaluative, and 5) professional.
After the domains were defined, the steering committee and AAMFT senior staff vetted
them, and each member of the steering committee was charged with developing competencies in
each domain. The contributions of each were then collated and the first draft was developed in
April of 2003, yielding 273 potential competencies. These 273 were then distilled and organized
into the domains resulting in 126 competencies. These 126 were then mapped upon the existing
domains of knowledge used by accreditors and regulators to ensure that the current draft
captured what was currently being used as the body of knowledge in the field.

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The competencies were then sent to the entire 50-member taskforce, and each was asked
to provide feedback on the 126 competencies. Refinement of and additions to the competencies
resulted from the feedback, resulting in 136 total. This version was sent to other interested
parties, including the major mental health professions, federal agencies in behavioral health,
consumer and advocacy groups, and was made available to all members of the AAMFT via our
website. The feedback from these groups resulted in the current version that contains 139 core
competencies (AAMFT, 2004).
Throughout the development process a concerted effort was made to capture aspects of
competence that were unique to the profession of marriage and family therapy and those
competencies that were shared with other mental health professionals. In fact, a tripartite model
was used to evaluate specific competencies on whether they were: 1) common to all/most mental
health professions; 2) common, but MFTs added something unique to the competency; and 3)
unique to MFTs. One of the competencies that is common to all mental health professions from
the Legal Issues, Ethics, and Standards domain is “MFTs develop safety plans for clients who
present with potential self-harm, suicide, abuse, or violence.” In contrast, a competency that is
considered unique to MFTs is “MFTs develop hypotheses regarding relationship patterns, their
bearing on the presenting problem, and the influence of extra-therapeutic factors on client
systems.” Finally, an example of a competency that most mental health professionals do, but the
profession believes MFTs add something unique is: “MFTs establish and maintain appropriate
and productive therapeutic alliances with the clients.” Since a significant portion of the services
provided by MFTs involve couples and families, the competency takes on a slightly more
complex meaning.

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The final version was viewed through several lenses to ensure its validity. In addition to
comparing it to the Validation Report for Marriage and Family Therapists conducted by the
California Office of Examination Resources (2002) and the Association for Marriage and Family
Therapy Regulatory Boards practice domains (Association of Marital and Family Therapy
Regulatory Boards, 2004), the core competencies were also mapped against the Commission on
Accreditation for Marriage and Family Therapy Education Programs (2003) training standards,
the IOM Crossing the Quality Chasm Report (Daniels & Adams, 2004; Institute of Medicine,
2001), and the report of the President’s New Freedom Commission on Mental Health (2003).
The next major step in the development of the core competencies was an educators’
summit that took place in July of 2004. This meeting brought together educators, regulators, and
accreditors to consider how to best implement the adoption and assessment of these core
competencies for the field. It is expected that at least two publications will be produced from the
project, one in the Journal of Marital and Family Therapy and one in the Family Therapy
Magazine. Future meetings with accreditors and regulators are also planned.
Professional Psychology
Frank L. Collins, Jr.
Over the past few years, a number of developments have occurred with respect to the
identification, training, and assessment of competencies for health and human service providers
in psychology. These efforts include conferences, workgroups, organizational projects, and
commissions throughout North America and Europe. Recent books have focused on defining and
selecting key competencies (Rychen & Salganik, 2001) and on competency-based education and
training in psychology (Sumerall, Lopez, & Oehlert, 2000). In November 2002, a conference was
held to bring together representatives from diverse education, training, practice, public interest,
research, credentialing, and regulatory constituency groups to focus on competencies in

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professional psychology (Kaslow et al., 2004). Organizers of this conference hoped that this
meeting might lead to the development of more specific definitions and descriptions of
competency areas.
In an effort to build on what had already been done, and to ensure maximum buy-in from
various constituency groups, the organizers of this conference developed an extensive survey and
sought guidance from the field in identifying core competencies. Eight core competency domains
were identified through the survey: 1) scientific foundations of psychology and research; 2)
ethical, legal, public policy/advocacy, and professional issues; 3) supervision; 4) psychological
assessment; 5) individual and cultural diversity; 6) intervention; 7) consultation and
interdisciplinary relationships; and 8) professional development. The conference assigned
delegates to workgroups addressing each of these topics, and to workgroups that focused on the
assessment of competence and the specialty (non-core) competencies. Each workgroup had
members with substantial knowledge about the competency area, as well as individuals with
other complimentary expertise.
Products from these workgroups included several papers, which were recently published
in the Journal of Clinical Psychology (July 2004, Vol 60, Issue 7). Four additional papers will
appear in the Journal of Clinical Psychology and Professional Psychology: Research and
Practice within the next year. While it is beyond the scope of this paper to summarize all of the
discussions, several cross cutting concepts emerged. For example, workgroups reaffirmed the
conceptualization of competence as including knowledge, skills, and attitudes. Several
workgroups used this conceptualization to organize their efforts to identify critical
subcompetencies within their competency domain. Equally important was the acknowledgement
among the groups that there are cross-cutting competencies relevant to all aspects of competence

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at all levels of professional development. These included, for example, individual and cultural
diversity, ethical practice, interpersonal and relationship skills, critical thinking, and knowledge
of self. Clearly, some competencies (such as cultural diversity and ethics) are viewed as both
core and subcompetencies. While this may seem inconsistent, it merely reflects the belief that
these competencies are core, but must be incorporated within other core competency areas.
All groups placed a strong value on developmentally informed education and training.
Several groups laid out a developmentally appropriate training sequence by describing
progressively more complex and sophisticated content and methods for teaching the
subcompetencies in their domain. Workgroups underscored the value of modeling, role-plays,
vignettes, in-vivo experiences, supervised experience, and other applied real-world experiences
as critical instructional strategies for teaching the competencies. The crucial role of establishing
and maintaining a respectful and facilitative learning environment was affirmed. Workgroups
also highlighted the importance of close mentoring relationships as key to high level professional
training. Every workgroup endorsed the central role of integrating science and practice into all
aspects of education and training, teaching evidence-based and informed practice, and the
importance of establishing during training an internalized commitment to life-long continuous
learning.
There was consensus that as a profession it is important to develop strategies to become
equally effective at assessing knowledge, skills, and attitudes for each competency domain. To
date, assessment of knowledge has been more successful than assessment of skills and attitudes
(e.g., course examinations and the national Examination for Professional Practice in
Psychology). Therefore, the assessment of overall competence in both integrated and
competency-by-competency formats, is an area ripe for growth in the context of education,

