Worldwide mental health services spend millionsof dollars each year on training their workforce.Training programs often pay lip service to evidence,but as a recent UK review [1] showed, training formental health professionals often lacks focus on corecompetencies and in the case of severe mental dis-order pays little regard to the research evidence. Inthis paper, it is argued that training programs shouldbe guided by evidence and should generate evidence.

In order to decide on the priorities for training, oneneeds to consider not only the evidence of clinicalinterventions, but also the priority attached to thoseinterventions for mental health services. Therefore,training needs to target those areas most importantand students need to be taught skills in delivering theeffective intervention. Hence, although there is alarge amount of evidence [2] that specific phobiascan be treated very effectively, this topic is not atraining priority as specific phobias, although verycommon in the population, are seldom cause forsevere levels of handicap and distress.

What then are the priority areas for mental healthservices? Clearly, the finite numbers of mental healthprofessionals and the huge array of mental healthproblems affecting very large proportions of the pop-ulation mean that mental health professionals willonly be able to treat a very small number of people

Ordinary article OA 615 EN

Training for the mental health workforce: a review of developments in the UnitedKingdom

Gordon Lambert, Kevin Gournay

O b j e c t i v e : Implementation of the National Mental Health Strategy has importantimplications for education and training of the Australian mental health workforce. T h i spaper discusses relevant developments in the United Kingdom that may providesome lessons for A u s t r a l i a .Method: A review was undertaken of a number of specific clinical education andtraining programs for mental health workers in the United Kingdom which have beensubjected to published evaluation.Results and conclusions: A finite mental health resource base dictates that edu-cation and training activity should: (i) be evaluated; (ii) target those clients most inneed; (iii) include evidence-based approaches such as assertive community treat-ment, medication management, cognitive–behaviour therapy and family interven-tions; and (iv) prepare mental health workers in the core competencies needed toimplement these approaches. Two programs, developed in the United Kingdom,which meet these criteria are presented as examples of best practice: the nursetherapy model established by Isaac Marks; and the Thorn initiative established inassociation with the Institute of Psychiatry, London and the University of Manchester.Key words: evaluation, evidenced-based, training.

Australian and New Zealand Journal of Psychiatry 1999; 33:694–700

Gordon Lambert, Senior Fellow (Correspondence)

Illawarra Institute for Mental Health, University of Wollongong,Wollongong, New South Wales, Australia. Email:<gordon_lambert@ouw.edu.au>

Kevin Gournay, Professor of Psychiatric Nursing

Institute of Psychiatry, De Crespigny Park, Denmark Hill, LondonSE5 8AF, England. Email: <k.gournay@iop.bpmf.ac.uk>

Received 2 October 1998; revised 14 April 1999; accepted 21 April 1999.

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who need and demand intervention. As stated below,there are compelling arguments to suggest that manyinterventions can be delivered by professionalswithout a mental health background, by non-profes-sionals and by other methods such as self-helpgroups and computers. Thus, perhaps we need toconsider the advice of Michael Shepherd and his col-leagues [3] from more than 30 years ago who stated:

Administrative and medical logic alike…suggestthat the cardinal requirement for the improvement ofthe mental health services is not a large expansion ofpsychiatric agencies, but rather a strengthening ofthe family doctor in his therapeutic role.

However, even if we succeed in our future effortsto equip primary care staff and others with mentalhealth skills, we will still be faced with a problem ofbeing unable to offer treatment to everyone in need.Goldberg and Gournay [4] have recently proposed adecision matrix about who to target based on fourfactors: diagnosis, level of handicap, likelihood ofspontaneous remission, and evidence of effectivetreatments (drug and non-drug).

With regard to levels of evidence, Lewis et al. [5],in a discussion of evidence-based approaches, high-lighted the relative lack of evidence in mental healthcare, compared with, for example, obstetrics andgynaecology where the systematic reviewing process(of the evidence) is virtually complete. Indeed, Lewiset al. [5] concluded that the task for completing com-prehensive reviews of the evidence in mental healthcare was, in their words, ‘truly Herculean’.

There are, of course, models for classifying levelsof evidence. For example, the levels could be:

(1) A number of randomised control trials testify-ing to efficacy of an intervention which have beensubject to systematic review.

(2) One or two randomised, control trials testifyingto efficacy, but not enough to meet the minimumrequirements for conducting a systematic review.

(3) No randomised, control trials, but trials thathave used reasonable controls (e.g. quasi-experimen-tal designs showing effectiveness).

(4) A number of single-case, experimental designsindicating effectiveness.

