Reay WE (2024) Mental Health Services and Services Research: Time to Reflect, Re-examine, and Rethink. Ann Community Med Pract 9(2): 1059.

Over the past several decades the children’s behavioral health system experienced a host of initiatives including the elevation of parental involvement in the care of their children; a valuebased system-of-care philosophical initiative aimed at creating a common set of values for service development and delivery; school-based behavioral health service development; and the advancement of empirically based treatment. These initiatives created an environment for other important initiatives including information transfer science; methodological advancements in evaluating services; and training programs designed to bring the applied science to every day practice. In many respects, these initiatives were and remain attempts to redesign the architecture of services; address funding mechanisms, inform training programs, and influence politics. Clearly, all of these initiatives are aimed at changing professional practice and influencing known social conditions associated with improving the lives of children with serious behavioral health problems and the lives of families.

By no small measure, these initiatives were a response to the writings of authors like Jane Knitzer and Ira Schwartz. These authors underscored the reality that children were receiving inhumane care; languishing in institutional settings; not improving in important areas of everyday functioning; and parents were marginalized and blamed for their children’s behavioral, emotional, and mental health problems. Important scholarship by professionals like Barbara Burns, Gary Melton, Leonard Bickman, and Allan Kazdin, advocated for alternatives to institutionalization and called for the development of effective behavioral health treatments for children and families, including the development of supportive neighborhoods and schools and systems that could sustain envisioned improvements.

Fortunately, some of us have been involved in these movements since the early 1980s, and have remained as both consumers and contributors to the emerging science. Arguably, some improvements have been made in the lives of some youth and some families. However, for many families, the envisioned promise of easy access to effective mental health care, living in supportive communities, and attending schools that are sensitive and responsive to the needs of parents and children with serious mental health conditions remains unfulfilled.

The challenges to the future of mental health services for children and families remain relatively unchanged over the past 3 decades. The field struggles with relevancy and our science remains defined by a series of demonstrations and pilots; none of which gain sufficient empirical, political or social support to sustain wide scale acceptance. Without such acceptance, meaningful sustainability is impossible. Research methods including model designs remain inflexible and infidelity to models has become one more reason to blame parents, youth and providers for multilevel failures. Consequently, funding bodies find little reason to see differentiation between treatments or providers and have relegated our craft to an economic model best described as a commodity. This failure has inadvertently assisted political leaders in understanding mental health services as discrete units. This degrading of public trust in our profession is one of the most significant challenges to the future of mental or behavioral health services, and break-through behavioral health services research.

As a legally trained psychologist, who has spent over 30 years as an organizational executive; academic researcher; expert witness in controverted mental health cases, and program architect of evidence-based treatments, I have lived through many of these behavioral health initiatives. As an “early adopter” of various evidence-based treatments and other technological and methodological advancements; and proponent of using information transfer science in training young professionals, I have also adopted and accommodated treatments and scientific results to different populations and environments. I have also been responsible to various funding bodies in an attempt to demonstrate “service worth” regardless of how those funding sources view the applied research. Those experiences have led me to several conclusions about the future of mental health services. I have identified the following areas which need to be addressed:

Commoditization

Our service products, including those responsible for delivering those products have been subject to commoditization. This is not unique to mental health, other services to children have also been commoditized. The social and economic worth of mental health services remain virtually the same as it has been understood for decades. Mental health treatment remains conceptualized by setting of service, not the actual treatment delivered. In other words, there is virtually no agreement within the profession that the delivery of service must separate setting of service; treatment(s) of the conditions; vehicles of delivery (people); supervision, surveillance, monitoring, and feedback regarding the effects of the treatment.

Academic Training

Beyond a few research oriented programs, graduate education programs have not adjusted core training to produce an adequately prepared workforce. Ann Garland highlighted that the vast majority of mental health service delivery is provided by less than terminally degreed professionals. There has been very little attention paid to how to get this workforce trained in effective mental health treatments. As highlighted by Alan Kazdin, the problem with implementation is formidable.

