The State of Integrated Primary and Behavioral Health Care Research in Counselor Education: A Review of Counseling Journals

Alexander M. Fields, Cara M. Thompson, Kara M. Schneider, Lucas M. Perez, Kaitlyn Reaves, Kathryn Linich, Dodie Limberg

The integration of behavioral health care within primary care settings, otherwise known as integrated care, has emerged as a treatment modality for counselors to reach a wide range of clients. However, previous counseling scholars have noted the lack of integrated care representation in counseling journals. In this scoping review, we identified 27 articles within counseling journals that provide integrated care implications. These articles appeared in 10 unique counseling journals, and the publication years ranged from 2004–2023. Articles were classified as: (a) conceptual, (b) empirical, or (c) meta-analyses and systematic reviews. The data extracted from the articles focused on the implications for integrated care training and practice for the next generation of counselors, evidence-based treatment approaches, and future research directions.

Keywords: integrated care, counseling journals, scoping review, implications, research


One in five U.S. adults are living with a mental illness or substance use disorder (e.g., major depressive disorder, generalized anxiety disorder, alcohol use disorder, nicotine use disorder) and individuals with a mental illness or substance use disorder are more likely to have a chronic health condition (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Integrated primary and behavioral health, also termed integrated care (IC), has emerged as a noted treatment strategy to meet the holistic needs of individuals with comorbid mental and physical health symptoms. Although IC has been operationalized inconsistently by scholars, most definitions describe the integration and coordination of behavioral health services within primary care settings (Giese & Waugh, 2017). The SAMHSA-HRSA (Health Resources and Services Administration) Center for Integrated Health Solutions expanded upon this definition to outline IC on a continuum of health care service delivery (Heath et al., 2013). Heath and colleagues described the progressive movement toward IC as (a) collaborative care: providers from multiple health care professions collaborating on holistic health care treatment planning at a distance;
(b) co-located care: providers from multiple health care professions sharing basic system integration, such as sharing physical proximity and more frequent collaboration; and (c) IC: providers from multiple health care professions having systematic integration (i.e., sharing electronic medical records and office space) and a high level of collaboration resulting in a unified treatment approach. Thus, health care consumers are able to receive care for their behavioral and physical health at the same time and location when an IC approach is applied, which may reduce barriers (e.g., transportation, child care, time off work) and increase access to behavioral health care (Vogel et al., 2014).

Beyond support from SAMHSA and HRSA, the IC movement has been endorsed through government legislation. The Patient Protection and Affordable Care Act (2010) paved the way for agencies and health care systems demonstrating an IC approach to receive additional funding for health care providers, as well as increased reimbursements for the services they deliver. Furthermore, the federal government has recently pledged to double the funding support for IC to be more accessible in hospitals, substance abuse treatment facilities, family care practices, school systems, and other health care settings (The White House, 2022). This may be the result of IC showing efficacy in reducing mental health symptoms (Lenz et al., 2018), saving health care expenditures (Basu et al., 2017), and promoting overall life satisfaction (Gerrity, 2016). Compared to traditional (i.e., siloed) care, IC involves simultaneous treatment from physical and mental health providers, thus providing additional access to mental health screenings and services. For example, McCall et al. (2022) concluded that a mental health counselor in an IC setting may support treatment engagement and reduce health care costs for an individual with a substance use disorder when utilizing the screening, brief intervention, and referral to treatment (SBIRT) model. However, the IC paradigm is not a novel concept; Aitken and Curtis (2004) introduced IC to counseling journals by providing emerging evidence of IC support and advocating for health care settings to recognize counselors as an asset to IC teams and for counselors to be trained in IC.

Brubaker and La Guardia (2020) noted that the Council for Accreditation of Counseling and Related Educational Programs (Section 5, Standard C.3.d; CACREP; 2015) required IC education in counselor-in-training (CIT) development. Additionally, the 2024 CACREP Task Force has also included these standards for its proposed revisions (CACREP, 2022). HRSA has funded counselor education programs to train CITs during practicum and internship experiences, funding over 4,000 new school, addiction, or mental health counselors during 2014–2022 through the Behavioral Health Workforce and Education Training (BHWET) Program (HRSA, 2022). Although IC training, education, and practice is occurring within counselor education, IC literature remains scarce in counseling journals (Fields et al., 2023). The lack of representation presents an issue for appropriate training for CITs and future research directions, which leads to sustainability concerns. Specifically, Fields et al. (2023) reported that a lack of IC literature in counseling journals creates a weak foundation to advocate for counselors to be included in the IC movement. With the understanding that nearly half of U.S. adults with poor mental health receive their mental health care in a primary care setting (Petterson et al., 2014), counselors may increase their access to additional clients when they are invited to IC settings. Furthermore, it weakens counselors’ professional identity if counselors are not trained in a standardized approach. As such, this scoping review aims to amalgamate current IC literature within counseling journals and provide CITs, counselors, and counselor educators from diverse backgrounds with a resource to inform their education, practice, and scholarship. The guiding research question for this review is: What are the publication trends (i.e., publication years and journals), study characteristics and outcomes, implications, and recommendations for future research from IC literature within counseling journals?


We conducted a scoping review to identify the publication trends, key characteristics of IC studies (i.e., type of article and study outcomes), and implications for future research of IC literature published in counseling journals (Munn et al., 2018). Our methodology followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews; Tricco et al., 2018) checklist to 1) establish eligibility, 2) identify sources of information, 3) conduct a screening process to select included articles, 4) identify and chart data items, 5) conduct a critical appraisal of included articles, and 6) synthesize results. We searched the following databases for eligible literature: (a) Alt HealthWatch, (b) APA PsycArticles, (c) APA PsycInfo, (d) Education Source, (e) EBSCOHost, (f) Health Source: Consumer Edition, (g) Health Source: Nursing/Academic Edition, (h) MEDLINE with Full Text, (i) Science Reference Center, (j) Social Sciences Full Text (H.W. Wilson), and (k) Social Work Abstracts. We used the search terms: “Integrat* care” OR “integrat* primary and behavioral healthcare” OR “integrat* primary and behavioral care” AND “counsel* education” OR “counsel*.” Additional criteria for this search were full-text, peer-reviewed journal articles, and an English translation.

Eligibility Criteria
     Eligibility criteria for articles included in this review are publication in a counseling journal, presentation of implications (i.e., recommendations for training and evidence-based counseling models or approaches) of IC practice for CITs and counselors through research methodology or conceptual themes, and discussion of future research on IC for counselor educators and counseling scholars through research methodology or conceptual themes. Eligible counseling journals included those published by divisions of the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American School Counselor Association (ASCA), the National Board for Certified Counselors (NBCC), and Chi Sigma Iota. Journals connected to international and regional divisions were also included. The initial database search resulted in 222 articles, which we reduced to 125 articles after removing duplicates. Another two articles were identified through additional sources. These additional sources included references identified through a review of an article and a social media post advertising an IC article. We reviewed titles and abstracts for inclusion criteria. This resulted in 28 articles that were fully reviewed. Research team members independently examined articles to summarize information relevant to the research question. During this process, articles were excluded if they did not provide future implications for IC in counseling or counselor education. Following this process, 27 articles were included. A visual representation of the eligibility and inclusion process can be found in Figure 1.

Data Extraction
     After consensus was reached on the final 27 articles, our research team assessed the available evidence and synthesized the results. The seven-member research team comprised four doctoral students in counselor education, an undergraduate student minoring in counselor education, a clinical assistant professor in a counselor education program, and an associate professor in a counselor education program. The initial data extraction process began with identifying journal representation and organizing articles based on similar characteristics. This resulted in classifying articles as either (a) conceptual, (b) empirical, or (c) meta-analyses and systematic reviews. Conceptual articles provided an overview of available literature and identified a current gap in IC understanding for counseling or counselor education. Articles classified as conceptual did not present original data or follow research methodology. Moreover, the conceptual models typically advocated for increased counseling representation in IC settings to reach traditionally underserved groups (e.g., LGBTQ+ clients, individuals from rural communities) or a replicable model of training grounded in empirical support to prepare CITs to work in IC settings. Data from these articles were presented in accordance with the authors’ population(s) of interest, the identified research gap, implications gathered from existing literature, and recommendations for future research. Empirical articles introduced a novel research question and presented results to address that question. Data from these articles were presented in accordance with the authors’ study classification (i.e., qualitative, quantitative, or mixed methods), research methodology, the number and profile of participants, research of interest, and results from their analyses. Lastly, meta-analyses and systematic reviews organized previous empirical studies and presented big picture results across multiple studies. Data from these articles were presented in accordance with the authors’ article classification (i.e., meta-analysis or systematic review), population of interest, number of included studies and number of total participants (if applicable), results, and implications for future research. Because of the broad scope and exploratory nature of this review, a quality assessment was not performed.

