Arthur C. Evans

Predictors of Community Therapists' Use of Therapy Techniques in a Large Public Mental Health System

IMPORTANCE Few studies have examined the effects of individual and organizational characteristics on the use of evidence-based practices in mental health care. Improved understanding of these factors could guide future implementation efforts to ensure effective adoption, implementation, and sustainment of evidence-based practices. OBJECTIVE To estimate the relative contribution of individual and organizational factors on therapist self-reported use of cognitive-behavioral, family, and psychodynamic therapy techniques within the context of a large-scale effort to increase use of evidence-based practices in an urban public mental health system serving youth and families. DESIGN, SETTING, AND PARTICIPANTS In this observational, cross-sectional study of 23 organizations, data were collected from March 1 through July 25, 2013. We used purposive sampling to recruit the 29 largest child-serving agencies, which together serve approximately 80% of youth receiving publically funded mental health care. The final sample included 19 agencies with 23 sites, 130 therapists, 36 supervisors, and 22 executive administrators. MAIN OUTCOMES AND MEASURES Therapist self-reported use of cognitive-behavioral, family, and psychodynamic therapy techniques, as measured by the Therapist Procedures Checklist-Family Revised. RESULTS Individual factors accounted for the following percentages of the overall variation: cognitive-behavioral therapy techniques, 16%; family therapy techniques, 7%; and psychodynamic therapy techniques, 20%. Organizational factors accounted for the following percentages of the overall variation: cognitive-behavioral therapy techniques, 23%; family therapy techniques, 19%; and psychodynamic therapy techniques, 7%. Older therapists and therapists with more open attitudes were more likely to endorse use of cognitive-behavioral therapy techniques, as were those in organizations that had spent fewer years participating in evidence-based practice initiatives, had more resistant cultures, and had more functional climates. Women were more likely to endorse use of family therapy techniques, as were those in organizations employing more fee-for-service staff and with more stressful climates. Therapists with more divergent attitudes and less knowledge about evidence-based practices were more likely to use psychodynamic therapy techniques. CONCLUSIONS AND RELEVANCE This study suggests that individual and organizational factors are important in explaining therapist behavior and use of evidence-based practices, but the relative importance varies by therapeutic technique.

Examining the impact of mental illness and substance use on recidivism in a county jail

This paper describes the recidivism patterns over a 4 year period for a cohort of people admitted to a large US urban jail system in 2003 and analyzes how these patterns vary based on presence of mental illness and substance abuse. Jail detention and behavioral health service records were merged for all admissions to a large urban jail system in 2003 (N=24,290). Descriptive statistics were used to analyze the recidivism patterns for people admitted to jail in 2003 (N=20,112) over a four year period. Recidivism patterns of people without mental illness or substance use disorders were compared with people with serious mental illness, substance abuse disorders, and dual diagnoses. These analyses found that over half of the people who returned to jail during the 4 year follow-up period did so in the first year. This finding did not differ by any diagnostic category. Analysis of the number of people readmitted to the jail found that people who had a diagnosis of mental illness alone had the lowest number of readmissions to jail in the 4 years after release with 50% having at least one readmission after their initial release. People with dual diagnoses, in contrast, had the highest number of readmissions to jail during the study time frame, with 68% having at least one readmission during the 4 years after release. Substance use is a driving force behind the recidivism of people with mental illness leaving a US urban jail. These findings illustrate the importance of developing interventions that provide timely access to intensive co-occurring substance abuse and mental health treatment during the immediate period after release that are capable of addressing both individual and environment factors that promote the return to drug use after release.

Policy to implementation: evidence-based practice in community mental health – study protocol

BackgroundEvidence-based treatments (EBTs) are not widely available in community mental health settings. In response to the call for implementation of evidence-based treatments in the United States, states and counties have mandated behavioral health reform through policies and other initiatives. Evaluations of the impact of these policies on implementation are rare. A systems transformation about to occur in Philadelphia, Pennsylvania, offers an important opportunity to prospectively study implementation in response to a policy mandate.Methods/designUsing a prospective sequential mixed-methods design, with observations at multiple points in time, we will investigate the responses of staff from 30 community mental health clinics to a policy from the Department of Behavioral Health encouraging and incentivizing providers to implement evidence-based treatments to treat youth with mental health problems. Study participants will be 30 executive directors, 30 clinical directors, and 240 therapists. Data will be collected prior to the policy implementation, and then at two and four years following policy implementation. Quantitative data will include measures of intervention implementation and potential moderators of implementation (i.e., organizational- and leader-level variables) and will be collected from executive directors, clinical directors, and therapists. Measures include self-reported therapist fidelity to evidence-based treatment techniques as measured by the Therapist Procedures Checklist-Revised, organizational variables as measured by the Organizational Social Context Measurement System and the Implementation Climate Assessment, leader variables as measured by the Multifactor Leadership Questionnaire, attitudes towards EBTs as measured by the Evidence-Based Practice Attitude Scale, and knowledge of EBTs as measured by the Knowledge of Evidence- Based Services Questionnaire. Qualitative data will include semi-structured interviews with a subset of the sample to assess the implementation experience of high-, average-, and low-performing agencies. Mixed methods will be integrated through comparing and contrasting results from the two methods for each of the primary hypotheses in this study.DiscussionFindings from the proposed research will inform both future policy mandates around implementation and the support required for the success of these policies, with the ultimate goal of improving the quality of treatment provided to youth in the public sector.

