Chapter 4: Curriculum Outline

Chapter Overview

This chapter provides a broad overview of curricular content for BHSS preparation in Washington state. The chapter may be helpful to educational programs interested in adopting the BHSS Clinical Training Program by introducing faculty and staff to the primary competencies for a BHSS.

Use the links below to jump to a particular section:

Curriculum Development Background
Meta-Competency 1: Health Equity
Meta-Competency 2: Helping Relationship
Meta-Competency 3: Cultural Responsiveness
Meta-Competency 4: Team-Based Care and Collaboration
Meta-Competency 5: Screening & Assessment
Meta-Competency 6: Care Planning & Care Coordination
Meta-Competency 7: Intervention
Meta-Competency 8: Law, Ethics, & Professional Practice

BHSS Curriculum Outline

Curriculum Development Background

The BHSS curriculum was shaped using a backward design approach. This process is explained in detail in Chapter 6. BHSS Curriculum Map. The BHSS Project Team first identified the competencies with the understanding that students would be engaged in general studies that lay a foundation for applied practice. Initial sources for conceptualizing BHSS competencies and scope of work included the Bree Collaborative Behavioral Health Integration Report and Recommendations (Washington State Health Care Authority, 2017), Washington Department of Health Report to the Legislature: Evaluating the Need for Creation of Bachelor’s Level Behavioral Health Credential (Health Systems Quality Assurance, 2019), recommendations from a Washington State Behavioral Health Workforce report (Skillman & Dunlap, 2022), recommendations from an early feasibility study reviewing a BHSS job description (Renn et al., 2023), the Core Competencies for Integrated Behavioral Health and Primary Care (Hoge et al., 2014), the occupational duties of the psychological wellbeing practitioner in England (NHS Health Careers, n.d.), and Agency for Healthcare Research and Quality Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary Care (Kinman et al., 2015).

In 2022, a series of statewide focus groups reviewed Version 1 of the BHSS competencies and recommended preparing the BHSS as a generalist to serve the spectrum of behavioral healthcare from crisis services to integrated care to specialty behavioral health settings.

Relationship between BHSS Clinical Training Program guidelines and a baccalaureate program’s accreditation through national or regional standards.

The BHSS Clinical Training Program’s goal is to lead the development of curriculum and guidelines that may be used by education programs to implement a BHSS curriculum. We recognize that programs’ existing national or regional accreditations may already require specific language for course catalogues and/or outcomes. In that case, we encourage education partners implementing a BHSS curriculum to look for general agreement between the materials in this Implementation Guide with your program’s existing course details. See Chapter 1. Program Description for more discussion on the connection between the BHSS curriculum and programs’ existing accreditation standards.

Curriculum Overview

Meta-Competency 1: Health Equity

Competencies

• Recognize the impact of health disparities on patient engagement.
• Practice use of inclusive communication that supports healthcare equity.

Definition

Health equity is defined as attaining the highest level of health for all people, regardless of cultural, demographic, or socio-economic factors (National Council for Mental Well Being, 2022).

Importance

Incorporating concepts and strategies to improve health equity into BHSS preparation is crucial to fostering a generation of informed and empathetic healthcare professionals. Health equity refers to the principle of ensuring that every person has equal opportunity to attain their full health potential and has a sense of belonging regardless of race, ethnicity, disability status, gender, sexual orientation, veteran status, or other personal identity variables associated with social determinants of health. By introducing this concept into BHSS preparation, students can develop a deeper understanding of the root causes of health disparities and learn how to address them through their jobs and community advocacy.

Usefulness

Including health equity as a topic in BHSS preparation will be useful in helping to improve health outcomes, especially for populations most impacted by health disparities. Understanding health equity involves challenging the biases and systemic barriers that perpetuate health disparities. By equipping BHSS students with these insights they can advocate for more equitable healthcare policies, contribute to community-based interventions, and promote inclusivity within the healthcare system.

Rationale for Inclusion in the Curriculum

The Institute for Healthcare Improvement originally outlined three aims: improving population health, enhancing the care experience, and reducing costs (Berwick et al., 2008). In 2014, the provider experience was added (Bodenheimer & Sinsky, 2014) to address exhaustion and burnout in the workforce. The first BHSS competency aligns with the fifth aim of healthcare improvement added in 2021 (Nundy et al., 2022): health equity. With knowledge of health disparities and skills that support inclusivity, BHSSs will be prepared to build trust with patients and contribute to organization-wide changes, optimizing efforts to improve patient outcomes. The identified competencies address knowledge, skills, and attitudes the BHSS may be able to utilize in their unique capacity to improve health equity.

