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Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings

Abstract

Background

The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families.

Objective

The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists’ self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children’s mental health services.

Method

One hundred and three therapists reported on two types of engagement challenges—Limited Client Engagement and Expressed Client Concerns—in 702 sessions with 274 clients.

Results

Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. Both types of engagement challenges were negatively associated with therapists’ report of their ability to carry out intended activities in the same session.

Conclusions

Findings suggest that therapists may benefit from learning strategies to address these two distinct types of engagement challenges encountered in implementation of EBPs with diverse families in community settings.

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References

  1. Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence-based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6(2), 61–74.

    PubMed  PubMed Central  Article  Google Scholar 

  2. Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 4–23.

    PubMed  Article  Google Scholar 

  3. Aarons, G. A., Wells, R. S., Zagursky, K., Fettes, D. L., & Palinkas, L. A. (2009). Implementing evidence-based practice in community mental health agencies: A multiple stakeholder analysis. American Journal of Public Health, 99(11), 2087–2095.

    PubMed  PubMed Central  Article  Google Scholar 

  4. Addis, M. E., Wade, W. A., & Hatgis, C. (1999). Barriers to dissemination of evidence-based practices: Addressing practitioners’ concerns about manual-based psychotherapies. Clinical Psychology: Science and Practice, 6(4), 430–441.

    Google Scholar 

  5. Aisenberg, E. (2008). Evidence-based practice in mental health care to ethnic minority communities: Has its practice fallen short of its evidence? Social Work, 53(4), 297–306.

    PubMed  Article  Google Scholar 

  6. Ballon, B., Kirst, M., & Smith, P. (2004). Youth help-seeking expectancies and their relation to help-seeking behaviours for substance use problems. Addiction Research and Theory, 12(3), 241–260.

    Article  Google Scholar 

  7. Becker, K. D., Boustani, M., Gellatly, R., & Chorpita, B. F. (2017). Forty years of engagement research in children’s mental health services: Multidimensional measurement and practice elements. Journal of Clinical Child and Adolescent Psychology, 47, 1–23.

    PubMed  Article  Google Scholar 

  8. Becker, K. D., & Chorpita, B. (2016). Enhancing the design of engagement interventions to enhance the public health impact of mental health treatments for youth. In K. Becker (Chair), Extending the reach and impact of science on clinical care for youth and families: Looking for new models for the old challenges. Symposium conducted at the NIMH Conference on Mental Health Services Research. Harnessing Science to Strengthen the Public Health Impact, Bethesda, MD.

  9. Becker, K. D., Lee, B. R., Daleiden, E. L., Lindsey, M., Brandt, N. E., & Chorpita, B. F. (2015). The common elements of engagement in children’s mental health services: Which elements for which outcomes? Journal of Clinical Child and Adolescent Psychology, 44(1), 30–43.

    PubMed  Article  Google Scholar 

  10. Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology: Science and Practice, 17(1), 1–30.

    Google Scholar 

  11. Berger, L. K., Zane, N., & Hwang, W. C. (2014). Therapist ethnicity and treatment orientation differences in multicultural counseling competencies. Asian American Journal of Psychology, 5(1), 53.

    PubMed  PubMed Central  Article  Google Scholar 

  12. Brookman-Frazee, L. I., Drahota, A., & Stadnick, N. (2012). Training community mental health therapists to deliver a package of evidence-based practice strategies for school-age children with autism spectrum disorders: A pilot study. Journal of Autism and Developmental Disorders, 42(8), 1651–1661.

    PubMed  PubMed Central  Article  Google Scholar 

  13. Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D., Farmer, E. M., et al. (1995). Children’s mental health service use across service sectors. Health Affairs, 14(3), 147–159.

    PubMed  Article  Google Scholar 

  14. Chorpita, B. F., & Southam-Gerow, M. A. (2006). Fears and anxieties. Treatment of Childhood Disorders, 3, 271–335.

    Google Scholar 

  15. Cook, J. M., Thompson, R., & Schnurr, P. P. (2015). Perceived characteristics of intervention scale: Development and psychometric properties. Assessment, 22(6), 704–714.

