Introduction
Any training experience may have multiple stakeholders with different primary criteria for determining success. In the training of junior psychiatrists in cognitive behavioural therapy (CBT), trainees will wish to complete a required training experience and be validated for obtaining psychotherapy competencies set down in the curriculum for Core Training in Psychiatry (Royal College of Psychiatrists, 2010). The training experience required to achieve these psychotherapy competencies is a ‘short case’ (12–16 sessions of therapy) and a ‘long case’ experience. The patients receiving their therapy will want to derive benefit; the service within which the therapy is delivered will additionally want to be assured that the cost in providing the supervision is sustainable and the training scheme organizers will want their trainees to move smoothly through the system.
Although ‘short’ and ‘long’ case experience could be in either psychodynamic or CBT modalities, the ‘short case’ training experience has been offered locally in CBT because of service configuration. In earlier times, provision of supervision in CBT was met by a ‘service-for-supervision’ arrangement, so that Newcastle CBT Centre (NCBTC) patients were seen by trainees and this service delivery contributed to meeting the commissioned role of the NCBTC. This allowed NCBTC therapists to devote time to providing supervision that would otherwise have been attached to service delivery because of commissioning based on payment-by-contact. In the last decade, an increasing focus on complex and therapy-unresponsive patients at the NCBTC has meant that this arrangement no longer works because patients are unsuitable for novice therapists and no stakeholders’ criteria for success were being met: patients usually did not benefit, the training experience was unsatisfactory and it represented poor value for service investment in providing the supervision.
This is consistent with theories of learning. For example, Wood and colleagues (Reference Wood, Bruner and Ross1976) described how an educator functions to ‘scaffold’ a learner developing a skill to a level higher than is the case at the start. However, the task should not be beyond the level at which scaffolding can successfully support the learner to perform. If this is attempted, failure and demoralization would be predicted.
Having recognized the end of the ability of the tertiary service to deliver training on a supervision-for-service arrangement, in our Trust we have attempted a range of solutions. Latterly, a group of CBT diploma-trained, enthusiastic and committed consultant psychiatrists with an interest in providing supervision in CBT to training doctors were able to provide the supervision. Trainees were seeing patients from these consultants’ clinics or benefiting from links to local primary-care services. However, in the same way as the clinical focus at the NCBTC has changed, the nature of work in secondary care has also evolved. In attempting to support trainee psychiatrists providing CBT to patients in secondary care, unsuccessful training outcomes have increasingly been the result in our experience. The inception of Improving Access to Psychological Therapies (IAPT) services effectively ended referrals of low complexity patients from primary care. This government initiative to create rapidly accessible services providing evidence-based therapies created a situation where there was little moral justification to offer patients treatment by relatively inexperienced psychiatric trainees outside of usual treatment pathways. Consequently, trainees were often stuck in CBT supervision (for nearly 3 years in one case) to complete this ‘short case’: waiting for identification of suitable patients or experiencing multiple (and demoralizing) patient dropouts. The possible adverse effects on patients can be imagined.
Access to patients in primary care with close supervision would be predicted to improve the chances that the task would be within ‘scaffolded’ reach of these trainees and a successful training (and treatment) experience result. It could be argued that there is little point in training people in a task that does not resemble the task to be performed at the completion of training (i.e. treating patients in primary care during training while seeing patients in secondary care later). However, this would be contrary to the principles of a competency-based training approach within what is known as a ‘spiral’ curriculum (Bruner, Reference Bruner1960). This explicitly encourages trainees to develop the skills and then become increasingly proficient in delivering them in more challenging circumstances as they progress up the competency spiral during training.
Information governance requirements for encrypted recording devices now make the process of video recording of clinical work very difficult without expensive technological solutions. Administrative tasks like room booking and appointment management (such as cancellations and rearrangements) had proven difficult at times with trainees working in one location and providing therapy at a different one. The trainees needed to hold patient-sensitive information such as name and contact information in their diaries, and patients needed to be able to retain trainees’ secretarial contact information. With the rest of their week full with pressing clinical or training activities, these could be quite demanding tasks to fulfil. Both of these would be solved if trainees could provide CBT in a service where treatment and supervision are at the same site and contact information is held on a patient database by a full-time administrative team, organizing rooms and appointments.