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training, and credentialing. Assessment techniques employed for licensure and other
credentialing (e.g., board certification) might begin during education and training at
developmentally appropriate times. This could result in a “culture shift” in psychology, so that
methods of assessment are used continuously throughout a psychologist’s training and career.
This conference was supported by more than 30 professional organizations with the
Association of Psychology Postdoctoral and Internship Centers serving as the host and
conference organizer. While this conference was an important starting point, it is critical that
multiple and diverse constituency groups work together to struggle with the challenging and
vexing questions that remain. In particular, agreement as to the definitions and components of
specific competencies are needed as well as methods for assessing such competencies using a
developmental framework. For example, what behaviors should demonstrate competency in
psychological assessment at the pre-internship level and post-doctoral level? As progress is
made, is will help the field better communicate to the public and to policy makers the
contributions that professional psychologists can make.
Psychiatric-Mental Health Nurse Practitioners
Judith Haber
Advanced Practice Psychiatric-Mental Health Nurses graduate from Master’s or PostMaster’s programs that, since 1954, have prepared graduates for the role of Psychiatric-Mental
Health Clinical Nurse Specialist (PMHCNS) or, more recently in the past 10 years, the role of
Psychiatric-Mental Health Nurse Practitioner (PMHNP). The nursing field most recently
completed entry-level competencies for graduates of Psychiatric-Mental Health Nurse
Practitioner programs who focus their clinical practice on individuals, families, or populations
across the life span that are at risk for developing mental health problems or have a psychiatric
disorder. The PMHNP is a specialist who provides primary mental health care to patients seeking

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services in a wide range of settings. This involves the continuous and comprehensive assessment
and treatment services necessary for the promotion of: 1) mental health; 2) prevention;
3) treatment of psychiatric disorders; and 4) health maintenance.
The PMHNP Competencies reflect the work of a multi-organizational National Panel, cochaired by Drs. Judith Haber and Kathleen Wheeler. The National Organization of Nurse
Practitioner Faculties (NONPF) facilitated the work of the National Panel through two distinct
phases that encompassed development and external validation of the PMHNP competencies
(2002-2003). The process used for this project models that used for developing the Nurse
Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological,
Pediatric, and Women’s Health (U.S. DHHS, 2002b). The National Panel included
representatives from six national nursing organizations whose foci include advanced practice
nursing education, psychiatric-mental health practice and certification of the PMHNP. A subgroup of the NONPF Psychiatric-Mental Health Special Interest Group participated as NONPF
representatives.
Initiated in 2002, Phase I of the project focused on the domains and competencies of
PMHNP practice, which were developed from a role delineation study that was completed using
an observational data collection method observing nurse practitioners in a range of situational
contexts. Competence among the nurses observed ranged from novice to expert (interpretive
situational base), and the results were intended to be used in conjunction with the Dreyfus model
of skill acquisition (1980, 1986). This model depicts human acquisition of psychomotor,
perceptual, and judgment skills as a generic progression through stages from novice to expert
and has been applied to nursing by Benner (1984) and Brykcznski (1999).

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Domain is defined as a cluster of competencies that have similar intentions, functions,
and meanings; they are used as an organizing framework. A competency is an interpretively
defined area of skilled knowledge, identified and described by its intent, function, and meaning.
Competencies are domain specific. Seven domains provide the organizing framework for the
PMHNP Competencies:
1. Health Promotion, Health Protection, Disease Prevention, and Treatment
1A. Assessment
1B. Diagnosis of Health Status
1C. Plan of Care and Implementation of Treatment
2. Nurse Practitioner-Patient Relationship
3. Teaching-Coaching Function
4. Professional Role
5. Managing and Negotiating Health Care Delivery Systems
6. Monitoring and Ensuring the Quality of Health Care Practice
7. Cultural Competence
The domain related competencies were developed to reflect the current knowledge base and
scope of practice for PMHNPs. For example, domain 1A., Assessment, emphasizes that integral
to the PMHNP role is performing a comprehensive physical and mental health assessment,
including a psychiatric evaluation. Domain 1B., Diagnosis of Health Status, reinforces that
PMHNPs are engaged in the diagnostic process, including critical thinking involved in
formulating a differential diagnosis and the integration and interpretation of various forms of
data. Domain 1C., Plan of Care and Implementation of Treatment, highlights that the PMHNP

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plan of care is biopsychosocial in nature and ranges from the prescribing of psychotropic and
related medications to the conduct of individual, group and family psychotherapy.
Phase II of the project focused on external validation of the PMHNP competencies. The
Validation Panel involved 21 individuals who had not served on the National Panel and had
expertise relevant to advanced practice psychiatric-mental health nursing. These areas of
expertise included education, clinical practice, credentialing, regulation, accreditation, and
employment of advanced practice psychiatric-mental health nurses. Using an evaluation tool, the
Validation Panel reviewed systematically each PMHNP competency for relevancy (Is the
competency necessary?) and specificity (Is the competency stated clearly and precisely?).
Comment was also provided on the comprehensiveness of the competencies (Is there any aspect
of PMHNP knowledge, skill or personal attributes missing?). The validation process
demonstrated overwhelming consensus; over 96% of the competencies remained after the
validation process. Over 53% of the competencies underwent revision to enhance their
specificity and several competencies were added, resulting in a final set of 68 competencies.
Completed in 2003, the PMHNP Competencies have been endorsed by 12 national nursing
organizations and can be downloaded from the NONPF website: http://www.nonpf.com
(Wheeler & Haber, 2004).
Progress in competency assessment is underway and reflected in the work of the NONPF
Educational Standards and Guidelines Committee, as well as curriculum and practice
demonstration projects nationwide. The objective of these projects is to develop valid and
reliable competency-based evaluation tools that accurately assess PMHNP practice and
outcomes. A variety of intra and interdisciplinary assessment modalities are being evaluated,
including: standardized formative and summative written exams, clinical performance exams,

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standardized simulations, interactive case studies, evidence-based practice projects, debates,
capstone projects, electronic portfolios, and credentialing exams. In addition, exploration is
occurring of recognized assessment modalities and tools effectively used by other mental health
disciplines to avoid “reinventing the wheel” in the assessment of core mental health
competencies. This may lead to a transcendent set of interdisciplinary assessment tools.
Future directions include the need for further progress in competency assessment, and
ongoing alignment of PMH Scope and Standards of Practice documents with endorsed PMHNP
competencies, educational curricula, program accreditation criteria, and credentialing processes.
The Scope and Standards Committee of the American Psychiatric Nurses Association is
currently revising the Scope and Standards of Practice for the psychiatric nursing specialty at the
Registered Nurse and Advanced Practice Registered Nurse levels. A challenge for this
committee will be to determine whether the PMHNP competencies developed by the National
Panel also reflect the specialty competencies for the specialty’s other advanced practice role, that
of Psychiatric-Mental Health Clinical Nurse Specialist, thereby paving the way for adoption of
core competencies reflecting the knowledge base and practice of all advanced practice
psychiatric-mental health nurses.
Psychiatric Rehabilitation Practitioners
Kenneth J. Gill
The study of the competence of Psychiatric Rehabilitation Practitioners is focused on the
skills and knowledge of persons who provide rehabilitation and community support services to
persons with severe and persistent mental illness. While most of these direct service staff have a
bachelor's degree education or less, studies of the workforce have actually found a broad range in
their educational preparation (Blankertz & Robinson, 1996). Despite the fact that formal
credentials are usually lacking, the consensus among subject matter experts is that these staff

