Scaling up evidence-based treatments in youth behavioral healthcare: Social work licensing influences on task-shifting opportunities

Abstract

Youth behavioral healthcare workforce shortages have inhibited the scale-up of evidence-based treatments to address longstanding unmet needs andinequitable service coverage. Task-shifting is a strategy that could bolster workforce shortages. Legal and regulatory barriers, such as scope of practice licensing regulations, have hampered the use of task-shifting. Social workers make up the majority of the behavioral healthcare workforce in the U.S. and most social workers provide services to children and families. As such, social workers would play a pivotal role in any scale-up effort. In this guest editorial, we discuss the importance of social work licensing and use a case example to illustrate the unintended consequences that certain licensing regulations have on scaling-up evidence-based treatments via task-shifting. We conclude with recommendations on how social workers could be involved in taskshifting efforts to scale-up evidence-based treatments.

Behavioral Health Workforce Shortages

Pronounced shortages in the mental healthcare workforce result in unmet needs and inequitable service coverage in youth mental healthcare (Andrilla et al., 2018; Cook et al., 2013). Unfortunately, workforce shortages have increased over time, with approximately 300 more Mental Health Profession Shortage Areas in 2016 than in 2012 (Olson & Tracey, 2017). One estimate suggests that by 2025 the United States will have almost one quarter of a million providers less than what will be needed (Health Resources and Services Administration, 2016). Consequently, it is not surprising that 43% of youth with mental health needs access any mental health care at all (Substance Abuse and Mental Health Services Administration, 2020).

Workforce shortages also inhibit the scale-up of evidence based treatments (EBTs) (Fagan et al., 2019), contributing to the fact that EBTs are only reaching 1%−3% of youth served in public mental health systems (Bruns et al., 2016). The public child mental health workforce varies greatly in educational background and training (Beck et al., 2018; Fagan et al., 2019) and suffers from high rates of staff turnover (Brabson et al., 2020). Use of EBTs can enhance youth outcomes (Weisz et al., 2017) and reduce staff turnover (Aarons et al., 2009), but widespread use of such interventions is limited in public behavioral health systems (Bruns et al., 2016). Insufficiencies in workforce size has been identified as a key barrier to widespread adoption of EBTs in public behavioral health organizations (Fagan et al., 2019).

Issues surrounding youth mental healthcare service availability, workforce shortages, EBT scale-up, and staff retention are key concerns for human service organization (HSO) administorators (Brabson et al., 2020; Collins-Camargo et al., 2019). Human service organization administrators face many challenges providing services to youth, particularly in regard to maintaining an adequate workforce to meet capacity and treatment needs of their target population (Brabson et al., 2020). HSO adminstrators are reporting that the demand for services is exceeding their capacity and there are challenges recruiting and retaining qualified staff (Collins-Camargo et al., 2019). HSO administrators are trying to meet their organizational missions by serving the public who often are relegated to waitlists (Thomas et al., 2020). They are bombarded by external demands to increase the efficacy of services vis-a-vie scaling-up EBTs (Bunger & Lengnick-Hall, 2019; Palinkas et al., 2018). And, they are managing internal demands from staff to reduce over-burdened caseloads (Griffiths et al., 2020). Our guest editorial discusses a mental health service strategy that HSO administrators and licensing authorities might consider to address these challenges. Specifically, this guest editorial will discuss the use of task-shifting to expand the youth mental healthcare workforce. We will define task-shifting, provide a case example, discuss the challenges deploying the strategy related to occupational licensing regulations, and then highlight the implications for social workers, human services leaders, and researchers.

Using Task-shifting to Expand the Workforce

Strategies exist that can bolster the workforce and support the scale-up of EBTs (Barnett et al., 2018; McQuillin et al., 2019; World Health Organization, 2008). Task-shifting is one approach to expand the behavioral healthcare workforce and extend the reach of effective services. Task-shifting is “a process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications” (World Health Organization, 2008, p. 7). It redistributes healthcare tasks among a broader workforce to support the diversification of care, the delivery of culturally fitting care, and the scale-up of necessary interventions (Orkin et al., 2021). For example, McQuillin and colleagues (2019) used school social workers and other school professionals to train and supervise non-clinically trained workers to provide a mentoring service to students. Another example involved shifting the delivery of a body image intervention to volunteer undergraduate college students (Kilpela et al., 2014).

