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 thePerelman 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.

Click here to view the full release.