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require a fairly advanced skill and knowledge set (Coursey et al., 2000a, 2000b; International
Association of Psychosocial Rehabilitation Services [IAPSRS], 2001; Pratt, Gill, Barrett, &
Roberts, 1999).
There has been significant progress in the efforts to identify psychiatric rehabilitation
competencies, which culminated in a report entitled, Role Delineation of the Psychiatric
Rehabilitation Practitioners (IAPSRS, 2001). Panels of subject matter experts were convened in
order to define the practitioners' role and identify tasks and knowledge needed. Over 500 experts
from the United States and Canada eventually had input. More than seventy tasks were identified,
each with several statements about the required knowledge and skills. These tasks were divided
into seven domains ranked in terms of importance, criticality, and frequency of use. They include:
1) interpersonal competence; 2) interventions; 3) assessment, planning, and outcomes; 4)
community resources competence; 5) professional role; 6) systems competence; and 7) diversity.
The domains, tasks, knowledge and skill statements, which are the primary findings of the role
delineation study, are available at http://www.iapsrs.org/certification/pdf/role_delineation.pdf. This
study will be updated within the next 2-3 years and a completely new role delineation study will
take place in approximately 5 years.
In conjunction with the Psychiatric Rehabilitation certification program developed by
IAPSRS and administered by its Commission on the Certification of Psychiatric Rehabilitation
Practitioners, competency assessment has been primarily conducted by two methods. One
method is ratings by supervisors who have direct knowledge of the practitioners' work. These
ratings include only a sampling of tasks. A more rigorous and extensive method is a standardized
multiple-choice examination. The exam meets current psychometric standards for reliability and
content validity. Academic programs offering psychiatric rehabilitation courses and majors are

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now attempting to incorporate this content into their curricula, and developed methods for
assessing the presence of these competencies in "lab" settings and actual clinical sites. Special
issues of two journals, Psychiatric Rehabilitation Skills (Gill, 2001; Nemec & Pratt, 2001) and
Rehabilitation Education (Pratt & Gill, 2001) have been devoted to these educational issues.
The International Association of Psychosocial Rehabilitation Services, recently renamed
the United States Psychiatric Rehabilitation Association, is principally responsible for this work.
IAPSRS funded various efforts as early as 1993 to study the psychiatric rehabilitation workforce,
its characteristics, and skills, and published the findings from a similar project in 1996, funded
by the National Institute of Disability Rehabilitation Research (Blankertz & Robinson, 1996). A
related effort, funded by the Center for Mental Health Services (CMHS) at SAMHSA, studied
the competencies of staff who work with persons with severe and persistent mental illness
(Coursey et al., 2000a, 2000b). This project identified similar competencies to those specified in
the IAPSRS role delineation study.
The IAPSRS role delineation project defined a complex, multi-skilled role that includes
many competencies. Even those with extensive education and experience in mental health or
other helping professions do not typically possess this full range of knowledge and skills. While
there is consensus on the complexity of the psychiatric rehabilitation role, the number of
individuals actually prepared to assume it is rather limited. The IAPSRS study highlights that
subject matter experts expect skilled practitioners who can work with persons who have complex
and disabling disorders, as well as with families, significant others, stakeholders and other
providers. Yet, there are limited educational and training opportunities to develop such
practitioners. This portion of the behavioral health and rehabilitation field seems particularly

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lacking in resources. Funding for workforce development activities and salaries remains very
modest.
Direct care staff members from a variety of levels of education have been evaluated with
the IAPSRS-sponsored competency assessment instrument. A fairly large proportion of test
takers (28-42%) fail to establish competence when assessed. While there are now more than 40
institutions of higher education that offer some form of psychiatric rehabilitation education, there
is clearly not enough training in these competencies. Psychiatric rehabilitation educators have
established a Consortium of Psychiatric Rehabilitation Educators who meet twice annually. This
group also established an electronic list-serv and website known as PSR-ED. They are tackling
the issues of: 1) incorporating these competencies within their courses; 2) developing
instructional techniques to develop these competencies; and 3) devising methods for assessing
whether students have acquired these competencies.
Psychiatry
Zebulon Taintor
Psychiatry is a diverse specialty and has displayed the usual American penchant for a
system of checks and balances and separation of powers. Thus, there are many groups and
organizations within the specialty that have contributed lists of competencies. These include:
•

The American Psychiatric Association and its Council on Medical Education, Career
Development committees, and task forces on specific populations (e.g., people with
severe mental illness) and services (e.g., prisoners). The APA set up a work group on
competencies, which realized its most useful role would be to make those developing
competency lists aware of each other’s work and products.

•

The American Association of Directors of Psychiatry Residency Training
(AADPRT), which has developed competency lists and model curricula for
psychiatry residencies.

•

The Association of Directors of Medical Student Education in Psychiatry
(ADMSEP), which has focused on the competencies to be developed in medical
school.

Competencies in Behavioral Health

26

•

The Association for Academic Psychiatry, which has focused on all levels of
psychiatric education.

•

The Group for the Advancement of Psychiatry (GAP) with its many subject-specific
committees, some of which have addressed competencies.

•

The American College of Psychiatrists, which gives the Psychiatry Residents in
Training Examination (PRITE) and thereby influences, through the questions it asks,
the competencies that are the focus during training.

With the work of these groups as background, psychiatry, as part of medicine, has
embarked on a new competency movement that has resulted both from internal dissatisfaction
with the variability in skills in the profession and from external pressures from patients and the
public.
The Accreditation Council for Graduate Medical Education (ACGME) sets training
requirements for all specialties and subspecialties approved by the American Board of Medical
Specialties. Twenty-six residency review committees within the ACGME structure review and
accredit individual programs using the general requirements for all physician training and the
specific requirements for each specialty. By 1999, the ACGME had completed its response to the
1980 U.S. Department of Education mandate to address educational outcomes, including
competencies. The result was a set of general competencies required for all physicians (Leach,
2001). These are available on the ACGME web site at:
www.acgme.org/outcome/comp/compFull.asp and include: 1) patient care, 2) medical
knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication
skills, 5) professionalism, and 6) systems-based practice.
The Psychiatry Residency Review Committee (RRC), which sets the accreditation
requirements for psychiatric residencies, has added to the six required general competencies an
additional requirement of demonstrated competency in five types of psychotherapy. These

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27

include: 1) brief, 2) cognitive-behavioral, 3) psychotherapy and psychopharmacology in
combination, 4) psychodynamic, and 6) supportive.
These requirements became effective in January 2001, but the process really is just
beginning. For example, the RRC offers no specification or detail on the psychotherapy
competencies. It simply states that residency programs must now be able to provide details
during accreditation visits as to how they verify that their graduates are attaining the general and
specific competencies. The RRC is currently reluctant to add greater specificity, exemplified by
its response to the family assessment and treatment competencies submitted for consideration by
the GAP Committee on the Family. The RRC deemed these competencies exemplary, but too
detailed for inclusion in the accreditation requirements for psychiatry. There is, however, a
growing literature on the psychotherapy competencies (Andrews & Burruss, 2004; Dewan,
Steenbarger, & Greenberg, 2004; Gabbard, 2004; Winston, Rosenthal, & Pinsker, 2004).
The RRC special requirements for psychiatry can be viewed on the ACGME web site at
www.acgme.org. There remains a strong emphasis in these accreditation guidelines on the use of
timed rotations to assure development of skills in various areas, such as emergency psychiatry,
consultation/liaison, and the treatment of children and adolescents. It is attractive to think that
training programs could be freed from these time constraints and offer flexibility while residents
developed specific competencies at a self-paced rate of learning. However, the science of
measuring competencies in psychiatry is just developing and is untested in psychiatry residency
training. AADPRT, the training directors association, has written to the RRC asking that the next
revision of the special requirements for psychiatry not substitute competencies for timed
rotations.

