A Needs Assessment to Evaluate Implementing a Relationship Enhancement Intervention for Couples at a Community Mental Health Clinic

Background: Divorce's harmful effects on individuals, families, and communities is a well-known concern. Dissatisfying relationships, even without divorce, are a significant source of stress and can contribute to increased morbidity and mortality. Relationship interventions reduce stress and improve relationship satisfaction in stressed and nondistressed couples, but most do not seek treatment. Barriers to treatment include the availability of trained providers, cost, time, and stigma. Group programs can be an effective strategy for overcoming treatment barriers. Local Problem: A community mental health clinic offers no relationship interventions other than traditional couples therapy. This project aimed to conduct a needs assessment to provide recommendations for implementing a group relationship enhancement program for couples at the community mental health clinic. Methods: The Kaizen model-driven needs assessment used electronic health record data extraction, a survey, and a discussion group to evaluate the current nature and effectiveness of relationship interventions at the community mental health clinic. A literature search and content expert recommendations informed the educational PowerPoint and intervention proposal presented to clinic partners. A post-presentation survey gathered outcome measures to evaluate the proposal's acceptability, appropriateness, and feasibility. Results: Most couples requesting services at the community mental health clinic did not receive treatment. Provider availability largely contributed to the inaccessibility of services. All clinic partners agreed that the proposal to implement an adapted version of Mindfulness-Based Relationship Enhancement (MBRE), an evidence-based relationship enhancement group program that captures nondistressed couples, was acceptable, appropriate, and feasible. Conclusion: Project results reveal a gap in services available to nondistressed couples at a community mental health clinic. Implementing evidence-based group programs at community mental health clinics may address barriers to treatment, including lack of providers and cost.

1 A Needs Assessment to Evaluate Implementing a Relationship Enhancement Intervention for Couples at a Community Mental Health Clinic Kristen Hoppe, Caroline Stephens College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 23, 2023 2 3 Abstract Background: Divorce's harmful effects on individuals, families, and communities is a well-known concern. Dissatisfying relationships, even without divorce, are a significant source of stress and can contribute to increased morbidity and mortality. Relationship interventions reduce stress and improve relationship satisfaction in stressed and nondistressed couples, but most do not seek treatment. Barriers to treatment include the availability of trained providers, cost, time, and stigma. Group programs can be an effective strategy for overcoming treatment barriers. Local Problem: A community mental health clinic offers no relationship interventions other than traditional couples therapy. This project aimed to conduct a needs assessment to provide recommendations for implementing a group relationship enhancement program for couples at the community mental health clinic. Methods: The Kaizen model-driven needs assessment used electronic health record data extraction, a survey, and a discussion group to evaluate the current nature and effectiveness of relationship interventions at the community mental health clinic. A literature search and content expert recommendations informed the educational PowerPoint and intervention proposal presented to clinic partners. A post-presentation survey gathered outcome measures to evaluate the proposal's acceptability, appropriateness, and feasibility. Results: Most couples requesting services at the community mental health clinic did not receive treatment. Provider availability largely contributed to the inaccessibility of services. All clinic partners agreed that the proposal to implement an adapted version of Mindfulness-Based Relationship Enhancement (MBRE), an evidence-based relationship enhancement group program that captures nondistressed couples, was acceptable, appropriate, and feasible. 4 Conclusion: Project results reveal a gap in services available to nondistressed couples at a community mental health clinic. Implementing evidence-based group programs at community mental health clinics may address barriers to treatment, including lack of providers and cost. Keywords: couples therapy, relationship enhancement interventions, nondistressed couples, MBRE 5 A Needs Assessment to Evaluate Implementing a Relationship Enhancement Intervention for Couples at a Community Mental Health Clinic Problem Description Divorce rates are a well-known concern, and in the United States, approximately 40 –50% of first marriages and 60% of second marriages end in divorce (National Marriage Project, 2019; Centers for Disease Control and Prevention, 2017). The U.S. Census Bureau (2021) estimated Utah's 2019 divorce rate at 9.40%, the 7th highest in the country. Individuals have ranked divorce as the second most stressful lifetime event (Whisman & Beach, 2009), and research has extensively documented the harmful effects of divorce on families, children, and communities (Schramm, 2006). Relationships that end in acrimony, even without divorce, can have negative repercussions. For example, dissatisfying