The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations

Predictive Validity of Addiction Treatment Clinicians' Post-Training Contingency Management Skills for Subsequent Clinical Outcomes

In the context of a contingency management (CM) implementation/effectiveness hybrid trial, the post-training implementation domains of direct-care clinicians (N=19) were examined in relation to a targeted clinical outcome of subsequently CM-exposed clients. Clinicians' CM skillfulness, a behavioral measure of their capability to skillfully deliver the intended CM intervention, was found to be a robust and specific predictor of their subsequent client outcomes. Analyses also revealed CM skillfulness to: (1) fully mediate an association between a general therapeutic effectiveness and client outcome, (2) partially mediate an association of in-training exposure to CM and client outcome, and (3) be composed of six component clinical practice behaviors that each contributed meaningfully to this behavior fidelity index. Study findings offer preliminary evidence of the predictive validity of post-training CM skillfulness for subsequent client outcomes, and inform suggestions for the design and delivery of skills-focused CM training curricula for the addiction treatment workforce.

Therapist perspectives on training in a package of evidence-based practice strategies for children with autism spectrum disorders served in community mental health clinics

Therapist perspectives regarding delivery of evidence-based practice (EBP) strategies are needed to understand the feasibility of implementation in routine service settings. This qualitative study examined the perspectives of 13 therapists receiving training and delivering a package of EBPs to children with autism spectrum disorders (ASDs) in community mental health clinics. Therapists perceived the training and intervention delivery as effective at improving their clinical skills, the psychotherapy process, and child and family outcomes. Results expand parent pilot study findings, and add to the literature on training community providers and limited research on training providers to deliver EBPs to children with ASD.

Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators

OBJECTIVE

Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder.

METHODS

The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT.

RESULTS

Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials.

CONCLUSIONS

Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.

Early assessment of implementing evidence-based brief therapy interventions among secondary service psychiatric therapists

This implementation study was part of the Ostrobothnia Depression Study, in Finland, which covered implementation of motivational interviewing (MI) and behavioral activation (BA) within regional public psychiatric secondary care. It aimed to evaluate the mid-term progress of implementation and related factors. Altogether, 80 therapists had been educated through the implementation program by the point of the mid-term evaluation. Eligible information for evaluation was gathered using two questionnaires (q1, q2) with a one-year interval. A total of 45 of the 80 therapists completed q1, 30 completed q2, and 24 completed both questionnaires. Professional education was the only background factor associated with adopting the interventions (q1: p=0.059, q2: p=0.023), with higher education indicating greater activity. On the basis of trends such as changes in overall usefulness score from q1 to q2, the most involved therapists were slightly more likely to adopt MI/BA. Our experience so far suggests that encouraging staff to begin using new interventions during education is very important. The Consolidated Framework for Implementation Research was found to be a useful tool for constructing the evaluation.

Protocol for a statewide randomized controlled trial to compare three training models for implementing an evidence-based treatment

BACKGROUND

Evidence-based treatments (EBTs) are available for treating childhood behavioral health challenges. Despite EBTs' potential to help children and families, they have primarily remained in university settings. Little empirical evidence exists regarding how specific, commonly used training and quality control models are effective in changing practice, achieving full implementation, and supporting positive client outcomes.

METHODS/DESIGN

This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359), which is currently in progress, will evaluate the effectiveness of three training models (Learning Collaborative (LC), Cascading Model (CM), and Distance Education (DE)) to implement a well-established EBT , Parent-Child Interaction Therapy, in real-world, community settings. The three models differ in their costs, skill training, quality control methods, and capacity to address broader implementation challenges. The project is guided by three specific aims: (1) to build knowledge about training outcomes, (2) to build knowledge about implementation outcomes, and (3) to test the differential impact of training clinicians using LC, CM, and DE models on key client outcomes. Fifty (50) licensed psychiatric clinics across Pennsylvania were randomized to one of the three training conditions: (1) LC, (2) CM, or (3) DE. The impact of training on practice skills (clinician level) and implementation/sustainment outcomes (clinic level) are being evaluated at four timepoints coinciding with the training schedule: baseline, 6 (mid), 12 (post), and 24 months (1 year follow-up). Immediately after training begins, parent-child dyads (client level) are recruited from the caseloads of participating clinicians. Client outcomes are being assessed at four timepoints (pre-treatment, 1, 6, and 12 months after the pre-treatment).

DISCUSSION

This proposal builds on an ongoing initiative to implement an EBT statewide. A team of diverse stakeholders including state policy makers, payers, consumers, service providers, and academics from different, but complementary areas (e.g., public health, social work, psychiatry), has been assembled to guide the research plan by incorporating input from multidimensional perspective.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02543359.

Implementing measurement-based care (iMBC) for depression in community mental health: a dynamic cluster randomized trial study protocol

Background

Measurement-based care is an evidence-based practice for depression that efficiently identifies treatment non-responders and those who might otherwise deteriorate [1]. However, measurement-based care is underutilized in community mental health with data suggesting fewer than 20 % of behavioral health providers using this practice to inform treatment. It remains unclear whether standardized or tailored approaches to implementation are needed to optimize measurement-based care fidelity and penetration. Moreover, there is some suggestion that prospectively tailored interventions that are designed to fit the dynamic context may optimize public health impact, though no randomized trials have yet tested this notion [2]. This study will address the following three aims: (1) To compare the effect of standardized versus tailored MBC implementation on clinician-level and client-level outcomes; (2) To identify contextual mediators of MBC fidelity; and (3) To explore the impact of MBC fidelity on client outcomes.

