Youthful advisers help shape a mental health program for their peers

Reviewed by Emily Henderson, B.Sc.Oct 4 2021

Phebe Cox grew up in what might seem an unlikely mental health danger zone for a kid: tony Palo Alto, California, in the heart of Silicon Valley. But behind its façade of family success and wealth, she said, is an environment of crushing pressure on students to perform. By 2016, when Cox was in middle school, Palo Alto had a teen suicide rate four times the national average.

Cox's family lived by the railroad tracks where many of the suicides occurred. She got counseling. But that option, she told KHN, is not always easily available to teens in crisis — and she and her peers regarded school mental health services as their last choice because of concerns about either confidentiality or anonymity.

A new program, designed largely by the people who use it, provides an alternative. Called Allcove, it offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost. Although Allcove is built to support a wide range of physical, emotional and social needs, its overarching goal is to deal with mental health challenges before they develop into deeper problems.

Allcove is yet in its infancy, with two sites just opened in the Bay Area and five more in the pipeline around California. It's modeled on a 15-year-old program in Australia, Headspace, which has 130 such clinics. Headspace has inspired programs in other countries as well, including Jigsaw in Ireland and Foundry in Canada. All of them, including Allcove, also offer online and phone services.

Allcove's core values resonate with Cox, now 19 and a student at Pitzer College in Claremont, California, and one of dozens of young people who have offered advice on the program's structure and services.

"Right away, I knew it was going to be a big thing," Cox said. "I felt pretty helpless as a young teenager, but Allcove is all about the students and the students' needs."

About half of all lifetime mental illness begins by age 14, and 75% before age 25, according to researchers. Yet access to mental health care in the U.S. is lacking. According to the National Alliance on Mental Illness, some 30 million adults and children with mental health conditions go without treatment, and 129 million people live in areas with shortages of mental health professionals. A 2017 survey found that Californians were five times more likely to go outside their private insurance network for mental health office visits than for medical or surgical needs.

Allcove meets some of that head-on by providing fully staffed safe spaces for teens and young adults to discuss and deal with their health, both mental and physical, along with substance misuse issues and educational support. California law allows those 12 and older to get outpatient mental health or counseling services without a guardian's consent.

Allcove's sites in Palo Alto and San Jose are filled with vibrant colors and plenty of open space, the result of input by a youth advisory group that numbers a dozen or more members and changes out about once a year. Inside Allcove, clients can access group or individual care, ask a doctor about a problem, and even get help preparing for college.

Unlike the Australian program, Allcove has no ongoing funding source yet. Allcove is "a really big lift, and we [at the state level] want to say, 'How can we help you?'" said Toby Ewing, executive director of the California Mental Health Services Oversight and Accountability Commission, which administers the fund that seeded the first two sites with $15 million.

Funding eventually may come from a combination of state, private and nonprofit sources, as well as Medi-Cal reimbursements, said Dr. Steven Adelsheim, a psychiatrist who directs Stanford University's Center for Youth Mental Health and Wellbeing.

Adelsheim previously spent nearly 30 years in New Mexico, helping that state build a network of school-based health centers. His experience convinced him that many students were likely to avoid mental health services at school. They were reluctant, he said, to discuss such issues with their own counselors, who might be the same people writing the students' letters of recommendation for college and might unwittingly breach privacy.

That realization led Adelsheim in 2014 to get exploratory funding from the Robert Wood Johnson Foundation to create Allcove. (KHN, which produces California Healthline, also receives funding support from the foundation.) "There is a crying need in the U.S. to reach kids with early intervention and help," Adelsheim said.

The idea struck a chord with Santa Clara County officials, who'd seen Palo Alto lashed by teen suicide clusters during the 2009-10 and 2014-15 school years. "The saddest part of the story is that a teen didn't reach out earlier, didn't have the opportunity to get help when and where they needed it," County Supervisor Joe Simitian said in announcing Allcove's opening in June. "The appeal of the Allcove model is it's designed to engage young people who are struggling, long before they hit a crisis point."

When Cox moved from middle school to Palo Alto's Henry M. Gunn High School, her therapist told her about Adelsheim's project and suggested Cox apply to be part of Allcove's youth council. One of Cox's contributions was to suggest weekday hours extending at least to 7 p.m., "because young adults are doing things and on the move all day. It's the evenings — and even the weekends — when we're dealing with things or feeling more helpless. For a lot of my friends, at night is when things can get overwhelming."

Both Foundry, the Canadian program, and Allcove address physical health as well. Steve Mathias, CEO of Foundry, said his program's emphasis is "on health and wellness, not just mental health, which is a part of wellness." Said Adelsheim, "Sometimes a kid may come in with a physical complaint, and only after a few visits is the mental suffering brought out into the open." When that happens, Allcove can make a "warm handoff" to a mental health specialist on-site.

The most significant difference between Headspace and Allcove may be funding. Headspace is part of the Australian government's mental health initiative, and thus budgeted. Allcove is essentially building on the fly, and its long-term ability to grow will depend on money.

California's Proposition 63, written in 2004 by then-Assembly member Darrell Steinberg (now the mayor of Sacramento), levies a 1% tax on personal incomes over $1 million to fund community mental health services. This year, the tax may yield $2.4 billion, Ewing said. Most of that goes to existing programs, but about 5% each year — more than $100 million in 2021 — feeds an innovation fund to encourage new approaches to mental health.

Santa Clara County got $15 million from that fund to launch Allcove. The state also has helped fund Allcove sites, in Sacramento, San Mateo and Orange counties, and two in Los Angeles County.

"We've made a $30 million-plus investment in this model," Ewing said. "We are assuming that it's going to be successful."

Success, say Adelsheim and Cox, would mean the establishment of hundreds of Allcove centers up and down the state, readily available to young people. The hope is that, if it catches on, Allcove could become a well-known brand for young Californians — and, eventually, others around the country.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.