APA Summary

An Engagement Intervention for Young Adults with Serious Mental Health Conditions

Michelle R. Munson, PhD Andrea Cole, MSW James Jaccard, PhD Derrick Kranke, PhD Kathleen Farkas, PhD Fred J. Frese III PhD

Abstract

Young adults with serious mental health conditions (SMHCs) often do not engage continuously with mental health services, and there are few engagement interventions designed for them. This qualitative study presents a blueprint for conceptualizing and developing an engagement intervention designed for young adults with SMHCs. The blueprint includes the following activities: (1) establishing a strong theoretical basis, (2) designing an initial manual based on previous research and practice, (3) systematically examining feedback on the manual from stakeholders, and (4) examining the feasibility, acceptability, and implementation demands of the intervention. Interviews, group discussions, and journaling were utilized to collect information from young adult participant-researchers, intervention facilitators (i.e., recovery role models and clinicians), and additional stakeholders (e.g., clinic staff and administrators) (N=43). Analyses were performed with multiple coders using constant comparative methods. Results revealed critical information to improve the intervention, while also suggesting that the engagement intervention for young adults with SMHCs has promise.

Address correspondence to Michelle R. Munson, PhD, New York University Silver School of Social Work, 1 Washington Square North, New York, NY 10003, USA. Email: [email protected]. Andrea Cole, MSW, New York University Silver School of Social Work, New York, NY, USA. James Jaccard, PhD, New York University Silver School of Social Work, New York, NY, USA. Derrick Kranke, PhD, Veterans Administration, Veterans Emergency Management Evaluation Center (VEMEC), North

Hills, CA, USA. Kathleen Farkas, PhD, Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH,

USA. Fred J. Frese III PhD, Department of Psychiatry, Northeast Ohio Universities College of Medicine, Rootstown, OH, USA.

Journal of Behavioral Health Services & Research, 2014. 542–563. c) 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9424-9

542 The Journal of Behavioral Health Services & Research 43:4 October 2016

Introduction

Unmet mental health needs among children and young adults (YAs) with serious mental health conditions (SMHCs), defined as either serious emotional disturbances or serious mental illness, is an urgent matter; one that experts have deemed a crisis.1 Many young adults, those ages 18 to 30, with SMHCs drop-out, or at best experience fragmentation, of mental health care during the transition to adulthood.2 Rates of some mental disorders among young adults are almost two times that of older age cohorts.3,4 Beyond prevalence, research has documented the difficulties young adults with SMHC face as they transition to adulthood, such as poor education outcomes, early parenting, and increased risk of suicidality.5 The majority of the young adults included in the present study had been, and/or were currently involved with, public systems of care (i.e., child welfare, juvenile justice, and mental health). These youth are arguably at heightened risk, as research shows their transition is often complicated by poverty, trauma, and loss of support.5,6 One reason these young adults have difficulties transitioning to adulthood is lack of continued engagement in services.7,8 Mental health treatment is unlikely to be effective if young adults do not receive a full dose or near-full dose of treatment. In sum, research reveals young adults have elevated rates of SMHCs and they do not consistently engage in treatment.

To address this situation, the current project conceptualized, developed, refined, and tested the feasibility and acceptability of a new and innovative engagement intervention designed with and for young adults with SMHCs. The intervention, Just Do You, is designed to improve engagement in mental health services among young adults through explicit acknowledgement that they are now the “drivers”8,9 of their mental health decisions. The intervention aims to orient young adults with SMHCs to the mental health clinics where they are initiating care, while educating and supporting them in addressing empirically based barriers to help-seeking.8 Unlike most engagement strategies, which focus on extending child-systems’ provision of services, Just Do You utilizes the adult mental health system as a leverage point for engagement of young adults. This study articulates a blueprint for the early stages of intervention development, when theory is first being translated into substantive application in real-world settings.

The project used elements of a “participatory action” framework10, learning side-by-side with young adult participant-researchers to understand intervention materials. Specifically, the project team examined what works and what does not work, while building a clearer understanding of the protocols and assessments needed to refine and solidify the intervention. The first step was to outline relatively novel theoretical frameworks used to formulate an initial draft of the intervention, including communication theory, relational-cultural theory, and narrative theory, among others. Then steps were taken to affirm, refine, and modify the intervention to reflect the perspectives of young adults with SMHC and key stakeholders from the types of organizations where the intervention ultimately will be implemented.

Theoretical underpinnings of the intervention

Systematic design of interventions to change behavior: What needs to change?

In the field of mental health services, there has been a dearth of theoretical scholarship on the phenomenon of disengagement of youth transitioning to adulthood with SMHCs. This is unfortunate as the problem of disengagement in services during the transition is common due to the coming together of systemic, relational, and developmental transitions.8 It is also an important phenomenon to understand as decisions during this time can impact the mental health of young adults for years. Just Do You is distinct because the development of the curriculum has been theoretically and empirically based. Furthermore, it was constructed with feedback at every step

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from young adults, professionals, advocates, and policy makers, all bringing their insights to bear on strategies they believe are best to impact behavior change and positive outcomes.

A theoretical framework of determinants of mental health decision making

Prior to the development of Just Do You, a study was conducted on mental health service experiences during the transition to adulthood among young adults (N=60), ages 18 to 25, all of whom were struggling with mood and emotional difficulties and had a history of both mental health and social service use during childhood.8 A major outcome of this effort was a mid-level theoretical framework for mental health decision-making among youth (see Fig. 1).11 This framework provides a starting point for identifying the determinants of mental health service use among youth with SMHCs, while providing a framework for conceptualizing and testing interventions.

The model draws upon theories of decision making, operant learning, and prior theories of mental health service use. It is described in detail elsewhere.11 As Figure 1 indicates, context matters (see boxes A and B), especially those surrounding critical social relationships and community resources and influencers. These contexts shape the ways in which young adults think and feel about engaging with the mental health system (boxes C–G). The study identified five classes of cognitions/affective reactions that are particularly relevant: (1) behavioral beliefs about engaging the system (i.e., perceived advantages and disadvantages of service use), (2) social norms associated with engaging the system (e.g., perceptions of important others approval/disapproval of using mental health services), (3) image management considerations (e.g., the image one thinks one will convey to others if they use services; stigma), (4) emotions one feels when thinking about engaging the system, and (5) efficacy, or one’s perceived ability to use services. Not all of these factors will be relevant for all populations; rather, the relative importance of these factors in shaping decisions to engage the system will differ depending on the population, behavior, or context. This, in turn, impacts the factors one addresses in one’s intervention.

These five classes of variables combine in complex ways to determine an individual’s decision or intention to engage the mental health system (box H). However, making the decision to engage the system is not enough. Individuals must translate those decisions into behavior. Figure 1 also identifies factors that facilitate or create barriers to an intention becoming a behavior (boxes I to L).

Figure 1 Determinants of mental health decision making

Determinants of Mental Health Decision-Making

A. Community

B. Social

C. Behavioral Beliefs

D. Social/Normative Factors

E. Image/Impression Management

F. Emotion

G. Self-Efficacy

H. Intention to

Use MHS

M. Mental Health

Service Use

Contextual Factors A. – B.

