Practitioner attitudes toward evidence-based practice: themes and challenges

Inter-organizational alignment and implementation outcomes in integrated mental healthcare for children and adolescents: a cross-sectional observational study

BACKGROUND

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOA in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

METHODS

SBMH clinicians from community-based organizations (CBOs; nclinician = 27) and their proximal student-support school staff (nschool = 99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

RESULTS

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

CONCLUSIONS

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

Inter-Organizational Alignment and Implementation Outcomes in Integrated Mental Healthcare for Children and Adolescents: A Cross-Sectional Observational Study

Background

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOAs in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

Methods

SBMH clinicians from community-based organizations (CBOs; nclinician=27) and their proximal student-support school staff (nschool=99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

Results

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

Conclusions

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

A Personalized, Transdiagnostic Smartphone Intervention (Mello) Targeting Repetitive Negative Thinking in Young People With Depression and Anxiety: Pilot Randomized Controlled Trial

BACKGROUND

Repetitive negative thinking (RNT) is a key transdiagnostic mechanism underpinning depression and anxiety. Using "just-in-time adaptive interventions" via smartphones may disrupt RNT in real time, providing targeted and personalized intervention.

OBJECTIVE

This pilot randomized controlled trial evaluates the feasibility, acceptability, and preliminary clinical outcomes and mechanisms of Mello-a fully automated, personalized, transdiagnostic, and mechanistic smartphone intervention targeting RNT in young people with depression and anxiety.

METHODS

Participants with heightened depression, anxiety, and RNT were recruited via social media and randomized to receive Mello or a nonactive control over a 6-week intervention period. Assessments were completed via Zoom sessions at baseline and at 3 and 6 weeks after baseline.

RESULTS

The findings supported feasibility and acceptability, with high rates of recruitment (N=55), uptake (55/64, 86% of eligible participants), and retention (52/55, 95% at 6 weeks). Engagement was high, with 90% (26/29) and 59% (17/29) of the participants in the Mello condition still using the app during the third and sixth weeks, respectively. Greater reductions in depression (Cohen d=0.50), anxiety (Cohen d=0.61), and RNT (Cohen d=0.87) were observed for Mello users versus controls. Mediation analyses suggested that changes in depression and anxiety were accounted for by changes in RNT.

CONCLUSIONS

The results indicate that mechanistic, targeted, and real-time technology-based solutions may provide scalable and effective interventions that advance the treatment of youth mental ill health.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621001701819; http://tinyurl.com/4d3jfj9f.

Cognitive behavioral therapies for individuals with cerebral palsy: A scoping review

AIM

To synthesize the evidence about the main intervention characteristics of cognitive behavioral therapies (CBTs) for individuals with cerebral palsy and identify barriers and facilitators to their success, focusing on aspects of feasibility and markers of success.

METHOD

A scoping review methodology informed a literature search for papers published between 1991 and 2021. Articles were screened, reviewed, and categorized using the DistillerSR systematic review software, and critically appraised for quantitative and/or qualitative criteria.

RESULTS

Out of 1265 publications identified, 14 met the inclusion criteria. Elements associated with the specific study participant characteristics (46% female; aged 6-65 years), type of CBT techniques used (third-wave [n = 6], cognitive [n = 3], cognitive and behavioral [n = 2], biofeedback training [n = 2]), and features of the study context and methodological quality (two randomized clinical trials and small sample sizes [n ≤ 12]), were identified. Most studies had psychological targets of intervention (n = 10) and secondary physiological (n = 3) or social (n = 2) objectives. Feasibility indicators were described in nearly one-third of the papers.

INTERPRETATION

This study highlights the high flexibility within CBT interventions, enabling their adaptation for individuals with cerebral palsy. However, relatively little, and only low-certainty evidence was identified. More high-quality research in terms of specific CBT techniques, optimal treatment doses, and detailed population characteristics are needed.

Identifying Beneficial Training Elements: Clinician Perceptions of Learning the Evidence-Based GenerationPMTO Intervention

Improving the process through which mental health professionals are trained in evidence-based practices (EBPs) represents an important opportunity for extending the implementation of EBPs in community settings. In this study, we used a qualitative approach to examine the specific training elements that were beneficial to clinicians' experiences learning an evidence-based intervention. Individual, semi-structured interviews were conducted with mental health professionals completing training in the GenerationPMTO parenting intervention. Data were analyzed using the tenets of thematic analysis. Overall, participants reported positive experiences in the training and growth in their attitudes, knowledge, and confidence in GenerationPMTO. The qualitative findings also suggested seven specific training elements that participants perceived as beneficial: support, role plays, engagement, structure, writing/visuals, working with training families, and experiencing the GenPMTO model. These results are discussed within the context of the existing literature on EBP training and more broadly as they relate to expanding the implementation of evidence-based interventions. We also suggest implications for practice meant to enhance future EBP training efforts.

Clinician Intentions to use the Components of Parent Coaching Within Community Early Intervention Systems

PURPOSE

Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component.