Figure 1
Integrated Care Literature in Counseling and Counselor Education Flow Chart

Note. This flow chart outlines the PRISMA-ScR (Tricco et al., 2018) search process.



This scoping review resulted in a wide variety of articles in counseling journals that may inform the future of IC research in counseling and counselor education. Additionally, articles included in our review have ranging implications at the CIT, counselor, and client levels. The results section will begin with an overview of IC publication trends within counseling journals, detailing the publication range and specific journals. Next, results for this review were organized based on study outcomes and the classification of the article. The study outcomes sections will further detail included articles that are conceptual, empirical, or meta-analyses and systematic reviews.

Publication Trends
     Articles included in this review range in publication year from 2004–2023. Articles are represented in 10 unique journals. Specifically, the following journals are represented in this review: (a) Counseling Outcome Research and Evaluation (n = 2); (b) International Journal for the Advancement of Counselling (n = 2); (c) Journal of Addictions & Offender Counseling (n = 2); (d) Journal of College Counseling (n = 1); (e) Journal of Counseling & Development (n = 7); (f) Journal of Creativity in Mental Health (n = 1); (g) Journal of LGBTQ Issues in Counseling (n = 1); (h) Journal of Mental Health Counseling (n = 9); (i) The Family Journal (n = 1); and (j) The Professional Counselor (n = 1).

Study Outcomes
Conceptual Articles
     Our review included 11 conceptual articles (see Appendix A). Of these studies, five described IC as a treatment approach for underserved populations. In each of these articles, the authors described how IC provided a “one-stop-shop” treatment approach that provided increased access to a mental health provider in a traditional primary care setting, which reduced barriers to transportation, cost per service, and provider shortages. Six studies focused on current licensed counselors in primary care settings, counselor educators, CITs in a CACREP-accredited program, and counselors interested in IC. Common implications of these articles included advocacy, education, communication, networking, and teamwork.

Eight studies described how additional research could empirically investigate their IC model. The authors of these conceptual articles recommended continued investigation of the current medical model and national recognition of gaps of care for both the chronic pain and substance abuse population; integrating the interprofessional education collaborative (IPEC) into the curriculum of mental health counselors; interprofessional telehealth collaboration (IPTC) through cognitive behavioral therapy (CBT) for rural communities; treatments aligned with cultural tailoring; implementation of IC for those in the LGBTQ+ community; trauma-informed IC; and the role of counselors in an IC team treating obesity. The conceptual models reported in Table 1 highlight evidence-based approaches a counselor can apply in IC settings to assess for substance abuse and mental health disorders, brief interventions (e.g., CBT technique of challenging automatic thoughts, motivational interviewing) to encourage engagement in preventative health care, and trauma-informed practices (e.g., psychoeducation on trauma somatization). Moreover, counselors trained in the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) can advocate for culturally tailored interventions to respect a client’s cultural identity.

Two studies highlighted different approaches to IC. Johnson and Mahan (2020) identified the IPTC model, which allows health professionals to use technology to increase access to services for rural communities. The IPTC model provides telehealth services to rural communities through an IC model to reduce negative social determinants of health, such as distance from a mental health provider. Specifically, Johnson and Mahan (2020) detailed their approach to working alongside primary care providers to deliver family counseling services and coordinate health care services to promote overall health and wellness for family systems. Goals of their family counseling sessions included increasing health literacy, enhancing a family’s coping strategies for medical conditions, and reducing family conflicts. The Chronic Care Model has been shown to improve the quality of care for clients with chronic medical conditions by increasing communication between health care professionals (Sheesley, 2016). Two articles also focused on the impact of two identified training programs. Johnson and Freeman (2014) identified the IPEC Expert Panel and their efforts to effectively train health professionals to collaborate. Lloyd-Hazlett et al. (2020) focused on the Program for the Integrated Training of Counselors in Behavioral Health (PITCH), which is a training program for master’s-level counseling students in a CACREP-accredited program aimed at training students to supply IC to rural, vulnerable, and underserved communities. These results are represented in Appendix A.

Empirical Articles
     Our review resulted in 13 empirical studies using the following designs: three mixed-methods designs, three quasi-experimental designs, two cross-sectional surveys, two pre-post designs, three phenomenological studies, and one exploratory cross-case synthesis. The studies were completed in a variety of settings, such as university clinics, trauma centers, and hospitals. Participant profiles varied across studies, with nine representing CITs or practicing counselors, three representing clients, and one representing both. In addition to counselors, studies with client-level data included service providers and undergraduate students from social work, speech–language pathology, dental hygiene, nursing, and physical therapy programs. Articles that reported client-level data tested an intervention (e.g., motivational interviewing in an IC setting for a substance use disorder), compared an IC approach to treatment as usual (TAU) in silos, or explored relationships between health care indicators and client engagement in a setting applying an IC modality. Furthermore, three studies in this article used Heath et al.’s (2013) conceptualization of IC, which was the most common model cited.

Most study outcomes were reported as positive benefits for IC. For CIT and counselor-level studies, six described a theme of increased ability and desirability to work with a collaborative approach on IC teams. Participants also commonly reported an increase in professional identity and self-efficacy. Participants in studies by Agaskar et al. (2021), Alvarez et al. (2014), and Lenz and Watson (2023) further demonstrated that working with underserved populations in IC settings increased their multicultural competence, specifically around areas of acceptance, advocacy, and awareness. A gap in IC awareness among service providers and organizational constraints were noted as potential barriers to IC care. Johnson et al. (2021) found interprofessional supervision as a potential barrier to remaining within a provider’s scope of practice, because a supervisor providing supervision to a supervisee from a different professional identity may not appropriately understand roles and responsibilities. Because of this, Johnson and colleagues noted implications for future research and graduate-level training in the classroom and field experience. All four of the studies completed with client-level data were quantitative, accounting for 2,378 client participants. Results of these studies suggested improvement in holistic client functioning (i.e., reduction in pathological symptoms and increase in preventative behaviors; Ulupinar et al., 2021), a decrease in crisis events (Schmit et al., 2018), and decrease in risky drinking behaviors for individuals receiving IC trauma care (Veach et al., 2018). The self-stigma of mental illness and of seeking help had an inverse relationship with mental health literacy among patients who received treatment in an IC setting (Crowe et al., 2017). These results are represented in Appendix B.

Meta-Analyses and Systematic Reviews
     Three articles in this review were meta-analyses or systematic reviews. Specifically, two articles were meta-analyses and one was a systematic review. Participants within these studies included adults with substance use disorders, mental health professionals receiving training to practice within IC, and individuals receiving mental health care in traditional primary care settings. All three articles described benefits of IC. Additionally, the authors differed on the number of studies and participants included in their analyses. Fields et al. (2023) completed a review of 18 articles that studied training interventions for mental health professionals to work on IC teams and concluded that training in IC promotes aspects of interprofessional collaboration, professional identity development, and self-efficacy. Balkin et al. (2019) concluded no statistical significance between IC treatment and TAU to decrease frequency of substance use. Balkin et al. also remarked that their study, including 1,545 participants, did not reach statistical power and results should be considered preliminary. Lenz et al. (2018) reported a decrease in mental health symptoms with a greater effect when a larger treatment team and number of behavioral health sessions are increased, compared to TAU. Lenz and colleagues generated their results from 14,764 participants. Lastly, Fields et al. (2023) and Lenz et al. (2018) both used Heath et al.’s (2013) model of IC for conceptualization. For all three of these studies, additional research is needed to understand IC at the client or consumer level, as well as how different variables affect the treatment process. These results are represented in Appendix C.


Implications for Counseling Practice
     The results of this scoping review have implications that may inform clinical practice for counselors and CITs. Most results suggested clinical benefits for individuals receiving counseling services through an IC setting. Clients or consumers that received IC treatment reported a reduction of mental health symptoms (Lenz et al., 2018; Ulupinar et al., 2021), mental health stigma (Crowe et al., 2018), and crisis events (Schmit et al., 2018). As almost half of individuals with poor mental health receive treatment in primary care settings (Petterson et al., 2014), integrating a counselor into a traditional primary care setting (e.g., hospital, community health care clinic) provides an additional treatment team member with specialized training to treat mental health concerns. Because of the potentially fast nature of IC settings, interested counselors are encouraged to review SAMHSA applications of SBIRT to facilitate brief meetings until more long-term services are provided. Furthermore, counselors may consider reviewing resources on evidence-based approaches, such as Ultra-Brief Cognitive Behavioral Interventions: A New Practice Model for Mental Health and Integrated Care (Sperry and Binensztok, 2019), and understanding common medical terminology, such as A Therapist’s Guide to Understanding Common Medical Conditions (Kolbasovsky, 2008).

