Internet Editor’s Note: Drs. Amantia Ametaj, Shannon Sauer-Zavala, and colleagues recently published an article titled “Evaluating Transdiagnostic, Evidence-based Mental Health Care in a Safety-net Setting Serving Homeless Individuals,” in Psychotherapy.
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Homeless and vulnerable individuals experience higher rates of mental health difficulties (National Institute of Mental Health, 2017) and are less likely to receive mental health care than the general population. Many of them meet criteria for multiple chronic psychological and medical morbidities (for example, severe mental illness, substance misuse, and diabetes) in addition to facing frequent financial and social stressors (Substance Abuse & Mental Health Services Administration, 2015). Due to the low availability of care, most vulnerable patients rely on safety-net clinics to receive medical and mental healthcare services (Burt, Khadduri, & Gubits, 2016). These settings accept patients that are uninsured or on Medicaid and are often overwhelmed with a high volume of cases. Similarly, mental health providers in these settings tend to be overburdened by heavy caseloads with a high numbers of patients with complex needs. As a result of a taxed and low-resourced system, clinician burnout and turn-over is high and patients’ complex mental health needs may go unmet.
Evidence-based treatments (EBTs), especially newer transdiagnostic approaches, may be one potential solution to some of the problems faced by low-resourced and overburdened settings, like safety-net clinics. EBTs are psychological treatments with clearly defined therapeutic procedures that are measured for their impact in rigorous clinical trials (APA Presidential Task Force on Evidence-Based Practice, 2006; Kazdin, 2008). EBTs may be helpful in safety net settings as they are particularly adept at offering fast-acting, efficient, and cost-effective care (Clark, 2018). EBTs have the most research-support of any therapeutic care and are designed to deliver benefits in a short period (e.g., three to four months). Thus, vulnerable individuals that face multiple stressors and experience transient lives would likely benefit from the most potent and fast-acting interventions available.
The Promise of Transdiagnostic Treatments
Transdiagnostic treatments, a type of EBT, might be especially helpful in low-resourced settings, like safety-net clinics, by addressing common barriers to implementing EBTs. Typical barriers include cost of EBT training, time burden for clinicians of learning and applying an EBT, and low added benefit of providing one EBT for one disorder only. On the other hand, transdiagnostic treatments like the Unified Protocol (UP; Barlow et al., 2018) are designed to target multiple common mental health disorders with one treatment, including anxiety, depression, traumatic stress, and substance use disorders (Barlow et al., 2017; Boswell, Anderson, & Barlow, 2014; Ciraulo et al., 2013; Gallagher, 2017). As such, these treatments may be helpful for homeless and vulnerable patients, who could receive one course of care to address most of their mental health needs. Also, these treatments may reduce therapist training burden and cost of training given that one protocol can treat most common mental health problems (McHugh, Murray, & Barlow, 2009).
Implementing the UP in a Safety-Net Setting
Together with a team from Massachusetts General Hospital (see original articles, Sauer-Zavala et al., 2019; Youn et al., 2019), our group conducted a small, pilot study testing if the UP could be delivered in a safety-net clinic in Boston, Massachusetts. As a first step, focus groups were held with patients, providers, and administrators in the safety-clinic to gather their opinions on the treatment and potential factors that would either help or impede its application. Overall, patients, providers, and administrators saw a need for the UP and felt it would be a helpful addition. However, barriers to deliver the UP included that providers experience heavy workloads and have insufficient time to see all their patients. Also, high staff turnover, staff burnout, and fatigue from recent changes (implementation of electronic medical records) were identified as possible problems. Despite these barriers, administrators were hopeful that the UP would help clinicians and that it would be in line with clinic requirements and supports for professional training.
