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 additional 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 a our provider workforce to deliver effective mental health care to an increasingly heterogeneous patient population. To address this challenge, Unmute has developed 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. Our CARE framework targets the assessment and engagement phase of treatment to reduce dropout, emphasizing skills-training for therapists to strengthen the therapeutic alliance, a change mechanism robustly associated with treatment outcome, but more difficult to cultivate across patient-provider differences. Aim 1: 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). Aim 2: 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. Unmute’s CARE framework aligns with NIMH’s Goal 4: Advance Mental Health Services to Strengthen Public Health. 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. We plan to commercialize Unmute’s CARE framework with health plans through a value-based care model that incentivizes providers to terminate patients when they have achieved significant symptom improvement and progress in self-defined treatment goals. By taking this approach, we are seeking to build provider capacity in a supply-constrained market to improve the accessibility of high-quality mental health care for all.