Articles that were classified as conceptual also suggested that IC treatment has the potential to enhance service delivery for clients from diverse populations, such as LGBTQ+ and medically underserved communities (Kohn-Wood & Hooper, 2014; Moe et al., 2018). The primary rationale described by scholars is that an IC approach advocates for diverse populations to reduce social determinants of health, such as proximity barriers, communications barriers, and availability of culturally appropriate interventions. Counselors interested in working in an IC setting are strongly encouraged to review the MSJCC (Ratts et al., 2016) and be prepared to serve as an advocate for their client as they navigate the health care system. The Hays (1996) ADDRESSING model also provides counselors a conceptualization model for understanding power and privileges associated with cultural differences. Information drawn from an understanding of power and privileges may further assist the interdisciplinary team with delivering culturally appropriate care. However, Balkin et al. (2019) concluded that IC may not result in a decrease in frequency of substance misuse. As IC may not be the most ideal approach depending on the client’s presenting concern and therapeutic goals, counselors are ethically bound to continue ongoing assessments to collaborate with their client to determine the most appropriate treatment setting.

Implications for Counselor Education
     In addition to counseling practice, the results of our scoping review provide implications for counselor education and ongoing counselor development. First, counselors or CITs that have received training in IC have commonly reported an increase in their professional identity development, as practicing in IC settings creates an opportunity for counselors and CITs to differentiate counseling responsibilities from related health care professionals (Brubaker & La Guardia, 2020; Johnson et al., 2015). Counselor educators and supervisors are encouraged to consider how they can create opportunities to challenge their students or supervisees to understand their role in the health care landscape. For example, Johnson and Freeman (2014) described an interdisciplinary health care delivery course to train counselors alongside students from other disciplines (e.g., nursing, physical therapy), and counselor educators may consider how they can form partnerships across departments to provide these opportunities. Counselor or CIT participants also expressed an enhanced self-efficacy for clinical practice (Brubaker & La Guardia, 2020; Lenz & Watson, 2023). As trainings and field experience for IC practice typically involve experiential components, counselors and CITs are provided additional opportunities to practice their previous clinical trainings in IC settings. Farrell et al. (2009) provided an example of how counselor educators can use standardized patients (i.e., paid actors simulating a presenting concern) to role-play a client in a primary setting. In such situations, the CIT can practice a variety of brief assessments (e.g., substance abuse, suicide, depression screenings) and interventions (e.g., motivational interviewing techniques, such as building ambivalence) in an IC setting.

With the counseling profession’s emphasis on aspects of valuing cultural differences and social justice, counselor educators and supervisors may consider how they can train counselors and CITs to reduce social determinants of health through integrated and collaborative practices that promote affirmative and proximal care. Counselors or CITs that received training to work in IC settings often reported higher understanding of multicultural counseling (Agaskar et al., 2021; Lenz et al., 2018). Thus, counselor educators and supervisors can provide their counselors and CITs with challenges to incorporate aspects of the MSJCC (Ratts et al., 2016) when delivering interdisciplinary care. All trainings in our review were administered across multiple modalities (e.g., face-to-face, hybrid, virtual, asynchronous), which gives counselor educators flexibility in how they train counselors or CITs. The variety in training administration is a promising result, as the COVID-19 pandemic highlighted the need for flexible training options for counselors and CITs. In addition, counselors and CITs in rural communities often have infrequent access to training as compared to their non-rural colleagues, and thus flexibility may enhance the accessibility of IC training (Alvarez et al., 2014). Lastly, counselors and CITs being trained in IC modalities do not need to work in IC settings to use interprofessional skills developed through trainings. Heath et al. (2013) remarked that IC is not always a feasible option, but helping professionals can still apply collaborative approaches to enhance their client’s holistic outcomes. In other words, counselors or CITs may apply IC principles of preventative health care and interdisciplinary treatment plans by collaborating with other health care professionals at a distance. Glueck (2015) corroborated this notion and described a theme that counselors who have previously worked in IC settings believe they are able to provide more holistic care because they are better equipped to collaborate with health care professionals from multiple disciplines. However, these counselors also reported that they would have been more prepared to work in IC if they received training at some point in their career.

Limitations and Recommendations for Future Research
     The methodology of a scoping review has noted limitations. Because of the nature of a scoping review, the data extraction process and results section are broad (Munn et al., 2018). Articles were not systematically evaluated to assess study quality, and the reader is encouraged to review a specific study before interpreting the results. In addition to study quality, scoping reviews include articles from a variety of article classifications, so the results and implications should be considered exploratory. Thus, we caution how readers draw conclusions from results presented in the included articles. Second, the search terms and inclusion criteria may have resulted in limitations. This search focused on IC; therefore, concepts such as interprofessional collaboration and interprofessional education may have been excluded. These concepts are discussed in the Heath et al. (2013) model, but they do not directly result in IC practice. Counseling and counselor education were also search terms, which may have excluded articles written by counseling scholars in journals outside of counseling and counselor education journals. Third, this review resulted in four studies that empirically investigated IC at the client level. With limited data at the client level, there are funding and advocacy sustainability concerns for IC within counseling and counselor education. Lastly, nine studies specifically provided implications for marginalized populations and multicultural competency development through an IC lens. Although Kohn-Wood and Hooper (2014) and Vogel et al. (2014) concluded that IC is a modality that advocates for the treatment of marginalized populations that have traditionally received services at unequal rates to their White, cisgender counterparts, this topic has limited representation in counseling IC literature. As discussed by Fields et al. (2023), this review demonstrates the need for understanding how the counseling professional identity rooted in social justice and advocacy may contribute to the advancement of IC services.

In light of our limitations, this review resulted in recommendations for future research directions. Conceptual articles included in this review synthesized literature on the importance of CITs and counselors understanding applications of IC, as well as potential treatment approaches to treat a variety of marginalized communities and clinical practices. Our research team recommends that counseling scholars reviewing the included conceptual articles consider how they can use the implications and future research directions to inform future research studies. These articles can also serve as support for counseling scholars who are applying for internal and external funding. Furthermore, the empirical studies, systematic reviews, and meta-analyses included in our review present data that can inform future research. For example, Balkin et al. (2019) and Veach et al. (2018) concluded contrasting results about IC in reducing substance abuse behaviors. Future research studies can continue researching substance misuse within IC settings to better understand evidence-based approaches to treat these populations. Twenty-one articles included recommendations for continued research at the client or consumer level, specifically for clients from marginalized communities. Counseling scholars are encouraged to stay up to date with program evaluation scholarship and implement a variety of methodical procedures to document the impact of IC on clients. Lastly, counseling scholars must advocate for continued IC literature publication within counseling and counselor education journals.


Our scoping review identified IC literature within counseling journals. Specifically, this review followed PRISMA-ScR protocols (Tricco et al., 2018) and identified 27 articles across 10 unique counseling journals. Most articles were within national flagship journals (such as those of ACA and AMHCA) and publication years ranged from 2004–2023. The articles in this review were organized according to their classification, and were described as either conceptual, empirical, or meta-analyses and systematic reviews. Implications for CITs, counselors, and clients were represented across each classification. Overall, IC implications from each article were positive for training and practice perceptions for CITs and counselors, as well as clinical outcomes for clients. Moving forward, authors unanimously encouraged counselor educators and counseling scholars to continue studying IC. Future scholarship would benefit from a deeper understanding of client-level implications, with an emphasis on how IC can benefit marginalized communities.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



Note. Studies with an asterisk (*) are included in the scoping review.

*Agaskar, V. R., Lin, Y.-W. D., & Wambu, G. W. (2021). Outcomes of “integrated behavioral health” training: A pilot study. International Journal for the Advancement of Counselling, 43, 386–405.

*Aitken, J. B., & Curtis, R. (2004). Integrated health care: Improving client care while providing opportunities for mental health counselors. Journal of Mental Health Counseling, 26(4), 321–331.

*Alvarez, K., Marroquin, Y., Sandoval, L., & Carlson, C. (2014). Integrated health care best practices and culturally and linguistically competent care: Practitioner perspectives. Journal of Mental Health Counseling, 36(2), 99–114.

*Balkin, R. S., Lenz, A. S., Dell’Aquila, J., Gregory, H. M., Rines, M. N., & Swinford, K. E. (2019). Meta-analysis of integrated primary and behavioral health care interventions for treating substance use among adults. Journal of Addictions & Offender Counseling, 40(2), 84–95.

Basu, S., Landon, B. E., Williams, J. W., Jr., Bitton, A., Song, Z., & Phillips, R. S. (2017). Behavioral health integration into primary care: A microsimulation of financial implications for practices. Journal of General Internal Medicine, 32(12), 1330–1341.