partnerships are a significant source of stress and contribute to increased morbidity and mortality from various psychological, cardiovascular, and endocrine disease processes (Shrout, 2021). Conversely, satisfying relationships, particularly satisfying intimate partnerships, are associated with a higher quality of life and mental wellness (Sbarra, 2015). As such, there is a need for interventions that provide those in intimate partnerships with skills that contribute to a satisfying relationship. Unfortunately, there is a lack of evidence-based, affordable relationship programs for couples in Salt Lake City. Available Knowledge Relationship interventions can include education, communication skills programs, relationship enhancement/enrichment, and couples therapy (Javadivala et al., 2021). Studies indicate that interventions that improve communication skills, increase connection, and heighten emotional intelligence can reduce stress and enhance relationship satisfaction (Eslami et al., 2014). Research at the Veteran's Administration Medical Center suggests that participation in various interventions for couples can also decrease substance use and depression (Salivar et al., 2020). Thus, relationship interventions 6 can potentially reduce overall healthcare costs via subsequent improvement in physical and mental health. Although couples therapy and evidence-based relationship interventions improve relationship satisfaction in distressed and nondistressed partnerships, most therapeutic approaches are reactive measures that target already distressed couples (Carson et al., 2006). Research indicates that lower stress levels and relationship commitment indicate a positive response to relationship interventions (Baucom et al., 2015), suggesting that these approaches may have increased benefits when used proactively by couples who are not currently distressed. Two unique evidence-based relationship enhancement programs that capture and positively impact nondistressed couples are the Prevention and Relationship Enhancement Program (PREP) (Anderson et al., 2013) and Mindfulness-Based Relationship Enhancement (MBRE) (Carson et al., 2004). Studies indicate that both programs successfully improve relationship satisfaction, communication skills, and stress coping (Carson et al., 2004; Javidhala et al., 2021). Despite the efficacy of such relationship interventions, most couples do not seek treatment proactively or reactively (Salivar et al., 2020). According to Johnson et al. (2002), only 36% of married couples attend premarital education programs, and only 19% seek couples therapy. Barriers to treatment include cost, availability of providers, logistics such as childcare and transportation, and the stigma around mental health care (Salivar et al., 2020). These barriers and additional concerns regarding health insurance are often more present in couples with low socioeconomic status (Ward et al., 2013). In addition, therapeutic alliance discrepancies, such as when one client perceives the therapist to be more aligned with their partner, can contribute to premature termination of treatment (Bartle-Haring et al., 2012). Group interventions can be an effective strategy for overcoming treatment barriers and other challenges (Goldin et al., 2016), and a study by Fawcett et al. (2020) illustrated the efficacy of the group model versus waitlist or no treatment. 7 Based on existing research, combining group therapeutic models with evidence-based relationship enhancement interventions may successfully address treatment barriers and improve relationship satisfaction. Beyond traditional couples therapy, no such intervention exists at the University of Utah's affiliated community mental health clinic. This project aimed to conduct a needs assessment to address this service gap and make intervention recommendations for nondistressed couples. Rationale This needs assessment adapted the Kaizen model, which emphasizes making small changes for the greater good (Sirk, 2020). The Kaizen method is a derivative of the well-known Plan Do Study Act model, used extensively in healthcare organizations and nursing processes, and encourages a non-linear approach to incremental change and outcome evaluations (Agency for Healthcare Research and Quality, 2020). Businesses and organizations utilize the Kaizen method around the globe to drive quality improvement and efficiency (Sirk, 2020). The Kaizen focus on understanding organizational processes relates to the objectives of this project, which involved understanding the current nature and effectiveness of couples' interventions at the community mental health clinic. The Kaizen model also encourages organizational engagement and participation from the ground up, and this needs assessment invited clinic partners at the community mental health clinic to participate in a discussion group. Principles of the Kaizen method include the Gemba Walk (Sirk, 2020), which guided the formulation of discussion group questions. The Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis is another tool to direct discussion groups (Goldberg, 2022). It is beneficial for needs assessments because it encourages clinic partners to give a neutral viewpoint of the current state of processes, in this case, couples’ interventions and their effectiveness. In this manner, both the Kaizen model and SWOT analysis facilitated the goal of this needs assessment project (Figure 1). 