Mental Health Task Sharing: Training Volunteers, Peers, and Interns

Abstract:

In task-sharing models, specific mental health tasks typically delivered by a licensed mental health clinician are assigned instead to a non-licensed individual. These approaches may address unmet mental health needs in rural and other low-resource areas. A growing body of evidence supports the feasibility, acceptability, and effectiveness of task sharing. Do More, Feel Better (DMFB) is an example of a mental health task-sharing approach for older adults with elevated depressive symptoms. DMFB is a streamlined behavioral activation program provided virtually by older adult peers, other volunteers, and social work interns who have been certified as coaches.

Key Words:

task sharing, lay health counselor, late-life depression, telehealth, mental health services

Depression has been identified as a leading cause of personal suffering, disability, and rising healthcare costs (Liu et al., 2020). There are substantial gaps, however, in the availability of mental health treatment across the United States, particularly for older adults. The reality is that few older adults with depression receive any sort of mental health treatment (Olfson et al., 2016). Lack of mental health care is due to many factors, including limited availability of geriatric mental health providers and lack of services that older adults find acceptable.

Task-sharing models have been proposed as one solution to address this treatment gap and represent an innovative way to offer acceptable and effective mental health services to older adults with mental health conditions. For example, landmark reports from the Institute of Medicine (2012) and the Substance Abuse and Mental Health Services Administration (SAMSHA) have recommended building up the workforce of nontraditional providers (SAMHSA, 2012). In task-sharing models, specific mental health tasks typically delivered by licensed mental health clinicians are assigned instead to non-licensed individuals or lay staff who have received appropriate training. These types of task-sharing approaches were first developed and tested in a number of low- and middle-income countries, such as India and Nigeria. Such efforts have typically involved training lay health providers, or those without formal mental health expertise, to provide specific brief behavioral interventions.

Research has documented that such task-sharing interventions are feasible, acceptable, and effective in treating and preventing depression. For example, the Healthy Activity Program (HAP) used lay counselors for a 6- to 8-week behavioral activation intervention delivered in 10 primary health centers in Goa, India (Singla et al., 2019). In rural Zimbabwe, village health workers were trained to deliver a 6-session problem-solving intervention designed for pregnant women with symptoms of depression. The “Friendship Bench” intervention used in the study was based upon Indigenous concepts of problem-solving such as uplifting, strengthening, and engaging the mind (Fernando et al., 2021).

Task-sharing approaches also have been implemented in high-income countries, most notably England’s National Health Service Talking Therapies (formerly known as Improving Access to Psychological Therapies; Wakefield et al., 2021). In this stepped-care program, patients are offered low-intensity mental health services before consideration for “stepping up” to a higher level of intervention. The low-intensity component of Talking Therapies makes use of Psychological Well-being Practitioners (PWPs). PWPs are non-specialists with some college or equivalent background who are trained to deliver brief structured behavioral interventions, conceptualized as a form of guided self-help. Only those patients who have high levels of functional impairment, more severe disorders, or who do not respond to lower intensity services are offered higher intensity services such as psychotherapy. This Talking Therapies model has shown clinical benefit to both mid-life and older adults (Prina et al., 2014).

Researchers in the United States also have begun to develop and test task-sharing models, in particular for older adults with depression or generalized anxiety. This emerging evidence suggests that lay health, peer, and bachelor’s-level providers may achieve clinical outcomes comparable to professional psychotherapists (Choi et al., 2020; Raue et al., 2019). Below, we highlight our own task-sharing program called “Do More, Feel Better” (DMFB) for community-dwelling older adults with depression (Raue et al., 2019, 2021).

Task sharing thus has great potential to support the reach and depth of mental health services. An important additional benefit is that licensed clinicians are able to focus on and use their advanced skills (i.e., psychotherapy) for individuals with more severe mental health conditions. Task-sharing approaches thereby provide opportunities for more individuals at all levels of need to receive services. Task sharing can be particularly helpful in addressing unmet mental health needs in rural and other low-resource areas where there are a limited number of licensed clinicians.

Opportunities for Task Sharing in Care Settings for Older Adults

Senior centers and other care settings for elders offer opportunities to provide acceptable mental health services to older adults, a vulnerable and underserved group. We know that individuals who attend senior centers represent large numbers of mid- to low-income older adults with multiple social service needs, nutritional insecurity, and financial vulnerability (Administration on Aging, 2016). We also know that 10% to 25% of older adults who make use of senior center programs or services experience clinically significant depression (Raue et al., 2019; Sirey et al., 2020).

