Slipping Through the Cracks: Clinicians' Perspectives on the Gaps in New York City's Public Mental Health System.

Most people who seek mental health treatment cannot access it. Certain groups (e.g., Medicaid enrollees and the uninsured) face particularly severe treatment access barriers along the care continuum. We interviewed 31 clinicians across two studies about their perspectives working in New York City's public mental health system. Because every clinician across both studies reported gaps in the system, we deployed an emergent, "serendipitous finding" approach and qualitatively analyzed the interviews together. Clinicians described three public mental health system gaps. First, many treatment-seekers must wait long periods of time to receive care and some never receive it at all. Second, patients with more serious challenges cannot access longer-term, higher-intensity, or specialized treatment. Third, some patients receiving high-intensity services may benefit from lower-intensity mental health support that is better integrated with medical and social service support. Coordinated and sustained financial investments at every step of the mental healthcare continuum are needed.

A Mixed Methods Examination of Session Planning Among Public Mental Health Therapists.

Session planning is a core activity for implementing evidence-based practices (EBPs), yet it is unknown whether public mental health settings provide the support for therapists to session plan. This two-part study conducted in collaboration with EBP leaders in Philadelphia's public mental health system deployed mixed methods to examine therapists' session planning practices and preferences. In Study 1, 61 public mental health therapists completed an online survey to identify session planning barriers and facilitators, current practices, and desired planning supports. In Study 2, nine therapists who ranked a session planning tool as a top choice support in Study 1 participated in two focus groups to elaborate on their survey responses and provide feedback on three session planning tool prototypes. Study 1 survey respondents cited multi-level barriers and facilitators to session planning. In both closed- and open-ended responses, analyzed descriptively and via content analysis respectively, therapists described wanting more time, lower caseloads, financial incentives for session planning, and additional clinical resources and guidance from trainings, peers, and supervisors to support session planning. Study 2 focus group participants, whose responses were analyzed using content analysis, reiterated the need for these multi-level supports and expressed the need for a "one-stop" database of session planning tools that would be free, easily searchable, and modifiable for varied clinical needs. All three session planning tool prototypes reviewed were acceptable; two were also considered feasible and appropriate. This investigation of an under-studied aspect of the EBP implementation process reveals the need for multi-level session planning supports.