While there have been advances in societal efforts to improve health equity – poverty, race, and ethnicity continue to be associated with poor health and poor conditions for health (O’Kane et al., 2021). Mortality rates, certain medical conditions such as obesity and heart disease, and rates of suicide are higher in certain groups that have experienced historical trauma and/or systemic exclusion from quality healthcare (National Academies of Sciences, Engineering, and Medicine, 2017). For example, American Indians and Alaska Natives have the highest suicide rates among racial and ethnic groups (Walker, 2021; Zamora-Kapoor et al., 2016). Understanding historical causes of distrust in healthcare, such as systemic exclusion or unethical withholding of treatment, may help encourage the use of inclusive and respectful communication with patients and their support systems (Nundy et al., 2022).

Program-Level Guidance

Educational partners may already provide academic opportunities to explore the root causes of health inequity, the impact of health inequity on health outcomes for specific groups, and models for improving health equity. By engaging students in discussions, case studies, and experiential learning opportunities, they can explore the complex interplay of factors that contribute to health inequities such as housing status, job status, community safety, and healthcare access.

Meta-Competency 2: Helping Relationship *Please see updates to MC2

Competencies

• Develop supportive and effective working alliance with patients and their support networks.
• Engage patients to enhance participation in care.
• Facilitate group psychoeducation.

Definition

The Helping Relationship (also called the working/therapeutic alliance or just “alliance”) Meta-Competency refers to the relationship between a patient and a trained provider, such as a BHSS. Its relevance is shown across models of therapeutic interventions, sometimes referred to as “transtheoretical” or “common factors” models (Wampold, 2015). The helping relationship can be characterized by (a) a shared bond between patient and provider, (b) agreement on goals of psychosocial interventions, and (c) agreement on how the patient can achieve the goals of psychosocial interventions (Bordin, 1979, as cited in Wampold, 2015).

Importance

The helping relationship has been considered a critical element of effective mental and behavioral health treatment primarily in the capacity of healing (Comas-Díaz, 2012). Yalom (as cited in Wyatt, et. al., 2009) explains that all healing is relational because humans are hardwired for connection. Evidence across studies suggests that professional helping relationships that support a patient to become whole or integrated have an impact on intervention outcomes (Cormier, 2017; Del Re, 2012, as cited in Wampold, 2015).

Usefulness

Since the BHSS role is focused on supporting mental and behavioral health treatment, available evidence across mental health and behavioral health treatment models supports the critical role of establishing a strong helping relationship (Comas-Díaz, 2012; Cormier, 2017; Wampold, 2015). This suggests that the success of the BHSS will be anchored in understanding the importance of trust, authenticity, and empathy in the context of the helping relationship.

Rationale for Inclusion in Curriculum

The Helping Relationship Meta-Competency is essential to include in BHSS training programs because it increases the likelihood that the interventions delivered by the BHSS will be well received and practiced by their patients between visits. Indeed, evidence across prior work suggests that patients’ perspectives of the quality of the helping relationship tends to be stable across encounters with clinical practitioners (Martin et al., 2000). The initial patient perspective of the quality of the helping relationship is a powerful predictor of the strength of the relationship from the patient’s perspective for the remainder of their encounters with the BHSS.

Program-Level Guidance

The Helping Relationship Meta-Competency intersects with the Intervention Meta-Competency in that some of the micro-skills related to active listening, such as, paraphrase, reflection, and summaries are mentioned in the knowledge, skills, and attitudes for the Interventions. Practical recommendations for enhancing the quality of the helping relationship, such as adopting a person-centered approach to care and collaboratively constructing goals for psychosocial interventions (Stubbe, 2018), will be critical aspects of BHSS education and training. We encourage BHSS training programs to reference available literature (e.g., Stubbe, 2018; Cormier, 2017) for actionable practices that BHSS students can implement to enhance the helping relationship during initial and ongoing encounters with patients.

Conyne & Diederich (2014) define group work as follows:

A broad professional practice involving the knowledge and skill of group facilitation to assist an interdependent collection of people to reach their mutual goals which may be intrapersonal, interpersonal, or work related and may include the accomplishment of tasks related to work, education, personal development, personal and interpersonal problem solving, or remediation of mental and emotional disorders (p. 5).

Groups may be a means of providing interventions that are both culturally responsive and effective (Conyne, 2010; Wheelan, 2005). Programs may address the group psychoeducation competency directly through a course on group work or integrate group facilitation strategies into another advanced course with a focus on prevention, population health, or patient education. At minimum, exposing students to group dynamics and facilitation of groups will be helpful for advancing students’ applied skills and contributions in the workplace.