8 Specific Aims This project aimed to conduct a needs assessment to provide recommendations for implementing a relationship enhancement intervention for couples at a community mental health clinic. Methods Context The needs assessment occurred at an academically affiliated, community-based, researchfocused mental health clinic on the University of Utah campus. The clinic provides sliding-scale treatment to individuals, children, and couples, serving a socioeconomically diverse patient population along the Wasatch Front and rural Utah. Two University of Utah Department of Psychology professors direct the clinic, which graduate-level trainees in nursing, social work, psychology, and psychiatry primarily staff. There is also an administrative assistant on staff (note: clinic directors, staff, and trainees will hereafter be referred to as 'clinic partners'). Intervention(s) This needs assessment project is based on the principles of Kaizen (Figure 1) and focused on assessing the clinic and engaging partners, understanding the existing evidence, determining the best intervention, and designing a plan for implementation, feedback, and measurement of success. There were four phases of this project. Phase One: Assessment & Clinic Partner Engagement Assessment of the clinic involved gathering data from the electronic health record (EHR) to better understand client demographics and patterns, including the number of couples treated, treatment length, and treatment cost. De-identified client data from September 1, 2021-September 30, 2022, was included in the assessment. The clinic partners were given a pre-survey (Appendix A), through the Research Electronic Data Capture (REDCap) platform, which collected demographic data and data on the perceptions of the 9 current nature and effectiveness of couples’ interventions offered at the clinic. The project leader (KH) facilitated partner engagement by hosting a discussion group, which took place during previously scheduled supervisor/trainee meetings, to ensure the partners agreed with the project's processes. During the virtual 30-minute virtual meeting, clinic partners: 1) provided input on the perceived barriers and facilitators to couples accessing therapy; and 2) engaged in a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis (Appendix B) to elucidate the internal and external forces impacting the clinic's ability to implement new therapeutic interventions. Phase Two: Evidence Appraisal Appraising the existing evidence involved an in-depth literature search of evidence-based couples’ interventions and recommendations from the project’s content expert. Recommendations from the content expert were shared through an online video conversation, which led to the decision to focus on Mindfulness-Based Relationship Enhancement (MBRE) as an intervention proposal. Phase Three: Intervention Proposal & Continued Partner Engagement For this project to be successful, clinic partner engagement was crucial, and clinic partners were involved in determining the best solution. The project leader (KH) shared an educational presentation (Appendix C), which summarized findings from the discussion group, including barriers to treatment, literature review, and content expert recommendations. The presentation also provided background information on MBRE, this program's structure, and the intervention proposal. The findings from phase one, literature aggregation, and content expert recommendations all informed the intervention proposal of implementing an adapted version of MBRE at the clinic as a relationship enhancement intervention. Clinic partners completed a post-presentation REDCap survey (Appendix D), which gathered data on the acceptability, appropriateness, and feasibility of the couples' intervention proposal, as well as perceived barriers and facilitators, qualitative feedback, suggestions for alternative interventions, and participant demographics. 10 Phase Four: Evaluating Feedback The project's final phase consisted of evaluating clinic partners' feedback; analyzing the acceptability, appropriateness, and feasibility outcome measures; and compiling this information into an executive summary, including proposal recommendations. Lastly, the community mental health clinic's co-directors received a copy of the executive summary (Appendix E). Study of the Intervention(s) The methods utilized to carry out the needs assessment project included EHR data extraction, surveys, a discussion group, a SWOT analysis, and an educational and proposal presentation. EHR data obtained in phase one provided client-level data, including the number of couples seeking treatment within the defined timeframe compared to the total number of patients on the waitlist. EHR data also provided demographic information for couples who did receive treatment and the length and cost of treatment. A survey (Appendix A) administered to clinic partners in phase one gathered clinic partnerlevel data, including clinic staff demographic information and qualitative data. The discussion group and SWOT analysis (Appendix B) facilitated in phase one provided additional qualitative data. Project evaluation consisted of obtaining feedback from clinic partners in phase three via a post-presentation survey (Appendix D) regarding the effectiveness of the educational presentation and obtaining acceptability, appropriateness, and feasibility outcome measures for the intervention proposal. Phase four of the project entailed analyzing the outcome measures and feedback. Based on existing literature, this intervention was expected to address the gap in available programs for couples requesting services at the community mental