Individual Factors MediatingC. - H.

Outcome M.

K. Behavioral Cues L. Habitual Processes

J. EnvironmentalI. Knowledge

Moderators I. - L.

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Specifically, the individual must have the knowledge and skills necessary to perform the behavior, there must be no or minimal environmental constraints that prevent the individual from performing the behavior, the behavior must be salient to the individual, and habitual and automatic processes cannot interfere with behavioral performance. Also, an intention to act may not translate into behavior because youth change their mind (e.g., based on new information) and decide not to get care after all. Decision analysis for this segment underscores the importance of recognizing that the focus of an intervention often needs to be helping youth carry out their (positive) intentions rather than convincing them to perform a behavior. Facets of this model informed Just Do You sessions, focusing on empirically based factors that emerged as relevant to mental health service use.

Theories to impact determinants of decisions/behavior: how to make change happen

It is not enough to suggest what variables to address to increase service engagement; research also needs to provide guidance on how to change such factors. The Just Do You intervention relied on two classes of theories for such purposes, communication and clinical theories.

Communication theory and service engagement program design

Most mental health service engagement programs for youth involve communication of some form in which the program educates youth about services and how to effectively interact with the system. Despite this, few intervention efforts have drawn upon formal communication theory when designing their programs.12 Classic theories of top-down communication distinguish five key facets of communication that may impact the effectiveness of an engagement intervention: (1) the source of the communication, (2) the content and structure of the communication (the message), (3) the medium or channel through which the message is transmitted (e.g., face-to-face, over the web), (4) unique characteristics of the recipients, and (5) the context in which the communication occurs.13

Each of these facets has subcomponents. For example, sources may differ in their age, gender, and perceived trustworthiness. Recipients of communications differ in their age, gender, motivation, and expectations. The surrounding environment varies in terms of its temporal, social, and cultural features. Variations in these factors represent key independent variables that can affect communication effectiveness. While there is not yet a compelling body of literature in the domain of young adult mental health that will help inform program decisions about these communication factors, Just Do You addresses each of them.

Clinical theories undergirding the young adult engagement intervention

Just Do You draws upon social-cognitive, relational cultural, empowerment, and narrative theories. Of note, many of these theories are in line with “The Pathways to Positive Futures model”.9

Social Cognitive Theory Social cognitive theory14,15 assumes that “most human behavior is learned observationally through modeling (p. 22).14 Observational learning happens through a four-step process: (1) individuals must attend to, and perceive accurately, the modeled behavior; (2) individuals must retain, or remember modeled behavior; (3) the symbolic representations are engaged, reproduced, and used to influence behavior; and (4) individuals must be motivated to reproduce the behavior.14,15 Social cognitive theory lays a foundation for understanding how role models influence health behaviors through vicarious learning16,17 A novel component of Just Do You is that it builds on social cognitive theory14,15 and youth mentoring18 through the inclusion of role models, as sources of communication, in two distinct ways as follows: (1) inclusion of a

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recovery role model as a co-facilitator and (2) introducing young adults to role models through the use of narrative mental health communication (see below).

Recovery role models (RRM) who co-facilitate Just Do You are typically a decade or more older than participants, have been in recovery for at least 3 years, and have achieved success in at least one “mental health in action outcome” (e.g., school and work). Also, they must be actively engaged in mental health services, as needed, and be willing and able to speak about key mediating determinants of service use, such as stigma, and developing trust in providers. Aworking premise of Just Do You is that role models’ voices (as a source) will be attended to closely and heard as particularly credible and trustworthy. In a previous study, young adults reported that they would like to hear from others who have been through similar experiences as the ones that they have been through.19 Recovery role models are conceptualized as a type of peer in that they also live with a SMHC. However, there is an important distinction between recovery role models and peers, namely they focus on modeling aspects of living independently as an adult with a SMHC and educating by sharing lessons on structured topics (i.e., moving toward acceptance) important to their recovery. The intervention also builds on the field of mentoring in that recovery role models are screened for a set of knowledge, skills, and experiences, including the ability to model healthy relationships and factors needed to achieve independence in adulthood. Recovery role models are trained to provide guidance on managing recovery while modeling life with a SMHC. Some peer support specialists meet the criteria to become a recovery role model; others do not.

Just Do You also exposes young adults to individuals whose courageous narratives can be heard through web videos (e.g., Mary J. Blige20), books (e.g., An Unquiet Mind21) and articles that discuss recovery narratives or provide examples of professionals who have been diagnosed with a SMHC.22 This is further elaborated upon in the below on narrative theory. Both types of modeling have promise as a complementary strategy to traditional peer support. Recovery role models deal, in part, with challenges that can surface in peer support, particularly with youth and young adults (e.g., high turnover, boundary issues, less rigorous screening and training). The use of recovery role models fits with a transforming mental health system, which has increased its focus on the use of a nonclinical workforce and outcome-based reimbursement. Recovery role models can be cost- effective colleagues in the mental health system.

Relational Cultural Theory Relational cultural theory (R-CT) suggests that the development of a mature self requires connection to others, as opposed to autonomy and differentiation. In R-CT, the central focus is growth through and toward relationships.23 R-CT suggests that mutual attachments are essential to psychological well-being throughout the life cycle, suggesting that “adolescents do not need to detach from parents or supports, rather they need to change the dynamics of support relationships to promote healthy development” (p. 53).24 Recently, R-CT has been applied with young girls living in institutions where Sparks (2004) found that provider authenticity was essential to gain the girls’ trust, as “they viewed all relationships (except those with a few close friends) as emotionally and/or physically dangerous” (p. 241).25 Taking into account the recipients (or audience) of Just Do You, in this case youth who may be lacking in trust of providers, the model draws upon the principles of R-CT, including the need for clinicians to be authentic and respectful to young adults in order to create an environment where the relationship between the interventionists and the clients is viewed as central to psychotherapeutic effects. Facilitators are trained on the importance of relational qualities in facilitating group. Co-facilitators stay closely attuned to relational dynamics, as one of the main goals is to improve the “connection” that young adults have to the clinic and their providers. Thus, the more youth trust and “connect” with the engagement facilitators, the more that may occur more broadly with clinic providers.

Empowerment Empowerment, conceptualized as “a process of increasing personal, interpersonal, or political power so that individuals can take action to improve their life,” (p. 149)26 focuses on

546 The Journal of Behavioral Health Services & Research 43:4 October 2016

increasing self-efficacy, reducing self-blame, and helping people assume personal responsibility for creating change in their lives.26 Just Do You draws on empowerment theory to encourage youth to feel confident in becoming the “drivers” in their mental health decisions.9 In developing Just Do You, researchers took into account that the recipients of Just Do You may feel like “the other” for having been diagnosed with a SMHC, and thus, may be especially lacking in power and confidence to change their situation.26 For this reason, Just Do You acknowledges racism, classism, homophobia, and the injustices that often accompany living with a SMHC. Through the inclusion of the role model, a focus on hope and providing clients with advocacy knowledge and skills, Just Do You seeks to empower young adults.