Methods/design

This study is a dynamic cluster randomized trial of standardized versus tailored measurement-based care implementation in Centerstone, the largest provider of community-based mental health services in the USA. This prospective, mixed methods implementation-effectiveness hybrid design allows for evaluation of the two conditions on both clinician-level (e.g., MBC fidelity) and client-level (depression symptom change) outcomes. Central to this investigation is the focus on identifying contextual factors (e.g., attitudes, resources, process, etc.) that mediate MBC fidelity and optimize client outcomes.

Discussion

This study will contribute generalizable and practical strategies for implementing systematic symptom monitoring to inform and enhance behavioral healthcare.

Trial registration

Clinicaltrials.gov NCT02266134.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0313-2) contains supplementary material, which is available to authorized users.

Methods to Improve the Selection and Tailoring of Implementation Strategies

Implementing behavioral health interventions is a complicated process. It has been suggested that implementation strategies should be selected and tailored to address the contextual needs of a given change effort; however, there is limited guidance as to how to do this. This article proposes four methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that could be used to match implementation strategies to identified barriers and facilitators for a particular evidence-based practice or process change being implemented in a given setting. Each method is reviewed, examples of their use are provided, and their strengths and weaknesses are discussed. The discussion includes suggestions for future research pertaining to implementation strategies and highlights these methods' relevance to behavioral health services and research.

Connecting Students to Mental Health Care: Pilot Findings from an Engagement Program for School Nurses

Schools function as the major provider of mental health services (MHS) for youth, but can struggle with engaging them in services. School nurses are well-positioned to facilitate referrals for MHS. This pilot study examined the feasibility, acceptability, and preliminary efficacy of an engagement protocol (EP) designed to enhance school nurses' utilization of evidence-based engagement practices when referring youth to MHS. Participants were six school nurses and twenty-five adolescents in a large, urban school district. School nurses reported positive attitudes towards the EP, suggesting that they found it feasible and acceptable. Though there were small increases in school nurses' use of engagement practices and in adolescents' readiness for services following training, due to limited sample size, differences were not statistically significant. Still, pilot results suggest preliminary efficacy of training school nurses to strategically implement evidence-based engagement practices to increase adolescents' engagement in MHS.

From training to practice: a survey study of clinical challenges in implementing cognitive behavioural therapy in Norway

This study examines potential barriers to the implementation of CBT as perceived by therapists participating in the training programmes of the Norwegian Association for Cognitive and Behavioural Therapy (NACBT). Based on a questionnaire to members of the NACBT, a factor analysis identified five underlying dimensions of implementation barriers. A one-way analysis of variance was conducted to examine differences in how barriers were perceived by therapists working in medicine, mental health and social services. A multiple regression analysis was performed to examine the relationship between the barriers and the therapists’ global satisfaction with CBT. The five factor-based barriers identified were related to Therapeutic skills, Aspects of the workplace, Supervision, Training, and Clients. Problems related to Supervision and Therapeutic skills were reported to be the most important obstacles. Nurses and others working at psychiatric wards reported the largest number, and psychologists and others working with outpatients, reported the lowest number of barriers. The study highlights the importance of implementation quality in the process of linking training and practice of CBT in Norway. Even if aspects of the training programmes were perceived to be among the smallest threats to implementation, training was not sufficient in order for candidates to implement CBT in clinical practice.

Building an evidence-base for the training of evidence-based treatments in community settings: Use of an expert-informed approach

In order to make EBTs available to a large number of children and families, developers and expert therapists have used their experience and expertise to train community-based therapists in EBTs. Understanding current training practices of treatment experts may be one method for establishing best practices for training community-based therapists prior to comprehensive empirical examinations of training practices. A qualitative study was conducted using surveys and phone interviews to identify the specific procedures used by treatment experts to train and implement an evidence-based treatment in community settings. Twenty-three doctoral-level, clinical psychologists were identified to participate because of their expertise in conducting and training Parent-Child Interaction Therapy. Semi-structured qualitative interviews were completed by phone, later transcribed verbatim, and analyzed using thematic coding. The de-identified data were coded by two independent qualitative data researchers and then compared for consistency of interpretation. The themes that emerged following the final coding were used to construct a training protocol to be empirically tested. The goal of this paper is to not only understand the current state of training practices for training therapists in a particular EBT, Parent-Child Interaction Therapy, but to illustrate the use of expert opinion as the best available evidence in preparation for empirical evaluation.

Task sharing in rural Haiti: Qualitative assessment of a brief, structured training with and without apprenticeship supervision for community health workers

Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

Evidence-based psychosocial treatment in the community: considerations for dissemination and implementation

BACKGROUND

In psycho-oncology care, steps toward dissemination and implementation of evidence-based treatments (EBTs) have not been made. For this to change, factors associated with real-world dissemination and implementation must be identified. In the community, providers, their organizations, and patients are key stakeholders.

METHOD

A focused review of literatures in continuing education, dissemination, and implementation of mental health services is provided.

RESULTS

Early-career providers are most ready to implement as they have greater openness and more positive attitudes toward EBTs. Current continuing education practices to teach EBTs have limited effectiveness. Instruction using interactive strategies tailored to therapists' clinical needs and the provision of post-education consultation is needed. There is tension between EBT delivery with fidelity and the necessity for adaptation. EBT service provision is the key outcome of implementation, and documenting such is important to patients, providers, and organizations.

