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

Mental Health Provider Reach and Engagement in a Countywide Training Initiative

Many training initiatives are underway to increase implementation of evidence-based practice (EBPs) in mental healthcare. However, little is known about what types of trainings and supports yield the highest reach and engagement. Supported by a tax-funded, countywide initiative to improve access to quality care for youths, the current mixed methods study evaluates mental health (MH) provider reach, or registering for the training initiative, and engagement, or participation in training activities, for several EBP training and implementation supports. MH providers were offered free 1) formal EBP workshops, 2) a biweekly learning community, 3) individual case consultation, and 4) confidential online clinical feedback system. To register, interested providers (N = 698) completed a web-based assessment measuring clinical practice information, organizational implementation climate, and EBP knowledge, attitudes, and practices. Thirteen providers, selected via purposeful sampling stratified by level of participation, completed semi-structured qualitative interviews. While the training initiative achieved high reach (66% of county agencies had a provider register), far fewer providers engaged substantially in training. Quantitative results indicated that providers whose professional discipline was not psychology, had higher baseline EBP knowledge, more extensive use of common evidence-based strategies, and less extensive use of other therapy strategies, engaged in more training. Rapid qualitative analysis of interviews expanded upon these findings and illuminated provider, organizational, system, practical, and training activity-specific barriers and facilitators to engagement. Findings suggest the importance of identifying strategies for improving provider engagement in training activities beyond workshops. Implications for future research and training initiatives are discussed.

Analysis of implementation processes in a hybrid effectiveness-implementation trial of interpersonal psychotherapy (IPT) for major depressive disorder in prisons: Training, supervision, and recommendations

BACKGROUND

There are 10 million admissions to U.S. prisons and jails each year. More than half of those admitted have mental health problems. The goal of this article is to inform: (1) implementation of evidence-based mental health treatments in prisons and jails, an important effort that needs more evidence to guide it; (2) psychotherapy and interpersonal psychotherapy (IPT) training efforts, especially in low-resource settings.

METHODS

A randomized hybrid effectiveness-implementation trial of group IPT for major depressive disorder (MDD) in state prisons found that IPT increased rates of MDD remission and lowered posttraumatic stress disorder symptoms relative to prison treatment as usual. The trial used prison counselors, only some of whom had prior psychotherapy training/experience, to deliver IPT. IPT treatment adherence was high (96%), but trial training and supervision were too costly to be scalable outside the trial. The current article reports results from a planned qualitative analysis of 460 structured implementation and supervision documents in that trial to describe training and supervision processes and lessons learned, inform training recommendations, and facilitate future work to optimize training and supervision for under-resourced settings.

RESULTS

Themes identified in implementation and supervision process notes reflected: work on psychotherapy basics (reflective listening, focusing on emotions, open-ended questions, specific experiences), IPT case conceptualization (forming a conceptualization, what is and is not therapeutic work, structure and limit setting, structure vs. flexibility), IPT techniques (enhancing social support, role plays, communication analysis), psychotherapy processes (alliance repair, managing group processes), and managing difficult situations (avoidance, specific clients, challenging work settings). Counselors were receptive to feedback; some relied on study supervisors for support in managing stressful prison working conditions.

CONCLUSIONS

Findings can be used to make future training and supervision more efficient. Based on our results, we recommend that initial and refresher training focus on IPT case conceptualization, steps for addressing each IPT problem area, and reflective listening. We also recommend supervision through at least counselors' first two rounds of groups. More low-cost, scalable training methods are needed to get mental health treatment to individuals who need it most, who are often served in challenging, low-resource settings such as prisons. This is a mental health access and equity issue.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (NCT01685294).

Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.

A multistep mediation model examining how consultation in prolonged exposure therapy affects PTSD treatment outcomes

Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or patient outcomes. The present study addressed these gaps by examining associations between consultation, provider self-efficacy, use of PE, and patient outcomes using a multistep mediation model. This study used data from Foa et al. (2020), a two-armed randomized implementation trial comparing two PE training models: standard training (workshop only) and extended training (workshop + 6-8 months of postworkshop expert consultation) at three U.S. Army sites. Participants were patients with PTSD (N = 242) receiving care from the participating providers (N = 103). Providers who received extended training reported greater PE self-efficacy compared to standard training providers, but self-efficacy was unrelated to their use of PE components or to patient outcomes. Extended training providers used more PE components and had superior patient outcomes than standard training providers, and patient outcomes were mediated by the use of PE components. To our knowledge, this is the first study to demonstrate that EBP consultation leads to improved clinical outcomes for patients through increased use of the EBP. PE adoption (i.e., use of PE components in therapy) was not explained by increases in self-efficacy among providers who received extended training. Therefore, future research should assess how other factors may influence provider behavior in implementing EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers

The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.

Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities

INTRODUCTION

Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers.

MATERIALS AND METHODS

As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site.

RESULTS

There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described.

CONCLUSIONS

The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: results from a cluster randomized trial

BACKGROUND

Little is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal level of support needed for TT strategies.

METHODS

The current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay.

RESULTS

Therapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores.

CONCLUSIONS

A TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02651402.

Design and Evaluation of Peer Supervision for Community Mental Health Workers: A Task-Shifting Strategy in Low-Resource Settings

The use of Lay Mental Health Workers (LMHWs) to tackle the treatment gap in low-resource settings is well established, and although they often receive training, the potential of proper supervision to improve outcomes remains untapped. Indeed, given the strain on expert resources, peer-supervision models based on supervisors' seniority of work experience have significant potential especially in relation to community knowledge and embedding of LMHWs. This study summarizes the evaluation of a pilot program for peer supervision on the basis of Social Cognitive Theories of Self-Efficacy for LMHWs in Kerala, India. Two experienced LMHWs worked as supervisors for a total of 12 LMHWs over the course of a year. These participants were subsequently interviewed to analyze their experiences in order to evaluate the potential of peer supervision and distil relevant information to improve future training of LMHWs. The findings include improved performance and emotional support for the participants.

Overcoming training bottlenecks: mixed-methods evaluation of digital training for non-specialists in postnatal depression self-help treatment

OBJECTIVES

This mixed-methods study evaluated the feasibility, acceptability and preliminary effectiveness of an interactive digital training programme for non-specialist supporters providing a guided self-help intervention for postnatal depression (PND).

METHODS

A total of 49 non-specialist trainees participated. Six digital training modules were flexibly delivered over a 5-week period. Training included a chatroom, moderated by a supervised assistant psychologist. Quantitatively, feasibility was assessed via participation and retention levels; acceptability was examined using course evaluation questionnaires; and effectiveness was measured pre-test-post-test quantitatively using a self-report questionnaire and pre-post using scenario questions. Participant focus groups explored feasibility, acceptability and effectiveness.

RESULTS

The training was feasible; 41 completed the course and 42 were assessed at follow-up. Quantitative course evaluation and thematic analysis of focus group feedback demonstrated high training acceptability. RANOVAs indicated training significantly improved knowledge and confidence pre- to post-test. There were demonstrable increases in specific skills at post-test as assessed via clinical scenarios.