health clinic, grow knowledge and usage of evidence-based interventions for couples, and increase clinic partners' acceptance of implementing a relationship enhancement program for nondistressed couples. Measures 11 Client-level, clinic-level, and clinic-partner-level data collected for this needs assessment came from several sources, including the EHR, a pre-discussion group REDCap survey, the discussion group and SWOT analysis, and a post-educational presentation REDCap survey. The project's content expert, scholarly chair, and faculty members approved the surveys, discussion group questions, educational PowerPoint, and outcome measures tool (Appendices A, B, C, and D). Client-Level Data Client-level data from the EHR included the number of couples who requested services from the community health clinic but were not treated, completed an intake but did not continue treatment, and those who received treatment. Additional client-level EHR data included sociodemographic information on clients who completed treatment and the length and cost of their treatment. The cost of services varied because the community mental health clinic utilizes a sliding scale to calculate the fee per session based on the total household income range and the education level of the clinician. Clinic and Clinic Partner-Level Data Two REDCap surveys (pre-discussion and post-presentation) and a discussion group with a SWOT analysis yielded clinic-level and clinic-partner-level quantitative and qualitative data. A 12-item pre-discussion group REDCap survey (Appendix A), developed by the project lead (KH), queried clinic partner demographics (e.g., age, gender, race/ethnicity, education level, role at the clinic, and years in clinical practice) and their perspectives on the current nature and effectiveness of couples' interventions at the community mental health clinic. Open-ended survey questions such as 'What interventions are available for couples at the clinic?' addressed the current nature of interventions. The survey queried effectiveness using a five-point Likert scale ranging from very effective to very ineffective. Additional survey questions requested input regarding barriers to couples seeking therapy and recommendations for couple’s interventions. In the discussion group, open-ended questions allowed clinic partners to provide further information on barriers to treatment. The discussion group's SWOT analysis (Appendix 12 B) focused on the internal and external forces impacting the clinic's ability to implement new therapeutic interventions and yielded additional qualitative data. An 18-item post-educational presentation REDCap survey (Appendix D) collected demographic data and included the validated outcome measures tool (Weiner, 2017) to evaluate the intervention proposal quantitatively. These measures included the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Additional survey questions obtained qualitative data about potential barriers and facilitators to implementing the proposal. A five-point Likert scale question, ranging from strongly agree to strongly disagree, queried the effectiveness of the presentation at addressing the clinical gap in relationship interventions available for nondistressed couples. Open-ended questions included in the survey ensured that clinic partners could provide feedback on improving the effectiveness of the presentation and give suggestions on alternative interventions. Analysis Descriptive statistics and frequency distributions were done on all quantitative data, including client and clinic provider demographics and Likert scale questions. Data from open-ended survey questions were analyzed using content analysis (Erlingsson & Brysiewicz, 2017), and responses were organized, categorized, and then summarized using frequency distributions. Ethical Considerations The University of Utah Institutional Review Board (IRB) deemed this needs assessment project quality improvement in nature and, therefore, not subject to IRB oversight. An administrative staff person employed by the community clinic extracted and de-identified the EHR data used in this project. There were no conflicts of interest concerning this project. Results 13 Phase One: EHR Data, Pre-Discussion Group Survey, Discussion Group Client-Level Data Of the 12 couples who requested treatment from the community mental health clinic, four (34%) received couples therapy. One couple (8%) completed an intake but did not receive treatment, and the other seven couples (58%) requested services but did not receive treatment. Data, including demographics and length and cost of treatment, for those who received treatment, are shown in Table 1. Treatment costs ranged from $160 for three months of therapy to $2610 for 12 months of therapy. The clinic did not collect data on the eight couples who sought treatment but did not receive it. Clinic-Level and Clinic Partner Data Demographic characteristics of the staff who completed the pre-discussion group survey (n=8) indicated that 87.5% (n=7) were Caucasian, and 75.0% (n=6) held a Master's Degree or higher (Table 2). Over half of the respondents (n=5) viewed the current interventions as effective or somewhat effective (Table 3). Open-ended questions referenced clinic staff perceptions of the barriers to couples seeking therapy or relationship interventions and revealed transportation, time, stigma, childcare, and uncertainty of the therapeutic process as categories most cited (Table 3). Most clinic staff (75%, n=6) were uncertain about interventions they would like to