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

Perspectives on Cognitive Therapy Training within Community Mental Health Settings: Implications for Clinician Satisfaction and Skill Development

Despite the mounting evidence of the benefits of cognitive therapy for depression and suicidal behaviors over usual care, like other evidence-based psychosocial treatments (EBTs), it has not been widely adopted in clinical practice. Studies have shown that training followed by intensive consultation is needed to prepare providers to an appropriate level of competency in complex, multisession treatment packages such as cognitive therapy. Given the critical role of training in EBT implementation, more information on factors associated with the success and challenges of training programs is needed. To identify potential reasons for variation in training outcomes across ten agencies in a large, urban community mental health system, we explored program evaluation data and examined provider, consultant, and training program administrator perspectives through follow-up interviews. Perceptions of cognitive therapy, contextual factors, and reactions to feedback on audio recordings emerged as broad categories of themes identified from interviews. These factors may interact and impact clinician efforts to learn cognitive therapy and deliver it skillfully in their practice. The findings highlight experiences and stakeholder perspectives that may contribute to more or less successful training outcomes.

Counselor training in several evidence-based psychosocial addiction treatments in private US substance abuse treatment centers

BACKGROUND

Given that most addiction counselors enter the field unprepared to implement psychosocial evidence-based practices (EBPs), surprisingly little is known about the extent to which substance abuse treatment centers provide their counselors with formal training in these treatments. This study examines the extent of formal training that treatment centers provide their counselors in cognitive behavioral therapy (CBT), motivational interviewing (MI), contingency management (CM), and brief strategic family therapy (BSFT).

METHODS

Face-to-face interviews with 340 directors of a nationally representative sample of privately funded US substance abuse treatment centers.

RESULTS

Although a substantial number of treatment centers provide their counselors with formal training in EBPs that they use with their clients, coverage is far from complete. For example, of those centers that use CBT, 34% do not provide their counselors with any formal training in CBT (either initially or annually), and 61% do not provide training in CBT that includes supervised training cases. Sizable training gaps exist for MI, CM, and BSFT as well.

CONCLUSIONS

The large training gaps found in this study give rise to concerns regarding the integrity with which CBT, MI, CM, and BSFT are being delivered by counselors in private US substance abuse treatment centers. Future research should examine the generalizability of our findings to other types of treatment centers (e.g., public) and to the implementation of other EBPs.

Essential Ingredients for Successful Redesign of Addiction Treatment

Since the passage of healthcare reform, there have been many discussions about how the mental health and substance use disorder (MH/SUD) system will need to change. Of the many components involved in a system redesign, the identification of essential ingredients is crucial to its success. In an effort to determine what essential ingredients the new MH/SUD system requires to optimally meet the needs of its customers, we convened a group of 16 multi-industrial experts who analyzed data collected from a string of 7 focus groups and 15 interviews with people dealing with or working in the SUD field. This paper summarizes the 11 essential ingredients our group identified.

Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers

BACKGROUND

Recent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC). MODEL AND CASE PRESENTATIONS: This paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors.

EVALUATION

We review the challenges experienced with this model, and propose some possible solutions.

DISCUSSION

We describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature.

CONCLUSION

In our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions.

Improving therapeutic use of homework: suggestions from mental health clinicians

BACKGROUND

The majority of mental health clinicians report the use of homework to support their case management, but practitioner surveys indicate that homework is not routinely used.

AIMS

To examine barriers that mental health case managers experience in implementing homework and to identify strategies to promote successful homework administration.

METHOD

One hundred thirty-four surveys were completed by mental health case managers. The survey examined their use of homework for individuals diagnosed with a severe mental health problem. It also asked them to identify barriers to regularly implement homework and describe strategies to promote more regular use of homework.

RESULTS

On average, homework was used at 50% of clinical contacts. The primary reasons for not using homework included allocating insufficient time at appointments, perceived client resistance for using homework and concerns that the client was too unwell. Strategies used to overcome these difficulties included prioritising the use of homework and ensuring that homework assignments were achievable.

CONCLUSIONS

Clinicians are able to identify a range of practical strategies to promote the use of homework. Discussion focuses on the application of the suggested strategies to promote regular use of homework. This includes discussion of possible training approaches to enhance systematic homework administration.