Note to Education Partners: Trauma-informed care (TIC) is a framework for conducting helping relationships at all levels of care. The practical tips that emerge from TIC literature (Evans, 2014; Racine et al., 2020; SAMHSA, 2023) to minimize re-traumatization in healthcare settings will be helpful in supporting patient engagement, the working alliance, and individual and group interactions. At present, the BHSS Project Team is assessing where TIC belongs in the competency framework. Education partners will help guide the inclusion of TIC in V2 of the Implementation Guide.

Meta-Competency 3: Cultural Responsiveness

Competencies

• Develop knowledge of a patient’s identities.
• Provide services responsive to a patient’s identities.
• Practice cultural humility in helping relationships.
• Strive to address one’s own biases in work with patients.

Definition

Cultural responsiveness is a framework for developing understanding of a patient’s identities. It describes the authentic, compassionate, curious, and humble interaction of provider with patient (Beaulieu & Jimenez-Gomez, 2022; Comas-Díaz, 2012). Through this framework, the provider simultaneously and continuously explores their own identities and the interacting effects of provider and patient identities.

Importance

Knowledge of models of personal identity development, the correlation of identities with health behaviors, and the history of healthcare disparity is critical to the provision of culturally responsive behavioral healthcare (Arredondo et al., 1996; Comas-Díaz, 2012; Sue, 1990; Tervalon & Murray-Garcia, 1998). A BHSS should appreciate this intersectionality and learn to work with patients from a framework of understanding and empathy (Crenshaw, 1991).

An example of a personal identity development model is the A-B-C Dimensions of Personal Identity (Arredondo et al., 1996). The A Dimension represents stable, fixed demographic factors such as age, culture, race, ethnicity, gender, language, physical abilities, sexual orientation, and class. Dimension B represents educational background, geographic location, income, relationship status, religious affiliation, citizenship status, military experience, and recreational interests. The C dimension represents the ecology and historical context of how people live and thrive. It is also characterized by the history of racial and ethnic disparities in health care. “Racial and ethnic disparities in health care exist even when insurance status, income and age are comparable. Death rates from cancer, heart disease, and diabetes are significantly higher in racial and ethnic minorities than in whites” (Nelson, 2002, p.666).

While this is one of many models for describing personal identity, it supports the notion that people are complex, and it is the intersection of these dimensions that helps healthcare providers understand the whole person in context. Part of becoming culturally responsive is to assess how bias, stereotyping, and prejudice may influence clinical judgement and discourage patient participation in their own healthcare.

Usefulness

Culture is the total collection of beliefs, values, customs, and practices of a group of individuals that people are born into or with whom they share similar demographic variables (Wing Sue & Sue, 2019; Ratts & Pedersen, 2014). Culture impacts human communication, daily routines, habits, parenting styles, concepts, values, beliefs, and other behaviors. Culture also has a significant impact on a broad range of health behaviors, such as health beliefs, and responses to medications and provider recommendations (Beaulieu & Jimenez-Gomez, 2022; Wing Sue & Sue, 2019). Efforts to understand a patient’s culture and the influence of culture on health and behavioral health are essential to building a therapeutic alliance and engaging in motivational enhancement work to help relieve patients of suffering and improve quality of life.

Rationale for Inclusion in Curriculum

In a study of the impact of cultural competence training with psychological wellbeing practitioners in the UK, Bucheeri and Faheem (2023) found that existing training was not sufficient and advocated for reflection on one’s own identities and personal experiences combined with training to improve cultural responsiveness. While there is debate in the literature between the terms “cultural competency” and “cultural humility,” we find cultural humility is most appropriate for BHSS preparation. Cultural humility involves understanding that one’s view of the world is impacted by one’s individual learning history and that different environmental and learning histories impact the behavior of others (Beaulieu & Jimenez-Gomez, 2022). The practice of cultural humility is a lifelong process of continual self-reflection to produce a provider and patient partnership that reduces power imbalances (Tervalon & Murray-Garcia, 1998). Clinicians never reach a finite point of fully understanding another person’s cultural identity, especially as culture shifts and changes with time.

