The road ahead: Task shifting, stepped care, and paraprofessional mentoring

by Jean Rhodes

As millions of children and adolescents cope with COVID-related loss, disruption, and social isolation, the demand for mental health services, including those provided by psychologists, counselors, and social workers, are expected to vastly exceed the supply. Even before the pandemic, less than a third of children and adolescents who needed mental health and related care actually received any services, most of which were not empirically supported. These rates are even lower in ethnic minority populations. In a new article in the American Journal of Community Psychology, summarized in this issue, Sam McQuillin, Alexandra Werntz, Matthew Hagler, and I propose a framework for paraprofessional youth mentors, defined as “a subgroup of professionally supervised, non-expert volunteer or paid mentors to whom aspects of professional helping tasks are delegated.” As we note, drawing on mentors to provide paraprofessional care will help narrow service gaps. The fact is that, even if every professional who provided youth services worked around the clock, there would simply never be enough of them to meet the needs of today’s youth. Most professional mental health workers earn graduate degrees and professional licenses that require several years of study and certification and their specialized services are in high demand. Many youth-serving mental health facilities are at capacity and have long waiting lists, and annual rates of staff turnover in the child- and adolescent-serving mental health workforce exceed 50%.

These shortages, as well as both attitudinal issues (e.g., concerns about stigma, cultural insensitivity, low treatment effectiveness) and structural issues (e.g., cost, transportation, time, and access), have created overwhelming barriers for many parents who are seeking professional care for their children.  Yet, left untreated, many of the early social, emotional, behavioral, and academic struggles that emerge in childhood and adolescence grow more complicated and difficult to resolve.  One solution is for youth to first work with paraprofessionals and then step up to more intensive professional services as needed. This gap will only widen unless there are substantial structural changes in how mental health services are provided. Mentors are well-positioned to help.

It’s important to note that the idea of deploying mentors to address mental health needs is not new. Indeed, more than fifty years ago, community psychologist George Albee pointed to the wide and unbridgeable gaps between the small number of highly trained mental health professionals and the vast number of people who need care and support. He called for new models in which psychologists and other helping professionals move from providing direct service to supporting frontline lay providers: Let me emphasize, I do not see psychology as the care-delivery field. We can never have the manpower to meet the demands. Rather, we must create the theory, and show how it is applicable, to enable care to be given by bachelor’s level people …Psychology can only be the developer of the conceptual models and of the research underpinning. American Psychological Association President George Miller, echoed this sentiment the following year in his presidential address, arguing that professionals’ responsibility is less to “try to apply psychology ourselves than to give it away to the people who really need it…I can imagine nothing we could do that would be more relevant to human welfare, and nothing that could pose a greater challenge to the next generation of psychologists, than to discover how best to give psychology away.”He made this rallying cry amid the growing calls of community psychologists to expand mental health services by offering affordable clinics in neighborhoods and by empowering affected individuals and their communities to create their own solutions. Innovative ideas—from developing mutual support groups to training bartenders, beauticians, and cab drivers in therapeutic techniques—were tested by community psychologists who saw the potential of lay providers on the continuum of care, able to provide help that was comparable, and even preferable, to that of [or from] experts.

Curiously, mentoring programs never really registered these clarion calls. Although they were essentially providing quasi-therapeutic care, volunteer mentors were rarely thought of as paraprofessionals (i.e., non-expert paid or volunteer care providers) or even as sitting on the same continuum of therapeutic care. The fact remains, however, that volunteer mentoring relationships and therapeutic relationships share much in common. And decades of research have shown that, with the right training and support, paraprofessionals can deliver interventions just as effectively as professionals if not more in ways that could help to bridge the substantial gaps in care.

A stepped-care model could improve access in underserved communities by delegating professional tasks to volunteer mentors who have fewer qualifications and less extensive training.  In stepped care models, youth progress toward more highly trained professionals and intensive services only if these earlier steps proved ineffective. nA stepped model of supervision, in which highly trained professionals provide supervision and consultation to direct supervisors who then support paraprofessionals, can also extend expertise in ways that can help to address unmet mental health needs, particularly in schools. The school counselors, nurses, and social workers are typically the first line of defense for children who are struggling emotionally.

A stepped-care model also enables program staff to more directly recognize the many professional and personal benefits to volunteers. Volunteer mentoring is a challenging undertaking, leading many mentors to give up when their sacrifice of time and energy is not rewarded with strong relationships, positive youth outcomes, or some indicator of success. Programs that provide academic or career credentials can recognize mentors’ training and service hours and sustain their commitment through the inevitable trials and tribulations of working with today’s mentees. This might include finding ways for mentors to satisfy pre-professional training requirements through access to professional supervision and/or providing opportunities for mentors to earn college credit, continuing education units, certifications, letters of recommendation, digital badges, and other micro-credentials. Volunteers will need the training and support to strike a balance between friendship and goals, and guard against rigidity and the impulse to put goal attainment above relationship formation and maintenance. This will involve finesse, flexibility, and a willingness to suspend or abandon planned lessons and activities when adherence contributes to an erosion of relationship building and trust. Striking this balance will improve mentor retention and ensure that the field retains its central identity and mission of providing relationship-based change.