Knowing What To Do and When To Do It: Mental Health Professionals and the Evidence Base for Treatment Engagement

Understanding How and When Therapists Misstep: Navigating Engagement Challenges in Youth Mental Health Services

Therapist "missteps" (i.e., inadvertent, less optimal, or noncollaborative therapist behaviors) have the potential to negatively impact youth and family engagement in community mental health services. The present study explores potential misstep occurrences and whether they varied across various distal and proximal factors related to treatment planning, preparation, and clinical context. Data were drawn from a multi-site cluster-randomized controlled trial focused on promoting therapist use of evidence-informed procedures to engage youth and families in urban and rural community mental health services. Audio recordings from 391 treatment sessions delivered by 92 therapists were transcribed and coded for missteps occurrences. Missteps were sporadic, but occurred in most sessions, frequently manifesting as advice giving, but taking a variety of other forms. Their occurrence appeared to be lower when supervision involved preparing a plan for engaging the client, when there was a single participant in the session, and when treatment sessions occurred soon after supervision. Engaging in preparatory activities in supervision and receiving timely supervision prior to treatment delivery may be more protective against therapist missteps than simply selecting a practice to deliver. Additionally, unique challenges of family sessions may increase the likelihood of missteps occurring, highlighting the importance of specialized training for conducting family sessions.

Ethnic Identity and Mechanisms of Mental Health Service Engagement Among Young Adults with Serious Mental Illnesses

PURPOSE

Young adults from minoritized racial and ethnic groups have lower rates of engagement in treatment for serious mental illnesses (SMI). Previous research suggests a relationship between ethnic identity development and engagement in mental health services, but it remains unclear how a sense of belonging and attachment to one's racial and ethnic group influences participation in treatment among young adults with SMI.

METHODS

Bivariate analyses and structural equation modeling (SEM) were used to examine whether ethnic identity was associated with treatment engagement (attendance and investment in treatment) and how ethnic identity might influence engagement through theoretical proximal mediators. Eighty-three young adults with SMI (95% from minoritized racial and ethnic groups) were recruited from four outpatient psychiatric rehabilitation programs and assessed at least 3 months after initiating services.

RESULTS

Stronger ethnic identity was associated with greater investment in treatment but not with treatment attendance. The SEM analysis indicated that stronger ethnic identity may improve investment in treatment by enhancing hope (0.53, p < .05) and beliefs that mental health providers are credible (0.32, p < .05), and by increasing self-efficacy (-0.09, p < .05). Proximal mediators of engagement were associated with investment in treatment (hope and credibility, p < .05, and self-efficacy p = 0.055).

CONCLUSIONS

Findings provide preliminary evidence of an empirical and theoretical relationship between ethnic identity development and engagement in treatment among young adults with SMI. Assessment and strengthening of a young person's ethnic identity may be a promising approach for improving their engagement in services and reducing inequities in their care.

Effects of Compliance to a Training Intervention for High School Students with ADHD

OBJECTIVE

We evaluated the effects of treatment compliance with the Challenging Horizons Program (CHP) for high school aged adolescents with attention-deficit hyperactivity disorder (ADHD).

METHOD

Participants were 185 high school aged adolescents (65% non-Hispanic White; 79% male) with a diagnosis of ADHD who were randomly assigned to either CHP or community control. Outcomes included parent-rated academic functioning, parent- and self-rated social-emotional functioning, and GPA. The complier average causal effect (CACE) was estimated using propensity-weighted models for youth engaging in ≥ 30 CHP individual sessions (15-20 min) across the academic year.

RESULTS

Most (78%) CHP participants engaged in≥30 CHP sessions. CACE analyses using latent growth curve modeling revealed significant treatment effects among treatment compliers across ratings of academic and social outcomes relative to similar control participants. For most outcomes, CACE estimates were larger than those found in intent-to-treat analyses, especially at 6-months follow-up.

