Community Mental Health Providers Research Articles

Opening up the ‘black-box’: what strategies do community mental health workers use to address the social dimensions of mental health?

PurposeCommunity-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.MethodsWe interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.ResultsCHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.ConclusionCommunity health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Urban Settings: Barriers and Facilitators to Implementation With Minoritized Youth.

Substance use in minoritized youth is associated with negative long-term health and life outcomes. The present study explores perspectives of school stakeholders at urban minority-serving schools regarding integration of an evidence-based intervention, screening, brief intervention, and referral to treatment (SBIRT) into existing school prevention models. Twenty-two participants were interviewed using the Consolidated Framework for Implementation Research to identify barriers and facilitators to SBIRT implementation. Qualitative data were transcribed, coded, and analyzed. Four major themes related to barriers to SBIRT implementation included: lack of training, unclear role expectations, student confidentiality, and punitive school climates. The 3 major facilitators included: the feasibility of the intervention, its fit within multi-tiered systems of support, and the districts increasing collaboration with community mental health providers. These major themes along with other minor themes are discussed. SBIRT implementation within low-income, minority-serving schools may reduce substance use disparities among minoritized youth, improving health and life outcomes. Recommendations addressed training, school climate, and student engagement, highlighting a collaborative and supportive approach involving all stakeholders. While SBIRT implementation has barriers and facilitators, overall, school staff were optimistic about implementation. In light of these findings, additional research should embed SBIRT in these settings.

Community agency launches new phase of comprehensive mental health site

A community mental health provider in the Pacific Northwest has launched the second phase of an ambitious three‐stage initiative to integrate multiple levels of care into one campus site. A combination of public, private and philanthropic sources is covering the Compass Health project's $68.5 million price tag.

CBT+ Training Initiative in Washington State Community Mental Health: An Evaluation of Child Clinical Outcomes.

The Washington State CBT+ Initiative offers a flexible training and consultation approach for community mental health providers in evidence-based practices for four child mental health targets: cognitive behavioral therapy for depression, anxiety, trauma, and behavioral difficulties. As part of consultation, clinicians used an online system to track delivery of treatment components and clinical outcomes using standardized symptom measures. The current study used these clinician-input data to examine symptom change for children using paired sample t-tests. Additionally, we explored if time elapsed or number of sessions between measurements related to symptom change using simple linear regression. Children had significant symptom reduction across all four targets. For most measures, children did not show greater improvements with increased length of time or increased number of sessions between assessment measures. Findings suggest that children treated by a CBT+ trained clinician may demonstrate symptom reduction for their primary clinical problem. Findings add to support for flexible training approaches for community mental health clinicians.

From court to the community: improving access to evidence-based treatment for underserved youth involved in the juvenile legal system at-risk for suicide

BackgroundJuvenile legal involved youth (JLIY) experience disproportionately high rates of suicidal and self-injurious thoughts and behaviors (SSITB). Many JLIY lack access to evidence-based treatment specifically designed to treat SSITB, thereby increasing the overall risk of suicide. The overwhelming majority of JLIY are not placed in secure facilities and almost all incarcerated youth are eventually released to the community. Consequently, SSITB are a major concern of JLIY residing in the community and it is critical that this population has access to evidence-based treatment for SSITB. Unfortunately, most community mental health providers who treat JLIY have not been trained in evidence-based interventions that are specifically designed to SSITB, which often leads to youth experiencing prolonged periods of SSITB. Training community mental health providers who serve JLIY in the detection and treatment of SSITB shows promise for decreasing the overall suicide risk for JLIY.MethodsThe current proposal aims to reduce SSITB among JLIY, and thus reduce mental health disparities in this vulnerable and underserved youth population, by increasing access to evidence-based treatment strategies specifically designed to treat SSITB behaviors. We will implement an agency-wide training among at least 9 distinct community mental health agencies that serve JLIY referred to treatment by a statewide court system in the Northeast. Agencies will be trained in an adapted version of the COping, Problem Solving, Enhancing life, Safety, and Parenting (COPES+) intervention. Training will be implemented via a cluster-randomized stepped wedge trial that proceeds through multiple phases.DiscussionThis research engages multiple systems (i.e., juvenile legal and mental health systems) serving JLIY and has the potential to directly inform treatment practices in juvenile legal and mental health systems. The current protocol has significant public health implications as the primary goals are to reduce SSITB among adolescents involved in the juvenile legal system. By implementing a training protocol with community-based providers to help them learn an evidence-based intervention, this proposal aims to reduce mental health disparities in a marginalized and underserved population.Trial registrationosf.io/sq9zt

Evaluating a community-based training program for evidence-based treatments for PTSD using the RE-AIM framework.

