Independent Contractors in Public Mental Health Clinics: Implications for Use of Evidence-Based Practices

Should We Use Clinician Self-Report to Tailor Implementation Strategies? Predicting Use of Youth CBT with Clinician Self-Report Versus Direct Observation

Developing tailored implementation strategies to increase the use of evidence-based practice (EBP) requires accurate identification of predictors of their use. However, known difficulties with measuring EBP use complicates interpretation of the extant literature. In this proof-of-concept study, we examined whether the same predictors of use of cognitive behavioral therapy (CBT) are identified when CBT use is measured with clinician self-report compared to direct observation. We examined four candidate predictors of CBT use - clinician participation in an EBP training initiative, years of experience, caseload, and employment status - in a sample of 36 clinicians (64% female; 72% White and 28% Black) from 19 community mental health agencies treating youth in greater Philadelphia. CBT use was captured for 100 unique client sessions (M = 2.8 recorded sessions per clinician) through both clinician self-report and direct observation, using parallel measures. We used three-level (client, clinician, and agency) regression models with random intercepts to estimate the relationship between each predictor variable and CBT use in both measures and compared the magnitude and direction of each model across self-report and direct observation using z-tests. There was no alignment for any of the four candidate predictors between predictive relationships identified by self-report compared to those identified by direct observation. The findings in this study extend literature documenting limitations of using clinician self-report to capture clinician behavior and suggest that even the characteristics that predict higher self-reported CBT use do not align with (and often are discordant with) those that predict directly observed CBT use. This raises questions about the utility of relying on self-reported use to inform implementation strategy design.

Policy Recommendations for Coordinated and Sustainable Growth of the Behavioral Health Workforce

Policy Points Demand for behavioral health services outpaces the capacity of the existing workforce, and the unmet need for behavioral health services is expected to grow. This paper summarizes research and policy evidence demonstrating that the long-standing challenges that impede behavioral health workforce development and retention (i.e., low wages, high workloads, training gaps) are being replicated by growing efforts to expand the workforce through task-sharing delivery to nonspecialist behavioral health providers (e.g., peer specialists, promotores de salud). In this paper, we describe policy opportunities to sustain behavioral health workforce growth to meet demand while supporting fair wages, labor protections, and rigorous training.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention

BACKGROUND

Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching.

METHODS

We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors.

RESULTS

The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching.

CONCLUSION

Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Organization-level variation in therapists' attitudes toward and use of measurement-based care

PURPOSE

Despite significant interest in improving behavioral health therapists' implementation of measurement-based care (MBC)-and widespread acknowledgment of the potential importance of organization-level determinants-little is known about the extent to which therapists' use of, and attitudes toward, MBC vary across and within provider organizations or the multilevel factors that predict this variation.

METHODS

Data were collected from 177 therapists delivering psychotherapy to youth in 21 specialty outpatient clinics in the USA. Primary outcomes were use of MBC for progress monitoring and treatment modification, measured by the nationally-normed Current Assessment of Practice Evaluation-Revised. Secondary outcomes were therapist attitudes towards MBC. Linear multilevel regression models tested the association of theory-informed clinic and therapist characteristics with these outcomes.

RESULTS

Use of MBC varied significantly across clinics, with means on progress monitoring ranging from values at the 25th to 93rd percentiles and means on treatment modification ranging from the 18th to 71st percentiles. At the clinic level, the most robust predictor of both outcomes was clinic climate for evidence-based practice implementation; at the therapist level, the most robust predictors were: attitudes regarding practicality, exposure to MBC in graduate training, and prior experience with MBC. Attitudes were most consistently related to clinic climate for evidence-based practice implementation, exposure to MBC in graduate training, and prior experience with MBC.

CONCLUSIONS

There is important variation in therapists' attitudes toward and use of MBC across clinics. Implementation strategies that target clinic climate for evidence-based practice implementation, graduate training, and practicality may enhance MBC implementation in behavioral health.

Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia's Public Mental Health Clinicians

OBJECTIVE

Efforts to improve mental health treatment delivery come at a time of rising inequality and cuts or insufficient increases to mental health funding. Public mental health clinicians face increased demands, experience economic stress, and treat underresourced patients disproportionately burdened by trauma. The authors sought to understand clinicians' current economic and psychological conditions and the relationship of these conditions to the delivery of an evidence-based intervention (EBI) designed to treat posttraumatic stress disorder among youths.