Following negotiations with a local IAPT service, a procedure and governance arrangements (available upon request) enabling psychiatric trainees to integrate with that service for a weekly ½-day was agreed upon. From the point of view of the IAPT service, provision of paired supervision (1 hour of supervisor time) could equate to the concurrent treatment of four patients (two patients each of two trainees) and this could occur twice (four patients for each trainee) in a 6-month attachment. This would represent efficient use of clinician-supervisor time. An undertaking was made to closely evaluate both the training experience and the clinical outcomes.
This study aims to test the hypothesis that attachments to an IAPT service would make the training system more efficient, while concurrently demonstrating that the therapy is helpful to the patients receiving it. Past CBT trainees (labelled ‘Old cohort’) are compared with the group of trainees who were attached to an IAPT service (‘IAPT cohort’) in a questionnaire study to determine efficiency and effectiveness of the training experience. The clinical symptomatic measures change of patients treated in the IAPT service is assessed to determine whether patients who were treated by these trainees also benefited.
Method
This is a naturalistic observational study with data from two sources. The clinical measures are determined by pre-post submissions from individual patients to the IAPT service (see below). The training experience data is provided by comparing results from an online questionnaire submitted by (a) IAPT-attached trainees and (b) trainees who are still working in the Trust but have completed their CBT training under the old system (this may have been several years past; see below).
Participants
Psychiatric trainees have completed a medical degree and 2 years of ‘Foundation Years Training’ across a range of medical specialities. They are usually in their second or third 6-month psychiatric training attachment and have completed about 30 hours of a multi-modal psychotherapy case discussion group. They have received at least 8 hours of lectures in CBT and a 2-day skills-focused introductory workshop in CBT. The skills-focused workshop linked information such as emotional change processes, goal setting, cross-sectional formulation and behavioural experimentation with practising therapy skills such as agenda setting, collaborative working and inductive questioning. An unreported proportion of sessions were recorded and viewed by the supervisor. The details of the process of therapy are not the focus of this study.
Patients were not systematically selected. Under the old system, guidance offered was that patients should have a specific focus of work (as a part of their broader needs) and have some understanding of how a CBT approach might be experienced. Within the IAPT system, patients were determined to be of a complexity suitable to receive a primary-care intervention and to have conditions such as a recent onset depressive episode or social phobia as determined by initial triage.
Clinical outcomes
Patient outcomes were determined by routine service-offered questionnaires measuring scores for depression (Patient Health Questionnaire, PHQ-9; Kroenke et al. Reference Kroenke, Spitzer and Williams2001) and anxiety (Generalized Anxiety Disorder questionnaire, GAD-7; Spitzer et al. Reference Spitzer, Kroenke, Williams and Löwe2006). The PHQ-9 has a range of 0–27, where scores between 10 and 14 are taken to correlate with moderate depression, and 15–19 are moderately severe. The GAD-7 has a range of 0–21, where scores between 8 and 14 indicate moderate levels of anxiety. Diagnoses were not sought for this study but caseness was examined according to IAPT contract currency definitions and a simulation of payment performed (IAPT, 2014). Length of treatment or number of sessions offered were not recorded.
Training experience
Trainee progress in the IAPT service was monitored closely for training governance purposes: in particular the length of time taken to complete the required training experience (one short case) was monitored. All trainees in the Trust who had previously received CBT case supervision (Old cohort) and trainees who entered these arrangements (IAPT cohort) were offered the opportunity to provide feedback on the training experience via an online intranet questionnaire. This was elicited by a Trust-wide email to all psychiatric trainees that included an embedded link to the intranet questionnaire (Questionnaire Creator v. 2). The questionnaire was written by the author and results were summarized on a spreadsheet.
Trainees were asked to think about the Kolbian learning cycle which describes a cyclical process of reflection on experience, conceptualizing that reflection, planning a modified approach and then implementing it (Kolb & Fry, Reference Kolb, Fry and Cooper1975). They were then requested to consider the various learning aspects of their experience with the therapy that went best in mind and rate (i) how appropriate was the patient for level of training (far too simple/too simple/about right/too advanced/far too advanced) and (ii) how appropriate was the supervision for their needs (far too basic/too basic/about right/too advanced/far too advanced)? They were also asked to report how many 6-monthly rotations the training stretched over.