Program-Level Guidance

Baccalaureate educational programs in psychology, social work, and behavioral healthcare likely have courses and learning objectives aligned with social and cultural foundations. The role of the BHSS Clinical Training Program is to provide recommendations for applied practice. We recognize that many educational programs may meet or exceed the recommendations in terms of content. Our intent is to focus on applied skills rather than a comprehensive overview of social and cultural studies. With this in mind, we recommend including a historical foundation into health disparities (see Meta-Competency 1: Health Equity), exploration of the role culture and personal identity play in health behavior, and opportunities to engage in reflective practice, exploring personal biases, stereotypes, and prejudices (See Meta-Competency 8: Law, Ethics, & Professional Practice). Since biases of all kinds are conditioned over many years, reflective practice should be guided and assessed by a program instructor to challenge thinking and encourage personal growth and expansion of awareness (Sue, 1990).

BHSS Project Team Note

The BHSS Clinical Training Program aligns with UW Medicine’s commitment to anti-racism in educational preparation and clinical practice (UW Medicine, 2020). Educational institutions may have their own form of expression related to anti-racism. We recommend highlighting these efforts in recruitment and admission, and throughout the academic program.

Meta-Competency 4: Team-Based Care and Collaboration

Competencies

• Integrate professional identity and scope of practice within a healthcare team.
• Practice interprofessional communication.
• Contribute to teams and teamwork.

Definition

Teams in healthcare and behavioral health care are often interdisciplinary by nature. Team members hold both unique and shared responsibilities for patient care consistent with their education, training, and experience. “Collaboration” implies the ability to recognize the unique roles of team members, appreciate the impact of the team on patient well-being, and invest in shared responsibility for patient outcomes, including patient safety.

Importance

Team-based care and collaboration support intentional and strategic comprehensive health care services. The services involve health professionals working collaboratively to share responsibilities with patients, families, and community partners. The composition of the team varies based on setting and care delivery model. The collaborative team shares measurable goals across settings to achieve safe, high quality, effective, timely, equitable, and patient-centered care (Schottenfeld, 2016). These factors assist in improving patient and staff experience, outcomes, and efficiency in services. Team-based care and collaboration leads to increased patient satisfaction, positive patient experiences, positive staff experience, and patient engagement (Sinsky, 2015).

Usefulness

Team-based care and collaboration assist in providing more effective and efficient services, as well as improved access to services (i.e., patient education, care coordination). Team-based care and collaboration increases communication among all members of the team, the practice, and patients (Smith, 2018). Staff work at the highest level of their scope of practice within proximity of each other, while reducing the administrative burden for individual professional team members. The professional team can see more patients due to time efficiency and increased access availability (Sinsky, 2015). The team prioritizes accountability and focuses on feedback from patients, communication around the process, and a collective drive to understand the community served.

Rationale for Inclusion in Curriculum

Effective team-based care and collaboration are essential to quality healthcare and improved outcomes (Smith, 2018). Patient outcomes are connected to the ability of a team to provide whole person care; patient safety, improved outcomes, staff well-being, and creating a culture of continuous quality improvement all require effective teamwork. By including this meta-competency in the curriculum, BHSSs will be prepared to represent the practice or team when working with a patient and will be able to effectively contribute to the overall functioning of the healthcare team.

All team members contribute their expertise to patient care; the BHSS has a particular responsibility to understand the general professional language of co-providers of service. Understanding and working within scope of practice promotes patient well-being, support, and trust that creates an environment of welcoming and belonging. The BHSS will be able to consider ways to expand their roles as a part of a team and incorporate patient voice as well as their own voice as a team member. They will be able to utilize their skills learned to create clearly defined roles, mutual trust, effective communication, measurable outcomes, shared goals, regular communication pathways, care plans for continuity of care, and foster shared decision-making, which is a component of patient centered care. The BHSS will be able to assist in organizational structure change in practice with patients and colleagues. They will have an astute ability to reflect on a team-based collaborative model of care and the necessary workflows needed, along with cross training endeavors to maximize resources available in one location.

Program-Level Guidance

Learning to work in teams may begin early in an educational program. Creating space for students to learn about team formation, leadership, and collaboration through the sometimes-challenging experience of group projects is one approach to teaching teamwork. Opportunities to process team-based experiences and discuss opportunities for alternate approaches to teamwork will help expand student awareness of their role, how their role impacts others, and their responsibility to a team.

Meta-Competency 5: Screening and Assessment

Competencies

• Utilize appropriate standardized screening tools to identify common behavioral health conditions.
• Conduct a suicide risk assessment and provide appropriate intervention under supervision.
• Conduct a patient-centered biopsychosocial assessment.
• Use measurement-based care to support stepped care approaches and adjust the type and intensity of services to the needs of the patient.

