COVID-19 provides an opportunity to design community based mental health care on digital platforms to deliver support to systematically marginalized communities. This article has been co- authored by Adam Brown, Sudeshna Mahata, Manaswi Sangraula, and Kendall Pfeffer. This article was originally published in Pandemic Discourses.
Over the course of the past year and half, there has been significant concern about the global impact of COVID-19 on mental health and wellbeing. Repeated studies show elevated rates of anxiety, depression and general distress in many parts of the world.[i] This is coupled with the ongoing disruptions or closure in the provision of mental health and social welfare services.
Limited access to critical lifesaving resources like ventilators and vaccines in both low-to-middle income countries (LMICs) and the United States is emblematic of the broad scale health inequalities that have most impacted communities of color, who have been hit the hardest by COVID-19. This has been reflected in mental health outcomes and underscores the treatment gap that has stood as a barrier to care for many marginalized persons well before the pandemic exacerbated it. Of course, the ability to access mental healthcare varies considerably by a wide range of geographic, economic, technological, political, and social determinants, which further underscores the need to identify ways to reduce barriers to care for individuals experiencing distress.
Throughout the world, issues of stigma, systemic inequities in access to mental healthcare, lack of trust in traditional healthcare systems, underrepresentation of BIPOC individuals among healthcare providers, and interventions that are not aligned with the cultural and contextual beliefs of the community receiving care have contributed to major, ongoing challenges. These changes have been a barrier for receiving appropriate mental health care which has disproportionately impacted the BIPOC community.
In the early days of the pandemic, we witnessed a rapid shift towards bringing healthcare services online to overcome the challenges of in-person appointments. This was certainly true of mental health support and counseling in places like New York City. Although remote (not in-person) mental health therapy is in many respects not new (i.e., smartphone apps, video sessions, telephone), COVID-19 greatly accelerated discussions about who can be reached, and how, through digital mental health tools. Throughout the world, issues of stigma, systemic inequities in access to mental healthcare, lack of trust in traditional healthcare systems, underrepresentation of BIPOC individuals among healthcare providers, and interventions that are not aligned with the cultural and contextual beliefs of the community receiving care have contributed to major, ongoing challenges. These changes have been a barrier for receiving appropriate mental health care which has disproportionately impacted the BIPOC community. Within the global mental health field, much attention has been devoted to addressing the gaps and inequities in care in low-to-middle income countries in humanitarian or emergency contexts; however, these issues persist in communities within the United States, and the pandemic highlighted the failure of many of our systems to provide high-quality and culturally responsive resources to systematically marginalized communities.
In the task-sharing model of care, non-specialists, or as one of our community partners coined the term “citizen helpers”, with shared lived experience are placed in the position to provide support to other community members. This helps to reduce the power disparity implicit in seeking help from traditional medical systems, fosters trust, and begins to address the need for more BIPOC and non-English speaking providers.
Over the past few years, many organizations have embarked on the development of a number of task-sharing mental health strategies. Given the major gap between the mental health burden and limited availability of specialists and infrastructure (e.g. hospitals, clinics) needed to provide such support, efforts are being made to train non-mental health specialists in basic forms of psychosocial support to increase access to mental health care. Overall, care from non-specialists has been found to be clinically effective.[ii] Some studies have even found care by non-specialists is just as effective as care delivered by specialized or licensed providers. Additionally, task-sharing addresses many of the barriers to care that contribute to health disparities, not merely the oft-mentioned treatment gap. In the task-sharing model of care, non-specialists, or as one of our community partners coined the term “citizen helpers”, with shared lived experience are placed in the position to provide support to other community members. This helps to reduce the power disparity implicit in seeking help from traditional medical systems, fosters trust, and begins to address the need for more BIPOC and non-English speaking providers.
Although this is not meant to replace higher levels of specialized care, recent findings demonstrate that PM+ is one promising way to help reduce distress in contexts where there are challenges to accessing traditional forms of mental healthcare.
Problem Management Plus (PM+) is one of these task-sharing interventions that was designed by Trauma and Global Mental Health Lab at the New School for Social Research in partnership with IFRC Psychosocial Centre, George Washington University Global Mental Health EQUITY Lab, and SOS Children’s Villages. PM+ explored whether it was possible to rapidly adapt task-sharing intervention to provide support to vulnerable communities during the pandemic. Specifically, the strategies employed in PM+ are (a) problem solving, (b) stress management, (c) behavioral activation (i.e., staying motivated) and (d) accessing or strengthening existing social support. PM+ focuses on practical and emotional problems by providing clients with tangible, transferable skills to manage their problems, which build self-efficacy at an individual and offers the potential to empower communities to build mental health capacity from the inside out. Although this is not meant to replace higher levels of specialized care, recent findings demonstrate that PM+ is one promising way to help reduce distress in contexts where there are challenges to accessing traditional forms of mental healthcare. For example, there are now several randomized control trials demonstrating that individual and group-delivered formats of in-person PM+ are effective.[iii]
To date, however, there are several questions about PM+ that have yet to be examined. First, current research on capacity building interventions such as PM+ has focused on low-resourced contexts. Second, PM+ has only been rigorously studied in an in-person format. Therefore, it is unknown if providers of PM+ could be trained remotely and whether the intervention itself could be delivered online. Third, while PM+ was designed to be delivered by people with little to no background in mental health support in the context of a public health emergency such as COVID-19, it might be useful to have a brief, manualized, trans-diagnostic intervention in place. This plan could be rolled out quickly on a large scale and should be designed to address a range of mental health concerns. It was in this context that our research lab began conversations with other organizations about adapting PM+ for remote training and delivery. So what did we learn from PM+ about these questions? What are the benefits of having ‘non-health professionals’? Do they relate better to the community? How does online consultation overcome infrastructure barriers?