CONCLUSION

This training is a feasible, acceptable and effective way to upskill non-specialists in supporting treatment for PND, however supervised practice is recommended to ensure participants embed knowledge competently into practice. The training offers an effective first step in upskilling non-specialist supporters to support women with PND treatment at scale.

Cascade training for scaling up care for perinatal depression in primary care in Nigeria

BACKGROUND

Task-shared care is a demonstrated approach for integrating mental health into maternal and child healthcare (MCH) services. Training and continued support for frontline providers is key to the success of task sharing initiatives. In most settings this is provided by mental health specialists. However, in resource constrained settings where specialists are in short supply, there is a need to explore alternative models for providing training and supportive supervision to frontline maternal care providers. This paper reports on the impact of a cascade training (train-the-trainers) approach in improving the knowledge and attitudes of primary healthcare workers (PHCW) to perinatal depression.

METHODS

Senior primary health care providers selected from across participating local government areas were trained to provide training to other PHCWs. The training sessions facilitated by these trainers were observed and rated for fidelity by specialist trainers, while the trainees provided their impression of and satisfaction with the training sessions using predesigned assessment forms. Training outcomes assessed included knowledge of depression (using mhGAP training questions and knowledge of depression questionnaire) and attitude towards providing care for depression (revised depression attitude questionnaire (R-DAQ)) measured pre and post training as well as six months after training.

RESULTS

Trainees were 198 PHCWs (94.4% female), who routinely provide MCH services in 28 selected primary care clinics and had between 6- and 34-years' experience. Training was provided by 11 trained trainers who were general physicians or senior nurses. Training sessions were rated high in fidelity and on training style. Sessions were rated excellent by 77.8% of the trainees with the trainers described as knowledgeable, effective and engaging. Knowledge of depression mean score improved from a pre-training level of 12.3 ± 3.5 to 15.4 ± 3.7, immediately post-training and 14.7 ± 3.2, six months post-training (both comparisons: p < 0.001). The proportion of PHCW workers endorsing statements indicative of positive attitudes on the professional confidence and the generalist perspective modules of the R-DAQ also increased with training.

CONCLUSION

Our findings suggest that cascade training can be an effective model for rapidly providing training and upskilling frontline PHCWs to deliver care for women with perinatal depression in resource limited settings.

TRIAL REGISTRATION

This study was retrospectively registered 03 December 2019. https://doi.org/10.1186/ISRCTN 94,230,307.

A Statewide Randomized Controlled Trial to Compare Three Models for Implementing Parent Child Interaction Therapy

OBJECTIVE

This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359) evaluated the effectiveness of three training models to implement a well-established evidence-based treatment, Parent-Child Interaction Therapy (PCIT).

METHOD

Fifty licensed outpatient clinics, including 100 clinicians, 50 supervisors, and 50 administrators were randomized to one of three training conditions: 1) Learning Collaborative (LC), 2) Cascading Model (CM) or 3) Distance Education (DE). Data to assess training and implementation outcomes were collected at 4 time points coinciding with the training period: baseline, 6- (mid), 12- (post), and 24-months (1-year follow-up).

RESULTS

Multi-level hierarchical linear growth modeling was used to examine changes over time in training outcomes. Results indicate that clinicians in CM were more likely to complete training, reported high levels of training satisfaction and better learning experiences compared to the other training conditions. However, supervisors in the LC condition reported greater learning experiences, higher levels of knowledge, understanding of treatment, and satisfaction compared to supervisors in other conditions. Although clinicians and supervisors in the DE condition did not outperform their counterparts on any outcomes, their performance was comparable to both LC and CM in terms of PCIT use, supervisor perceived acceptability, feasibility, system support, and clinician satisfaction.

CONCLUSIONS

Through the use of a randomized controlled design and community implementation, this study contributes to the current understanding of the impact of training design on implementation of PCIT. Results also indicate that although in-person training methods may produce more positive clinician and supervisor outcomes, training is not a one-size-fits-all model, with DE producing comparable results on some variables.

Barriers to and facilitators of using evidence-based, cognitive-behavioral anxiety interventions in integrated primary care practice

Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

External and Internal Validity Considerations in Youth Effectiveness Trials: Lessons Learned from the COMET Study

OBJECTIVE

Effectiveness trials aim to increase the generalizability and public health impact of interventions. However, challenges associated with this design present threats to external and internal validity. This paper illustrates these challenges using data from a two-site randomized effectiveness trial, the Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET) and presents recommendations for future research.

METHOD

COMET was a randomized effectiveness trial conducted in 19 community mental health clinics in two states comparing three interventions: treatment as usual (TAU), TAU with measurement-based care (TAU+), and the Unified Protocol forTransdiagnostic Treatment of Emotional Disorders in Adolescents with MBC (UPA). Participants included 176 clinicians (mean age = 35.5; 85.8% cisgender female; 53.0% racially and/or ethnically minorized) and 196 adolescents (mean age = 14.7; 65.3% cisgender female; 69.4% racially and/or ethnically minorized). Analyses outlined participant flow from recruitment to study completion, described participant characteristics, and examined site differences.

RESULTS

Analysis of participant flow suggested that recruitment and retention of clinicians and adolescents was challenging, raising questions about whether participants were representative of participating clinics. Both the clinician and adolescent samples were racially and ethnically diverse and adolescents were low income and clinically complex. Significant site differences were observed in clinician and adolescent characteristics.

CONCLUSIONS

While this study was successful in recruiting a diverse and historically under-represented sample, difficulties in recruitment and retention raise questions about external validity and site differences present challenges to internal validity of study findings. Suggestions for future effectiveness studies, drawing from implementation science approaches, are discussed.

Comparing In-Person and Synchronous Online Training for an Evidence-Based Treatment

Online trainings in evidence-based treatments (EBT) can be effective platforms and may provide better access to community providers as compared with traditional in-person trainings. However, questions remain as to whether online trainings can achieve similar rates of training engagement and model application to traditional in-person trainings. We compared training engagement and model application (e.g., extent of use, fidelity) between participants attending in-person (n = 127) and synchronous online (n = 277) trainings for an EBT (Alternatives for Families: a Cognitive Behavioral Therapy; AF-CBT). Data were collected through pre- and post-training questionnaires and trainers' records. Chi-square analyses and t-tests were used to test for differences between groups. Engagement regarding attendance at workshops and consultation calls was high for both groups, with no significant differences. A total of 81% and 76% presented at least one case and submitted at least one audio recording of an actual AF-CBT session, respectively. Participants rated the training workshop as high quality (M > 4.5/5), and the consultation calls as medium-to-high quality (M > 4/5) across both modalities, indicating good training engagement. In-person training participants were significantly more likely to submit two or more audio recorded sessions than online training participants. This was the only training requirement outcome that differed between the two groups. In examining model application, there were no significant differences between in-person and online training participants in self-reported delivery of AF-CBT, the number of clients with whom it was implemented, the extent they used the model, or the fidelity with which they delivered it. Both groups reported similar improvements in comfort when working with aggressive families, being directive, and using learning techniques like role plays. Online evidence-based treatment skills training appears to be feasible, efficient, and beneficial, with engagement and performance comparable to in-person training. We discuss potential advantages of online training (e.g., fewer costs, greater flexibility for staff from independent practices) and disadvantages (e.g., less satisfaction).

