The Juggling Act of Supervision in Community Mental Health: Implications for Supporting Evidence-Based Treatment

A Mixed Methods Examination of Session Planning Among Public Mental Health Therapists

Session planning is a core activity for implementing evidence-based practices (EBPs), yet it is unknown whether public mental health settings provide the support for therapists to session plan. This two-part study conducted in collaboration with EBP leaders in Philadelphia's public mental health system deployed mixed methods to examine therapists' session planning practices and preferences. In Study 1, 61 public mental health therapists completed an online survey to identify session planning barriers and facilitators, current practices, and desired planning supports. In Study 2, nine therapists who ranked a session planning tool as a top choice support in Study 1 participated in two focus groups to elaborate on their survey responses and provide feedback on three session planning tool prototypes. Study 1 survey respondents cited multi-level barriers and facilitators to session planning. In both closed- and open-ended responses, analyzed descriptively and via content analysis respectively, therapists described wanting more time, lower caseloads, financial incentives for session planning, and additional clinical resources and guidance from trainings, peers, and supervisors to support session planning. Study 2 focus group participants, whose responses were analyzed using content analysis, reiterated the need for these multi-level supports and expressed the need for a "one-stop" database of session planning tools that would be free, easily searchable, and modifiable for varied clinical needs. All three session planning tool prototypes reviewed were acceptable; two were also considered feasible and appropriate. This investigation of an under-studied aspect of the EBP implementation process reveals the need for multi-level session planning supports.

Managers' Micro-Communities Matter: The Impact of Clinical Supervision Team on Therapist Perception of the Organization

Positive organizational climate - employee perceptions of their work environment and the impact of this environment on well-being and functioning - is associated with desirable organizational and client-level outcomes in mental health organizations. Clinical supervisors are well-positioned to impact organizational climate, as they serve as intermediaries between higher-level administrators who drive the policies and procedures and the therapists impacted by such decisions. This cross-sectional study examined the role of clinical supervisors as drivers of therapist perceptions of organizational climate within supervisory teams. Specifically, the present study investigated: (1) shared perceptions of organizational climate among therapists on the same supervisory team; (2) predictors of therapist climate perceptions. Eighty-six therapists were supervised by 22 supervisors. Indices of interrater agreement and interrater reliability of therapists on the same supervisory team were examined to determine shared or distinct perceptions of organizational climate. Multi-level models were used to examine whether supervisor attitudes towards evidence-based practices and therapist perceptions of supervisor communication predicted perceived organizational climate. Results showed perceptions of organizational cohesion and autonomy were shared among therapists on the same supervisory team and distinct from therapists on different supervisory teams. Therapist perceptions of their supervisor's communication was positively associated with perceptions of organizational cohesion and autonomy. These findings align with emerging evidence that middle managers shape their employees' experience of their work environment through communication strategies. These findings also point to the potential for intervening at lower organizational levels to improve overall organizational climate.

Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions-symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal-as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

Job Satisfaction of Nurses in the Context of Clinical Supervision: A Systematic Review

The purpose of this systematic review is to gather and analyze data from existing research on the effects of clinical supervision (CS) intervention on nurses' job satisfaction and related outcomes such as stress levels, burnout, and care quality. Using the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria, a systematic review of the research available in the databases PubMed, PsycInfo, Cochrane Library, and CINAHL, well as Google Scholar, between January 2010 and May 2023 was carried out. Out of the 760 studies assessed, only 8 met the criteria for inclusion in the review based on Hawker's assessment tool. The results indicate that CS has a positive impact on nurses' job satisfaction and related outcomes such as reduced burnout, stress levels, and the quality of care. The study also found that the effectiveness of CS in enhancing job satisfaction was most evident during the 6-month follow-up period. However, nurses who did not receive CS did not show any noticeable improvement in their knowledge or practice. Additionally, nurses who required more efficient clinical oversight reported little to no positive impact on their practice or training. The review also highlighted gaps in knowledge regarding the frequency and number of sessions required for the impact of CS on nurses' job satisfaction and other outcomes. Due to the limited number of studies included in this review, further research is recommended to evaluate the influence of CS on nurses' job satisfaction.

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

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.

