Morning Zen Guest Blog Post ~ Eliot Brenner ~
Author’s note: The ideas presented in this Morning Zen were influenced by Dr. Alan Kazdin, whose thoughts have shaped the science of psychotherapy and children’s mental health over the past four decades. I have tried to translate some of his cutting-edge thinking to my everyday experience running a children’s mental health agency.
Mental health treatments have come a long way in the last fifty years. During this time, researchers have developed hundreds of evidence-based mental health treatments. There now exist evidence-based treatments for most common children’s mental health problems. But how accessible are these interventions for those who need them?
Sadly, in the United States, approximately 70% of people who have a mental health problem do not receive any treatment, much less an evidence-based one. For children, depending on where they live, this figure may be closer to 80%. In short, we have powerful psychosocial interventions, but they only reach a fraction of the children who need them. Further, of those who receive any mental health treatment, only a third receives minimally adequate treatment as defined by existing treatment guidelines.
Defining Access to Healthcare
The World Health Organization outlines three primary components of access to healthcare: physical accessibility, financial affordability, and acceptability. Physical accessibility involves healthcare being available geographically close and at times that are convenient for the people who need it. Affordability means that those who want healthcare can get it without financial hardship. Acceptability means that people believe healthcare is effective and respectful of their social and cultural background.
Challenges Accessing Evidence-Based Mental Health Treatment
For the past two decades, there has been optimism that implementation science might help address the problem of access to evidence-based care. Implementation science is the study of systematically developing and testing strategies for implementing, scaling, and sustaining evidence-based practices. Connecticut is a leader in using implementation science to spread evidence-based children’s mental health treatments throughout the state.
For example, the Child Health and Development Institute (CHDI) collaborated with the Department of Children and Families (DCF) to implement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) with good outcomes to help 4,500 children. CHDI and DCF have worked to ensure that TF-CBT providers are available in most areas of the state. If we apply the World Health Organization’s definition of access, this service is physically accessible to many Connecticut children. CHDI is also working to ensure that Child First, an evidence-based, dyadic intervention for at-risk young children and their parents is available throughout the state. Similarly, CHDI recently received a Substance Abuse and Mental Health Services Administration grant to implement Attachment, Regulation, and Competency (ARC), an evidence-based treatment for young children who have had a traumatic experience. All of these are outstanding interventions with good outcomes for the children fortunate enough to get the treatments. I am proud that the Agency that I lead, the Child Guidance Center of Southern Connecticut, provides all three of these interventions, as well as another home-based evidence-based treatment, Multidimensional Family Therapy.
Last year, of the approximately 1,500 children the Child Guidance Center served with outpatient and home-based psychosocial treatment, 8% (114) of these children received an evidence-based intervention that adheres to strict standards established by the developers of these treatments. The numbers served are small because of the extensive training and consultation that is required to deliver an evidence-based intervention with fidelity to the treatment model. I believe that every child we serve should receive an evidence-based intervention because research suggests that outcomes are superior, but this is not financially feasible. None of the grants we receive to implement and sustain evidence-based practices come close to covering their costs. A recent article that examined the costs of sustaining TF-CBT in Connecticut calculated an incremental per patient annual cost of $1,896. The researchers admonished that “reimbursement models for supporting evidence-based practices must consider the costs of sustainment.”
Indeed, for the Child Guidance Center of Southern Connecticut to treat all children in need of outpatient or home-based services with an evidence-based practice like TF-CBT would cost an additional $2,627,856 ($1,896 per patient x 1,386 patients). This would increase our $5.2 million annual budget by more than 50% and would require twice the amount of funding we currently receive from the state of Connecticut to deliver these services. Even if Connecticut weren’t in dire budget circumstances -- we are three months into the current fiscal year and the state has not passed a budget -- this would never happen. Thus, while some evidence-based practices might be physically accessible, they are clearly not affordable.
While there is considerable scientific support for evidence-based psychosocial interventions for children’s mental health problems, this support is based primarily on studies of Caucasian, European American children. There is considerably less evidence supporting these interventions for ethnic minority youth. It is likely that cultural factors -- perceived stigma or different conceptions of mental illness or treatment -- influence the effectiveness of existing evidence-based interventions. Further, there is a dramatic shortage of ethnic minority mental health clinicians. Approximately 90% of mental health clinicians in the U.S. are non-Hispanic White, but 30% of people in the U.S. belong to a racial or ethnic minority. In states like Connecticut that have growing immigrant populations, competition is fierce amongst nonprofit mental health agencies seeking to hire qualified bilingual clinicians because there simply aren’t enough of them to serve the expanding population.
To summarize, it would appear that, with great effort, it is possible to make select evidence-based interventions physically accessible – at least for select populations in a small New England state - but making them affordable and acceptable remains elusive.
Expanding Access to Evidence-Based Treatment: New Solutions
The shortage of racial and ethnic minority mental health clinicians is part of a much larger problem. Given the prevalence of mental health concerns, there are not enough clinicians of any race or culture. As noted earlier, only a small fraction of children in the United States in need of mental health treatment receive it. Dr. Alan Kazdin, an internationally renowned psychologist and long-time developer of and advocate for evidence-based treatments, has recently concluded that it is not possible to use the dominant model of psychosocial treatment, individual psychotherapy, to address the gap between those who need mental health treatment and those who receive it:
"Expanding the workforce to deliver treatment with the usual, in person, one-to-one model of care with a trained mental health professional is not likely to have a major impact on reaching the vast number of people in need of services. The increased person power is not likely to provide treatments where they are needed, for the problems that are needed, and attract the cultural and ethnic mix of clientele that are essential." Dr. Alan Kazdin
Kazdin is not suggesting that we stop providing individual, evidence-based treatments. Rather, he is arguing that we also need to develop new methods of delivery to reach the vast majority of those who need help but will never receive individual therapy.