CONCLUSION

A multilevel conceptual framework, Setting, Therapist, Education, imPlementation, and Sustainability, is offered and provides directions for dissemination and sustainable implementation. Guidelines from the Commission on Cancer of the American College of Surgeons and the American Society of Clinical Oncology underscore the timeliness of the proposed framework to move EBTs from the research settings where they were developed to the practice settings where they are needed.

Scalable Options for Extended Skill Building Following Didactic Training in Cognitive-Behavioral Therapy for Anxious Youth: A Pilot Randomized Trial

A sizable gap exists between the availability of evidence-based psychological treatments and the number of community therapists capable of delivering such treatments. Limited time, resources, and access to experts prompt the need for easily disseminable, lower cost options for therapist training and continued support beyond initial training. A pilot randomized trial tested scalable extended support models for therapists following initial training. Thirty-five postdegree professionals (43%) or graduate trainees (57%) from diverse disciplines viewed an initial web-based training in cognitive-behavioral therapy (CBT) for youth anxiety and then were randomly assigned to 10 weeks of expert streaming (ES; viewing weekly online supervision sessions of an expert providing consultation), peer consultation (PC; non-expert-led group discussions of CBT), or fact sheet self-study (FS; weekly review of instructional fact sheets). In initial expectations, trainees rated PC as more appropriate and useful to meet its goals than either ES or FS. At post, all support programs were rated as equally satisfactory and useful for therapists' work, and comparable in increasing self-reported use of CBT strategies (b = .19, p = .02). In contrast, negative linear trends were found on a knowledge quiz (b = -1.23, p = .01) and self-reported beliefs about knowledge (b = -1.50, p < .001) and skill (b = -1.15, p < .001). Attrition and poor attendance presented a moderate concern for PC, and ES was rated as having the lowest implementation potential. Preliminary findings encourage further development of low-cost, scalable options for continued support of evidence-based training.

Clearing Hurdles: The Challenges of Implementation of Mental Health Evidence-Based Practices in Under-resourced Schools

Schools have become the main provider of services to children with mental health needs. Although there is substantial literature on barriers to implementation of evidence-based practices (EBPs) in under-resourced school districts, less has been written on how to overcome those barriers. Providing mental health services in the school setting presents a tremendous opportunity to increase access to quality mental health care for underserved youth. This review provides a brief overview of the barriers to successful implementation and sustainment of EBPs in under-resourced public schools and provides recommendations for overcoming them. The discussion is organized around an established conceptual framework adapted for the delivery of services in under-resourced schools that focuses on interdependent factors that exist at the individual-, team, school-, and macro-levels. This manuscript explores some recommendations and strategies for effectively addressing challenges related to implementation of EBPs. Research ideas are offered to bridge the research-to-practice gap that impacts many under-resourced public school districts.

Provider-agency fit in substance abuse treatment organizations: implications for learning climate, morale, and evidence-based practice implementation

Background

Substance abuse agencies have been slow to adopt and implement evidence-based practices (EBPs), due in part to poor provider morale and organizational climates that are not conducive to successful learning and integration of these practices. Person-organization fit theory suggests that alignment, or fit, between provider- and agency-level characteristics regarding the implementation of EBPs may influence provider morale and organizational learning climate and, thus, implementation success. The current study hypothesized that discrepancies, or lack of fit, between provider- and agency-level contextual factors would negatively predict provider morale and organizational learning climate, outcomes shown to be associated with successful EBP implementation.

Methods

Direct service providers (n = 120) from four substance abuse treatment agencies responded to a survey involving provider morale, organizational learning climate, agency expectations for EBP use, agency resources for EBP use, and provider attitudes towards EBP use. Difference scores between combinations of provider- and agency-level factors were computed to model provider-agency fit. Quadratic regression analyses were conducted to more adequately and comprehensively model the level of the dependent variables across the entire “fit continuum”.

Results

Discrepancies, or misfit, between agency expectations and provider attitudes and between agency resources and provider attitudes were associated with poorer provider morale and weaker organizational learning climate. For all hypotheses, the curvilinear model of provider-agency discrepancies significantly predicted provider morale and organizational learning climate, indicating that both directions of misfit (provider factors more favorable than agency factors, and vice-versa) were detrimental to morale and climate. However, outcomes were most negative when providers viewed EBPs favorably, but perceived that agency expectations and resources were less supportive of EBP use.

Conclusions

The current research benefits from a strong theoretical framework, consistent findings, and significant practical implications for substance abuse treatment agencies. Comprehensive attempts to strengthen outcomes related to EBP implementation must consider both provider- and agency-level characteristics regarding EBP use. Organizational efforts to more closely align provider attitudes and agency priorities will likely constitute a key strategy in fostering the implementation of EBPs in substance abuse treatment organizations.

Investigating bang for your training buck: a randomized controlled trial comparing three methods of training clinicians in two core strategies of dialectical behavior therapy

The present study examined the efficacy of online training (OLT), instructor-led training (ILT), and a treatment manual (TM) in training mental health clinicians in two core strategies of Dialectical Behavior Therapy (DBT): chain analysis and validation. A randomized controlled trial compared OLT, ILT, and TM among clinicians naïve to DBT (N=172) who were assessed at baseline, post-training, and 30, 60, and 90 days following training. Primary outcomes included satisfaction, self-efficacy, motivation, knowledge, clinical proficiency, and clinical use. Overall, ILT outperformed OLT and TM in satisfaction, self-efficacy, and motivation, whereas OLT was the most effective method for increasing knowledge. The conditions did not differ in observer-rated clinical proficiency or self-reported clinical use, which both increased to moderate levels after training. In addition, ILT was particularly effective at improving motivation to use chain analysis, whereas OLT was particularly effective at increasing knowledge of validation strategies. These findings suggest that these types of brief, didactic trainings may be effective methods of increasing knowledge of new treatment strategies, but may not be sufficient to enable clinicians to achieve a high level of clinical use or proficiency. Additional research examining the possible advantages of matching training methods to types of treatment strategies may help to determine a tailored, more effective approach to training clinicians in empirically supported treatments.