Therapist use of cognitive behavior therapy and eye movement desensitization and reprocessing components for the treatment of posttraumatic stress disorder in practice settings

Introduction

Treatment practice guidelines for posttraumatic stress disorder (PTSD) recommend both Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavior Therapy (CBT); however, implementation in practice setting remains challenging. Here we aim to foster implementation efforts for PTSD by identifying the relative use of the various components of empirically supported treatments by therapists and the characteristics that predict their use.

Methods

Surveyed 346 therapists (84.07% female) of whom 272 participants (78.61%) were trained primarily in CBT and 135 participants (39.02%) were trained in primarily in EMDR. Assessed relative use of various EMDR and CBT components as well as several training and personality factors.

Results

Psychoeducation about trauma was the most common element used. "Off label" use of components was also identified with application of EMDR techniques to other diagnoses. Findings also suggest underutilization of in vivo exposure techniques across therapists. EMDR therapists reported relatively high use of core EMDR techniques (i.e., greater use of EMDR core techniques). Big five personality factors, therapy efficacy, and anxiety were associated with differential component use.

Discussion

Results identify trends in empirically supported component use and therapist characteristics that are associated with the use of various techniques for PTSD. The findings suggest implementation efforts could foster training in underused techniques, address barriers to their utilization and develop knowledge of effective packages of components.

Implementing internet-delivered cognitive behavioral therapy in healthcare services: a qualitative exploration of stakeholder experience

Background

This study consisted of a qualitative exploration of stakeholder experience regarding the implementation of internet-delivered cognitive behavioral therapy (iCBT) as part of routine service provision within the UK's Improving Access to Psychological Therapies program.

Methods

Stakeholder groups included service providers (n = 6), commercial iCBT representatives (n = 6) and patients who received a course of iCBT as part of treatment at the service (n = 7). Participants took part in a semi-structured interview over the telephone, and subsequent data were qualitatively analyzed using the descriptive-interpretive approach.

Results

Service providers highlighted the importance of effective leadership and management, training initiatives, the provision of feedback to commercial iCBT representatives and creating work structures around iCBT to facilitate iCBT supporting staff in their use of it. Commercial iCBT representatives similarly reported the importance of training clinicians in iCBT use, identifying the appropriate individuals at all levels of the service to drive iCBT implementation, and the importance of being responsive to any problems or needs that arise from the service. Patients reported an overall positive experience of receiving iCBT but highlighted a need for more information from their supporter and the intervention to better structure their usage. Contextual factors, in terms of barriers and facilitators, were also highlighted by service provider and commercial participants; citing negative clinician attitudes and technological issues/bugs as barriers to implementation, and the exposure to iCBT created by COVID-19 and perseverance in using iCBT over time as facilitators.

Discussion

The findings contribute to a growing field of literature that seeks to understand the experience of relevant stakeholders who are involved with and contribute to iCBT implementation, including commercial iCBT representatives who, to our knowledge, have not been accounted for as part of published research to date.

Enhancing Quality of Care Through Evidence-Based Practice: Training and Supervision Experiences

OBJECTIVE

Evidence-based practice (EBP) is the preferred approach to treatment in mental health settings because it involves the integration of the best available research, clinical expertise, and patient values to optimize patient outcomes. Training on empirically supported treatments (ESTs) in mental health settings is an important component of EBP, and supervision of therapists' implementation of ESTs is critical for therapists to develop and maintain a strong EBP skill set. This study aimed to evaluate training and supervision histories of therapists in outpatient and inpatient psychiatric care settings as an essential first step in improving patient outcomes.

METHODS

Electronic surveys were completed by 69 therapists, most of whom had a master's degree, within a psychiatry and behavioral sciences department at an academic institution. Participating therapists were recruited from several outpatient and inpatient mental health settings serving children, adolescents, and adults.

RESULTS

Although most therapists reported completing some form of EST-related coursework, a majority did not receive any supervision related to implementation of ESTs (51% for cognitive-behavioral therapy cases, 76% for dialectical behavior therapy cases, and 52% for other EST cases) during graduate and postgraduate training.

CONCLUSIONS

Although research from the past decade has supported the need for improvements in training on ESTs, and especially in supervision, problems related to limited exposure to training and supervision among therapists still exist. These findings have implications for how mental health centers can evaluate staff members' EST training and supervision experiences, training needs, and associated training targets to improve the quality of routine care.

The impact of module dosage on treatment response in a modular transdiagnostic intervention for sleep and circadian dysfunction (TranS-C)

The efficacy of modular evidence-based psychological treatments is promising, yet variation in module delivery is understudied. This study evaluated module delivery of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) and its impact on patient outcomes. Adults (N = 108) with serious mental illness and sleep and circadian dysfunction treated in a community setting were randomized to receive TranS-C plus usual care, or 6 months of usual care followed by delayed treatment with TranS-C. Data from both conditions were combined to maximize power. These secondary analyses tested whether the "dosage" of module delivery (defined as the proportion of total sessions in which a module was delivered) predicted treatment response, measured as functional impairment, psychiatric symptoms, sleep and circadian dysfunction, and sleep health, at post-treatment and 6-month follow-up. Higher dosages of seven modules were associated with improvement in the outcome variables (βs = -0.11-0.44; ps = 0.000-0.030). Higher dosages of three modules were associated with a worsening of one or two outcome variables (βs = 0.22-0.29; ps = 0.001-0.043). Higher dosages of the remaining modules were not associated with outcomes. Although more evidence is needed, it may be wise to consider focusing provider trainings on ensuring fidelity to certain modules, given limited training time in community settings. ClinicalTrials.gov Identifier: NCT02469233, registered June 9, 2015.

Implementing traumatic brain injury screening in behavioral health treatment settings: results of an explanatory sequential mixed-methods investigation

BACKGROUND

Traumatic brain injury (TBI) is a complex condition common among individuals treated in behavioral healthcare, but TBI screening has not been adopted in these settings which can affect optimal clinical decision-making. Integrating evidence-based practices that address complex health comorbidities into behavioral healthcare settings remains understudied in implementation science, limited by few studies using theory-driven hypotheses to disentangle relationships between proximal and medial indicators on distal implementation outcomes. Grounded in the Theory of Planned Behavior, we examined providers' attitudes, perceived behavioral control (PBC), subjective norms, and intentions to adopt The Ohio State University TBI Identification Method (OSU TBI-ID) in behavioral healthcare settings.