Currently, most centers throughout the country do not conduct mental health screening or offer treatment. And if depression is identified among older adults, few accept mental health referrals or engage in treatment (Gum et al., 2014; Sirey, 2013). However, there are opportunities to integrate mental health services within senior centers and aid them in fulfilling their mission to help older adults live in their community as independently as possible.

Task-sharing models as described above may hold particular promise to be implemented within senior centers and other care settings for older adults. Task sharing would be expected to be less costly than interventions delivered by licensed clinicians, equally effective in reducing the severity of depressive symptoms, and equally or more acceptable to older adults experiencing depression compared to clinician-delivered interventions. The acceptability of task-sharing approaches to those in need may be due to meeting with peers from their own community who understand them and can empathize with their experience. Along those lines, using volunteer or peer providers in the community provides opportunities to better serve the growing population of culturally diverse older adults.

Do More, Feel Better: A Task-sharing Intervention in Senior Centers

We have developed a streamlined Behavioral Activation intervention called Do More, Feel Better for older adults experiencing depression. We engaged in task sharing of Behavioral Activation in two different projects, a National Institute of Mental Health (NIMH) grant focused on testing the intervention provided by trained older lay health volunteers or peers (R01MH124975) and an ACL grant focused on implementing the intervention by both younger and older volunteers and by social work interns (90INNU0027). The development of DMFB was inspired by task-sharing models in low- and middle-income countries; our goal is to grow a sustainable workforce capable of providing geriatric mental health services in community settings in the United States such as senior centers.

We chose Behavioral Activation as the basis for DMFB given strong evidence for its broad use and documented effectiveness among older adults from many backgrounds (Dimidjian et al., 2011). Behavioral Activation has also been shown to be a good fit for older adults with low education levels or mild cognitive impairment. The theoretical model of Behavioral Activation proposes that depression is maintained due to consistent reduction in positively reinforcing events (Martell et al., 2013). The depressed mood that results then leads to further avoidance and withdrawal from activities, which creates a downward spiral that further increases inactivity, isolation, rumination, and low mood. Behavioral Activation intervention strategies thus include a focus on eliciting personal values, activity monitoring, and planning rewarding activities, all of which can counteract the depressive tendency to withdraw, be inactive, and isolate oneself.

While retaining the key therapeutic strategies of Behavioral Activation, we simplified and manualized the intervention to better match the skill set of lay health providers and volunteers. Also, we shortened the number of sessions from as many as 20 in some settings to nine brief sessions. A fundamental component of the DMFB intervention is helping older adults increase their engagement in rewarding and meaningful activities. DMFB retains the following core Behavioral Activation strategies:

• providing psychoeducation about depression;
• discussing the rationale for engaging in rewarding activities;
• helping the older adult brainstorm and plan enjoyable and rewarding activities to pursue in between meetings;
• helping the older adult review prior plans, reflecting on satisfaction levels and troubleshoot any barriers;
• creating new weekly activity plans for the coming week; and
• discussing relapse prevention or a “stay well” plans toward the end of the program.

We have pilot tested DMFB in senior centers as delivered by trained older adult peer volunteers for older adults with depression and found to be it to be feasible and acceptable (Raue et al., 2019, 2021). We also have successfully implemented DMFB in an Administration on Community Living grant to address associated depressive symptoms of older adults in New York City experiencing nutritional insecurity. This implementation project trained volunteers, older adult peers, and social work interns to serve as coaches.

Outreach Strategies for Identifying Volunteers

Volunteers, peers, and interns are selected based upon their interest in providing the DMFB program and for their strong interpersonal and organizational skills. We have experimented with several strategies for conducting outreach to identify qualified individuals and have had optimal success implementing three primary methods. The first strategy is a direct referral from senior center directors or a trusted and authorized individual.

The second strategy involves posting flyers, online announcements, or providing a formal “outreach presentation” of the project to the community to identify potential volunteer coaches. The final strategy uses internal partnerships, where existing volunteer coaches connect our team with community members. These outreach strategies highlight the importance of securing community collaboration when identifying lay health providers appropriate for task-sharing efforts like DMFB. Other implementation projects may recruit interns from various fields such as social work or nutrition, which can provide early training for those interested in developing early clinical skills.