Characterizing supervision-as-usual: Findings from two provider surveys

Although clinical supervision is widely seen as critical for professional training and for safeguarding and promoting client well-being in mental health care, it is understudied, particularly in publicly funded services. In surveys of two large samples of youth mental health service providers (a state sample of providers billing Medicaid [N = 1,057] and a national sample of professional guild members [N = 1,720]), we examined the amount of time providers reported spending in supervision and consultation in a typical workweek and its covariation with characteristics of providers' caseloads and work settings. Across both samples, providers reported spending an average of 2-3 hr per week in supervision. Serving higher percentages of low-income clients was associated with significantly more supervision time. Working in private practice was associated with less supervision, while community mental health and residential facilities were each associated with more supervision time. The national survey also measured providers' perceptions of their current supervision. On average, providers endorsed feeling comfortable with the amount of supervision received and supported by their supervisors. However, working with more low-income clients was associated with greater need for supervisor approval and oversight and with less comfort in the amount of supervision received. Those working with more low-income clientele may benefit from additional supervision time or more focused supervision coverage of the specific needs of clients with low-income. More in-depth research on critical processes and content in supervision is a much-needed future direction for supervision research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mechanisms of change for a family intervention in Kenya: An Integrated Clinical and Implementation Mapping approach

To increase cultural relevance and maximize access for historically underserved populations, there is a need to explore mechanisms underlying treatment outcomes during piloting. We developed a mixed-method approach, Integrated Clinical and Implementation Mapping (ICIM), to explore clinical and implementation mechanisms to inform improvements in content and delivery. We applied ICIM in a pilot of Tuko Pamoja, a lay counselor-delivered family intervention in Kenya (10 families with adolescents ages 12-17). ICIM is a 3-phase process to triangulate data sources to analyze how and why change occurs within individual cases and across cases. We synthesized data from session and supervision transcripts, fidelity and clinical skills ratings, surveys, and interviews. Outputs included a comprehensive narrative and visual map depicting how content and implementation factors influenced change. For Tuko Pamoja, ICIM results showed common presenting problems, including financial strain and caregivers' distress, triggering negative interactions and adolescent distress. ICIM demonstrated that active treatment ingredients included communication skills and facilitated, prescribed time together. Families improved communication, empathy, and hope, facilitated improved family functioning and mental health. Key implementation mechanisms included provider clinical competencies, alliance-building, treatment-aligned adaptations, and consistent attendance. Results guided manual and training refinements and generated hypotheses about mechanisms to test in larger trials.

In Search of the Common Elements of Clinical Supervision: A Systematic Review

The importance of clinical supervision for supporting effective implementation of evidence-based treatments (EBTs) is widely accepted; however, very little is known about which supervision practice elements contribute to implementation effectiveness. This systematic review aimed to generate a taxonomy of empirically-supported supervision practice elements that have been used in treatment trials and shown to independently predict improved EBT implementation. Supervision practice elements were identified using a two-phase, empirically-validated distillation process. In Phase I, a systematic review identified supervision protocols that had evidence of effectiveness based on (a) inclusion in one or more EBT trials, and (b) independent association with improved EBT implementation in one or more secondary studies. In Phase II, a hybrid deductive-inductive coding process was applied to the supervision protocols to characterize the nature and frequency of supervision practice elements across EBTs. Twenty-one of the 876 identified articles assessed the associations of supervision protocols with implementation or clinical outcomes, representing 13 separate studies. Coding and distillation of the supervision protocols resulted in a taxonomy of 21 supervision practice elements. The most frequently used elements were: reviewing supervisees' practice (92%; n = 12), clinical suggestions (85%; n = 11), behavioral rehearsal (77%; n = 10), elicitation (77%; n = 10), and fidelity assessment (77%; n = 10). This review identified supervision practice elements that could be targets for future research testing which elements are necessary and sufficient to support effective EBT implementation. Discrepancies between supervision practice elements observed in trials as compared to routine practice highlights the importance of research addressing supervision-focused implementation strategies.

Clinical supervision approach predicts evidence-based trauma treatment delivery in children's mental health

OBJECTIVE

Observational studies of practices used in clinical supervision-as-usual can be leveraged to advance the limited research on workplace-based supervision as an evidence-based treatment (EBT) implementation strategy. This exploratory observational study examined the presence of supervision approaches (comprised of supervision techniques) and whether these predicted clinicians' EBT technique delivery.