Feedback from focus groups and close collaboration with clinic staff was used to guide most study and treatment delivery procedures. A shortened version of the UP, which was recently abbreviated to five modules for patients undergoing brief inpatient stays at an area safety-net hospital (Bentley et al., 2017), was selected given the similarities between patient populations and clinical presentations (e.g., substance misuse, housing instability). Also, the office-based addiction treatment program was chosen to deliver the UP given that patients attended treatment regularly to receive medication-assisted opioid treatment (e.g., buprenorphine and naltrexone) in addition to counseling and case management. Lastly, we changed the UP delivery based on feedback from focus groups, including having clinicians select a UP skill most relevant to each session given their frequent focus on crisis management with their patients. Since the UP is modular, it can be re-ordered without impacting the quality of care (see, Sauer-Zavala, Cassiello-Robbins, Ametaj, Wilner, & Pagan, 2019). In addition, many study procedures, including patient recruitment, were decided in collaboration with clinic staff who understood the clinic best.
The “Messy” Reality of Community Clinics
Overall, the study yielded mixed results with regard to acceptability and feasibility of the UP in this setting. Two clinicians were trained on the UP and provided the treatment to three patients in full and three patients partially (who received two-four skills). Typically, there are four clinicians in the clinic, but one position was unfilled, and one clinician declined participation in the study due to being busy. The two clinicians that participated reported favorable view of the UP, learned the treatment quickly, and applied it with fidelity based on expert ratings of their audio-recorded sessions. At the same time, the clinicians reported being strapped for time and not being able to deliver the treatment at times, veering off from skills to focus on crises.
Patients’ acceptability and feasibility data were also mixed. Patients seemed to understand the UP skills based on their scores (average of 82%) on our knowledge acquisition quizzes that were given after each completed module. Also, patients reported strong satisfaction with the UP. However, despite understanding the skills and finding the UP acceptable, only three of six patients completed treatment and data from all six showed limited change on symptoms of anxiety and depression following treatment. Unfortunately, there was a lot of variability among individual patients and our small sample size precludes us from drawing conclusions. To understand whether the results from the small study can be improved, a larger scale effectiveness study that addresses the above-mentioned barriers and compares the UP with the treatment as usual is needed.
Lessons for the Future: How Flexible Can EBTs be Before They Break?
The tension between fidelity to the original treatment and flexibility of its application to a specific setting and/or patient has persistently plagued EBTs and is a particularly important question for low-resourced settings like safety-net clinics. Many research questions need further exploration. For example, what is the lowest “dose” of an EBT that a patient can receive and still improve in meaningful ways? How can clinicians “follow the recipe” outlined in the manual but deviate and “substitute ingredients” as needed without replacing the whole original dish (i.e., fidelity)? In our case, the clinicians in the study met fidelity criteria and patients learned the information about UP skills, but clinicians reported feeling pulled away from the manual to address crises. Also, learning information and applying skills differ greatly (as most of the readers likely know, regular physical exercise improves health, but most likely do not meet the minimum criteria of recommended exercise each week).
Clinicians in safety-net settings face a number of obstacles to flexibly applying an EBT like the UP and patients face many obstacles to practicing their treatment skills. At the same time, it is important to help clinicians to flexibly apply EBTs even in the face of crises. Patients can learn to apply skills learned from EBTs to manage difficult situations and reduce their suffering. However, many clinicians who were not trained in EBTs feel confined by the guidelines and unempathetic in their delivery, often dropping the protocol when it may be most useful. Even flexible and principle-based treatments like the UP can be difficult for therapists to apply in the face of patient crises. Perhaps, more research is needed on how to standardize flexibility.
Transdiagnostic treatments hold promise for helping patients in low-resourced settings received the care that they need. These treatments may address several common barriers that community clinics may face in adopting traditional EBTs. Our preliminary results, including enthusiasm from the providers and patients for the treatment, indicate that the UP may be seen as acceptable in low-resourced clinics. However, many barriers were identified during this small pilot study that need to be addressed and several questions about implementing EBTs remain. Overall, conducting research in community clinics provides helpful information about necessary changes to EBTs developed in academic settings that could increase the likelihood that they are adopted in the real world.
Cite This Article
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