Training, Certification, and Supervision

Licensed mental health or social work professionals who have been designated as master DMFB trainers can provide training and ongoing supervision for lay health volunteers, peers, and interns. Training encompasses four virtual two-hour sessions over 2–4 weeks and is designed to teach DMFB by using demonstration, roleplay, and instructional webinars. Formal certification as a coach involves individual role play of DMFB session 1 to fidelity standards. To this end, we have created a volunteer fidelity form that assesses fundamental components for administering the intervention.

Subsequently, coaches began an initial case where their ability to deliver DMFB was ensured by a supervisor. Coaches participate in weekly group supervision where cases are discussed in detail and in-session paperwork reviewed. The supervision meetings not only enhance quality of care delivery and fidelity to DMFB but also have fostered a sense of community within the group, allowing participants to exchange best practices and support each other.

Ongoing Efforts

We are conducting a large definitive study funded by the NIMH to establish to evidence base for DMFB. Participating academic sites are the University of Washington, Weill Cornell Medical College (New York City), and University of South Florida (Tampa Bay region). Across the three sites, 288 English-speaking and 96 Spanish-speaking older adults with depression are being enrolled. Half of eligible older adults will be randomized to receive DMFB, and half to receive clinician-delivered Behavioral Activation as a benchmark to evaluate the effectiveness of coach-delivered DMFB.

Most of our research activities have been conducted virtually, either via video conferencing or by telephone. The study is being conducted in partnership with eight senior centers per site, which assist with outreach and recruitment of volunteer coaches and older adults experiencing depression. Centers also have made physical space available for participants who prefer to meet in-person.

Older adult participants and volunteer coaches have reported positive experiences to date across all our projects. Many older adult participants have reported reduced severity of their depressive symptoms after 9 weeks of DMFB. They also have reported becoming more active in many domains, including increasing the quality of their social connections, physical activity, and community and recreational activities. Participants report spending more time with family and friends, participating in their local senior center, gardening, helping others, and engaging in leisure activities they enjoy.

Older adults have been able to become more active despite challenges that many typically face, such as chronic pain, difficulty getting around, being socially or physically isolated, experiencing grief over loss of loved ones, experiencing transitions in life such as retirement, and navigating COVID-related challenges. The following are select older adult testimonials:

• “I didn’t know this was something that would benefit me, but it definitely is.”
• “The program gave me an ability to cope so that’s what I really think helps so much and what I got out of it. It provided little steps.”
• “[The program] benefited me by allowing me to do things for myself, being responsible for my life and doing things to help myself. I feel, to a certain extent, that it may have saved my life.”

Our volunteer coaches have reported enjoying learning the intervention and being able to help others who are experiencing depression. They also have valued engaging with each other during group training and ongoing supervision, consistent with building a community of people interested in helping others from their community. The following are select coach testimonials:

• “You know, I really enjoyed meeting the people. I was honored that they had trust and confidence in me enough to be fairly personal and share their lives and their struggles. I was honored to have them as clients.”
• “I got something out of it too, in that these people gave me ideas and, you know, we shared information. So, it was helpful to me ... So much of the information that was exchanged was not just one way.”
• “I think this program is progress for older adults. The best part of the progress is that we are a part of it.”

Next Steps

While we complete the current study across the next 2 years, we are preparing for larger-scale dissemination. This preparation acknowledges the importance of establishing sustainable procedures for training and supervision needs, and reliable methods to assure intervention fidelity and older adult appropriateness and safety. Toward this end, we have developed an implementation manual that includes resources for service organizations in the aging sector, including guidance and tools to select, train, and supervise DMFB coaches; identify eligible older adults and enroll them in DMFB; and conduct program evaluation.

A small number of service organizations in aging outside the research study are piloting DMFB and conducting program evaluation, with ongoing technical assistance from our team. Interested senior center or aging services personnel are welcome to contact us at dmfb@uw.edu for more information.

Patrick J. Raue, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington in Seattle. He may be contacted at praue@uw.edu. Kiana Seresinhe is a research assistant in the Department of Psychiatry at Weill Cornell Medicine in White Plains, NY.

Photo credit: Shutterstock/Prostock-studio

References

Administration on Aging. (2016). Fiscal year 2015 report to Congress: Older Americans Act. United States Department of Health and Human Services.