Community mental health providers increasingly serve veterans with posttraumatic stress disorder (PTSD). However, recent surveys find that less than 20% of community providers are adequately trained to implement evidence-based treatments (EBTs) for PTSD. Since 2017, the STRONG STAR Training Initiative (SSTI) model has adapted traditional learning collaboratives aimed at increasing availability of EBTs for PTSD in community settings. This study reports on STRONG STAR program evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to assess dissemination and implementation outcomes. Between January 2018 and January 2020, 280 mental health providers from 25 states participated. Providers initiating EBTs for PTSD with 930 patients, reaching 29% who had PTSD among their caseload. Overall, 238 of patients who initiated EBT completed treatment. Patients who completed treatment demonstrated a 32.51-point decrease, t(237) = 25.27, p < .001, in PTSD symptom severity and an 8.73-point decrease, t(231) = 19.95, p < .001, in depression symptom severity following treatment. High rates of SSTI providers continued implementing EBT for PTSD at 6 months (cognitive processing therapy [CPT]: 95%; prolonged exposure [PE]: 72%) and 1-year (CPT: 87%; PE: 77%) posttraining, similar to outcomes reported by community and Department of Veterans Affairs providers. In reporting on the first evaluation of a National Training Program for community-based mental health providers, we look ahead to continued work in refining scalable models for building provider competence in delivery of EBTs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

COMMENT: Age and autonomy: An ethical dilemma in community mental health.

Mental illnesses are proven to have their onset in the mid-teens, making early mental healthcare interventions necessary among adolescents. While school-based mental health awareness programmes have gained prominence in recent years, adolescents identify issues around confidentiality, privacy and the need for parental consent impinging on their autonomy, as barriers to accessing mental healthcare, for their perceived needs. We aim to discuss the various ethical dilemmas faced by community mental health providers in using age as a sole marker for determining autonomy for adolescents, focusing on the potential impact of these challenges on adolescent mental healthcare and wellbeing.

Effects of Modularized Workshop Trainings on Youth Clinical Progress in a Public Mental Health System

Research suggests that a modular approach to treatment and training may be a promising method for promoting evidence-based practices (EBPs). Furthermore, there is growing evidence that the effects of training on specific technique implementation are affected by therapist and youth factors as well as the type of problem area addressed during training. The current study expanded these findings by examining the extent to which youths’ clinical progress improved as a result of therapists’ attendance at modular workshop trainings. Longitudinal, archival data from community mental health providers ( n = 48) who participated in a series of anxiety and/or disruptive behavior workshops in modular approaches to EBPs for youth were examined using cross-classified multilevel modeling. Results indicated that youths’ month in treatment and therapists’ practice behaviors following their training significantly and positively influenced clinical progress. However, only therapists who attended a disruptive behavior training reported greater rates of improved youth treatment progress. Therapists’ knowledge of the trained techniques was not a significant moderator of outcomes. Results suggest that therapists may require differential training and implementation supports that vary as function of problem area to positively enhance youth outcomes. Limitations and implications for EBP dissemination and implementation are discussed.

Virtual Technology's Critical Role in Sustaining Coordinated Specialty Care in Texas During the COVID-19 Pandemic.

This report examined challenges and adaptations to sustaining multidisciplinary team-based coordinated specialty care (CSC) for early-onset psychosis during the COVID-19 pandemic in Texas. In June 2020, team leaders from 23 Texas CSC sites participated in semistructured phone interviews about CSC implementation barriers and adaptations. Transcripts were analyzed with thematic analysis. CSC implementation barriers included difficulty delivering critical CSC components (i.e., community education and vocational exploration) and client recruitment limitations. Virtual technology integration (i.e., texting and videoconferencing) largely sustained CSC outreach, service delivery, and client engagement. However, sites faced virtual competency and accessibility issues, exhaustion from virtual technology use, lack of structural support, and unanticipated disengagement. The surveyed sites rapidly integrated virtual technology into CSC delivery. This integration promoted CSC engagement during the pandemic, especially in rural areas, and increased insight into what resources and policies are needed to sustain virtual technology use among community mental health providers.

