Responding to Needs: Collaborations for Broad Impact




By Thomasine Heitkamp, LCSW
PI and Co-Director of the Mountain Plains ATTC and MHTTC


The Mountain Plains ATTC collaborated with the Mountain Plains MHTTC to create a shared product entitled Depression, Alcohol and Farm Stress: Addressing Co-Occurring Disorders in Rural America, [Co-occurring Disorders] April 2020 (M. Shogren, R. Landwehr, D. Terry, A. Moore and A. McLean). This blog discusses the rationale for product development, a brief description of the product, end-user comments, and collaborations with organizations, localities, and states. The topic of co-occurring disorders (substance use and mental health concerns) was identified as a significant training and technical assistance (TA) need in recent formal assessments conducted by the Region 8 ATTC and MHTTC shown below.


In response to this identified need, Region 8 offered training/TA activities and developed products related to treating co-occurring disorders. Given the rural and frontier nature of Region 8, the issue of treating co-occurring disorders requires an examination of this topic in the context of farming families and their communities. 


The Co-occurring Disorders product was produced to assist Region 8 behavioral health providers to improve and enhance their skills in treating co-occurring disorders. Users of this product are provided a fictitious case scenario that walks them through applications regarding use of screening tools (AUDIT-C, PHQ-2, PHQ-9, Health Leads, SIREN) to determine the needs of a farmer who is ultimately diagnosed with an alcohol use disorder and depression. The Co-occurring Disorders product also underscores the importance of family supports, referral to treatment, provider flexibility, and addressing compassion fatigue. The 66-page product includes evidence-based resources (81 references and 26 resources) and colorful photos to provide a narrative regarding screening and intervention related to co-occurring disorders.


“It was easy to understand, and one of the parts that I really liked was that we followed John through the entire process, from the initial start to the emergency room. I liked that because it was easy to see how it would work into a practice; the storyline and how it is incorporated into patient care and practice.”

“It reminds me that as a primary care provider, you might get a little numb to all the barriers that people are facing.”



Following publication and dissemination of the Co-occurring Disorders product, the Mountain Plains ATTC assessed end-user perceptions, including feedback by advanced practice nurses and APRN students who suggested incorporating this document into health career curricula, especially to prepare primary care providers. All feedback was positive, with a note regarding the informative nature of the product and the practical approach to assisting providers in expanding their capacity to address co-occurring disorders among farmers and rural residents. In less than three months, this product has served as the backdrop for additional training/TA activities provided by both the Region 8 ATTC and MHTTC. This includes:

  • Collaboration with Great Lakes MHTTC and the American Psychological Association to offer two trainings - (1) Approaching and Treating Co-Occurring Mental and Substance Use Disorders in Farming and Rural Communities and (2) Co-Occurring Mental and Substance Use Disorders in Farming and Rural Communities: Assessment, Ethics, and Preventing Compassion Fatigue;
  • Co-authoring a companion piece in June 2020 with Mountain Plains MHTTC and Mid-America ATTC and MHTTC, entitled Farm Stress Facts, Impact of Covid-19, Resources, and Training Needs of Mental Health Care Providers (S. Schroeder, T. Heitkamp, B. Clark, E. Holiday, A. Breigenzer, & S. Johnson);
  • A Mountain Plains ATTC Enhanced Professional Learning series that establishes a learning community to expand treatment capacities on co-occurring disorders.
The Co-occurring Disorders product has been accessed and marketed by multiple organizations, including the RHI hub, the National Rural Health Association, and the National Organization for State Offices of Rural Health, which provided a review in their monthly newsletters. Representatives of the United States Department of Agriculture (USDA) lead offices in the Region 8 states (CO, MT, ND, SD, UT, WY) have received the product and are critical collaborators in working on the topic of addressing farm stress through their numerous office locations. USDA has participated in past trainings and is more readily accessing TTC resources, given this collaboration. This effort reflected meaningful and ongoing collaborations among the TTCs and other behavioral health partners to increase awareness and enhance expertise on how co-occurring disorders are addressed in rural areas.


Thomasine Heitkamp, LCSW, is the PI and Co-Director of the Mountain Plains ATTC and MHTTC. She is a Chester Fritz Distinguished Professor at the University of North Dakota with more than 30 years of experience in behavioral health workforce development.