Educational interventions: equipping general practice for youth mental health and substance abuse. A discussion paper

BACKGROUND

Youth mental health issues and substance abuse are important causes of morbidity and mortality in Ireland. General practice is a frequent point of contact for young people, however, reluctance amongst this population group to disclose mental health issues and a lack of confidence amongst GPs in dealing with them have been reported. Focussed training interventions with formal evaluation of their acceptability and effectiveness in achieving learning, behavioural change and impact on clinical practice are needed.

AIMS

This paper aims to examine the literature on general practice in youth mental health, specifically, factors for an educational intervention for those working with young people in the community.

METHODS

This review paper was carried out by an online search of PubMed on the recent literature on mental health and on educational interventions for health care workers in primary care.

RESULTS

A number of papers describing educational interventions for GPs and primary care workers were found and analysed. Key areas to be addressed when identifying and treating mental health problems were prevention, assessment, treatment, interaction with other services and ongoing support. Important elements of an educational intervention were identified.

DISCUSSION

Several barriers exist that prevent the identification and treatment of these problems in primary care. An educational intervention should help GPs address these issues. Any intervention should be rigorously evaluated.

CONCLUSION

With the shift in services to the community in Irish health policy, the GP with appropriate training could take the lead in early intervention in youth mental health and addiction.

Strategies for integrating mental health into schools via a multitiered system of support

To fully realize the potential of mental health supports in academic settings, it is essential to consider how to effectively integrate the mental health and education systems and their respective resources, staffing, and structures. Historically, school mental health services have not effectively spanned a full continuum of care from mental health promotion to treatment, and several implementation and service challenges have evolved. After an overview of these challenges, best practices and strategies for school and community partners are reviewed to systematically integrate mental health interventions within a school's multitiered system of student support.

Adapting the helpful responses questionnaire to assess communication skills involved in delivering contingency management: preliminary psychometrics

A paper/pencil instrument, adapted from Miller and colleagues' (1991) Helpful Responses Questionnaire (HRQ), was developed to assess clinician skill with core communicative aspects involved in delivering contingency management (CM). The instrument presents a single vignette consisting of six points of client dialogue to which respondents write 'what they would say next.' In the context of an implementation/effectiveness hybrid trial, 19 staff clinicians at an opiate treatment program completed serial training outcome assessments before, following, and three months after CM training. Assessments included this adaptation of the HRQ, a multiple-choice CM knowledge test, and a recorded standardized patient encounter scored for CM skillfulness. Study results reveal promising psychometric properties for the instrument, including strong scoring reliability, internal consistency, concurrent and predictive validity, test-retest reliability and sensitivity to training effects. These preliminary findings suggest the instrument is a viable, practical method to assess clinician skill in communicative aspects of CM delivery.

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Pre-Practicum Training in Professional Psychology to Close the Research-Practice Gap: Changing Attitudes Towards Evidence-Based Practice

Despite the rapid proliferation of mental health interventions with proven benefit for youth, empirically supported interventions (ESIs) are underutilized in most service settings. Treatment outcome studies in these community-based settings suggest that the majority of youth do not show improvement, underscoring the importance of addressing the gap between research and practice. Clinician attitudes toward evidence-based practice (EBP) may limit the use of ESIs, and efforts to address these attitudes with post-graduate training pose significant challenges. Pre-practicum training in EBP may address these challenges by familiarizing students with the framework of EBP as well as with the current youth treatment evidence base and the theories and strategies of well-supported interventions. We describe a required EBP course within a professional psychology doctoral program. Forty-two students in two class cohorts completed a measure of attitudes toward EBP prior to the first class and after the final class lecture. Students were predominantly Caucasian women with bachelor's degrees. As expected, over the course of the class, student attitudes became significantly more favorable toward EBP. Students who had previously received a master's degree had more favorable attitudes prior to the class, and students with a prior bachelor's degree showed the greatest change in attitude. The results support the use of pre-practicum training in EBP to improve attitudes toward EBP, which may lead to use of effective practices with clients following training.

Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment

BACKGROUND

Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities.

OBJECTIVE

The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making.

METHODS

Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory.

RESULTS

MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making.

CONCLUSION

This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.

Clinician use of standardized assessments following a common elements psychotherapy training and consultation program

Despite increasing emphasis on the implementation of evidence-based treatments in community service settings, little attention has been paid to supporting the use of evidence-based assessment (EBA) methods and processes, a parallel component of evidence-based practice. Standardized assessment (SA) tools represent a key aspect of EBA and are central to data-driven clinical decision making. The current study evaluated the impact of a statewide training and consultation program in a common elements approach to psychotherapy. Practitioner attitudes toward, skill applying, and use of SA tools across four time points (pre-training, post-training, post-consultation, and follow-up) were assessed. Results indicated early increases in positive SA attitudes, with more gradual increases in self-reported SA skill and use. Implications for supporting the sustained use of SA tools are discussed, including the use of measurement feedback systems, reminders, and SA-supportive supervision practices.