Statistical analysis
Clinical measures were analysed using a paired t test and effect size was assessed by Cohen's d (Cohen, Reference Cohen1969). Comparison of completion of the required ‘short case’ training experience within 6 months was made across cohorts by a Fisher's exact test (Fisher, Reference Fisher1922). Statistical analysis was performed using SPSS v. 21.0.0.0 (IBM Corp., USA).
Results
Clinical outcomes in the IAPT group
Although diagnostic information was not specifically sought at the start of treatment, 13 of the 16 patients scored in the range considered to be a depression ‘case’ according to the PHQ-9 (mean score = 16, range 3–24; caseness cut-off, moderate depression = 10) and 12 scored in the range considered to be an anxiety ‘case’ according to GAD-7 (mean score = 12.5, range 2–20, IAPT caseness cut-off = 8, although this represents mild anxiety in scale validation studies; Spitzer et al. Reference Spitzer, Kroenke, Williams and Löwe2006). Fourteen patients achieved caseness according to either scale and 11 patients according to both.
The results are summarized in Table 1, reporting mean scores on the PHQ-9 and GAD-7. Effect size of the intervention on these scores can be calculated according to Cohen's d and show an effect size of 1.05 (large) on the PHQ-9 score and 0.74 (medium) on the GAD-7 score.
Table 1. Clinical outcomes following treatment by the IAPT cohort of 11 trainees. Mean scores shown for 16 patients
IAPT, Improving Access to Psychological Therapies; PHQ, Patient Health Questionnaire; GAD, Generalized Anxiety Disorder questionnaire.
It is interesting to consider this work in terms of recovery and statistically reliable change as defined within the payment-by-results (PBR) formulae for IAPT. The clinical outcomes are reported in terms of recovery and statistical reliability of the change. The proportion of treatments eligible for payment for this work is simulated. This is based on the idea that recovery from caseness, along with statistically reliable change, attracts a payment of 1 for each patient. This is proportionately reduced if a patient does not recover from all, but still makes statistically reliable change.
Of 11 patients who reached caseness status on both measures at intake, five achieved recovery (R) and statistically reliable change (SRC) on both measures (PBR = 5); one did not reach criteria for R on either measure but nevertheless achieved SRC on both measures (PBR = 0.52); one achieved R and SRC on one measure but neither on the other (PBR = 0.5); one achieved SRC on one measure but not R on either (PBR = 0.25); three patients did not achieve R on either measure or did achieve R, but without SRC (PBR = 0).
Three patients reached caseness status on either the GAD7 (n = 1) or the PHQ9 (n = 2) but not the other. Two of these achieved R with SRC (PBR = 2); one did not achieve R on either measure or did achieve R, but without SRC (PBR = 0). Two patients did not reach initial caseness criteria on either measure and so would not have attracted any payment. In this sample, it may be calculated that payment would be received by the service for 8.27 treatments from the 16 patients.
Online questionnaire survey
Three of the IAPT trainee cohort (n = 11) left the region at the end of the rotation and before the evaluation questionnaire was distributed. Seven (88%) of the eight remaining IAPT cohort of trainees responded to the questionnaire. There were 26 potential Old cohort trainees that received the email of whom eight (30%) responded.
Monitoring of trainee progress for the purposes of training governance showed that nine (82%) out of 11 from the first two IAPT cohorts achieved completion of the short case within a single 6-month attachment and the remaining two in the second. Four (50%) of the eight Old cohort respondents had completed within 6 months (Fisher's exact test, p = 0.17). In this survey the longest period taken to complete the CBT ‘short case’ for the Old cohort extended over four attachments (2 years of training).
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(1) All respondents but one from each group reported that the patients they had completed therapy with were ‘about right’ in terms of difficulty. One (12.5%) from the Old cohort reported that the case was ‘a bit too advanced’ and one (14%) of the IAPT cohort responded that the case was ‘far too advanced’.
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(2) All respondents from the old group reported the supervision to be ‘about right.’ Six of the seven in the IAPT cohort responded that it was ‘about right’, while one reported it to be ‘far too basic’. The latter added, ‘I felt that the supervision provided was disappointing. After such a good introductory workshop I would have hoped to have used supervision sessions to build on these skills but felt that all it was talking about the session and then moving on to the next case. I would have preferred supervision from a medical psychotherapist who understood what our learning outcomes were.’