Definition

Screening tools help identify safety risks or other behavioral health needs. The assessment expands on information gathered from screening tools and incorporates information from additional sources to provide a more specific and comprehensive examination of an individual’s identified needs. Further, the assessment provides a more complete picture, which is critical for providing whole health care.

Importance

The systematic and repeated use of validated screening tools provides valuable information about symptoms and functioning over time (Alter et al., 2021). This information facilitates measurement-based care by indicating a need for treatment adjustment, which can include a step up or down in service intensity. There is strong evidence supporting measurement-based care, as the use of repeated and validated measures has been shown to improve behavioral health outcomes (Fortney et al., 2017).

Usefulness

A BHSS will be expected to utilize standardized screening tools such as the PHQ-9, GAD-7, AUDIT, etc., to identify symptom severity and monitor for improvement or decline. Utilizing these screening and assessment tools provides information that assists in providing appropriate and person-centered care. While screening tools are not definitively diagnostic, the score may indicate a need for brief intervention or for further evaluation.

Rationale for Inclusion in the Curriculum

Screening and assessment provide the care team with information needed to take a person-centered, whole health approach. The BHSS will administer standardized instruments and ask follow-up questions when indicated. Information gathered from screening and assessment also provides a common language for effective and efficient communication across the treatment team. For example, a provider licensed to assess, diagnose, and treat mental and behavioral health conditions may use a BHSS assessment as part of the diagnostic process. The BHSS also participates in suicide risk assessments and works closely with the team to determine next steps and promote safety.

Program Level Guidance

Measurement-based care (AIMS Center, n.d.) is a population health approach that helps systems identify behavioral health needs within their patient population that might otherwise go unnoticed. While the use of measures may seem impersonal, screening should be accompanied by a follow-up interview with the patient to understand the patient’s perspective on their scores. An example of this process is demonstrated in the Brief Negotiated Interview (BNI) connected to Screening, Brief Intervention and Referral (SBIRT) for substance use concerns. Once a patient’s behavioral health needs have been identified and brief interventions are offered with patient consent, it may be beneficial to have a system to re-measure the symptoms to track patient improvement, stagnation, or decline. This approach helps systems to mobilize resources where they are needed. A BHSS who engages in measurement-based care in consultation with a supervisor will benefit from understanding the impact of their interventions related to patient improvement. The BHSS Project Team understands that there is variability in the use of measures and measurement-based care within healthcare systems. Teaching measurement-based care will help advance the professional identity of the BHSS across different systems of care.

The BHSS Project Team is in the process of creating learning tools to assist education partners in scaling training, especially for suicide screening. An Intelligent Tutoring System (ITS) module will be available to all participating BHSS programs and may be delivered through the school’s Canvas course. The ITS utilizes the Columbia-Suicide Severity Rating Scale (C-SSRS) protocol to guide students in understanding their obligation to systematically assess for risk. While programs are not required to use the ITS learning tool, students will benefit from guided instruction that leads to competency in the use of similar screening tools. Discussion of validity, reliability, and the value of protocol will be helpful for framing the delivery of all screening instruments for behavioral health conditions.

Meta-Competency 6: Care Planning and Care Coordination

Competencies

• Contribute to the development of a whole health care plan and stay well plan with the patient, the patient’s support network, and healthcare team members.
• Maintain a registry to systematically track patient treatment response to interventions.
• Ensure the flow and exchange of information among patients, patients’ support networks, and linked providers.
• Facilitate external referrals to social and community-based services (housing assistance, food banks, vocational rehabilitation, substance use disorder treatment, etc.).
• Demonstrate accurate documentation of services provided and summaries of contact with linked providers in the patient record.
• Recognize the interaction between behavioral health conditions, chronic physical health conditions, and their associated symptoms.

Definition

Care planning involves creating a comprehensive and individualized roadmap for a patient’s treatment and management (whole health care plan) and recovery (stay well plan). A whole health care plan (treatment plan, goal plan, etc.) is built on asking what matters to the patient rather than asking what is wrong with the patient. Three pillars describe a whole health care plan: (1) Treat disease within a whole health approach combining medical and behavioral healthcare when needed; (2) Equip patients with self-help and skill building strategies to manage their health over time, and (3) Empower patients through partnership (Kligler, 2022). A stay well plan (recovery plan, relapse prevention plan, etc.) empowers patients to maintain progress toward health goals with the understanding that progress is often a spiral, versus a linear trajectory. Care coordination involves seamless collaboration and communication among various team members to ensure that patients receive comprehensive care. Coordination includes communication with the patient and the patient’s primary social support system.