see available for couples at the clinic (Table 3). However, some respondents stated they would like to see relationship enhancement groups (12.5%, n=1) or briefer interventions like skills training or communication workshops (12.5%, n=1). The SWOT analysis revealed several themes (Appendix B). Identified Strengths included the affordability of services offered at the community mental health clinic, an interdisciplinary approach, and an ongoing influx of trainees. Identified Weaknesses involved lag time in client treatment associated with onboarding trainees. Opportunities recognized included a community need for couple’s programs and a lack of offerings in Salt Lake City. Threats identified involved the cultural context of Salt Lake City and the potential negativity couples may feel in seeking faith-based counsel for relationship support. 14 Phase Three: Educational Presentation and Intervention Proposal Based on findings from Phases 1 and 2, the project leader (KH) proposed implementing an adapted format of MBRE (Appendix D). The majority of clinic partners who participated in the educational PowerPoint and proposal presentation (n=4) were female (75%, n=3), Caucasian (100%, n=4), and held a Master’s Degree or higher (75%, n=3; Table 4). Phase Four: Outcome Measures and Feedback Analysis Qualitative Findings Open-ended questions in the post-presentation survey asked about barriers and facilitators to the proposed intervention (Table 5). Barriers to implementation included trainees' lack of experience (25%), lack of resources (25%), and recruiting enough couples for the first group offering (25%). The primary facilitator was the expertise and training of clinic directors, staff, and interns (100%). Additional feedback regarding the quality and effectiveness of the presentation, as well as suggestions for other programs to consider implementing at the clinic, were summarized (Table 5). All participants strongly agreed that the PowerPoint presentation clearly addressed the clinical gap regarding the availability of relationship interventions for nondistressed couples. Quantitative Findings The post-presentation survey AIM, IAM, and FIM outcome measures revealed that 100% of clinical staff agreed or completely agreed the proposal was acceptable, appropriate, and feasible (Table 6). Discussion Summary Divorce and its harmful effects on families, children, and communities is a well-known concern (Schramm, 2006). Dissatisfying relationships, even without divorce, are a significant source of stress and can contribute to increased morbidity and mortality (Shrout, 2021). Evidence suggests relationship 15 interventions can improve relationship satisfaction (Eslami et al., 2014); however, this needs assessment revealed a local community mental health clinic only offers traditional couples therapy and no other beneficial interventions for couples. Even though research indicates nondistressed couples are likely to respond better to interventions (Baucom et al., 2015), traditional couples therapy commonly targets distressed couples. This needs assessment further confirmed that the majority of couples requesting services at the community mental health clinic did not receive treatment and that provider availability largely contributed to the inaccessibility of services. Group programs can effectively address this clinical gap (Mongelli et al., 2020) and additional treatment barriers such as cost (Goldin et al., 2016). This project demonstrated an interest amongst clinic partners in implementing a group program for couples, as all clinic partners agreed that the proposal to implement an adapted version of MBRE was acceptable, appropriate, and feasible. One of the major strengths of the project included clinic partner engagement, achieved by following the Kaizen methodology of encouraging organizational engagement and participation from the ground up. O'Rourke et al. (2016) state, "The importance of including a variety of stakeholders in change initiatives aimed at improving healthcare systems worldwide cannot be underestimated” (p. 261). At the outset, this project invited clinic partners from all levels to participate in a discussion group, creating a more intimate setting and welcoming them to share their knowledge, perspective, and feedback. This knowledge was vital to the needs assessment and instrumental in formulating an intervention proposal aligned with the community mental health clinic's mission to engage in evidence-based, innovative clinical services, research, and training. Interpretation While most clinic partners rated the current interventions at the community mental health clinic as very effective or somewhat effective, there is a shortage of adequately trained staff to provide couples therapy, and potential clients have trouble accessing the services. This finding aligns with the 16 literature, suggesting critical barriers to accessing mental health services include a shortage of professionals and insufficient community mental health services (Carbonell et al., 2020). The proposal to use a group model to address treatment access barriers is also congruent with the literature, which suggests that the group model is more effective than waitlist or no treatment (Fawcett et al., 2020). Since the majority of couples who sought therapy at the community mental health clinic did not receive treatment, offering couples an affordable group program is a viable alternative to no treatment or waitlist. Proposal support was surprising given the strict facilitator requirements outlined in the