Law and Psychology

There are very effective legal strategies that can be used to advance the use of effective mental health treatments. The judicial branch of government at every level can and will, given certain circumstances, advance evidence-based treatments and the development of an adequately trained and supported workforce. Several behavioral health practitioners and research scientists have experience in taking advantage of these circumstances, but their contributions have largely gone unharvested, e.g. Bruce Chorpitia’s work in Hawaii, and Len Bickman’s work in North Carolina. Although these individuals capitalized through their individual efforts, insufficient analysis of the psycho-legal environments that led to their opportunities. The intersection between ripe legal conditions that could be used to promote or advance the use of evidence-based treatments should be investigated. Similarly, consent decrees, and the advancements that were made possible by the involvement of the United States Department of Justice have not received the retrospective analysis that could lead to a better understanding of how mental health leaders and scholars can take advantage of situations that are “ripe” or ready for policy, practice, and research advancements.

Error Analysis

Unlike most every other industry, the mental health services industry does not analyze system/research-to-practice failures. Failed initiatives seem to just lose favor, much like a social or political fad. Analyzing failures, from a systems perspective allows scientists and program architects to begin the process of building models associated with various levels of failure. For example, some of the EBPs are seen as complicated to implement at the provider level. Assumptive arguments provided by mental health service researchers place relatively high importance on “fidelity” but rarely provide a detailed analysis related to the reasons for that failure beyond the individual practitioner or organizational culture. However, comprehensive error or failure analysis needs to include the relative contributions to many factors associated with that failure. Reason’s Model of Error Analysis would be a good starting point.

Market Disrupters

Learn from service entrepreneurs and market disrupters. Entrepreneurs and market disruptors are more than mere risk takers. Results from economic science research indicate a much more complex picture of these professionals. They tend to have a high tolerance for ambiguity, and look for areas to push for rule expansion. These leaders tend to see opportunities for application and innovation where others do not. They also tend to see both external and internal barriers to goal attainment far more clearly than other more traditional leaders, and build relationships aimed at assisting them in their goal attainment. Moreover, they tend to also market their successes in ways other do not.

The United States government and business communities have been trying to design social strategies to manage the troubled, troubling and poor for more than two centuries. The social conditions which prompted the “post-Jane Knitzer” period need to be understood in terms of the larger social context and the understandings and beliefs which needed to be reformed at that time. However, it is important to understand how our long-standing social attitudes toward certain groups within our country drive how we, as academics and mental health professionals respond to those who provide the narrative about the target groups of poor, troubled, and troubling. In other words, the social politics that drive our research questions, influence our metrics and ultimately our service response.

The above-mentioned problems are interrelated. A new inclusive model needs to be developed. This model must be driven not only by quality research, but by a full appreciation of the challenges and tragedies experienced by those with various presentations of mental illnesses. Academic training programs need to jettison the scientist-practitioner model of graduate training. This “Boulder Model” was built in 1944 and supported under specific social conditions that do not reflect the social complexion of 2023 or who delivers mental health services. Today, the vast majority of mental health service is being delivered by non-terminally degreed persons; a delivery system that was not anticipated when the scientist-practitioner model was adopted, and there has not been any attempt to meaningfully adapt the model to non-PhD/PsyD persons.

The Research-to-Practice Model of [academic] training would be more expansive to include the applied and theoretical research related to consumer perspective(s) and on implementing evidence-based treatments, adapted to the ongoing challenges that face young parents, professionals and non-professionals experience. The model would train in community-based care for those individuals with chronic, multi co-morbid disorders, including “wicked problems,” as well as increasing the number of culturally and ethically diverse lay and specialist providers trained to provide evidence-based services.

There is a cultural crisis in mental health literacy and competency in the United States. This illiteracy is similar to other historic crises this country has experienced. Although presenting as a mental health crisis, the problem may lie in the unsuccessful transmission of rudimentary non-critical and non-professional skills necessary to navigate critical requirements of the social context of everyday life. The remedy needs to be tied to an economic model that includes a mental health ideology that teaches children to master complex social, interpersonal, cognitive, and emotional demands.

This functional illiteracy of mental health became more visible as a consequence of the pandemic and shifts in both economic and social conditions, e.g., disruptions with formal schooling, online education, and the increased dependency of social media. Becoming mental health literate involves the reconstruction of the mental health experiences of becoming literate, viewed within the larger context of sociocultural ideologies within which mental health elements are embedded. The question becomes how to identify, describe, and transfer those “mental health artifacts” in a manner that children at any developmental level can acquire those discrete characteristics. Central to that consideration is how it becomes organized in culture-specific ways according to certain norms, and how it gets transmitted.