    PubMed  Article  Google Scholar 

  16. Costello, E. J., Copeland, W., & Angold, A. (2011). Trends in psychopathology across the adolescent years: What changes when children become adolescents, and when adolescents become adults? Journal of Child Psychology and Psychiatry, 52(10), 1015–1025.

    PubMed  Article  Google Scholar 

  17. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), 50.

    PubMed  Article  Google Scholar 

  18. Danko, C. M., Garbacz, L. L., & Budd, K. S. (2016). Outcomes of parent–child interaction therapy in an urban community clinic: A comparison of treatment completers and dropouts. Children and Youth Services Review, 60, 42–51.

    Article  Google Scholar 

  19. Dickson, K. S., Zeedyk, S. M., Martinez, J., & Haine-Schlagel, R. (2017). Examining ethnic disparities in provider and parent in-session participation engagement. Journal of Children’s Services, 12(1), 47–58.

    PubMed  PubMed Central  Article  Google Scholar 

  20. DiMeo, M. A., Moore, G. K., & Lichtenstein, C. (2012). Relationship of evidence-based practice and treatments: A survey of community mental health providers. Journal of Community Psychology, 40(3), 341–357.

    Article  Google Scholar 

  21. Drake, R. E., Goldman, H. H., Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., et al. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services, 52(2), 179–182.

    PubMed  Article  Google Scholar 

  22. Edmunds, J. M., Read, K. L., Ringle, V. A., Brodman, D. M., Kendall, P. C., & Beidas, R. S. (2014). Sustaining clinician penetration, attitudes and knowledge in cognitive-behavioral therapy for youth anxiety. Implementation Science, 9(1), 1–12.

    Article  Google Scholar 

  23. Frankel, F., & Simmons, J. Q., III. (1992). Parent behavioral training: Why and when some parents drop out. Journal of Clinical Child Psychology, 21(4), 322–330.

    Article  Google Scholar 

  24. Godley, S. H., Hedges, K., & Hunter, B. (2011). Gender and racial differences in treatment process and outcome among participants in the adolescent community reinforcement approach. Psychology of Addictive Behaviors, 25(1), 143.

    PubMed  Article  Google Scholar 

  25. Greenhalgh, T., Glenn, R., Bate, P., Macfarlane, F., & Kyriakidou, O. (2005). Diffusion of innovations in health service organizations: A systematic literature review. Oxford: Blackwell.

    Book  Google Scholar 

  26. Guan, K., Lau, A. S., Zhang, A., Chlebowski, C., Haine-Schlagel, R., & Brookman-Frazee, L. (2018). In-session caregiver behaviors during evidence-based intervention delivery for children with ASD in community settings (under review).

  27. Haen, C. (Ed.). (2011). Engaging boys in treatment: Creative approaches to the therapy process. London: Taylor and Francis.

    Google Scholar 

  28. Haine-Schlagel, R., & Walsh, N. E. (2015). A review of parent participation engagement in child and family mental health treatment. Clinical Child and Family Psychology Review, 18(2), 133–150.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Hawley, K. M., & Weisz, J. R. (2003). Child, parent and therapist (dis) agreement on target problems in outpatient therapy: The therapist’s dilemma and its implications. Journal of Consulting and Clinical Psychology, 71(1), 62.

    PubMed  Article  Google Scholar 

  30. Henggeler, S. W., & Schaeffer, C. M. (2016). Multisystemic therapy®: Clinical overview, outcomes, and implementation research. Family Process, 55(3), 514–528.

    PubMed  Article  Google Scholar 

  31. Hinkin, T. R. (1995). A review of scale development practices in the study of organizations. Journal of Management, 21, 967–988.

    Article  Google Scholar 

  32. Hinkin, T. R. (1998). A brief tutorial on the development of measures for use in survey questionnaires. Organizational Research Methods, 1, 104–112.

    Article  Google Scholar 

  33. Hoagwood, K. E., Olin, S. S., Horwitz, S., McKay, M., Cleek, A., Gleacher, A., et al. (2014). Scaling up evidence-based practices for children and families in New York State: Toward evidence-based policies on implementation for state mental health systems. Journal of Clinical Child and Adolescent Psychology, 43(2), 145–157.

    PubMed  PubMed Central  Article  Google Scholar 

  34. Jungbluth, N. J., & Shirk, S. R. (2009). Therapist strategies for building involvement in cognitive–behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77(6), 1179.