METHODS

Participants included 28 supervisors, 70 clinician supervisees, and 60 youth clients and guardians from 17 public mental health organizations. Data included audio recorded supervision-as-usual sessions over 1 year, audio recorded Trauma-focused Cognitive Behavioral Therapy (TF-CBT) treatment sessions with youth for 6 months, and youth-reported post-traumatic stress severity scores. Audio recordings of 438 supervision sessions were coded for session duration and the presence of 13 supervision techniques and intensity of their coverage. Audio recordings of 465 treatment sessions were coded for presence and intensity of coverage of TF-CBT practice elements. Agglomerative hierarchical cluster analysis examined the presence of clusters of supervision technique use, termed supervision approaches. Generalized estimating equations estimated the relation between supervision approaches and delivery of TF-CBT elements.

RESULTS

Two supervision approaches were identified- Supportive-Directive and Supportive- that discriminated between use of five supervision techniques. Clinicians who received a higher proportion of supportive-directive supervision sessions had greater odds of delivering the trauma narrative with a client.

CONCLUSION

Findings suggest that patterns of supervision techniques can be identified and may shape EBT delivery. Supervision approaches show some evidence of being tailored to individual clinicians. Implications for the development of supervision implementation strategies and future directions are discussed.

Supporting the mental health needs of underserved communities: A qualitative study of barriers to accessing community resources

This study examined the accessibility of community resources (e.g., welfare programs and afterschool programs) for underserved youth and families with mental health needs. Mental health professionals (n = 52) from a large community mental health and welfare agency serving predominantly low-income, Latinx families completed a semistructured interview that asked about the accessibility of community resources. Participant responses were coded using an inductive thematic analysis. Results showed that 71% of participants endorsed availability barriers (e.g., limited local programs), 37% endorsed logistical barriers (e.g., waitlists), 27% endorsed attitudinal barriers (e.g., stigmatized beliefs about help-seeking), and 23% endorsed knowledge barriers (e.g., lacking awareness about local programs). Professionals' perceived availability barriers were mostly consistent with the actual availability of community resources. Findings highlight the compounding challenges that underserved communities face and point to opportunities for promoting enhanced well-being and functioning for youth and families with mental health needs.

"I see your punitive measure and I raise you a person-centered bar": Supervisory Strategies to Promote Adoption of Person-Centered Care

Person-centered care remains a high priority within community mental health services. Clinical supervision is an embedded resource for professional development and promotion of high quality care. This study examined supervisory strategies during the implementation of person-centered care planning (PCCP) across two northeastern US States. A criterion sample of supervisor-provider teams participated in qualitative interviews (N = 34) and direct observation from 2016 to 2017. Modified grounded theory analyses were conducted and three supervisory strategies were identified. Supervisory attunement to providers (knowing their audience), active collaborative engagement with providers (practicing together), and infusing reminders and opportunities for feedback (chipping away) were critical strategies to engage providers in adopting PCCP. These strategies changed providers' practice patterns by improving supervisors' calibration to dynamic contextual and individual needs during implementation and communicating supervisors' expectations of PCCP enactment. Workplace-based clinical supervision holds promise as a key intervention point to embed high quality care.

Contributions et défis de l’utilisation des technopédagogies à des fins de soutien à l’appropriation des meilleures pratiques en santé mentale

Contexte Malgré les ressources considérables consacrées et les efforts des nombreux acteurs concernés, l’écart entre la production de connaissances scientifiques et leur utilisation dans la pratique demeure un défi. L’utilisation des technologies de l’information et des communications (TICs) constitue un outil précieux pour réduire cet écart. Afin de relever ce défi, un projet de démonstration misant sur l’utilisation des technologies à des fins d’application des connaissances a été déployé auprès de 23 équipes de soutien dans la communauté de 5 régions du Québec (2016-2018). Plus de 324 professionnels de la santé mentale, chefs d’équipe et gestionnaires ont bénéficié de l’initiative À portée de main, les meilleures pratiques axées vers le rétablissement.