*Brubaker, M. D., & La Guardia, A. C. (2020). Mixed-design training outcomes for fellows serving at-risk youth within integrated care settings. Journal of Counseling & Development, 98(4), 446–457.

Council for Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards.

Council for Accreditation of Counseling and Related Educational Programs. (2022). 2024 CACREP standards, draft three.

*Crowe, A., Mullen, P. R., & Littlewood, K. (2018). Self-stigma, mental health literacy, and health outcomes in integrated care. Journal of Counseling & Development, 96(3), 267–277.

Farrell, M. H., Kuruvilla, P., Eskra, K. L., Christopher, S. A., & Brienza, R. S. (2009). A method to quantify and compare clinicians’ assessments of patient understanding during counseling of standardized patients. Patient Education and Counseling, 77(1), 128–135.

​​Fields, A. M., Linich, K., Thompson, C. M., Saunders, M., Gonzales, S. K., & Limberg, D. (2023). A systematic review of training strategies to prepare counselors for integrated primary and behavioral healthcare. Counseling Outcome Research and Evaluation, 14(1), 1–14.

Gerrity, M. (2016). Evolving models of behavioral health integration: Evidence update 2010–2015. Milbank Memorial Fund.

Giese, A. A., & Waugh, M. (2017). Conceptual framework for integrated care: Multiple models to achieve integrated aims. In R. E. Feinstein, J. V. Connelly, & M. S. Feinstein (Eds.), Integrating behavioral health and primary care (pp. 3–16). Oxford University Press.

*Glueck, B. P. (2015). Roles, attitudes, and training needs of behavioral health clinicians in integrated primary care. Journal of Mental Health Counseling, 37(2), 175–188.

Hays, P. A. (1996). Addressing the complexities of culture and gender in counseling. Journal of Counseling & Development, 74(4), 332–338.

Health Resources and Services Administration. (2022). Health professions training programs.

Heath, B., Wise-Romero, P., & Reynolds, K. A. (2013). Standard framework for levels of integrated healthcare. SAMHSA-HRSA Center for Integrated Health Solutions.

*Jacobson, T., & Hatchett, G. (2014). Counseling chemically dependent chronic pain patients in an integrated care setting. Journal of Addictions & Offender Counseling, 35(1), 57–61.

*Johnson, K. F., Blake, J., & Ramsey, H. E. (2021). Professional counselors’ experiences on interprofessional teams in hospital settings. Journal of Counseling & Development, 99(4), 406–417.

*Johnson, K. F., & Freeman, K. L. (2014). Integrating interprofessional education and collaboration competencies (IPEC) into mental health counselor education. Journal of Mental Health Counseling, 36(4), 328–344.

*Johnson, K. F., Haney, T., & Rutledge, C. (2015). Educating counselors to practice interprofessionally through creative classroom experiences. Journal of Creativity in Mental Health, 10(4), 488–506.

*Johnson, K. F., & Mahan, L. B. (2020). Interprofessional collaboration and telehealth: Useful strategies for family counselors in rural and underserved areas. The Family Journal, 28(3), 215–224.

*Kohn-Wood, L., & Hooper, L. (2014). Cultural competency, culturally tailored care, and the primary care setting: Possible solutions to reduce racial/ethnic disparities in mental health care. Journal of Mental Health Counseling, 36(2), 173–188.

Kolbasovsky, A. (2008). A therapist’s guide to understanding common medical conditions: Addressing a client’s mental and physical health. W. W. Norton.

*Lenz, A. S., Dell’Aquila, J., & Balkin, R. S. (2018). Effectiveness of integrated primary and behavioral healthcare. Journal of Mental Health Counseling40(3), 249–265.

*Lenz, A. S., & Watson, J. C. (2023). A mixed methods evaluation of an integrated primary and behavioral health training program for counseling students. Counseling Outcome Research and Evaluation, 14(1), 28–42.

*Lloyd-Hazlett, J., Knight, C., Ogbeide, S., Trepal, H., & Blessing, N. (2020). Strengthening the behavioral health workforce: Spotlight on PITCH. The Professional Counselor, 10(3), 306–317.

McCall, M. H., Wester, K. L., Bray, J. W., Hanchate, A. D., Veach, L. J., Smart, B. D., & Wachter Morris, C. (2022). SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs. Journal of Substance Abuse Treatment, 132, 108510.

*Moe, J., Johnson, K., Park, K., & Finnerty, P. (2018). Integrated behavioral health and counseling gender and sexual minority populations. Journal of LGBT Issues in Counseling, 12(4), 215–229.

Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 18(1), 1–7.

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Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips, R. L., Jr. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, & Health, 32(2), 157–166.

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.

*Regal, R. A., Wheeler, N. J., Daire, A. P., & Spears, N. (2020). Childhood sexual abuse survivors undergoing cancer treatment: A case for trauma-informed integrated care. Journal of Mental Health Counseling, 42(1), 15–31.

*Schmit, M. K., Watson, J. C., & Fernandez, M. A. (2018). Examining the effectiveness of integrated behavioral and primary health care treatment. Journal of Counseling & Development, 96(1), 3–14.

*Sheesley, A. P. (2016). Counselors within the chronic care model: Supporting weight management. Journal of Counseling & Development, 94(2), 234–245.

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Appendix A

Conceptual Articles

Author(s) Population(s) of Interest Research Gap Identified Implications and Future Directions
Aitken & Curtis, 2004 Counselor educators
and counselors
Lack of IC literature in counselor education journals Increased training for counselors to work competently in IC. Increased advocacy efforts to be on insurance panels. Build relationships with other health care professionals. More literature is needed in counselor education journals.
Jacobson & Hatchett, 2014 Clients who are chemically dependent with chronic pain Lack of literature for clients who are chemically dependent with chronic pain Clients that have co-occurring chemical dependence and chronic pain have reported benefits when their symptoms are treated by mental and physical health providers. Additional research is needed to understand treatment strategy effectiveness.
Johnson & Freeman, 2014 Health care undergraduate and graduate students (including CITs)
learning IC strategies
Lack of literature documenting IC training across multiple disciplines, specifically including CITs Provides a framework for IC training across multiple disciplines in accordance with SAMHSA IC competency standards. Additional research is needed to understand the effectiveness for each discipline and as a whole.
Johnson & Mahan, 2020 Family counselors
in rural and
underserved areas
Family counselors leading connection between rural families and other providers
of health care services
Emphasis on interprofessional collaboration (IPC) and use of telehealth options where family counselors use systemic training to advocate for rural, marginalized families, as well as network and connect families to health care providers when family members have unmet medical health needs or need specialized mental health care treatment. Additional research is needed to understand this phenomenon.
Kohn-Wood & Hooper, 2014 Mental health professionals working
in primary care settings
How culturally tailoring evidence-based treatment models can reduce mental health disparities Cultural tailoring of treatments should be a primary factor that is evaluated in future research studies. Future researchers should consult existing literature on culturally tailoring treatment to increase engagement and improve outcomes for diverse groups.
Lloyd-Hazlett et al., 2020 CITs Need for a replicable model
to train CITs in IC
The Program for the Integrated Training of Counselors in Behavioral Health (PITCH) model creates community partnerships, introduces CITs to applications of IC, and awards CITs a graduate certificate. Additional research is needed to demonstrate sustainability.
Moe et al., 2018 LGBTQ+ clients Lack of LGBTQ+ literature pertaining to IC CITs, counselors, and other health care professionals working with LGBTQ clients may benefit from additional training and supervision in collaborative care and IC. Additional research is needed to understand the impact IC has with the LGBTQ+ population.
Regal et al., 2020 Clients with cancer who are survivors of childhood sexual abuse Lack of trauma-informed
care literature pertaining
to IC, specifically for individuals with adverse childhood experiences (ACEs)
IC offers opportunities for appropriate assessments to identify ACEs for holistic care, as represented in the case study. Additional research is needed to understand universal screening for ACEs and the integration of trauma-informed practices within traditional primary care settings.
Sheesley, 2016 Counselor educators, counselors, and primary care settings Elaborate on the role of mental health counselors within the Chronic Care Model (CCM) Counselors influencing the future of obesity treatment within the CCM. Additional research is needed to understand evidence-based practices for counselors within the CCM for the treatment of obesity.
Tucker et al., 2008 An international student’s experience receiving IC on a college campus The effect of an IC program and mindfulness-based cognitive therapy (MCBT) approach As reported by the multidisciplinary team, clients using medication and individual and group therapy improved from the first time they had met. The authors emphasized the use of MCBT in treatment. Additional research is needed for IC on college campuses.
Vogel et al., 2014 Counselors considering IPC Access issues, adherence, and the effectiveness of IPC with particular attention to culturally diverse groups Increased training in evidence-based culturally tailored practices. Increased education for counselors regarding IPC to help determine if primary care is a good fit. Additional research is needed on various aspects of successful IPC execution.