What then do we know about training outcomes?The answer, in brief, is very little. The best exampleof a well-evaluated program of training is that ofIsaac Marks [6], who developed a training programfor nurses in behaviour therapy in 1972 at theInstitute of Psychiatry in London. The program hascontinued at the Maudsley and several other sites in

the United Kingdom, and the Republic of Irelandover the last 25 years. Nurses enrolled in the programare given intensive full-time training (18 months) inassessment and intervention skills for the behav-ioural and cognitive–behavioural treatment ofphobic, obsessional and sexual problems. Graduatesroutinely collect outcome data on patients and thishas allowed Duggan et al. [7] to describe the clinicaloutcomes of more than 2000 patients seen by nursetherapists over a 15-year period. The audit showedsustained improvement in patient symptoms andsocial functioning. In addition to these very encour-aging data, Marks [6] has conducted a randomised,controlled trial using nurse therapists to treat phobicand obsessional problems in primary care. The studynot only provided convincing evidence that nursetherapists are very clinically effective with theirpatients (compared with routine general practitionercare), but it also included an economic analysiswhich demonstrated clear cost benefit to the patientand the healthcare system.

This research is in marked contrast to the resultsobtained by Gournay and Brooking [8] in a ran-domised, controlled trial and economic analysis ofcommunity psychiatric nurses using counsellingskills with a primary care population suffering fromdepression, anxiety and adjustment disorders. Theoutcomes showed that these nurses produced no ben-efits to the patient or to the healthcare system. Tocompound these negative outcomes, Gournay andBrooking [9] also found that their interventions were,in economic terms, very expensive. It is worth point-ing out that in Marks’s nurse therapy training, nursesprovided very focused, research-based interventionsfor specific diagnostic groups, whereas communitypsychiatric nurses in Gournay and Brooking’s studywere attempting to deal with an array of disorders(which probably had very high rates of spontaneousremission) using interventions with no research base.Indeed, although counselling has almost reached thestatus of a religion in some countries, there is to thepresent day, no randomised, controlled trial evidenceto support its usefulness, unless it is applied in veryspecific fashion for very specific populations [4].

It should be noted that evidence for efficacy is onlyfound where evidence is sought. This raises ques-tions about who sets the research agenda, andwhether we should focus our research efforts in areaswhere conditions are complex and research is diffi-cult to carry out. Some examples include conditionsthat present in combination, such as social phobiawith depression or treatment approaches which are

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difficult to dismantle, such as a combination of psy-chotherapeutic and pharmacological interventions.Another problem that may result from focusing toonarrowly on evidence for treatment efficacy is thatwe may overlook components of treatments that leadto the maintenance of the status quo. A person whohas recovered from an acute episode of schizo-phrenia but still needs to cope with some level ofresidual symptoms and social handicap may requiresupport from a mental health worker to preventfurther relapse. It could be argued that an approachthat provides this support, although it may lack anevidence base, is nevertheless efficacious andwithout it the patient would deteriorate.

H o w e v e r, if we are to address the needs of specificpopulations of people with a mental illness, the deci-sion-making matrix developed by Goldberg andGournay [4] is useful because it provides a rationalbasis for targeting interventions. The first group inthe matrix comprise severe mental disorders includ-ing the schizophrenias, organic disorders, bipolardisorder and life-threatening cases of eating dis-o r d e r. They represent conditions which are unlikelyto remit spontaneously, are associated with highlevels of disability and where care will usuallyinvolve both primary care and the communitymental health team (CMHT). Most of this group willrequire at least one hospital admission and will bereferred for follow-up by a CMHT. A second groupincludes anxious depression, pure depression, gener-alised anxiety, panic disorder and obsessive–com-pulsive disorder. These disorders are also associatedwith low levels of spontaneous remission and dis-ability but have effective pharmacological andpsychological treatments available which can beo ffered entirely within a primary care setting pro-vided staff have the specific training required. Athird group of disorders include somatised presenta-tions of distress, panic disorder with agoraphobiaand eating disorders which have effective psycho-logical therapies available and for which pharmaco-logical therapies have a more limited role.Spontaneous remission can occur, but in the case ofsomatoform disorders and fatigue states they canbecome chronic with subsequent high levels of dis-a b i l i t y. In the case of panic disorder with agorapho-bia and eating disorders, once again there aree ffective psychological treatments available andthey can be managed within primary care, providedthat there is access to trained staff. The final groupcomprise bereavement and adjustment disorder.These represent conditions that will usually resolve

spontaneously and for which supportive help, ratherthan specific mental health intervention, is required.