CONCLUSIONS

Compliance with 30 or more individual CHP sessions appeared to be an attainable threshold associated with incremental gains across several academic and social outcomes. Effects of compliance were amplified at 6-months follow-up, supporting the hypothesized theory of change of training interventions. Future work should focus on facilitators of treatment engagement and feasibility of the CHP as delivered by high school personnel.

Engagement Barriers to Behavior Therapy for Adolescent ADHD

OBJECTIVE

To identify barriers to behavior therapy for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND) and understand the relationship between barriers and treatment engagement.

METHOD

A mixed-method design with qualitative coding of 822 audio-recorded therapy sessions attended by 121 adolescents with ADHD (ages 11-16; 72.7% male, 77.7% Latinx, 7.4% African-American, 11.6% White, non-Latinx) and parents. Grounded theory methodology identified barriers articulated by parents and adolescents in session. Barriers were sorted by subtype (cognitive/attitudinal, behavioral, logistical) and subject (parent, teen, dyad). Frequency and variety of barriers were calculated by treatment phase (engagement, skills, planning). Generalized linear models and generalized estimating equations examined between-phase differences in frequency of each barrier and relationships between barriers frequency, subtype, subject, and phase on engagement (attendance and homework completion).

RESULTS

Coding revealed twenty-five engagement barriers (ten cognitive/attitudinal, eleven behavioral, four logistical). Common barriers were: low adolescent desire (72.5%), parent failure to monitor skill application (69.4%), adolescent forgetfulness (60.3%), and adolescent belief that no change is needed (56.2%). Barriers were most commonly cognitive/attitudinal, teen-related, and occurring in STAND's planning phase. Poorer engagement was associated with cognitive/attitudinal, engagement phase, and dyadic barriers. Higher engagement in treatment was predicted by more frequent behavioral, logistical, parent, and skills/planning phase barriers.

CONCLUSIONS

Baseline assessment of barriers may promote individualized engagement strategies for adolescent ADHD treatment. Cognitive/attitudinal barriers should be targeted at treatment outset using evidence-based engagement strategies (e.g., Motivational Interviewing). Behavioral and logistical barriers should be addressed when planning and reviewing application of skills.

Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service

The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.

How Do Treatment Protocols Affect the Use of Engagement Practices in Youth Mental Health Services?

PURPOSE

Treatment engagement poses challenges for youth mental health providers. With the expansion of evidence-based treatments (EBTs), providers face complex decisions regarding how to engage youth and families using available information sources. This study investigated how EBT protocols are associated with the selection and delivery of engagement practices.

METHOD

Twenty engagement practices were coded in a sample of digital recordings of early treatment sessions (N = 193) from the Child STEPs in California study, a randomized trial testing modular treatment and community-implemented treatment for youth mental health problems. Data were collected on which protocols mental health providers reportedly used to guide their sessions and the protocols in which they had received training. We examined which information sources (i.e., the guiding protocol, other protocols in training history, unspecified source) were associated with observed engagement practices.

RESULTS

In sessions guided by a protocol, most observed engagement practices were accounted for by the guiding protocol (p < .001), rather than protocols in training history or unspecified sources (p < .001). In sessions not guided by a protocol, most observed practices were accounted for by training history (p < .001). Practice frequency and extensiveness was generally greater when a protocol guided the session.

CONCLUSIONS

Inclusion in protocols is associated with the selection and delivery of engagement practices, but this strategy might be insufficient for supporting the use of the full range of engagement practices supported by evidence. Supports are needed that leverage the engagement evidence base to ensure that selected practices empirically fit the engagement needs of youth and families.

Testing the Impact of a Peer-Delivered Family Support Program: A Randomized Clinical Effectiveness Trial

OBJECTIVE

The effectiveness of NAMI Basics, a peer-led family support program for caregivers of children with mental health concerns, was tested in a sample of caregivers referred to five National Alliance on Mental Illness (NAMI) affiliates in a large southwestern state.