Importance

The Care Planning and Care Coordination Meta-Competency ensures that patients receive effective, coordinated, and personalized care. Care planning and care coordination are important because these skills help bridge gaps between the numerous factors relevant to a patient’s care. These factors may include different settings (e.g., community-based mental health, primary care, substance abuse treatment), information (e.g., medical history, justice system history, military), and people (e.g., caregiver, family, etc.). When well-coordinated, the patient experiences care that is more efficient, effective, and better aligned with their goals.

Usefulness

A whole health plan that supports understanding of the mind-body connection helps care teams collaborate for the benefit of the patient. For example, if a patient is experiencing the effects of hyperglycemia due to Type 2 diabetes accompanied by depressive symptoms, it is essential for a care team to address both the physical health concerns and the mental health concerns of the patient. A whole health care plan identifies problems, treatments, providers, and patient response to interventions. Clear documentation by each member of the team, including the BHSS, helps ensure coordinated care.

Rationale for Inclusion in the Curriculum

Care planning and care coordination facilitate whole health care by keeping everyone involved in a patient’s care on the same page. To work effectively in a team-based environment, the BHSS needs to participate and at times lead facilitation of care planning and care coordination. BHSS activities that fall under care planning include tracking/monitoring symptoms, facilitating referrals, documenting, and sharing information.

Program Level Guidance

Care planning and care coordination likely appear in behavioral healthcare degree programs as part of a mental health systems course or issues in behavioral healthcare. In other degree programs, the competencies will likely be taught across different courses. For example, learning to maintain a registry to track patient progress may be closely tied to screening and assessment, while documentation in the patient record might be connected to a law and ethics module or course. It may be useful to think of the competencies in this section as modules that may be introduced, reinforced, and assessed as proficient within a reasonable timeframe across the curriculum.

Meta-Competency 7: Intervention *Please see updates to MC 7.

Competencies

• Integrate motivational interviewing strategies into practice. 
• Provide psychoeducation to patients and their support network about behavioral health conditions and treatment options consistent with recommendations from the healthcare team.
• Apply brief, evidence-based strategies for common behavioral health presentations, based on cognitive behavioral principles and behavioral activation. 
• Apply brief, evidence-based strategies for mild-to-moderate depression, based on cognitive behavioral principles and behavioral activation.
• Apply brief, evidence-based strategies for mild-to-moderate anxiety, based on cognitive behavioral principles and behavioral activation.
• Utilize a screening, brief intervention, and referral (SBIRT) approach appropriate to patient alcohol or substance use problems. 
• Demonstrate a clear understanding of the evidence base for brief intervention strategies that focus on symptom reduction. 

Definition

Evidence-based interventions delivered by a BHSS are expected to:

• Be delivered consistently with measurement-based and biopsychosocial assessment (see Meta–Competency 5: Screening and Assessment),
• Be delivered under supervised interventions that target the reduction of specific behavioral health symptoms (e.g., anxiety and depressive symptoms), and
• Incorporate motivation enhancement strategies to facilitate achievable patient engagement (e.g., motivational interviewing).

While a BHSS may be trained to deliver a variety of interventions intended to address various mental health conditions, their interventions are limited by being brief, which is differentiated from longer-term psychotherapies. For this implementation guide, “brief interventions” refer to interventions that target relief of behavioral health symptoms with a typical range of 1 – 12 sessions, possibly depending on the treatment setting and symptoms being managed (e.g., crisis services, integrated care, or specialty care). Of relevance to this section, BHSS providers are required to deliver all interventions under the supervision of a licensed provider who can diagnose mental and behavioral health conditions.

Importance

Evidence-based interventions (EBIs) are strategies with research-based efficacy to address desired outcomes, such as reduction in anxiety and/or depressive symptoms. EBIs have been the focus of various provider disciplines, such as social work, nursing, and psychology (Satterfield et al., 2009). While there is variability in the form and conditions that brief behavioral interventions have been shown to address, they have been shown to improve individual outcomes for populations of people (Hunter et al., 2017). The importance of using behavioral health interventions to manage specific symptoms, such as depressive symptoms, which are based on empirical evidence, has been described in detail elsewhere (e.g., Levant & Hasan, 2008; Myers & Wodarski, 2014). Promising efforts to adapt EBIs to diverse communities (e.g., Asnaani et al., 2022) and populations towards the beginning and ending of the human development continuum (e.g., Raue et al., 2022) have found support. In addition, the interventions that BHSSs utilize are intended to be under supervision and brief because the threshold of their training is at the bachelor’s level, and they are not qualified to diagnose mental or medical conditions found in the latest versions of the Diagnostic and Statistical Manual for Mental Disorders (DSM) (American Psychiatric Association, 2022) and/or International Classification of Diseases and Related Health Problems (ICD-11) (World Health Organization, 2022). Evidence-based interventions delivered by BHSSs can help address the gap between the large need for behavioral health services and the workforce struggling to address that need (see Renn et al., 2023).