METHODS

Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component.

RESULTS

Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving.

CONCLUSION

These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target.

Psychological therapists' perceptions of adolescent depression and its treatment: A mixed methods online survey

BACKGROUND

Challenges to implementating interventions for adolescent depression exist. Exploring the perceptions of key stakeholders in the treatment of adolescent depression is essential for improving implementation . This study aimed to explore psychological therapists' perceptions of, and experiences treating, adolescent depression to identify future avenues for exploration.

METHOD

Data were collected opportunistically via a survey integrated within an e-learning package about adolescent depression.

RESULTS

Participants believed that adolescent depression was characterised by adolescents' lack of understanding, isolation, and a lack of hope and knowledge. Participants overcame engagement barriers by building trust. Following the e-learning, participants expressed increased understanding of the risk factors associated with adolescent depression and of assessment using different measures. Several key areas for future research to explore were identified and discussed, including (1) whether clinicians of different modalities or at different career stages have difference perceptions, (2) how to meaningfully engage adolescents in treatment and (3) how to train clinicians on different modalities so patients have a choice over their treatment.

CONCLUSION

This study demonstrates the value of knowledge gained from understanding psychological therapists' perceptions and illustrates how this can contribute to the improved treatment of adolescent depression.

The experience of young people receiving cognitive behavioural therapy for major depression: A qualitative study

AIM

Major depressive disorder (MDD) has far reaching impacts for young people, their families and society. Cognitive behavioural therapy (CBT) is one of the first-line treatments for young people experiencing MDD; however, there is limited research examining how young people with MDD experience CBT. The aim of this study was to explore their experience and their views of this intervention.

METHODS

We employed a qualitative research design, with semi-structured interviews and thematic analysis. Eight participants aged between 17 and 24 years who received CBT for MDD in a randomized controlled trial were recruited.

RESULTS

Five themes were identified: the importance of relationship with clinician; the range of useful components within CBT; the ability for CBT to accommodate different techniques and presenting issues; the importance of checking in with clients during the process of therapy; and the impacts of MDD on therapy.

CONCLUSIONS

The findings highlight the importance of clinicians having a youth friendly and collaborative approach that allows a modular delivery of a range of CBT techniques to suit the client's presenting issue and formulation. There is a need to continually check how young people are responding to interventions, and to be aware of potential cognitive deficits and adjust therapy accordingly. This is a small study that provides insight into how young people with MDD experience CBT and avenues to explore for tailoring provision of CBT to enhance the therapeutic experience for this population.

Professional wellbeing and turnover intention among child therapists: a comparison between therapists trained and untrained in Trauma-Focused Cognitive Behavioral Therapy

Background

Poor professional wellbeing and job turnover is challenging for child mental health clinics and despite an increasing interest in implementing evidence-based practices (EBPs) in mental health services, little is known about if and how using EBPs may influence therapists’ professional wellbeing and turnover intention. To investigate this, we compare the average level of compassion satisfaction, burnout, secondary traumatic stress, and turnover intention between therapists trained in an EBP (Trauma-Focused Cognitive Behavioral Therapy – TF-CBT) and untrained therapists. We also explore the prevalence of and the associations between these personal and organizational outcomes.

Method

In this cross-sectional study, the data is collected from a national sample of 373 therapists 5 years after an implementation program began (i.e., in the sustainment phase). The variables were measured by the Professional Quality of Life and the Turnover Intention Scales. The Evidence-Based Practice Attitude Scale was also used to measure therapists’ attitudes toward EBPs.

Results

Over 70% of the respondents reported medium to high levels of burnout, secondary traumatic stress symptoms, and compassion satisfaction, whereas one-third of the respondents reported a high level of intention to leave their job in the current or near future. Higher ratings on burnout and secondary traumatic stress were significantly associated with lower compassion satisfaction and higher turnover intention. Finally, we found significantly lower degree of burnout and turnover intention along with higher compassion satisfaction among TF-CBT therapists (n = 96), compared to other therapists who were not trained in TF-CBT (n = 231). These differences could not be explained by between-group differences in age, job tenure, educational background, or therapists’ attitudes towards EBPs. However, mean differences in ratings on secondary traumatic stress symptoms were not statistically significant.

Conclusion

Although the prevalence findings are in general alarming, the present study provides the first empirical evidence for a potential positive effect of being trained in TF-CBT on therapists’ wellbeing and turnover intention. We discuss these findings in the light of self-efficacy theory and the job demands-resources model.

Mental health clinician perspectives regarding factors impacting implementation of evidence-based psychotherapies in Veterans Health Administration community-based outpatient clinics

OBJECTIVE

Uptake of Evidence-Based Psychotherapies (EBPs) by mental health (MH) clinicians, especially in community settings, remains highly variable. This formative pilot study aimed to understand the attitudes and practices of Veterans Health Administration community-based MH clinicians regarding EBPs and to identify multi-level factors that enable and hinder EBP implementation in this unique context.

