Rinad S. Beidas

Training and Consultation to Promote Implementation of an Empirically Supported Treatment: A Randomized Trial

OBJECTIVE The study evaluated the efficacy of three training modalities and the impact of ongoing consultation after training. Cognitive-behavioral therapy (CBT) for anxiety among youths, an empirically supported treatment, was used as the exemplar. Participants were randomly assigned to one of three one-day workshops to examine the efficacy of training modality: routine training (training as usual), computer training (computerized version of training as usual), and augmented training (training that emphasized active learning). After training, all participants received three months of ongoing consultation that included case consultation, didactics, and problem solving. METHODS Participants were 115 community therapists (mean age of 35.9 years; 90% were women). Outcome measures included the Adherence and Skill Checklist, used to rate a performance-based role-play; a knowledge test; and the Training Satisfaction Rating Scale. RESULTS All three training modalities resulted in limited gains in therapist adherence, skill, and knowledge. There was no significant effect of modality on adherence, skill, or knowledge from pretraining to posttraining. Participants were more satisfied with augmented and routine training than with computer training. Most important, number of consultation hours after training significantly predicted higher therapist adherence and skill at the three-month follow-up. CONCLUSIONS The findings suggest that training alone did not result in therapist behavior change. The inclusion of ongoing consultation was critical to influencing therapist adherence and skill. Implications for implementation science and mental health services research are discussed.

Stigma and Sexual Health Risk in HIV-Positive African American Young Men Who Have Sex with Men

Understanding the multiple forms of stigma experienced by young HIV-positive African American men who have sex with men and how they relate to sexual risk behaviors is essential to design effective HIV prevention programs. This study of 40 African American young MSM found that 90% of those surveyed experienced sexual minority stigma, 88% experienced HIV stigma, and 78% experienced dual stigma. Sexual minority stigma was characterized by experiences of social avoidance, and HIV stigma, by shame. Individuals with high HIV stigma were significantly more likely to engage in unprotected sex while high or intoxicated. Associations between stigma and sexual practices were examined; youth endorsing higher levels of sexual minority stigma engaged in less insertive anal intercourse. Individuals endorsing more HIV stigma reported more receptive anal intercourse. These findings support the development of stigma-informed secondary prevention interventions for African American HIV-positive young MSM.

Treating Socially Phobic Youth with CBT: Differential Outcomes and Treatment Considerations

Social phobia (SP) is characterized by a fear of one or more social or performance situations.StudiesofcomorbidityinSPyouthfindanxietyandaffectivedisordersco-occurring. The present study examined children with primary SP and compared them to children with primary Separation Anxiety Disorder (SAD) or Generalized Anxiety Disorder (GAD) prior to treatment and in response to treatment. The groups differed significantly on self- , parent- and teacher-rated pretreatment measures. Additionally, the two groups showed differential treatment outcomes. When the SP youth with comorbid Affective Disorder were excluded in treatment outcome analyses, there were non significant differences, indicating that comorbid affective disorders likely contributed to differential treatment outcome. Results are discussed in terms of treatment recommendations for socially phobic youth.

Consultation as an Implementation Strategy for Evidence-Based Practices Across Multiple Contexts: Unpacking the Black Box

There is great interest in the dissemination and implementation of evidence-based treatments and practices for children across schools and community mental health settings. A growing body of literature suggests that the use of one-time workshops as a training tool is ineffective in influencing therapist behavior and patient outcomes and that ongoing expert consultation and coaching is critical to actual uptake and quality implementation. Yet, we have very limited understanding of how expert consultation fits into the larger implementation support system, or the most effective consultation strategies. This commentary reviews the literature on consultation in child mental health, and proposes a set of core consultation functions, processes, and outcomes that should be further studied in the implementation of evidence-based practices for children.

Training Research: Practical Recommendations for Maximum Impact

This review offers practical recommendations regarding research on training in evidence-based practices for mental health and substance abuse treatment. When designing training research, we recommend: (a) aligning with the larger dissemination and implementation literature to consider contextual variables and clearly defining terminology, (b) critically examining the implicit assumptions underlying the stage model of psychotherapy development, (c) incorporating research methods from other disciplines that embrace the principles of formative evaluation and iterative review, and (d) thinking about how technology can be used to take training to scale throughout all stages of a training research project. An example demonstrates the implementation of these recommendations.

Children and Terrorism-Related News : Training Parents in Coping and Media Literacy

This study examined associations between televised news regarding risk for future terrorism and youth outcomes and investigated the effects of training mothers in an empirically based approach to addressing such news with children. This approach--Coping and Media Literacy (CML)--emphasized modeling, media literacy, and contingent reinforcement and was compared via randomized design to Discussion as Usual (DAU). Ninety community youth (aged 7-13 years) and their mothers viewed a televised news clip about the risk of future terrorism, and threat perceptions and state anxiety were assessed preclip, postclip, and postdiscussion. Children responded to the clip with elevated threat perceptions and anxiety. Children of CML-trained mothers exhibited lower threat perceptions than DAU youth at postclip and at postdiscussion. Additionally, CML-trained mothers exhibited lower threat perceptions and state anxiety at postclip and postdiscussion than did DAU mothers. Moreover, older youth responded to the clip with greater societal threat perception than did younger youth. Findings document associations between terrorism-related news, threat perceptions, and anxiety and support the utility of providing parents with strategies for addressing news with children. Implications and research suggestions are discussed.

The Intolerance of Uncertainty Scale for Children: A Psychometric Evaluation

Intolerance of uncertainty (IU) has contributed to our understanding of excessive worry and adult anxiety disorders, but there is a paucity of research on IU in child samples. This gap is due to the absence of a psychometrically sound measure of IU in youth. The present study adapted parallel child- and parent-report forms of the Intolerance of Uncertainty Scale (IUS) and examined the internal consistency, convergent validity, and classification properties of these forms in youth aged 7-17 (M = 11.6 years, SD = 2.6). Participating youth (N = 197; 100 girls, 97 boys) either met diagnostic criteria for an anxiety disorder (n = 73) or were nonreferred community participants (n = 124). The child-report form (i.e., IUS for Children, or IUSC), and to a lesser extent the parent-report form, demonstrated strong internal consistency and convergent validity, evidenced by significant associations with anxiety and worry (and reassurance-seeking in the case of the child-report form). Children diagnosed with anxiety disorders scored higher than nonreferred community youth on both forms. Receiver operating characteristic (ROC) analysis demonstrated acceptable overall utility in distinguishing the 2 groups of youth. Findings provide preliminary support for use of the IUSC for continuous measurement of childrens ability to tolerate uncertainty.

Methods to Improve the Selection and Tailoring of Implementation Strategies

Implementing behavioral health interventions is a complicated process. It has been suggested that implementation strategies should be selected and tailored to address the contextual needs of a given change effort; however, there is limited guidance as to how to do this. This article proposes four methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that could be used to match implementation strategies to identified barriers and facilitators for a particular evidence-based practice or process change being implemented in a given setting. Each method is reviewed, examples of their use are provided, and their strengths and weaknesses are discussed. The discussion includes suggestions for future research pertaining to implementation strategies and highlights these methods’ relevance to behavioral health services and research.

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.

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.