Narrative Narrative therapy proposes that through the telling of stories, one ascribes meaning to their experiences, and through interaction with others in sharing the stories, those others become participants in the shaping of meaning.27 Just Do You utilizes these strategies as a channel through which to communicate, both through the use of creative arts to share individual narratives of those in the group, coupled with the use of narratives brought into the group of others’ stories of living well with SMHC. Research has found that being exposed to individuals’ narratives can both decrease resistance and increase hope.28,29,30 As young adults tell their own stories and hear stories from recovery role models, there may be a normalizing effect as they realize their stories are similar to others who are doing well in their recovery.

The use of narratives is designed to help young adults reframe the meanings they ascribe to the challenges of living with a SMHC. In the modules, young adults listen to the narratives of the recovery role model who is there in person, (the channel is face-to-face) and public figures who have spoken/written publicly (the channel is video, book, or article) about their mental health challenges.20,22 In order to make Just Do You as relevant and compelling as possible to this age group, it includes art-related activities, providing youth with art kits and allowing time during the sessions for them to express their stories creatively through drawing and writing. There is also time to share narratives. Such tailored approaches, which were suggested in previous research, may help to capture and maintain young adult’s attention, potentially more than the standard manualized versions of psychoeducation content lessons.19 In addition to normalizing, these techniques hold youth’s attention so as to make an impact on cognitive, social, and affective processes that influence intentions and behaviors.

ADAPT Finally, the Just Do You program uses the ADAPT model to address the need for flexibility in group sessions while also assuring fidelity to the model. ADAPT is based on Yalom’s core principles of group work,31 but also trains facilitators to use the acronym ADAPT as a reminder of the five components of each module: (1) An introduction of purpose and content, (2) Discussion, (3) Activity, (4) Process of activity, and (5) Take-home points.

The feasibility research described here had eight key components: (1) exploring the viability and utility of the intervention in a participatory action framework with young adults who ultimately will use the program as well as key stakeholders who administer the program in clinic contexts; (2) using the theoretical frameworks described above to guide exploration of participant reactions to the initial manual in the context of face-to-face interviews; (3) based on interviews, revising the manual to better reflect the perspectives of participants; (4) recruiting participants to formally participate in the intervention and provide feedback on sessions; (5) conducting post-session meetings with participants for feedback on each session; (6) asking facilitators to write in a journal their feedback on each intervention session; (7) conducting postintervention interviews on the acceptability and implementation of the intervention program within the practice setting; and (8) making revisions in the manual as well as intervention to reflect the prior steps. The remainder of this article elaborates and illustrates features of this blueprint.

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The present study

Intervention Just Do You is a theory-driven, empirically based intervention, directly informed by young adults and the professionals who have worked with them in mental health settings. The intervention is innovative in that it was designed to improve young adult mental health treatment engagement through the enhancement of acceptance, hope, literacy, and efficacy, as well as the decrease of negative attitudes, mistrust, and negative emotion towards mental health care. It provides young adults with an opportunity to learn about mental health and ways that services can help combat symptoms and enhance functioning. The intervention is based on positive identity development and formation through the modeling of a positive orientation toward mental health care as part of recovery.

Setting and purpose Just Do You was piloted in three urban mental health settings in the United States. The purpose was (1) to describe the conceptualization and refinements to the intervention using data obtained from stakeholder interviews as well as feedback obtained from young adult participants, and (2) examine the feasibility, acceptability, and implementation outcomes of a small- scale, preliminary evaluation of the intervention.

Methods

Recruitment and participants

Participants in the pilot study were recruited from three agencies serving young adults with SMHCs. They included young adults (N=27), recovery role models (N=2), and key stakeholders (e.g., clinic staff, administrators, and experts in the field) (N=14), totaling 43 participants for the study. Many participants were interviewed on more than one occasion. Young adults who met the following inclusion criteria met with the research staff to learn about the study: (1) between the ages of 18 and 30, (2) diagnosed with a SMHC, and (3) living in the community. Recovery role models were invited to participate if they met the following inclusion criteria: (1) living with a mental illness, (2) approximately 10 years older than the participants, (3) in recovery for at least 3 years, and (4) managing their illness with services as needed. Key stakeholders, including clinic staff, were recruited to participate if they had worked at the agencies for at least 3 months, or were experts in young adult mental health. Young adults were excluded if they were currently psychotic, and/or they did not speak English well enough to participate. Sample statistics for the young adult study participants are in Table 1. An IRB approved all protocols.

Data collection

Data collection strategies included (1) individual interviews with key stakeholders who critiqued the program manual, (2) post-session feedback meetings, and (3) postintervention face-to-face individual interviews on acceptability and implementation. The majority of the qualitative interviews were audio-recorded and transcribed (on some occasions investigators took hand- written notes). Interviews lasted between 10 min and 1 h. Research staff developed interview protocols for the following: (1) preintervention interviews about the manual, (2) post session feedback meetings, and (3) postintervention acceptability study (which included separate questions for young adults and agency staff; see Table 2 for example questions).

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Data analysis

For all qualitative analyses, the team utilized a constant comparative approach.32 Two analysts read, in depth, all transcripts, comparing and contrasting data elements within and between interviews. Analysts wrote notes and memos on emerging codes, and emerging questions that responses engendered. Then, analysts met numerous times to discuss memos, ideas, and make a list of meaningful topics that were important to understanding the intervention program. One analyst took notes and then merged the perspectives of both analysts, building a set of codes and larger themes that incorporated both analysts’ points of view. Then, one analyst again read through the transcripts, this time coding them for empirical data elements that fit a given code or theme. When questions emerged, the analysts met to discuss them and the coding scheme. This process continued until the analysts agreed they had a completed codebook that was inclusive of the grouped codes and themes from the interview data. Themes and illustrative quotes from the interviews constitute the research results.

Results

Preintervention feedback on the manual from stakeholders

Preintervention feedback interviews (N=13) were conducted to learn about perspectives on the intervention manual. Ten participants were clinicians or administrators, one was a recovery role

Table 1 Sample characteristics (N=24*)

Variables Mean (SD) or Mean (%)

Age 21.5 (2.9) Sex Female 12 (50%) Race White/Caucasian

Black/African-American Latino/Hispanic Biracial/Multiracial Other

5 (21%) 11 (46%) 2 (8%) 5 (21%) 1 (4%)

Diagnoses Note 1: These are young adults that reported specific diagnoses. Note 2: Participants reported comorbidities

Bipolar Depression Mood disorder Dysthymia Anxiety Schizophrenia spectrum Psychotic disorder Disruptive behavioral disorder ADHD Personality disorder Adjustment Disorder Cannabis abuse Don’t know/not sure

5 (21%) 7 (29%) 1 (4%) 1 (4%) 7 (29%) 2 (8%) 1 (4%) 3 (13%) 1 (4%) 1 (1%) 1 (1%) 2 (8%) 3 (13%)

Medication use Psychotropic medication use ever 22 (92%)

*Did not capture baseline data from all young adults who participated, as some became part of the project after the first session and therefore never completed a baseline interview

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model, one was a young adult, and one was an expert in mental health among youth. The themes that emerged were (1) manual language, (2) narrative mental health communication, (3) recovery role model as co-facilitator, (4) focus on young adults, and (5) global suggested changes. In addition to the quotes in the text, see Table 3 for additional quotations.