The Perfect Storm: Collision of the Business of Mental Health and the Implementation of Evidence-Based Practices

Financing has been hypothesized to be an important driver of the implementation of evidence-based practices (EBPs), yet there has been little systematic investigation of financing as a factor in EBP implementation. This column presents findings from a qualitative study of the effects of financial factors on the implementation of EBPs in a large urban publicly funded mental health system. Interviews with 33 agency leaders and 16 policy makers identified financial distress in community mental health agencies, leading to concerns about complex and expensive implementation of EBPs. Stakeholders agreed that the cost of EBP implementation should be shared between the agencies and the system; however, the stakeholders did not agree on how EBPs should be financed.

A Prospective Examination of Clinician and Supervisor Turnover Within the Context of Implementation of Evidence-Based Practices in a Publicly-Funded Mental Health System.

Staff turnover rates in publicly-funded mental health settings are high. We investigated staff and organizational predictors of turnover in a sample of individuals working in an urban public mental health system that has engaged in a system-level effort to implement evidence-based practices. Additionally, we interviewed staff to understand reasons for turnover. Greater staff burnout predicted increased turnover, more openness toward new practices predicted retention, and more professional recognition predicted increased turnover. Staff reported leaving their organizations because of personal, organizational, and financial reasons; just over half of staff that left their organization stayed in the public mental health sector. Implications include an imperative to focus on turnover, with a particular emphasis on ameliorating staff burnout.

Community Mental Health Provider Modifications to Cognitive Therapy: Implications for Sustainability

OBJECTIVE This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation. METHODS A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system. RESULTS Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level. CONCLUSIONS Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the clients needs or to the clinicians therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.

A Community’s Response to Suicide Through Public Art: Stakeholder Perspectives from the Finding the Light Within Project

Suicide is a preventable public health problem and a leading cause of death in the United States. Despite recognized need for community-based strategies for suicide prevention, most suicide prevention programs focus on individual-level change. This article presents seven first person accounts of Finding the Light Within, a community mobilization initiative to reduce the stigma associated with suicide through public arts participation that took place in Philadelphia, Pennsylvania from 2011 through 2012. The stigma associated with suicide is a major challenge to suicide prevention, erecting social barriers to effective prevention and treatment and enhancing risk factors for people struggling with suicidal ideation and recovery after losing a loved one to suicide. This project engaged a large and diverse audience and built a new community around suicide prevention through participatory public art, including community design and production of a large public mural about suicide, storytelling and art workshops, and a storytelling website. We present this project as a model for how arts participation can address suicide on multiple fronts—from raising awareness and reducing stigma, to promoting community recovery, to providing healing for people and communities in need.

Applying the Policy Ecology Framework to Philadelphia's Behavioral Health Transformation Efforts.

Abstract Raghavan et al. (Implement Sci 3(26):1–9, 2008) proposed that effective implementation of evidence-based practices requires implementation strategies deployed at multiple levels of the “policy ecology,” including the organizational, regulatory or purchaser agency, political, and social levels. However, much of implementation research and practice targets providers without accounting for contextual factors that may influence provider behavior. This paper examines Philadelphia’s efforts to work toward an evidence-based and recovery-oriented behavioral health system, and uses the policy ecology framework to illustrate how multifaceted, multilevel implementation strategies can facilitate the widespread implementation of evidence-based practices. Ongoing challenges and implications for research and practice are discussed.

Recovery-Focused Behavioral Health System Transformation: A Framework for Change and Lessons Learned from Philadelphia

The concept of recovery is fast becoming the prevailing paradigm in behavioral health policy arenas. Consequently, behavioral health care systems are trying to align their services with a recovery-oriented approach. To date, no blueprint exists to guide systems and communities through the complex process of transformational change. The vision of “what” a recovery-oriented system looks like is becoming increasingly clear, but the process for “how” systems transform and align themselves with this vision remains obscure. This chapter draws upon work in the City of Philadelphia to propose a framework for the recovery-focused transformation of behavioral health systems. Concrete examples of change strategies and lessons learned are discussed.

Public-Academic Partnerships: The Beck Initiative: A Partnership to Implement Cognitive Therapy in a Community Behavioral Health System

The Beck Initiative is a partnership between researchers and clinicians at a large university and an urban behavioral health managed care system. Both partners share a commitment to ensuring that consumers in the community have access to competently delivered, individualized, evidence-based mental health care and that the providers who serve them have the support they need to deliver high-quality evidence-based treatments. Central features of the program are individualized training and consultation in cognitive therapy for each provider agency and policies to promote the sustainability of the initiative and its continuing evolution to meet the needs of providers and consumers.