METHODS

We used an explanatory sequential mixed-methods design. In Phase I, 215 providers from 25 organizations in the USA completed training introducing the OSU TBI-ID, followed by a survey assessing attitudes, PBC, norms, and intentions to screen for TBI. After 1 month, providers completed another survey assessing the number of TBI screens conducted. Data were analyzed using structural equation modeling (SEM) with logistic regressions. In Phase II, 20 providers were purposively selected for semi-structured interviews to expand on SEM results. Qualitative data were analyzed using thematic analysis, integrated with quantitative results, and combined into joint displays.

RESULTS

Only 25% (55/215) of providers adopted TBI screening, which was driven by motivations to trial the intervention. Providers who reported more favorable attitudes (OR: 0.67, p < .001) and greater subjective norms (OR: 0.12, p < .001) toward TBI screening demonstrated increased odds of intention to screen, which resulted in greater TBI screening adoption (OR: 0.30; p < .01). PBC did not affect intentions or adoption. Providers explained that although TBI screening can improve diagnostic and clinical decision-making, they discussed that additional training, leadership engagement, and state-level mandates are needed to increase the widespread, systematic uptake of TBI screening.

CONCLUSIONS

This study advances implementation science by using theory-driven hypothesis testing to disentangle proximal and medial indicators at the provider level on TBI screening adoption. Our mixed-methods approach added in-depth contextualization and illuminated additional multilevel determinants affecting intervention adoption, which guides a more precise selection of implementation strategies.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: study protocol for a hybrid type 2 effectiveness-implementation cluster-randomized trial using train-the-trainer

BACKGROUND

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes and (b) providers' perceptions of fit.

METHODS

TTT will be implemented in nine CMHCs in California, USA (N = 60 providers; N = 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality), and (3) evaluate other possible moderators.

DISCUSSION

This trial has potential to (a) inform the process of embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) add to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advance our understanding of providers' perceptions of EBPT "fit" across TTT generations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05805657 . Registered on April 10, 2023.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: Study protocol for a hybrid type 2 effectiveness-implementation cluster- randomized trial using train-the-trainer

Background

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes (b) providers' perceptions of fit.

Methods

TTT will be implemented in nine CMHCs in California, United States (N= 60 providers; N= 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will: (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality); and (3) evaluate other possible moderators.

Discussion

This trial has potential to inform the process of (a) embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) adding to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advancing our understanding of providers' perceptions of EBPT 'fit' across TTT generations.

Trial registration

Clinicaltrials.gov identifier: NCT05805657. Registered on April 10, 2023. https://clinicaltrials.gov/ct2/show/NCT05805657.

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.

Taking a Magnifying Glass to Measurement-Based Care Consultation Sessions: with What Issues Do Mental Health Clinicians Struggle?

PURPOSE

Ongoing consultation following initial training is one of the most commonly deployed implementation strategies to facilitate uptake of evidence-based practices, such as measurement-based care (MBC). Group consultation provides an interactive experience with an expert and colleagues to get feedback on actual issues faced, yet there is little research that unpacks the questions raised in consultation and what types of issues are important to address.

METHODS

The current study characterized the questions and concerns raised by community mental health clinicians (N = 38 across six clinics) during group consultation sessions completed as part of an MBC implementation trial. We conducted a qualitative content analysis of consultation forms completed by clinicians before each MBC consultation session.

RESULTS

Clinicians sought MBC consultation for clients across a range of ages and levels of depression severity. Qualitative results revealed five main questions and concerns in consultation sessions: (1) how to administer the PHQ-9, (2) how to review PHQ-9 scores, (3) how to respond to PHQ-9 score, (4) the types of clients for whom MBC would be appropriate, and (5) how MBC could impact a clinician's usual care.

CONCLUSION

Findings highlight the need for ongoing consultation and limitations of workshop training alone. Practical recommendations for addressing the common questions and concerns identified are presented to support MBC use.

Implementation of a Low-Cost, Multi-component, Web-Based Training for Trauma-Focused Cognitive-Behavioral Therapy

Effective, interactive trainings in evidence-based practices remain expensive and largely inaccessible to most practicing clinicians. To address this need, the current study evaluated the impact of a low-cost, multi-component, web-based training for Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) on clinicians' TF-CBT knowledge, strategy use, adherence and skill. Clinician members of a practice-based research network were recruited via email and randomized to either an immediate training group (N = 89 assigned) or waitlist control group (N = 74 assigned) that was offered access to the same training after six months, with half of each group further randomized to receive or not receive incentives for participation. Clinicians completed assessments at baseline, 6 months, and 12 months covering TF-CBT knowledge, strategy use, and for a subset of clinicians (n = 28), TF-CBT adherence and skill. Although significant differences in overall TF-CBT skillfulness and readiness were found, there were no significant differences between the training and waitlist control group on TF-CBT knowledge and strategy use at six months. However, there was considerable variability in the extent of training completed by clinicians. Subsequent post-hoc analyses indicated a significant, positive association between the extent of training completed by clinicians and clinician TF-CBT knowledge, strategy use, demonstrated adherence and skill across the three TF-CBT components, and overall TF-CBT readiness. We also explored whether incentives predicted training participation and found no differences in training activity participation between clinicians who were offered an incentive and those who were not. Findings highlight the limitations of self-paced web-based trainings. Implications for web-based trainings are discussed.

Psychometric evaluation of a pragmatic measure of clinical supervision as an implementation strategy

BACKGROUND

Valid and reliable measurement of implementation strategies is essential to advancing implementation science; however, this area lags behind the measurement of implementation outcomes and determinants. Clinical supervision is a promising and highly feasible implementation strategy in behavioral healthcare for which pragmatic measures are lacking. This research aimed to develop and psychometrically evaluate a pragmatic measure of clinical supervision conceptualized in terms of two broadly applicable, discrete clinical supervision techniques shown to improve providers' implementation of evidence-based psychosocial interventions-(1) audit and feedback and (2) active learning.

METHODS

Items were generated based on a systematic review of the literature and administered to a sample of 154 outpatient mental health clinicians serving youth and 181 community-based mental health providers serving adults. Scores were evaluated for evidence of reliability, structural validity, construct-related validity, and measurement invariance across the two samples.

RESULTS

In sample 1, confirmatory factor analysis (CFA) supported the hypothesized two-factor structure of scores on the Evidence-Based Clinical Supervision Strategies (EBCSS) scale (χ2=5.89, df=4, p=0.208; RMSEA=0.055, CFI=0.988, SRMR=0.033). In sample 2, CFA replicated the EBCSS factor structure and provided discriminant validity evidence relative to an established supervisory alliance measure (χ2=36.12, df=30, p=0.204; RMSEA=0.034; CFI=0.990; SRMR=0.031). Construct-related validity evidence was provided by theoretically concordant associations between EBCSS subscale scores and agency climate for evidence-based practice implementation in sample 1 (d= .47 and .55) as well as measures of the supervision process in sample 2. Multiple group CFA supported the configural, metric, and partial scalar invariance of scores on the EBCSS across the two samples.