METHODS

Semi-structured interviews were conducted with MH clinicians (N = 40) working in community-based outpatient clinics (CBOCs) in metro/urban (n = 20) and non-metro/rural (n = 20) locations. Interviews were guided by the Consolidated Framework for Implementation Research and were analyzed using rapid content analysis. Results were organized by system-, clinician-, patient-, and innovation-levels.

RESULTS

EBPs were consistently perceived as important to delivering quality MH care, with most clinicians having received training in at least one VHA EBP. However, limited EBP training and consultation opportunities, inadequate autonomy to schedule EBP sessions, high and complex caseloads, and feelings of isolation at CBOCs decreased EPB use. Social workers perceived disparities in EBP training access relative to psychologists. Some barriers were more salient in non-metro/rural settings (e.g., patient-level privacy concerns).

CONCLUSIONS

Increased EBP training opportunities- particularly for social workers-, greater flexibility over schedules and caseloads, and more mechanisms for consultation and professional development may increase EBP uptake in community-based clinics.

Exploring attitudes about evidence-based practice among speech-language pathologists: A survey of Japan and Malaysia

Purpose: To investigate speech-language pathologists' current perceptions, previous training experiences, resources, barriers, and training needs in terms of evidence-based practices (EBPs) in two Asian countries.Method: Their knowledge and attitudes about EBP were explored using an online questionnaire. A descriptive analysis was conducted with consideration of the effect of demographic variables on knowledge and attitudes about EBP.Result: Malaysian speech-language pathologists (n = 98) displayed more positive attitudes toward EBPs, with a significantly higher (t (143) = 5.91, p < .01) total mean score (Mean = 120.7, SD = 11) compared to the Japanese speech-language pathologists (n = 47, Mean = 107.8, SD = 13.5). Malaysian practitioners who were female, worked full-time, and worked in government settings reported higher motivation to develop EBP skills. Japanese practitioners who worked in private sectors reported higher EBPs training needs than those in government settings. In both countries, speech-language pathologists with higher education levels tended to express fewer perceived barriers towards EBP.Conclusion: Findings could help local governance and speech-language pathologist associations to understand the current practices and professional development needs of speech-language pathologists, leading to more effective training programs and educating employers and managers who can reinforce EBP among practitioners.

Improving the Quality of Children's Mental Health Care with Progress Measures: A Mixed-Methods Study of PCIT Therapist Attitudes

Progress measures are an evidence-based technique for improving the quality of mental health care, however, clinicians rarely incorporate them into treatment. Research into how measure type impacts clinician preference has been recommended to help improve measure implementation. Parent–Child Interaction Therapy (PCIT) is an assessment-driven treatment that serves as an ideal intervention through which to investigate measure preferences given its routine use of two types of assessments, a behavioral observation (the Dyadic Parent–Child Interaction Coding System) and a parent-report measure (the Eyberg Child Behavior Inventory). This study investigated PCIT therapist attitudes towards progress measures used within PCIT and children’s mental health treatment generally. A mixed-method (QUAN + QUAL) study design examined PCIT therapist attitudes towards two types of progress measures and measures used in two contexts (PCIT and general practice). Multi-level modeling of a survey distributed to 324 PCIT therapists identified predictors of therapist attitudes towards measures, while qualitative interviews with 23 therapists expanded and clarified the rationale for differing perceptions. PCIT therapists reported more positive attitudes towards a behavioral observation measure, the DPICS, than a parent-report measure, the ECBI, and towards measures used in PCIT than in general practice. Clinician race/ethnicity was significantly related to measure-specific attitudes. Qualitative interviews highlighted how perceptions of measure reliability, type of data offered, ease of use, utility in guiding sessions and motivating clients, and embeddedness in treatment protocol impact therapist preferences. Efforts to implement progress monitoring should consider preferences for particular types of measures, as well as how therapists are trained to embed measures in treatment.

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%-50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9-14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.

Treating Adults With Complex Posttraumatic Stress Disorder Using a Modular Approach to Treatment: Rationale, Evidence, and Directions for Future Research

ICD-11 complex PTSD (CPTSD) is a new condition, and, therefore, there are as yet no clinical trials evaluating interventions for its treatment. In this paper, we provide the rationale for a flexible multimodular approach to the treatment of CPTSD, its feasibility, and some evidence suggesting its potential benefits. The approach highlights flexibility in the selection of empirically supported interventions (or a set of interventions) and the order of delivery based on symptoms that are impairing, severe, and of relevance to the patient. The approach has many potential benefits. It can incorporate the use of interventions for which there is already evidence of efficacy allowing the leveraging of past scientific efforts. It is also consistent with patient-centered care, which highlights the importance of patient choice in identification of the problems to target, interventions to select, and outcomes to monitor. Researchers on modular treatments of other disorders have found that, compared to disorder-specific manualized protocols, flexible multimodular treatment programs are superior in resolving identified problems and are associated with greater therapist satisfaction and reduced patient burden. We briefly identify types of interventions that have been successful in treating trauma-exposed populations as well as emerging interventions that are relevant to the particular problems associated with exposure to complex trauma. We conclude with examples of how such treatments can be organized and tested. Research is now urgently needed on the effectiveness of existing and new intervention approaches to ICD-11 CPTSD treatment.