Therapist training in empirically supported treatments: a review of evaluation methods for short- and long-term outcomes

Therapist training efforts have been assessed using several outcomes. A model for evaluating therapist training in empirically supported treatments is presented, adapted from Kirkpatrick's (in: Craig and Bittel (eds.) Training and development handbook, 1967) training evaluation model. The adapted framework includes short-term outcomes, such as reactions to training and changes in attitude, knowledge, or skills, and longer-term outcomes, such as changes in therapist behavior in practice or client outcomes. Evaluation methods for these outcomes are reviewed, with information on their validity, reliability, and feasibility. An agenda for further research to improve therapist training evaluation is presented, with discussion of how evaluation can inform other areas of the field.

A model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders

While a plethora of cognitive behavioral empirically supported treatments (ESTs) are available for treating child and adolescent anxiety and depressive disorders, research has shown that these are not as effective when implemented in routine practice settings. Research is now indicating that is partly due to ineffective EST training methods, resulting in a lack of therapist competence. However, at present, the specific competencies that are required for the effective implementation of ESTs for this population are unknown, making the development of more effective EST training difficult. This study therefore aimed to develop a model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders using a version of the well-established Delphi technique. In doing so, the authors: (1) identified and reviewed cognitive behavioral ESTs for child and adolescent anxiety and depressive disorders, (2) extracted therapist competencies required to implement each treatment effectively, (3) validated these competency lists with EST authors, (4) consulted with a panel of relevant local experts to generate an overall model of therapist competence for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders, and (5) validated the overall model with EST manual authors and relevant international experts. The resultant model offers an empirically derived set of competencies necessary for effectively treating children and adolescents with anxiety and depressive disorders and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines for working with this population. This model thus brings us one step closer to bridging the gap between science and practice when treating child and adolescent anxiety and depression.

Developing the mental health workforce: review and application of training approaches from multiple disciplines

Strategies specifically designed to facilitate the training of mental health practitioners in evidence-based practices (EBPs) have lagged behind the development of the interventions themselves. The current paper draws from an interdisciplinary literature (including medical training, adult education, and teacher training) to identify useful training and support approaches as well as important conceptual frameworks that may be applied to training in mental health. Theory and research findings are reviewed, which highlight the importance of continued consultation/support following training workshops, congruence between the training content and practitioner experience, and focus on motivational issues. In addition, six individual approaches are presented with careful attention to their empirical foundations and potential applications. Common techniques are highlighted and applications and future directions for mental health workforce training and research are discussed.

Allegiance Bias and Therapist Effects: Results of a Randomized Controlled Trial of Binge Eating Disorder

"Allegiance bias" has been hypothesized to compromise the findings of randomized controlled trials (RCTs). In contrast, our multi-site RCT involving the collaboration of investigators with different allegiances regarding interpersonal psychotherapy (IPT), guided self-help cognitive behavior therapy (CBTgsh), and behavioral weight loss therapy (BWL) for binge eating disorder showed no evidence of any differential site × treatment effects. The findings indicate that "allegiance bias" does not necessarily occur in well-controlled RCTS with appropriate therapist training. We also examined the role of individual therapist differences that have been alleged to be more important than treatment effects. No individual therapist effects emerged on any measure in either IPT or CBTgsh, both of which were significantly more effective than BWL at two-year follow-up.

Therapist competence, therapy quality, and therapist training

Large numbers of therapists worldwide wish to receive training in how to deliver psychological treatments. Current methods of training are poorly suited to this task as they are costly and require scarce expertise. New forms of training therefore need to be developed that are more cost-effective and scalable. Internet-based methods might fulfil these requirements whilst having the added advantage of being able to provide trainees with extensive exposure to the treatment as practised. New strategies and procedures for evaluating training outcome are also required. These need to be capable of assessing the therapist's knowledge of the treatment and its use, as well as the therapist's ability to apply this knowledge in clinical practice. Standardised role play-based techniques might be of value in this regard.