Appendix B

Empirical Articles

Author(s) Methodology N and
Research of Interest Results
et al., 2021
Mixed methods; quantitative: single-group design; qualitative: thematic analysis 12 CITs The effect of an IPC and evidence-based practices curriculum to enhance students’ ability to work with at-risk youth in IC settings CITs reported an increase in multicultural competence and ability to work on IC teams, utilize evidence-based practices, and implement suicide interventions.
et al., 2014
Qualitative; exploratory
cross-case synthesis
8 service providers in an IC setting The experiences of IC service providers working with culturally and linguistically diverse populations Three themes emerged: (a) patient-centered care benefits underserved populations, (b) desirability of a multidisciplinary team, and
(c) importance of the organization to change with circumstances.
Brubaker & La Guardia, 2020 Quantitative;
single case and quasi-experimental
11 CITs The effect of an IC training intervention, Serving At-Risk Youth Fellowship Experience for Counselors (SAFE-C) CITs reported an increase in understanding professional identity, self-efficacy, and interprofessional socialization.
et al., 2017
Cross-sectional survey design
102 clients from an IC medical facility To examine the relationship between mental health self-stigmas, mental health literacy, and health care outcomes Self-stigma of mental illness and self-stigma of seeking help had an inverse relationship with mental health literacy.
Glueck 2015 Qualitative; phenomenological 10 mental health professionals working in IC settings Roles and attitudes of mental health professionals working in IC and perceived training needs Mental health professionals reported that they were involved in brief interventions and assessments, administrative work, and consultation and that additional graduate training is needed in classroom and field experiences.
et al., 2015
Mixed methods; qualitative: the pre- and post-survey design; qualitative: thematic analysis 22 CITs, as well as dental hygiene, nursing, and
physical therapy students
CITs’ attitudes toward interprofessional learning and collaboration following an interdisciplinary course on IPC Perceptions about learning together and collaboration improved, negative professional identity scores decreased, and higher reports of positive professional identity.
et al., 2021
Qualitative; phenomenology 11 counselors in hospital setting Experiences of counselors working on interprofessional teams (IPTs) in a hospital setting Four themes emerged:
(a) counselors rely on common factors and foundational principles; (b) counselors must have interprofessional supervision; (c) counselors must remember their scope of practice; and (d) counselors must adhere to ethical codes and advocacy standards.
Lenz & Watson, 2023 Mixed-methods; quantitative: non-experimental pre- and post-test; qualitative: thematic analysis 45 CITs The impact an IC training program has on CITs’ self-efficacy, interprofessional socialization, and multicultural competence, as well as barriers to student growth Increase in self-efficacy, interprofessional socialization, and aspects of multicultural competence. Most reported barriers were IC awareness and organizational constraints.
et al., 2018
196 clients; 98 received IC and 98 received treatment as usual (TAU) The effect of IC for individuals with severe mental illness compared
to TAU
Group that received the IC intervention demonstrated an improvement in overall functioning, including a
decrease in crisis events.
Ulupinar et al., 2021 Quantitative;
1,747 clients and 10 counselors To examine the therapeutic outcomes and client dropout rates of adults experiencing mental disorders in an IC center The addition of counselors resulted in a decrease in client symptom reports.
et al., 2018
Quantitative; pre- and post-test survey 333 clients in a trauma-based IC center A brief IC counseling intervention for risky alcohol behavior The IC counseling intervention resulted in reduced risky alcohol behaviors.
et al., 2018
Qualitative; phenomenological inquiry 13 graduate students; five CITs  and eight speech– language pathologists The effect of interprofessional education (IPE) on the development of collaborative practice for both CITs and speech– language pathologists-in-training Five themes emerged:

(a) benefits of IPE,
(b) expectations of collaborative practice, (c) benefits of experienced IC providers,
(d) challenges of IC practice, and
(e) optimization of IC practice.

et al., 2020
cross-sectional survey design
155 undergraduate students studying psychology and aspects of counseling How factors related to prevention and wellness relate to topics that counselors are adept at addressing, such as optimism, social support, and resilience Results indicated that health anxiety was positively correlated with fear of cancer, but that psychosocial variables either had no relationship or were not significant moderators between health anxiety and fear of cancer.


Appendix C

Meta-Analyses and Systematic Reviews

Author(s) Article Classification Population of Interest Number
of Included Studies and Participants
Results and Implications
et al., 2019
Meta-analysis Adults with substance use disorders 8 studies with 1,545 participants;
722 received IC and 823
received alternative
Effects of IC were small with this sample (i.e., small effect in decrease in substance use).
Authors recommended additional research to understand substance use disorders within an IC context and variables beyond use of substances.
et al., 2023
Systematic review Mental health professionals and mental health professionals-in-training receiving education on IC 18 studies Four themes emerged:
(a) HRSA-funded studies,
(b) trainee skill development, (c) enhancement of
self-efficacy, and
(d) increased understanding of interprofessional collaboration. Authors recommended more studies focusing on client-level data and more multicultural competencies.
et al., 2018
Meta-analysis Individuals receiving mental health care in traditional primary care settings 36 studies with 14,764 participants Effects of IC, as compared to alternative treatments, resulted in a decrease in mental health symptoms. A greater effect is shown with a larger treatment team and number of behavioral health sessions.


Alexander M. Fields, PhD, is an assistant professor at the University of Nebraska at Omaha. Cara M. Thompson, PhD, is an assistant professor at the University of North Carolina at Pembroke. Kara M. Schneider, MS, is a doctoral candidate at the University of South Carolina. Lucas M. Perez, MA, is a doctoral candidate at the University of South Carolina. Kaitlyn Reaves, BS, is a doctoral student at Adler University. Kathryn Linich, PhD, is a clinical assistant professor at Duquesne University. Dodie Limberg, PhD, is an associate professor at the University of South Carolina. Correspondence may be addressed to Alexander M. Fields, University of Nebraska at Omaha, College of Education, Health, and Human Services, Department of Counseling, Omaha, NE 68182,

Strengthening the Behavioral Health Workforce: Spotlight on PITCH

Jessica Lloyd-Hazlett, Cory Knight, Stacy Ogbeide, Heather Trepal, Noel Blessing

The coordination of primary and behavioral health care that holistically targets clients’ physical and mental needs is known as integrated care. Primary care is increasingly becoming a de facto mental health system because of behavioral health care shortages and patient preferences. Primary care behavioral health (PCBH) is a gold standard model used to assist in the integration process. Although counselor training addresses some aspects of integrated care, best practices for counselor education and supervision within the PCBH framework are underdeveloped. This article provides an overview of the Program for the Integrated Training of Counselors in Behavioral Health (PITCH). The authors discuss challenges in implementation; solutions; and implications for counselor training, clinical practice, and behavioral health workforce development.

Keywords: integrated care, primary care, counselor training, PITCH, behavioral health workforce development

In 2016, 18.3% of adults were diagnosed with a mental illness and 4.2% of adults were diagnosed with a serious mental illness (SMI; Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Of those with a mental illness, only 41% received mental health services, leaving more than half unserved (SAMHSA, 2015). Many of these untreated adults turn to their primary care provider (PCP) for help and report preference for behavioral health services within primary care (Ogbeide et al., 2018). In fact, data show that primary care has become the de facto mental health system in the United States (Robinson & Reiter, 2016).

Although PCPs attempt to provide pharmacological interventions and appropriate behavioral health referrals, patients often return still experiencing distress because they are unable to follow through on referrals (Cunningham, 2009; Robinson & Reiter, 2016). On average, this circular process results in substantially longer medical visits (e.g., 20 minutes versus 8 minutes) and fewer billable services (e.g., one versus five or more; Meadows et al., 2011). This also results in a significant increase in health care spending, with patients incurring 30%–40% higher costs because of the presence of a mental health condition (de Oliveira et al., 2016; Wammes et al., 2018). There is a need for professionals trained in behavioral health care working within the primary care setting (Serrano et al., 2018).

Counselor training addresses some aspects of the role of behavioral health professionals in primary care. The most recent version of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) entry-level program standards mandates that all accredited programs, regardless of specialty, orient counseling students to “the multiple professional roles and functions of counselors across specialty areas, and their relationships with human service and integrated behavioral health care systems, including interagency and interorganizational collaboration and consultation” (CACREP, 2016, Standard F.1.b.). As patients’ needs and training mandates increase, there is a demand for counselor training programs to respond with models and practices for counselor training in behavioral health in primary care settings.