Broadly, task-shifting involves three key processes: modification, training, and supervision (Gopalan, 2016). First, the intervention should be modified such that it can be delivered by non-clinically trained workers. It is possible that an intervention may not require modification if its components could be delivered by providers without clinical training. Indeed, more evidence-based interventions are being developed or adapted to be provided by non-clinical or licensed providers (Ametaj et al., 2021; Gopalan, 2016). Next, the non-clinically trained workers should be trained on how to deliver the modified intervention within their scope of practice. And finally, clinically trained and licensed providers supervise the delivery of the intervention (Gopalan, 2016).

Administrators and researchers have deployed task-shifting for a variety of health and behavioral health conditions throughout the world and find it to be a promising way to expand the reach of care (Deimling Johns et al., 2018; Joshi et al., 2014). Task-shifted workers in Low- and Middle-Income (LMIC) countries have effectively treated conditions like anxiety, depression, trauma, and schizophrenia (Deimling Johns et al., 2018). Similarly, researchers in High-Income countries (HIC) have effectively used task-shifting to treat conditions like depression, stress, eating disorders, and substance use (Barnett, Gonzalez, et al., 2018; Hoeft et al., 2018; Kilpela et al., 2014). Reviews of task-shifting report it to be effective (Deimling Johns et al., 2018; Hoeft et al., 2018; Singla et al., 2017), to be a viable option for system cost savings (Seidman & Atun, 2017), and to be a means for addressing inequities in service delivery (Barnett, Gonzalez, et al., 2018). Thus task-shifting may be an important strategy for HSO leaders, for whom increasing service effectiveness and equity are high priorities (Bunger & Lengnick-Hall, 2019; Hoefer, 2019).

One form of task-shifting that nearly all states have used is working through credentialed peer-providers (Chapman et al., 2018). Peer providers are individuals with lived experience who collaborate with other care providers to support service recipients (Merritt et al., 2020). Peer providers also can be involved in the co-creation and design of services by providing important user insights (Aakerblom & Ness, 2021). Peers workers have been integrated into the delivery of behavioral health services to improve service user engagement, promote hope, reduce stigma, and improve service user quality of life (Shalaby & Agyapong, 2020). Meta-analyses found that peers providing one-on-one services to adults yielded positive psychosocial outcomes (White et al., 2020), and in LMICS, peer-provided services improved depression and post-traumatic stress outcomes (Vally & Abrahams, 2016). Administrators and researchers have also included parent- and youth-peer-providers to deliver emotional support, guidance, and education to families and youth mental health consumers (Acri et al., 2017; Gopalan, Lee, Harris, et al., 2017).

This guest editorial focuses on a separate segment of the behavioral healthcare workforce. There are non-clinically licensed social workers with Bachelor’s degrees or Masters’ degrees who would be excellent candidates for task-shifting. There are also social service workers with other Bachelor’s degrees (e.g., psychology, sociology) who could be task-shifting candidates.

However, notwithstanding the presence of these potential task-shifting candidates, there are barriers to deploying this workforce innovation. Task-shifting has largely been successfully used in LMICs. Several have advocated for the importation of successful innovations from LMICs to HICs (Dearing et al., 2019; Zinsstag et al., 2019). One formidable obstacle to expanding the use of task-shifting in HICs are legal and regulatory barriers (Rowthorn et al., 2016). Licensing scope of practice regulations are one such barrier (de Haan et al., 2019). The external policy context can have significant impacts on the implementation of service changes (Albers & Shlonsky, 2020). A recent task-shifting study in the U.S. provides an example of how licensing regulations may deter the use of task-shifting with non-clinically licensed social workers and other social service workers.