Kernels vs. Ears, and Other Questions for a Science of Treatment Dissemination

Combining intervention diffusion with change in clinical practice and public policy is an ambitious agenda. The impressive effort in Hawaii can be instructive, highlighting questions for a science of treatment dissemination. Among these questions, some of the most important are the following: (a) Who should be targeted for change? (e.g., "downstream" clinicians in practice, "upstream" clinicians in training, consumers, "brokers," policy makers, or payers?); (b) What should be disseminated? (e.g., full evidence-based protocols, specific treatment elements or "kernels"?); and (c) Which procedures maximize change? (e.g., what combination and duration of teaching, supervision, consultation, and other support?). Ultimately, change efforts need to assess what aspects of practice were actually altered, what measurable impact the changes had on clinical outcomes, and what changes in practices and outcomes can be sustained over time.

An evaluation of the effect of an educational intervention for Australian social workers on competence in delivering brief cognitive behavioural strategies: a randomised controlled trial

Background

Broad community access to high quality evidence-based primary mental health care is an ongoing challenge around the world. In Australia one approach has been to broaden access to care by funding psychologists and other allied health care professionals to deliver brief psychological treatments to general practitioners' patients. To date, there has been a scarcity of studies assessing the efficacy of social worker delivered psychological strategies. This study aims to build the evidence base by evaluating the impact of a brief educational intervention on social workers' competence in delivering cognitive behavioural strategies (strategies derived from cognitive behavioural therapy).

Methods

A randomised controlled trial design was undertaken with baseline and one-week follow-up measurement of both objective and self-perceived competence. Simulated consultations with standardised depressed patients were recorded on videotape and objective competence was assessed by blinded reviewers using the Cognitive Therapy Scale. Questionnaires completed by participants were used to measure self-perceived competence. The training intervention was a 15 hour face-to-face course involving presentations, video example consultations, written materials and rehearsal of skills in pairs.

Results

40 Melbourne-based (Australia) social workers enrolled and were randomised and 9 of these withdrew from the study before the pre training simulated consultation. 30 of the remaining 31 social workers (97%) completed all phases of the intervention and evaluation protocol (16 from intervention and 14 from control group). The intervention group showed significantly greater improvements than the control group in objective competence (mean improvement of 14.2 (7.38-21.02) on the 66 point Cognitive Therapy Scale) and in subjective confidence (mean improvement of 1.28 (0.84-1.72) on a 5 point Likert scale). On average, the intervention group improved from below to above the base competency threshold on the Cognitive Therapy Scale whilst the control group remained below.

Conclusions

Social workers can attain significant improvements in competency in delivering cognitive behavioural strategies from undertaking brief face to face training. This is relevant in the context of health reforms that involve social worker delivery of evidence based psychological care. Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.

Fidelity in the Field: Developing Infrastructure and Fine-tuning Measurement

Mazzucchelli and Sanders (2010) provide a thoughtful, detailed, and complex description of how to encourage flexible fidelity to one well-established, evidence-based treatment, the Triple P- Positive Parenting Program. As the authors highlight, many of the "lessons learned" from this wealth of treatment, research, and implementation experience were developed over decades and can be applied to other evidence based treatments. Underlying many of the recommendations provided by Mazzucchelli and Sanders (2010) is a well-refined infrastructure to support implementation and the need to refine the measurement of fidelity in the field. This commentary will discuss each of those topics. It seems that we have many lessons to learn and hurdles to clear in this emerging area of science, which will be hastened by pioneers like Mazzucchelli and Sanders.

Treatment research for children and youth exposed to traumatic events: moving beyond efficacy to amp up public health impact

OBJECTIVE

Population-based demands for trauma services have accelerated interest in the rapid deployment of efficacious interventions to address the diverse mental health consequences of traumatic experiences. However, optimal strategies for supporting either implementation or dissemination of trauma-focused interventions within healthcare or mental healthcare systems are underdeveloped.

METHODS

This work offers suggestions for adapting treatment research parameters in order to advance the science on the implementable and practical use of trauma-focused interventions within a public health framework. To this end, we briefly examine the current status of research evidence in this area and discuss efficacy and effectiveness treatment research parameters with specific attention to the implications for developing the research base on the implementation and dissemination of effective trauma practices for children and adolescents.

RESULTS

Examples from current studies are used to identify approaches for developing, testing and enhancing strategies to roll out effective treatment practices in real-world settings.

CONCLUSIONS

New approaches that reflect the contexts in which these practices are implemented may enhance the feasibility, acceptability, replicability and sustainability of trauma treatments and services, and thus improve outcomes for a broader population of youth and families.