Objectif Cet article présente les résultats de l’étude de satisfaction effectuée auprès des chefs d’équipe responsables du soutien clinique dans les équipes de soutien dans la communauté à l’étude. L’objectif de cette étude consiste à enrichir la compréhension d’enjeux colligés en cours d’implantation et d’émettre des recommandations en vue d’une mise à l’échelle pérenne du programme d’application des connaissances mis en oeuvre.

Méthode Un devis qualitatif en recherche évaluative a été privilégié. Au terme du processus d’implantation du programme, 2 entrevues de groupe ont été effectuées avec les chefs d’équipe. Une analyse de contenu suivant une approche inductive à 3 niveaux de codification a été réalisée.

Résultats Les résultats montrent un décalage numérique important au sein du réseau de la santé et des services sociaux québécois comparativement à d’autres secteurs d’activités. Les participants soulignent l’importance de se doter de mécanismes d’échange et de transfert des connaissances intégrés aux pratiques organisationnelles (temps dédié, supervision clinique formelle, etc.) mettant à contribution les TICs.

Conclusion Malgré une importante mise à niveau technologique requise, les résultats confirment la pertinence d’utiliser les technopédagogies comme principal moyen pour soutenir l’application des connaissances et la transformation des pratiques. Les outils conçus et les modalités de soutien explorés semblent faciliter l’accès aux meilleures pratiques en santé mentale et favoriser leur adoption.

Building community-based helping practices by training peer-father counselors: A novel intervention to reduce drinking and depressive symptoms among fathers through an expanded masculinity lens

BACKGROUND

Problem drinking and co-occurring depression symptoms affect men at high rates and are associated with increased risk of family violence. In low- and middle-income countries, there is a large treatment gap for services due to a lack of human resources. Moreover, masculine norms are a barrier to men seeking treatment for drinking and depression in healthcare settings. We examined an approach for engaging peer-fathers to deliver an intervention to reduce alcohol use, improve depressive symptoms, and increase family involvement among fathers in Kenya with problem drinking. The intervention-LEAD (Learn, Engage, Act, Dedicate)-combines motivational interviewing, behavioral activation, and masculinity discussion strategies.

METHODS

Community and religious leaders nominated fathers with no mental health training to serve as counselors (N=12); clients were recruited through community referrals. Nominated fathers completed a 10-day training beginning with treatment principles followed by manualized content. Three counselors were selected after training based on quantitative and qualitative assessments of communication skills, intervention knowledge, willingness to learn, ability to use feedback, and empathy. Supervision was tiered with local supervisors and clinical psychologist consultation. During LEAD delivery, counselor fidelity, delivery quality, and general and intervention-specific competencies were assessed. To evaluate acceptability, qualitative interviews were conducted with lay-counselors and clients (N=11). Descriptive statistics were calculated for quantitative outcomes; interviews were analyzed using thematic analysis.

RESULTS

Peer-father lay counselors treated nine clients, with eight completing treatment. Counselors reached high rates of fidelity (93.8%) and high to optimal ratings on quality of delivery, clinical competency, and intervention-specific competencies. Qualitative results suggested high acceptability, with counselors expressing satisfaction and empowerment in their roles. Clients likewise described positive experiences with counselors.

CONCLUSIONS

Findings provide initial support for the acceptability and feasibility of recruitment, selection, and training processes for peer-father lay counselors to deliver LEAD through a lens of masculinity that aligned with clients help-acceptance practices.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Implementing Person-Centered Care Planning: A Randomized Controlled Trial

OBJECTIVE

Person-centered care is a key quality indicator and central to promoting integrated and recovery-oriented services. Person-centered care planning (PCCP) is a manualized intervention promoting the collaborative cocreation of a recovery-oriented care service plan on the basis of an individual's most valued life goals. This cluster randomized controlled trial tested the effect of PCCP training on person-centered care delivery in community mental health clinics.

METHODS

Fourteen clinic sites were randomly assigned to receive either PCCP training (N=7; experimental condition) or service planning as usual (N=7; control condition). Data were collected from online surveys, and service plans were completed by 60 provider teams. The Person-Centered Care Planning Assessment Measure was administered via chart review at baseline, 12 months, and 18 months, and surveys were used to measure supervision, implementation leadership, and program type. The main effect was examined with linear mixed-effects regression models, with observations over time.