    PubMed  Article  Google Scholar 

  35. Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63(3), 146.

    PubMed  Article  Google Scholar 

  36. Kazdin, A. E., & Wassell, G. (1999). Barriers to treatment participation and therapeutic change among children referred for conduct disorder. Journal of Clinical Child Psychology, 28(2), 160–172.

    PubMed  Article  Google Scholar 

  37. Kazdin, A. E., & Whitley, M. K. (2003). Treatment of parental stress to enhance therapeutic change among children referred for aggressive and antisocial behavior. Journal of Consulting and Clinical Psychology, 71(3), 504.

    PubMed  Article  Google Scholar 

  38. Kim, J. J., Brookman-Frazee, L., Gellatly, R., Stadnick, N., Barnett, M. L., & Lau, A. S. (2018). Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health. Professional Psychology: Research and Practice, 49(2), 132.

    Article  Google Scholar 

  39. King, G., Currie, M., & Petersen, P. (2014). Child and parent engagement in the mental health intervention process: A motivational framework. Child and Adolescent Mental Health, 19(1), 2–8.

    Article  Google Scholar 

  40. Kiselica, M., & Englar-Carlson, M. (2008). Establishing rapport with boys in individual counseling and psychotherapy: A male-friendly perspective. In M. S. Kiselica, M. Englar-Carlson, & A. M. Horne (Eds.), Counseling trouble boys: A guidebook for practitioners (pp. 49–65). London: Routledge.

    Google Scholar 

  41. Langley, A. K., Nadeem, E., Kataoka, S. H., Stein, B. D., & Jaycox, L. H. (2010). Evidence-based mental health programs in schools: Barriers and facilitators of successful implementation. School Mental Health, 2(3), 105–113.

    PubMed  PubMed Central  Article  Google Scholar 

  42. Lau, A. S., & Brookman-Frazee, L. (2016). The 4KEEPS study: Identifying predictors of sustainment of multiple practices fiscally mandated in children’s mental health services. Implementation Science, 11(1), 1.

    Google Scholar 

  43. Lau, A. S., Fung, J. J., Ho, L. Y., Liu, L. L., & Gudiño, O. G. (2011). Parent training with high-risk immigrant Chinese families: A pilot group randomized trial yielding practice-based evidence. Behavior Therapy, 42(3), 413–426.

    PubMed  Article  Google Scholar 

  44. Lau, A. S., Gonzalez, J. C., Barnett, M. L., Kim, J. J., Saifan, D., & Brookman-Frazee, L. (2018). Community therapist reports of client engagement challenges during the implementation of multiple EBPs in children’s mental health. Evidence-Based Practice in Child and Adolescent Mental Health, 3, 197–212.

    PubMed  PubMed Central  Article  Google Scholar 

  45. Lee, M. T., Garnick, D. W., O’Brien, P. L., Panas, L., Ritter, G. A., Acevedo, A., et al. (2012). Adolescent treatment initiation and engagement in an evidence-based practice initiative. Journal of Substance Abuse Treatment, 42(4), 346–355.

    PubMed  Article  Google Scholar 

  46. Lim, A., Nakamura, B. J., Higa-McMillan, C. K., Shimabukuro, S., & Slavin, L. (2012). Effects of workshop trainings on evidence-based practice knowledge and attitudes among youth community mental health providers. Behaviour Research and Therapy, 50, 397–406.

    PubMed  Article  Google Scholar 

  47. Lindsey, M. A., Chambers, K., Pohle, C., Beall, P., & Lucksted, A. (2013). Understanding the behavioral determinants of mental health service use by urban, under-resourced Black youth: Adolescent and caregiver perspectives. Journal of Child and Family Studies, 22(1), 107–121.

    PubMed  Article  Google Scholar 

  48. Lochman, J. E., Dishion, T. J., Boxmeyer, C. L., Powell, N. P., & Qu, L. (2017). Variation in response to evidence-based group preventive intervention for disruptive behavior problems: A view from 938 coping power sessions. Journal of Abnormal Child Psychology, 45(7), 1271–1284.