CONCLUSIONS

Scores on the EBCSS provide a valid basis for inferences regarding the extent to which behavioral health providers experience audit and feedback and active learning as part of their clinical supervision in both clinic- and community-based behavioral health settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04096274 . Registered on 19 September 2019.

Development of an Online Training Platform and Implementation Strategy for School-Based Mental Health Professionals in Rural Elementary Schools: A Mixed-Methods Study

Children in rural settings are less likely to receive mental health services than their urban and suburban counterparts and even less likely to receive evidence-based care. Rural schools could address the need for mental health interventions by using evidence-based practices within a tiered system of supports such as positive behavioral interventions and supports. However, very few school professionals, with or without mental health training, have received training on evidence-based practices. Rural schools need implementation strategies focused on training to prepare school personnel for the implementation of interventions with fidelity. Little is known about training strategies that are feasible and appropriate for the rural school context. User-centered design is an appropriate framework for the development of training strategies for professionals in rural schools because of its participatory approach and the development of products that fit the context where they are going to be used. The purpose of the study was to develop and assess components of an online training platform and implementation strategy based on the user-centered design. Quantitative and qualitative data from 25 participants from an equal number of schools in rural areas of Pennsylvania were used in the study. A mixed-methods design utilizing complementary descriptive statistics and theme analyses indicated that the training platform and implementation strategy were perceived as highly acceptable, appropriate, feasible and usable by school professionals. The resulting training platform and implementation strategy will fill a void in the training literature in rural schools.

Operationalizing antiracism in health systems: Strategies state government administrative organizations use towards racial and ethnic mental health equity

Although a growing body of literature recommends strategies for improving racial equity in organizations and populations, little is known about how racial equity goals are operationalized in actuality, particularly in the context of state health and mental health authorities (SH/MHAs) attempting to promote population wellness while navigating bureaucratic and political constraints. This article seeks to examine the number of states engaging in racial equity work in mental health care, what strategies SH/MHAs use to improve their state's racial equity in mental health care, and how the workforce understands these strategies. A brief survey of 47 states found that all but one state (98%) is enacting racial equity interventions in mental health care. Through qualitative interviews with 58 SH/MHA employees in 31 states, I created a taxonomy of activities within six overarching strategies: 1) running a racial equity group; 2) gathering information and data about racial equity; 3) facilitating training and learning for staff and providers; 4) collaborating with partners and engaging with communities; 5) offering information or services to communities and organizations of color; and 6) promoting workforce diversity. I describe specific tactics within each of the strategies as well as the perceived benefits and challenges of the strategies. I argue that strategies bifurcate into development activities, which are activities creating higher-quality racial equity plans, and equity-advancing activities, which are actions directly impacting racial equity. The results have implications for how government reform efforts can impact mental health equity.

The Implementation Playbook: study protocol for the development and feasibility evaluation of a digital tool for effective implementation of evidence-based innovations

BACKGROUND

Evidence-based innovations can improve health outcomes, but only if successfully implemented. Implementation can be complex, highly susceptible to failure, costly and resource intensive. Internationally, there is an urgent need to improve the implementation of effective innovations. Successful implementation is best guided by implementation science, but organizations lack implementation know-how and have difficulty applying it. Implementation support is typically shared in static, non-interactive, overly academic guides and is rarely evaluated. In-person implementation facilitation is often soft-funded, costly, and scarce. This study seeks to improve effective implementation by (1) developing a first-in-kind digital tool to guide pragmatic, empirically based and self-directed implementation planning in real-time; and (2) exploring the tool's feasibility in six health organizations implementing different innovations.

METHODS

Ideation emerged from a paper-based resource, The Implementation Game©, and a revision called The Implementation Roadmap©; both integrate core implementation components from evidence, models and frameworks to guide structured, explicit, and pragmatic planning. Prior funding also generated user personas and high-level product requirements. This study will design, develop, and evaluate the feasibility of a digital tool called The Implementation Playbook©. In Phase 1, user-centred design and usability testing will inform tool content, visual interface, and functions to produce a minimum viable product. Phase 2 will explore the Playbook's feasibility in six purposefully selected health organizations sampled for maximum variation. Organizations will use the Playbook for up to 24 months to implement an innovation of their choosing. Mixed methods will gather: (i) field notes from implementation team check-in meetings; (ii) interviews with implementation teams about their experience using the tool; (iii) user free-form content entered into the tool as teams work through implementation planning; (iv) Organizational Readiness for Implementing Change questionnaire; (v) System Usability Scale; and (vi) tool metrics on how users progressed through activities and the time required to do so.

DISCUSSION

Effective implementation of evidence-based innovations is essential for optimal health. We seek to develop a prototype digital tool and demonstrate its feasibility and usefulness across organizations implementing different innovations. This technology could fill a significant need globally, be highly scalable, and potentially valid for diverse organizations implementing various innovations.

Systematic review of training in cognitive-behavioral therapy: Summarizing effects, costs and techniques

With the steadily growing importance of psychotherapeutic care, there is also an increasing need for high-quality training. We analyze the literature published between 2009 and 2022 on the effectiveness of training in cognitive behavioral therapy. The review addresses current gaps in the literature by focusing on the description of specific training components and their associated costs, as well as examining therapist-level predictors of training effectiveness. Our findings confirm the effect of additional supervision on both therapist competence and patient outcomes. Instructor-led training and self-guided web-based training seem to moderately increase competence, especially when targeting specific and highly structured treatments or skills. The level of prior training and experience of a therapist appears to predict the strength of training-related gains in competence. Few studies analyzed the differential effect of certain elements of training (e.g., the amount of active learning strategies) and training costs were generally not reported. Future studies should replicate or expand the existing evidence on active ingredients and therapist-level predictors of training effectiveness. Costs should be systematically reported to enhance the comparability of different training strategies.

Training of interventionists and cultural adaptation procedures: A systematic review of culturally adapted evidence-based parenting programs in Africa

There has been an increase in the implementation of evidence-based parenting programs from high-income countries to several African countries. In this review, we systematically evaluated intervention studies of culturally adapted parenting programs in nine African countries with the objective of examining the quality of training for interventionists and cultural adaptation procedures. A total of 18 studies, obtained from an electronic search of 6 databases, met the inclusion criteria and were evaluated following PRISMA guidelines. The Ecological Validity Model was adopted to organize data on cultural adaptation procedures. Sixteen of the 18 studies reported information regarding the clinical training of interventionists and the cultural adaptations undertaken. Live and interactive workshops were the most common format used to train interventionists in the focal intervention. Overall, cultural adaptations in most studies included translation of intervention protocols into the local language. However, studies varied in the way cultural adaptation procedures were reported with some studies failing to report on cultural adaptation procedures. Concurring with previous literature, attending to issues of culture, power, privilege, access, sustainability, and other relevant concepts to increase the cultural relevance is highly encouraged in parent intervention studies in Africa. This review provides a baseline upon which future training and adaptation procedures can be built.

