Navigating the U.S. behavioral health care system can be overwhelming, especially for people living with mental illness or substance use disorders, making the daily fight toward recovery seem insurmountable. The demoralizing experiences range from encounters with providers who may not listen or understand what patients want from care, to visits that seem too short to resolve a multitude of long-term problems, to appointments that conflict with everyday responsibilities. Securing appointments and navigating the insurance process is complicated enough for middle-class Americans with English as a first language; it can be a maze for anyone with limited English proficiency, multiple jobs with reduced time availability, or reasonable distrust in public institutions. And for those who finally do access care in community clinics, long-term recovery outcomes can initially seem like a low return on investment, with many appointments far in between and high provider turnover. Exacerbating these problems is that the quality and outcomes of behavioral health care are worse for people of color than for the non-Latinx white population.1
Given the high demand for, and burnout among, providers in low-resource settings, how do we build a behavioral health care system that not only stays afloat but that strives toward providing optimal evidence-based services? How do we rapidly grow a culturally and linguistically adequate workforce that resembles the changing demographics of the patient population and that best represents their interests? The following six strategies offer potential innovation to expand and strengthen the workforce in mental health and substance use treatment services.
PROMOTE SHARED DECISION MAKING TO IMPROVE INTERPERSONAL AND CLINICAL SKILLS
The Mass General Health Decision Sciences Center defines shared decision making (SDM) as “a communication process by which patients and clinicians work together to make optimal health care decisions that align with what matters most to patients.” This is our best chance at personalized medicine. A systematic review of SDM interventions among disadvantaged groups (i.e., ethnic minority, low literacy, low socioeconomic status, or medically underserved) indicates significant improvements in patient knowledge, participation in decision making, and many aspects of decision quality.2 Studies of ethnic-minority patient preferences in SDM suggest that interventions highlight trust building as the foundation for long-term patient activation, and reconceptualize SDM as a dynamic state that can evolve with patient preferences over time.3 SDM interventions designed for mental health or substance use disorder treatment are still emerging, and it is essential to tailor them to the specific needs of disadvantaged groups.3 The small samples, variation in study designs, and lack of representation of racial/ethnic minority populations in these studies warrant more research—ideally through randomized, controlled trials—before SDM can be recommended for racial/ethnic minority patients. SDM interventions are unlikely to be harmful, however, and incorporating and evaluating SDM in ongoing behavioral health education presents an important and sustainable opportunity to reduce service disparities.
PRIORITIZE PUBLIC RESOURCES TO FUND THE MENTAL HEALTH SYSTEM
Similar to the Affordable Care Act, universal coverage in Massachusetts, and the Mental Health Services Act in California, we need to advocate for more structural public support to cover mental health. The Mental Health Services Act, including a 1% tax on Californians who earn more than $1 million, pays for expanded mental health care; $2 billion a year has been raised for mental health services. The act led to expanded access to therapy and case management for almost 130,000 young people in Los Angeles County.4 It is remarkable that 65% of the youth served were new clients, and while youth of all ethnic/racial backgrounds responded well to the services, Latinx and Asian youth had especially good outcomes relative to other programs. This tax has given California counties $16.53 billion from 2005–18. The RAND Corporation evaluation demonstrated that the policy succeeded in reducing homelessness, incarceration, and hospitalization among people with mental illness, and that it improved the well-being of people served by the funded programs.4 Policy makers nationwide are encouraged to follow California’s lead and to consider adopting such policies.
