Mental health symptoms (e.g., anxiety, depression) among youth in the U.S. have increased from 8.7 to 13.2% over the last decade (Twenge, Cooper, Joiner, Duffy, and Binau, 2019). When unaddressed, these symptoms result in poorer functioning, including lower educational attainment and lower quality of life (Swan and Kendall, 2016). Despite the significant impact of mental health symptoms, only 1 in 5 youth who need services are actually able to access mental health care (Kataoka, Zhang, and Wells, 2002). This unmet need is even greater for racial/ethnic minorities, as almost 90% of Latino/a and African American youth with mental health problems do not receive services (Kataoka et al., 2002). Traditional mental health delivery methods are limited in their ability to address this access to care problem as they rely on resource-intensive and nonscalable setups, including in-person contact and trained mental health professionals (Kazdin, 2019). Furthermore, training needed to become a mental health professional is costly and time intensive. As a result, the current model of service delivery is expected to lead to a shortage of a quarter of a million qualified mental health providers in the U.S. by 2025 (Health Resources and Services Administration, 2016), and thus, will likely significantly worsen the access to care problem. Therefore, it is imperative to develop novel methods to increase access to evidence-based care.
Founded in 2013, Community Psychiatry Program for Research in Implementation and Dissemination of Evidence-based Treatments (PRIDE) at Massachusetts General Hospital is dedicated to increasing access to evidence-based mental health care in resource restricted settings and improving the lives of youth facing adversity. PRIDE aims to build the capacity of the mental health workforce by training and coaching non-mental health professionals (i.e., paraprofessionals) to deliver evidence-based skills to youth. To achieve this aim, PRIDE relies on implementation science to systematically address barriers and leverage facilitators to implement evidence-based, paraprofessional-delivered interventions in community settings. Employing community-based participatory research (CBPR) principles, PRIDE establishes long-term, equitable relationships with community partners based on mutual respect. Through each partnership, an implementation design is collaboratively created and executed to promote adoption, fidelity, and long-term sustainability (Proctor et al., 2011) of the intervention within the organization.
An example of a successful initiative to address the access to care problem through paraprofessional workforce development is demonstrated by the five-year partnership between PRIDE and Roca, Inc. (hereafter, Roca), an organization dedicated to disrupting the cycle of poverty and incarceration of justice-involved young men at high risk for reoffending and unemployment (for a detailed description of the implementation process, see Valentine et al., 2019). Guided by a robust implementation science framework, namely Intervention Mapping (Bartholomew Eldredge et al., 2016), a comprehensive needs assessment was conducted to identify the mental health needs at Roca and barriers and facilitators to using evidence-based skills at Roca. Concurrently, PRIDE researchers completed an extensive literature search to understand prior evidence-based skills programming implemented for justice-involved youth. Synthesized results revealed a lack of available evidence-based skills programs that could sufficiently address the complex emotional and behavioral needs of high-risk young men and be delivered flexibly within Roca’s organizational structure. Therefore, the unique expertise of each partner, PRIDE and Roca, was leveraged to co-create a modular 10-skill cognitive behavioral theory (CBT) curriculum that could be flexibly delivered by paraprofessionals, a workforce delivery method shown to be effective for other underserved populations (Barnett et al., 2018). PRIDE ensured that each skill was evidence-based, and Roca adapted the delivery of the content to fit their population of service, thus increasing uptake. Adaptations included re-naming skills to be attuned to the youth’s experiences and developing applicable and relevant case examples to facilitate knowledge acquisition. For example, a skill based on cognitive restructuring was renamed “Flex Your Thinking” and taught using an example of a justice involved young man trying to get a job.
