PHILADELPHIA—Community mental health clinics, where most specialty mental health treatment is delivered, have been relying more on independent contractors to treat patients, largely for budgetary reasons. Many of these clinics have simultaneously been moving towards the greater use of evidence-based psychosocial practices (EBPs), broadly defined as talk therapies that are informed by rigorous research as well as clinician expertise and patient preferences. A new, first-of-its-kind study from the Perelman School of Medicine at the University of Pennsylvania suggests that these two trends may be in conflict. The findings appear this month in Psychiatric Services.
“The independent contractor therapists we surveyed turned out to have less positive attitudes towards evidence-based talk therapies for youth such as cognitive-behavioral therapy and less knowledge about them, compared with salaried employee therapists,” said lead author Rinad S. Beidas, PhD, an assistant professor of Psychology in the department of Psychiatry at Penn Medicine. CBT emphasizes problem-solving and teaching youth specific skills to correct distorted thinking and change behavior.
Beidas, who is also director of Implementation Research at Penn’s Center for Mental Health Policy and Services Research, has shown in previous work how attitudes, knowledge, and organizational culture influence the implementation of EBPs in public mental health clinics.
In recent decades, all healthcare disciplines have been moving towards better, more standardized care by identifying EBPs and pushing for their greater use. Specifically, the City of Philadelphia Department of Behavioral Health, led by commissioner Arthur C. Evans, PhD, Jr, created an innovative program in 2007 to foster and support EBPs in its public mental health clinics.
Three years ago, Beidas and her colleagues began studying EBP implementation in Philadelphia. “One of the things that my team initially noticed, which we did not expect, was that there were a lot of independent contractor therapists at these agencies,” Beidas said.
Indeed, some of the agencies had begun to use independent contractors exclusively. That appeared to reflect a national trend in mental health clinic staffing, moving away from salaried therapists and towards contractors—who are cheaper to maintain because they are paid only when they see patients, and don’t require the overhead costs of employees such as insurance benefits.
The apparent proliferation of contractors led Beidas and colleagues to wonder if these therapists would be as involved in EBP implementation compared to salaried therapists. “When we looked in the literature, we found nothing on this,” Beidas said.
Her team addressed this question by surveying 130 therapists working at 23 Philadelphia public mental health clinics. Nearly 60 percent of these therapists were independent contractors, and the rest were salaried employees.
Compared with their salaried counterparts, contractors reported they would be less willing to adopt EBPs even if they found them appealing, specifically, they scored .28 points lower on a four-point scale measuring this attitude. Contractors also showed significantly less knowledge of EBPs for children with psychiatric disorders, scoring approximately five points less on a 160-point scale measure of knowledge. Beidas hypothesized that it is likely that these staff did not have access to the professional development opportunities available to salaried staff.
Interviews with the executive administrators at nine of the agencies represented in the survey corroborated this hypothesis: the agencies reported not sending contractors to the EBP training programs attended by their salaried staff.
“The agencies seemed less willing to invest in the professional development of their independent contractor therapists, because they perceived them as more likely to leave once they found a more permanent position,” Beidas said.
The interviews also confirmed that agencies tend to hire such contractors in order to stay within their increasingly tight budgets.
“Because of its modest sample size, this study is preliminary, but we hope it opens up a new research agenda nationally to understand the implications of this shift in the workforce model in public mental health clinics — particularly in regard to EBPs – where we think there may be a collision between this new contractor-based workforce model and efforts to improve services,” Beidas said.
She and her colleagues plan to gather further data on this issue, as part of an ongoing National Institutes of Health-funded study, and may in the future suggest interventions, such as increasing professional development opportunities for independent contractors at such clinics or creating a culture where independent contractors are more integrated into the fabric of organizations.
Co-authors of the study were Rebecca E. Stewart, Courtney Benjamin Wolk, Danielle R. Adams, Steven C. Marcus, Trevor R. Hadley, Frances K. Barg, and David S. Mandell, of Penn; Arthur C. Evans, Jr. and Matthew O. Hurford, of the Philadelphia Department of Behavioral Health and Intellectual Disability Services, Philadelphia; and Kamilah Jackson, Geoffrey Neimark, Joan Erney and Ronnie Rubin, of Community Behavioral Health, Philadelphia.
Funding was provided by the National Institute of Mental Health (K23 MH099179, F32 MH103960, F32 MH103955).
Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, excellence in patient care, and community service. The organization consists of the University of Pennsylvania Health System and Penn’s Raymond and Ruth Perelman School of Medicine, founded in 1765 as the nation’s first medical school.
The Perelman School of Medicine is consistently among the nation's top recipients of funding from the National Institutes of Health, with $550 million awarded in the 2022 fiscal year. Home to a proud history of “firsts” in medicine, Penn Medicine teams have pioneered discoveries and innovations that have shaped modern medicine, including recent breakthroughs such as CAR T cell therapy for cancer and the mRNA technology used in COVID-19 vaccines.
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