METHODS

In July 2020, 49 public mental health clinicians from 16 Philadelphia clinics who were trained in an EBI, trauma-focused cognitive-behavioral therapy (TF-CBT), were surveyed by e-mail. Respondents reported on their economic precarity, financial strain, burnout, secondary traumatic stress (i.e., the stress response associated with caring for people exposed to trauma), and TF-CBT use. Associations between clinicians' job-related stressors and their use of TF-CBT were examined with mixed models. Content coding was used to organize clinicians' open-ended responses to questions regarding financial strain related to the COVID-19 pandemic.

RESULTS

Clinicians' economic precarity, financial strain, and job-related stress were high; 37% of clinicians were independent contractors, 44% of whom wanted a salaried position. Of 37 clinicians with education debt, 38% reported owing ≥$100,000. In the past year, 29% of clinicians reported lack of personal mental health care because of cost, and 22% met the cutoff for experiencing secondary traumatic stress symptoms. Education debt was negatively associated with use of TF-CBT (p<0.001).

CONCLUSIONS

The stress of providing care in underresourced clinical settings may interfere with efforts to integrate scientific evidence into mental health care.

Stakeholder intention to engage in fidelity measurement methods in community mental health settings: A mixed methods study

Background

The current gold standard for measuring fidelity (specifically, adherence) to cognitive behavioral therapy (CBT) is direct observation, a costly, resource-intensive practice that is not feasible for many community organizations to implement regularly. Recent research indicates that behavioral rehearsal (i.e., role-play between clinician and individual with regard to session delivery) and chart-stimulated recall (i.e., brief structured interview between clinician and individual about what they did in session; clinicians use the client chart to prompt memory) may provide accurate and affordable alternatives for measuring adherence to CBT in such settings, with behavioral rehearsal yielding greater correspondence with direct observation.

Methods

Drawing on established causal theories from social psychology and leading implementation science frameworks, this study evaluates stakeholders’ intention to use behavioral rehearsal and chart-stimulated recall. Specifically, we measured attitudes, self-efficacy, and subjective norms toward using each, and compared these factors across the two methods. We also examined the relationship between attitudes, self-efficacy, subjective norms, and intention to use each method. Finally, using an integrated approach we asked stakeholders to discuss their perception of contextual factors that may influence beliefs about using each method. These data were collected from community-based supervisors ( n = 17) and clinicians ( n = 66).

Results

Quantitative analyses suggest moderately strong intention to use both methods across stakeholders. There were no differences in supervisors’ or clinicians’ attitudes, self-efficacy, subjective norms, or intention across methods. More positive attitudes and greater reported subjective norms were associated with greater reported intention to use either measure. Qualitative analyses identified participants’ specific beliefs about using each fidelity measure in their organization, and results were organized using the Consolidated Framework for Implementation Research.

Conclusions

Strategies are warranted to overcome or minimize potential barriers to using fidelity measurement methods and to further increase the strength of intention to use them. Plain Language Summary: The best way to measure fidelity, or how closely a clinician follows the protocol, to Cognitive Behavioral Therapy (CBT) is watching the session. This is an expensive practice that is not feasible for many community organizations to do regularly. Recent research indicates that behavioral rehearsal, or a role-play between the clinician and individual with regard to session delivery, and chart-stimulated recall, or a brief discussion between an individual and the clinician about what they did in session with the clinician having access to the chart to help them remember, may provide accurate and affordable alternatives for measuring fidelity to CBT. We just completed a study demonstrating that both methods are promising, with behavioral rehearsal offering scores that are the most similar to watching the session. Drawing on established theories from social psychology and leading implementation science frameworks, this study evaluates future supervisor and clinician motivation to use these fidelity measurement methods. Specifically, we measured supervisor (n = 17) and clinician (n = 66) attitudes, norms, self-efficacy, intentions, and anticipated barriers and facilitators to using each of these fidelity measurement tools. Quantitative and qualitative analyses suggest similar intention to use both methods, and concerns about barriers to using each method. Further research is warranted to minimize the burden associated with implementing fidelity measurement methods and deploying strategies to increase use.