METHOD

Caregivers of children with mental health concerns (N=111; 69% biological mothers, 45% Hispanic/Latinx, 33% Caucasian, and 12% African American) were randomly assigned to a six-class NAMI Basics course led by peer parents or an 8-week waitlist condition. At baseline and 8 weeks after the course began, all caregivers completed measures assessing services engagement and activation, attitudes toward mental health services, parenting stress, and youth symptoms. Data were analyzed by using linear regression.

RESULTS

Compared with caregivers in the waitlist condition, NAMI Basics participants reported significant increases in parent engagement and activation, as well as intentions to engage with mental health services. NAMI Basics participants also reported significant decreases in their child's intrapersonal and interpersonal distress, compared with those in the waitlist group. No significant differences were noted on measures of parenting stress, attitudes toward mental health services, or stigma.

CONCLUSIONS

NAMI Basics affected caregiver outcomes and youth symptoms, as measured by caregiver report, compared with a waitlist control group. Peer-led services, such as NAMI Basics, may increase engagement with effective mental health services for youths and families.

A Multidimensional Examination of the Measurement of Treatment Engagement: Implications for Children's Mental Health Services and Research

OBJECTIVE

The gap between rates of children's mental health problems and their participation in services highlights the need to address concerns related to engagement in mental health services more effectively. To identify, understand, and resolve engagement concerns appropriately requires effective measurement. In this study, we employed a multidimensional conceptual framework of engagement to examine the measurement of engagement in intervention studies focused on improving children's and/or families' engagement in services.

METHOD

We coded 52 randomized controlled trials (RCTs) of interventions designed to enhance treatment engagement published between 1974 and 2019 to examine what engagement constructs have been measured, how these constructs have been measured, who has provided information about engagement, and when and why engagement measures have been administered.

RESULTS

Attendance was measured in 94.2% of studies, and 59.6% of studies measured only attendance. Furthermore, most studies (61.5%) measured only one engagement dimension. One hundred twelve unique indicators of treatment engagement were used (61.6% measuring attendance). Infrequent measurement of youth (19.2% of studies) or caregiver (26.9%) perspectives was apparent. About half (54.7%) of measures were completed on one occasion, with 53.7% of measures completed after treatment was concluded.

CONCLUSIONS

Results highlight how the field's measurement of engagement has focused narrowly on attendance and on interventions that improve attendance. We consider promising new directions for capturing the multidimensional, dynamic, and subjective aspects of engagement, and for leveraging measurement in research and practice settings to feasibly and effectively identify, monitor, and address engagement challenges.

Engaging Parents in Mental Health Services: A Qualitative Study of Community Health Workers' Strategies in High Poverty Urban Communities

Empirical engagement-promoting strategies in child and family mental health services have been identified largely within the context of clinic-based services delivered by mental health professionals. However, the magnitude of unmet youth mental health need necessitates expanding the scope of mental health services, and the associated engagement strategies, beyond traditional models and service providers. The present study aimed to extend our understanding of engagement strategies to a school-based mental health service model, using a community health worker (CHW) workforce implementing an early intervention program with parents and school-aged children (K-4) in high poverty urban communities. Qualitative semi-structured individual interviews were conducted with 16 CHWs to capture their descriptions of the engagement strategies they utilized with parents throughout program implementation. Transcripts were coded and themes were identified following procedures for thematic analysis. Thematic analyses revealed ten themes describing a range of engagement strategies falling into two overarching categories: (1) rapport building, and (2) responsive delivery. Themes within the rapport building category included non-judgmental supportive listening, increasing social proximity, praise, privacy and confidentiality, and leveraging relationships. Themes within the responsive delivery category included flexibility, consistency, advocacy, incentives, and meeting needs. Findings provide preliminary evidence regarding the ability of CHWs to identify and implement a range of engagement strategies with parents and families that parallel empirically-based engagement strategies in traditional services. These findings speak to the potential of this workforce to engage underserved families in mental health services, underscoring the important role for CHWs in reducing mental health disparities.