Table 2 Qualitative interview protocol item examples

Project section Participant/focus Example items

Manual feedback individual interviews

Young adult Recovery role models Clinicians Supervisors Clinic administrators

1. What are your overall general impressions of the manual?

2. Do you have any reactions to the idea of a recovery role model working alongside a social worker?

3. How do you think the young adults would react to the narrative mental health communication (i.e., testimonials)?

Post-session process group interviews

Young adult participant- researchers

Developed for each session 1. After the introductory session, what

do you know about this program, Just Do You? 2. What questions do you have—or what

remains unclear—about Just Do You? 3. When a new group begins, it is important

to feel safe. Also, having a chance to express yourself in a way that you would like to—and learning a little about other members and the facilitators can make it more likely for participants to return. Did this happen for you?

4. Was anything said—or not said—during this session that makes you feel unsure about coming again?

5. What was the main point you’ll take away from this session?

Individual interviews for “acceptability study”

Young adults Recovery role models Clinicians Supervisors Clinic administrators

1. Did attending the “Just Do You” group impact your overall experience at the agency would you say? And if so, how?

2. How did your experiences in the “Just Do You” group impact how you experienced your other services, like medication or counseling?

3. And of all the topics, do any of the topics from the group or the discussions topics stand out to you or things you did?

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Table 3 Pre-intervention feedback themes and exemplars

Themes Exemplar quotations

Manual language Term “mental health struggles”

is nonalienating “I prefer to use the word ‘struggles’ myself. I even try to avoid “issues.”

Language is simple, understandable.

“And it seems like it is simple enough for counselors and peer supports that are so busy.”

Language is respectful “I mean the impression I got when I was skimming it you know was it is respectful. It breaks it down in a respectful way.”

Language is normalizing “You know sort of normalize the idea that life presents everyone with lots of struggles and challenges, whether it be you know depression, whether it be financial issues, whether it be physical, right, but you know overcoming these are certainly possible.”

Language is hopeful “I see thus far all of it having potentials for hope and healing.” The name Just Do You will

resonate with YAs “They’re gonna resonate with that title…And so I thought that

that was kind of catchy, and some of them are gonna run with it and others will hopefully be able to internalize it and then figure out what the definition of it means for them.”

Language is extensive enough to allow for fidelity

“I think it will make it easier in terms of fidelity, and that’s one of the things that I know our group facilitators had varying degrees of experience, and so when using a new model, if it does need to be…you know if we’re worried about fidelity, actually giving them scripts is actually a great idea.”

Narrative mental health communication Videos are relatable (abuse

experiences in particular) “The only thing about her is that she’s very good. She’s very

grand, but yet her words are really relatable and humbling and the themes she talks about, abuse, about family neglect, they’re universal.”

“There’s somebody that actually I can identify with and that goes through the same sort of issue.”

Videos help combat stigma (particularly among African- Americans)

“I think oftentimes, like in our department, we’re pretty much all White females, so I think you know seeing an African- American male who’s talking about mental health and showing like a vulnerability I think that would really you know get them interested.”

“I also like that he’s African American, because I think there’s a significant stigma in the African American community.”

Create motivation and hope “I think you know he embodies the idea of the role model and someone that these guys can look up to and see that you know there’s clearly hope.”

Demonstrate goal-setting and insight

“So I think that setting goals, that he wanted to make sure he was successful, and he definitely talked about that and I think that would be good for the kids to hear that.”

“I think even if a person can’t identify, I mean it’s just enough to give them insight and some more education.”

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Table 3 (continued)

Themes Exemplar quotations

Illustrate importance of seeking help

“He talked about it [help-seeking], and then he even said, ‘you could go to your dad’, or so who to actually go to. So I did like that part of it.”

Show value of supportive family

“I think that was great. He talks about support systems, ‘cause we believe it’s one of the biggest issues for our kids…Who are they? Are they trying to connect with some family while they’re here so that they can build that once they go out into the community? And I like the fact he kind of talks about other adults that you can go to…”

Recovery role model (RRM) as co-facilitator Provides perspective YAs can

connect with “I think they would be more receptive to hearing something

from them [RRM] than me and another co-facilitator that’s just a social worker also.”

Concerns about RRM age “Well my first reaction was a bit too old, but I mean because it’s just a communications struggle.”

Concern about possible “personality issues”

“I would wonder what headbutting would go on, especially with personality types.”

Important to make clear the role of RRM in session

“And then some also clear boundaries that were drawn from the beginning in terms of the kids understanding that ‘this facilitator [RRM] might be personal, but this facilitator can’t’. So I think it’s gonna have to be very clearly explained to the clients.”

Appreciation for age of RRM “I think it’d be really beneficial, since you know being only a decade older, they’re still, like they could probably still feel they could relate to them, and especially if I’m sure they would probably have similar experiences, or like at least be able to relate to them.”

Provides hope “I think some kids say ‘Wow. She did it, so I could do it,’ which is of course what we would like for them to get from it, and others say ‘That’s her problem. Not ours.’”

Allows RRM to gain skills “I think it’s a great thing because it will allow [RRMs] to be more sharp in the work they do. It’ll allow [RRMs] to facilitate groups in a more structured way, to be more sufficient in what they do.”

Focus on young adults Encourages YAs to “buy in” to

treatment “I personally think they would really relate to it [NMHC] and

buy into it more than if it was just me in here, like I said, doing worksheets or talking with them on the symptoms and stuff. I think that they would really buy into it.”

Reduces stigma for YAs “I think it’s a good concept [Just Do You] and I think it would be beneficial for those, especially obviously those who are very reluctant or maybe haven’t had therapy before and just have this like stigma about it, it would definitely I think help them to get them to a point that they either will be agreeable…to going to a therapist…”

Table 3 (continued)

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Table 3 (continued)

Themes Exemplar quotations

Encourages YAs to advocate for themselves

“So to introduce, to in a way reintroduce them to an idea that will address their new status might be more meaningful to them and help them to see themselves in a different light, that they are not just passive recipients by virtue of the fact that they’re a child and we can tell them what to do, but that now they’re an adult who had choices.”

Focus on hope will resonate with YAs

“I definitely think the Instilling Hope and Empowerment piece is what I think that they will react to the strongest because they have so many strong feelings about being controlled by the system and not feeling like they having any choices.”

Art therapy will help YAs express themselves

“I mean I think all the creative arts are ways to help kids to bring out whatever it is inside them that they want to show, explain, and so I think that yeah, that would be…It’s one of the tools.”

Focus intervention more on practical issues relevant to YAs.