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(3) The identity of supervisors who had supported the Old cohort was elicited and it included each clinician who had contributed to this work. This feedback supports the quality of work provided by this group of clinicians.
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(4) Other comments received from the Old group:
‘I think a more structured information pack about the process of CBT training and cases/supervision would have been helpful. If I hadn't been proactive in seeking details regarding the CBT course and procedure I probably would have missed the course.’
‘My main issue with the CBT training was trying to find a case which delayed me starting. There was no real guidance about how to find a case despite me asking numerous people.’
‘I found the CBT training and supervision to be highly useful with a clear emphasis on integrating the skills gained through the case into everyday practice. Doing a short case allowed me to better appreciate the complexities of performing therapy.’
‘If it was possible to have more than one case or a case/cases as a higher trainee it would be a good way to keep up skills and competencies.’
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(5) Other comments received from the IAPT group:
‘Do not under go this if doing a split job within patient and community involvement as it makes a supposedly nice experience quite herculean.’ (This trainee is highlighting a reasonable point of view that, if the primary attachment is split across two services, then adding a third with this ½-day attachment is too demanding.)
‘The organization at NTT was excellent and compared to other trainees elsewhere in the region it made the administrative side very easy for us.’
‘Poor admin support . . . repeatedly not informing me of when they were aware that a patient would not turn up.’ (This was the same trainee who reported that the case was ‘far too advanced’.)
Discussion
Through the evaluation of an initiative to improve CBT training for junior psychiatrists, support has been shown for the initial hypotheses. The study demonstrated good reliability of access to patients for training with 9 out of 11 trainees successfully completing their ‘short case’ experience within a single 6-month attachment. Trainees evidenced good ability to engage and help this group of patients, achieving statistically significant gains on measures of depression and anxiety and providing a medium to large clinical effect size. In relation to the ethical stance concerning trainees’ treatment of patients, although there is no comparator group, outcomes are comparable to the IAPT aim of a 50% recovery rate among those completing treatment (Department of Health, 2012). Evidence supports the argument that this makes good business sense for the IAPT service too.
There are several limitations to this study. It is fairly small and it is not randomized or controlled. Furthermore, patients were specifically chosen for these trainees and there was no comparator group so generalization is limited at this stage. Patients did not go through a diagnostic process and other IAPT questionnaire results were not requested. Consequently the patients treated are classified only according to self-report scores. How they might relate to other clinical populations is unclear and there may be other information about their presentation, lost as a consequence of only examining PHQ-9 and GAD-7 scores. Information about dropouts would also be helpful to determine with greater clarity the effectiveness of this workforce in this population. Despite this, it is likely that dropouts were relatively few, given the short period of attachment and the evident completion of training requirements. Patients scoring on other measures are less likely to be chosen for these clinicians because of the requested patient profile.
This report provides the much-needed patient-outcome perspective to the debate about psychiatric trainees delivering therapy. Kelleher et al. (Reference Kelleher, Hayde, Tone, Dud, Kearns, McGoldrick and McDonough2015) report the development of therapeutic competence, assessed by the Cognitive Therapy Scale – Revised version (CTS-R; Blackburn et al. Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001), among psychiatric trainees following three 2-hour training workshops during their first case. While this runs contrary to accepted wisdom about the poor ability of brief training among resultant therapists to bring about patient benefit, there are a number of factors cited in this study that lie in common with the current report. First, patients are carefully chosen for low levels of complexity and ease of engagement. Second, the supervision provided is relatively intense and of high quality. These reports dovetail in these ways and the current study evidences the ability of these trainees, under these conditions, to bring about patient gains. The current report also helps address the difficulties cited by Kelleher et al. (Reference Kelleher, Hayde, Tone, Dud, Kearns, McGoldrick and McDonough2015) of achieving protected time (our trainees are scheduled to a weekly ½-day attachment within the IAPT service) and demonstrates the conditions under which the provision of supervision may be sustainable for the supervising therapists’ services.
The IAPT system brings much greater clarity to the throughput of our trainees: they are identified in their preceding posts, preparation is made in advance for this ½-day attachment and local induction in the service provided. While surprises occasionally occur, there is a much greater level of explicit planning in the process, enabling trainees to have some certainty about their training. Progress is monitored and clinical symptom change measured. The service ensures that helpful discharge letters are completed.