Case Example of the Impact of State Licensing Policy on Task-shifting

The following case example illustrates one way that task-shifting could be used to serve youth with cross-system needs and the role that licensing regulations can play in facilitating or hindering the use of this innovation. In particular, our case example focuses on a vulnerable population who experiences multiple inpediments accessing needed mental health care and a way to promote a more integrated care approach to service delivery. And it speaks to concerns about licensure requirements, an area that HSO adminstrators have identified as challenging (Collins-Camargo et al., 2019). Our case example is also a strong candidate for task-shifting because it meets the necessary conditions for launching a task-shifting program (Orkin et al., 2021). Youth with cross-system needs face several challenges salient to HSO administrators.

There is a great need to better tend to the mental health needs of youth involved in the child welfare (CW) system. They have disproportionaly higher prevalence rates of mental illness compared to the general population (Bronsard et al., 2016). Yet, CW involved youth have similar to lower mental health service access rates than non-CW-involved youth (Burns et al., 2004; Horwitz et al., 2012). And these service utlization rates have decreased over time for CW-involved youth (Kim et al., 2018) even though their mental health needs have increased (Mowbray et al., 2017). The intensity of their needs lead CW-involved youth to have longer treatment engagement with the service system (Reid et al., 2021). Mental health service access among CW-involved youth is also inequitable. Youth from socioeconomically disadvantaged backgrounds and youth of color are less likely to receive mental health care and these disparities have been increasing (Kim & Garcia, 2016). Lack of access and these inequities are powerful social factors that prompt service delivery reforms (Schmid, 2019).

Disruptive behavior disorders (DBDs) are the most common mental illness among CW-involved youth (Bronsard et al., 2016). DBDs include conditions where youth exhibit behaviors that are considered hyperactive, aggressive, and/or oppositional (Gopalan, 2016). In addition to being prevalent, DBDS are impairing and costly (Foster & Jones, 2005; Merikangas et al., 2010). DBDs are best treated using behavioral parent training EBTs (Epstein et al., 2015).

But, families involved in CW often experience logistical barriers (e.g. childcare, conflicts with other services demands, finances) hindering accessing to parent training treatments (Kemp et al., 2009). Shortages of mental health providers also serve as barriers to CW involved youth receiving services (Bai et al., 2009). While there is variation among states (Pecora et al., 2019), most front-line CW workers have bachelor’s degrees (Staudt et al., 2015), and CW workers are typically not trained to identify and treat child mental health difficulties (Dorsey et al., 2012). Prerequisites to deliver many behavioral parent training programs often include advanced mental health training, experience, and/or a graduate degree (e.g., PCIT International, 2020). Providing behavioral parent training in CW agencies, through task-shifting, where families are already receiving care could overcome these barriers.

A research team used task-shifting to increase the reach of EBTs for CW-involved youth with disruptive behavior disorders (DBDs) (Gopalan, 2016). Following the task-shifting model, the team modified a behavioral parenting EBT with stakeholder and treatment developer feedback such that it could be delivered in a CW service setting by non-clinically licensed caseworkers (Gopalan et al., 2019). The stakeholders included CW caseworkers, supervisors, an administrator, and parents with previous CW experience. Researchers then trained non-clinically licensed caseworkers in the modified intervention. To be included, the caseworkers could have no prior advanced mental health training, no previous mental health employment, and no mental health certifications. The agency also modified some internal structures and expectations (e.g., reduced worker caseload) so that the caseworkers could implement the intervention. The caseworkers delivered the intervention with weekly supervision from a licensed clinical social worker. Preliminary findings suggest the intervention is generally feasible and acceptable to stakeholders while maintaining a high degree of fidelity (Gopalan, Lee, & Lucienne, 2017). This pilot study suggests that enlisting non-clinically-licensed caseworkers could increase the reach of EBTs, as participating families would have experienced significant barriers accessing youth mental health EBTs.