Psychological Science and Innovative Strategies for Informing Health Care Redesign: A Policy Brief

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Sustained Implementation of Cognitive-Behavioral Therapy for Youth Anxiety and Depression: Long-term Effects of Structured Training and Consultation on Therapist Practice in the Field

Identifying factors that promote sustained implementation of evidence-based treatments (EBTs) after therapists receive training is critical for professional psychology. To address the field's minimal knowledge in this area, we interviewed community-based therapists (N = 23) who had completed intensive training in cognitive behavioral therapy (CBT) for either anxiety or depression as part of a randomized effectiveness trial (Southam-Gerow et al., 2010; Weisz et al., 2009). Therapists were interviewed three to five years after completion of the initial trial, representing one of the longest-term follow-ups of therapist practices after training. Therapists viewed each protocol and their individual CBT strategies as effective and appropriate for the majority of their current anxiety and depression caseloads. However, therapists used parts of each protocol much more frequently than the protocol as a whole (i.e., 78.5% used parts of the Coping Cat, and 7.5% used the whole protocol; 58.6% used parts of the PASCET, and 20% used the whole protocol). Therapists reported using problem-solving the most and exposure exercises the least for current anxious cases; they used cognitive restructuring the most and homework the least for current depression cases. Interventions that were more difficult to implement in usual care settings were less likely to be sustained. Future efforts should evaluate the characteristics and structure of EBTs that are most acceptable to therapists and should investigate which kinds of ongoing learning supports will maintain therapist skills in and continued use of EBTs.

Do they practice what we teach? Follow-up evaluation of a Schema Therapy training programme

This study evaluated a 3-day Schema Therapy (ST) training programme for trainee clinical psychologists. The training used an experiential model of learning, which was intended to encourage the transfer of knowledge and techniques from the learning environment into clinical practice. Using a mixed-methods approach, the training programme was evaluated in terms of: (1) self-reported changes in knowledge, confidence and willingness to use ST-informed techniques; (2) whether the training was integrated into clinical practice; and (3) the perceived barriers/facilitators to achieving practice integration. Participants – 17 of the 19 trainee clinical psychologists enrolled on the ST training programme – completed assessments immediately pre- and post-training. Participants were subsequently followed-up for reassessment 3 months after the training. Group- and individual-level analyses showed that most participants reported training-related gains in knowledge and confidence; these were largely sustained at follow-up, and were associated with post-training practice integration of ST concepts and techniques. Analysis of qualitative data identified factors moderating use of training in practice. Findings of the study have implications for future delivery and evaluation of training in cognitive-behavioural therapies.

Reducing eating disorder risk factors: a controlled investigation of a blended task-shifting/train-the-trainer approach to dissemination and implementation

Recent advances in psychological intervention research have led to an increase in evidence-based interventions (EBIs), yet there remains a lag in dissemination and implementation of EBIs. Task-shifting and the train-the-trainer (TTT) model offer two potential strategies for enhancing reach of EBIs. The Body Project, an EBI found to prevent onset of eating disorders, served as the vehicle for this dissemination/implementation study. The primary aim of this study was to determine if training of peer-leaders for the Body Project could be task-shifted to undergraduate students using a hybrid task-shifting/TTT model. Our secondary aim was to determine if subgroups of participants evidenced different trajectories of change through 14-month follow-up. Regarding the first aim, we found almost no evidence to suggest that a presence of a doctoral-level trainer yielded superior participant outcomes compared to training by undergraduates alone. Regarding Aim 2, almost all classes for all variables evidenced improvement or a benign response. Additionally, for three key risk factors (thin-ideal internalization, body dissatisfaction, and ED symptoms) virtually all trajectories showed improvement. This study provides initial support for the use of a blended task-shifting/TTT approach to dissemination and implementation within prevention generally, and further support for broad dissemination of the Body Project specifically.

The development of an online measure of therapist competence

The topic of therapist training has been relatively neglected in the research literature. Similarly, the related issue of the measurement of the outcome of training, especially therapist competence, has been largely overlooked. Data supporting the effectiveness of various methods of clinician training and those providing estimates of the level of competence achieved by clinicians are scarce. Validated scalable methods for the measurement of clinician outcomes such as competence are required to evaluate both existing and new methods of training. This study focuses on the development and testing of an online measure (eMeasure) to assess therapists' applied knowledge of Enhanced Cognitive Behaviour Therapy (CBT-E), a transdiagnostic evidence-supported treatment for the full range of eating disorders. The eMeasure meets the stringent requirements of the Rasch model and has three equivalent versions making it suitable for repeat testing of trainees in outcome studies. Preliminary best cut points to distinguish between those who are competent and those who are not are identified. While the present work focused on CBT-E, the method described may be used to develop and test other measures relating to therapist competence.

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The development and testing of an online measure of CBT-E competence is described.

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Uses Rasch model to estimate latent ability from item responses.

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Three equivalent versions of the measure for use in outcome and follow up studies.

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Describes a method for developing scalable measures of therapist competence.

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Method may be applied to devising competence measures for other treatments.

Exposing clinicians to exposure: a randomized controlled dissemination trial of exposure therapy for anxiety disorders

OBJECTIVE

The present study evaluated three technology-based methods of training mental health providers in exposure therapy (ET) for anxiety disorders. Training methods were designed to address common barriers to the dissemination of ET, including limited access to training, negative clinician attitudes toward ET, and lack of support during and following training.