RESULTS

Analyses controlling for service user and program characteristics revealed that at 12 months, the group assigned to PCCP training showed significant improvements in delivering person-centered care compared with the control group (b=1.10, SE=0.50, p=0.03). At 18 months, this effect was even more pronounced (b=1.47, SE=0.50, p=0.01), representing a medium-to-large effect size of d=0.71 (95% confidence interval=0.23-1.20).

CONCLUSIONS

These findings indicate that training providers in PCCP increases provider competency in delivering person-centered care. Using an objective measure of person-centered care, the authors show that a comprehensive training strategy can target both the philosophical shift and the technical skills needed to promote client recovery.

Clinical Supervision of Mental Health Services: A Systematic Review of Supervision Characteristics and Practices Associated with Formative and Restorative Outcomes

In this review, the authors examined supervision characteristics and practices associated with formative (e.g., skill development) and restorative (e.g., well-being) provider outcomes. We used qualitative review to summarize supervision characteristics associated with desired outcomes. Then, we applied a distillation approach (Chorpita et al., 2005) to identify practices associated with formative and restorative outcomes. The most common practices for promoting formative outcomes were corrective feedback, discussing intervention, and role play. Findings indicate several supervision strategies have demonstrated empirical support for improving formative outcomes. However, more rigorous research is needed in community settings, particularly for understanding which strategies improve restorative outcomes.

Clinical Supervision in Community Mental Health: Characterizing Supervision as Usual and Exploring Predictors of Supervision Content and Process

Clinical supervision can be leveraged to support implementation of evidence-based practices in community mental health settings, though it has been understudied. This study focuses on 32 supervisors at 23 mental health organizations in Philadelphia. We describe characteristics of supervisors and organizations and explore predictors of supervision content and process. Results highlight a low focus on evidence-based content and low use of active supervision processes. They underscore the need for further attention to the community mental health context when designing supervision-targeted implementation strategies. Future work should assess whether supervision models specific to community mental health are needed.

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients

BACKGROUND

The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene.

OBJECTIVE

To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection.

DESIGN

Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057).

PARTICIPANTS

A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study.

MAIN MEASURES

Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records.

KEY RESULTS

Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively).

CONCLUSIONS

Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.

Preventing harm related to CBT supervision: a theoretical review and preliminary framework

Like any treatment, cognitive behavioural therapy (CBT) may have negative as well as positive outcomes, and the same is true of CBT supervision. This is recognized in definitions of supervision, which prioritize helping supervisees to ‘do no harm’ to their patients. Client harm is associated with personal distress in supervisees (therapists), such as burnout, resulting in sub-standard therapy which causes harm to patients. Some supervisors have contributed to the supervisees’ distress, and consequently to patient harm. Harm may also arise from other staff members, or from situational factors that impact negatively on various aspects of the healthcare environment. At a more distal level, the host organization may create a context that allows such problems to go unchecked (e.g. a failure to train or support supervisors adequately). It follows that a large-scale framework is necessary to fully understand and address this multi-dimensional and systemic context for harm. Therefore, this theoretical review sketches out a preliminary ‘infidelity framework’ in order to classify ten types of problem behaviour that commonly contribute to harm that is linked to supervision. Drawing on related frameworks and neighbouring literatures, the infidelity framework also offers an understanding of the typical antecedents and consequences of each of these ten behaviours. This generic functional analysis leads to examples of evidence-based CBT supervision that might prevent or rectify harm.

Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study

OBJECTIVE

This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa.

METHOD

One hundred and ninety recorded FBT sessions from 68 adolescents with anorexia nervosa and their families were recruited across multiple sites (N = 6). Each site provided 1-4 tapes per family over four treatment time points, and each was independently rated for therapist adherence.

RESULTS

There were differences in adherence scores within and between sites. ANOVA produced a main effect for site, F(5, 46) = 8.6, p < .001, and phase, F(3, 42) = 12.7, p < .001, with adherence decreasing in later phases. Adherence was not associated to end of treatment percent ideal body weight after controlling for baseline percent ideal body weight (r = .088, p = .48).

CONCLUSIONS

Results suggest that FBT can be delivered with adherence in phase one of treatment. Adherence was not associated with treatment outcome as determined using percent ideal body weight.

Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial

BACKGROUND

General medical hospitals provide care for a disproportionate share of patients who misuse substances. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance misuse.

OBJECTIVE

To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients.

DESIGN

Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057).

PARTICIPANTS

Thirty-eight providers (physicians, physician assistants, nurses) from 13 general medical inpatient services, and 1173 of their patients admitted to an academically affiliated acute care hospital.

INTERVENTIONS

Implementation strategies included (1) a continuing medical education workshop on detection of substance misuse and provision of a motivational interview; (2) workshop plus bedside supervision (apprenticeship condition); and (3) a workshop plus ability to place a medical order for an interview from a consultation-liaison service (consult condition).

MAIN MEASURES

Primary outcomes were the percentage of study-eligible patients who received an interview for substance misuse and the integrity (adherence, competence) of the interviews. The secondary outcome was the percent of patient statements within the interviews that indicated motivation for reducing substance misuse.

KEY RESULTS

20.5% of patients in the consult condition received an interview, compared to 0.8% (Hedge's g = 1.49) and 3.0% (Hedge's g = 1.26) in the respective workshop only and apprenticeship conditions (p < 0.001). Motivational interviews in the consult condition were performed with more fundamental motivational interviewing adherence and competence than the other conditions. Most statements made by patients during the interviews favored reducing substance misuse, with no differences between conditions.

CONCLUSIONS

Providers' ability to place an order to have experts from the consultation-liaison service deliver a motivational interview was a more effective implementation strategy than a workshop or apprenticeship method for ensuring motivational interviewing is available to medical inpatients who misuse substances.

TRIAL REGISTRY

NCT01825057.

Elucidating the influence of supervisors' roles on implementation climate

Background

Supervisors play an essential role in implementation by diffusing and synthesizing information, selling implementation, and translating top management’s project plans to frontline workers. Theory and emerging evidence suggest that through these roles, supervisors shape implementation climate—i.e., the degree to which innovations are expected, supported, and rewarded. However, it is unclear exactly how supervisors carry out each of these roles in ways that contribute to implementation climate—this represents a gap in the understanding of the causal mechanisms that link supervisors’ behavior with implementation climate. This study examined how supervisors’ performance of each of these roles influences three core implementation climate domains (expectations, supports, and rewards).

Materials and methods

A sequenced behavioral health screening, assessment, and referral intervention was implemented within a county-based child welfare agency. We conducted 6 focus groups with supervisors and frontline workers from implementing work units 6 months post-implementation (n = 51) and 1 year later (n = 40) (12 groups total). Participants were asked about implementation determinants, including supervision and implementation context. We audio-recorded, transcribed, and analyzed focus groups using an open coding process during which the importance of the supervisors’ roles emerged as a major theme. We further analyzed this code using concepts and definitions related to middle managers’ roles and implementation climate.

Results

In this work setting, supervisors (1) diffused information about the intervention proactively, and in response to workers’ questions, (2) synthesized information by tailoring it to workers’ individual needs, (3) translated top managements’ project plans into day-to-day tasks through close monitoring and reminders, and (4) justified implementation. All four of these roles appeared to shape the implementation climate by conveying strong expectations for implementation. Three roles (diffusing, synthesizing, and mediating) influenced climate by supporting workers during implementation. Only one role (diffusing) influenced climate by conveying rewards.

Conclusions

Supervisors shaped implementation climate by carrying out four roles (diffusing, synthesizing, mediating, and selling). Findings suggest that the interaction of these roles convey expectations and support for implementation (two implementation climate domains). Our study advances the causal theory explaining how supervisors’ behavior shapes the implementation climate, which can inform implementation practice.

Clinical Supervision of Mental Health Professionals Serving Youth: Format and Microskills

Clinical supervision is an element of quality assurance in routine mental health care settings serving children; however, there is limited scientific evaluation of its components. This study examines the format and microskills of routine supervision. Supervisors (n = 13) and supervisees (n = 20) reported on 100 supervision sessions, and trained coders completed observational coding on a subset of recorded sessions (n = 57). Results indicate that microskills shown to enhance supervisee competency in effectiveness trials and experiments were largely absent from routine supervision, highlighting potential missed opportunities to impart knowledge to therapists. Findings suggest areas for quality improvement within routine care settings.