MBRE manual and the time requirements of administering the program as designed (Carson et al., 2004). Enablers of intervention implementation, such as the clinic co-director’s relationship with MBRE creator Dr. James W. Carson, may have balanced the program's barriers. Additionally, the clinic has the MBRE manual, and there is a possibility of adapting the current structure and facilitator requirements to suit clinic and client needs better. All these components presumably made MBRE a promising program to implement, as all clinic partners agreed or completely agreed the proposal was acceptable, appropriate, and feasible. Unexpected results included the small number of couples who sought and received treatment at the community mental health clinic over the one year of data examination (September 2021September 2022). While the clinic opened in May 2021, it didn’t recruit patients for a few months. The newness of the clinic may have contributed to a lack of community awareness that it existed as a mental health resource. The co-directors also indicated trainees primarily staff the clinic, and particular dynamics, such as losing trainees over the summer and lags between the onboarding of cohorts, influenced the provision of services. Such organizational context underscores the value of implementing a group intervention to better meet client needs, especially with literature indicating group programs are more effective than no treatment or waitlist (Fawcett et al., 2020). 17 Though the project did not directly impact couples looking to improve relationship satisfaction, the needs assessment addressed a clinical gap and created a pathway to future intervention implementation at the community mental health clinic. The group program proposal acknowledged cost as a barrier to treatment and addressed the inaccessibility of relationship interventions for socioeconomically disadvantaged couples by increasing the number of services and decreasing waitlist time and cost. Literature speaks to the importance of considering cost-effectiveness when addressing clinical gaps and contemplating treatment strategies (Mongelli et al., 2020). Given the value of implementing a program like MBRE at the community mental health clinic, the co-directors and trainees may be proponents of moving the project proposal to implementation phase. A sustainability plan could include trainees from the College of Social Work and College of Nursing individually or collaboratively introducing, facilitating, and monitoring a group program. Costs associated with implementing MBRE as a relationship intervention may include printing flyers as a component of a marketing campaign and ancillary staff wages if involved in facilitating the program. Limitations Limitations of the project included a lack of data, specifically demographic information, on couples who did not receive treatment. We attributed those who did not receive treatment to a lack of resources; however, if we had had additional data on this group, there may have been insight into other explanations for the lack of treatment. The small, homogenous sample of clinic partners comes with additional limitations. Only four clinic partners, who may have biases, attended the educational and proposal presentation, reducing the significance of the outcome measures obtained. While the project leader (KH) emphasized the importance of gathering data versus supporting the intervention proposal, clinic partners may have responded out of allegiance to the project leader. Lastly, the small sample size and lack of diversity within the sample limits the generalizability of these findings to other contexts. 18 However, the project intended to look specifically at the community mental health clinic, and future studies could scale a similar study to their clinic or setting. Conclusion Findings from this needs assessment and the literature underscore the overarching need for additional community mental health services (Carbonell et al., 2020). This is particularly important for nondistressed couples, given the growing body of evidence demonstrating satisfying intimate partnerships are associated with a higher quality of life and mental wellness (Sbarra, 2015) and that proactive relationship interventions can improve relationship satisfaction (Baucom et al., 2015). Implementing innovative programs, such as MBRE, that incorporate the group model may further address barriers to accessing treatment, including lack of providers or resources, cost, and stigma. Given that the community mental clinic in this project has an ongoing influx of trainees from various disciplines, this proposed group model provides an excellent opportunity for future trainees to move the program proposal to implementation and evaluation. Lastly, this project highlights how conducting a community mental health clinic Kaizen-driven needs assessment may be a conduit for promoting incremental change that has a ripple effect on the health of individuals, families, and communities. Funding This project received no outside funding. Acknowledgments This endeavor would not have been possible without the support, guidance, and invaluable feedback my Project Chair, Dr. Caroline Stephens, provided. I would also like to express my deep gratitude to my Content Expert, Dr. Brian Baucom, who generously offered knowledge and inspired me to turn my interest in mindfulness-based interventions and the group model into a scholarly project. 