The Program for the Integrated Training of Counselors in Behavioral Health (PITCH) is a 4-year project sponsored by a Health Resources and Services Administration (HRSA) Behavioral Health Workforce Education and Training (BHWET) grant received by the Department of Counseling at the University of Texas at San Antonio. The purpose of this article is to describe this innovative program. Toward this end, we briefly outline the Primary Care Behavioral Health (PCBH) consultation model undergirding PITCH. Next, we describe the need for behavioral health integration in primary care settings. Then, we delineate our implementation of PITCH to date, including specialized field placements, training curriculum, and program evaluation methodologies. Following, we discuss challenges and resolutions gleaned from the first 1.5 years of implementation. Finally, we explore implications for counselor education to further enhance counselor preparation and engagement in behavioral health care delivery in primary care settings.

Primary Care Behavioral Health
The coordination of primary and behavioral health care that holistically targets clients’ physical and mental needs is known as integrated care (SAMHSA, 2015). One model used to assist in the integration process is the PCBH consultation model—a team-based and psychologically informed population health approach used to address physical and behavioral health concerns that arise in the primary care setting (Reiter et al., 2018). A hallmark of the PCBH model is integration of behavioral health consultants (BHCs), who dually function as generalist clinicians and as consultants to the primary care team (Serrano et al., 2018).

A BHC is different than a traditional counselor. In fulfilling their roles and functions, a BHC:

Assists in the care of patients of any age and with any health condition (Generalist); strives to intervene with all patients on the day they are referred (Accessible); shares clinic space and resources and assists the team in various ways (Team-based); engages with a large percentage of the clinic population (High volume); helps improve the team’s biopsychosocial assessment and interventions skills and processes (Educator); and is a routine part of psychosocial care (Routine). (Reiter et al., 2018, p. 112)

BHCs conduct brief functional assessments, collaborate with patients on treatment goals, implement evidence-based treatment interventions, and provide PCPs with feedback and recommendations for future patient care and support (Hunter et al., 2018). In addition, BHCs see patients for approximately 15–30-minute visits, with an average range between two and six visits per episode of care (Ray-Sannerud et al., 2012). In many ways, the BHC role involves a new professional identity for mental health professionals (Serrano et al., 2018). To date, BHC training and employment has typically involved social workers and psychologists. However, the counseling profession is increasingly recognized and engaged in integrated PCBH (HRSA, 2017).

Need for Integrated Services
Primary care settings must begin to consider behavioral health integration in order to increase the quality of life of their patients. Over recent years, there has been a significant increase in patients who receive psychotropic medication for mental health complaints in the primary care setting (Olfson et al., 2014). PCPs are managing increasingly complex diagnoses beyond anxiety and depression. These include bipolar, disruptive, and other comorbid disorders (Olfson et al., 2014). Individuals diagnosed with an SMI such as these also show a high prevalence of chronic health conditions, including diabetes and cardiovascular disease. Untreated psychological symptoms can often present themselves in somatic forms and can have a strong impact on chronic health conditions (McGough et al., 2016). People with SMIs prefer behavioral health services from their PCP; however, treatment outcomes for those with SMIs that seek services from their PCP are generally of lesser quality (Viron & Stern, 2010). Patient, provider, and systemic-level factors influence this phenomenon. Relevant factors may include impacts of patients’ mental health diagnoses on treatment adherence, misdiagnosis from PCPs, and minimal collaboration between medical and behavioral health providers (Viron & Stern, 2010).

The PITCH program addresses several critical needs of individuals seeking behavioral health services in the local community, where conditions that necessitate behavioral health services, including mental illness and substance use disorders, are common. In a focus group run in 2011 with members of the community, the group identified mental health as a key concern (Health Collaborative, 2013). Although mental health services were offered in a psychiatric facility for children, adolescents, and adults, members of the focus group reported that the demand for mental health providers and psychiatric beds exceeded the supply. The stigma associated with mental health also was seen as a barrier to care. As a result, many people go undiagnosed and untreated (SAMHSA, 2015).

PITCH also addresses the need for interdisciplinary approaches to behavioral health workforce development. The expansion of PCBH consultation services amplified this need (Robinson & Reiter, 2016). Unlike other models of integrated care (i.e., Collaborative Care Model, Chronic Care Model), the PCBH model makes available primary care–focused behavioral health services across an entire clinic population and across all possible patient presentations. This model also requires a skilled mental health professional adept at a variety of patient presentations and able to manage processes like clinic flow and a new role as consultant—skills and roles not commonly present in training for specialty mental health services (Robinson & Reiter, 2016).

PITCH: An Overview

PITCH is housed within a CACREP-accredited master’s-level clinical mental health counseling (CMHC) program enrolling more than 100 students each year. The principal investigator (PI) of PITCH is a professor specializing in clinical supervision, bilingual counselor education, and professional advocacy. Other PITCH team members include an assistant professor (Co-PI, university liaison) specializing in family counseling, program evaluation, and ethics; an assistant professor and board-certified clinical health psychologist (consultant); and an external project evaluator.

The primary purpose of PITCH is to develop a highly trained workforce of professional counselors to provide integrated behavioral health care (IBH) to rural, vulnerable, and underserved communities in primary care. Sub-goals of the PITCH program include establishing meaningful, longitudinal interdisciplinary partnerships as well as a graduate-level certificate in IBH to support sustainability. Toward this, 12 advanced counseling students enrolled in the aforementioned CMHC program are selected to participate each year from a competitive application pool. Selected trainees are required to complete two specialized IBH courses and two 300-hour clinical rotations in designated primary care settings. In exchange, trainees receive a $5,000 stipend upon completion of each semester rotation. Additionally, PITCH staff coordinate quarterly interprofessional trainings, including workshops focused on primary care, behavioral health, supervision, funding, and policy.

Specialized Field Placements
A unique feature of the PITCH program is the development of specialized field placement sites. Other behavioral health integration projects have relied on existing clinical placement sites (Sampson, 2017). Often these sites have low levels of existing integration, as well as underdeveloped infrastructure to support behavioral health delivery in primary care. When existing clinical site placements do have some integrated services, they are most often co-located services (Peek & the National Integration Academy Council, 2013). Instead of field site development, previous efforts have emphasized student training through workshops (Canada et al., 2018). These workshops are often open to community members. Individuals are then charged to bring knowledge back to extant clinical sites. Although this offers some positive benefits, it may not be as impactful. Further, this approach may fall short of establishing infrastructure to support longitudinal changes (Serrano et al., 2018).

To start development of specialized field placements, we identified potential sites interested in IBH delivery. We then set up initial meetings with sites to discuss the PITCH project and to determine the feasibility of placing a BHC trainee. If sites were amenable, we scheduled a series of follow-up visits to provide orientation to clinic staff on IBH, the PCBH model, and the role and scope of BHCs. During these visits, we also provided consultation on infrastructure components, such as electronic medical record documentation procedures, suggestions for clinic flow, and room spacing (Robinson & Reiter, 2016). Throughout the field placement, we remained active in checking with sites to make workflow adjustments as needed. Trainees complete certificate-based coursework prior to beginning field placements as well as during the clinical rotations.

Trainee Curriculum
Selected trainees are required to complete two specialized courses in IBH, as well as two 300-hour clinical rotations at one of the specialized field placement sites discussed above. The PCBH model scaffolds all aspects of the PITCH training and delivery. We utilize this model to support conceptualization of the BHC role in primary care settings, interventions, and supervision.

As part of the PITCH program, two didactic courses were created to provide training in IBH and PCBH. The courses were developed and instructed by the PITCH IBH consultant. The first course, IBH-I, introduces students to the primary care setting (e.g., family medicine, pediatrics, geriatrics), the PCBH model of care, behavioral health consultation, health behavior change, and common mental and chronic health conditions encountered in primary care, and offers a basic understanding of brief, cognitive-behavioral–based and solution-focused interventions used in primary care (Reiter et al., 2018; Robinson & Reiter, 2016).

Students must complete the following assignments in the course: two exams, an IBH journal article review, a primary care clinic tour, an interview with a PCP, a presentation on one commonly seen problem in primary care (e.g., insomnia, chronic pain, depression), and a term paper highlighting treatment on a common problem in primary care using the 5A’s model (Hunter & Goodie, 2010). The 5A’s is a behavioral change model that includes assessing, advising, agreeing, assisting, and arranging. Upon demonstrating satisfactory performance, students may enroll in IBH-II.

The primary purpose of the second course is to begin applying foundational knowledge of PCBH as well as practice functional and contextual assessment and cognitive-behavioral intervention skills in the primary care setting. Trainees demonstrate their skills through a series of in-class role-plays, leading up to a final evaluation of their performance in a 30-minute initial consultation visit with a standardized patient. Trainees must complete both courses to maintain their status in PITCH. Both courses are open as electives to students enrolled in the counseling program or a related discipline (e.g., social work).