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It is critical to note that the American Board of Psychiatry and Neurology (ABPN) is the
only organization that actually certifies individual psychiatrists. It has a list of competencies,
which can be found at www.abpn.com/geninfo/competencies.html and in two books that ABPN
produced (Scheiber, Kramer, & Adamowski, 2003a, 2003b). The ABPN competency list, which
incorporates the six core competencies from ACGME, carries great weight in the field, as it is
the bases for the board certification exam. A general consensus is developing against generating
multiple, conflicting lists of competencies and for support of the core ABPN list. However,
inconsistencies exist, exemplified by the fact that the ABPN has not incorporated the
psychotherapy competencies required by the RRC.
As to the future, the RRC expects to revise the specific requirements for general
psychiatry, having just completed the requirements for subspecialty training in addiction,
forensic, geriatric, psychosomatic medicine, and sleep psychiatry. It is also focusing on child
psychiatry, for which competencies have been suggested (Sexson et al., 2001). Work on
competency development and assessment is expected to get increasing attention due to the
ongoing ACMGE competency initiative and further fueled by concerns about the 48% failure
rate among psychiatrists on Part II of the ABPN examination in 2003.
Social Work
Anita L. Rosen
The task of summarizing the work related to competencies for the social work profession
is somewhat daunting. No single organization is responsible for competency promulgation. In
fact, a multiplicity of organizations is involved in examining and promoting competency in
social work practice. In addition, a distinctive aspect of the social work profession is the wide
range of settings, organizations and populations with which social workers practice.
Compounding the issue is the psychosocial orientation of social work training and practice,

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which does not focus solely on mental health, but rather focuses on a broad conceptualization of
health, mental health, and the social and economic aspects of the lives of individuals, groups, and
communities.
Social work in its various forms addresses the multiple, complex transactions between
people and their environments. Its mission is to enable all people to develop their full potential,
enrich their lives, and prevent dysfunction, through problem solving and change. The profession
is an interrelated system of values, theory and practice. This orientation, combined with a broad
range of service delivery settings and populations served, means that there often is no one group
or organization that “owns” social work or defines competent practice for the profession. In
addition, there are differing views of how to define “competency” within the profession.
Given this disclaimer, there are a number of organizations that have attempted to define
competencies and develop standards for competent psychosocial practice in social work. Three
important organizations are: the National Association of Social Workers (NASW,
www.naswdc.org), the major membership organization of the profession; the Association of
Social Work Boards (ASWB, www.aswb.org), which is a coalition of boards that regulate social
work and develops and maintains the social work licensing examination used across the country;
and the Council on Social Work Education (CSWE, www.cswe.org), which is the accrediting
body for the over 600 social work education programs in the United States.
NASW has developed practice standards in 12 areas such as palliative care, cultural
competency, and clinical practice (http://www.naswdc.org/practice/default.asp). These standards
generally refer to knowledge, skills and ethics, and have been developed by cadres of experts,
with input from practitioners. The standards are not competencies, but do provide guidelines for

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further explication, and are used by members, educators and licensing bodies for defining the
role and function of social work.
ASWB, in its role as developer of national licensing examinations, including one for
clinical practice, conducts a thorough job analysis on a periodic basis through a rigorous,
national sampling process that is then used by experts to develop examination questions. Four
levels of examination to test competency have been developed, each covering a variety of
content areas (e.g., human behavior, diversity, diagnosis and assessment, the therapeutic
relationship).
CSWE has created the Educational Policy and Accreditation Standards for social work
education and requires the use of evidence and outcome measures by training programs, with the
goal of helping to assure that social work education is preparing students for competent practice.
The current standards were developed through a multi-year process with a diverse, expert
committee and substantial input from members. These standards are used as guidelines and are
translated into competencies by individual social work education programs and faculty.
CSWE also has a project, funded by the John A. Hartford Foundation, called
Strengthening Aging and Gerontology Education for Social Work (SAGE-SW,
www.cswe.org/sage-sw/). SAGE-SW has developed a set of social work gerontology/geriatric
competencies for education and practice, using a unique methodology (www.cswe.org/sagesw/resrep/competenciesrep.htm). After developing a list of 65 competencies related to
knowledge, skill and professional ethics through a search of the literature and feedback from a
panel of experts, a survey was mailed to a national sample of social work practitioners and
academics, both with and without interest in aging. Survey participants were asked to identify the
competencies that all social workers needed, those needed only by advanced practitioners, and

Competencies in Behavioral Health

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those needed by geriatric specialists. This list of competencies, and the guidance given by the
survey participants, has been used and adapted by educators, practitioners, trainers and national
curriculum projects.
Other social work organizations, institutions and coalitions have developed competencies
or practice standards for specific areas of practice. For example, individual social work education
programs that have U.S. Children’s Bureau funding for Title IV-E Child Welfare Training have
developed outcomes based competencies for training students. A coalition of national
organizations related to health care has developed standards for social work best practices in
healthcare case management that incorporate outcome/practice evaluation. Social work
competencies for interdisciplinary settings also have been developed. One such endeavor in
palliative care from the Center to Advance Palliative Care can be found at:
http://64.85.16.230/educate/content/elements/socialworkercompetencies.html.
The American Board of Examiners (ABE) in clinical social work (www.abecsw.org)
provides the Board Certified Diplomate in Clinical Social Work credential. This organization has
developed practice competencies in clinical social work and has available on-line a position
paper and bibliography related to competencies and clinical social work. Finally, the Institute for
the Advancement of Social Work Research (IASWR, http://www.iaswresearch.org) has
undertaken efforts to help promote the translation of research findings into education and
practice, examine the availability of evidence as it relates to practice competence, and engage
social work researchers in this process (see example at:
http://www.charityadvantage.com/iaswr/images/iaswr%20aug%2003%20newsletter.pdf).
Currently, the interest in and activities related to competent professional practice are
gaining currency in social work. As the profession moves forward, there is need to foster

