As the COVID-19 pandemic and its economic effects spread, concerns about mental health impacts continue to grow. For example, we worry for health and human services professionals whose duties involve higher risk for trauma exposure and post-traumatic stress. Reports of global increases in family violence also suggest that there will be many violence victims and witnesses in need of mental health support. Add to this the potential effects of social isolation, health-related anxiety, and that these mental health problems may persist and worsen long after society goes back to “normal.”
And this is all happening as the United States already was facing a mental health crisis: Suicide rates going up. Tens of thousands of overdose deaths attributed to opioids. And in any given year, an estimated 19% of adults and 17% of youth will experience mental illness, including common conditions like depression and anxiety.
Yet even in “normal” times — apart from this pandemic — a large proportion of those who need mental health or substance use treatment never get it. It is simply hard to find care in the United States — especially evidence-based treatment. Waiting lists are often months long, and in some regions people must travel hundreds of miles to reach the nearest psychiatrist. Mental health care also can be very expensive; many providers do not take insurance and require that patients pay out of pocket. In short, our mental health system is already strained and the number of people needing help is continuing to grow.
COVID-19 has forced fast changes to laws, allowing increased access to tele-medicine for mental health, as one example. But most of this work still relies on traditional mental health providers: psychologists, psychiatrists and clinical social workers. Some communities, however, have been experimenting with new and innovative mental health approaches. For instance, New York City leaders have recognized that many things mental health professionals do don’t require a graduate degree or license in a mental health or medical field. Since 2016, as part of the city’s Connections to Care (C2C) program, community-based organizations (CBOs) have been offering screenings for common mental health problems such as depression and anxiety, as well as psychoeducation and other counseling strategies, with training and support from a licensed mental health provider (MHP) organization. The majority of C2C clients are low-income, ethnic minority New Yorkers — the same population who is most highly impacted by COVID-19.
When the screening questions suggest a client might need further assessment or treatment, the trained CBO staff helps them connect with a clinician. Through C2C, CBOs and their MHP partners create and strengthen new referral pathways, removing logistical barriers to engaging in care. CBOs also deliver or help people find services such as peer support groups and workshops for increasing coping skills. MHPs offer ongoing treatment for those with more acute needs. Although the program was designed for in-person interactions, CBOs and their MHP partners have continued much of their work via telephone and video chat during the pandemic. As a result, CBOs and MHPs have been able to continue their “warm handoffs” through 3-way calls, provide virtual support and psychotherapy groups, and provide CBO staff support as they maintain contact with some of those most impacted by COVID-19.
C2C is one example of mental health “task-sharing” or “task-shifting,” a model where some activities — screening, active/supportive listening, and other elements of mental health care — can be taken on by people outside the traditional mental health workforce. This then allows psychologists and psychiatrists to devote more of their time to specialized and complex tasks, such as diagnostic assessments, prescribing psychiatric medication, and therapies.
Similar models also have been used across the world. Zimbabwe’s Friendship Bench program, for instance, trains grandmothers in active listening and an evidence-based approach to treating depression called cognitive therapy. The grandmothers sit on park benches, available for people seeking help. Although sitting side-by-side on a park bench may be unadvisable during this pandemic, it is not hard to imagine the utility of making trained, friendly community members available (e.g., via telephone or video chat) for people who need someone to talk to about their depression or anxiety.
Task sharing also can reduce stigma around mental health care: For some it may feel easier to talk about feelings of depression with the job developer who has been helping you find work than it is to make a formal appointment with a mental health provider.
If trends continue, the mental health workforce won’t be able to meet the level of need without including these “nontraditional” workers. We should expect similar task sharing models to pop up in more and more communities in the future.
We’ve been studying New York’s Connections to Care program for several years, and based on that we have some recommendations for how to maximize the success of mental health task sharing. First, good training and supervision are critical and community organizations should enlist a trusted, licensed mental health provider as a partner. In addition, the tasks to be shared should be ones that are shown through research to be effective in detecting or reducing mental health symptoms. They should also be tasks that ethically and legally can be performed by people without formal mental health training and licensure.
Many communities and policymakers are desperate to stem the tide of unaddressed mental health needs, and with the right investments in training, task-shifting models have enormous potential to bolster available, accessible mental health services.
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