“So in terms of I think that the overall goal is absolutely needed by our kids. My experience with the transition youth is the mental illness or identity of having a mental illness or mental health struggles is extremely separate in their mind to being a transitioning youth. I don’t think they blend the two things together. I don’t think they think about ‘how is my mental health gonna impact my ability to transition successfully into adulthood?”

Suggested changes Add psychoeducation around

mental illness “I think probably the psychoeducation, just to help them maybe

get more of an understanding or like an insight on their symptoms and what that really means, ‘cause a lot of time I think you know they don’t see it as like depression or as that serious as we probably feel it is. They say ‘Well I’m just lazy or I’m unmotivated.’”

Steps of CBT are broken down “I do like the idea that you all are introducing basic concepts of CBT, not as a therapeutic intervention, but breaking down concepts like in a teacher kind of way.”

Add SAMHSA recovery principles

“Personally, I love using the SAMHSA’s principles of recovery” “What I really love, in fact it would be number one on my principle, is that recovery is a very individualized path. There is no one route to recovery.”

Add positive scenario to CBT section

“So my immediate reaction is I would like to create situations that put a more positive spin. ‘So you are going out’, instead of ‘You find out you did not get a job,’…I’d like a scenario, ‘You have an interview today for a job at Target.’”

Add young adult workbook “One of the things, though, that I’m wondering if we could sort of integrate into the manual is how to make this more personalized for them in terms of this being a workbook that is useable.”

Focus more on strengths and “For me personally, I would probably switch the first two

Table 3 (continued)

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Manual language

Some participants reported liking the use of the term “mental health struggles,” as this language is not alienating and is easier for youth to connect with, as opposed to mental disorder/mental illness. Some participants reported that the language was simple and understandable, which is important since youth will enroll who may have cognitive, reading, and processing challenges. Other feedback included reports that the language was respectful, normalizing, and hopeful. One participant reported that the name, Just Do You, should resonate with young adults (it was chosen because it was a phrase used by young adults in previous research by our team). Participants reported the language was simple enough for clinicians and recovery role models to learn, and the script was extensive enough to allow for fidelity.

Narrative mental health communication

Participants provided a number of comments related to the narrative mental health communication (NMHC) videos featuring Ron Artest, a professional basketball player with a mood disorder, and Mary J. Blige, a famous singer/hip hop artist with an abuse history and past battles with mood challenges and suicidality. A number of participants reported that they believed young adults were able to relate to the narrative content in the videos. In particular, participants felt that the description of abuse experiences would resonate with many young adults. They also felt that it was helpful that both Mary and Ron are African-American, as they modeled mental health treatment use. Such modeling helps combat stigma among African-American participants. Some participants reported that the NMHC helps with the following outcomes: (1) creating motivation and hope, (2) demonstrating the importance of goal-setting and having insight, (3) the importance of seeking help, and (4) showing the value of supportive family members and others in the recovery process. One participant stated, “…For him [Ron Artest] to acknowledge his own vulnerabilities and to break down what he had to do, I think somebody, I think a person can identify and may probably be motivated probably after watching it.”

Recovery role model as co-facilitator

Participants provided feedback on the inclusion of a recovery role model as a co-facilitator who provides modeling. Several participants reported that the role model provides an important perspective that is easier for youth to connect with than the clinician. Two participants reported concerns about the age of the role model, reporting that s/he may be too old for the clients to relate to, and one participant reported the concern that the role model’s lack of training may lead to “personality issues” that could get in the way of the treatment process. Participants also provided

Table 3 (continued)

Themes Exemplar quotations

recovery sentences by starting with a more positive statement by saying ‘We want to first acknowledge your strengths’ and starting out with a more positive comment.”

Table 3 (continued)

554 The Journal of Behavioral Health Services & Research 43:4 October 2016

feedback that it is important for the co-facilitators to make clear the role of the role model, since this is a new treatment model.

In contrast to reservations about age, others liked the idea of the role model being a decade older. One participant pointed out that the recovery role model, not being a peer of the same age, may bring less “drama” and more clear boundaries between participant and the role model. One participant also reported that a recovery role model may be a better exemplar than a peer support specialist because s/he has already met developmental milestones, such as obtaining and maintaining employment. One staff member said, “so the idea of having someone who is a generation older, who’s not only figured things out, but who’s been able to have a job and learn how to navigate, I like that concept.” Participants reported other positive aspects of the recovery role model, including that s/he may provide hope to the youth. Perspectives also were shared that the recovery role model position allows for them to gain skills through working with the clinician. One participant stated with regards to the role model sharing his/her narrative:

I think that’s definitely a good thing. It’s an absolute good thing…I think it gives the participant a little bit more hope or much more hope knowing that you know you have people that overcame the struggles that you know a participant is going through at that time.

Narrative mental health communication in the form of both individuals who have spoken publicly about their stories and a role model who co-facilitates the group sharing narrative segments of their recovery story in a structured way is a promising dimension of Just Do You.

Focus on young adults

Participants commented on aspects related to the focus on young adults. Several reported on the importance of an intervention like Just Do You because there is a need for programming that encourages youth to “buy in” to mental health treatment, to reduce stigma, and to encourage youth to advocate for themselves in the treatment process. Others felt that the intervention’s focus on hope and empowerment would resonate with young adults. A few participants reported that they felt the inclusion of art therapy will help youth express themselves. In terms of improvements, some participants suggested that the intervention should focus more clearly on practical issues, such as housing and obtaining a job.

Suggested changes

There were also suggestions for additions and changes to Just Do You. Several participants felt that Just Do You should include a psychoeducation component that helps young adults understand what a mental illness is, what diagnosis they have, and what that diagnosis means. These participants cited the importance of this beginning step in the treatment process. In contrast, two participants highlighted that Just Do You clarifies the treatment process and helps young adults to understand what therapy is. Another participant noted that s/he liked that the intervention breaks down the steps of CBT and other concepts such as stigma, emotions, beliefs, knowledge, and efficacy. One participant suggested integrating the SAMHSA Principles of Recovery and also including additional hopeful messages throughout the intervention. Other suggestions included adding a more positive scenario to the section on understanding cognitive behavioral therapy, as opposed to only negative scenarios, including a workbook the young adults can reference during the sessions and afterwards, increasing the emphasis on the individual nature of recovery, and focusing more on strengths.

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Conclusion of the stakeholder feedback

The research team responded to this feedback by integrating a number of the suggestions into the Just Do You manual before piloting the intervention. For example, SAMHSA’s Principles of Recovery were added and sections related to understanding mental illness and diagnoses were enhanced. Positive scenarios were added to the description of CBT and a “young adult workbook” was developed.

Post-session feedback

Post-session feedback was gathered through meetings held immediately after each session with young adults (N=27a). In addition, facilitators kept journal notes of the group process that they provided the investigators at the end of the pilot project.