It must be also be recognised that while some formof decision matrix is essential when allocating finiteresources, there are difficulties inherent in thisapproach. The first question that arises is how do wejudge disability? For example, in the case of a persons u ffering from schizophrenia who experiencesimpairment of daily living skills, their disability maybe obvious to all and relatively easy to measure.However, the inner turmoil and subtle avoidancebehaviours of many patients with social phobia isless easily judged in an objective fashion. In turn, ifwe use level of disability as a criterion for allocationto treatment, who makes the judgement? Should thisbe a primary care physician, a psychiatrist, or in thecase of managed care in the USA, a desk-boundemployee of an insurance company?

In order to address the needs of the target popula-tions identified using the matrix, there is evidencethat merely configuring mental health professionalsinto new case management-orientated communityteams provides no benefit. Muijen et al. [10], in a ran-domised controlled trial conducted in South London,showed that community psychiatric nurses (CPNs)working as case managers had no better outcomesthan CPNs working generically. However, Brooker e ta l . [ 11], in a quasi experimental study, provided someevidence that nurses can be trained to deliverresearch-based interventions, in this case familyinterventions for schizophrenia. Brooker’s work andthat of several other groups in the United Kingdomhave led to the development of the Thorn Initiative.This project, which commenced at the Institute ofPsychiatry and the University of Manchester in 1992,has developed a training program for nurses and otherprofessionals and non-professionals in skills inresearch-based interventions in assertive communitytreatment, cognitive–behaviour therapy and familyinterventions. So far, more than 150 nurses have beentrained, and although there are no controlled dataavailable, the outcomes of patients is measured by anindependent evaluator showed positive changes inclinical and social functioning in those peoplemanaged by people undertaking this course [12].

Fidelity to training is a key issue to consider.Kavanagh et al. [13] showed that workers trained infamily interventions quickly stopped using theirskills once they had returned to a service setting.Experience in the Thorn program supports thisfinding that even with intensive training, fidelityremains a key issue and that preparation of the

697G. LAMBERT, K. GOURNAY

service setting from whence the Thorn students havecome for training, is critical. The work of McFarlaneand his colleagues [14,15] reinforces this point. Theirresearch demonstrates that evidence-based familyinterventions can be disseminated into routine clini-cal practice in a public hospital setting provided thereis management support and that clinicians are pro-vided with adequate training and supervision toensure fidelity. Consequently, the involvement ofservice managers is crucial if investment in staff edu-cation and training is to be translated into more effec-tive services. As the New York DemonstrationProject of McFarlane et al. [14] showed, providinghealth services managers from the participating hos-pitals with information about the evidence base forfamily intervention, in particular its potential toreduce patient relapse rates, facilitated the imple-mentation process. This was manifest in seeminglyinsignificant but fundamentally important decisions(e.g. adjusting staff rosters to enable them to attendevening meetings with family members). Clearly,service managers and clinicians must work coopera-tively in the development of optimal services andtraining needs to be a key component of all servicesplanning.

Areas for training

In order to consider areas for training, it is impor-tant to address the needs of those with severe mentaldisorders and those people who should probablyalways be managed by primary care team.

The training needs of those working with peoplewith severe mental disorders

As stated, the evidence for effectiveness of inter-ventions in mental health care is sparse. However,there are effective models of case management whichcan be classified under umbrella of assertive commu-nity treatment (ACT) techniques. There are tremen-dous difficulties in defining exactly what ACT andcase management are, and indeed, these terms areused interchangeably. However, as several reviews[10,16–18] have mentioned, there are clear diff-erences in effective and ineffective models of casemanagement. Effective models of case managementare delivered by workers who have a range of clini-cal skills in assessment and therapy areas, case loadsizes are small and the case manager has a centralstable and therapeutic relationship with the patient.Conversely, ineffective models of case management

are characterised by approaches which include bro-kering and networking as central interventions andcase load sizes are very large.

Assertive community treatment, of course, com-prises a number of components which must includebrokering and networking skills to ensure that theperson is availed of a range of services to providethem with the most effective social support.However, it is increasingly recognised that there arethree therapeutic strands which should be pursuedwithin this model. First, the use of medication iscentral to the management of severe and enduring ill-nesses and there is significant evidence to testify tothe efficacy of drugs for the treatment of schizo-phrenia. Treatment options have now been enlargedwith the addition of the new atypical compounds andthese promise a great deal in terms of increased effi-cacy and reduced side effects. However, non-adher-ence with medication is, and probably will be for theforeseeable future, a substantial issue [19]. Recently,Kemp et al. [20] have demonstrated that a cogni-tive–behavioural package of education and motiva-tional interviewing can lead to increased levels ofadherence, and hence the reduction of relapse. Aresearch team from the Institute of Psychiatry inLondon is currently investigating whether it is possi-ble to train nurses in this approach by measuring bothskill acquisition and patient outcome. Furthermore,these issues need to be investigated within thecontext of the rising tide of populations with a dualdiagnosis of serious mental illness and substance/alcohol abuse [21].