Organizational factors associated with community therapists' self-efficacy in EBP delivery: The interplay between sustainment leadership, sustainment climate, and psychological safety

Background

Inner context organizational factors proximally shape therapist experiences with evidence-based practice (EBP) implementation and may influence therapist self-efficacy, which has been linked to sustained use of EBPs in community mental health settings. Research has primarily focused on constructs such as implementation leadership and climate. However, the effects of such factors may depend upon other inner context dimensions, such as psychological safety. Psychologically safe environments are conducive to taking risks, speaking up about problems, and requesting feedback and may promote therapist self-efficacy during implementation. This study examines whether organizational sustainment leadership and sustainment climate relate to therapist EBP self-efficacy only under conditions of psychological safety.

Methods

Data were collected from 410 clinicians in 85 programs during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. Therapists reported on their organization's sustainment leadership, sustainment climate, psychological safety, and their own self-efficacy in delivering specific EBPs. Multilevel regression analyses were conducted to account for nested data structure.

Results

Among program-level variables, sustainment leadership and psychological safety both significantly predicted therapist self-efficacy. However, there were no significant interactions between program-level sustainment climate and psychological safety. Exploratory post-hoc analyses revealed a significant interaction between program-level sustainment leadership and therapist-level perceptions of psychological safety such that that the conditional effect of psychological safety on EBP self-efficacy was significant at high levels of sustainment leadership, but not at low or average levels.

Conclusion

We noted independent links between sustainment leadership, organizational psychological safety and therapists feelings of confidence and mastery with EBPs. Therapists' individual perceptions of psychological safety were linked to self-efficacy only in programs with high sustainment leadership. Thus, sustainment leadership and psychological safety may both represent implementation intervention targets, but it may not be critical to assess for perceptions of psychological safety before deploying organizational leadership strategies.Plain language abstract Therapist self-efficacy is a therapist's belief that they are capable, knowledgeable, and skilled enough to deliver evidence-based practices (EBPs), and is thought to promote improved clinical and implementation outcomes, such as therapists' sustained use of EBPs. Conditions within community mental health organizations may influence therapists' sense of EBP self-efficacy. Leaders' support and expectations for EBP implementation, and collective staff perceptions about the organization's climate to support EBPs are linked to positive therapist attitudes and EBP adoption. However, less is known about how these implementation-specific organizational factors associated with therapist EBP self-efficacy in the long-term, and how this may depend on general workplace conditions. Specifically, psychologically safe environments - where therapists feel safe taking risks such as asking questions, admitting mistakes, and trying new skills - may be needed to promote self-efficacy when therapists are tasked with learning and using complex multi-component EBP innovations. The current study tested the prediction that leader-driven and program-wide focus on EBP sustainment may promote therapist EBP self-efficacy only in organizations where conditions for learning are psychologically safe. Our findings confirmed that fostering strong sustainment focused leadership and psychologically safe environments may each be important for increasing therapists' EBP self-efficacy. The model results suggested that individual therapist perceptions of psychological safety were more strongly related to EBP self-efficacy in programs with greater implementation leadership. Findings suggest the importance of increasing EBP leadership behavior to fully potentiate other facilitating conditions for therapist learning in the sustainment phase of EBP implementation initiatives.

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services

Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.

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.

Therapist Financial Strain and Turnover: Interactions with System-Level Implementation of Evidence-Based Practices

Therapist turnover is a major problem in community mental health. Financial strain, which is composed of cognitive, emotional, and behavioral responses to the experience of economic hardship, is an understudied antecedent of therapist turnover given the tumultuous financial environment in community mental health. We prospectively examined the relationship between therapist financial strain and turnover in 247 therapists in 28 community mental health agencies. We expected greater therapist financial strain to predict higher turnover and participation in a system-funded evidence-based practice (EBP) training initiative to alleviate this effect. Controlling for covariates, financial strain predicted therapist turnover (OR 1.12, p = .045), but not for therapists who participated in an EBP training initiative. Reducing financial strain and/or promoting EBP implementation may be levers to reduce turnover.