In general, feedback regarding the intervention sessions was positive. Youth reported that they liked attending a group that was tailored to their age cohort, and facilitators observed that participants were able to provide support to one another around developmentally relevant issues such as finding jobs, relationships, and treatment. Young adults reported that the inclusion of a role model and the narrative mental health communication were relatable and that hearing stories through narratives helped them to feel less alone and more hopeful. Facilitators suggested that there be more inclusion of community resources. Facilitators also reported that the ADAPT model allowed for flexibility, so the group was both guided but could unfold naturally.

There were suggestions for changes as well. Some youth enjoyed the art kits and felt it gave them an opportunity to express themselves. Facilitators found it effective to allow participants to write feelings or experiences in narrative form (i.e., poetry and lyrics) if they did not feel comfortable engaging in art. The reactions to the young adult workbook were mixed; some participants thought it helped to solidify the points of the group, while other participants interpreted the workbook to be “paperwork.” With regards to the CBT principles, both young adults and facilitators commented that participants seemed to understand the concepts well after the two sessions, but that having back-to-back sessions on CBT was redundant.

Preliminary evaluation of just do you: feasibility, acceptability, and implementation

The team conducted postintervention face-to-face interviews with 14 young adults, 2 role models, and 8 clinic staff to examine feasibility, acceptability, and implementation. The themes that emerged were as follows: (1) acceptance of the recovery role model, (2) shifting motivation, (3) improved attitudes, (4) improved attendance and medication adherence, (5) emotional effects, (6) social relationships, (7) goal setting, and (8) other outcomes.

Acceptance of the recovery role model

The young adults reported general acceptance of the recovery role model and had a number of positive responses to his or her inclusion. Some young adults reported feeling that the recovery role model was relatable and that they believed that the role model had been through many of the same types of hardships that they had been through. One young adult reported feeling appreciative that the recovery role model could open up and trust the group members in the way that s/he did. Another young adult described it as a “relief” to realize that s/he and the recovery role model had experienced the same “kinds of problems.” A number of youth reported feeling that the recovery role model was inspiring, was someone to look up to, and was like a mentor. One participant stated the recovery role model inspired him/her to make something out of his/her hardship and another

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said, “The recovery role model does not put you down. They put you up.” Some young adult participants were impacted by the resilience of the recovery role model, explaining:

Look what [RRM] went through and look what ___ is. ____ fought through all that stuff, all that shit that happened to ___ and ___ made something of it to help other people. …And I look up to [RRM] that way because ___ made something out of it, and I want to be just like that, and I just can’t get over how amazing [RRM] is. Sometimes I think they’re not doing this for the money. I think they’re doing it just to help us, and that’s the feeling they give me.

Finally, one young adult talked about how the most “useful” part of the recovery role model was when the model spoke about outcomes young adults wanted for themselves, such as housing, “The most useful part was when the recovery role model talked about being in a residence and what that process was like.”

Clinicians also generally reported high levels of acceptance of the recovery role model and noted a number of positive aspects of this innovation. One clinician reported that s/he felt that co- facilitating the group gave the role model an opportunity to be active, to take ownership, and be an equal participant in leading the group. Another clinician reported that s/he developed a strong relationship with the recovery role model through the process of co-facilitating the intervention. Other clinicians felt that the role model was able to learn new skills through mentorship by the clinician, such as how to maintain appropriate boundaries with clients.

Finally, role models reported on their experiences. They found that by sharing their story, the young adults felt more comfortable sharing their own stories as well. Recovery role models believed that they provided hope to the young adults and helped them to feel less alone. One role model reported hearing young adults state that now they know they have potential, that they are important. A role model stated that through their experience co-facilitating the group, the recovery role models also feel less alone, and it helped them form a closer relationship with other staff at the agency. One recovery role model felt that their role in the group had helped to facilitate some of the individual work they were engaged in with the young adult participants.

Shifting young adult motivation

Generally, young adults had positive reactions to the group, stating it helped, they were glad they decided to attend, and the group made them feel like they were “a part of something.” A number of young adults reported that given the opportunity, they would attend the group again. One young adult stated the group gave him/her something to look forward to: “Yeah, like ‘cause every single time I went I wasn’t dragging my feet to get there. I was just, I went with a smile on my face. I was happy to go…you know I enjoyed it. I like being able to share my poems with other people that understand it.” This is a valuable outcome, as shifting motivation to attend clinic appointments and increasing actual attendance at clinic appointments, through the use of creative, young adult- centered activities, are the main goals of the intervention program.

Improved young adult attitudes

A goal of Just Do You is to improve engagement and attendance in mental health services. In part, the theory proposes this change occurs through a change in participant cognitions and attitudes. Participants felt that engaging in Just Do You helped them to get more out of mental health treatment, “This group helped with the other PTSD group I’m in and dealing with the past.” Participants also reported increased trust in mental health service providers. For example, a participant reported that his/her attitude towards services had changed, included feeling more comfortable opening up to staff and understanding that staff are there to help rather than control or judge. Another participant shared that while she had had negative experiences with providers in the past, she is learning to “put those feelings aside and learn to trust a new provider.” When reflecting on the role model, one person

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stated, “S/he made me realize that s/he’s there to actually hear us out, you know. S/he’s not there to judge us. So that was really, I mean I like feel really comfortable with him/her now.”

Improved attendance and medication adherence

There were also reports by participants of increased attendance at mental health services as well as increased medication compliance. One participant reported that the group influenced him/her to be more connected to the mental health agency, “I told my ICM [Intensive Case Manager] here at [agency] that since I wasn’t working this summer, I would spend more time at [agency].” Some participants also reported that because of Just Do You, they understood the need for medication better and would be more likely to see a psychiatrist or counselor for mental health challenges.

It helps me want to take my medication more, because like regardless, I always felt I had to do it for somebody else and the Just Do You group made me feel like my medicine, I should do it for me, do it for myself. That’s what I got from it. So it helped me with that.

Another participant stated:

It made me want to take my medication, ‘cause I’m starting to realized the older I get, the more I need it … Like I would take them, but then I would go days without taking them, and then I would take them, but now I take them every day. Like I do it every day now at the same time every day.

Emotional effects

Young adults also reported positive emotional effects. Some stated that through the group, they learned new ways of dealing with emotions, learned to control their anger and stress, and learned to make better decisions when upset. One participant stated that participation in the Just Do You intervention helped to decrease anxiety and PTSD symptoms.

Social relationships

Many young adults reported that participation in the group increased their peer social support, stating that they developed new friendships, provided advice to each other, and were able to understand each other’s problems. Two participants reported appreciating that everyone in the group was a young adult because it made it easier for them to relate to each other and express themselves. One participant reported that the group helped him/her to understand that s/he was not the only one with difficult experiences. Some young adults also reported that participation in the group helped them to develop new and stronger connections to agency staff. One young adult stated that s/he got to see a side of the recovery role model s/he had never seen before, and this was “inspiring.”

Other outcomes

With regards to other aspects of the intervention, young adults believed that both the inclusion of art as well as the CBT concepts were helpful. A few reported that the inclusion of art, music, and writing helped them process difficult feelings and express themselves in a different way. One participant stated that s/he used the art supplies at home on a daily basis, and another participant reported that engaging in art helped bring a sense of calm and focus. The sharing of poems and songs also helped bring about understanding between the participants, according to one young adult. Some participants reported using CBT outside of the group to reduce impulsivity and implement positive conflict resolution skills.

