Laura C. Skriner

Trajectory and Predictors of Alliance in Cognitive Behavioral Therapy for Youth Anxiety

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7–17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel “alliance rupture” model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

Cross-ethnic measurement invariance of the SCARED and CES-D in a youth sample.

This study evaluated the cross-ethnic measurement invariance of 2 common screening measures of anxiety and depressive symptoms in youth. The measurement invariance of the Screen for Childhood Anxiety and Related Emotional Disorders (SCARED) and the Center for Epidemiologic Studies Depression Scale (CES-D) was tested across 881 African American (Black; n = 396), Hispanic (n = 185), non-Hispanic White (White; n = 166), and Asian/Indian (n = 134) youth in the 7th grade. The measures were administered as part of a grade-wide screening to identify youth with elevated anxiety and depressive symptoms. The 5-factor model of the SCARED and the 4-factor model of the CES-D best represented the data for all ethnic groups. Results provided support for strong invariance of the SCARED across all 4 ethnic groups. Results provided support for strong invariance of the CES-D across Black, White, and Asian/Indian youth, and partial strong invariance for Hispanic youth. Overall, results suggest that factor means and total scores can be compared across groups. Factor mean differences across groups were identified for both measures. In particular, Hispanic youth reported greater levels of anxiety and depression in certain domains than White, Black, and Asian youth. Our findings support the use of the SCARED and CES-D as tools for measuring anxiety and depressive symptoms in ethnically diverse youth in the United States. Results are discussed with respect to the importance of establishing measurement invariance for screening measures of anxiety and depressive symptoms prior to comparing symptom levels across ethnic groups.

Client-therapist alliance discrepancies and outcome in cognitive-behavioral therapy for youth anxiety.

BACKGROUND Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. OBJECTIVE The current study explored the degree to which youth with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, anxiety disorders and their therapists agree in their ratings of the alliance at multiple assessment points and evaluated whether inter-rater discrepancies predicted treatment outcome. METHOD Youth (N = 62; Mage = 12.43, SD = .76) received empirically supported CBT. Paired samples t tests assessed for significant disagreement between youth- and therapist-rated alliance at sessions 4, 8, and 12. Regression analyses were conducted to evaluate whether discrepancies between raters at each time point predicted posttreatment anxiety symptom scores. RESULTS Overall, alliance was positive for both child (aged 7-12 years) and adolescent (aged 13-16 years) clients. Discrepancies between youth and therapist ratings of alliance were statistically significant at session 4 for children and session 8 for adolescents, with youth rating the relationship more favorably than therapists. However, rating discrepancies did not predict youth- or parent-reported treatment outcome. CONCLUSIONS Considerable variability may exist between youth and therapist perspectives on the therapeutic alliance, indicating potential attunement problems, particularly during earlier phases of treatment. However, these discrepancies did not negatively affect treatment response. Implications for alliance research and clinical practice are discussed.

Lessons learned while building a trauma-informed public behavioral health system in the City of Philadelphia

Exposure to traumatic experiences among youth is a serious public health concern. A trauma-informed public behavioral health system that emphasizes core principles such as understanding trauma, promoting safety, supporting consumer autonomy, sharing power, and ensuring cultural competence, is needed to support traumatized youth and the providers who work with them. This article describes a case study of the creation and evaluation of a trauma-informed publicly funded behavioral health system for children and adolescents in the City of Philadelphia (the Philadelphia Alliance for Child Trauma Services; PACTS) using the Exploration, Preparation, Implementation, and Sustainment (EPIS) as a guiding framework. We describe our evaluation of this effort with an emphasis on implementation determinants and outcomes. Implementation determinants include inner context factors, specifically therapist knowledge and attitudes (N=114) towards evidence-based practices. Implementation outcomes include rate of PTSD diagnoses in agencies over time, number of youth receiving TF-CBT over time, and penetration (i.e., number of youth receiving TF-CBT divided by the number of youth screening positive on trauma screening). We describe lessons learned from our experiences building a trauma-informed public behavioral health system in the hopes that this case study can guide other similar efforts.

The relationship between consumer, clinician, and organizational characteristics and use of evidence-based and non-evidence-based therapy strategies in a public mental health system

We investigated the relationship between consumer, clinician, and organizational factors and clinician use of therapy strategies within a system-wide effort to increase the use of cognitive-behavioral therapy. Data from 247 clinicians in 28 child-serving organizations were collected. Clinicians participating in evidence-based practice training initiatives were more likely to report using cognitive-behavioral therapy when they endorsed more clinical experience, being salaried clinicians, and more openness to evidence-based practice. Clinicians participating in evidence-based practice initiatives were more likely to use psychodynamic techniques when they had older clients, less knowledge about evidence-based practice, more divergent attitudes toward EBP, higher financial strain, and worked in larger organizations. In clinicians not participating in evidence-based training initiatives; depersonalization was associated with higher use of cognitive-behavioral; whereas clinicians with less knowledge of evidence-based practices were more likely to use psychodynamic techniques. This study suggests that clinician characteristics are important when implementing evidence-based practices; and that consumer, clinician, and organizational characteristics are important when de-implementing non evidence-based practices. This work posits potential characteristics at multiple levels to target with implementation and deimplementation strategies.

