Beyond the Guild

New Models for Mental Health-Care Delivery

Mary M. McKay, New York University, discusses her research on Multiple Family Group Therapy, which treats children with conduct issues by addressing overall family dynamics.

Despite the recent national focus on increased access to health care, 55 percent of counties in the United States still have no practicing psychiatrists, psychologists, or social workers. It is clear from such arresting statistics that mental health-care delivery needs radical change. Clinicians and researchers are beginning to think beyond the guild — the federation of psychologists and psychiatrists who provide traditional mental health services — to find new and innovative ways to reach underserved populations in rural and urban communities.

A panel of experts came together at a symposium at the 25th APS Annual Convention to discuss the benefits and logistical challenges of expanding mental health care delivery. The panelists said a major challenge is fitting the latest scientific knowledge and training into real-world clinical settings, where understaffed clinics often struggle with limited resources. A key change will involve expanding teams of providers beyond psychologists and psychiatrists to include social workers and trained parent advocates and family members.

“We very much want to integrate the voices of parents and young people into our services to adapt our science to meet their needs in better and better ways,” said social worker Mary McKay.

McKay, a professor and the director of the McSilver Institute for Poverty Policy and Research at New York University, is putting this idea into practice with her research on an approach to treating children with conduct issues. Called Multiple Family Group Therapy, it is designed to address overall family dynamics rather than a single behavioral problem. Groups are made up of six to eight families, including children, their parents, and others that make up the support networks. The groups are led by facilitators as families share information and discuss concerns to improve communication and support. McKay’s own research has borne out the effectiveness of this nontraditional model, showing that not only are families much more likely to stick with this program than typical treatment paradigms, but that it also has a significant positive effect on children’s conduct difficulties and family dynamics.

Jennifer Watling Neal, an assistant professor of psychology at Michigan State University, hopes to improve mental health-care delivery to children in a different setting: their schools. Using social network modeling  to examine  patterns of relationships between the individuals or components that make up a social system, Neal has looked at the relationships among teachers to determine their influence on each other’s practices, specifically when it comes to trying new classroom initiatives. She has found that rather than adopting practices in the top-down manner that many school implementation policies assume, teachers are more likely to adopt the same practices as those who occupy similar positions in their network (e.g., they give advice to the same people). This finding could have implications for the way implementation practices are designed in the future.

According to Lawrence Wissow, a professor of health, behavior, and society at the Johns Hopkins Bloomberg School of Public Health, another nontraditional but viable setting for mental health services is primary care, which often serves as patients’ main point of contact with the health-care system. But retrofitting traditional mental health treatment modalities into a primary care setting is no simple task.

Take mental health screening. Wissow says there are significant pros for these assessments, including their universality and reliability, which assures that a practitioner need not be an expert in mental health to administer or score them. However, these general screening tools tend to be poor predictors of actual psychopathology, and in a one-stop-shop environment like primary care, they can be overshadowed by other medical concerns or seen as just another piece of paperwork to complete. But they still have value, as “experienced clinicians use screenings in very creative ways,” said Wissow. Doctors use the screening as an icebreaker to talk about difficult issues; the patient’s answers become talking points for issues they might not otherwise raise with their primary care physician.

“Deguilding” the mental health-care system can be effective in improving outcomes, panelists agreed, but must focus on systemically redesigning the delivery of services — using practices that are not only evidence-based but work in the real world.

References

McKay, M. M., Gopalan, G., Franco, L., Dean-Assael, K., Chacko, A., Jackson, J. M., & Fuss, A. (2011). A collaboratively designed child mental health service model: Multiple family groups for urban children with conduct difficulties. Research on Social Work Practice, 21, 664–674.

Neal, J. W., Neal, Z. P., Atkins, M. S., Henry, D. B., & Frazier, S. L. (2011). Channels of change: Contrasting network mechanisms in the use of interventions. American Journal of Community Psychology, 47, 277–286.

Observer Vol.26, No.6 July/August, 2013

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