The team originally designed the study to be executed in two states, but ultimately only one state allowed the study to move forward. The licensing office of one state deemed shifting the modified intervention to non-clinically licensed caseworkers as being outside the scope of authorized practice. Shifting the intervention was not permissible—even though the intervention had been modified and the caseworkers were supervised. The intervention excluded activities (e.g., diagnosing, crisis management, mental health psychotherapy) set apart in the protected licensed clinical social worker scope of practice. The other state, however, allowed certain non-clinically licensed social workers to engage in counseling activities, enabling implementation efforts to move forward. This case study provides an example of how regulations influence task-shifting and and subsequent service access. Other researchers have noted the necessity of regulatory support to actualize task-shifting efforts (e.g., Deller et al., 2015).

Occupational Licensing and Its Implications for Task-shifting Approaches to Behavioral Health Workforce Expansion

The case study provides an example of the impact of licensing regulations on task-shifting to social workers without clinical licenses and on the mental health care access implications for vulnerable populations within the two involved states. It illustrates how individual states may provide starkly different opportunities to expand the reach of care to youth and families because of differing licensing policies. This is because states have sole jurisdiction over licensing and accreditation standards for human services (Kleiner & Vorotnikov, 2017). Collins-Camargo and colleagues (2019) found that licensure-related expectations and changes were among some of the top concerns for HSO administrators. We believe that it is possible to modify occupational licensing polices to ensure the public is protected while also expanding workforce through a task-shifting approach. This section discusses occupationl licensing, its unintended consequences, the role of licensing in social work, and concludes with implications on task-shifting.

Occupational licensing plays a significant role in the shaping of the general workforce (Kleiner & Krueger, 2010, 2013). Occupational licensure refers to the process by which state governments demark the necessary qualifications and sanctioned tasks associated with a given profession (Kleiner & Vorotnikov, 2017). Holders of that license are then able to use the occupational title and receive pay for providing those services. Approximately 22% of the U.S. workforce hold a professional license (Cunningham, 2019), and the number of workers with a license has increased 5 times over the past 70 years (Department of the Treasury Office of Economic Policy et al., 2015). Proponents of occupational licensing suggest that it protects the public and can improve the quality of services (Anderson et al., 2020).

Some claim that licensure ensures the quality of services, but research suggest this is not always the case. For example, social work licensure in skilled nursing facilities did not lead to improved service quality or client quality of life (Bowblis & Smith, 2021). Others have found shifting tasks to nurse practitioners from medical doctors also did not result in quality or safety differences (Kleiner et al., 2016).

Occupational licensing can also have unintended consequences (Kleiner & Soltas, 2019). Given that licensing requirements vary state-to-state, researchers have found that occupational licensing negatively influences professionals moving to different states (Johnson & Kleiner, 2020). Licensing can also restrict the supply of providers, increase the cost of services for consumers, and can exacerbate inequialities (Department of the Treasury Office of Economic Policy et al., 2015).

Social work is a licensed profession. The role of licensing in social work is particularly salient given that social workers make up the majority of the behavioral health workforce in the U.S. (Frank & Glied, 2006) and most social workers provide services to children and families through publicly funded organizations, including in child welfare settings (Salsberg et al., 2017). As such, social work licensing is particularly important for expanding the reach of EBTs in public mental health.

United States social work licensing began in the 1930s; today, every state in the United States has social work licensing laws (Association of Social Work Boards, 2020a; Dyeson, 2004). Like other occupational licenses, these laws determine who can use the title “social worker” and what scope of activities are permissible under that title (Donaldson et al., 2016; Dyeson, 2004). In social work, the foremost reason for licensing is to protect the public (Association of Social Work Boards, 2020b). Licensing seeks to ensure that social workers are competent and provide ethical and safe services. Licensing also provides the public an avenue of recourse if services fail to meet those standards. In social work, licensing boards have intervened in an array of instances where social workers were providing harmful or inadequate care (Boland-Prom, 2009). This sort of profession protection can enhance the public’s confidence in the social work profession. Social work licensing also serves as signal of professionalism, it can bolster social worker’s self-respect, and it sets a professional standard (Grise-Owens et al., 2016).

Notwithstanding the positive aspects of social work licensing, there may be unintended consequences (Donaldson et al., 2014, 2016). For example, Senreich & Dale (2021) have found racial dispairites in social work licensure. White MSW graduates were more likely than their colleagues of color to have licensure (Senreich & Dale, 2021). And older social workers of color had even lower rates than younger social workers of color.