Therapist and Organizational Factors Associated with Participation in Evidence-Based Practice Initiatives in a Large Urban Publicly-Funded Mental Health System

The goal of this study was to identify therapist and organizational characteristics associated with participation in evidence-based practice (EBP) training initiatives sponsored by a large publicly funded mental health system. Self-report data from therapists (N = 247) nested within 28 mental health clinics was collected in 2015. Results from regression analyses indicated that length of time employed at an organization was associated with individual therapist participation in an EBP initiative. Organizational and implementation climate were associated with organizational participation in an EBP initiative. Organizations characterized by higher levels of stress were more likely to participate in EBP initiatives and organizations characterized by higher engagement and educational support for EBPs were less likely to participate. Implications include the need for systems to consider organizational characteristics when sponsoring organizations in EBP initiatives.

Community-academic partnerships in implementation research

Community-academic partnerships(CAPs) are a critical component of implementing and sustaining evidence-based practices (EBPs) in community settings; however, the approaches used and mechanisms of change within CAPs have not been rigorously studied. The first step to advancing the science of CAP is to operationally define and contextualize the approaches used in CAP as part of the implementation process. Our research group has gleaned valuable lessons about the best ways to develop, support, and nurture community partnerships within the context of implementation. In this article, we share these lessons learned and relate them to implementation strategies that are most relevant to community-partnered implementation endeavors. The implementation strategies most relevant to CAPs are as follows: (a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem solving, (e) using an advisory board or workgroup, (f) tailoring strategies, (g) promoting adaptability, and (h) auditing and providing feedback. We offer suggestions for future research to systematically evaluate these strategies, with an eye toward advancing the science of CAP and implementation science and the goal of guiding future research and improving the implementation of EBPs in community settings.

Relationship Between Supervisor Factors and Therapist Knowledge, Attitudes, and Use of EBP in a Large Public Behavioral Health System

TO THE EDITOR: In a letter to the editor of Psychiatric Services (1), somemembers of the senior Yale Psychiatry faculty viewed the analyses I offer in “Perhaps I Touched the Minaret, or How Patient-Centered Care Remains a Dream” (2) as driven by “defeat,” “despair,” “discouragement,” and “disillusionment” (1). Their only reference to the analyses was the “unfortunate” citing of 1960s programs as “evidence that public psychiatry has declined.” I still take my later failures to replicate this 1960s collaboration with the Texas Department of Rehabilitation as such evidence (3). The state-sponsored training resulted in full-time, continuous competitive employment of multiple chronically hospitalized patients. In contrast, a recent benchmark for employment success was 41% working at least one day within a three-month period. I leave it to readers to decide whether competitive employment opportunities for people with severe mental illness have declined. The Yale critics go on to cite “tremendous progress . . . in recent years” (1). One example they provide is “jail diversion” at Yale (1). In the years up to 1997, when I retired from academia, I worked in no community or department where we allowed people with a mental illness to be sent to jails. For example, the Springfield, Illinois, police routinely called our 24-hour on-call case manager or Community Support Network office. A typical request was, “We have someone who we think is your client, and if she isn’t, she should be. Will you come?” We went to the site and took responsibility if the person was our client or mentally ill (4). The Yale critics reported participation in the Connecticut jail diversion program. Has diversion met the needs of New Haven’s citizens who have psychiatric illness? In 2015, Supervisory Assistant Public Defender Bevin Salmon, who works at the New Haven Superior Court, said “I’ve been doing this for about 13 years, and . . . to see [my] mentally ill clients incarcerated because there aren’t enough treatment spots for them . . . has been a constant problem” (5). The state of social and community psychiatry truly disappoints me (2), and reports from academia provide no reassurances. Contrary to the Yale critics’ speculations, as I said in my Personal Accounts column (2), I remain gratified by my work and by the patients I have helped and who have taught me medicine. I have learned from them that we cannot depend on all patients’ coming to our offices. Psychiatrists have pioneered prevention programs to identify vulnerable people with severe mental illness who are living in community settings and to provide active care over time to improve their well-being. Programmatic prevention can be used to reduce police encounters and the need for diversion. Two elements are important in this effort. First, interventions in the community can address functional impairments and disabilities of people with severe mental illness: homelessness, unemployment, substance abuse, encounters with police, and so forth. Second, collaborative arrangements can provide on-site mental health workers to intervene when police are concerned about a client or nonclient with mental illness. By understanding our patients, we become experts in the tailoring of medicine and environments to protect and restore health to individuals. By having all medical students and psychiatric residents master the skills of preventive interventions, home visits, agency collaborations that concern a patient, and on-site home or work supervision to ensure that patients take their prescribed medications, we take an important step toward overcoming today’s adversities.