A qualitative exploration of factors influencing medical staffs' decision-making around nutrition prescription after colorectal surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients' diets after surgery, this study explored factors which influenced medical staffs' decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions.

METHODS

This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition.

CONCLUSIONS

Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs' decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations.

Attitudes of mental health providers towards adoption of evidence-based interventions: relationship to workplace, staff roles and social and psychological factors at work

Background

Gaining insight into factors influencing the adoption of evidence-based interventions (EBI) is essential to ensuring their sustainability in the mental healthcare setting. This article describes 1) differences between professional staff roles in attitudes towards EBI and 2) individual and organizational predictors of attitudes towards adopting EBI.

Methods

The participants were psychologists and psychiatric nurses (N = 792). Student t-tests were used to investigate group differences of global attitude scores on the Evidence-based Practice Attitude Scale-36 (EBPAS-36). A confirmatory factor analysis (CFA) of the EBPAS-36 measurement model, and a principal component analysis (PCA) of the factor scores were used to obtain attitudinal components for the subsequent hierarchical regression analyses.

Results

Three second-order attitudinal components were retained and named: professional concern, attitudes related to work conditions and requirements, and attitudes related to fit and preferences. Nurses’ global attitudinal scores were more positive than those of psychologists, while clinicians had less positive global attitudinal scores than non-clinicians. Hierarchical regression analysis showed that provider demographic, social and psychological factors in the workplace and staff role predicted attitudes towards adopting EBI, e.g. male gender, older age and working in private practice predicted more negative global attitudes, while working in academia, experiencing social support from colleagues and empowering leadership predicted more positive global attitudes to adopt EBI. The prediction outcomes for the specific attitudinal components are presented, as well.

Conclusion

The findings suggest that implementation efforts may benefit from being tailored to the different needs and values of the affected professionals, including the role of the context they operate within. Implications with a special emphasis on training efforts and organizational development are discussed.

Evidence-Based Treatment Strategies in Youth Mental Health Services: Results from a National Survey of Providers

Previous surveys indicate infrequent use of evidence-based treatment (EBT) manuals in usual care youth mental health, but the extent to which providers use core and common EBT strategies and what contextual factors impact EBT strategy implementation need further study. In a national, multidisciplinary survey of 1092 youth-serving providers, providers reported regular use of many EBT strategies. Provider learning theory orientation, more recent degree, more standardized and ongoing assessment use, more positive attitudes toward innovation and evidence, fewer low-income clients, and perceptions that their agency valued quality care and provided fewer training resources predicted more frequent EBT strategy use.

Who Wants Feedback? Effects of Transformational Leadership and Leader-Member Exchange on Mental Health Practitioners' Attitudes Toward Feedback

OBJECTIVE

The purpose of this study was to identify the mechanisms through which different aspects of leadership affect mental health practitioners' attitudes toward supervisory feedback.

METHODS

Data were collected from 363 practitioners nested in 68 treatment teams in public-sector mental health organizations. A multilevel path analysis was conducted to examine the associations of transformational leadership (supervisor's ability to inspire others to follow a course of action) and leader-member exchange (quality of the supervisor-practitioner relationship) with practitioner attitudes toward feedback.

RESULTS

Transformational leadership and leader-member exchange were directly and positively associated with practitioners' attitudes toward feedback. Transformational leadership was also indirectly associated with practitioners' attitudes toward feedback through the quality of supervisor-practitioner relationships.

CONCLUSIONS

Study results contribute to the growing body of evidence suggesting that leaders play a key role in shaping mental health service delivery. Both leadership behavior and high-quality supervisor-practitioner relationships are important in supporting practitioners in delivering evidence-based mental health care. Policymakers, administrators, and researchers should consider an integrative approach when developing leadership training interventions.

Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET): A comparative effectiveness trial of a transdiagnostic treatment and a measurement feedback system

Emotional disorders, encompassing a range of anxiety and depressive disorders, are the most prevalent and comorbid psychiatric disorders in adolescence. Unfortunately, evidence-based psychosocial therapies typically focus on single disorders, are rarely adopted by community mental health center clinicians, and effect sizes are modest. This article describes the protocol for a comparative effectiveness study of two novel interventions designed to address these challenges. The first intervention is a transdiagnostic treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A), a promising new approach that uses a small number of common strategies to treat a broad range of emotional disorders, and their underlying shared emotional vulnerabilities. The second intervention is a standardized measurement feedback system, the Youth Outcomes Questionnaire (YOQ), designed to improve clinical decision making using weekly symptom and relational data. The three study arms are treatment as usual (TAU), TAU plus the YOQ (TAU+), and UP-A (used in combination with the YOQ). The primary aims of the study are to [1] compare the effects of the UP-A and TAU+ to TAU in community mental health clinics, [2] to isolate the effects of measurement and feedback by comparing the UP-A and TAU+ condition, and [3] to examine the mechanisms of action of both interventions. Design considerations and study methods are provided to inform future effectiveness research.