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collaboration of practice and academic organizations to develop and implement social work
competencies, link evidence and outcome measures to the concept of competency, and attract
federal funding to help social work assess the state of research knowledge for practice and to
conduct translational activities that help define competent education and practice.
POPULATION FOCUSED COMPETENCIES
Children’s Mental Health
Marsali Hansen
There is wide recognition of the need for a workforce skilled in both quality clinical
practice and a systems of care approach for children (Hansen, 2002; Tharinger et al., 1998). In
1999, the Child, Adolescent and Family Branch of the Center for Mental Health Services in the
Substance Abuse and Mental Health Services Administration (SAMHSA) published a series of
monographs on Promising Practices in Children's Mental Health. Volume V of the series
addressed training strategies, including core competencies (Meyers, Kaufman & Goldman,
1999). The monograph highlighted the notion of competence, with various definitions, but
generally meaning a shared perspective of doing the right thing for the right reason at the right
time. The authors emphasized the view that competence is not necessarily acquired only through
training, but also requires personal characteristics such as flexibility, common sense, problem
solving ability, and compassion. Two sets of competencies that address these workforce concerns
are cited in this SAMHSA monograph.
The first set of competencies was developed by Trinity College in Vermont for its
master’s program in Community Mental Health. The core competencies were developed by
experts in the field and reviewed nationally. The materials highlight the specific knowledge,
skills, and values required to function within a community-based system of care for children and
adolescents with serious emotional disorders (SED). The skills incorporate the fundamental best

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practice of community mental health with the values and expectations articulated in systems-ofcare documents (Hansen, 2002).
The following is an example:
V. Demonstrates ability to design, deliver, and ensure highly individualized services and
supports.
A. Routinely solicits personal goals and preferences.
B. Designs personal growth/service plans, which fit the needs and preferences of the
child/adolescent and family.
C. Encourages and facilitates personal growth and development toward maturation
and wellness.
D. Facilitates and supports natural support networks.
The Commonwealth of Pennsylvania fostered the creation of the second set of core
competencies identified in the SAMHSA monograph. The Pennsylvania Child and Adolescent
Service System Program (CASSP) Training and Technical Assistance Institute (1995) that
developed the competencies is funded by the Commonwealth and is part of Penn State
University. As part of the development process, these competencies were reviewed by
academics, professional associations, policy experts, practitioners, family members and others
(Hansen et al., 1999).
These competencies serve as the foundation for all training efforts throughout
Pennsylvania and have been shared with other states. They are also used among family advocates
as a set of performance expectations for professionals. Pennsylvania has a certification process
for family therapists involved in a three-year in-service training program. The competencies
serve as a foundation for the certification. A statewide assessment of children’s mental health
providers is under way to identify gaps in workforce competence based on this document.

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This competency set was designed to be relevant for all mental health professionals
working with children regardless of discipline. It is more clinically focused than the set of
competencies developed in Vermont. The core competencies include both fundamental clinical
expectations as well as the skills needed for the expanded roles for practitioners within systems
of care. The three sections focus on children (in developmental context), families, and
communities. Examples include:
Child/young adult/assessment (100-VII-G):
1. Professionals will be able to demonstrate general knowledge of the types of
assessments likely to be used with teens, including familiar tests, standards of
current practice and the pitfalls in interpretation and how to involve parents
and families.
Family/intervention skills (200-11-B):
1. Professionals will be able to demonstrate the following specific skills in
conducting the initial contact:
A. Ability to start where the family is and acknowledge the family’s
central role.
B. Ability to obtain an initial definition of the problem.
C. Ability to set up the initial session and establish a time, place, and who
will be present.
These core competencies are designed to address the specific integration of system-ofcare values, professional standards of practice, and models of clinical best practice across mental
health disciplines. As the professions cry out for models of core competencies, Pennsylvania's
document serves as an example of a comprehensive effort to present the expectations for best
practice for children and adolescents with SED and their families. Such a model can serve as a
foundation for other efforts within disciplines, professions, and child-serving systems, and for
other statewide approaches.

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At the national level, current efforts focus on the widely recognized crisis in children's
mental health; a crisis that includes concerns about recruitment and retention, as well as the
recognition that the workforce is poorly prepared to address the needs of children with SED.
These efforts embrace core competencies as a foundation for future developments. Training
initiatives on many fronts are increasingly starting with sets of specific clinical expectations for
individuals who work with children with SED. These competency expectations, when combined
and integrated with professional standards, will serve as a foundation for curriculum revisions
that will better prepare students for entry into the workforce and, through continuing education,
better prepare those individuals already in the workforce.
Serious and Persistent Mental Illness
Alexander S. Young
During the past decade, there have been remarkable advances in our understanding of
how to provide care to people with serious and persistent mental illness (SPMI). Clinical
research has demonstrated that a wide range of well-defined pharmacologic and psychosocial
interventions substantially improve outcomes in people with these disorders (Young &
Magnabosco, 2004). Multi-disciplinary, team-based approaches have become widely accepted as
an optimal structure for care. There is increasing agreement that care should be consumercentered, and include attention to recovery, rehabilitation and consumer empowerment.
Researchers (Young & Magnabosco, 2004) have compared care in routine treatment
settings with treatment practices that are known to be effective, and have found large
discrepancies. Effective pharmacologic and psychotherapeutic interventions are used with only
one third of the individuals with depression and anxiety who could benefit from these treatments
(Young, Klap, Sherbourne, & Wells, 1999). Evidence-based psychotherapies are often not
delivered outside of academic and research settings. Among individuals with schizophrenia,

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many do not receive medications, such as clozapine, that could substantially improve their
symptoms (Lehman, 1999). Effective psychosocial treatments, such as supported employment
and family interventions, are provided to a small proportion of eligible individuals.
Projects have been conducted to improve care for people with severe and persistent
mental illness, and have found that a substantial proportion of current providers and provider
organizations do not possess necessary competencies (Corrigan, Steiner, McCracken, Blaser, &
Barr, 2001; Drake et al., 2001; McFarlane, McNary, Dixon, Hornby, & Cimett, 2001; Young,
Forquer, Tran, Starzynski, & Shatkin, 2000). For example, professionals often have negative
attitudes toward rehabilitation, mutual support, and recovery which can hinder the provision of
client-centered care (Chinman, Kloos, O'Connell, & Davidson, 2002; Corrigan, McCracken,
Edwards, Kommana, & Simpatico, 1997). It has been estimated that more than three-quarters of
providers in the United States caring for individuals in the public sector have a bachelors degree
or less education, with little training about severe mental illness or its treatment (CMHS, 2004).
Even among the small proportion of doctoral-level professionals who work with this population,
many have not been exposed to curricula or practicum experiences that are relevant to the care of
people with serious mental illness (Hoge, Stayner, & Davidson, 2000).
In the United States, two projects have used a national consensus process to define core
competencies. One was funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA), and coordinated by the Center for Mental Health Policy and
Services Research at the University of Pennsylvania. This project convened a national panel of
28 experts from a broad range of stakeholder groups, including academia, clinicians, consumers,
family members, state mental health agencies, and managed care corporations. They reviewed
empirical research, standards of care, and clinical guidelines. A set of 12 core clinical