Usefulness

The BHSS role is focused on targeted behavioral health symptom management, which is guided by screening, measurement-based care, and biopsychosocial assessment. While EBIs may be specifically intended for certain conditions (e.g., behavioral activation for depression), it is anticipated that training in motivational enhancement strategies (e.g., motivational interviewing), cultural responsiveness, assessment, and trauma-informed care will guide the BHSS in appropriate selection and utilization of evidence-based interventions (e.g., recognizing that cultural background may impact responses to mental health symptom severity measures). Thus, the BHSS will be trained to deliver EBIs that will be tailored to patient characteristics and collaboratively constructed goals of care to maximize the likelihood of effective symptom management.

Rationale for Inclusion in the Curriculum

Essential to the BHSS role, training in brief EBIs will provide BHSS students with the basic skills to deliver brief and effective behavioral health interventions. Depending on training settings and professional development, a BHSS may expand the spectrum of interventions they deliver, given documented training and intervention delivery under supervision. Indeed, BHSS students may opt to continue their clinical training into graduate training programs (e.g., mental health counseling), which may build upon their BHSS training and expand the scope of their practice.

Program-Level Guidance

The BHSS Project Team is developing detailed guidance and curricular materials for brief interventions including motivational enhancement, behavioral activation, CBT for anxiety, and brief psychosocial interventions for substance use concerns. These approaches are evidence-based and effective across broad populations when delivered with culturally responsive care. Educational partners may have developed their own approaches to teaching similar models. One of the distinctions of a BHSS is the competency to deliver brief evidence-based interventions for depression and anxiety with fidelity. Please consult with the BHSS Project Team if your program needs assistance in developing, delivering, or evaluating intervention curriculum.

Meta-Competency 8: Law, Ethics, & Professional Practice

Competencies

• Identify and apply federal and state laws to practice.
• Integrate foundations of interprofessional ethics into practice.
• Utilize supervision and consultation to guide practice.
• Engage in on-going reflective practice.

Definition

Laws are understood as the minimum expectation for behavior among citizens reflecting the customs and values at the time the laws were created (Corey, 2011; Wheeler, 2015). Ethics serve as a guide to clinical practice and decision-making and represent a profession’s thoughtful reflection on the values and beliefs of the profession’s membership (Koocher, 2015). Professional practice describes the expectations of local members of a professional group or interprofessional group regarding job performance, patient interaction, and representation of an organization to the public.

Importance

As a new member of the Washington State Behavioral Health Workforce, it will be essential to prepare the BHSS with knowledge and skills related to law, ethics, and professional practice. The BHSS has a duty and obligation to promote the public good and protect the public from harm, as do all Washington behavioral health provider types. A BHSS will develop a professional identity both within the educational program and through supervised practice and employment. BHSS supervisors are from various professions and may belong to one or more professional associations (for example, psychology, social work, counseling, marriage, and family therapy) with ethical codes specific to the profession. The BHSS holds a dependent credential (this means supervision is required to practice) and therefore will frequently rely on the guidance of the supervisor in managing ethical dilemmas.

Usefulness

A BHSS who demonstrates competence in law, ethics, and professional practice will be an asset to organizations and managers by building trust and confidence in their work. A successful BHSS will minimize risk related to liability by understanding and practicing standards for professional practice. To that end, a BHSS will also benefit from understanding how to respond to requests from superiors in an organization that may be outside of the BHSS scope of practice. Professional communication, thoughtful exchange of ideas, and conflict resolution skills are important for team-based work, quality supervisory relationships, and the care of patients.

Rationale for Inclusion in the Curriculum

Per SSB 5189 (opens in a new tab), persons who graduate from a BHSS program and apply for a state credential will need to take a state jurisprudence exam. For clarity, the jurisprudence exam has not been created as of V1 of this Implementation Guide. More information is expected to be available through DOH in the future. The jurisprudence exam will likely cover the Revised Code of Washington (RCWs) and the Washington Administrative Code (WACs) pertinent to BHSS practice. Exposure to ethical concepts and state laws during the bachelor program will be essential for successful completion of the jurisprudence exam. Examples of laws and regulations pertinent to practice are found in each profession’s credentialing homepage created by the Department of Health (for example, Psychology, Social Work, Mental Health Counseling, Marriage, and Family Therapy).