Technology Transfer and Organizational Resilience in the age of COVID-19



Michael S. Shafer, Ph.D.
Pacific Southwest Addiction Technology Transfer Center
Arizona State University

February 4-6, 2020, 39 behavioral health professionals representing 13 agencies throughout HHS Region 9 gathered in Oakland, California for three days to participate in the PSATTC’s Organizational Process Improvement Initiative (OPII) Change Facilitator Academy, launching a 10-month, long-term intensive technical assistance program. Each agency’s group of newly trained facilitators returned home with a plan to brief their Executive Sponsor (who had previously provided a letter of commitment for staff to attend) and hold an organizational change team kick off meeting within 30-45 days. Schedules were coordinated to ensure that I could travel to and attend each of these meetings; no small feat considering sites were located in two states (CA & AZ) and two Pacific Jurisdictions (RMI & CNMI) half a world away. This wordle, captured at the conclusion of the 3-day Academy, denotes the spirit and emotion of the participants.

These are agencies that were ready for change and innovation; they had applied to the PSATTC OPII program to enhance their ability to do so. Selected agencies were required to survey their staff using the TCU Organizational Readiness to Change Assessment. Academy participants had to view three hours of asynchronous video modules before arriving in Oakland. CEOs had to provide a letter of commitment with specific deliverables and action items associated with the OPII model.

And then COVID-19 happened. Site visits were cancelled, kick off meetings were put on hold and change teams suspended, as agencies responded with immediate crisis management actions to protect staff and patients and begin to reimagine service engagement with clients in a physically-distant manner. One agency executive director approved $80,000 in expenditures related to ramping her agency’s telehealth capacity in the two weeks following implementation of her state’s stay at home order. In late March and early April, however, the most important thing these agencies had to focus on changing and innovating was protecting their staff and patient’s safety.

In the four months since the onset of the COVID-19 pandemic, six of the 13 teams have resumed meeting regularly, virtually, and advancing in the 4-phased OPII model. Two of the agencies withdrew their participation, while one agency postponed their change team launch until July. Our ATTC team pivoted our TA procedures. We launched a series of group and individual agency email and zoom meeting communications encouraging agencies to consider altering their improvement change goal to address agency-pressing COVID related issues (such as telehealth adoption). In lieu planned site visits, I began holding Zoom check-ins with each agency every 4-6 weeks. Using Zoom’s recording and transcription capacities has proven a great innovation for documentation and evaluation purposes! We launched a monthly 1-hour Community of Practice (CoP) Zoom session to introduce virtual facilitation tools and skills (such as Zoom and Mural; this portion of the CoP is called the “spark session”) to support facilitators’ virtual team facilitation skill development. These virtual CoP sessions also afford an opportunity for agencies to check-in on their team progress in the OPII change model, while sharing facilitation successes and struggles. These communications are providing insights into the organizational resilience of these agencies in the face of massive short- and yet-to-be-defined long-term changes, and the impact of an ATTC-mediated technical assistance model on strengthening their capacity for technology transfer and innovation.

ATTC Region 2: Preparing and Managing Natural Disasters




Robert Peralta De Jesus, MA, MHS
Northeast & Caribbean ATTC


The Institute of Research, Education and Services in Addiction at the Universidad Central del Caribe, School of Medicine has provided various trainings for first responders, community leaders and healthcare providers. In early January of this year, with the atmospheric events that occurred in Puerto Rico, being impacted by earthquakes, we developed a series of trainings in order to train first responders, community leaders, and healthcare providers to be able to cover the needs of citizens who were directly and indirectly affected. The first training was Psychological First Aid, based on scientific evidence to help children, adolescents, adults and families to face the immediate consequences of disasters or acts of terrorism. It was designed to reduce the initial distress produced by traumatic events, promote adaptive functioning and coping skills. We then provided a training in Psychological Strategies for disaster recovery so that the trainees could acquire skills in managing distress and coping with the stress caused by the events that occurred. Given the situation that the first responders and healthcare providers were going through, we decided to provide them with the tools and training they would need to avoid Compassion Fatigue. This series of trainings were offered in both languages ​​(English and Spanish) for both Puerto Rico and the USVI, and they were also modified to the COVID-19 pandemic.

As part of our commitment to educate and train during the pandemic, we offered a training titled; Skills for managing the isolation period among people recovering from substance use disorders. This was aimed for first responders, to offer tools to people who are in the recovery process with a substance use disorder, in the face of stressors that can cause social isolation due to the pandemic. Understanding the impact that this can have on the family, we also offered a training titled; How to prepare the family to offer support to a family member who is recovering during isolation.
This training was aimed at mental health workers to provide tools for the families of those still in treatment for substance use disorder during COVID-19, in which everyone must remain at home.