Our case example points out that restricting mental health service access could be another unitended consequence of licensing policies. The language of one state’s licensing law prevented the supervised delivery of a modified intervention by social workers without clinical licenses. But the laws of another jurisdiction allowed the supervised delivery of the same intervention. As such, state variation in licensing laws (Donaldson et al., 2014) could exacerbate the uneven distribution and availability of EBTs, inhibiting national efforts to upgrade the quality and effectiveness of public mental health care (Zima et al., 2013).

We learned from our experience with the case example that states can modify their licensing laws such that additional cadres of workers can provide supervised clinical services to otherwise unserved populations. Licensed professionals supervised the delivery of an EBT to trained non-licensed workers. This new strata of workers were embedded in CW settings where there is both disproportiaonte need and disproportionate barriers. Three cohorts of families received care they otherwise would not have received, and this was accomplished using an existing workforce. Licensing policies can be written to both protect the public and increase access to care.

Potential Social Worker Roles in Task-Shifting Efforts

There are ways to preserve the benefits of social work licensing and use all social workers to expand the workforce. Social workers are poised to be a powerful resource to expand the reach of mental health care by supporting several dimensions of the task-shifting phases. Elevating and leveraging frontline social workers’ and HSO administrators’ expertise is in-line with an organizational learning approach advocated by Mosely et al.(2019) . This approach can temper some of the negative, unintended consequences of top-down methods (Mosley et al., 2019).

Social workers can help with the task-shifting preparatory work. They can help assess the current reach of services and formulate realistic incremental targets for EBT scale-up. They can identify specific practice competencies which could be shifted to non-clinically licensed workers. Social workers could also be involved in the subsequent phases of task shifting. Table 1 outlines three of the phases of task-shifting. Based on our experience with the case example, we have listed the goals/objectives of each phase along with the resources, benefits and challenges.

Table 1.

Phases of task-shifting and lessons learned based on task-shifting case example.

Phase	Goals/Objectives	Resources needed	Expected Benefits	Expected Challenges
Intervention Modification	Goal: Modify the intervention so that it can be delivered by non-specialist providers in their unique work contexts Objectives: Break down complex treatment procedures Simplify language Tailor for delivery in new context (e.g., consider changes in modality)	Information about new providers’ existing skill set and workplace contextual influences (day-to-day schedule, etc.) Information on new providers’ scope of practice regulations Treatment developer input Sample of stakeholders across administrative levels to provide feedback Facilitators who can solicit and synthesis feedback	Better fit with CW frontline provider context, roles/responsibilities, existing skill set, scope of practice, and client population Increased acceptability by frontline providers and new client population	Balancing the need to maintain treatment developer defined core components with exigencies of new practice capacities Reconciling disparate perspectives and recommendations from stakeholders Not all recommended changes can be made – prioritizing those that are most feasible within the time frame allotted and provider buy-in
Training	Goal: Train the non-specialist provider to deliver the modified intervention Objectives: Add content regarding relevant knowledge, skills, and attitudes which may not be part of non-specialist provider’s existing skill set Implement training using mixture of didactic and experiential learning strategies	Information about new providers’ existing skill set and workplace contextual influences (etc., day-to-day schedule) Coordination with providers in new context to arrange for physical space and scheduling for providers to attend training Modified intervention treatment manual Trainer with expertise in the intervention	Non-specialist providers have necessary knowledge and skills to deliver modified intervention	Finding time and space with non-specialist providers in high-intensity, fast-paced contexts (e.g., child welfare services) Potential for role conflict as existing work role may differ from intervention role
Supervision	Goal: Specialist providers supervise non-specialist providers on the modified intervention Objectives: Provide structure, direction, and coaching around clinical skills need to deliver the modified intervention Provide expertise and guidance about clinical issues (e.g., child or caregiver MH) emerging during group process	Information about new providers’ existing skill set and workplace contextual influences (day-to-day schedule, etc.) Scheduled weekly or bi-weekly phone or web calls Information on availability of resources if clinical service linkages are needed (e.g., psychiatric emergencies) Specialist with expertise in the intervention and availability to provider supervision Resources to pay supervisor and cover supervision time of non-specialists	Non-specialist providers have specialized clinical support to address ongoing clinical issues and emergent crises Non-specialist providers have coaching from supervision to master clinical skills to deliver modified intervention, aligning with training/supervision best practices	Managing boundaries between supervision on the modified intervention and larger work Finding time with fast-paced, high intensity work contexts Added workload burden onto existing non-specialist providers