When psychological science fails to be heard: the lack of evidence-based arguments in a ministerial report on child sexual abuse

One of the most debated issues in relation to child sexual abuse (CSA) is whether there should be a limitation period for prosecutions. In 2017 a French ministerial report was released proposing extension of the limitation period in part because of the sometimes long delay between the alleged events and the disclosure of the abuse. For this, the report relied on dissociative amnesia. It also advocated for the development of child victim interview protocols by victim associations. We show that dissociative amnesia is not consensual within the scientific community. Instead, we recommend scientifically reliable cognitive principles to explain the lack of memory. Moreover, interviewing techniques for children have already been designed by memory researchers to enhance recall and report of CSA, from which any uncontrolled deviation might put the child's testimony at risk. We conclude by advocating for the use of evidence-based psychology, and for co-operation between practitioners, judges and researchers.

Training community-based treatment providers to implement contingency management for opioid addiction: Time to and frequency of adoption

Contingency management (CM) is a well-established treatment for opioid use, yet its adoption remains low in community clinics. This manuscript presents a secondary analysis of a study comparing a comprehensive implementation strategy (Science to Service Laboratory; SSL) to didactic training-as-usual (TAU) as a means of implementing CM across a multi-site opioid use disorder program. Hypotheses predicted that providers who received the SSL implementation strategy would 1) adopt CM faster and 2) deliver CM more frequently than TAU providers. In addition, we examined whether the effect of implementation strategy varied as a function of a set of theory-driven moderators, guided by the Consolidated Framework for Implementation Research: perceived intervention characteristics, perceived organizational climate, and provider characteristics (i.e., race/ethnicity, gender). Sixty providers (39 SSL, 21 TAU) across 15 clinics (7 SSL, 8 TAU) completed a comprehensive set of measures at baseline and reported biweekly on CM use for 52 weeks. All participants received didactic CM training; SSL clinics received 9 months of enhanced training, including access to an external coach, an in-house innovation champion, and a collaborative learning community. Discrete-time survival analysis found that SSL providers more quickly adopted CM; provider characteristics (i.e., race/ethnicity) emerged as the sole moderator of time to adoption. Negative binomial regression revealed that SSL providers also delivered CM more frequently than TAU providers. Frequency of CM adoption was moderated by provider (i.e., gender and race/ethnicity) and intervention characteristics (i.e., compatibility). Implications for implementation strategies for community-based training are discussed.

Emergent Life Events: An In-Depth Investigation of Characteristics and Provider Responses during Youth Evidence-Based Treatment

Emergent life events (ELEs), or acute client stressors disclosed within psychotherapy sessions, are not addressed by many evidence-based psychosocial treatments (EBTs). Preliminary provider-report studies suggest that ELEs may interfere with effective EBT implementation. The present study offers a detailed, observational examination of ELEs and their impact on EBT within therapy sessions. Data were observationally coded from 274 sessions with 55 primarily low-income, Latino youth clients (58% male, ages 5-15) in the modular EBT condition (Modular Approach to Therapy for Children [MATCH]) of the Child STEPs California trial. The ELE Coding System-Revised was used to measure ELEs, their characteristics, and provider responses to ELEs, including provider adherence to MATCH. Interrater reliability was generally high. At least one ELE was identified in 13% of randomly selected sessions. ELEs ranged widely in content, and their characteristics did not cluster together. Providers responded more frequently to ELEs with non-EBT content (e.g., information gathering, empathy) than EBT content; use of the ELE as a "teaching moment" for EBT content was the least common response (40% of ELEs). Multilevel regression analyses revealed that compared to sessions without an ELE, ELE sessions were significantly associated with reduced provider adherence to MATCH. Within ELE sessions, higher client distress when discussing the ELE was associated with reduced provider adherence to MATCH, but only when ELE severity was high. Beyond provider report, observational measures indicate that ELEs are prevalent and unpredictable in community settings and disrupt EBT delivery. Findings can inform the development of structured ELE management procedures to enhance existing EBTs.

How Intervention and Implementation Characteristics Relate to Community Therapists' Attitudes Toward Evidence-Based Practices: A Mixed Methods Study

Therapists' perceptions toward evidence-based practices (EBPs) are important in implementation efforts, however little is known about characteristics of EBPs associated with more positive attitudes. This mixed-methods study examined how intervention and implementation characteristics of six EBPs related to therapist attitudes. Quantitative analysis of 793 cross-sectional surveys revealed that therapists endorsed more positive attitudes toward EBPs with (1) prescribed session content and order and (2) required consultation. Associations between these intervention and implementation characteristics and attitudes were not moderated by therapist experience or emotional exhaustion. Qualitative analyses complemented quantitative findings, indicating that "structure" was appealing for interventions and that therapists felt supported by consultation.