A Brief Text-Messaging Intervention for Suicidal Youths After Emergency Department Discharge.

Research has shown that the months after hospital discharge following treatment for suicidal thoughts or behaviors is a high-risk period for suicide. Moreover, the needs of a subset of youths at increased risk for suicide are not being met by community mental health providers, resulting in frequent emergency department (ED) visits. While undertaking a quality improvement effort, the authors' health care system piloted caring text messages to support youths discharged from the hospital after screening positive for suicide risk in the ED. The text-messaging intervention was feasible and acceptable, and youths reported that the messages helped reduce their suicidal thoughts and behaviors postdischarge. The results of this text-messaging intervention prompted the Maryland Department of Health to offer a similar intervention to all Marylanders.

Effectiveness of Online Mindfulness Training for People Experiencing Mental Illness

Background: Evidence has shown that self-guided web application mindfulness training can improve mental health. In this study, the “Be Mindful” online-based mindfulness training software application was offered through a United Kingdom (UK) universal community healthcare provider to patients with a mental illness diagnosis. Be Mindful is an online course providing instruction on mindfulness theories and practice training, progress tracking, integrated guidance/feedback, and motivational emails. Objective: The aim of this paper is to present feasibility findings and outcomes on anxiety, depression, and stress of an intervention offering Be Mindful. Participants were adults who had a mental illness diagnosis and were under the care of community mental health services. Methods: Open-label patient cohort design, with no control group. Pre- and post-intervention assessment using participant self-report measures: Generalised Anxiety Disorder-7 (GAD-7); Perceived Stress Scale (PSS-10); and Patient Health Questionnaire-9 (PHQ-9; a measure of depression severity). Results: Two hundred and seventy-four started and thirty-one patients completed the Be Mindful programme and outcome measures. PSS scores at baseline significantly improved from 24.6 (1.79) to 18.7 (2.05) at the end (p p 0.354. PHQ-9 scores at baseline significantly improved from 13.7 (1.42) to 9.09 (1.76) to 9.81 (1.77) at end (p 0.378. Limitations: There was no control group, and the intervention was adjunct to existing treatment. Conclusions: Be Mindful can be offered through a UK community NHS Trust and can have a significant impact on symptoms of anxiety, depression, and stress in patients with experience of mental illness. Roll-out through community mental health providers to people with experience of mental illness is justified. Well-designed and sufficiently powered randomised controlled trials of theory-driven online mindfulness training for mental illness patient populations are required.

Alpha-Stim AID Cranial Electrotherapy Stimulation (CES) for Anxiety Treatment: Outcomes in a Community Healthcare Service

Background: Symptoms of anxiety disorders are highly common and can have a severe impact on people’s lives; they are typically treated with psychotherapy and/or anti-anxiety medication. These treatments are not suitable for, acceptable to, or effective for everyone. Alpha-Stim AID is a cranial electrotherapy stimulation (CES) device with evidence of effectiveness in treating symptoms of anxiety. In this study, Alpha-Stim AID was offered through a United Kingdom (UK) universal community healthcare provider, Intermediate Care Team (ICT) community healthcare service to patients who reported signs of anxiety. Objective: The aim of this paper is to present feasibility findings and outcomes on anxiety, health status, and quality of life. Methods: Open-label patient cohort design, with no control group. Participants were adults who reported symptoms of anxiety and were under the care of universal national health service (NHS) Intermediate Care Team (ICT) community healthcare service in the United Kingdom (UK). Pre- and post-intervention assessment used participant self-report measures: generalised anxiety disorder (GAD-7) and health related quality of life (EQ-5D-5L). The three ICT staff members who offered the Alpha-Stim AID to patients completed a questionnaire on their experience. Results: Eighteen patients used the Alpha-Stim and completed outcome measures. GAD-7 scores significantly improved from 13.9 (SD = 4.3) to 7.3 (SD = 5.7) (p p = 0.036), with a small effect size of 0.12. EQ-VAS scores at baseline improved from 49.2 (SD = 24.0) to 64.4 (SD = 26.2) at the end (p = 0.05), with a small effect size of 0.12. Limitations: There was no control group, and the intervention was adjunct to existing treatments. Conclusions: Alpha-Stim AID CES can be offered through a UK NHS Trust Intermediate Care Team (ICT) community healthcare service and can have a significant positive impact on symptoms of anxiety, quality of life, and health status in patients who report experience of anxiety symptoms. Roll-out through community mental health providers to people with experience of anxiety symptoms is feasible. An appropriately designed and sufficiently powered randomised controlled trial of Alpha-stim for anxiety is required.