Regarding the ability of this study to show improvement in the training experience and efficiency in access to patients or completing the training, it is a small sample and there is limited data from trainees under the old system. Although the findings seem about right, it is unclear how representative findings concerning the latter group are. Among the trainees to whom the questionnaire link was sent, there has been no system of tracking who had received supervision in the previous system. Many of those who had received CBT supervision in the old system would have moved on to training in other locations or become consultants. Other trainees who had completed some training elsewhere will have entered the programme. Consequently, it is difficult to know what proportion of the 26 trainees who were approached had been through this system and therefore the response rate among eligible potential participants is uncertain.
The relative balance of completion within one 6-month attachment appears improved and none of the IAPT cohort approached the need for four attachments, as identified in the Old cohort responses (the usual reasons for this were difficulties in case finding and patient dropout). However, it is too small a group to perform reliable statistical testing of this finding and this study might have been better conducted by first identifying willing participants and then interviewing them to gain a more comprehensive picture of the training experience. For example, although the supervision experience was generally good, trainees were asked to think only of the learning experience related to the patient with whom the therapy went best.
From the point of view of the business arrangement and the plan to have two trainees supervised at a time with each seeing two patients, physical space in the IAPT service's accommodation and time availability of some trainees (demands to attend other training or service activities) limited the opportunity to take on two concurrent cases per trainee to only 5/11 trainees. Nevertheless, 1 hour weekly of supervision time to treat a possible 16 patients over a 12-month period makes a supportive business argument for the IAPT service to facilitate access to patients and provide the supervision. Although supervision time was greater than this to manage the number of trainees, this cohort of trainees would have achieved payment for over eight treatments. With greater therapy room-space capacity, this could have been more.
While the Old group comments give a flavour of the extent to which trainees struggled with case-finding procedures, the difficulty experienced in the past in managing administrative tasks like room booking and appointment management (such as cancellations and rearrangements) was only highlighted by one of the IAPT group (presumably this trainee had heard about previous difficulties within the scheme). It would be interesting to speculate on which combination of therapist, patient, supervisor and system factors may have brought about the experiences of the IAPT cohort trainee with administrative difficulties and a case felt to be ‘far too advanced’. However, this is not the focus of this paper. It demonstrates that complacency in regard to engagement and progress of trainees within any aspect of a training system would not be justified and oversight by training governance structures is required. This may be a role for a medical psychotherapist. Such consultants may be trained in CBT, psychodynamic therapy, systemic therapy or mixed (all three in balance). It would seem that a CBT or ‘mixed’ training consultant would be best placed to deliver this.
Informally two trainees approached the author at the end of a lecture with thanks for how much they had enjoyed their CBT training. One reported it to be ‘the most fulfilling [clinical] experience’ so far in his career. The proviso for this comes from the trainee reporting the task to be ‘herculean’ if undertaken during a split post. There were several trainees who were unable to take up this offer as they were unable to fit it into their job plans. The planning described, inherent in this system, should ensure that consideration is given in advance to the demands of this system. We are at an early stage of identifying posts from which this training is possible so that a match may be achieved between training needs and rotational placement.
For the most part, the IAPT cohort found both patients and supervision ‘about right’ for their needs. One trainee would have preferred supervision from a medical psychotherapist, felt the supervision was too basic and complained that the supervision was merely case-focused. This mismatch presumably reflects the trainee's close understanding of an additional curriculum requirement to integrate skills achieved into routine clinical practice. An Old group trainee highlighted the helpfulness of the medical supervisor in building the therapeutic skills in a manner that was integrative with daily practice. Clarity of expectation that this supervision has been set up to focus on developing and delivering CBT skills in the current treatment of the patient in focus would be helpful.
The expectation to integrate the competencies demonstrated, within a therapy setting, into ‘routine practice’ is an additional step that some trainees may be able to manage concurrently under appropriate supervision conditions (Alfaraj et al. Reference Alfaraj, Whitfield and Townend2015). Reference is made directly to this need in two out of 15 responses. Little is known empirically about this process and it could be hypothesized that it is more likely to be achievable when supervision is provided by a psychiatrist who has already achieved this. Psychiatrists trained in CBT also endorse this idea (Alfaraj et al. Reference Alfaraj, Whitfield and Townend2015). A move to base CBT training wholly within a primary-care setting may impair achievement of this step for some trainees. However the approach described here secures this early training experience. Hitherto, we had focused on using limited resources to meet the minimum requirements, prioritizing the first short-case training experience. Thus resources may now be focused on this additional step at a later training experience with emphasis specifically on integration.