Predictors of Burnout among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children's Mental Health

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.

The Development of a Community-Based Drug Intervention for Filipino Drug Users

This article documents the development of a community-based drug intervention for low- to mild-risk drug users who surrendered as part of the Philippine government's anti-drug campaign. It highlights the importance of developing evidence-informed drug recovery interventions that are appropriate to the Asian culture and to developing economies. Interviews and consultations with users and community stakeholders reveal the need for an intervention that would improve the drug recovery skills and life skills of users. Evidence-based interventions were adapted using McKleroy and colleagues’ (2006) Map of Adaptation Process (MAP) framework. The resulting intervention reflected the country's collectivist culture, relational values, propensity for indirect and non-verbal communication, and interdependent self-construal. The use of small groups, interactive and creative methodologies, and the incorporation of music and prayer also recognised the importance of these in the Philippine culture.

Impact of Brief Intervention Workshops on Addiction Provider Knowledge, Skills, Negative Attitudes, and Interest in Implementing Evidence-Based Practices

This study evaluated the impact of Motivational Interviewing (MI) and Screening, Brief Intervention, and Referral to Treatment (SBIRT) workshops on posttraining knowledge, skills, negative attitudes, and interest in implementing evidence-based practices (EBPs). Participants ( N = 70) were primarily mental health counselor (41.4%), social workers (20.0%), substance abuse counselors (15.7%), school counselors (5.7%), and nursing professionals (4.3%) who selected the 1- or 2-day workshop for continuing education credit. Participants attended either a Basic MI training workshop (1 day) or a Basic MI training plus an advanced MI/SBIRT training workshop (2 days) to assess if exposure to two EBPs would improve training outcomes. Participants in both the 1-day and 2-day workshops reported posttraining increased perceived knowledge and skills, decreased negative attitudes toward EBPs, and increased interest in implementing EBPs from pretraining to posttraining. There were no differences between participants in the Basic MI or MI plus advanced MI/SBIRT training conditions. Implications for reducing the research-practice gap in EBPs are discussed.

Practitioner Review: Empirical evolution of youth psychotherapy toward transdiagnostic approaches

BACKGROUND

Psychotherapy for children and adolescents (herein, 'youths') has grown more precise and focused over the decades, shifting toward empirically supported treatments standardized via therapist manuals. The manuals have increasingly emphasized precise targeting of single disorders or problems, or homogenous clusters. These focal treatments represent a valuable advance, with intervention benefit documented in hundreds of studies. However, relatively few of these treatments are widely used in everyday clinical practice, and their level of benefit may not be ideal, particularly in practice contexts and when compared to usual clinical care.

THESIS

These limitations may be due, in part, to a mismatch between focal treatment design and the young people treated in real-world clinical care, who are diagnostically heterogeneous, and very frequently present with comorbidity. Improved fit may be achieved via transdiagnostic treatment approaches designed to address multiple disorders and problems, if these approaches can retain the benefits of manualization and the substantive clinical strength that has generated empirical support to date.

SCOPE

Here we review the evolution of empirically-based youth psychotherapy from focal treatment manuals toward transdiagnostic approaches, and we describe and illustrate three transdiagnostic treatment strategies: (a) a core dysfunction approach, (b) a common elements and modular design approach, and (c) a principle-guided approach.

CLINICAL APPLICATIONS

We complement research findings with a clinical perspective based on our use of manual-guided transdiagnostic intervention in clinical care settings, and we propose directions for research and practice.

Common Factors in Community Mental Health Intervention: A Scoping Review

While there is considerable research and commentary devoted to common factors in psychotherapy, their implications for community mental health interventions are much less clear. In response, a scoping review was conducted to answer the question, 'What is the evidence base for common factors in community mental health intervention?' A comprehensive search of MEDLINE, PsycINFO, and Google Scholar was completed. A total of 60 publications were identified in this review with a focus primarily upon therapeutic alliance. Though methodologically diverse, this review supports the likely importance of alliance in the outcomes of community mental health interventions.

Evidence-Based Psychotherapy: Advantages and Challenges

Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Psychiatric disorders are prevalent worldwide and associated with high rates of disease burden, as well as elevated rates of co-occurrence with medical disorders, which has led to an increased focus on the need for evidence-based psychotherapies. This chapter focuses on the current state of evidence-based psychotherapy. The strengths and challenges of evidence-based psychotherapy are discussed, as well as misperceptions regarding the approach that may discourage and limit its use. In addition, we review various factors associated with the optimal implementation and application of evidence-based psychotherapies. Lastly, suggestions are provided on ways to advance the evidence-based psychotherapy movement to become truly integrated into practice.

Non-participants in policy efforts to promote evidence-based practices in a large behavioral health system

Background

System-wide training initiatives to support and implement evidence-based practices (EBPs) in behavioral health systems have become increasingly widespread. Understanding more about organizations who do not participate in EBP training initiatives is a critical piece of the dissemination and implementation puzzle if we endeavor to increase access in community settings.