Regarding the second therapeutic strand, a recentreview by Mari et al. [22] conducted for theCochrane Collaboration showed that family interven-tions in schizophrenia are an effective treatmentmodality. However, there is some debate regardingthe relative efficacy of the components of thisapproach, with Solomon et al. [23] making a strongcase for the use of more widespread educationalmethods rather than the use of programs that focus onexpressed emotion [24]. It has already been statedthat there are some data which suggest that familyinterventions can be taught to, and delivered by,mental health nurses [13]. However, as noted above,Kavanagh et al. [13] showed that fidelity to trainingin family interventions may be a major issue. Clearly,institutions that develop training programs need toattend carefully to this variable.

Regarding the third therapeutic strand of ACT,there is an increasing awareness of the potential use-fulness of behavioural and cognitive–behavioural

698 TRAINING FOR THE MENTALHEALTH WORKFORCE

interventions with people with severe mental disor-ders. Smith et al. [25] have pointed to the substantial,randomised, controlled trial data, supporting the useof social skills training. This treatment modality is generally overlooked in favour of the newer,cognitively based approaches that have much lessevidence to support efficacy. However, these cogni-tive–behavioural approaches are demonstrating somepromise and, provided that they are delivered in jux-taposition to other therapeutic approaches, may havemuch to offer in the amelioration of the distresscaused by hallucinations and delusions [26–28].

Therefore, the training priorities for the workforcedealing with the seriously mental ill should centre onskills in ACT, with a core of skills in assessment andtherapeutic areas which should include behaviouraland cognitive–behavioural interventions and psy-choeducational family approaches. At the same time,case managers need to have sophisticated skills inmedication management as, de facto, they are in apivotal position to report side effects and clinicalstatus to the prescribing physician, while at the sametime being ideally placed to deal with adherenceissues.

The training needs of those working withprimary care populations

The quotation from Shepherd e t a l. [3] citedearlier, concerning the need to strengthen the thera-peutic role of the general practitioner, encapsulatesthe issue for the provision of services. Those in ourmental health services probably need to focus onpeople with severe mental disorders, while at thesame time support their colleagues in primary care todeal with the vast array (a great majority) of mentalhealth problems. Within primary care, the numbersof people with mental health problems are so largethat for the foreseeable future there will always be aneed to make decisions regarding who should andwho should not receive mental health services. It hasbeen stated that the decision matrix can provide arational basis for providing services. Goldberg andGournay [4] believe that there is a great deal of evi-dence for effective non-drug interventions for some,but by no means all, problems. Using the decisionmatrix, they argue that conditions such as adjustmentdisorder and bereavement should seldom be targetedby specialist interventions, but this very large groupof patients may need supportive care from voluntaryagencies, self-help groups and other non-specialistworkers. If one examines the effectiveness literature,

the strongest evidence for effectiveness is attached toa cluster of conditions that also have low sponta-neous remission rates and which, if untreated, causesignificant handicap. Notable among these condi-tions are: panic disorder with agoraphobia, obses-sive–compulsive disorder, some somataformdisorders, and a few other problem categories. Theoverwhelming evidence suggests that behaviouraland cognitive–behavioural therapies are successful,although there is of course some evidence to supportother approaches (e.g. interpersonal therapy in themanagement of depression). However, the treatmentof depression itself, and of generalised anxiety dis-order in primary care, remains somewhat contentiousas arguably these groups which may show a greatwaxing and waning, if not complete remission overtime, may not show the magnitude of improvementsustained at follow-up attributable to, for example,behavioural treatments for agoraphobia [29,30].

The only training program in cognitive–behaviourtherapy which has been comprehensively evaluatedis that of Marks [2]. The program specifically targetsphobic and obsessional disorders, and throughout its25 years this narrow focus has been maintained.Nurses from this program have been involved in arandomised, controlled trial and economic analysis inprimary care demonstrating benefits to the patientand the healthcare system for nurse therapist treat-ment compared with routine general practitioner care[6]. In addition, extensive audits of this program havebeen conducted which show significant gains inphobic and obsessional symptoms maintained tofollow-up [7]. A 20-year follow-up of nurses trainedon this course was conducted by Newell andGournay [31], who showed that large numbers ofthese nurse therapists remain in clinical practice evenmany years after completion of their training andreport that they continue to target specific groupswith behavioural interventions. Furthermore, manyof these nurse therapists continue to use multiple reli-able measures of change. A 25-year follow-up ofnurse therapists is currently underway conducted byGournay and a team from the Institute of Psychiatry.