Program-Level Guidance

Delivery

If a program already offers a course specific to law and ethics, the program may update the course to include learning objectives relevant to clinical practice. Another approach may be to distribute law, ethics, and professional practice across several relevant courses. A third possibility is to offer an overview of law and ethics pre-practicum, then provide seminars during the practicum experience that address law, ethics, and professional practice in more depth.

Laws

We understand laws may be rescinded, modified, changed, or added over time. Our intent in this manual is to provide examples of what might be covered in a program, course, seminar, or learning module at the time of this writing.

We recommend addressing federal laws foundational to privacy and confidentiality such as HIPAA, HITECH, and CRF 42. Understanding federal law will support understanding of Washington state privacy law, for example, the disclosure law (RCW 70.02.020). Bachelor-level students do not need to know all the details of federal laws; rather, they should be familiar with the general principles that impact clinical practice.

In referencing state laws, we recommend identifying laws impacting all behavioral health providers. Examples of general state laws are: privileged communication (RCW 5.6.060); mandatory reporting for child (RCW 26.44.030) and vulnerable adult (RCW 74.34) abuse; unprofessional conduct (RCW 18.130.180); fraud or misrepresentation in obtaining or maintaining a license (18.130.200); and concepts such as the least restrictive alternative, involuntary commitment, and patient rights. Additionally, the WAC has more detailed information to interpret the RCW. Examples are found in WAC 246.16 covering standards of professional conduct for health care providers.

Ethics

A frequent question posed to the BHSS Project Team is: “since the BHSS is not part of a recognized profession, what ethical codes will guide their practice?” Professional literature (Corey, 2011) distinguishes between principle ethics (obligation) and virtue ethics (ideal). Principle ethics are often found in a profession’s ethical codes. Virtue ethics are themes that underly most ethical codes and reflect the expectations of the public for the day-to-day work of the professional. Examples of common virtues associated with psychology and counseling are autonomy, beneficence, nonmaleficence, veracity, fidelity, justice, and self-care (Barnett & Cooper, 2009; Meara et al., 1996). Exposure to these virtues and examples in practice will provide a foundation to ethical practice critical for all professionals in their early development.

An educational program may be inclined to teach ethics referencing a code of ethics within the professional identity of the program or faculty. For example, a psychology program may choose to teach from the American Psychological Association (APA)’s (2022) Code of Ethics while a social work program may choose to teach from the National Association of Social Worker (NASW)’s Code of Ethics. Exposing BHSS students to a particular profession’s code of ethics is a reasonable choice.

There is a growing body of literature related to the study of professional ethics within interprofessional teams (Kanzler et al., 2013; Koocher, 2015; Opsahl et al., 2020; Runyan et al., 2018). Utilizing foundational ethical principles (virtue ethics), employing steps for ethical decision-making, and exploring the ethical guidelines of multiple professions (principle ethics) to guide decision-making may be an option within BHSS programs.

One of the anticipatory outcomes of the BHSS Clinical Training Program is that BHSS graduates may enter the workforce pipeline to graduate work in one of many behavioral health professions. BHSS students will naturally be exposed to ethics from different disciplines due to supervisor assignment during the academic program, as well as during employment.

Professional Practice

Honesty, patience, curiosity, collaboration, leveling, care for the patient, and care for oneself are all elements of professional practice (Uhlig et al., 2018). A key aspect of professional practice highlighted in the BHSS Clinical Training Program is the concept of the reflective practitioner (Johns, 2022; Schön, 1983). Educational programs can assist students with developing critical thinking skills, understanding the importance of critical inquiry, and practicing reflexivity in their work. The ability to honestly assess one’s interactions with others takes time, practice, and support. This work is part of the reward of belonging to the behavioral health professions, as well as one of the great challenges. Educators may model the reflective practitioner in the classroom, in reviewing assignments, and providing feedback to students. The art of learning to self-assess and self-critique is lifelong. Continuing education beyond the degree program will also support the development of professional practice.

Summary

• The BHSS Clinical Training Program curriculum is organized into 8 Meta-Competencies.
• Through collaboration with community partners, the BHSS Project Team created the BHSS competencies to address the important areas that a BHSS will need to develop proficiency in to provide whole person health care and be a member of a functioning healthcare team.

Up Next

The next chapter, Chapter 5. Practicum, will describe the recommended guidelines for a practicum for BHSS students. By the end of Chapter 5, you will have the context and information needed to begin analyzing your program’s readiness for a BHSS curriculum.