Given the uncertainty of what might happen in the future, we set out to offer training based on TAP 34; Emergency Response Planning: Behavioral Health Services for People Using Psychoactive Substances. Emergency response planning is an institutional standard, as it enables the continuity of essential services for communities in critical circumstances. The effectiveness of a plan depends on its consistency with the needs of the population it serves. This webinar is intended to integrate behavioral health services for people who use psychoactive substances as an essential part of a comprehensive emergency response plan.

It is our expectation to continue to provide trainings to all first responders, community leaders and healthcare professionals so they can provide quality service to all that are in need of there assistance.


David Jefferson, MSW
Director of Training and Technical Assistance
Northwest ATTC

Over the past three years, in collaboration with the Northwest ATTC, I have led a large technical assistance project to support implementation of Motivational Interviewing (MI) for 200+ members of the behavioral health workforce employed at social service agencies in Whatcom County, Washington. During the course of this targeted technical assistance project, workforce members participated in basic and intermediate MI training workshops and received individualized, skills-focused coaching. In March 2020, when I became the Director of Training and Technical Assistance at the Northwest ATTC and we found ourselves in the midst of the pandemic, with providers being asked to quickly pivot to telehealth, it seemed like the perfect opportunity to build on their MI skills.

In mid-March, local programs discontinued face-to-face sessions and their workforce started providing all services virtually (i.e. phone, video-conferencing). Knowing we had a robust number of MI-trained workforce members, we thought this would be an opportune time to offer them individualized coaching in applying MI in their telehealth services. We speculated workforce members needed to increase their confidence in providing care, needed skills in this new medium, and could use guidance on how to be more effective with MI. We also knew many programs would be overwhelmed with administrative and programs complications related to Covid-19.

In response to this need, the Northwest ATTC developed a MI telehealth coaching protocol and by early April started delivering individualized coaching sessions to 41 workforce members. The coaching sessions were 30 minutes in length and delivered via Zoom. Prior to each coaching session, workforce members filled out a skill development form, which included identifying skills they were interested in developing, and writing out a case scenario. During the sessions, the coach role-played the client and the workforce member practiced his or her skills. The sessions ended with a debrief about what worked well, what were the challenges, and what skills to improve. Workforce members were offered up to four individual coaching sessions, and most completed at least three. In all, we completed 99 coaching sessions through the end of May.

The coaching revealed a depth of dedication and commitment by workforce members, who signed up to advance their skills during a time when their stress was peaking, workloads were more complicated and certainty in their day-to-day lives, hard to find. Workforce isolation prompted us to invite all participants to a one-hour Zoom session with the goal of sharing lessons learned and strengthening community. We asked the 25 attendees to answer three questions in small groups and report their top impressions. Here are the questions and responses.

What have you learned to improve your Telehealth services?
  • Workforce members benefit from setting up a workspace, being prepared to provide guidance and structure for the call and taking responsibility for setting the tone.
  • It is important to start calls by checking in about the basics. Asking the client initial questions like: “is this still a good time?”, “are you in an appropriate location?”, and “do you have privacy?” was critical, prior to exploring their comfort and skill level around using the phone and/or computer for services.
  • Acknowledge the common awkwardness, empathize with your shared dilemma of this new medium, and use humor to defuse the situation.
  • Adjust to shifting goals and respect the silence, not all clients like to talk on the phone.

What MI skills have been most useful?
  • The Four Processes of MI; Engagement, Focusing, Eliciting and Planning are helpful for structuring the call and guiding the conversation.
  • Slowing down helps clients make faster connections
  • Moving away from my “to-do list” and developing an agenda with the client.
  • Open-ended questions and reflection keep the conversation going but the reflections need to be deeper and lean toward what is possible, what is helpful, and what is hopeful.
  • Meaningful and well-crafted affirmations shine a light on clients’ skills and abilities especially during these times when they feel desperate and stagnant. Affirming that they have the resources to go forward helps them identify their self-efficacy.
  • Summaries help start and end the conversations and add structure. They create a story or narrative about the client’s life that is difficult to capture in these two-dimensional settings.
  • Explore the discord, as it helps increase engagement.