Impact of the person-centred intervention guided self-determination across healthcare settings-An integrated review

AIM

To review the evidence of the existing literature on the impact of guided self-determination across methodologies in different healthcare settings.

METHODS

An integrated five-stage review.

RESULTS

Forty-five eligible papers were included. Guided self-determination was applied in full- or small-scale, or combined with another intervention or approach in different healthcare settings handling, for example diabetes, stroke survivorship, schizophrenia, attention-deficit hyperactivity disorder and medical disorder, gynaecological and breast cancer, endometriosis, persons with chronic pain, persons in haemodialysis and intensive care survivors. The included studies covered 12 randomised trials, 26 qualitative and seven papers of different methodology. A statistically significant effect was found in three trials. Six main themes describe the qualitative findings across papers on patients: (1) Guided self-determination reduces disease-related loneliness, (2) Insight enables integration of life and disease, (3) Reflection sheets-appreciated but challenging tool to prompt insights and person-specific knowledge, (4) New person-specific knowledge enables person-centred support, (5) Feeling seen and believed in a new and trusted relationship and (6) Exchange of knowledge enables the development of life skills. Four themes describe the healthcare professionals' experience: (1) Change of usual practice-a decision from above, (2) A new role-unlearning previous behaviour and need for support, (3) Reflection sheets as facilitators and barriers and (4) Discovering the benefits of changing to a person-centred approach.

CONCLUSION

Overall, guided self-determination proved to have a great impact on patient important outcomes and was useful and well-accepted by the majority of patients and healthcare professionals. Albeit guided self-determination is not a 'one size fits all' method. Continuous training and supervision of professionals are a necessary mean when implementing guided self-determination to enhance adoption and sustainability in clinical practice.

Training home visitors in mentalization-based practice: A qualitative case study of clinical supervision in mothering from the inside out

Attachment-based interventions are important for improving parent-child outcomes. These interventions must be scaled and made available to under-resourced communities. An important part of scaling these interventions is delineating and reproducing high-quality training, including clinical training which often requires the completion of a supervised case. However, descriptions and guidelines for clinical training are frequently broad or not available in the literature. A detailed description of clinical training could lead to further research to improve the effectiveness and dissemination of evidence-based interventions. Mothering from the Inside Out (MIO) is an attachment-based parenting intervention effective at reducing substance use and depression, improving caregiving, and enhancing child attachment. It is now being brought from research to community settings. This paper outlines the didactic and clinical training components of MIO. We then present a qualitative case study of one community-based counselor participating in the clinical training of MIO and employ qualitative methods to describe the main themes that arose during the training. We aim to illustrate how the trainer assisted the counselor in implementing the core components of MIO, which included (a) refining the language used in MIO sessions, (b) making space to explore mental states, and (c) addressing trauma. We conclude by presenting the implications of these findings.

WhatsApp supervision for a lay-led Islamic trauma-focused intervention in Somaliland: Qualitative content analysis

Clinical supervision is critical for the uptake of psychotherapy but difficult to facilitate in countries with limited providers, resources, and internet infrastructure. Innovative supervision approaches are needed to increase access to mental health treatments in low-to-middle income countries (LMICs). This study examined the content and feasibility of remote WhatsApp text supervision conducted as part of an open clinical trial in Somaliland. Islamic Trauma Healing ITH) is a brief, group, lay-lead, trauma-focused, mosque-based intervention that has demonstrated initial efficacy in pilot studies in the United States and Somaliland. After a 2-day, in-person training, lay leaders led four groups of five to seven members focused on trauma-related psychopathology and community reconciliation. Somali lay leaders trained in ITH (n = 9) and the research team (n = 6) attended weekly WhatsApp supervision during the intervention. Content was logged and subjected to qualitative analysis by two coders. Comments related to intervention implementation indicated that lay leaders understood the treatment rationale, adhered to treatment procedures, and believed the intervention components to be helpful and culturally relevant. Themes related to engagement suggested perfect attendance across groups and high levels of participation. Lay leader psychoeducation and skill development; supervisor praise, support, and encouragement; and supervisee gratitude emerged as additional themes. Remote text supervision conducted via WhatsApp was technologically feasible and may have facilitated skill development and the effective implementation of this lay-led intervention. When tailored to the local context, remote supervision approaches hold promise for increasing access to services in LMICs with limited resources.

Therapist and supervisor perspectives about two train-the-trainer implementation strategies in schools: A qualitative study

Background

Train-the-trainer (TT) implementation strategies (in which designated clinicians are trained to then train others in an intervention) are promising approaches to support mental health clinician use of evidence-based interventions in school contexts. However, there is little evidence to date examining clinicians' perceptions of the acceptability and feasibility of TT strategies, or comparing clinicians' perceptions of different types of TT strategies.

Methods

The current study was conducted as part of a larger hybrid effectiveness-implementation trial, in which school-based therapists and supervisors received one of two different types of implementation support to implement cognitive behavioral therapy (CBT) groups for anxiety: TT (i.e., initial training for therapists and supervisors) or enhanced TT (TT+; i.e., initial training for therapists and supervisors, and ongoing external consultation for supervisors). We used applied thematic analysis to compare qualitative interview transcripts from 28 therapist interviews and 33 supervisor interviews from therapists and supervisors who received TT or TT+ support and report themes that were similar and different across the two groups.

Results

Most themes were similar across the TT and TT+ conditions: therapists and supervisors in both conditions perceived the group anxiety intervention as acceptable and viewed supervision as acceptable, helpful, and feasible. Therapists and supervisors in both conditions had mixed impressions of the contextual appropriateness of the group anxiety intervention, and some reported logistical challenges with weekly supervision. Some unique themes were identified among the TT+ condition, including supervisors experiencing professional growth, and therapists and supervisors perceiving supervision as critically important and enjoyable.

Conclusions

These results suggest that TT implementation support, using a model in which an internal supervisor receives initial training and then provides ongoing supervision, is acceptable and feasible to support a group CBT intervention in schools. The results also highlight additional benefits that therapists and supervisors perceived when supervisors received ongoing consultation.

Clinical Trial Registration Information

The clinical trial from which these data were derived was registered at ClinicalTrials.gov (https://clinicaltrials.gov/) prior to the time of first patient enrollment. The registration number is: NCT02651402.

Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation

BACKGROUND

Exposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs.

METHODS

The study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training.

ANTICIPATED RESULTS

It is hypothesized that the E2E training condition will produce greater reductions in therapists' negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients.

CONCLUSION

Implementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.

Adaptation, personalization and capacity in mental health treatments: a balancing act?

PURPOSE OF REVIEW

There are increasing calls for mental health treatments to be adapted for different groups to maximize their acceptability and benefit to patients. However, adaptations can be costly to develop and evaluate, difficult to implement in routine clinical practice and may reduce service capacity at a time when there is unprecedented unmet need. An alternative method is personalization on an individual level. This review provides an overview of the issues related to personalization and adaptation of mental health interventions.