Developing a community-based multidisciplinary service exit typology for young adults with serious mental health conditions.

Objective: Increasingly, community mental health providers are implementing multidisciplinary treatment models blending child and adult evidence-based practices to boost young adult engagement. Although promising, limited research examines how and why young adults disengage from these new models. This study examines provider documentation of treatment discharges to create a more developmentally-attuned young adult service exit typology. Method: Service records of 18-25 year-olds (n = 124) who discharged from a young adult-tailored multidisciplinary treatment team over a 5-year period were analyzed. A research team conducted a systematic content analysis of discharge forms and service notes. Planned and unplanned exits emerged as primary categories, each having distinct subcategories with noted prevalent associated experiences. Results: Participants (n = 124) were enrolled between 7 days to 3.80 years (M = 11.41 months) prior to exit. Those with "planned" exits (n = 71) were enrolled longer than those with "unplanned" exits (n = 53), means respectively 13.17 versus 9.06 months. Planned exits included: transitions either to a lower, similar or higher level of care, a return to previous provider, or insurance issues. Moving outside team geographic area contributed to planned and unplanned exits. Unplanned exits were disproportionately found among participants who were Black, had justice involvement histories, and/or experienced housing instability or homelessness. Conclusions and Implications for Practice: Young adult service exits are complex; planned exits are not always positive and unplanned exits are not always negative. Provider and research use of this new service exit typology has particular implications for identifying engagement disparities-and further tailoring models to be more attractive, culturally responsive, and impactful with young adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An examination of work engagement's antecedents and consequences in a sample of U.S. community mental health providers.

The study examined the relationship between job demands and resources, work engagement, and turnover intentions in a community mental health context. Using path analysis, we tested a conceptual model where we hypothesised that job demands (pressure to produce and role ambiguity) had a negative relationship to work engagement (H1) and resources (team commitment, supervisor relationship, and connection to organisational mission) were positively related to engagement (H2). Furthermore, greater engagement would be related to lower intention to leave the job (H3). Additionally, we hypothesised that there was an indirect effect of job demands and resources on turnover intention mediated via engagement (H4). The study used cross-sectional data collected in 2018 from a sample of N=170 mental health providers employed in a community mental health centre in the Southwest region of the United States. The study findings suggest that the job demands tested, pressure to produce and role ambiguity, were negatively related to engagement (H1). Of the job resources tested, only team commitment and connection to mission were positively related to engagement (H2). Work engagement was negatively related to intention to leave (H3). There were indirect effects of job demands and job resources (pressure to produce, role ambiguity and connection to the organisation mission) on intention to leave mediated through engagement (H4). The findings suggest that managers and administrators in community mental health organisations may help promote a more stable workforce by bolstering the resources that lead to greater work engagement and mitigating the job demands that reduce engagement.

Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings.

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute serviceuser needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

Providers as Stakeholders in Addressing Implementation Barriers to Youth Mental Healthcare.

Research has shown that youth with mental health disorders often do not receive adequate care. School- and community-based mental health organizations are integral to implementing evidence-based mental healthcare to the vast majority of youth. It is therefore important to understand the perspectives of this stakeholder group, to determine how to improve access to high-quality care. A series of three focus groups with community mental health providers and three school counselors and social workers focus groups were conducted to get their perspective on existing barriers that prevent youth who need mental health services from being treated. A grounded theory inductive qualitative analysis revealed six major themes (Lack of Services, Lack of Knowledge, Stigma, Logistics, Poor Past Experiences with Mental Health, and Poor Coordination of Services). Each of these themes are discussed and implications are framed within the context of implementation science.

TA organizations supporting MH workforce during pandemic

As the pandemic continues to bring about structural changes in the public mental health sector, including a shift to telehealth and financial strain for community mental health organizations and clinicians — not to mention a risk of burnout among clinicians and staff — technical assistance (TA) organizations have supported community mental health providers in adapting to these changes, an opinion piece in the October issue of Psychiatric Services stated.

