Courtney Beard, PhD, faced a problem familiar to many Harvard Medical School researchers: How to diversify your research studies to make them more applicable to the general population.

In Beard’s case, she was planning a study in the general population to evaluate a mental health app she developed as a cognitive-behavioral tool for so-called interpretation bias, which studies suggest is an important factor in anxiety and depression. The app was first tested at McLean Hospital, which serves a mostly white, well-educated population. She wanted to make sure her app also worked well for people historically under-represented in research studies, including people who identify as Black, Hispanic, and Latinx.

Serendipitously, Beard learned from a colleague about the study review service offered by the Community Coalition for Equity in Research, and immediately signed up. She filled out a two-page equity-focused template describing her study and made a 10-minute video outlining her research interests. Shortly thereafter, she found herself video-conferencing with a panel of community-embedded experts who provided individualized advice and guidance on how to make her study more equitable.

Beard, a clinical psychologist with expertise in anxiety disorders and cognitive behavior therapy, is associate professor of psychology in the Department of Psychiatry at Harvard Medical School (HMS), and director of the Cognition and Affect Research and Education (CARE) Laboratory at McLean Hospital.

The app you’ve developed, HabitWorks, supports new ways of thinking for people facing mental health problems. How does this fit into the CARE lab?

Much of our work involves identifying mechanisms that keep people anxious or depressed, such as mental habits, and then developing treatments to target those very specific mental habits. Habit Works is a perfect example of that. It focuses on how people interpret the countless ambiguous situations they face throughout the day. We know that interpretation bias plays a big role in how people feel in the moment, and it impacts what they do, especially if they’re feeling anxious.

HabitWorks has been developed and tested over a number of years in people who have lived experience with these conditions. The aim is to help people become more aware of how they’re interpreting situations and consider opening to alternative interpretations. Perhaps they become a little more flexible in their thinking, or at least start to pause when they notice themselves jumping to a particular type of conclusion.

Your second HabitWorks study plan was reviewed by the Community Coalition for Equity in Research in September of 2022. Did your approach change at all as a result of the review?

Yes, it changed substantially. We originally planned to jump right into a pilot study to test our app in a general population and recruit a few hundred people. As a result of the review, we decided to take a step back and do a much smaller study specifically with people who identify as Black, Hispanic, or Latinx. We wanted to understand how they were experiencing the intervention and make sure it was acceptable to them before testing it more broadly, precisely because it had been first developed and tested in the primarily white population served by McLean. At the end of the study, we interviewed participants to clearly understand how they were using and experiencing the app.

“That warm handoff is critical. It has enabled us to be much more successful in getting people to respond to us. Otherwise, I’m just another Harvard professor wanting something from them.”

A particular concern was that the app presents day-to-day situations that are uncertain or ambiguous in some way. For people from minoritized backgrounds, those types of situations may bring up discrimination experiences or questions of identity in addition to the anxiety-related interpretations that are being targeted for reframing. We wanted to be sure the app wasn’t bringing up thoughts about discrimination, causing stress, or creating a perception that we were asking people to reappraise certain types of situations, which could be invalidating and unhelpful.

With changes recommended by the Coalition, we were able to answer many of those questions in advance of the bigger study in a broader population, which we’ve now just started. We found the app itself was easily accepted. People enjoyed using it and it didn’t cause harm. That was very reassuring.

In response to the Coalition’s recommendations, we also expanded and revamped the resources we provide to people along with the app. We added more resources around finding a therapist based on various aspects related to identity, as well as information on topics such as financial supports and coping with discrimination. We now have an exhaustive resource list that we give people.

You’re also working with the new Community Ambassador Initiative on a separate research program that uses the HabitWorks app to tackle parental transference of anxiety. What does that entail?

The community ambassadors have been helping us form connections and spread the word about an NIMH-funded trial that is testing how parents’ interpretation bias might get passed down and ultimately cause anxiety in kids.

Quite a bit of data supports the idea that anxieties are passed down, and parenting behaviors might be even more important than genetics. Some data suggests that how parents interpret threat in their world leads them to engage in parenting behaviors that teach the child that the world is threatening, that maybe they can’t handle it and should avoid it. Those behaviors can keep the parent anxious as well as transfer anxiety to the children.

We’re using the HabitWorks app to manipulate parents’ interpretations and examine the downstream effects on their anxiety and their parenting behaviors related to anxiety. Then we bring in their kids and assess their own interpretations and anxiety.

What were some of the challenges you faced that the community ambassadors have been helping address?

We’re trying to enroll 300 parent-child dyads and would like at least 30% of those to be parents of color, mostly focusing on Black, Hispanic, and Latinx families. We also want fathers to represent 30% of our cohort because they have been largely ignored in this literature so far.

“Everyone’s hopefully realizing that if we want our research to have an impact, community-engaged research is something everyone should be trained in and conducting.”

We’ve been partnering with different organizations in the Springfield area in Western Massachusetts. We’re still early in the process, but we hope to expand the reach of our study beyond the populations of Boston and its affluent suburbs. The goal is to have a representative sample from which we can draw meaningful conclusions for all groups of people.

The people we’re working with are deeply embedded in their communities. They’re very well connected across many different community-based organizations and have helped us identify which might be a good fit for our outreach. When I reach out to these organizations, I can say I’m working with someone they already know.

That warm handoff is critical. It has enabled us to be much more successful in getting people to respond to us. Otherwise, I’m just another Harvard professor wanting something from them. That’s not a good way to start.

Community-engaged research has become such a buzzword. What does it mean to you and what do you think it means to other researchers?

It’s something I wish I had learned about when I was in graduate school. A subset of people have been doing this type of research for a long time, but it was not necessarily viewed as relevant to all researchers. I think that is changing now. Everyone’s hopefully realizing that if we want our research to have an impact, community-engaged research is something everyone should be trained in and conducting.

In my work developing treatments for depression and anxiety, I’ve always included the perspectives of people with lived experience. A patient advisory board helped us develop the app, and we’ve asked people about their experiences. But our community engagement had always been specific to the clinic I was partnering with, whether at McLean or primary care clinics. Working with the Coalition has helped me go even further.

I’m eager to get to know these communities, to learn more from them, and to have them inform our future studies. So far, what we research has always been led by my team and me. I’m eager to realize the next phase of this process, to really listen to what research the community thinks is important to conduct.