METHOD

Clinicians naïve to ET (N=181, Mage=37.4, 71.3% female, 72.1% Caucasian) were randomly assigned to (a) an interactive, multimedia online training (OLT), (b) OLT plus a brief, computerized motivational enhancement intervention (OLT+ME), or (c) OLT+ME plus a Web-based learning community (OLT+ME+LC). Assessments were completed at baseline, posttraining, and 6 and 12weeks following training. Outcomes include satisfaction, knowledge, self-efficacy, attitudes, self-reported clinical use, and observer-rated clinical proficiency.

RESULTS

All three training methods led to large and comparable improvements in self-efficacy and clinical use of ET, indicating that OLT alone was sufficient for improving these outcomes. The addition of the ME intervention did not significantly improve outcomes in comparison to OLT alone. Supplementing the OLT with both the ME intervention and the LC significantly improved attitudes and clinical proficiency in comparison to OLT alone. The OLT+ME+LC condition was superior to both other conditions in increasing knowledge of ET.

CONCLUSIONS

Multicomponent trainings that address multiple potential barriers to dissemination appear to be most effective in improving clinician outcomes. Technology-based training methods offer a satisfactory, effective, and scalable way to train mental health providers in evidence-based treatments such as ET.

Advancing training to identify, intervene, and follow up with individuals at risk for suicide through research

Research and training on suicide is critical given the fact that the majority of suicide deaths are preventable with accurate identification of risk and intervention by trained individuals. However, implementing and evaluating training is difficult because of the multiple factors involved, including, but not limited to, the heterogeneity of trainees, their diverse roles in suicide prevention, absence of clear guidelines for training content across settings, and limited methods for assessing outcomes. Here, three groups of trainees are discussed: community and professional gatekeepers and behavioral health providers. The roles each group plays in managing suicide risk and the training content it needs to be effective are addressed. A staged training approach is proposed, building on the core components of currently used suicide training: knowledge, attitudes, and skills/behaviors. Limitations of current assessment methods are identified and recommendations for alternative methods are provided. The article concludes with a discussion of next steps in moving the field forward, including overcoming challenges and identifying and engaging opportunities.

Sustaining motivational interviewing: a meta-analysis of training studies

BACKGROUND AND AIMS

Previous research indicates that motivational interviewing (MI) skills decline over time among participants in training workshops when post-workshop feedback and coaching are not provided. This study explored moderators of skill retention among trainees learning MI mainly for substance use disorder treatment in real-world treatment settings, including workshop enhancements and type and dose of post-workshop feedback and coaching.

METHODS

A meta-analysis of training studies was conducted with studies that reported MI skills using observational measures and that included trainees from real-world agency settings. Standardized change scores were calculated to indicate the magnitude of pre-post training change in MI skills; standardized change scores from post-training to 3 and 6+ months follow-up were calculated to indicate the sustainability of training gains over time. Effect sizes were aggregated using random effects models.

RESULTS

Twenty-one papers that reported the effects of MI training on agency staff were included in this review. Across studies, training yielded gains in MI skills (d = 0.76). Studies that did not include feedback and/or coaching reported eroding skills over a 6-month follow-up (d = -0.30), whereas post-workshop feedback/coaching sustained skills (d = 0.03). Effects of post-workshop feedback/coaching were moderated by frequency, duration and length of training. Moreover, studies reporting low levels of attrition from training protocols showed small increases in skills over the 6-month follow-up period (d = 0.12), whereas studies with high attrition showed skill erosion (d = -0.29).

CONCLUSIONS

On average, three to four feedback/coaching sessions over a 6-month period sustain skills among trainees for motivational interviewing, mainly for substance use disorder treatment. However, high rates of attrition from feedback/coaching contributes to post-workshop skill erosion.

Sustaining clinician penetration, attitudes and knowledge in cognitive-behavioral therapy for youth anxiety

Background

Questions remain regarding the sustainment of evidence-based practices following implementation. The present study examined the sustainment of community clinicians’ implementation (i.e., penetration) of cognitive-behavioral therapy, attitudes toward evidence-based practices, and knowledge of cognitive-behavioral therapy for youth anxiety two years following training and consultation in cognitive-behavioral therapy for youth anxiety.

Methods

Of the original 115 participants, 50 individuals (43%) participated in the two-year follow-up. A t- test examined sustainment in penetration over time. Hierarchical linear modeling examined sustainment in knowledge and attitudes over time. Time spent in consultation sessions was examined as a potential moderator of the change in knowledge and attitudes.

Results

Findings indicated sustained self-reported penetration of cognitive-behavioral therapy for anxious youth, with low fidelity to some key CBT components (i.e., exposure tasks). Follow-up knowledge was higher than at baseline but lower than it had been immediately following the consultation phase of the study. Belief in the utility of evidence-based practices was sustained. Willingness to implement an evidence-based practice if required to do so, appeal of evidence-based practices, and openness toward evidence-based practices were not sustained. Participation in consultation positively moderated changes in knowledge and some attitudes.

Conclusions

Sustainment varied depending on the outcome examined. Generally, greater participation in consultation predicted greater sustainment. Implications for future training include higher dosages of consultation.

Coaching teachers to improve implementation of the good behavior game

This study explored the association between coaching and the implementation of the Good Behavior Game (GBG) by 129 urban elementary school teachers. Analyses involving longitudinal data on coaching and teacher implementation quality indicated that coaches strategically varied their use of coaching strategies (e.g., modeling, delivery) based on teacher implementation quality and provided additional support to teachers with low implementation quality. Findings suggest that coaching was associated with improved implementation quality of the GBG. This work lays the foundation for future research examining ways to enhance coach decision-making about teacher implementation.