PITCH trainees also complete two semester-long clinical rotations in primary care. Trainees are assigned to one of the specialized field placement sites based on availability, interest, and anticipated fit. Trainees are required to clock 300 hours each semester, 120 of which must represent direct clinical engagement. Direct clinical engagement time includes patient visits, consultation with the primary care team, and facilitating psychoeducational groups tailored to unique clinical populations. Trainees are required to participate in at least 1 hour of clinical supervision with an on-site supervisor each week. Additionally, trainees attend a bi-weekly group supervision course on campus instructed by a CMHC faculty member. After successful completion of didactic and clinical courses of the PITCH program, trainees are eligible to earn a graduate certificate in IBH. Adjustments to specialized field placement sites and the trainee curriculum are made as needed based on ongoing informal and formal evaluation of the program.

Program Evaluation
The HRSA BHWET grant supporting PITCH prioritizes evaluation activities related to workforce training and development effectiveness (HRSA, 2017). In partnership with our external evaluator, we are conducting program evaluation across several domains of PITCH, including evaluations focused on trainees and clinical sites (e.g., level of integration).

Trainee-Focused Metrics
We have several evaluation metrics that are focused on trainees. Trainees complete the Behavioral Health Consultant Core Competency Tool (BHC CC Tool; Robinson & Reiter, 2016) and the Primary Care Brief Intervention Competency Assessment Tool (BI-CAT; Robinson, 2015) at the beginning, midpoint, and conclusion of clinical rotations. The BHC CC Tool measures and tracks skill development across four domains of BHC practice: clinical practice, practice management, consultation, and documentation. The BI-CAT includes domains of practice context, intervention design, intervention delivery, and outcomes-based practice. On-site observations of trainees also are conducted using the PCBH Observation Tool as part of the certificate coursework. These competency tools were developed based on observations of BHC clinical behaviors likely to work effectively in a PCBH model of service delivery. These measures have not yet been formally assessed for psychometric properties or predictive outcomes (Robinson et al., 2018).

In addition to tools that target individual trainee development, program evaluation efforts also attend to the macro experiences of trainees in the program. Specifically, trainees participate in focus groups facilitated by the external evaluator at the end of each semester. Focus groups provide the opportunity to understand pathways and barriers to program development. We also have developed an online database to track trainees’ postgraduation employment trajectories and sustained engagement in PCBH.

Site-Focused Metrics
Although this particular HRSA grant is primarily concerned with trainee-focused outcomes (e.g., employment), we also ask identified clinical site liaisons to complete the Integrated Practice Assessment Tool (IPAT; Waxmonsky et al., 2013) at the start and finish of each rotation. Scores on the IPAT provide a snapshot estimation of the level of integration of clinical sites. Levels of integration correspond to those identified by A Standard Framework for Levels of Integrated Healthcare (Heath et al., 2013) and range from 1–6. Levels 1 and 2 are indicative of minimal, coordinated collaboration, with behavioral health and PCPs maintaining separate facilities and systems. Levels 3 and 4 reflect shared physical space and enhanced communication among behavioral health and PCPs; however, practice change toward system-level integration is underdeveloped. Finally, Levels 5 and 6 are indicative of transformed, team-based approaches in which both “providers and patients view the operation as a single health system treating the whole person” (Heath et al., 2013, p. 6). Focus groups also were conducted with members of selected clinical training sites to explore barriers and pathways to PCBH delivery as a function of level of integration. At this time, the IPAT has not yet been formally assessed for psychometric properties.

Rapid Cycle Quality Improvement
Finally, program evaluation efforts include ongoing rapid cycle quality improvement (RCQI), a quality-improvement method that identifies, implements, and measures changes to improve a process or a system (Center for Health Workforce Studies, 2016). RCQI can be targeted at different aspects of the program. To date, RCQI has targeted trainee competencies related to functional assessment interviews, breadth of referrals concerns, and patient visit length. For example, after tracking trends in daily activity logs submitted by trainees, we noted a majority of referrals centered on anxiety and depression. We then provided supplemental training on identifying behavioral health concerns related to chronic health conditions, such as diabetes and asthma. Following this instruction, we reviewed the daily activity logs and noted greater breadth of referral concerns.

Challenges and Solutions

Best practices for PCBH implementation within the context of workforce development are still developing. Further, available guidelines do not speak to counselor training programs specifically. In the section below, we discuss challenges we have encountered in the first 1.5 years of implementation of the PITCH program. We also share solutions we have generated to support optimal training experiences.

Challenge: On-Site Clinical Supervision
A significant challenge we encountered was related to on-site clinical supervision for the PITCH trainees. National accreditation standards require trainees to participate in regular supervision with both an on-site and university supervisor (CACREP, 2016). The on-site supervisor must have at least 2 years of postgraduate experience, as well as hold a master’s degree in counseling or a related field (e.g., psychology, social work). Furthermore, best practices for BHC training support a scaffolded supervision approach (Dobmeyer et al., 2003), wherein trainees’ initial time is spent completing 360 clinic shadowing visits with an experienced BHC. As trainee skills develop, leadership within patient visits transitions from co-visits to visits. In time, the trainee leads the visits, with an experienced BHC in independent practice shadowing. Additionally, the PCBH model emphasizes preceptor-style supervision, where the supervisor is readily available on-site for patient consultation as needed (Dobmeyer et al., 2003).

Solution: Changes to Specialized Field Placement Sites
During Year 1 of PITCH, almost two thirds of the specialized field placement sites we partnered with did not employ the PCBH model at the time, and thus did not have a BHC available to provide on-site clinical supervision. To meet this need, we provided intensive PCBH and supervision training to four doctoral students enrolled in our counselor education and supervision program. Doctoral student supervisors were asked to spend at least half a day on-site with trainees with this amount tapering off with time and experience.

Although this solution met national accreditation requirements for supervision (CACREP, 2016), we noticed stark differences between the clinical experiences of trainees placed at field sites with an on-site BHC versus doctoral student supervisors. As such, we made the difficult decision in Year 2 to separate from all but two field placement sites that lacked an on-site BHC to provide supervision. The inclusion of a BHC to supervise became a requirement for all the new sites we partnered with in Year 2. Additionally, we made modifications to our grant funding allocations to support graduate assistantships focused on supervision for two of the four doctoral supervisors utilized in Year 1.

Challenge: Knowledge About PCBH and the BHC Role
We encountered internal and external gaps in knowledge about the PCBH model, the BHC role, and the general culture of primary care settings. Internally, members of our faculty less connected to PITCH expressed support but also concern about alignment of PITCH training experiences and the experiences of other counseling students. Specific points of concern related to the brevity of visits, frequency of single encounters with patients, and the underpinning medical model. Additionally, because of patient privacy restrictions, PITCH field placement sites do not permit audio or video recording of clinical work, which is a typical supervision practice for counseling trainees. PITCH trainees also expressed some tension between the professional identity and skills training obtained in the CMHC program to date with the PCBH model and BHC role. Externally, we observed varying degrees of provider knowledge and buy-in about the PCBH approach to integrated practice. Areas of provider disconnect were more prominent at placement sites without existing integrated primary care services.

Solution: Ongoing Education and Advocacy
At the internal level, we provided a brief educational session about the PCBH model at regular faculty meetings. It was important to emphasize PCBH as a different context of practice that, similar to school counseling, requires modes of practice outside of traditional 50-minute sessions. We also sought faculty consultation related to curriculum and structure for our specialized coursework. For example, faculty members expressed concern about missing opportunities for recorded patient visits, so we developed two assignments for the clinical courses that could meet this need. The first was a mock visit with a classmate that was video recorded and transcribed. Students then analyzed micro-skills and reflected. The second assignment consisted of a live observation by the university- or site-based supervisors of the trainee’s work on-site with a patient.

We also encountered various levels of provider buy-in at our different sites. We encouraged students to reframe this resistance as an opportunity for learning and advocacy. As students gained knowledge about what we call the primary care way, students could better contextualize the questions or concerns of providers. For example, students could understand the premiums placed on time and space. From this position, students could tailor their approach to PCPs to enhance the PCP workflow. Additionally, faculty and supervisors emphasized the importance of ongoing psychoeducation about the PCBH model to their teams. Students are encouraged to be proactive in reviewing daily patient schedules for prospective services (i.e., scrubbing the schedule) and educating providers about how BHC services can augment patient care. The use of the BHC competency tools also facilitated this process, which encouraged students to consistently engage in behaviors conducive to BHC practice.

Challenge: Shortage of Spanish-Speaking Service Providers
A final challenge we faced related to a shortage of Spanish-speaking service providers. Some sites offered formal translation services (i.e., in-person medical translator, phone- or tablet-based translators), while others utilized informal resources (i.e., other staff members). When placing students, we prioritized placement of bilingual trainees at locations with the greatest number of Spanish-speaking patients. However, we were not able to accommodate all sites.