Agreement and Discrepancy Between Supervisor and Clinician Alliance: Associations with Clinicians' Perceptions of Psychological Climate and Emotional Exhaustion

Despite increasing interest in supervision as a leverage point for bolstering public mental health services, the potential influence of supervisory alliance on organizations and direct service providers remains understudied, particularly in the context of supporting evidence-based treatment (EBT) use. This study examined agreement and discrepancy between supervisor and clinician ratings of alliance associated with clinicians' perceptions of psychological climate and emotional exhaustion. Results indicated that discrepancies in alliance ratings were common and associated with clinicians' perceptions of psychological climate. These findings have important implications for collaboration among supervisors and clinicians within a community mental health organizational context and the provision of EBTs.

Psychology's Replication Crisis and Clinical Psychological Science

Despite psychological scientists' increasing interest in replicability, open science, research transparency, and the improvement of methods and practices, the clinical psychology community has been slow to engage. This has been shifting more recently, and with this review, we hope to facilitate this emerging dialogue. We begin by examining some potential areas of weakness in clinical psychology in terms of methods, practices, and evidentiary base. We then discuss a select overview of solutions, tools, and current concerns of the reform movement from a clinical psychological science perspective. We examine areas of clinical science expertise (e.g., implementation science) that should be leveraged to inform open science and reform efforts. Finally, we reiterate the call to clinical psychologists to increase their efforts toward reform that can further improve the credibility of clinical psychological science.

Implementing evidence-based treatment protocols: Flexibility within fidelity

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

Implementation Climate and Time Predict Intensity of Supervision Content Related to Evidence Based Treatment

Objective: Children infrequently receive evidence-based treatments (EBTs) for mental health problems due to a science-to-practice implementation gap. Workplace-based clinical supervision, in which supervisors provide oversight, feedback, and training on clinical practice, may be a method to support EBT implementation. Our prior research suggests that the intensity of supervisory focus on EBT (i.e., thoroughness of coverage) during workplace-based supervision varies. This study explores predictors of supervisory EBT intensity.

Methods: Participants were twenty-eight supervisors and 70 clinician supervisees. They completed a baseline survey, and audio recorded supervision sessions over 1 year. Four hundred and thirty eight recordings were coded for supervision content. We chose to explore predictors of two EBT content elements due to their strong evidence for effectiveness and sufficient variance to permit testing. These included a treatment technique (“exposure”) and a method to structure treatment (“assessment”). We also explored predictors of non-EBT content (“other topics”). Mixed-effects models explored predictors at organizational/supervisor, clinician, and session levels.

Results: Positive implementation climate predicted greater intensity of EBT content coverage for assessment (coefficient = 0.82, p = 0.004) and exposure (coefficient = 0.87, p = 0.001). Intensity of exposure coverage was also predicted by more time spent discussing each case (coefficient = 0.04, p < 0.001). Predictors of greater non-EBT content coverage included longer duration of supervision sessions (coefficient = 0.05, p < 0.001) and lower levels of supervisor EBT knowledge (coefficient = −0.17, p = 0.013). No other supervisor- or clinician-level variables were significant predictors in the mixed effects models.

Conclusion: This was the first study to explore multi-level predictors of objectively coded workplace-based supervision content. Results suggest that organizations that expect, support and reward EBT are more likely to have greater intensity of EBT supervision coverage, which in turn may positively impact clinician EBT fidelity and client outcomes. There was evidence that supervisor knowledge of the EBT contributes to greater coverage, although robust supervisor and clinician factors that drive supervision are yet to be identified. Findings highlight the potential effectiveness of implementation strategies that simultaneously address organizational implementation climate and supervisor practices. More research is needed to identify mechanisms that support integration of EBT into supervision.

Implementing Transdiagnostic Cognitive Behavioral Psychotherapy in Adult Public Behavioral Health: A Pilot Evaluation of the Feasibility of the Common Elements Treatment Approach (CETA)

Few evidence-based psychotherapies are provided in adult public behavioral health (PBH), despite the need for such treatments. The common elements treatment approach (CETA) was developed for use by lay providers in low- and middle-income countries and may have relevance in PBH given its unique application with individuals with multiple diagnoses including PTSD, depression, and anxiety. This study utilized data collected as part of the implementation of CETA in 9 PBH agencies in Washington State with 58 providers, including a 2-day workshop and 6 months of consultation. Outcomes included provider-perceived skill in CETA delivery, training and consultation completion rates, and perceived appropriateness of CETA for clients. Thirty-nine (67%) providers completed requirements for training and consultation, and delivered CETA to a total of 56 clients. Perceived competence in delivering CETA improved over time, as well as client symptom scores. CETA shows promise for feasible and effective implementation within US-based PBH systems.