Mental health providers frustrated with Louisiana's Medicaid MCOs

A recent survey of mental health providers found dissatisfaction with several of the organizations Louisiana uses to manage Medicaid services, according to a Sept. 27 Greater Baton Rouge Business Report. The report, released this month, comes as the state prepares to choose a new set of managed care organizations (MCOs). The multibillion‐dollar contracts account for about 25% of Louisiana's annual operating budget and cover health care for one‐third of Louisiana's residents, according to The Associated Press. They allow private companies to oversee health care services for about 90% of Louisiana's Medicaid enrollees, mostly adults covered by Medicaid expansion, pregnant women and children. Magellan Health, which focuses on behavioral health, received an A‐ on the Louisiana Rural Mental Health Alliance's report card, but no other MCO graded higher than a C+, which was the overall grade for Louisiana Healthcare Connections and United Healthcare Community Plan. Aetna and AmeriHealth Caritas Louisiana both received a C‐ and Healthy Blue received a D. The report card is the result of an associationwide provider satisfaction survey seeking to compare how the current Medicaid MCOs are performing with their network community mental health providers.

23.3 ADDRESSING RACIAL AND ETHNIC DISPARITIES IN ACCESS TO MENTAL HEALTH CARE FOR CHILDREN AND ADOLESCENTS: THE ROLE OF CHILD PSYCHIATRY ACCESS PROGRAMS

Child psychiatry access programs (CPAPs) are regional clinical services designed to improve access to care by supporting and enhancing the ability of pediatric primary care teams to address mental health needs of children and adolescents in the primary care setting. Although racial and ethnic disparities in access to mental health care have been well-described for decades, the attention of CPAPs to understanding and addressing them is recent and long overdue. The Massachusetts CPAP (MCPAP), the first and longest continually operating CPAP, has identified the issue of health equity as integral to its mission and operation, and has engaged in planning efforts both internally and in collaboration with stakeholders and peer programs across the United States. Components of planning include identification of unique access barriers for Black, Indigenous, and People of Color (BIPOC) and Latinx populations and exploring administrative and clinical strategies for mitigating them. Training modules are aimed at MCPAP clinical and administrative staff as well as our network of affiliated primary care providers for the purpose of raising awareness of individual, systemic, historical, and structural factors contributing to access barriers for BIPOC/Latinx children and their families. Other key components of the MCPAP strategy are: 1) applying continuous performance improvement methodology including quantitative measures for assessing progress in health equity in relation to baseline; 2) developing processes to include consumer voices in the planning and oversight of our efforts; 3) engaging community mental health providers in mitigating access barriers; and 4) collaborating with similar programs across the United States to identify best practices and compare data. In the context of their mission to improve access to mental health care for children and their families, CPAPs have a unique opportunity and responsibility to address issues of health equity for BIPOC and Latinx populations.

Examining community mental health providers'delivery of structured weight loss intervention to youth with serious emotional disturbance: An application of the theory of planned behaviour.

Rates of overweight and obesity are disproportionately high among youth with serious emotional disturbance (SED). Little is known about community mental health providers' delivery of weight loss interventions to this vulnerable population. This study examined attitudinal predictors of their providers' intentions to deliver weight loss interventions to youth with SED using the theory of planned behaviour. This study used a cross-sectional, single-time-point design to examine the relationship of the theory of planned behaviour constructs with behavioural intention. Community mental health providers (n = 101) serving youth with SED in the United States completed online clinical practice and theory of planned behaviour surveys. We examined the relationship of direct attitude constructs (i.e., attitude towards the behaviour, social norms and perceived behavioural control), role beliefs and moral norms with behavioural intention. Analyses included a confirmatory factor analysis and two-step linear regression. The structure of the model and the reliability of the questionnaire were supported. Direct attitude constructs, role beliefs and moral norms predicted behavioural intention to deliver weight loss interventions. While there is debate about the usefulness of the theory of planned behaviour, our results showed that traditional and newer attitudinal constructs appear to influence provider intentions to deliver weight loss interventions to youth with SED. Findings suggest preliminary strategies to increase provider intentions. This study was designed and the results were interpreted as part of a larger, community-based participatory research effort that included input from youth, families, providers, administrators and researchers. Collaborative discussions with community mental health providers and administrators particularly contributed to the study question asked as well as interpretation of results.