Solution: Recruitment and Resources
We have implemented several solutions to address this challenge. Among these, we have moved to weighing Spanish language fluency more heavily in PITCH selection criteria. We also are exploring future partnerships with the bilingual counseling certificate program that is housed in the University of Texas at San Antonio Department of Counseling. Additionally, we provide basic training and support to trainees related to the use of translators (in-person and virtual), and we have employed Spanish-speaking doctoral graduate assistant supervisors where possible for extra support.


The implementation of PITCH provides challenges but also solutions to the growing need for counselor education to focus on training in primary care. Patients prefer behavioral health services in primary care (Ogbeide et al., 2018). Thus, equipping the behavioral health workforce to provide services in this setting has proved to be imperative. Although primary care and interprofessional education is relatively new to counselor education, other behaviorally inclined disciplines (e.g., psychology, social work, nursing) have provided a training blueprint for counselor education programs to use and continue developing a place for themselves in primary care (Hooper, 2014; Vogel et al., 2014).

Serrano and colleagues (2018) shared recommendations for PCBH workforce development. These recommendations include: (a) development of an interprofessional certification body; (b) PCBH-specific curricula in graduate studies, including both skills and program development; (c) a national employment clearinghouse; and finally, (d) coalescing knowledge around provision of technical assistance sites. Below we discuss the implications of counselor education programs seeking to advance PCBH workforce development.

Standardized Training Models
An important implication for training future counselors is the use of standardized training models (Tang et al., 2004). Throughout this article, much of the focus has centered on the PCBH consultation model (Reiter et al., 2018). In recent years, training standards have emerged for BHCs in primary care. These standards focus on a psychologically informed, population-based approach to treatment, in which BHCs are trained to create clinical pathways, collaborate with medical providers, conduct a brief functional assessment, and provide a brief behavioral intervention, mostly consisting of skills training and self-management (Reiter et al., 2018)—all of which is done in under 30 minutes. This clinical practice approach has become the de facto model in most BHC preparation programs throughout the United States (Hunter et al., 2018) and is currently endorsed by the Veterans Administration and the Department of Defense for integrated primary care (Funderburk et al., 2013). However, inconsistencies exist in how the PCBH model is taught, and there is a lack of available internship opportunities for master’s-prepared behavioral health providers to receive clinical training (Hall et al., 2015). This challenge is especially relevant to future counselors, who lack a standardized model of training for primary care (Hooper, 2014). Our experience suggests that programs such as PITCH accomplish the joint goals of focusing on instruction and supervised practice in PCBH, developing BHC competencies, and meeting accreditation standards of orienting counselors to their role in integrated care settings (CACREP, 2016).

Behavioral Health Integration
One of the largest challenges facing the PCBH model is behavioral health integration (Hunter & Goodie, 2010). Moreover, the PCBH model requires full integration (e.g., Level 5–6 integration) to be maximally effective. Traditionally, PCPs would refer patients to a local mental health practitioner for issues related to depression or anxiety (Cunningham, 2009). However, these referrals would result in a low rate of success and deter many individuals from seeking out mental health services in the future (Davis et al., 2016). Co-located care (an in-house mental health practitioner conducting traditional psychotherapy or counseling) became the logical next step. This level of integration resulted in quicker referrals but led to poor communication and confidentiality issues between PCPs and mental health providers. This also left out other common, behaviorally influenced conditions in primary care such as diabetes, chronic pain, hypertension, and tobacco cessation (which are not routinely addressed or treated by mental health providers). Full integration (in which PCPs and mental health providers work collaboratively in the same setting) has become the ideal standard for the integration of behavioral health services in primary care (Heath et al., 2013).

Despite the many benefits, full integration might be impractical for clinics just beginning PCBH services. Clinics may not have the staff support, leadership support, and organizational buy-in to be successful because “successful integration is really hard” (deGruy, 2015). Integration, in a sense, causes a necessary disruption in how a clinic functions and serves patients. Although necessary, it is still a disruption and it can take time for a team to normalize their new way of practicing primary care. Clinics may need specific support to help establish pathways for behavioral health referrals (Landis et al., 2013), allow clinic staff more time to adjust to integrated services, and provide a pathway for the development of fully integrated services (Reiter et al., 2018). Investing in technical assistance experts can aid in integration efforts (Serrano et al., 2018). Additionally, clinics that already offer co-located services might benefit from a quality-improvement plan (Wagner et al., 2001) such as a plan-do-study-act model (PDSA; Speroff & O’Connor, 2004) to move to a higher level of integration. A sample PDSA cycle might consist of identifying barriers to improved patient care, creating a team-based plan for addressing barriers, designating a project overseer, tracking outcomes across time, and evaluating project success (Speroff & O’Connor, 2004). Both suggestions are great steps toward full integration and can be performed by counselors and counselor educators with training in PCBH and program evaluation (Newcomer et al., 2015). Funding for counselors in BHC roles would assist in meeting the aforementioned goals.

Funding for Counselors in PCBH
One of the greatest barriers to providing accessible behavioral health services in primary care is funding (Robinson & Reiter, 2016). Insurers are just beginning to reimburse for same-day services (both a PCP and BHC visit; Robinson & Reiter, 2016). However, this recent development has primarily benefited psychologists and social workers in primary care and excludes licensed counselors, who account for 14%–25% of the mental health labor force (U.S. Department of Health and Human Services, 2016). Licensed counselors are a crucial part of the growing behavioral health workforce (Vogel et al., 2014) and bring a strong wellness and systems-based perspective to primary care (Sheperis & Sheperis, 2015). Furthermore, licensed counselors, along with other behavioral health providers, can help in a variety of ways such as reducing patient costs in the medical system (Berwick et al., 2008), reducing patient emergency room visits (Kwan et al., 2015), and implementing continuous quality improvement (Wagner et al., 2001).

Robinson and Reiter (2016) offered several suggestions regarding funding for BHCs unable to conduct same-day billing. The first is for BHCs to understand that PCPs will always be the main source of clinic revenue. Therefore, BHCs can provide support to the primary care team through behavioral consultation; improve screening and clinical pathway procedures; provide support for difficult patients and frequent visitors; and reduce PCP visit time through warm handoffs, with the patient witnessing the transfer of their care between PCP and BHC. Second, BHCs can secure bottom-up support from PCPs by providing “curbside” consultation services (consulting face-to-face with PCPs about a patient without directly treating the patient). It comes as no surprise that PCPs feel more supported when BHCs are an available part of the medical team. Third, BHCs can generate top-down support through billing for group visits such as drop-in group medical appointments and 30-minute follow-up visits (Robinson & Reiter, 2016). Finally, grants represent another potential source of funding for behavioral health implementation (HRSA, 2017, 2018). HRSA and SAMHSA have been a tremendous resource in providing training grants specifically aimed at increasing the BHC workforce (e.g., HRSA, 2017) and addressing the nation’s opioid epidemic (e.g., HRSA, 2018). In Texas, the Hogg Foundation has provided training grants for training future BHCs. Finally, the counseling profession must continue advocacy efforts toward establishing licensed counselors as Medicare providers. With this key change, licensed counselors would be more readily employable in medical settings (Dormond & Afayee, 2016).


Primary care has been the de facto mental health system in the United States for decades. Providing comprehensive primary care to patients is imperative, and in order to do this well, our workforce needs to be equipped to meet the growing behavioral health needs where patients show up to receive care. Given clinical measures such as successful patient outcomes and CACREP accreditation standards targeting integrated health care knowledge, it behooves counselor training programs to consider developing models for BHC training. This article presents the key aspects of the PITCH program in the hopes that our model will be useful to other counselor education programs as the profession moves toward integrated practice models in order to meet the ever-changing needs of the health care landscape.

Conflict of Interest and Funding Disclosure
PITCH is funded by a Behavioral Health Workforce Education
and Training grant from the Health Resources and Services
Administration. There is no known conflict of interest.


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Jessica Lloyd-Hazlett, PhD, NCC, LPC, is an associate professor at the University of Texas at San Antonio. Cory Knight, MS, is a master’s student at the University of Texas at San Antonio. Stacy Ogbeide, PsyD, ABPP, is a behavioral health consultant, licensed psychologist, and associate professor at the University of Texas Health Sciences Center San Antonio. Heather Trepal, PhD, LPC-S, is a professor and coordinator of the Clinical Mental Health Counseling Program at the University of Texas at San Antonio. Noel Blessing, MS, is a doctoral student at the University of Texas at San Antonio. Correspondence may be addressed to Jessica Lloyd-Hazlett, 501 W. Cesar E. Chavez Blvd., DB 4.132, San Antonio, TX 78207,