Consultation as an implementation strategy for evidence-based practices across multiple contexts: unpacking the black box

There is great interest in the dissemination and implementation of evidence-based treatments and practices for children across schools and community mental health settings. A growing body of literature suggests that the use of one-time workshops as a training tool is ineffective in influencing therapist behavior and patient outcomes and that ongoing expert consultation and coaching is critical to actual uptake and quality implementation. Yet, we have very limited understanding of how expert consultation fits into the larger implementation support system, or the most effective consultation strategies. This commentary reviews the literature on consultation in child mental health, and proposes a set of core consultation functions, processes, and outcomes that should be further studied in the implementation of evidence-based practices for children.

An examination of behavioral rehearsal during consultation as a predictor of training outcomes

The training literature suggests that ongoing support following initial therapist training enhances training outcomes, yet little is known about what occurs during ongoing support and what accounts for its effectiveness. The present study examined consultation sessions provided to 99 clinicians following training in cognitive-behavioral therapy for youth anxiety. Recorded consultation sessions (N = 104) were coded for content and consultative methods. It was hypothesized that behavioral rehearsal (an active learning technique) would predict therapist adherence, skill, self-efficacy, and satisfaction at post-consultation. Regression analyses found no significant relation, however, clinician involvement during consultation sessions positively moderated the relationship between behavioral rehearsals and skill. Implications, limitations, and future directions are discussed.

Consultants' perceptions of school counselors' ability to implement an empirically-based intervention for adolescent social anxiety disorder

Social anxiety is highly prevalent but goes untreated. Although school-based CBT programs are efficacious when delivered by specialized psychologists, it is unclear whether school counselors can implement these interventions effectively, which is essential to promote sustainable school programs. We present an initial consultation strategy to support school counselor implementation of group CBT for social anxiety and an evaluation of counselors' treatment fidelity. Counselors were highly adherent to the treatment, but competence varied based on measurement. Counselors and consultants demonstrated good agreement for adherence, but relatively modest correspondence in competence ratings. We discuss future directions for school-based implementation efforts informed by these initial findings.

Comparing Client Outcomes for Two Evidence-Based Treatment Consultation Strategies

Posttraining expert case consultation is a key component of transporting and scaling up evidence-based treatments, and hopefully retaining their efficacy. Live practice observation and in vivo coaching is a strategy used in academic training environments, but is rarely feasible in field settings. Post hoc telephone consultation is a substitute strategy but does not approximate many aspects of live coaching. Live video technology offers a closer approximation but has not yet been sufficiently tested. Using a roll-out experimental design, this study compared client outcomes across doses of two posttraining expert consultation strategies-standard telephone consultation and live video coaching. The study was conducted during a two-state, 30-agency implementation involving 80 therapists and 330 cases receiving Parent-Child Interaction Therapy (PCIT). Child behavior problems fell from well above to below clinical cutoff values, with about a 1 standard deviation improvement in 14 sessions, which is within the range reported in laboratory efficacy trials. Symptom improvement was augmented by increased therapist dose of live video consultations. Phone consultation dose had no association with client level outcomes. PCIT benefits appear to be retained when the model is transported at scale into the field, and live video consultation appeared to offer small but significant advantages over telephone consultation as one element of an overall transport strategy.

Improving therapist psychological flexibility while training acceptance and commitment therapy: a pilot study

Acceptance and Commitment Therapy (ACT) training often includes experiential elements aimed at improving therapist psychological flexibility, yet the effects of ACT training on therapist psychological flexibility have yet to be evaluated. This pilot study examines the effects of experiential phone consultation as an adjunct to a standard continuing education workshop on psychological flexibility and burnout among therapists learning ACT. In this study, counselors taking a 2-day ACT workshop were randomly assigned to either six 30-min phone consultation sessions (n = 10) or no additional contact (n = 10). The results show that those in the consultation condition reported higher psychological flexibility at the 3-month follow-up compared to the workshop-only condition. Improvements in ACT knowledge, overall burnout, and personal accomplishment were found in both groups, independent of whether they received phone consultation, and this increase was maintained over time. In conclusion, ACT phone consultation contributed to counselor psychological flexibility above the workshop alone and appears to be feasible as a means to improve counselor psychological flexibility.

Supporting universal prevention programs: a two-phased coaching model

Schools are adopting evidence-based programs designed to enhance students' emotional and behavioral competencies at increasing rates (Hemmeter et al. in Early Child Res Q 26:96-109, 2011). At the same time, teachers express the need for increased support surrounding implementation of these evidence-based programs (Carter and Van Norman in Early Child Educ 38:279-288, 2010). Ongoing professional development in the form of coaching may enhance teacher skills and implementation (Noell et al. in School Psychol Rev 34:87-106, 2005; Stormont et al. 2012). There exists a need for a coaching model that can be applied to a variety of teacher skill levels and one that guides coach decision-making about how best to support teachers. This article provides a detailed account of a two-phased coaching model with empirical support developed and tested with coaches and teachers in urban schools (Becker et al. 2013). In the initial universal coaching phase, all teachers receive the same coaching elements regardless of their skill level. Then, in the tailored coaching phase, coaching varies according to the strengths and needs of each teacher. Specifically, more intensive coaching strategies are used only with teachers who need additional coaching supports, whereas other teachers receive just enough support to consolidate and maintain their strong implementation. Examples of how coaches used the two-phased coaching model when working with teachers who were implementing two universal prevention programs (i.e., the PATHS curriculum and PAX Good Behavior Game [PAX GBG]) provide illustrations of the application of this model. The potential reach of this coaching model extends to other school-based programs as well as other settings in which coaches partner with interventionists to implement evidence-based programs.

