Clinician Training Efforts in Outpatient Mental Health Improve Outcomes

How can additional training in specific mental health diagnoses improve outcomes and clinician confidence?

During the COVID-19 pandemic, mental health conditions such as obsessive-compulsive disorder (OCD), anxiety and eating disorders rose sharply among children and adolescents, and they haven’t yet slowed down. At Children’s Hospital Colorado, that has translated into a particularly high demand for specialty outpatient services. But with a thinly stretched mental health workforce, kids and clinicians alike have felt the strain on the system, which has highlighted a deep need for specialized training.

“The majority of clinicians identify as generalists in mental health, meaning that they broadly treat children and adolescents for a wide range of presenting concerns,” says Kim Sheffield, PhD, eating disorders psychologist and Associate Training Director at Children's Colorado. “And while that is wonderful and we certainly want to address all of those concerns, it often leads to a gap in training for specific diagnoses.”

To address this gap, the team at Children’s Colorado’s Pediatric Mental Health Institute turned inward, taking every opportunity to increase specialty training among its workforce and rising clinicians. Now, researchers are sharing training efforts and successes externally to show others what’s possible.

Eating Disorders Outpatient Clinic

According to Dr. Sheffield, most mental health trainees don’t receive significant training in eating disorder treatment unless they identify a particular interest and choose to specialize.

“That, of course, then breeds discomfort in treating those patients because you don't feel like you have the expertise,” she adds. “So, we were running into this consistent issue of not having providers in our outpatient clinic to step our patients down from our higher levels of care.”

When kids finished an emergency visit, inpatient stay or partial hospitalization program, Dr. Sheffield’s team was often tasked with needing to refer them to private practices for outpatient care — something that can be both expensive and difficult to access. Additionally, each time a kid left the Children’s Colorado system, the team lost a chance at providing the kind of continuous care that can lead to better outcomes.

Working with child and adolescent psychologist Jessica Hawks, PhD, Dr. Sheffield began exploring opportunities to not only increase technical competencies among other mental health providers at Children’s Colorado, but also to ensure they felt supported and comfortable along the way. That included securing funding to pay for the time participants would need to spend engaging with training.

The pair began with a cohort of five master’s degree-level team members, including social workers and licensed professional counselors. The initial training included a monthlong shadowing period, as well as assigned reading on the most effective evidence-based treatment approach for kids with eating disorders — family-based treatment. For the six months after that, Dr. Sheffield provided weekly consultations as the clinicians began to see patients in the Outpatient Psychiatry Clinic.

Additionally, because eating disorders have such a significant impact on the physical health of patients, members of the training cohort needed to acquire a general knowledge of the medical complexities associated with the condition.

In 2024, Dr. Sheffield published the findings of her training study. Using an adapted measure of competence with eating disorders, she found that all participant scores were reflective of increased knowledge, comfort and competence with the population.

“In many of the cases, we were going from zero comfort and confidence at baseline to feeling moderate and even above moderate comfort, which was great,” she says. “Anecdotally, we were seeing that they were knowledgeably speaking about eating disorders and they were taking on these more complicated patients and managing those cases when previously, they were not seeing eating disorder patients at all.”

Though not all of the newly trained providers have remained with Children’s Colorado, Dr. Sheffield says the impact on the program and patients is tangible.

“My mission in all aspects of what I do with training and research is really to demystify eating disorders,” Dr. Sheffield explains. “I think there's a feeling that if you're not a specialist, there's nothing you can do to help kids with eating disorders, and we know that's just not true.”

Training for OCD and anxiety treatment

When it comes to treating kids with OCD and anxiety, the only evidence-based treatment is cognitive behavioral therapy with a strong emphasis on a type of exposure therapy called exposure with response prevention. This requires specific training and can be difficult to undertake for a variety of reasons, says Ben Mullin, PhD, a psychologist in the Outpatient OCD and Anxiety Clinic.

“Not everybody has had the training to staff a program like this because the treatment we do is pretty specific and challenging,” he explains. “It is actually very complicated to implement exposure in an effective and ethical way. And so, there's a lot of training that's required to get people up to speed where they feel really comfortable doing that kind of work.”

What’s more, exposure can be tough for providers because it requires inducing stressful situations to collaboratively work through them with patients. This teaches the brain that it can face threats. For people who love working with children and helping them reach a state of calm and comfort, this can be emotionally difficult for the therapist.

To account for these challenges and help more clinicians feel confident in doing this type of work, Dr. Mullin first turned to the literature to determine key elements that trainees would need to know. Ultimately, he developed a six-month training program and used endowed chair funding to support the additional time required from both his own schedule and training participants.

Since then, he has worked in cohorts of two to three faculty members with an interest in working with patients with anxiety and OCD. These individuals were already seeing patients, so in addition to that work, Dr. Mullin proceeded with training through role-playing article reviews, case presentations, videos, client session supervision and more.

The program has been so successful that he’s run out of people to train. The clinic has roughly 10 newly trained clinicians supporting its work. Dr. Mullin has also adapted the training for other team members, such as social workers and postdoctoral fellows, who will complete the work over the course of a year, rather than six months.

Recently, Dr. Mullin worked to measure the efficacy of the program through a study and published qualitative findings that he hopes will inspire others.

“People are feeling much more comfortable inheriting complex anxiety and OCD patients on their caseload. The biggest thing we are looking for is that they feel like they can actually implement the things that we've trained them in, and the feedback has been uniformly really positive around that,” he says.

In addition to this accomplishment, Dr. Mullin says that the additional support has allowed the clinic to flourish and grow in meaningful ways.

“We have a child intensive outpatient program, we have two summer camps that we now run — one for kids with OCD and one for kids with social anxiety, and we have what's called an exposure-only group that we now run,” he explains. “There are so many cool things that have actually come out of it. We have a much bigger footprint now, and so we're able to get reach a lot more kids, and we are very confident they are getting evidence-based services.”

Citations

1. Sheffield, K., Horvath, S., & Hawks, J. (2024). Training mental health clinicians to provide evidence-based treatment for pediatric eating disorders in the outpatient setting. Evidence-Based Practice in Child and Adolescent Mental Health, 9(3), 358-366.
2. Mullin, B.C., Baumann, C., Meintzer, M.K., & Hawks, J. (2024). Training in evidence-based assessment and treatment of pediatric anxiety and OCD in a large hospital outpatient psychiatric clinic. Evidence-Based Practice in Child and Adolescent Mental Health, 1-10.