The nurse therapy workforce in the UK is a rela-tively small one, and it needs to be said that if oneextrapolated from the data obtained by Newell andGournay [32], this group, who each on average com-plete treatment on 80 patients a year, only treat a totalof 16 000 patients annually. Goldberg and Gournay[4] have estimated that the entire workforce of theUK trained in cognitive–behaviour therapy (compris-ing psychiatrists, psychologists, nurses and others)

699G. LAMBERT, K. GOURNAY

will complete something less than 70 000 treatmentsper year. Given that the point prevalence of panic dis-order with agoraphobia of clinical severity in the UKis approximately 300 000, it is clear that we need tomake choices about where our efforts should beplaced. As noted above, mental health workers needto use the decision matrix based on disabilities, spon-taneous remission and effectiveness of availabletreatments. Nevertheless, we must consider ways ofexpanding the delivery of effective treatments. Thereis promise in a number of areas. For example, wehave known for some time that phobic disorders canbe effectively treated with minimal therapist time,using computer programs [33]. Recently, this workhas expanded considerably with developments beingmade in computer-assisted treatments for phobias,general anxiety, obsessions and depression. Workwith these developments indicates that consumer sat-isfaction levels are excellent and clinical gains sub-stantial. The efficacy of self-help is also not to beunderestimated. Recently, Tanner and Gournay [34]have shown that patients using a telephone confer-ence facility run by anxiety sufferers and usingbehavioural self-help methods achieve good clinicaloutcomes. It is also important to consider the trainingof more numerous work forces. For example, there isevidence that general trained nurses can be used inthe management of depression with considerableeffect [35], and health visitors are effective in themanagement of postnatal depression [36]. However,as a corollary of these possible developments for dis-seminating effective interventions, in many countriesthere continues to be an emphasis on the use of inef-fective interventions with populations who may getbetter anyway. For example, in the United Kingdom,counselling in general practice is extremely wide-spread with some 15 000 counsellors who are largelyemployed in the treatment of adjustment disorderswith non-specific counselling. This phenomenonseems to continue despite evidence to suggest thatcounselling has no measurable benefits [37–39].

Discussion

What emerges from the above review of trainingissues is that we need to mount targeted initiatives. Inp a r t i c u l a r, we need programs to train case managerswithin an assertive community treatment model,ensuring that these individuals have skills in clinicalinterventions, such as medication management, cogni-tive–behaviour therapy, and family work. Amodel forthis training is already being developed in England

within the context of the Thorn initiative. T h i sprogram was originally confined to nurses, but lately ithas become multidisciplinary, accepting students froma range of professional and non-professional back-grounds. The program has been subject to an evalua-tion, wherein patients case managed by these workershave been assessed before and after the period of casemanagement. Initial results have been reported [12]and are very encouraging, demonstrating clear gains inclinical and social functioning in patients cared for bythis group of workers, and there is also evidence thatthese workers do actually develop skills in clinicalinterventions and knowledge. Such training programsshould be subject to a properly controlled trial, andalthough such an endeavour would be expensive, thereis little doubt that this would be an excellent invest-ment in our future.

With regard to the primary care area, the nursetherapy model of training is obviously one that needssome extension, and as noted above mental healthservices need to examine how more numerousgroups such as general nurses could acquire skills inspecific intervention for targeted groups.

Overall, training for the workforce represents a con-siderable challenge for those who provide education,and it seems clear that future training initiatives needto be highly focused on particular target groups withan imperative to train workers with skills in interven-tions for which there is a sound research base.Although the delineation is somewhat artificial, it alsoseems that we need to consider two distinct areas: thatis, i.e. that of people with severe mental disorders suchas schizophrenia, and the more numerous populationsin primary care. Across the world, training programsfor the mental health workforce have developed in anidiosyncratic fashion, and perhaps the future should becharacterised by attacking the challenges posed bystrategic, rather than ad hoc e n d e a v o u r s .

Acknowledgements

We are grateful to Harvey W h i t e f o r d ,Commonwealth Director of Mental Health, for hishelpful comments and to Frank Deane and LindsayOades, Illawarra Institute for Mental Health for theireditorial support.

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