Improving implementation of evidence based practice for people with psychosis through training the wider workforce: Results of the GOALS feasibility randomised controlled trial

BACKGROUND AND OBJECTIVES

There is a pressing need to improve access to evidence-based practice for people with psychosis. The primary aim of this study was to assess clinical feasibility of a manualised, evidence-based CBT intervention (GOALS) targeting a personalised recovery goal, delivered by the frontline workforce, following brief training. Secondly, we aimed to conduct preliminary statistical analyses of key outcomes and costs.

METHODS

The GOALS study is a feasibility randomised controlled trial (ISRCTN 73188383). 75 participants with current psychosis were recruited and randomly allocated to receive either treatment as usual alone or with GOALS therapy.

RESULTS

Brief training enabled frontline staff to deliver the therapy according to protocol and 74% of therapy participants partially or fully achieved their goals. There were significant improvements with a moderate effect size of 0.56 on goal attainment. However, preliminary statistical analyses found no significant differences between groups on our primary outcome of activity levels or other secondary outcomes Health economic analysis found that point estimates of costs, controlling for baseline costs, implied savings (even including intervention costs), but the difference was not statistically significant.

LIMITATIONS

The study was designed as a feasibility RCT, and therefore the results of secondary estimates of efficacy effects should be treated with caution.

CONCLUSIONS

This approach holds promise in supporting people with psychosis to reach personal recovery goals, cost effectively.

Synchronizing Watches: The Challenge of Aligning Implementation Science and Public Systems

This special issue of Administration and Policy in Mental Health explores the complexities of the outer system context in implementation science research. In this commentary, we highlight areas of asynchrony between implementation science research and policy realities of public systems. Timing is a critical factor for many aspects of system-level implementation including when and how evidence-based practice initiatives are launched, short and inconsistent timeframes for funding and support, need for early indicators of success and demonstrating return on investment. Greater consideration for the timing that drives change in public systems will strengthen efforts to implement and sustain EBPs in community settings.

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

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

Are general and strategic measures of organizational context and leadership associated with knowledge and attitudes toward evidence-based practices in public behavioral health settings? A cross-sectional observational study

BACKGROUND

Examining the role of modifiable barriers and facilitators is a necessary step toward developing effective implementation strategies. This study examines whether both general (organizational culture, organizational climate, and transformational leadership) and strategic (implementation climate and implementation leadership) organizational-level factors predict therapist-level determinants of implementation (knowledge of and attitudes toward evidence-based practices).

METHODS

Within the context of a system-wide effort to increase the use of evidence-based practices (EBPs) and recovery-oriented care, we conducted an observational, cross-sectional study of 19 child-serving agencies in the City of Philadelphia, including 23 sites, 130 therapists, 36 supervisors, and 22 executive administrators. Organizational variables included characteristics such as EBP initiative participation, program size, and proportion of independent contractor therapists; general factors such as organizational culture and climate (Organizational Social Context Measurement System) and transformational leadership (Multifactor Leadership Questionnaire); and strategic factors such as implementation climate (Implementation Climate Scale) and implementation leadership (Implementation Leadership Scale). Therapist-level variables included demographics, attitudes toward EBPs (Evidence-Based Practice Attitudes Scale), and knowledge of EBPs (Knowledge of Evidence-Based Services Questionnaire). We used linear mixed-effects regression models to estimate the associations between the predictor (organizational characteristics, general and strategic factors) and dependent (knowledge of and attitudes toward EBPs) variables.

RESULTS

Several variables were associated with therapists' knowledge of EBPs. Clinicians in organizations with more proficient cultures or higher levels of transformational leadership (idealized influence) had greater knowledge of EBPs; conversely, clinicians in organizations with more resistant cultures, more functional organizational climates, and implementation climates characterized by higher levels of financial reward for EBPs had less knowledge of EBPs. A number of organizational factors were associated with the therapists' attitudes toward EBPs. For example, more engaged organizational cultures, implementation climates characterized by higher levels of educational support, and more proactive implementation leadership were all associated with more positive attitudes toward EBPs.

CONCLUSIONS

This study provides evidence for the importance of both general and strategic organizational determinants as predictors of knowledge of and attitudes toward EBPs. The findings highlight the need for longitudinal and mixed-methods studies that examine the influence of organizational factors on implementation.