Social workers could play a pivotal role in the first phase of task-shifting: the development or adaptation of interventions that can be implemented within the existing service system infrastructure. Social workers can collaborate with treatment developers and clients to adapt and modify evidence-based interventions to fit the constraints of the service system. Wide-spread adoption of EBTs in children’s public mental health care has been limited due to various system complexities (Bruns et al., 2016; Fagan et al., 2019). For example, these organizations have multiple sources of public funding and various licensing and accreditation standards to follow. Little research details these complexities for intervention developers to draw upon when developing interventions for public practice (Graaf & Snowden, 2020a). Social workers develop intimate knowledge of the state and local policies that shape service delivery. They are also keenly aware of client realities, strengths, and challenges, and they can leverage this insight in adaptation of interventions.

Social workers could also play indispensable roles during the second and third phases of task-shifting. Clinically licensed social workers could train social workers without clinical licenses in the modified interventions, and subsequently supervise their delivery. Licensed social workers would retain those practices which would be inappropriate to shift, such as providing direct care for youth who have greater levels of need (e.g., greater impairment, comorbid conditions). This mirrors the U.K. stepped care model (Richards, 2012). In this model lower intensity treatments are offered first by task-shifted providers supervised by clinically licensed providers. If clients require specialized treatment, they would be stepped up to care provided by clinically licensed providers.

Potential HSO Researcher Roles in Task-Shifting Efforts

HSO researchers could help improve and refine task-shifting by contributing to the scholarship. There are several questions remaining about the best way to deploy a task-shifting strategy. For example, the case study included researchers with implementation expertise to work as an intermediary between the treatment developer and the frontline CW agency. Research about these implementation supporters is needed. Researchers have conducted preliminary work on the extent to which intermediary organizations exist, the strategies they use as well as key competencies required to be successful (Metz et al., 2021; Proctor et al., 2019). Many implementation studies test a small set of discrete strategies to install a new practice (e.g., a new practice could be task-shifting), but researchers are finding that implementation requires many more strategies than the trials are testing (Waltz et al., 2021). HSO researchers could examine the implementation decision processes of organizations to improve the selection of strategies. Implementation strategy tracking methods could support such studies (Boyd et al., 2018; Bunger et al., 2017). In addition, we need to know more about what sort of competencies implementation supporters need, how to develop those competencies, and how to bolster that segment of the behavioral health workforce (Metz et al., 2021).

The unintended consequences of task-shifting in highly regulated environments is another area HSO researchers could explore. Task-shifting, while promising, has its limitations, issues, and unintended consequences. For example, shifting could increase supervisor responsibilities, the new workers could experience heavy workloads, the new cadre of workers may have few opportunities for career advancement, or service quality could be uneven (McQuillin et al., 2019). Some would argue that task shifting would introduce another strata of the workforce that could become subject to licensing regulations and all of its attending strengths/limitations as outlined previously in this editorial. Providing additional training to a cadre of workers would justify increased pay, which may not be fiscally possible for certain HSOs. We need research that can illuminate these unintended consequences to ensure that the benefits of task-shifting outweigh its trade-offs. System dynamics methods like group model building, causal loop diagram development, and computer simulation could be a fruitful approach to address these questions (Langellier et al., 2019; Trani et al., 2016).