The innovative CBT program was introduced to Roca staff through a series of pilot trials designed to iteratively evaluate and enhance the curriculum and implementation (Valentine et al., 2019). During the first pilot study, all 10 skills were introduced to supervisors and frontline staff (i.e., youth workers) through experiential trainings. Focus groups following the initial pilot elucidated a need for a full saturation implementation, which resulted in a full staff training for the second pilot. Aligned with implementation science principles, focus ges et al., under review). In addition, having at least one CBT encounter was positively associated with having a job; compared to young men that did not use any roups were again conducted following the second pilot. Evaluation of preliminary implementation outcomes (Proctor et al., 2011) from both pilots informed revisions to increase the relevance of the CBT curriculum content and the design of a feasibility trial, and the results showed that the curriculum had good feasibility and acceptability from the perspective of Roca staff, and good satisfaction from the young men (Valentine et al., 2019). The final phase of the partnership focused on ongoing internal training and coaching to maintain sustainability and uptake at the organization (Youn et al., 2019). To evaluate the effectiveness of the CBT curriculum, the partnership used programmatic data collected by Roca during 2014–2017. The results showed that over 900 young men reported using CBT. As compared to young men who did not use any skills, young men who had at least one CBT encounter had a 66 percent lower risk of unenrolling from Roca programming prior to graduation (Marquskills, young men who had at least one CBT encounter had a 65 percent higher risk of obtaining a job (Marques et al., under review). Ultimately, a phase-based approach grounded in implementation science and a strong CBPR partnership of mutual respect resulted in the successful development of a novel workforce equipped to deliver CBT skills to high risk youth who previously lacked access to emotional and behavioral health care
PRIDE is now focused on scaling this method to further build the mental health workforce and increase access to evidence-based skills. PRIDE continues to partner with organizations that service youth in need across sectors, including nonprofit organizations, schools, and governmental organizations. PRIDE is also actively engaged in policy-level discussions to address the systemic barriers that maintain the current access to care problem and facilitate the development and implementation of innovative solutions to this crisis. Find out more information about current PRIDE projects or how to partner with us.
Bartholomew Eldredge, L.K., Markham, C.M., Ruiter, R.A., Fernández, M.E., Kok, G., and Parcel, G.S. (2016). Planning health promotion programs: an intervention mapping approach. John Wiley and Sons.
Barnett, M.L., Gonzalez, A., Miranda, J., Chavira, D.A., and Lau, A.S. (2018). Mobilizing community health workers to address mental health disparities for underserved populations: a systematic review. Administration and Policy in Mental Health and Mental Health Services Research, 45(2), 195-211. https://doi.org/10.1007/s10488-017-0815-0
Kataoka, S.H., Zhang, L., and Wells, K.B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 1548-1555. https://doi.org/10.1176/appi.ajp.159.9.1548
Kazdin (2019). Annual research review: Expanding mental health services through novel models of intervention delivery. Journal of Child Psychology and Psychiatry, 60(4), 455-472. https://doi.org/ 10.1111/jcpp.12937
Marques, L., Youn, S., Zepeda, E.D., Chablani-Medley, A., Bartuska, A.D., Baldwin, M., and Shtasel, D.L. (2020). “CBT helped me not shoot someone”: Effectiveness of cognitive behavioral skills in high-risk justice involved youth. Manuscript submitted for publication.
Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., ... and Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7
Swan, A.J., and Kendall, P.C. (2016). Fear and missing out: Youth anxiety and functional outcomes. Clinical Psychology: Science and Practice, 23(4), 417-435. https://doi.org/10.1111/cpsp.12169
Twenge, J.M., Cooper, A.B., Joiner, T.E., Duffy, M.E., and Binau, S.G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017. Journal of Abnormal Psychology, 128(3), 185-199. https://doi.org/10.1037/abn0000410
U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce. National Center for Health Workforce Analysis. (2016). National Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-2025. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf (PDF, 452KB)
Valentine, S.E., Ahles, E.M., De Silva, L.E.D., Patrick, K.A., Baldwin, M., Chablani-Medley, A., ... and Marques, L. (2019). Community-based implementation of a paraprofessional-delivered cognitive behavioral therapy program for youth involved with the criminal justice system. Journal of Health Care for the Poor and Underserved, 30(2), 841. https://doi.org/10.1353/hpu.2019.0059
Youn, S., Valentine, S.E., Patrick, K.A., Baldwin, M., Chablani-Medley, A., Aguilar Silvan, Y., ... and Marques, L. (2019). Practical solutions for sustaining long-term academic-community partnerships. Psychotherapy, 56(1), 115-125. https://doi.org/10.1037/pst0000188