Choi, N. G., Marti, C. N., Wilson, N. L., Chen, G. J., Sirrianni, L., Hegel, M. T., Bruce, M. L., & Kunik, M. E. (2020). Effect of telehealth treatment by lay counselors vs by clinicians on depressive symptoms among older adults who are homebound: A randomized clinical trial. JAMA Network Open, 3(8), e2015648. https://doi.org/10.1001/jamanetworkopen.2020.15648

Dimidjian, S., Barrera, M., Martell, C., Muñoz, R. F., & Lewinsohn, P. M. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology, 7(1), 1–38. https://doi.org/10.1146/annurev-clinpsy-032210-104535

Fernando, S., Brown, T., Datta, K., Chidhanguro, D., Tavengwa, N., Chandna, J., & Prendergast, A. (2021). The Friendship Bench as a brief psychological intervention with peer support in rural Zimbabwean women: A mixed methods pilot evaluation. Global Mental Health, 8, E31. https://doi.org/10.1017/gmh.2021.32

Gum, A. M., Hirsch, A., Dautovich, N. D., Ferrante, S., & Schonfeld, L. (2014). Six-month utilization of psychotherapy by older adults with depressive symptoms. Community Mental Health Journal, 50(7), 759–764. https://doi.org/ 10.1007/s10597-014-9704-0

Institute of Medicine. (2012). The mental health and substance use workforce for older adults: In whose hands? The National Academies Press. https://doi.org/10.17226/13400

Liu, Q., He, H., Yang, J., Feng, X., Zhao, F., & Lyu, J. (2020). Changes in the global burden of depression from 1990 to 2017: Findings from the Global Burden of Disease study. Journal of Psychiatric Research, 126, 134–140. https://doi.org/10.1016/j.jpsychires.2019.08.002

Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2013). Behavioral activation for depression: A clinician’s guide (Paperback ed). Guilford Press.

Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of adult depression in the United States. JAMA Internal Medicine, 176(10), 1482. https://doi.org/10.1001/jamainternmed.2016.5057

Prina, A. M., Marioni, R. E., Hammond, G. C., Jones, P. B., Brayne, C., & Dening, T. (2014). Improving access to psychological therapies and older people: Findings from the Eastern Region. Behaviour Research and Therapy, 56, 75–81. https://doi.org/10.1016/j.brat.2014.03.008

Raue, P. J., Hawrilenko, M., Corey, M., Lin, J., Chen, S., & Mosser, B. A. (2021). “Do More, Feel Better”: Pilot RCT of lay-delivered behavioral activation for depressed senior center clients. Behavior Therapy, S0005789421001350. https://doi.org/10.1016/j.beth.2021.11.005

Raue, P. J., Sirey, J. A., Dawson, A., Berman, J., & Bruce, M. L. (2019). Lay‐delivered behavioral activation for depressed senior center clients: Pilot RCT. International Journal of Geriatric Psychiatry, 34(11), 1715–1723. https://doi.org/10.1002/gps.5186

Substance Abuse and Mental Health Services Administration. (2012). Behavioral Health: United States, 2012. https://store.samhsa.gov/product/behavioral-health-united-states-2012/sma13-4797

Singla, D. R., Hollon, S. D., Fairburn, C. G., Dimidjian, S., & Patel, V. (2019). The roles of early response and sudden gains on depression outcomes: Findings from a randomized controlled trial of behavioral activation in Goa, India. Clinical Psychological Science, 7(4), 768–777. https://doi.org/10.1177/2167702619825860

Sirey, J. A. (2013). Engaging to improve engagement. Psychiatric Services, 64(3), 205. https://doi.org/10.1176/appi. Ps.640301

Sirey, J. A., Raue, P. J., Solomonov, N., Scher, C., Chalfin, A., Zanotti, P., Berman, J., & Alexopoulos, G. S. (2020). Community delivery of brief therapy for depressed older adults impacted by Hurricane Sandy. Translational Behavioral Medicine, 10(3), 539–545. https://doi.org/10.1093/ tbm/ibz145

Wakefield, S., Kellett, S., Simmonds‐Buckley, M., Stockton, D., Bradbury, A., & Delgadillo, J. (2021). Improving Access to Psychological Therapies (IAPT) in the United Kingdom: A systematic review and meta‐analysis of 10‐years of practice‐based evidence. British Journal of Clinical Psychology, 60(1), 1–37. https://doi.org/10.1111/bjc.12259