    PubMed  PubMed Central  Article  Google Scholar 

  49. Lynn Mensinger, J., Diamond, G. S., Kaminer, Y., & Wintersteen, M. B. (2006). Adolescent and therapist perception of barriers to outpatient substance abuse treatment. The American Journal on Addictions, 15, 16–25.

    Article  Google Scholar 

  50. Mak, W. W., Law, R. W., Alvidrez, J., & Pérez-Stable, E. J. (2007). Gender and ethnic diversity in NIMH-funded clinical trials: Review of a decade of published research. Administration and Policy in Mental Health and Mental Health Services Research, 34(6), 497–503.

    PubMed  Article  Google Scholar 

  51. McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence based psychological treatments: A review of current efforts. American Psychologist, 65(2), 73–84.

    PubMed  Article  Google Scholar 

  52. McKay, M. M., & Bannon, W. M., Jr. (2004). Engaging families in child mental health services. Child and Adolescent Psychiatric Clinics, 13(4), 905–921.

    Article  Google Scholar 

  53. Morrissey-Kane, E., & Prinz, R. J. (1999). Engagement in child and adolescent treatment: The role of parental cognitions and attributions. Clinical Child and Family Psychology Review, 2(3), 183–198.

    PubMed  Article  Google Scholar 

  54. Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 341–352.

    Article  Google Scholar 

  55. Muthén, B. (1994). Multilevel covariance structure analysis. In J. Hox & I. Kreft (Eds.), Multilevel modeling, a special issue of Sociological Methods and Research, 22, 376–398.

  56. Muthén, L. K., & Muthén, B. O. (2012). Mplus Version 7 user’s guide. Los Angeles, CA: Muthén and Muthén.

    Google Scholar 

  57. Nakamura, B. J., Higa-McMillan, C. K., Okamura, K. H., & Shimabukuro, S. (2011). Knowledge of and attitudes towards evidence-based practices in community child mental health practitioners. Administration and Policy in Mental Health and Mental Health Services Research, 38(4), 287–300.

    PubMed  Article  Google Scholar 

  58. Nelson, M. M., Shanley, J. R., & Bard, E. (2012). Therapists’ attitudes toward evidence-based practices and implementation of parent–child interaction therapy. Child Maltreatment, 17(1), 47–55.

    PubMed  Article  Google Scholar 

  59. Ollendick, T. H., Greene, R. W., Austin, K. E., Fraire, M. G., Halldorsdottir, T., Allen, K. B., et al. (2016). Parent management training and collaborative and proactive solutions: A randomized control trial for oppositional youth. Journal of Clinical Child and Adolescent Psychology, 45(5), 591–604.

    PubMed  Article  Google Scholar 

  60. Orrell-Valente, J. K., Pinderhughes, E. E., Valente, E., Laird, R. D., Bierman, K. L., Coie, J. D., et al. (1999). If it’s offered, will they come? Influences on parents’ participation in a community-based conduct problems prevention program. American Journal of Community Psychology, 27(6), 753–783.

    PubMed  PubMed Central  Article  Google Scholar 

  61. Panichelli-Mindel, S. M., Flannery-Schroeder, E., Callahan, S., & Kendall, P. C. (1995). Disclosure and nondisclosure among anxiety-disordered youth: Participant characteristics and treatment outcome differences. In Poster presented at the convention for the Association for the Advancement of Behavior Therapy, Washington, DC.

  62. Patterson, G. R., & Chamberlain, P. (1994). A functional analysis of resistance during parent training therapy. Clinical Psychology: Science and Practice, 1(1), 53–70.

    Google Scholar 

  63. Pemberton, J. R., Conners-Burrow, N. A., Sigel, B. A., Sievers, C. M., Stokes, L. D., & Kramer, T. L. (2015). Factors associated with clinician participation in TF-CBT post-workshop training components. Administration and Policy in Mental Health and Mental Health Services Research, 44(4), 524–533.

    Article  Google Scholar 

  64. Podsakoff, P. M., MacKenzie, S. B., Lee, J. Y., & Podsakoff, N. P. (2003). Common method biases in behavioral research: A critical review of the literature and recommended remedies. Journal of Applied Psychology, 88(5), 879.