What are your pending challenges to strengthen services?
  • Building rapport and making genuine connections over the phone is the hardest part. Not all clients are comfortable with using phones for counseling sessions and do not see the value.
  • Maintaining connections via virtual sessions is hard and must be attended to each time.
  • Ambivalence is on the increase. Everything seems to be put on hold. Encouraging change talk is a bit harder as clients are hesitant to move on, due to fear, etc. (e.g., some have chronic diseases are afraid to go to healthcare providers).
  • They want Covid-19 information, which is limited, so it triggers the desire to fix clients and leaves workforce members feeling like they did not help.
  • Hard to move people to the eliciting phase. Need to make use of looking forward strategies to build hope and rekindle dreams.

Offering this cohort an opportunity to practice their MI skills with mock client role-plays, seemed well timed, and many expressed their appreciation and gratitude. The success of the project led the Northwest ATTC to offer the same opportunity starting in late May to the Idaho behavioral health workforce and we are exploring the possibility of expanding in other areas in region Ten.


Addressing the Syndemic of Addiction, COVID-19, and Structural Racism by Strengthening the Workforce



By Sara Becker 
New England ATTC

According to the latest data from the Centers for Disease Control and Prevention, over 105,000 Americans have died and at least 1.7 million Americans have been infected with the novel coronavirus disease (COVID-19). Social distancing measures put in place to contain the spread have decimated entire sectors of the United States economy, with the stock market dropping so precipitously that it erased three years of gains. Unemployment rates are also at historically high levels with the national rate rapidly approaching 15%. In a few short months, COVID-19 has upended our country and harmed millions of Americans.

Data on the toll of COVID-19 are troubling in aggregate, but even more concerning when we consider those Americans hit the hardest. Recent commentary by NIDA director Nora Volkow (2020) underscored how individuals who use opioids are at increased risk for the most adverse consequences of COVID-19 due to both direct (e.g., slowed breathing due to opioid use) and indirect (e.g., housing instability, incarceration) pathways. In addition, Black Americans and Hispanics have been disproportionately affected by COVID-19: emerging regional data suggests that the COVID-19 death rate for Black and Hispanic Americans is about 2.5 times higher than for whites. The disproportionate toll of disease reflects the effects of structural racism, which manifests in increased risk of underlying health conditions (e.g., chronic respiratory disease); decreased access to testing and care; and decreased ability to socially isolate due to factors such as crowded living conditions and employment in sectors deemed essential. Taken together, these data indicate that the United States is in the midst of a syndemic - defined as the interaction of a set of linked health problems involving two or more conditions, interacting synergistically and contributing to excess burden of disease. Addressing the syndemic of addiction, COVID-19, and structural racism requires responses on multiple levels and across multiple fronts. One of those fronts is ensuring that the addiction treatment workforce is equipped with the tools needed to help patients facing these interacting epidemics.

The Addiction Technology Transfer Center (ATTC) Network has been working to meet this challenge by developing new products and resources focused on these intertwined public health issues. The National Coordinating Office hosted a Listening Session and a 5-part Strategic Discussion Series focused on emerging issues around COVID-19 and social determinants of health. The Listening Session solicited feedback on ways COVID-19 has highlighted racial and ethnic disparities, and each Strategic Discussion focused on concrete actions that could be taken to support specific communities of color.

Regional ATTCs have also risen to the challenge to create new tools for the addiction workforce during these unprecedented times. The New England ATTC has developed multiple products including a 2-part webinar series (in partnership with the New England Mental Health Technology Transfer Center) focused on the intersection of addiction, mental health, and COVID-19; a training focused on Trauma-Informed Approaches to Substance Use Assessment and Intervention (which includes new content on how to sensitively assess and address the trauma of racism and the traumas inflicted by COVID-19); and a workshop on Cultural Intelligence and Cultural Humility (which has been adapted to address the disparities and racism highlighted by COVID-19). The New England ATTC has also partnered with the South Africa HIV ATTC to develop a series of products focused on provider self-care in recognition of the toll that caretaking places on front-line health professionals. Finally, in October 2020 the New England ATTC will proudly host this year’s national Addiction Health Services Research Conference (delivered fully virtually)! One of the plenary talks by Dr. Ayana Jordan will specifically address the intersection of structural racism and addiction, and spotlight awards will be given to addiction researchers from underrepresented minority groups.

The New England ATTC is proud to join other Regional ATTCs in not only building the skills of the SUD workforce but also providing supportive strategies for sustaining hope and encouraging self-compassion during this trying times. Please visit the New England ATTC’s COVID-19 resource page to see the latest products and training events devoted to addressing this syndemic.