Implementation Science in School Mental Health: Key Constructs in a Developing Research Agenda

In this paper, we propose an implementation science research agenda as it applies to school mental health (SMH). First, we provide an overview of important contextual issues to be considered when addressing research questions pertinent to the implementation of mental health interventions in schools. Next, we critically review three core implementation components: (a) professional development and coaching for school professionals regarding evidence-based practices (EBPs); (b) the integrity of EBPs implemented in schools; and (c) EBP sustainment under typical school conditions. We articulate research questions central to the next generation of research in each of these areas as well as methods to address such questions. Our intent in doing so is to contribute to a developing blueprint to guide community-research partnerships as well as funding agencies in their efforts to advance implementation science in SMH.

Acting Locally and Globally: Dissemination and Implementation Around the World and Next Door

Murray et al. (this issue) present a fascinating account of their international dissemination and implementation (D&I) research focused on training therapists in Thailand and Iraq to provide a modular treatment approach called Common Elements Treatment Approach to youth. In this commentary, we use Murray et al. as a springboard to discuss a few general conclusions about the current direction of D&I research. Specifically, we reflect on current D&I models, highlighting their ecological focus and their emphasis on stakeholder involvement. Next, we discuss the central importance of implementation supports such as treatment programs, training approaches, assessment and outcome monitoring tools, and organizational interventions. We conclude with a consideration of how D&I work that aims to adapt implementation supports for local needs represent a key path to our goal of sustainability.

Evaluation of an implementation initiative for embedding Dialectical Behavior Therapy in community settings

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N=64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

Implementation of multi-family psychoeducational psychotherapy for childhood mood disorders in an outpatient community setting

Despite advances in evidence-based treatments (EBTs), research suggests these interventions are not utilized in practice settings. This study examined implementation of multi-family psychoeducational psychotherapy (MF-PEP), an EBT for childhood mood disorders, in two outpatient community clinics. Fifteen community therapists facilitated MF-PEP. Twenty community clinicians referred 40 children ages 8-12 with mood disorders and their parents who participated in MF-PEP. Preliminary descriptive findings based on observations and self-report questionnaires demonstrated implementation outcomes of acceptability, adoption, appropriateness, feasibility, implementation cost, penetration, and sustainability of MF-PEP at these clinics. Parents also demonstrated significant improvement in knowledge of mood disorders posttreatment. Preliminary results support implementation of MF-PEP in practice settings and suggest community-based MF-PEP may be associated with improvement in clinical outcomes.

Child sexual abuse

This article begins by defining sexual abuse, and reviews the literature on the epidemiology of child sexual abuse (CSA). Clinical outcomes of CSA are described, including health and mental health. An outline is given of all the services often involved after an incident of CSA, and the need for coordination among them. Treatment strategies and evidence-based recommendations are reviewed. Challenges around dissemination and implementation, cultural considerations, and familial dynamics are described. Possible future directions are discussed.

Expert Recommendations for Implementing Change (ERIC): protocol for a mixed methods study

BACKGROUND

Identifying feasible and effective implementation strategies that are contextually appropriate is a challenge for researchers and implementers, exacerbated by the lack of conceptual clarity surrounding terms and definitions for implementation strategies, as well as a literature that provides imperfect guidance regarding how one might select strategies for a given healthcare quality improvement effort. In this study, we will engage an Expert Panel comprising implementation scientists and mental health clinical managers to: establish consensus on a common nomenclature for implementation strategy terms, definitions and categories; and develop recommendations to enhance the match between implementation strategies selected to facilitate the use of evidence-based programs and the context of certain service settings, in this case the U.S. Department of Veterans Affairs (VA) mental health services.

METHODS/DESIGN

This study will use purposive sampling to recruit an Expert Panel comprising implementation science experts and VA mental health clinical managers. A novel, four-stage sequential mixed methods design will be employed. During Stage 1, the Expert Panel will participate in a modified Delphi process in which a published taxonomy of implementation strategies will be used to establish consensus on terms and definitions for implementation strategies. In Stage 2, the panelists will complete a concept mapping task, which will yield conceptually distinct categories of implementation strategies as well as ratings of the feasibility and effectiveness of each strategy. Utilizing the common nomenclature developed in Stages 1 and 2, panelists will complete an innovative menu-based choice task in Stage 3 that involves matching implementation strategies to hypothetical implementation scenarios with varying contexts. This allows for quantitative characterizations of the relative necessity of each implementation strategy for a given scenario. In Stage 4, a live web-based facilitated expert recommendation process will be employed to establish expert recommendations about which implementations strategies are essential for each phase of implementation in each scenario.

DISCUSSION

Using a novel method of selecting implementation strategies for use within specific contexts, this study contributes to our understanding of implementation science and practice by sharpening conceptual distinctions among a comprehensive collection of implementation strategies.

Not just a walk in the park: efficacy to effectiveness for after school programs in communities of concentrated urban poverty

This study examined a model for mental health consultation, training and support designed to enhance the benefits of publicly-funded recreational after-school programs in communities of concentrated urban poverty for children's academic, social, and behavioral functioning. We assessed children's mental health needs and examined the feasibility and impact of intervention on program quality and children's psychosocial outcomes in three after-school sites (n = 15 staff, 89 children), compared to three demographically-matched sites that received no intervention (n = 12 staff, 38 children). Findings revealed high staff satisfaction and feasibility of intervention, and modest improvements in observed program quality and staff-reported children's outcomes. Data are considered with a public health lens of mental health promotion for children in urban poverty.