RECENT FINDINGS

Several terms have been used to describe changes to existing therapies, these reflect different extents to which existing treatments have been changed. Evidence-based practice and modular therapies allow a level of flexibility within intervention delivery without formal changes and not all changes to therapy should be considered as a new/adapted treatment but instead regarded as 'metacompetence'. Implementing existing interventions in new contexts is preferable to developing new interventions in many instances. New guidance outlines how researchers can adapt and transfer interventions to varied contexts.

SUMMARY

The review provides proposed definitions of different changes to therapy. Modified and personalized treatments may improve acceptability to patients whilst maximizing implementation of evidence-based practice within clinical services.

Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America

BACKGROUND

Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru.

OBJECTIVE

To describe the process of development and cultural adaptation of the clinical intervention and training package.

METHODS

We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework.

RESULTS

In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway.

CONCLUSION

Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Building a multicultural peer-consultation team: Planning, implementing, and early sustainment evaluation

This article represents an implementation-focused evaluation of a multicultural peer-consultation team situated within a psychiatry department in a large academic medical center in the Southern United States. The evaluation comprised anonymous self-report questionnaires (n = 14) as well as individual (n = 3) or group interviews (n = 10) conducted by outside independent evaluators. Participants were current and former team members (i.e., graduate trainees, mental health care providers, clinical and research staff members) who voluntarily participated in this multimethod implementation evaluation. Results indicated that attendance on the team had several important impacts on members, and most notably an increased ability to provide multiculturally competent care, that is treatment that carefully and routinely considers the influence of culture and context on patients and therefore their clinical presentation. Further, no negative impacts from participating on the team were noted. A primary strength of the team's sustainability is that participation on the team was deemed to be relevant and useful by current and former team members. A major barrier to participation on the team is competing demands, such as high clinical loads. We conclude that this model for multicultural peer-consultation holds promise as an effective and implementable educational method for mental health care professionals. We discuss strengths, limitations, and future directions for research.

Development of a Web-Based Training Platform for School Clinicians in Evidence-Based Practices for ADHD

Lack of training for school clinicians in evidence-based practices (EBPs) contributes to underutilization of such services for youth with attention-deficit/hyperactivity disorder (ADHD). Advances in web-based technology and videoconferencing have allowed for expanded access to and optimization of training. We describe the development and outcomes of a novel web-based platform for training school clinicians to gain skills in EBPs for school-age youth with ADHD. The training platform is adapted from an empirically supported, in-person training for a school-home behavioral intervention (Collaborative Life Skills program) and includes skill modules for working with teachers, parents, and students. Training methods include web-accessed manuals/handouts, skill example video clips, automated progress monitoring tools, and consultation/in-session coaching via videoconferencing. We gathered stakeholder qualitative and quantitative feedback during discovery and design phases of the iterative development. We then evaluated the usability, acceptability, fidelity and clinician and student outcomes of the remote training program. Focus group themes and qualitative feedback identified clinician preferences for remote training features (e.g., interactive, brief, role-plays/coaching methods), video tools (recorded samples of skills and therapy sessions), and progress monitoring tools (e.g., clear, easy to use). Clinician usability ratings of the platform were high with most components rated as moderately to very useful/easy to use. Clinician ratings of usability, fidelity implementing the treatment, and their EBP knowledge and confidence following training were favorable. Student's outcomes were similar to those achieved in prior studies of clinician in-person training. Results support the promise of remote, web-based clinician training for the dissemination of evidence-based practices.

Evaluating the implementation of the active life improving health behavior change program "BCP-VAMOS" in primary health care: Protocol of a pragmatic randomized controlled trial using the RE-AIM and CFIR frameworks

Introduction

The effective translation of evidence-based interventions has contributed to implementing actions that impact public policies and the population's health. However, there is a gap in the literature regarding the factors associated with the successful implementation of these interventions. The Active Life Improving Health Behavior Change Program (BCP-VAMOS) uses behavioral strategies to promote an active and healthy lifestyle in the community. Characterized as a health innovation, it also provides health professionals with online training to implement the program in Primary Health Care (PHC). Our study describes a pragmatic trial that aims to evaluate the implementation of BCP-VAMOS, version 3.0, in PHC in southern Brazil.

Methods and analysis

A pragmatic randomized controlled trial (PRCT) of two arms comparing a group of PHC professionals who will participate in a traditional didactic approach (control group) vs. a group that will receive ongoing support (intervention group) for the implementation of BCP-VAMOS. The intervention will be available to adults (≥18 years old) registered at PHC. Program recipient's will be assessed at baseline and post-intervention (9 months after) to measure markers of physical activity and eating behavior (primary outcomes). Program's implementation process will be monitored for 12 months and will be evaluated using the RE-AIM and Consolidated Framework for Implementation Research (CFIR) frameworks.

Discussions

The survey findings can be used widely throughout Brazil, guiding the work of health professionals, service planners and policy-makers. Also, the results may help to inform the national health promotion policy to plan interventions and improve the implementation of programs in PHC. This research results will provide practical guidance for researchers to develop similar protocols to implement and adapt public health interventions.

Ethics and dissemination

Ethics approval has been granted by the Human Research Ethics Committee of the Federal University of Santa Catarina (UFSC), Brazil, under no. 1394492. Results will be published in full as open access in the UFSC library and main trial results and associated papers in high-impact peer-reviewed journals.

Trial registration number

RBR-2vw77q-Brazilian Registry of Clinical Trials - ReBEC (http://www.ensaiosclinicos.gov.br).

Implementing Evidence-Based Mental-Health Treatments: Attending to Training, Fidelity, Adaptation, and Context

This article provides a very high-level overview of some key considerations in the field of implementation science as it relates to clinical psychology. The article reviews recent findings regarding treatment fidelity, adaptation of treatments, and clinical outcomes. It then details some recent findings on training therapists to provide evidence-based therapies as they were designed to be delivered, with sufficient skill and adaptations if needed to ensure better fit for clients who receive treatments in different treatment settings. Finally, the article considers implications for implementing and sustaining new treatments and supporting their fidelity and adaptation, as well as key directions for future research.

An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation

Background

One approach towards advancing the quality of mental health care is to improve psychotherapists’ skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students’ skills.

Methods

In a pragmatic mixed-methods trial, 120 first year students in a Master’s degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students’ and therapists’ experiences with the intervention will be explored in focus group interviews.

Discussion

To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care.

Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

How low can you go? Examining the effects of brief online training and post-training consultation dose on implementation mechanisms and outcomes for measurement-based care

BACKGROUND

Initial training and ongoing post-training consultation (i.e., ongoing support following training, provided by an expert) are among the most common implementation strategies used to change clinician practice. However, extant research has not experimentally investigated the optimal dosages of consultation necessary to produce desired outcomes. Moreover, the degree to which training and consultation engage theoretical implementation mechanisms-such as provider knowledge, skills, and attitudes-is not well understood. This study examined the effects of a brief online training and varying dosages of post-training consultation (BOLT+PTC) on implementation mechanisms and outcomes for measurement-based care (MBC) practices delivered in the context of education sector mental health services.

