Unmute's CARE Framework: A Novel Approach to Strengthen the Therapeutic Alliance and Reduce Treatment Disparities

Despite decades of research exploring approaches to tailoring mental health services to meet the needs of a heterogeneous patient population, significant disparities remain. When patients and providers do not share a similar background, it can result in patients' greater reluctance to engage in treatment, lower satisfaction, and a higher likelihood of dropping out of care, resulting in worsening overall health and contributing to over $153B in excess healthcare costs annually. Two promising approaches to addressing this problem- professional development training to raise provider awareness of the issues, and adapting treatments to specific groups- have failed to reduce treatment disparities. First, studies evaluating the effects of training to enhance providers' ability to tailor services to patient needs find that they tend to focus on abstract concepts, without practical training in skills development. Second, although treatments adapted for specific groups are more effective than unadapted treatments, system constraints (time, cost) limit capacity to train clinicians to deliver multiple adapted treatments to different groups with fidelity. Therefore, a major challenge is how to most feasibly and effectively train our provider workforce to deliver effective mental health care to an increasingly heterogeneous patient population.

Unmute has begun to address this challenge by developing the CARE framework, an innovative process-focused, protocol-based, and modular approach that addresses a preference among many patients for short- term, problem-focused, and individually-tailored treatment to reduce health disparities. Unmute's CARE framework targets the assessment and engagement phase of treatment to reduce dropout, emphasizing skills- training for providers to strengthen the therapeutic alliance, a change mechanism robustly associated with treatment outcome in both telehealth and in-person formats, but more difficult to cultivate across patient-provider differences. Providers receive training in 3 core areas: 1) evidence-informed assessment protocols to facilitate tailoring of treatment, 2) alliance-focused training, an evidence-based approach to repairing breakdowns in the alliance, and 3) consultation with experts in working with specific groups to guide the development of a customized case conceptualization and treatment plan. To date, Unmute's CARE framework has been pilot tested with 10 patients, with 100% returning after the first session, and promising evidence of feasibility and acceptability of core model components. Building on these results, the focus of this Phase I proposal is to train a larger cohort of providers to implement Unmute's CARE framework with patients whose backgrounds differ from their own. We hypothesize that this innovative modular approach to provider training and patient engagement, will increase the feasibility, acceptability, and preliminary effectiveness of providers' efforts to cultivate a strong alliance, reduce dropout rates, and improve treatment engagement and outcome.

Aim 1 will be to expand and adapt the CARE framework to train providers to cultivate a strong early alliance with patients who do not share their background (e.g., mismatched dyads). Guided by pilot data and a community advisory board, we will develop two new training modules: a) a group-specific module, and b) a bridging differences module, to strengthen the patient-provider alliance in mismatched dyads.

Aim 2 will be to establish the feasibility, acceptability, and preliminary effectiveness of the adapted CARE framework in mismatched dyads involving 8 providers and 40 patients receiving 15 sessions of teletherapy. We will collect self-report and observer data for evaluation and refinement as needed.

By combining general and group-specific alliance-building components, Unmute's CARE framework can be adapted for other populations to provide high quality, evidence-based care in an efficient and cost-effective way. Our team is well positioned to execute on this plan; Unmute is cofounded by Colleen Leung, serial entrepreneur and MBA graduate of Babson College, and Dr. Doris Chang, clinical psychologist and expert on culture and mental health and psychotherapy process and outcome in mismatched dyads, with support from the Centers of Alliance Focused Training and New York University's Silver School of Social Work.