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Family Process, 60(3), 694–711. https://doi.org/10.1111/famp.12683 25 Table 1 Couples Data Extracted from Electronic Health Records at a Community Mental Health Clinica (N=4) Study Sample Characteristics Couple Sexual Orientation Heterosexual Race White/Caucasian Biracial Marital Status Married Monogamous partnership Unavailable Education High school diploma or equivalent, Some college Graduate/professional degree Unavailable Length & Cost of Treatmentb 12 months, 29 sessions x $90 per = $2,610 9 months, 30 sessions x $50 = $1,500 6 months, 17 sessions x $90 = $1,530 3 months, 4 sessions x $40 = $160 Note. Electronic Health Records from September 2021-September 2022. N % 4 100% 2 2 50% 50% 2 1 1 50% 25% 25% 1 2 1 25% 50% 25% 1 1 1 1 25% 25% 25% 25% aOf the 12 couples who requested treatment from the community health clinic, only 4 (34%) received couples' therapy. One couple (8%) completed an intake but did not receive treatment, and another 7 (58%) requested services but did not receive treatment. Demographics, length, and cost of treatment are shown for the four couples who received couples therapy. bThe community mental health clinic utilizes a sliding scale to calculate the fee per session based on the total household income range and the education level of the clinician. 26 Table 2 Characteristics of Clinic Partnersa Participating in Pre-discussion Group (N=8) Demographic Characteristics N Age (years) 21-30 4 31-40 3 41-50 1 50+ 0 Gender Male 3 Female 5 Transgender 0 Non-binary/non-conforming 0 Prefer not to respond 0 Other, Write in 0 Ethnicity/Race American Indian or Alaskan Native 0 Asian 1 Black or African American 0 Hispanic or Latino or Spanish Origin 0 Native Hawaiian or Other Pacific Islander 0 White or Caucasian 7 Multiracial or Biracial 0 A race/ethnicity not listed here 0 Education Level High School Level 0 Bachelor's Degree 1 Master's Degree 4 Ph.D. or higher 2 Doctorate or higher 0 Trade School 0 Role at Clinic Clinician/Therapist 2 Codirector 2 Staff 1 Trainee 3 Length of time in practice (years) One year or less 3 2-5 3 5-10 0 11 years or more 2 aClinic partners included trainees, therapists, and a clinic co-director. % 50.0% 37.5% 12.5% 0.0% 37.5% 62.5% 0.0% 0.0% 0.0% 0.0% 0.0% 12.5% 0.0% 0.0% 0.0% 87.5% 0.0% 0.0% 0.0% 25.0% 50.0% 25.0% 0.0% 0.0% 25.0% 25.0% 12.5% 37.5% 37.5% 37.5% 0.0% 25.0% 27 Table 3 Frequency of Clinic Partner Perceptions from Pre-Discussion Group Survey Regarding Nature and Effectiveness of Current Interventions, Barriers to Treatment, and Intervention Recommendations Nature and Effectiveness of Interventions What interventions are available for couples? Cognitive Behavioral Conjoint Therapy Integrative Behavioral Couples Therapy Cognitive Behavioral Therapy for couples Couples Therapy Unsure How effective are the current interventions? Very Effective Somewhat Effective Neutral Somewhat ineffective Very Ineffective Barriers and Intervention Recommendations What barriers do couples face when seeking therapy or other interventions? Time/Scheduling difficulties Transportation Childcare Stigma Availability of providers Mismatch between services available and need Uncertainty about role of therapy/mental health Unsure What interventions would you like to see available for couples at the community mental health clinic? Briefer interventions, communication/skills workshops Relationship enhancement groups Uncertain/Don't know Category Frequency % 1 3 1 3 1 12.5% 37.5% 12.5% 37.5% 12.5% 3 2 3 0 0 37.5% 25.0% 37.5% 0.0% 0.0% 4 3 2 2 1 1 3 1 50.0% 37.5% 25.0% 25.0% 12.5% 12.5% 37.5% 12.5% 1 1 6 12.5% 12.5% 75.0% 28 Table 4 Characteristics of Clinic Partnersa Participating in Educational and Proposal Presentation (N=4) Demographic Characteristics Age (years) 21-30 31-40 41-50 50+ Gender Male Female Transgender Non-binary/non-conforming Prefer not to respond Other, Write in Ethnicity/Race American Indian or Alaskan Native Asian Black or African American Hispanic or Latino or Spanish Origin Native Hawaiian or Other Pacific Islander White or Caucasian Multiracial or Biracial A race/ethnicity not listed here Education Level High School Level Bachelor's Degree Master's Degree Ph.D. or higher Doctorate or higher Trade School Role at Clinic Clinician/Therapist Codirector Staff Trainee Length of time in practice (years) One year or less 2-5 5-10 11 years or more aClinic partners included trainees and clinic co-directors. N % 2 1 1 0 50% 25% 25% 0% 1 3 0 0 0 0 25% 75% 0.0% 0.0% 0.0% 0.0% 0 0 0 0 0 4 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 100% 0.0% 0.0% 0 1 1 2 0 0 0.0% 25% 25% 50% 0.0% 0.0% 0 2 0 2 0.0% 50% 0.0% 50% 2 0 0 2 50% 0.0% 0.0% 50% 29 Table 5 Frequency of Clinic Partner Perceptions from Post-Presentation Survey Regarding Proposal Barriers and Facilitators, Presentation Feedback, and Alternative Recommendations Category Frequency % Please share what you believe may be barriers to implementing the relationship enhancement proposal at the community health clinic Lack of experience in trainees Lack of resources Recruiting enough couples for the first group Uncertain Please share what you believe may be facilitators to implementing the relationship enhancement proposal at the community mental health clinic Expertise and experience of directors, staff, and interns Community interest The PowerPoint Presentation was clear in addressing the clinical gap regarding relationship interventions available for nondistressed couples Strongly Agree Agree No Opinion Disagree Strongly Disagree What about the presentation contributed to your understanding of the topic? In-depth explanations, good flow