558 The Journal of Behavioral Health Services & Research 43:4 October 2016

Goal setting

Participants also stated that the Just Do You group improved their level of motivation and goal- setting. For example, one participant stated that the group made him/her feel like s/he had a purpose. Another reported that taking part motivated him/her to take the GED exam and another was able to find stable housing after 6 months of homelessness.

Discussion

Promising intervention, protocols, manuals, and processes

A major goal of the pilot study, beyond a feasibility test of the intervention, was the development and testing of all protocols, manuals, and processes to execute a larger efficacy trial of the intervention. Results suggest that young adults find the overall program to be engaging, helpful, and for some, the program changed attendance, adherence, attitudes, and motivation. Results also suggested that the co-facilitation model of a clinician and a recovery role model is promising, with young adults reporting acceptance of the role model and the program components delivered by the recovery role model. Interestingly, data also suggested mixed perspectives on the use of a recovery role model who is approximately a decade older than the participants, with some respondents stating it is a good idea, while one respondent raised concern about whether young adults can relate to someone older. The data suggest that the recovery role models were indeed relatable. Also, clinic staff and administrators perceived a need to develop developmentally specific engagement interventions for young adults. Staff and administrators also supported the necessary processes to develop and pilot test the feasibility of the program within their mental health setting.

Furthermore, results suggested reducing the number of sessions from eight sessions over 4 weeks to four sessions over 2 weeks. Participants reported that there was redundancy in working on understanding principles of evidence-based treatments (i.e., cognitive behavioral therapy and psychoeducation) on more than one occasion. Also, the feasibility study illuminated clinic challenges of delivering an eight-session engagement intervention. Therefore, the manual (see Tables 4 and 5 for an outline of the eight and the four session format) was modified so as to not lose important content, while also decreasing the program to a more feasible number of sessions. In addition, the team is continuing to develop training protocols for the recovery role model, as it is a new role in the mental health system. As the position develops, the team will be involved in developing protocols for recruitment, screening, training, monitoring, and supervision.

Finally, similar to research in other related health fields (i.e., cancer), the present study found that narrative mental health communication increases hope and addresses barriers to help-seek- ing.28,29,30 These results suggest the use of narratives as a promising channel of communication for positive messages about mental health services. More research is needed to examine the efficacy of narratives as a channel for young adults.

Implications for behavioral health

Currently, there are no evidence-based engagement interventions for young adults with SMHCs. The field needs to invest in moving forward programs that are designed explicitly to improve the engagement of young adults in mental health services, as they have been found to be less likely to seek mental health services33 and more likely to drop out of treatment.2 The present article has outlined theoretical frameworks that can be used to develop service engagement interventions for young adults with SMHCs. The frameworks can be applied to develop and test programs designed to improve mental health service use, mental health outcomes, and functioning among young adults. It is critical for behavioral health programs to base the development of programs and empirical tests of those programs on established behavior change and communication theories.

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Table 4 Description of eight sessions of Just Do You

Session 1 • Introduce SAMHSA Recovery Principles • Video of Ron Artest speaking about living with mental illness • Recovery role model shares his/her own journey • YAs complete a personal life goals worksheet

Session 2 (Psychoeducation I)

• Discussion of various causes of mental illness • Discussion of ways to cope with MI • RRM presents his/her experience with receiving a diagnosis, process of acceptance, coping, and the usefulness of knowledge and skills

Session 3 (Instilling hope and healing I)

• Discussion on oppression and disempowerment, how this interacts with mental illness

• YAs create a piece of art depicting their past • RRM shares his/her piece of art describing aspects of the past that have been difficult

Session 4 (CBT I)

• Introduction to cognitive-behavioral therapy • Exercise for understanding the connections between situations, thoughts, feelings, and behaviors

• Video of Mary J. Blige discussing her journey with mental illness and addiction

• Discussion of how Mary J. Blige connects situations, thoughts, feelings, and behaviors

• Homework: participants encouraged to bring to next session song lyrics, poetry, readings, that reflect emotions re: living with SMI

Session 5 (CBT II)

• Continued review of CBT • Use adaptation of exercises for understanding connections between situations, thoughts, feelings, and behaviors, encouraging YAs to apply situations from their own lives

• Homework: participants are encouraged to bring to next session song lyrics, poetry, and readings that reflect emotions around living with SMI

Session 6 • Discussion on how to access mental health services • Handout on local mental health service agencies • RRM shares his/her own experiences of trust/mist-trust when accessing mental health services and YAs discuss their own experiences

Session 7 (Instilling hope and healing II)

• Arts exercise—YAs create art piece depicting what they hope to achieve in the future

• RRM models by sharing his/her own art piece and discussing what s/he hopes to achieve in the future

• Participants share their pieces with one another, if comfortable Session 8 • Review of content from previous seven sessions

• Discussion regarding what YAs have learned in group • RRM sharing what they have taken from group • Discussion of the importance of supportive others in recovery • Graduation ceremony—each YA given a certificate of completion

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Just Do You includes a promising position for the workforce, a recovery role model. The position has considerable potential and may be a cost-effective way for providers to employ others who have experienced recovery to share their narratives in a structured way, to model their strategies for coping, and to teach ways of managing to live with a SMHC. Future research in behavioral health is needed to test the recruitment, screening, training, and employment of recovery role models in mental health settings. In addition, future research studies can examine Just Do You to further understand the underlying mechanisms of change, and also which elements of the intervention make the greatest impact. An example of the latter could be comparing outcomes of Just Do You if delivered with and without a recovery role model.

Table 5 Description of four sessions of Just Do You

Session 1: recovery and “doing you” (Debunking stigma, increasing hope)

• Group ground rules and introduction • Presentation of concepts: recovery, stigma, and hope • SAMHSA Recovery Principles • Discussion of recovery, stigma, and hope • Narrative mental health communication (NMHC, Ron Artest)

• Recovery role model shares his/her journey • Certification for YAs who have completed all four modules

Session 2: need for trust, learning about access and understanding

(Processing mistrust and services at clinic)

• Group ground rules and introduction • Presentation of concepts: need for trust (processing mistrust), access, and understanding

• Discussion: trust, access, and understating • CBT exercise (with NMHC, Mary J Blige) • Worksheet and discussion on services • Recovery role model journey II • Certificates for YAs who have completed all four modules

Session 3: processing past (Hope and recovery)

• Group ground rules and introduction • Presentation of concepts: processing the past, hope, and recovery

• Creative arts to depict the past • Discussion of past and art pieces, with RRM leading • Certificates for YAs who have completed all four modules

Session 4: processing future and “doing you”

(Hope and recovery)

• Group ground rules and introduction • Presentation of concepts: processing the future, hope, and recovery

• Creative arts to depict the future/hope • Discussion of the future with RRM leading • Certificates for YAs who have completed all four modules

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Finally, Just Do You holds promise for changing important behavioral health outcomes, such as motivation, attitudes, emotions, and behavior, as is evidenced by the empirical data in the present study. Improving young adult motivation, attitudes, and behavior around treatment through engagement interventions may decrease missed appointments and ultimately increase clinic efficiency. The next step in this research is to test change in outcomes in a randomized clinical trial design.