Methods

We conducted 30 1-h semi-structured interviews with leaders in non-participating agencies who did not formally participate in system-wide training initiatives to implement EBPs in the City of Philadelphia, with the goal to understand why they did not participate.

Results

We found that despite not participating in training initiatives, most agencies were adopting (and self-financing) some EBP implementation. Leadership from agencies that were implementing EBPs reported relying on previously trained staff to implement EBPs and acknowledged a lack of emphasis on fidelity. Most leaders at agencies not adopting EBPs did not have a clear understanding of what EBP is. Those familiar with EBPs in agencies not adopting EBPs reported philosophical objections to EBPs. When asked about quality assurance and treatment selection, leaders reported being guided by system audits.

Conclusions

While it is highly encouraging that many agencies are adopting EBPs on their own, significant questions about fidelity and implementation success more broadly remain.

Factors associated with the implementation of the Familias Unidas intervention in a type 3 translational trial

This study highlights how Familias Unidas, a Hispanic-specific, evidence-based, family centered preventive intervention, progressed from intervention development (type 1 translation; T1) through rigorous evaluation (T2) and examines the role of intervention fidelity-adherence and competence-in a T3 trial. Effects of participant, provider, and organizational variables on direct (observational) and indirect (self-reported) fidelity were examined as were effects of fidelity. Two structural equation models were estimated using data from 367 Hispanic parent-adolescent dyads randomized to Familias Unidas. Facilitator perceptions of parental involvement in schools, school performance grade, and school socioeconomic status predicted indirect adherence ratings, which were positively related to adolescent substance use. Facilitator openness to evidence-based practices was associated with indirect competence ratings, school performance grade and size were associated with direct competence ratings, and direct competence ratings were negatively associated with substance use. Findings highlight unique contributions of direct and indirect fidelity ratings in the implementation of Familias Unidas.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

The role of setting versus treatment type in alliance within youth therapy

OBJECTIVE

Does the strength of the youth-therapist alliance differ across treatment settings or treatment type? We examined these questions in the context of youth therapy.

METHOD

Eighty-nine youths (M age = 10.56, SD = 1.99; 63.70% Caucasian; 52.80% male) diagnosed with an anxiety disorder received (a) manual-based individual cognitive-behavioral therapy (ICBT) in a research setting, (b) manual-based ICBT in practice settings, or (c) nonmanualized usual care (UC) in practice settings. Coders, using the Therapy Process Observational Coding System-Alliance scale, rated 865 sessions. Youth completed the Therapeutic Alliance Scale for Children at posttreatment.

RESULTS

Youth who received ICBT in a research setting had significantly higher observer-rated alliance than youth who received either therapy delivered in practice settings. In practice settings, youth who received ICBT had significantly stronger observer-rated alliance early in treatment than youth in UC, but this difference was not observed at the end of treatment. Similarly, youth-report alliance at posttreatment was significantly higher in ICBT in the research setting, and there was no difference between ICBT and UC delivered in practice settings. Alliance differences largely held when controlling for youth characteristics; however, differences early in treatment between the ICBT groups were no longer statistically significant when controlling for anxiety severity or primary anxiety diagnosis.

CONCLUSIONS

Our findings suggest that (a) the alliance may be stronger in research settings, and (b) treatment manuals do not undermine alliance. Future research is required to help pinpoint whether other youth, therapist, or setting factors contribute to the lower alliance seen in practice settings.

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.

Psychoeducation as a Mediator of Treatment Approach on Parent Engagement in Child Psychotherapy for Disruptive Behavior

Parent engagement in treatment for child disruptive behavior has been associated with improved child outcomes in care. However, many families who enter care do not receive an adequate dose of treatment, and parents are often not involved. We examined therapists' use of psychoeducation, a therapeutic practice used to present factual information about target problems and treatments, and its association with parent engagement in child psychotherapy. Participants were drawn from the Child System and Treatment Enhancement Projects' multisite trial contrasting standard evidence-based treatments, modular treatment, or usual care. We included an ethnically diverse sample of 46 youth (ages 7-13) who received treatment for disruptive behavior in modular treatment or usual care. A reliable observational coding system was developed to assess therapists' in-session use of psychoeducation strategies (e.g., discussing causes of misbehavior, describing and providing rationale for treatment, etc.), as well as other engagement strategies (e.g., collaborative goal setting, managing expectations, etc.), in the early phase of treatment. Findings revealed that modular treatment therapists provided more psychoeducation and other engagement strategies compared with usual care therapists. Furthermore, psychoeducation strategies employed by therapists early on uniquely predicted subsequent parent involvement in treatment, over and above the use of other engagement strategies. Finally, therapists' use of the psychoeducation strategy of discussing causes of child's misbehavior mediated the effect of treatment condition on parent involvement in their child's therapy. These findings suggest that the implementation of psychoeducation strategies upon entry into care promotes parent involvement in child psychotherapy for disruptive behavior.