Feasibility and provisional evidence of effectiveness of the latter is supported by a report to the Royal College of Psychiatrists Annual Congress (Saeed & Moorhead, Reference Saeed and Moorhead2014). This would additionally help address the feedback from an Old cohort trainee reflecting on the lack of further CBT training opportunities. Some clarification of expectations of the nature and focus of supervision prior to embarking on this will be helpful. This should include clarity about later ‘integrative’ training opportunities.
This approach may be worth considering for other competencies, such as psychiatric history taking and mental state examination, particularly in the earlier stages of training or for medical students. A more fulfilling training experience is more likely to result in greater interest in pursuing the career. An additional aspiration of both primary- and secondary-care clinicians (and managers) involved in this has been that relationships and understanding between primary care and secondary care in the longer term will deepen. Such improved relationships may facilitate application of these principles to wider training experiences.
It may also be worth considering this in other professions. Training community psychiatric nurses to treat patients with CBT in primary care, for example, may be a better option than exhorting them to provide it to secondary-care patients as their learning experience. Low confidence and uncertainty about role delineation can be significant barriers to getting started. These may be further eroded when trying to engage patients who, by virtue of risk, chronicity, severity, complexity or disability, are more difficult to help. A more joined-up health service might even see rotation of such staff between primary and secondary care so that higher levels of psychological therapy skills could become systematically embedded in secondary care.
While it might be interesting to compare the outcomes of psychiatric trainees with IAPT therapists, there would be difficulties in determining what would be the best method. For example, would a randomized controlled trial be helpful or ethical? The matching of patient need with therapist skill is an important confounder and may need a complicated stratifying procedure to answer comparability questions. Patient satisfaction questionnaire data would have enhanced this report. There is no objective assessment of therapy competence in relation to standard CBT assessment measures. While the Royal College of Psychiatrists requires supervisor feedback, it does not match these formats and reflects an appropriately lower level of technical application along with generic psychotherapy competencies. For ongoing and routine evaluation of the service as a whole, it would be useful to identify the professional role of the therapist providing treatment on the IAPT database. In this case, over time, comparison of outcomes stratified by clustering data may be assessed.
Summary and conclusions
Evaluation of the success of trainee psychiatrists providing CBT in an IAPT service has been examined from the perspectives of several stakeholders: the trainees have received a good learning experience; patients have benefited; the service has seen investment of supervisor time repaid in terms of clinical throughput and the training system has seen smooth transition of trainees through the training experience. This strongly supports the continuation of this arrangement. The clinical outcomes are indicative of an overall good match between skill level, supervision and patient complexity and later training focused on integration to routine practice should be encouraged. Consideration should be given to adopting this approach more widely in the mental health workforce to ensure the development of clinical competencies through learning experiences designed to be based soundly in learning theory. This would advocate ensuring that complexity of task to be learned under supervision is not too distant from current ability.
Acknowledgements
Thanks are due to the committed and enthusiastic consultant psychistrists, Sarah Brown, Sabia Chaudhry, Mani Krishnan and Ushi Reckermann, who enabled several generations of trainees in this locality to gain a good experience from CBT training. Thanks also to Pauline Callcott and Rebecca Eadie whose vision in the Newcastle talking Therapies IAPT service enabled this work. Thanks are also due also to Simon Carver for his enthusiastic provision of the supervision and especially to Bryony Lowe for her patient gathering and reliable supply of the outcome data.
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of Interest
None.
Recommended follow-up reading
Royal College of Physicians and Surgeons of Canada (CanMEDS) (2005). CanMEDS 2005 framework (http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e.pdf).
Learning objectives
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(1) Improved understanding of core psychiatric training requirements in relation to psychological therapies.
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(2) Improved understanding of the application of theories of learning to modern workplace training.
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(3) Improved understanding of the role that trainee health professionals can play in the mental health workforce.
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(4) Reflection on a service cost versus benefit analysis of providing training.
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