Great overview Very well organized Background and rationale What would make the presentation more effective at addressing the topic? More examples, talking slower More time to go over content Specific example of how a team leads this intervention Unanswered Is there an intervention different from the proposal you would like to see implemented at the community health clinic I think groups are great and I would love to see more of them No Unanswered 1 1 1 1 25% 25% 25% 25% 4 1 100% 25% 4 0 0 0 0 100% 0.0% 0.0% 0.0% 0.0% 1 1 1 1 25% 25% 25% 25% 1 1 1 1 25% 25% 25% 25% 1 2 1 25% 50% 25% 30 Table 6 Outcome Measuresa Obtained from Post-Presentation Survey Participantsb (N=4) Outcome Measure Acceptability of Intervention Measure The relationship enhancement proposal meets my approval Completely Agree Agree The relationship enhancement proposal is appealing to me Completely Agree Agree I like the relationship enhancement proposal Completely Agree Agree I welcome the relationship enhancement proposal Completely Agree Agree Intervention Appropriateness Measure The relationship enhancement proposal seems fitting Completely Agree Agree The relationship enhancement proposal seems suitable Completely Agree Agree The relationship enhancement proposal seems applicable Completely Agree Agree The relationship enhancement proposal seems like a good match Completely Agree Agree Feasibility of Intervention Measure The relationship enhancement proposal seems implementable Completely Agree Completely Disagree The relationship enhancement proposal seems possible Completely Agree Completely Disagree The relationship enhancement proposal seems doable Completely Agree Agree The relationship enhancement proposal seems easy to use Completely Agree Agree N % 2 2 50.0% 50.0% 3 1 75.0% 25.0% 2 2 50.0% 50.0% 2 2 50.0% 50.0% 3 1 75.0% 25.0% 2 2 50.0% 50.0% 2 2 50.0% 50.0% 2 2 50.0% 50.0% 3 1 75.0% 25.0% 3 1 75.0% 25.0% 3 1 75.0% 25.0% 2 2 50.0% 50.0% 31 aValidated Outcome Measures Tool: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) (Weiner, 2017). bSurvey participants included trainees and clinic co-directors. 32 Figure 1 Adaptation of Kaizen-Guided Principlesa a(Sirk, 2020) Evaluate Outcome Measures & Feedback Assess Clinic & Engage Partners Propose a Solution Appraise the Evidence 33 Appendix A 34 35 Appendix B Internal SWOT Analysis Results Obtained from Discussion Group Participantsa (N = 8) • • • • • Beneficial Harmful Strengths Weaknesses Sliding Scale/Affordability Evidence-based treatments Interdisciplinary approach Resources offered by broader U of U network Influx of trainees from multiple disciplines • • • External Opportunities aDiscussion • • Community need Limited offerings in SLC Lag time of onboarding trainees Trainee turnover can disrupt continuity of care No current group offerings Threats • • Cultural context of SLC: Stigma associated with marital problems Faith-based offerings: Bishop support, other religious programs might be more appealing group participants included trainees, therapists, and a clinic co-director. 36 Appendix C Educational PowerPoint Presentation and Proposal 37 38 39 40 41 42 43 44 45 Appendix D 46 47 48 49 Appendix E Executive Summary: A Needs Assessment to Evaluate Implementing a Relationship Enhancement Program for Couples at a Community Mental Health Clinic Situation Relationship interventions reduce stress and improve relationship satisfaction, particularly among nondistressed couples; however, traditional couples therapy is the only intervention available for couples seeking treatment at a community mental health clinic. This executive summary aims to address the need for an alternative intervention to traditional couples therapy and make a practice recommendation. Background Divorce's harmful effects on individuals, families, and communities are a well-known concern. Dissatisfying relationships, even without divorce, are a significant source of stress and can contribute to increased morbidity and mortality. Despite the efficacy of relationship interventions, most couples do not seek treatment. Barriers to treatment include the availability of trained providers, cost, and stigma. Group programs that capture nondistressed couples can effectively overcome treatment barriers and prevent intimate partnerships from deteriorating. Assessment This needs assessment consisted of four phases: 1) Assess the clinic via electronic health record data extraction, survey administration, and discussion group facilitation. 2) Appraise the evidence by conducting a literature search and consulting the content expert. 3) Present the evidence to clinic partners via an educational PowerPoint and propose a relationship enhancement intervention. 4) Obtain & analyze proposal outcome measures & feedback.  Assessment findings: o The majority of couples seeking treatment (n=12) at the clinic did not receive therapy (n=8) o A lack of trained providers largely contributed to the inaccessibility of services  Proposal Outcome Measures: o All clinic partners (n=4) agreed or completely agreed that the proposal to implement an adapted version of Mindfulness-Based Relationship Enhancement (MBRE) was acceptable, appropriate, and feasible Recommendation 1. Implement an evidence-based group program that captures nondistressed couples, such as a modified version of MBRE, at the community health clinic championed by a trainee. 2. After implementation, analyze clinic data to evaluate if the program increases the number of couples receiving treatment. References and Evidence Table Available Upon Request