The program uses innovative engagement strategies (i.e., art), while also utilizing strategies found to be effective in increasing hope and decreasing resistance in other related health behavior fields, such as narrative health communication.28,29,30 In the young adult mental health field, the online website “half of us” is a great resource for access to compelling narrative mental health communication for research teams to utilize.31 Further research is needed to examine the effectiveness of this channel of communication as well, compared to standard psychoeducation curriculums and motivational interviewing interventions.

Acknowledgments

The authors would like to especially thank the Ohio Department of Mental Health and the Fahs Beck Fund/New York Community Trust for financial support and all of the participants who helped us develop and refine the young adult engagement intervention reported on in this article.

Conflict of Interest None for any authors.

Notes There were 27 young adults that were part of post-session process discussions, which is more than the 24 young adults described in Table 1, because 3 young adult participants consented and became involved after the baseline data was collected.

References

1. Koplewicz H. Call to Action. Journal of Child and Adolescent Psychopharmacology. February 2013; 23(1): 2–2. 2. Edlund MJ, Wang PS, Berglund PA, et al. Dropping out of mental health treatment: Patterns and predictors among epidemiological

survey respondents in the United States and Ontario. American Journal of Psychiatry 2002; 159: 845–851. 3. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National

Comorbidity Survey Replication. Archives of General Psychiatry 2005; 62(6): 593–602. 4. Blanco C, Okuda M, Wright C, et al. Mental health of college students and their non-college-attending peers: Results from the National

Epidemiologic Study on Alcohol and Related Conditions. Archives of General Psychiatry 2008; 65(12): 1429–1437. 5. Gralinski-Bakker JH, Hauser ST, Billings RL, et al. Risks along the road to adulthood: Challenges faced by youth with serious mental

disorders. In: DW Osgood, EM Foster, C. Flannagan, GR Ruth (Eds). On your own without a net: The transition to adulthood for vulnerable populations. Chicago: University of Chicago Press, 2005, pp.272–303.

6. Osgood DW, Foster EM, Courtney ME. Vulnerable Populations and the Transition to Adulthood, Focus on Children 2010; 20(1): 209– 229.

7. Perlick DA, Hofstein Y, Michael LA. Barriers to Mental Health Service Use in Young Adulthood. In: JE. Grant & MN. Potenza, (Eds). Young Adult Mental Health. New York: Oxford University Press, 2010, pp.195–205.

8. Munson MR, Scott LD, Jr., Smalling S, et al. Former system youth with mental health needs: Routes to adult mental health services, insight, emotion, and mistrust. Children and Youth Services Review 2011; 33(11): 2261–2266.

9. Walker J, Gowen K, Jivanjee P, et al. Pathways to Positive Futures: State-of-the-science conference proceedings (part 1). Portland, OR: Portland State University, Research and Training Center for Pathways to Positive Futures, 2013.

10. Whyte WF. Participatory Action Research. Sage focus editions, Vol. 123. Thousand Oaks, CA: Sage Publications, Inc, 1991. 11. Munson MR, Jaccard J, Smalling S, et al. Static, dynamic, integrated, and contextualized: A framework for understanding mental health

service utilization among young adults. Social Science & Medicine 2012; 75(8): 1441–1449. 12. Kim H, Munson MR, McKay MM. Engagement in mental health treatment among adolescents and YAs: A systematic review. Child and

Adolescent Social Work Journal 2012; 29(3): 241–266. 13. Jaccard J. Careful, Current, and Consistent: Tips to Improve Contraceptive Use. Washington, DC: National Campaign to Prevent Teen

and Unplanned Pregnancy, 2010.

562 The Journal of Behavioral Health Services & Research 43:4 October 2016

14. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977. 15. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Upper Saddle River, NJ: Prentice Hall, 1986. 16. Perry CL, Williams CL, Veblen-Mortenson S, et al. Project Northland: Outcomes of a communitywide alcohol use prevention program

during early adolescence. American Journal of Public Health 1996; 86(7): 956–965. 17. Auslander W, Haire-Joshu D, Houston C, et al. The short-term impact of a health promotion program for low-income African American

women. Research on Social Work Practice 2000; 10(1): 78–97. 18. Rhodes JE. Stand by me: The risks and rewards of mentoring today's youth. Cambridge, MA: Harvard University Press, 2002. 19. Munson MR, Lox JA. Clinical social work practice with former system youth with mental health needs: Perspective of those in need.

Clinical Social Work Journal 2012; 40(2): 255–260. 20. Half of Us. Ron Artest. Available online at http://www.halfofus.com/video/depression/. Accessed December 15, 2013. 21. Jamison KR. An Unquiet Mind. New York, NY: Random House, 1995 22. Frese FJ, Knight EL, Saks E. Recovery from Schizophrenia: With Views of Psychiatrist, Psychologists, and Others Diagnosed with the

Disorder, Schizophrenia Bulletin 2009; 35(2): 370–380. 23. Jordon J. The meaning of mutuality. In: JV Jodan, AG Kaplan, JB Miller, et al (Eds). Women’s Growth in Connection. New York: The

Guilford Press, 1991, pp. 81–96. 24. Miller JB, Stiver I. The Healing Connection. Boston: Beacon Press, 1997 25. Sparks E. Relational experiences of delinquent girls: A case study. In: M Walker, WB Rosen (Eds). How connections heal: Stories from

relational-cultural therapy. New York, NY: Guilford Press, 2004. 26. Gutierrez LM. Working with women of color: An empowerment perspective. Social Work 1990; 35(2): 149–153. 27. White M. Narrative means to therapeutic ends. New York, NY: W.W. Norton & Company, Inc, 1990. 28. Dal Cin S, Zanna MP, Fong GT. Narrative persuasion and overcoming resistance. In: ES Knowles, J Linn (Eds). Resistance and

persuasion. Mawah, NJ: Lawrence Erlbaum, 2004, pp. 275–191. 29. Chelf J, Deshler A, Hillman S, et al. Storytelling: A strategy for living and coping with cancer. Cancer Nursing 2000; 23: 2–5. 30. Kreuter MW, Green MC, Cappella JN, et al. Narrative communication in cancer prevention and control: A framework to guide research

and application. Annals of Behavioral Medicine 2007; 33(3): 221–235. 31. Yalom ID. The Theory and Practice of Group Psychotherapy (4th Edition). New York, NY: Basic Books, 1995. 32. Lincoln NK, Denzin YS. The Sage Handbook of Qualitative Research (3rd Edition). Thousand Oaks, CA: Sage Publications, Inc, 2005. 33. Rickwood D, Deane FP, Wilson C, et al. Young people’s help-seeking for mental health problems. Australian e-Journal for the

Advancement of Mental Health 2005; 4(3): 1–34.

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