UTILIZE PEER-SUPPORT SYSTEMS IN RECOVERY
A rapidly growing component of the behavioral health workforce in the United States is peer-delivered recovery support services. Sometimes called peer-support specialists or recovery coaches, these individuals with lived experience in long-term recovery are trained and hired to provide a range of services, including connecting people in institutions with local, community-based resources and helping them navigate new daily routines. Some evidence supports the effectiveness of peer-delivered recovery support services in improving substance use and overall well-being outcomes in ethnically diverse samples,5 and the Centers for Medicare and Medicaid Services classify many peer-based services as part of an evidence-based, reimbursable model of care. Yet the professionalization of peers is relatively new; we need more-rigorous research methods using appropriate comparison groups (preferably through randomized allocation) and benchmarks of effectiveness. This research can help determine how to best scale up and sustain an effective peer workforce with appropriate training, supervision, and supports. We know that accessibility and attainment of recovery resources (i.e., social support, health insurance, employment) can aid remission from substance use disorders through reducing biopsychosocial stress.6 Thus, peer support specialists present an opportunity to reduce racial/ethnic disparities in recovery outcomes by strengthening the recovery capital of disadvantaged groups, who are less likely to have the financial resources and more likely to experience additional stressors like discrimination. Research evaluating peer-delivered services should expand outcomes to include recovery-resource domains such as housing stability, employment, educational status, and social support.
OPEN OPPORTUNITIES TO AN AVAILABLE IMMIGRANT WORKFORCE
Approximately one in three psychiatrists nationwide graduated from a foreign medical school, and in some states, it is one in two.7 Foreign-born health professionals in the United States already play a large role in serving mental health needs of underserved populations, especially in rural counties, and are essential to meeting the growing psychiatry workforce shortage.7 The Cuban Adjustment Act of 1966, which allowed Cubans to become permanent residents at least one year after arriving in the United States, enabled many to practice their health professions under licensed supervisors. At least in the short term, we should offer similar opportunities for immigrants to obtain licensure in mental health care through supervised work. This change would cultivate a linguistically and culturally diverse workforce, which is necessary to meet current demand and fill future shortages.
DEVELOP MOBILE APPS FOR CHWs TO BECOME A FLEXIBLE WORKFORCE
Well-trained, supervised, and supported community health workers (CHWs; i.e., lay providers, indigenous paraprofessionals) have shown potential to improve access to care, quality of care, and health equity in low-resource communities for people with mental health and substance use disorders.8 Oftentimes, they establish the trust of marginalized people, who see them as one of their own. Mobile apps have recently been developed to coordinate CHW work within community-based organizations and to integrate CHWs into primary and secondary care teams. To our knowledge, however, no current app connects care providers and managers with behavioral health CHWs for on-demand, short-term work. Similar to the Care.com model, which connects families with caregivers, an app could allow providers, care managers, and researchers to hire credentialed CHWs for specific time-sensitive projects, such as delivering psychoeducation interventions, linking people in acute care with more long-term community-based resources, and providing social support.8 Key considerations include protections for workers and ensuring state health-system standards of credentialing and supervision. Importantly, this option is designed to expand coverage for extra supports during critical periods (e.g., transitions in early recovery, when relapse risk is higher) and is not an alternative to professional providers for long-term recovery maintenance. There are already over 120,000 CHWs nationwide, and creating this digital platform could ameliorate service disparities by growing the CHW workforce and connecting them with the communities where they are most needed.
UTILIZE TELEHEALTH AS A MEANS OF SERVICE DELIVERY
Technology has shown promise as a means of service delivery, including telehealth (e.g., sessions by phone or videoconference), smartphone apps, and video interventions. Benefits include convenience, accessibility, affordability, and stigma reduction. A systematic review and meta-analysis of nine randomized clinical trials showed that total anxiety scores were significantly reduced in smartphone interventions.9 Initial evidence suggests telehealth can improve mental health care access for rural residents,10 which is promising since public mental health services are becoming more selective and specialized, excluding hard-to-reach populations. Smartphones are already helping black and Latinx populations to bridge the digital gap with whites, providing support for the feasibility of telehealth and its promise for bridging racial/ethnic disparities in access to behavioral health care.
Some of the above suggestions are in their infancy, requiring development and evaluation, while others have worked and now require adaptation, replication, and implementation. They all share the perspective that moving the psychiatry field forward should begin with investing in the people on its front lines and by supporting communities that continue to be underserved. Like prior proposals in this Disruptive Innovation series, these strategies aim to balance core values that promote innovation in psychiatry: inclusiveness and community, optimism and sensibility. Given all we know, we can accelerate innovations in behavioral health to ensure we build a system of care that represents the twenty-first century and is equitable for all.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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