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competencies and 52 sub-competencies was developed (Coursey et al., 2000a, 2000b), and is
available at http://www.uphs.upenn.edu/cmhpsr/cmhs_reports.htm.
A second project was funded by the Robert Wood Johnson Foundation through the
Center for Healthcare Strategies, and coordinated by the UCLA-RAND Health Services
Research Center and the Department of Veterans Affairs Desert Pacific Mental Illness Research,
Education and Clinical Center. The project reviewed existing literature and competency
statements, and conducted focus groups and interviews with similar stakeholder groups as in the
SAMHSA project. A national panel was convened, and a structured process led to the
identification of 37 core competencies in 7 domains that are critical for providing recoveryoriented care (Young, Forquer, Tran, Starzynski, & Shatkin, 2000). The competencies are
available at http://www.mirecc.org/product-frames.html. Both the UCLA-RAND and SAMHSA
projects produced competency sets that cover a comprehensive range of important clinical
domains such as the clinician-client relationship, assessment, rehabilitation, consumer
empowerment and caregiver support.
In the United Kingdom, a national competency development effort that focuses on severe
mental illness was coordinated by the Sainsbury Centre for Mental Health, in conjunction with
the National Health Service (U.K. Department of Health, 1999). This project was based on the
concept of the “capable practitioner,” defined as clinicians who can adapt to change and new
knowledge, and continuously improve their practice (Fraser & Greenhalgh, 2001). The project
defined a set of competencies that enable clinicians to care for individuals with severe mental
illness, within the context of the National Service Framework for Mental Health, which defines
national care models, standards, and plans for service provision in the UK. The resulting
competency set, which includes 67 competencies clustered in 7 domains, is designed to inform

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training and curricula within the field (Lindley, O'Halloran, & Juriansz, 2001). It is available at
www.scmh.org.uk.
Other work is relevant to this field of competency development. The work on
psychosocial rehabilitation, described in an earlier section of this article focused largely on
caring for individuals with severe and persistent mental illness. Similarly, SAMHSA has
supported the development of a number of “Evidence-Based Practice Implementation Resource
Kits” (tool-kits) designed to help providers and agencies implement evidence-based practices for
this population (CMHS, 2003). These tool-kits focus on illness management and recovery,
medication management, assertive community treatment, family psychoeducation, supported
employment, and management of co-occurring substance abuse. By offering standardized
training for various types of personnel, these tool-kits focus on competencies deemed essential
for this work.
Now that several comprehensive competency sets have been developed, the focus of
work has moved to development of interventions that improve the competency of providers.
While there have been some successes (Young et al., 2004), substantially more work is needed to
evaluate the effectiveness of novel interventions and approaches to improving competency.
When evaluating the quality of mental health care, provider competencies are one aspect of the
structure of care. Therefore, competencies have a direct effect on health care processes -- the
care that consumers actually receive. As such, the value and accuracy of competency sets and
models will be best understood by determining the extent to which provider performance can be
improved, and evaluating how this improvement can lead to better care for consumers.
SPECIAL APPROACHES TO CARE
Work on competencies has begun in three critical areas that involve special approaches to

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39

care. These include the provision of recovery-oriented treatment, culturally competent care, and
the delivery of services by trained peer specialists.
Recovery-Oriented Competencies
Janis Tondora & Maria J. O’Connell
Advances in our understanding about the process and possibilities of recovery from
severe mental illness, fueled by consumer advocacy efforts, has contributed to a recent national
focus on the need to improve the capacity of individual providers and the systems in which they
work to deliver recovery-oriented care (New Freedom Commission on Mental Health, 2003).
However, with the many and varied definitions of recovery (Ralph, Kidder, & Phillips, 2000).
and few models of care that operationalize principles of recovery into concrete, objective
practices (Anthony, 2000), the development of recovery-oriented capacities has been challenging
at best.
In the past few years, several organizations have attempted to clarify the meaning of
recovery and recovery-oriented care through research, training, and dissemination efforts. This
work has placed considerable emphasis on the competency of systems as opposed to individuals.
In June of 2000, the Evaluation Center@HSRI published a compendium of recovery-related
instruments that assess important aspects of the recovery process and recovery-related outcomes
(Ralph, Kidder, & Phillips, 2000). In 2002, the National Association of State Mental Health
Program Directors (NASMHPD) and the National Technical Assistance Center for state mental
health planning (NTAC) published what is commonly known as the “What Helps, What
Hinders” report on recovery (Onken, Dumont, Ridgway, Dornan, & Ralph, 2002). Drawing on
1000 pages of focus group transcripts from 115 consumers, this workgroup conceptualized an
“emerging recovery paradigm” that focuses on the individual’s unique identity, hope, strengths,
and self-determination, while emphasizing holistic approaches to care, self-help, empowerment,

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choice, natural supports, community integration, active growth, normative roles, asset building,
and self-efficacy. The second phase of this “What Helps, What Hinders” project involved the
development of a 42-item self-report measure of recovery-oriented supports and an
administrative-data profile containing 16 system performance indicators and 23 associated
measures (Recovery Oriented System Indicators, ROSI; Onken, Dumont, Ridgway, Dornan, &
Ralph, 2004). The ROSI is currently undergoing pilot testing and will be used to inform the
development of a “report card” to assess recovery-oriented supports across state mental health
systems.
A state-based effort has been conducted by the Connecticut Department of Mental Health
and Addiction Services, in conjunction with the Yale Program for Recovery and Community
Health. Drawn from an analysis of elements of recovery identified through an extensive review
of the literature and from focus groups with consumers of behavioral health services, the goals of
this project have been to conceptualize the elusive construct of recovery, to identify measurable
indicators of a recovery-oriented environment and recovery-oriented care, and to provide
competency-based training to behavioral health service providers, managers, and administrators
(Davidson, O’Connell, Tondora, Kangas & Evans, 2004; Davidson, O’Connell, Tondora,
Staeheli, & Evans, 2004; http://www.dmhas.state.ct.us/recovery.htm).
Common principles of recovery and recovery-oriented systems of care were first
identified (Davidson, O’Connell, Sells, & Staeheli, 2003). These were followed by separate
models of recovery pertaining to mental health and/or addictions to help practitioners learn to
differentiate recovery-oriented practices from non-recovery oriented practices. The assessment of
recovery-oriented competencies has been conducted through the creation of the Recovery SelfAssessment (O’Connell, Tondora, Evans, Croog, & Davidson, in press). Based on the literature

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41

reviews and information gathered from the focus groups, this tool was developed to provide state
programs with a method of gauging the degree to which constituents believed that their programs
implement practices that are consistent with the principles of recovery. Efforts are now underway
to train individual providers statewide in recovery practices through a Recovery Institute.
International efforts have been underway to identify recovery-oriented competencies.
For example, the New Zealand Mental Health Commission developed such a competency set
through a project that was led by consumers and gathered data through focus groups with
consumers and written comments submitted by providers and government employees (O'Hagan,
2001). The final product includes 39 competencies in 10 domains, and can be accessed at
www.mhc.govt.nz/pages/publications.htm.
Work has also begun on formally assessing the recovery-oriented competencies of
individual providers. Investigators at UCLA-RAND developed a paper-and-pencil instrument to
measure 15 competencies that are critical to recovery-oriented care. The psychometric properties
of this Competency Assessment Instrument (CAI) were evaluated in 341 clinicians at 38 clinical
sites in 2 western states. The 15 scales were generally found to have good internal consistency,
test-retest reliability, and validity (Chinman et al., 2003). The CAI and instructions for scoring
are available at http://www.mirecc.org/education-frames.html.
Cultural Competency
D. J. Ida
Quality services must, by definition, be culturally competent. In other words, it is not
possible to provide competent services if one fails to adequately address the cultural and
linguistic needs of diverse populations. The President’s New Freedom Commission Report
(2003) identified the lack of quality services for African Americans, Asian American/Pacific
Islanders, Latinos and Native Americans and stated that:

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42

The current mental health system has neglected to incorporate, respect or understand the
histories, traditions, beliefs, languages and value systems of culturally diverse groups.
Misunderstanding and misinterpreting behaviors have led to tragic consequences,
including inappropriately placing individuals in the criminal and juvenile justice systems.
There is a need to improve access to quality care that is culturally competent. (p. 49)
Similar conclusions have been reached in the Institute of Medicine’s report Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care (2003b) and the Surgeon General’s
Report on Culture, Race and Ethnicity (U.S. DHHS, 2001).
The need to increase the number of bicultural and bilingual service providers is reflected
in the glaring discrepancy between the growing number of Latinos, African Americans, Asian
American/Pacific Islanders and Native Americans and the number of service providers from each
of these communities. According to the 2000 Census, the four major ethnic groups comprised
30% of the population and by the year 2025 will represent almost 40% of the U.S. population.
They are, however, greatly underrepresented in the number of mental health service providers
that are available. Ninety four percent of psychologists, 88% of social workers, 92% of
psychiatric nurses, 93% of marriage and family therapists and 95% of school psychologists are
White (not Hispanic) (Center for Mental Health Services [CMHS], 2004).
The solution to making the workforce responsive to the needs of communities of color is
complex, multifaceted, and goes beyond efforts to hire culturally diverse and bilingual
individuals. It occurs at all levels and involves training paraprofessionals as well as
professionals, and consumers. It involves changing not only who we train, but also the ‘what’
and ‘how’ of our training. It is teaching how culture defines the problem, and how language
influences how the problem is articulated.

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In 2002, the U.S. Department of Health and Human Services, SAMHSA, and the Center
for Mental Health Services awarded four grants as part of the Reducing Racial and Ethnic
Disparities through Workforce Training initiative. The four award sites are Drexel University;
the National Asian American Pacific Islander Mental Health Association (NAAPIMHA); Our
Lady of the Lake University; and the University of Medicine & Dentistry of New Jersey/Robert
Wood Johnson Medical School. Each site is implementing a training program that is designed to
improve the quality of service to diverse populations. Drexel University and the Robert Wood
Johnson Medical School provide training to service providers currently working with multiethnic populations in the Philadelphia and New Jersey communities, respectively. Our Lady of
the Lake University trains interns to provide bilingual and bicultural services to the Spanish
speaking Latino population in San Antonio, Texas.
The focus of NAAPIMHA’s training is to improve the quality of services for Asian
American and Pacific Islander consumers. It brought together experts from a range of groups to
write the first national training curriculum to improve services for Asian American and Pacific
Islanders. The groups included the Asian Counseling and Referral Services in Seattle, the Asian
Pacific Development Center in Denver, Hamilton Madison House in New York City, Hale Na’au
Pono of the Wai’ane Community Mental Health Center on Oahu and RAMS, Inc. and the Asian
American Psychiatric Inpatient Unit of the University of San Francisco General Hospital in San
Francisco. The result was the Growing Our Own curriculum (NAAPIMHA, 2002), which is
designed to train interns at the masters and doctoral level in psychology, counseling and social
work, as well as psychiatric residents. In addition, an effort is underway to train consumers to
assist in teaching Module II of the curriculum, which is called Connecting with the Consumer.

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At the state level, California is in the process of completing the California Brief
Multicultural Competency Training Program to increase the cultural competency of their mental
health workforce. The project was funded partially by the California Dept. of Mental Health and
an unrestricted educational grant from Eli Lilly and Company. It is a collaborative effort that
brought together the California Department of Mental Health, the California Institute for Mental
Health/Center for Multicultural Development, the Tri-City Mental Health Center, the University
of La Verne and Portland State University to write a curriculum based on the California Brief
Multicultural Competence Scale developed by Richard Dana of Portland State University. This
scale is a 21 item self-report instrument to determine the training needs of service providers. This
curriculum will be piloted in several counties this fall to assess the need for making any
modifications before rolling it out to other parts of the state.
Two additional resources that are useful in identifying and teaching competencies are
worthy of note. The SAMHSA Center for Mental Health Services Cultural Competence
Standards (SAMHSA, 1998) identify the knowledge, skills and attitudes that comprise the basic
elements of cultural competence. Information on these competencies can be accessed at
http://www.uphs.upenn.edu/cmhpsr/. The DSM-IV Outline for a Cultural Formulation and a
related training video (U.S. DHHS, 2002a) provides the practical framework for teaching the
impact and role of culture in the assessment, diagnosis and treatment of diverse populations and
is used in both the California and NAAPIMHA training programs to help clinicians accurately
assess, diagnosis and treat consumers.
Finally, as a special issue, the need to train interpreters is another important workforce
competency issue as the growing number of individuals with limited English proficiency far
outweighs the availability of bilingual service providers. Frequently, family members, including

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children, or other untrained individuals are inappropriately used to provide interpreting services,
seriously compromising the quality of services. The National Alliance of Multi-Ethnic
Behavioral Health Associations (NAMBHA), located in Washington, D.C. recently completed
the development of a curriculum to train interpreters to work specifically in the mental health
arena. The training will be piloted in California and Texas, which have high concentrations of
those who are either bilingual or monolingual non-English speaking.
Future efforts must continue to develop integrated models that train service providers
across all disciplines of mental health, primary health and addictions. Services must be
culturally, linguistically and developmentally appropriate to meet the needs across the life span
of an individual. More research is also required to measure the core competencies, such as the
ability to do a cultural formulation and to establish a therapeutic alliance with linguistically and
culturally diverse populations.
Peer Specialists
Larry Fricks & Cherryl V. Finn
The President’s New Freedom Commission Report (2003) on transforming mental health
care in America proclaims a vision that all mental health consumers can recover.
Recommendation 2.2 of the Report states:
Recovery-oriented services and supports are often successfully provided by consumers
through consumer-run organizations and by consumers who work as providers in a
variety of settings, such as peer-support and psycho-social rehabilitation programs...
Because of their experiences, consumer-providers bring different attitudes, motivations,
insights and behavioral qualities to the treatment encounter… In particular, consumeroperated services for which an evidence base is emerging should be promoted. (p. 37)