Changes in Healthcare
Several changes in healthcare are likely to foster new models of delivery that improve the accessibility of care for children struggling with mental health problems. The first change involves health insurers moving from reimbursement based upon fee for service to reimbursement based on population health outcomes, or value-based care. Payers, including Medicare and Medicaid, have already begun to change from paying providers for each procedure (e.g., a session of individual therapy) to paying them to manage the health of an entire insured population.
The change to payment for value (outcomes) is driving healthcare delivery systems to engage in task shifting, using less specialized (and less expensive) providers when they are able to yield good outcomes. Task shifting has been happening for decades in the U.S., as physician’s assistants and nurses, for example, have assumed many of the responsibilities previously managed exclusively by physicians. Task shifting has been used to treat mental health concerns such as depression and anxiety in low and middle-income countries where there are few specialized providers.
A particularly innovative example of task shifting is Project Echo, which trains primary care clinicians to provide specialty services by linking these clinicians via video conference to multidisciplinary teams of specialists in academic medical centers. Project Echo’s first test of its model with hepatitis C in rural New Mexico was so successful that it has been expanded to dozens of other medical conditions, including adult psychiatric and substance use disorders. The Robert Wood Johnson Foundation has funded Project Echo to treat behavioral health problems in pediatric care. The Project Echo model aims to reduce disparities in access to care, expand the workforce of behavioral health clinicians, and diffuse best practices. As some researchers have cautioned, however, there is limited evidence supporting the clinical outcomes or cost-effectiveness of this model for diseases other than hepatitis C.
The professionalization of lay counselors into “peer specialists” is an example of the further development of task shifting. In March 2017, Mental Health America, in collaboration with the Florida Certification Board and Kaiser Permanente, developed the National Certified Peer Specialist Credential, which requires background checks, work experience, training, a certification test, and continuing education. In Connecticut, Beacon Health Options, the state’s administrative care organization for Medicaid, has employed peer specialists to reduce psychiatric inpatient days by 57% for children transitioning to a different level of care.
Another market force influencing the development of new models of delivery is the Affordable Care Act (ACA). ACA funding has incentivized the further integration of medical and behavioral healthcare. Federally Qualified Health Centers (FQHCs) are perhaps the most widespread example of integrated care. Many FQHCs provide fully integrated medical, dental, and behavioral healthcare for children and adults. This facilitates “one-stop shopping” where entire families can get treatment for multiple concerns at the same site at the same time. The Affordable Care Act provided incentives for physician practices to adopt the patient-centered medical home, an integrated care delivery model with the physician at the center of a fully-integrated team that includes behavioral health specialists. The Milbank Memorial Fund recently issued a white paper outlining the many benefits of integrating behavioral health treatment within pediatric care.
Growth of Digital Technology
Digital technology – computers, the internet, mobile devices, and mobile software applications (apps) - offers considerable promise toward overcoming stigma and expanding access to evidence-based mental health care. There are digital versions of a range of evidence-based therapies, including cognitive behavioral treatments for anxiety and depression, mindfulness, interpersonal psychotherapy, and problem solving therapy. In addition, there are on-line self-help interventions for anxiety and depression such as MoodGym, which is based on cognitive-behavioral therapy and has served more than 750,000 people. When supported by clinicians, digital interventions such as MindSpot have been found to be as effective as face-to-face treatment.
Virtual reality exposure treatment, an evidence-based treatment for anxiety offers considerable promise for reaching people who might not get help otherwise. Similarly, apps for anxiety and depression and text messaging interventions for alcohol and substance abuse, both of which can reach people who might not access treatment otherwise, have been shown to be effective.
A Public Health Approach
As Kazdin has noted, to increase access to care, new evidence-based treatments will need to take more of a public health approach that considers, from the beginning of treatment development, the most effective ways to reach the most people. This will involve considering at the outset issues such as the cost of services, policy and legal constraints, and cultural and ethnic influences.
Looking to the Future
Currently, only 20% of children in the U.S. who need mental health treatment receive it, and only a third of these children receive minimally adequate treatment. A much smaller percentage of this third receives an evidence-based intervention delivered with fidelity. Poor access to evidence-based interventions is not likely to be addressed by the traditional model of individual psychotherapy. There are promising new ways of delivering evidence-based interventions that include task shifting and digital technology that will play important roles in ensuring that in the future all children in need of evidence-based treatment receive it. The design of new models of evidence-based treatment will need to take a public health approach that considers the most effective ways to reach the greatest number of people.
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Eliot Brenner is a nonprofit executive with 15+ years experience in child welfare, mental health, and philanthropy. He is also a licensed clinical psychologist with a private practice. Dr. Brenner is currently the President and Chief Executive Officer of the Child Guidance Center of Southern Connecticut, which provides mental health treatment, education, and support to more than 3,300 children annually. Dr. Brenner currently serves on the Praesidium National Advisory Council for the development and implementation of national child safety and abuse prevention policies and practices for 2,600 YMCAs that have 20,000 staff and serve 9 million children annually. Dr. Brenner holds a B.A. from the University of Chicago, where he was Phi Beta Kappa and a Ph.D. in clinical psychology from Yale University. Dr. Brenner currently serves on the Children's Mental Health Network Advisory Council.