The task-shifting approach we discussed in our case study is an example of scaling-out. Scaling-out is “the deliberate use of strategies to implement, test, improve, and sustain [EBTs] as they are delivered in novel circumstances distinct from, but closely related to, previous implementations” (Aarons et al., 2017, p. 2). Specifically, our case study would be considered a Type 3 scale-out where an intervention is serving a different population (i.e., CW involved families with their unique stressors) and is delivered in a different service system (i.e., CW service agency instead of a mental health clinic). Installing a practice in a new environment raises several questions: what sort of worker is best suited for task-shifting, what organizational changes need to be made to help task-shifted employees stay and thrive in their modified roles, how do existing work flows need to be modified, what revenue streams could sustain the practice, and what are the best ways to tailor the intervention? Workflow mapping methods (Kammoun et al., 2021; Steckowych & Smith, 2019), institutional ethnography methods (Kearney et al., 2019; Rankin, 2017), and intervention adaptation methods (Miller et al., 2020) could be used to address these questions.

Also, the current paper’s focus on task-shifting has implications for future research related to Transfer of Learning, the extent to which skills learned in training are consistently and competently applied in daily work practice (Antle et al., 2009). This is important as successful implementation of evidence-based practices heavily rely on the ability of frontline providers to deliver the necessary skills for EBTs to be effective (Aarons & Palinkas, 2007; Feldstein & Glasgow, 2008). Relevant factors promoting the transfer of skills into the workplace include supervisory and peer support, opportunities to use new skills on the job, positive work transfer environment, job aids, post-training follow-up and feedback, relapse prevention, as well as self-management and goal setting strategies (Grossman & Salas, 2011). However, task-shifting from clinically trained social workers to non-clinically trained social workers in potentially new service contexts (as exemplified in the case study) adds an additional layer of complexity, as the resources, capacities, and priorities between old and new service contexts are likely to differ. As a result, additional research is needed to identify factors that facilitate and hinder transfer of learning when EBTs are task-shifted to non-clinically trained social workers in potentially new service settings. A mixed methods approach could address these questions. For example, examining the fidelity of EBT implementation and the number of clients who receive the treatment (quantitatively) and the factors impacting fidelity and consistency of EBT use (qualitatively).

A final future research area to consider involves the complexity of task-shifting in environments with state licensing regulations and associated scopes of practice regulations. Local understanding of these laws is critical for organizational or system readiness to implement this strategy for workforce expansion. Because the scope of practice authorized for various levels of licensure varies significantly across states (Association of Social Work Boards, 2021), human service organizational leaders can be aided in the use of task-shifting through detailed examinations of the scope of practice regulations that exist for various types of professional human service provider licensing across all fifty states. Policy surveillance of mental health licensing practices across the United States is lacking and will have significant implications for the wider use of task-shifting models and the role that social workers can play in implementing these models. In addition to mapping the licensure policies across states (Burris et al., 2016) for dissemination to organizational leaders, qualitative studies that examine the decision making processes of mental health policy makers and administrators can be useful for designing advocacy strategies (Graaf & Snowden, 2020b) to amend licensing provisions and associated scopes of practice that can facilitate adoption of task-shifting workforce strategies.

Conclusion

There is no panacea to expand the reach of behavioral health services to children and their families. Task-shifting is also only one system-level strategy to increase the reach of care. It has been the focus of this guest editorial because it appears to be effective and because it was the strategy deployed in the case example (Gopalan, 2016; Hoeft et al., 2018).

Another strategy to expand the workforce is through the expansion of peer-specialist programs (Shalaby & Agyapong, 2020). Many states have developed certifications and/or licenses for individuals who have lived experience to provide a cadre of support services (Heller, 2016). Interestingly, both states in our case example have peer certification programs, but the workers in our study would not qualify for peer certification, nor would they qualify for the licensed clinical social worker designation. Our case example points to a middle group of workers who could have certain tasks shifted to them. Our guest editorial speaks to the possibility of expanding the umbrella of tasks that LCSWs could supervise and that non-clinically trained social work degree holding workers could deliver.

Given extensive evidence demonstrating the effectiveness of task-shifting as a means of expanding behavioral health services, social work licensing laws could be modified so that social workers can better maximize the benefits and minimize the trade-offs of task-shifting.