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In pioneering Medicaid-billable consumer-operated services, Georgia has utilized
consumer-providers, demonstrating both cost effectiveness and recovery outcomes that are
transforming the system. In order to accomplish such a service implementation it was critical to
identify and foster the development of specific competencies for the consumer-provider
workforce. In 2002, the Georgia Mental Health Consumer Network (GMHCN) was awarded a
three-year CMHS State Networking Grant, which provided the initial funding to develop and
implement the training and certification of peers for the new Medicaid-funded peer support
services. To implement proposed consumer directed services, there had to be assurances that the
consumer “providers” had adequate training to perform job responsibilities as set forth in
developing guidelines, and to establish a base of professionalism recognized within the system
among consumers, professionals, administrators and funding authorities. Partnering with the
state Division of Mental Health, Developmental Disabilities and Addictive Disease
(DMHDDAD; http://www2.state.ga.us/departments/dhr/mhmrsa/index.html), through its Office
of Consumer Relations, a training and certification program for a consumer “provider” was
established.
Initial qualifications and competencies were established to identify consumers eligible for
admission into the training program. Focus groups were held to determine specific competencies
that were necessary for peer specialists to be successful in these new roles. Included in the focus
groups were representatives of the GMHCN, the DMHDDAD, as well as service provider
organizations. Consideration was given to the categories of service in which peer specialists
could be employed, and from that discussion, more specific peer specialist roles and duties in
each service were identified. With a fuller understanding of desired roles and duties, the group
began to identify specific competencies that peer specialists must either possess or be trained to

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47

develop. The identified competencies were then incorporated in the Certified Peer Specialist
(CPS) job description that is utilized for recruiting peers for employment and for their
performance evaluation as staff members.
First and foremost candidates must be willing to self-identify as former or current
consumers of mental health or co-occurring MI/SA services. They must be well grounded in
their own recovery experience, with at least one year between initial diagnosis and application
for training. They must possess a high school diploma or a GED, and be able to demonstrate
basic reading comprehension and effective written communication skills. Finally they must have
demonstrated experience with leadership, including advocacy or implementation of peer-to-peer
services.
Competencies taught and developed through the training program can be grouped into
several distinct categories: 1) Understanding Mental Illnesses; 2) Recognizing the Possibility of
Change; 3) Developing Commitment to Change; 4) Fostering Action for Change; 5) the Georgia
Mental Health System; and finally 6) Professional Ethics. Peer Specialists learn about the
development of mental illness and the phases through which an individual progresses from
despair to hope. They are taught principles of recovery and elements necessary to foster a
“recovery environment.” Group process and facilitation as well as effective listening and the art
of asking questions are critical competencies that are emphasized throughout the training
program. The importance of spirituality and cultural competence are also vital components of the
program. Perhaps the most important skills to be developed through the training program are
problem solving and goal setting, and the ability to articulate the difference between the two
activities.

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Forty hours of training is conducted in two 4-day sessions. Approximately one month
after the training, these peers sit for their one-day certification exam, which is both written and
oral. Finally, upon successful completion of training and passing the exam, the newly Certified
Peer Specialist (CPS) is asked to sign the Professional Code of Ethics for CPSs. Understanding
the importance of professional ethics is the foundation for quality performance in the role of
CPS.
Continuing education is held quarterly, to reinforce specific skills or tools, and to address
issues that emerge from daily practice experience. Some emerging issues lead to the
development of additional training modules that strengthen the training curriculum. Recently, the
Office of Consumer Relations held a weeklong training in mediation for the CPSs, to further
develop their communication skills. This was followed by the employment of two full-time staff
trained in mediation, to provide on-site technical assistance to any CPS needing help with
conflict resolution.
A work force of approximately 200 Certified Peer Specialists are currently employed in
Georgia’s public mental health system, promoting outcomes of independence and illness selfmanagement by teaching recovery skills that can be replicated and evaluated. Approximately
2500 consumers will receive Peer Support services in the states’ 2004 fiscal year, with an
expected Medicaid billing for their services of $6 million. Training and certification activities
continue, with the costs now fully supported by DMHDDAD through Mental Health Block Grant
funds. Further information pertaining to the Certified Peer Specialist Project can be obtained at
http://www.gacps.org.
The utilization of peers in service provision is growing rapidly across the country. South
Carolina is already well underway with its own training and certification program modeled on

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49

the Georgia initiative. Hawaii is also moving in this direction, with staff from Georgia
conducting initial training classes and providing technical assistance for developing a consumerprovider staff cohort. To further expand the growth of consumer-providers nationwide a “Tool
Kit Manual” for replicating Medicaid funded Peer Support services and the training and
certification of Peer Specialists was commissioned by CMHS and written by Georgia staff and
other contractors.
Another exciting new initiative is the Peer-to-Peer Resource Center, a National Consumer
Self-Help Technical Assistance Center (TAC) sponsored by the Depression and Bipolar Support
Alliance (DBSA; http://www.dbsalliance.org) and funded by the federal Center for Mental
Health Services. The DBSA TAC considers peers a key workforce to promote self-directed
recovery, independence and community integration for mental health consumers. In a newly
piloted training and certification program, 25 consumers from around the country were taught
skills to promote both illness self-management and supported employment in the summer of
2004. Specific competencies for supporting consumers seeking to return to or gain employment
were included in this training program. Participants took both a pre-test and a post-test to
determine the effectiveness of the training. The long-range goal of this training and certification
program is replication nationwide and creation of a national network of trained and certified peer
supporters working side by side with other providers of mental health services. DBSA is also
working with its Scientific Advisory Board to develop further evidence for the effectiveness of
using Certified Peer Specialists.

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DISCUSSION
A review of these highly varied efforts to identify and assess competencies in behavioral
health yields an array of general conclusions. It appears that most of the work on this topic is
relatively recent and remains in an early stage of development. The major focus in most
initiatives has been on identifying the knowledge, skills, and attitudes required for practice, with
some efforts to organize these requirements into manageable clusters or competency domains.
To date, significantly less attention has been focused on developing and implementing strategies
to assess the identified competencies among students and current members of the workforce.
There appear to be rather striking similarities in the content of competencies identified, at
least in terms of the more general competency domains. Yet the work of the groups and
organizations described above is occurring independently. Recognizing that inter-professional
rivalries may impede collaboration, the question remains as to whether some level of
collaboration around identifying, defining, and assessing common or core competencies would
increase the resulting reliability, validity, and research base.
Several critical issues emerge from this review. First, it appears that consumer and family
involvement in the process of identifying and assessing competencies needs to be significantly
increased, as they do not appear to have played a major role in most of the work that has been
done to date. Second, many of the competencies identified have not been adopted or incorporated
by training programs, licensing agencies, and certification boards. Until this occurs, the work on
competencies is likely to have limited impact on the field. Finally, there remains a question about
whether the emerging competency sets, which have typically been identified by experts, are so
comprehensive and idealistic as to be unachievable by the typical student or practitioner. To
examine this question, the field must complement expert opinion with other data sources, such as

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observation of capable practitioners, to better define the competencies required to practice
effectively.
These issues aside, the work that is underway on defining and assessing competencies is
extraordinarily important. This work will be critical in guiding efforts to reshape and reform
training and education for the diverse groups that comprise the behavioral health workforce. We
must strive continually to define, with increasing precision, the knowledge, skills, and abilities
that effective practice requires. Through the process of assessment, we must ensure that those
competencies are, in fact, developed.

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52

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