It must be noted that the trainings took place in the summer of 2020, soon after the murder of George Floyd and at the height of the Black Lives Matter protests. As a result, those participating in the training not only found themselves in intellectual and emotional dissonance, but the training itself became a safe space to discuss the events, what it meant for them personally, and how it shaped their thinking about their individual goals and equity in mental health care more broadly. It also created a learning environment that was both vulnerable and generative. The structure, implementation and relevance of PM+ was openly examined, questioned and adapted. For example, the importance of provider self-care in task-sharing models, particularly when citizen Helpers are living and coping with problems similar to their clients (e.g., working multiple jobs to make ends meet, daily encounters of prejudice and the knock-down effects of systemic racism), was a frequent topic. While the risk of over-burdening providers (e.g. community health workers) when shifting mental health responsibilities onto non-specialists has been well documented, this dynamic connotes additional concerns when we consider mental health delivery within marginalized communities in the United States. These discussions were the genesis of an adapted course-style training model in which PM+ Helper trainings take place over several months, with once weekly meetings, to mitigate the risk of burnout. There were ongoing discussions throughout the training about the underlying assumptions of an intervention designed for global reach and the limits of what it can change such as individual vs. systemic causes of stress. Such emergent and meaningful conversations continue to play an important role in our work as a research group, as we try to better understand how capacity building can be used as a tool of empowerment and political change and how best to adapt PM+ within different local contexts.[iv]
Although preliminary, the findings are very promising. Thus far, most people who complete PM+ remotely are showing a reduction in several measures of distress, including anxiety and depression symptoms. Furthermore, the program is designed using a set of digital tools to examine the competencies of people being trained via live roleplay assessments in which the trainee practices their skills with an actor simulating a client the trainee might encounter within their community. One of the concerns about task-sharing models that has emerged frequently in conversations with community partners and citizen Helpers is that it may be perceived as another instance of substandard care. A competency-based training model ensures that citizen Helpers have achieved necessary benchmarks and skills to deliver high-quality care. Technical skills such as recognizing high-risk clients in order to make referrals to more specialized services when necessary, and intervention-specific skills like training individuals on how to teach the PM+ strategies are integrated into the training. Critical therapeutic and basic helping skills can all be taught to non-specialists, and competency-based assessments ensure that those receiving care in a task-sharing intervention meet cultural needs as well as ethical and technical standards.
The pandemic forced us to think quickly about how we can bring together digital tools and community-based strategies to rapidly deliver support in a way that is grounded in cultural and scientific frameworks.
We are also seeing excellent retention. Very few people drop out once they begin PM+. Importantly, the post intervention interviews we are conducting are highlighting the many ways people are bringing these skills into the most personal and important aspects of their lives, frequently sharing the skills they acquire with loved ones and children. Although this is not meant to be a replacement for long-term therapy, the brief, structured, and action-oriented nature of the intervention seems to be resonating with those who received PM+. As one of our community partners said, “People who are unlettered have been taking care of each other throughout time. [In PM+] the clinician is not the lead, it’s the person who has the concern. It is an important paradigm shift”. There are still many big questions we need to answer when it comes to the remote delivery of task-sharing and capacity building interventions, especially in places like NYC.
The pandemic forced us to think quickly about how we can bring together digital tools and community-based strategies to rapidly deliver support in a way that is grounded in cultural and scientific frameworks. Although COVID-19 has been grueling on the mental health and wellbeing of so many, community-based efforts such as these, are giving us hope that we will emerge from this with new learning and strategies that may ultimately transform mental healthcare into a more equitable system.
Adam Brown is the Vice Provost for Research and Associate Professor of Psychology at the New School University, where he directs the Trauma and Global Mental Heath Lab. He is also an Adjunct Assistant Professor in the Department of Psychiatry at NYU School of Medicine. His work focuses on the identification of factors that contribute to mental heath issues following exposure to traumatic events and building large-scale capacity for mental health through community-based strategies.
Kendall Pfeffer is 2nd year clinical psychology PhD student at The New School, whose research is focused on training, supervision and sustainability of community-based and task-sharing interventions for under-resourced and minoritized communities. She is currently conducting a single-arm trial of Problem Management Plus for COVID-impacted New Yorkers and co-facilitating remote PM+ Helper trainings and supervision for staff at local community-based organizations.
Sudeshna Mahata, an alumnus of Parsons School of Design at The New School is a systems thinker and transdisciplinary designer working at the intersection of design, technology, and psychology. Evangelizing design thinking and futures thinking, her work focuses on facilitating co-creative and collaborative spaces for capacity building.
Manaswi Sangraula is a postdoctoral researcher at The New School for Social Research and Zolberg Institute of Migration and Mobility. Her work focuses on the intersection of culture and mental health, migration, and the implementation of task-sharing interventions in low-resource settings.
[i] Ahmed et al., 2020; Brooks et al., 2020; Pierce et al., 2020; Rossi et al., 2020; Torales et al., 2020; Twenge & Joiner, 2020; Xiong et al., 2020
[ii] Cuijpers 2018
[iii] Bryant et al., 2017; de Graaff et al., 2020; Rahman et al., 2016, 2019
[iv] Kormendi & Brown, 2021