METHODS

A national sample of 75 clinicians who provide mental health interventions to children and adolescents in schools were randomly assigned to BOLT+PTC or control (services as usual). Those in BOLT+PTC were further randomized to 2-, 4-, or 8-week consultation conditions. Self-reported MBC knowledge, skills, attitudes, and use (including standardized assessment, individualized assessment, and assessment-informed treatment modification) were collected for 32 weeks. Multilevel models were used to examine main effects of BOLT+PTC versus control on MBC use at the end of consultation and over time, as well as comparisons among PTC dosage conditions and theorized mechanisms (skills, attitudes, knowledge).

RESULTS

There was a significant linear effect of BOLT+PTC over time on standardized assessment use (b = .02, p < .01), and a significant quadratic effect of BOLT+PTC over time on individualized assessment use (b = .04, p < .001), but no significant effect on treatment modification. BOLT + any level of PTC resulted in higher MBC knowledge and larger growth in MBC skill over the intervention period as compared to control. PTC dosage levels were inconsistently predictive of outcomes, providing no clear evidence for added benefit of higher PTC dosage.

CONCLUSIONS

Online training and consultation in MBC had effects on standardized and individualized assessment use among clinicians as compared to services as usual with no consistent benefit detected for increased consultation dosage. Continued research investigating optimal dosages and mechanisms of these established implementation strategies is needed to ensure training and consultation resources are deployed efficiently to impact clinician practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05041517 . Retrospectively registered on 10 September 2021.

Modular-based psychotherapy (MoBa) versus cognitive-behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial

INTRODUCTION

In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and a high rate of comorbid disorders. Personalised treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and factors like early childhood maltreatment may lead to better outcomes. A modular-based psychotherapy (MoBa) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoBa has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalised approaches.

METHODS AND ANALYSIS

In a randomised controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbidity and childhood maltreatment are treated in 20 individual sessions with MoBa or standard cognitive-behavioural therapy for depression. The three modules of MoBa focus on deficits associated with early childhood maltreatment: the systems of negative valence, social processes and arousal. According to a specific questionnaire-based treatment algorithm, elements from cognitive behavioural analysis system of psychotherapy, mentalisation-based psychotherapy and/or mindfulness-based cognitive therapy are integrated for a personalised modular procedure.As a proof of concept, this trial will provide evidence for the feasibility and efficacy (post-treatment and 6-month follow-up) of a modular add-on approach for patients with depression, comorbidities and a history of childhood maltreatment. Crucial feasibility aspects include targeted psychopathological mechanisms, selection (treatment algorithm), sequence and application of modules, as well as training and supervision of the study therapists.

ETHICS AND DISSEMINATION

This study obtained approval from the independent Ethics Committees of the University of Freiburg and the University of Heidelberg. All findings will be disseminated broadly via peer-reviewed articles in scientific journals and contributions to national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00022093.

Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

Background

Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up.

Methods

A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs.

Results

SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions).

Conclusions

The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools.

Trial registration

ClinicalTrials.gov, NCT03541317, May 30, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01211-w.

Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA

BACKGROUND

Despite an established taxonomy of implementation strategies, minimal guidance exists for how to select and tailor strategies to specific practices and contexts. We employed a replicable method to obtain stakeholder perceptions of the most feasible and important implementation strategies to increase mental health providers' use of measurement-based care (MBC) in schools. MBC is the routine use of patient-reported progress measures throughout treatment to inform patient-centered, data-driven treatment adjustments.

METHODS

A national sample of 52 school mental health providers and researchers completed two rounds of modified Delphi surveys to rate the relevance, importance, and feasibility of 33 implementation strategies identified for school settings. Strategies were reduced and definitions refined using a multimethod approach. Final importance and feasibility ratings were plotted on "go-zone" graphs and compared across providers and researchers to identify top-rated strategies.

RESULTS

The initial 33 strategies were rated as "relevant" or "relevant with changes" to MBC in schools. Importance and feasibility ratings were high overall for both survey rounds; on a scale of 1 to 5, importance ratings (3.61-4.48) were higher than feasibility ratings (2.55-4.06) on average. Survey 1 responses resulted in a reduced, refined set of 21 strategies, and six were rated most important and feasible on Survey 2: (1) assess for readiness and identify barriers and facilitators; (2) identify and prepare champions; (3) develop a usable implementation plan; (4) offer a provider-informed menu of free, brief measures; (5) develop and provide access to training materials; and (6) make implementation easier by removing burdensome documentation tasks. Provider and researcher ratings were not significantly different, with a few exceptions: providers reported higher feasibility and importance of removing burdensome paperwork than researchers, providers reported higher feasibility of train-the trainer approaches than researchers, and researchers reported higher importance of monitoring fidelity than providers.

CONCLUSIONS

The education sector is the most common setting for child and adolescent mental health service delivery in the USA. Effective MBC implementation in schools has the potential to elevate the quality of care received by many children, adolescents, and their families. This empirically derived, targeted list of six implementation strategies offers potential efficiencies for future testing of MBC implementation in schools.

Development and evaluation of a remote training strategy for the implementation of mental health evidence-based practices in rural schools: pilot study protocol

Background

An increasing number of schools in rural settings are implementing multi-tier positive behavioral interventions and supports (PBIS) to address school-climate problems. PBIS can be used to provide the framework for the implementation of evidence-based practices (EBPs) to address children’s mental health concerns. Given the large service disparities for children in rural areas, offering EBPs through PBIS can improve access and lead to better long-term outcomes. A key challenge is that school personnel need technical assistance in order to implement EBPs with fidelity and clinical effectiveness. Providing ongoing on-site support is not feasible or sustainable in the majority of rural schools, due to their remote physical location. For this reason, remote training technology has been recommended for providing technical assistance to behavioral health staff (BHS) in under-served rural communities.

Objectives

The purpose of this study is to use the user-centered design, guided by an iterative process (rapid prototyping), to develop and evaluate the appropriateness, feasibility, acceptability, usability, and preliminary student outcomes of two online training strategies for the implementation of EBPs at PBIS Tier 2.

Methods

The study will employ a pragmatic design comprised of a mixed-methods approach for the development of the training platform, and a hybrid type 2, pilot randomized controlled trial to examine the implementation and student outcomes of two training strategies: Remote Video vs. Remote Video plus Coaching.

Discussion

There is a clear need for well-designed remote training studies focused on training in non-traditional settings. Given the lack of well-trained mental health professionals in rural settings and the stark disparities in access to services, the development and pilot-testing of a remote training strategy for BHS in under-served rural schools could have a significant public health impact.

Ethics and dissemination

The project was reviewed and approved by the institutional review board. Results will be submitted to ClinicalTrials.gov and disseminated to community partners and participants, peer-reviewed journals, and academic conferences.

Trial registration

ClinicialTrials.gov, NCT05034198 and NCT05039164