    PubMed  PubMed Central  Article  Google Scholar 

  65. Rapp, C. A., Bond, G. R., Becker, D. R., Carpinello, S. E., Nikkel, R. E., & Gintoli, G. (2005). The role of state mental health authorities in promoting improved client outcomes through evidence-based practice. Community Mental Health Journal, 41(3), 347–363.

    PubMed  Article  Google Scholar 

  66. Reding, M. E., Chorpita, B. F., Lau, A. S., & Innes-Gomberg, D. (2014). Providers’ attitudes toward evidence-based practices: Is it just about providers, or do practices matter, too? Administration and Policy in Mental Health and Mental Health Services Research, 41(6), 767–776.

    PubMed  Article  Google Scholar 

  67. Reid, M. J., Webster-Stratton, C., & Beauchaine, T. P. (2001). Parent training in head start: A comparison of program response among African American, Asian American, Caucasian, and Hispanic mothers. Prevention Science, 2(4), 209–227.

    PubMed  PubMed Central  Article  Google Scholar 

  68. Ringle, V. A., Read, K. L., Edmunds, J. M., Brodman, D. M., Kendall, P. C., Barg, F., et al. (2015). Barriers to and facilitators in the implementation of cognitive-behavioral therapy for youth anxiety in the community. Psychiatric Services, 66(9), 938–945.

    PubMed  Article  Google Scholar 

  69. Rogers, E. M. (1962). Diffusion of innovations. New York, NY: Free Press.

    Google Scholar 

  70. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.

    Google Scholar 

  71. Schoenwald, S. K., Chapman, J. E., Kelleher, K., Hoagwood, K. E., Landsverk, J., Stevens, J., et al. (2008). A survey of the infrastructure for children’s mental health services: Implications for the implementation of empirically supported treatments (ESTs). Administration and Policy in Mental Health and Mental Health Services Research, 35(1–2), 84–97.

    PubMed  Article  Google Scholar 

  72. Southam-Gerow, M. A., Chorpita, B. F., Miller, L. M., & Gleacher, A. A. (2008). Are children with anxiety disorders privately referred to a university clinic like those referred from the public mental health system? Administration and Policy in Mental Health and Mental Health Services Research, 35(3), 168–180.

    PubMed  Article  Google Scholar 

  73. Southam-Gerow, M. A., Rodríguez, A., Chorpita, B. F., & Daleiden, E. L. (2012). Dissemination and implementation of evidence based treatments for youth: Challenges and recommendations. Professional Psychology: Research and Practice, 43(5), 527.

    Article  Google Scholar 

  74. Southam-Gerow, M. A., Weisz, J. R., Chu, B. C., McLeod, B. D., Gordis, E. B., & Connor-Smith, J. K. (2010). Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test. Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 1043–1052.

    PubMed  PubMed Central  Article  Google Scholar 

  75. Stadnick, N. A., Haine-Schlagel, R., & Martinez, J. I. (2016). Using observational assessment to help identify factors associated with parent participation engagement in community-based child mental health services. Child and Youth Care Forum, 45(5), 745–758.

    PubMed  Article  Google Scholar 

  76. Sussman, S., Skara, S., & Ames, S. L. (2008). Substance abuse among adolescents. Substance Use and Misuse, 43(12–13), 1802–1828.

    PubMed  Article  Google Scholar 

  77. Webster, S., & Harrison, L. (2008). Constructing a research based pre-care model to improve mental health interventions for young people. The Australian Journal of Advanced Nursing, 25(4), 31–39.

    Google Scholar 

  78. Weisz, J. R., & Kazdin, A. E. (Eds.). (2010). Evidence-based psychotherapies for children and adolescents. New York, NY: Guilford Press.

    Google Scholar 

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Funding

This study was funded by NIMH (R01MH100134).

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Correspondence to R. Gellatly.

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Resham Gellatly, M.A., Anna Lau, Ph.D., and Lauren Brookman-Frazee, Ph.D. take responsibility for the integrity of the data and the accuracy of the data analysis.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Gellatly, R., Brookman-Frazee, L., Barnett, M. et al. Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings. Child Youth Care Forum 48, 55–75 (2019). https://doi.org/10.1007/s10566-018-9472-z

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Keywords

  • Community mental health
  • Dissemination and implementation
  • Barriers
  • EBP implementation
  • Engagement