Proposing a Mechanistic Model of Clinician Training and Consultation

To make evidence-based treatments deliverable, effective, and scalable in community settings, it is critical to develop a workforce that can deliver evidence-based treatments as designed with skill. However, the science and practice of clinician training and consultation lags behind other areas of implementation science. In this paper, we present the Longitudinal Education for Advancing Practice (LEAP) model designed to help span this gap. The LEAP model is a mechanistic model of clinician training and consultation that details how training inputs, training and consultation strategies, and mechanisms of learning influence training outcomes. We first describe the LEAP model and then discuss how key implications of the model can be used to develop effective training and consultation strategies.

Supervision in Community Mental Health: Understanding Intensity of EBT Focus

The goal of the present study was to examine clinician, supervisor, and organizational factors that are associated with the intensity of evidence-based treatment (EBT) focus in workplace-based clinical supervision of a specific EBT, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Supervisors (n = 56) and clinicians (n = 207) from mental health organizations across Washington State completed online self-report questionnaires. Multilevel modeling (MLM) analyses were used to examine the relative influence of nested clinician and supervisor factors on the intensity of EBT focus in supervision. We found that 33% of the variance in clinician report of EBT supervision intensity clustered at the supervisor level and implementation climate was the only significant factor associated with EBT supervision intensity. While individual clinician and supervisor factors may play a role in EBT coverage in supervision, our results suggest that an implementation climate that supports EBT may be the most critical factor for improving intensity of EBT coverage. Thus, implementation efforts that address the extent to which EBTs are expected, rewarded, and supported within an organization may be needed to support greater coverage of EBT during workplace-based supervision.

Objective coding of content and techniques in workplace-based supervision of an EBT in public mental health

BACKGROUND

Workplace-based clinical supervision as an implementation strategy to support evidence-based treatment (EBT) in public mental health has received limited research attention. A commonly provided infrastructure support, it may offer a relatively cost-neutral implementation strategy for organizations. However, research has not objectively examined workplace-based supervision of EBT and specifically how it might differ from EBT supervision provided in efficacy and effectiveness trials.

METHODS

Data come from a descriptive study of supervision in the context of a state-funded EBT implementation effort. Verbal interactions from audio recordings of 438 supervision sessions between 28 supervisors and 70 clinicians from 17 public mental health organizations (in 23 offices) were objectively coded for presence and intensity coverage of 29 supervision strategies (16 content and 13 technique items), duration, and temporal focus. Random effects mixed models estimated proportion of variance in content and techniques attributable to the supervisor and clinician levels.

RESULTS

Interrater reliability among coders was excellent. EBT cases averaged 12.4 min of supervision per session. Intensity of coverage for EBT content varied, with some discussed frequently at medium or high intensity (exposure) and others infrequently discussed or discussed only at low intensity (behavior management; assigning/reviewing client homework). Other than fidelity assessment, supervision techniques common in treatment trials (e.g., reviewing actual practice, behavioral rehearsal) were used rarely or primarily at low intensity. In general, EBT content clustered more at the clinician level; different techniques clustered at either the clinician or supervisor level.

CONCLUSIONS

Workplace-based clinical supervision may be a feasible implementation strategy for supporting EBT implementation, yet it differs from supervision in treatment trials. Time allotted per case is limited, compressing time for EBT coverage. Techniques that involve observation of clinician skills are rarely used. Workplace-based supervision content appears to be tailored to individual clinicians and driven to some degree by the individual supervisor. Our findings point to areas for intervention to enhance the potential of workplace-based supervision for implementation effectiveness.

TRIAL REGISTRATION

NCT01800266 , Clinical Trials, Retrospectively Registered (for this descriptive study; registration prior to any intervention [part of phase II RCT, this manuscript is only phase I descriptive results]).