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.

Community-based treatment for youth with co- and multimorbid disruptive behavior disorders

Little is known about the types of psychotherapeutic practices delivered to youth with comorbid and multimorbid diagnoses in community settings. The present study, based on therapists' self-reported practices with 569 youth diagnosed with a disruptive behavior disorder (ODD or CD), examined whether specific therapeutic practice applications varied as a function of the number and type of comorbid disorders. While type of comorbid disorder (AD/HD or internalizing) did not predict therapists' practices, youth with more than two diagnoses (multimorbid) received treatment characterized by a more diverse set and a higher dosage of practices.

Factors influencing the implementation of a brief alcohol screening and educational intervention in social settings not specializing in addiction services

Although alcohol use continues to be a major problem, when high-risk users enter social services, they are not provided with empirically supported treatments (ESTs). This study investigates predictors of successful implementation in agencies not specializing in addiction services. Fifty-four frontline workers in six organizations were enrolled in the study. After completing self-administered surveys of organizational culture and climate and attitudes toward ESTs, workers were trained to implement a brief intervention. The results indicate that organizational factors and attitudes may not be related to implementation. Although high implementers had similar traits, further research is needed to characterize successful EST implementers.

Perceptions of speech-language pathologists linked to evidence-based practice use in skilled nursing facilities

PURPOSE

This study explored whether perceptions of evidence or organizational context were associated with the use of external memory aids with residents with dementia in skilled nursing facilities (SNFs).

METHOD

A survey design, supplemented by a small sample of exploratory interviews, was completed within the Promoting Action on Research Implementation in Health Services framework. Ninety-six speech-language pathologists (SLPs) and 68 facility rehabilitation directors (FRDs) completed the Organizational Readiness to Change Assessment (Helfrich, Li, Sharp, & Sales, 2009) in relationship to the use of external memory aids. Five SLPs completed an interview exploring perceptions of evidence and context in relationship to memory aid use.

RESULTS

SLPs and FRDs had favorable perceptions of evidence supporting memory aids. FRDs perceived the organizational context of the SNF more favorably than SLPs. SLP participants used external memory aids in the past 6 months in 45.89% of cases of residents with dementia. For SLP participants, a 26% (p < .05) increase of external memory aid use was associated with every 1-unit change in favor of the evidence. Interview data revealed barriers to external memory aid implementation.

CONCLUSIONS

Part of evidence-based practice implementation may be influenced by clinician perceptions. Efforts to increase implementation of external memory aids in SNFs should address these clinician perceptions.

"If it's worth my time, i will make the time": school-based providers' decision-making about participating in an evidence-based psychotherapy consultation program

This study evaluated influences on school-based clinicians' decision-making surrounding participation in a modular psychotherapy training and consultation program lasting one academic year. Clinicians were recruited from three participation groups: those who never engaged, those who engaged and then discontinued, and those who participated fully. Qualitative interviews explored influences on initial and continued participation, as well as differences in decision-making by participation group, knowledge about evidence-based practices, and attitudes toward evidence-based practices. Eight major themes were identified: time, practice utility, intervention/training content, training process, attitudes toward training, social influences, commitment to training, and expectations. Some themes were discussed universally across all comparison groups, while others varied in frequency or content. Recommendations for increasing participation are presented, based on the findings.

The SmartCAT: an m-health platform for ecological momentary intervention in child anxiety treatment

INTRODUCTION

Cognitive behavioral therapy (CBT) for child anxiety, although efficacious, typically requires 16-20 weekly sessions with a therapist. Brief CBT (BCBT; eight sessions) for child anxiety is promising but may have less favorable outcomes owing to reduced session time. Mobile health (m-health) has the potential to improve BCBT efficacy by delivering ecological momentary intervention to engage youth in learning and practicing CBT skills in their everyday lives (in vivo).

MATERIALS AND METHODS

We developed an m-health platform entitled SmartCAT (Smartphone-enhanced Child Anxiety Treatment). SmartCAT consists of (1) a smartphone application (app) that cues youth to use the CBT skills taught in sessions, (2) an online portal that allows therapists to monitor skill use, to send cues and treatment-related materials, to engage youth in real-time via secure messages, and to manage rewards, and (3) a communication protocol that allows real-time bidirectional exchange between the app and the portal. A pilot study with nine youth (9-14 years old) examined the platform's feasibility as an adjunct to BCBT.

RESULTS

SmartCAT was found to be capable of supporting BCBT for child anxiety and received positive feedback from both therapists and youth patients. Patients rated the app as highly usable (mean=1.7 on a 1-7 scale, with 1="easy"). Patients completed 5.36 skills coach entries per session (standard deviation=1.95) and took an average of 3.14 min (standard deviation=0.98 min) to complete the entries.

CONCLUSIONS

A smartphone app is feasible within CBT for child anxiety. Users found SmartCAT both acceptable and easy to use. Integrating an m-health platform within BCBT for anxious children may facilitate involvement in treatment and dissemination of effective procedures.