Population mental health science: Guiding principles and initial agenda.

A recent American Psychological Association Summit provided an urgent call to transform psychological science and practice away from a solely individual-level focus to become accountable for population-level impact on health and mental health. A population focus ensures the mental health of all children, adolescents, and adults and the elimination of inequities across groups. Science must guide three components of this transformation. First, effective individual-level interventions must be scaled up to the population level using principles from implementation science, investing in novel intervention delivery systems (e.g., online, mobile application, text, interactive voice response, and machine learning-based), harnessing the strength of diverse providers, and forging culturally informed adaptations. Second, policy-driven community-level interventions must be innovated and tested, such as public efforts to promote physical activity, public policies to support families in early life, and regulation of corporal punishment in schools. Third, transformation is needed to create a new system of universal primary care for mental health, based on models such as Family Connects, Triple P, PROmoting School-community-university Partnerships to Enhance Resilience, Communities That Care, and the Early Childhood Collaborative of the Pittsburgh Study. This new system must incorporate valid measurement, universal screening, and a community-based infrastructure for service delivery. Addressing tasks ahead, including scientific creativity and discovery, rigorous evaluation, and community accountability, will lead to a comprehensive strategic plan to shape the emergent field of public mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Critical Need for a Population Health Approach: Addressing the Nation's Behavioral Health During the COVID-19 Pandemic and Beyond.

The COVID-19 global pandemic highlights the necessity for a population health approach to identify and implement strategies across systems to improve behavioral health. Adopting a population health approach helps to address the needs of the total population, including at-risk subgroups, through multiple levels of intervention and to promote the public's behavioral health and psychological well-being.

Correction to: A repeated cross-sectional study of clinicians' use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia.

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A repeated cross-sectional study of clinicians' use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia.

BACKGROUND: Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static. METHOD: Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia's public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years (n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised. RESULTS: Clinicians were 80% female and averaged 37.52 years of age (SD = 11.40); there were no significant differences in clinician characteristics across waves (all ps > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 (M = 3.18) to wave 3 (M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques (p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use (p = .019) but no change in psychodynamic technique use (p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048). CONCLUSIONS: System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.

Concordance Between Administrator and Clinician Ratings of Organizational Culture and Climate.

Organizational culture and climate are important determinants of behavioral health service delivery for youth. The Organizational Social Context measure is a well validated assessment of organizational culture and climate that has been developed and extensively used in public sector behavioral health service settings. The degree of concordance between administrators and clinicians in their reports of organizational culture and climate may have implications for research design, inferences, and organizational intervention. However, the extent to which administrators' and clinicians' reports demonstrate concordance is just beginning to garner attention in public behavioral health settings in the United States. We investigated the concordance between 73 administrators (i.e., supervisors, clinical directors, and executive directors) and 247 clinicians in 28 child-serving programs in a public behavioral health system. Findings suggest that administrators, compared to clinicians, reported more positive cultures and climates. Organizational size moderated this relationship such that administrators in small programs (<466 youth clients served annually) provided more congruent reports of culture and climate in contrast to administrators in large programs (≥466 youth clients served annually) who reported more positive cultures and climates than clinicians. We propose a research agenda that examines the effect of concordance between administrators and clinicians on organizational outcomes in public behavioral health service settings.

Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems.

OBJECTIVE: Use of expert-led workshops plus consultation has been established as an effective strategy for training community mental health (CMH) clinicians in evidence-based practices (EBPs). Because of high rates of staff turnover, this strategy inadequately addresses the need to maintain capacity to deliver EBPs. This study examined knowledge, competency, and retention outcomes of a two-phase model developed to build capacity for an EBP in CMH programs. METHODS: In the first phase, an initial training cohort in each CMH program participated in in-person workshops followed by expert-led consultation (in-person, expert-led [IPEL] phase) (N=214 clinicians). After this cohort completed training, new staff members participated in Web-based training (in place of in-person workshops), followed by peer-led consultation with the initial cohort (Web-based, trained-peer [WBTP] phase) (N=148). Tests of noninferiority assessed whether WBTP was not inferior to IPEL at increasing clinician cognitive-behavioral therapy (CBT) competency, as measured by the Cognitive Therapy Rating Scale. RESULTS: WBTP was not inferior to IPEL at developing clinician competency. Hierarchical linear models showed no significant differences in CBT knowledge acquisition between the two phases. Survival analyses indicated that WBTP trainees were less likely than IPEL trainees to complete training. In terms of time required from experts, WBTP required 8% of the resources of IPEL. CONCLUSIONS: After an initial investment to build in-house CBT expertise, CMH programs were able to use a WBTP model to broaden their own capacity for high-fidelity CBT. IPEL followed by WBTP offers an effective alternative to build EBP capacity in CMH programs, rather than reliance on external experts.

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.

Predictors of clinician use of exposure therapy in community mental health settings.

Exposure therapy is recognized as the key component of cognitive-behavioral treatment for anxiety. However, exposure is the least used evidence-based treatment in community mental health settings and is the most challenging technique for clinicians to adopt within the context of effectiveness and implementation trials. Little work has examined clinician and organizational characteristics that predict use of exposure, which is important for identifying implementation strategies that may increase its use. In a large sample of community health clinicians (N=335) across 31 clinical practice sites, this study characterized clinician and organizational predictors of exposure use and relaxation for anxiety. Mixed effects regression analyses indicated that both clinician attitudes and an organization's implementation climate may be important levers for interventions seeking to increase clinician exposure use. Greater clinician use of relaxation strategies was also associated with less exposure use. Results point to important implications for implementing cognitive-behavioral therapy for anxiety, including de-emphasizing relaxation and attending to organizational climate.

Non-participants in policy efforts to promote evidence-based practices in a large behavioral health system.

BACKGROUND: System-wide training initiatives to support and implement evidence-based practices (EBPs) in behavioral health systems have become increasingly widespread. Understanding more about organizations who do not participate in EBP training initiatives is a critical piece of the dissemination and implementation puzzle if we endeavor to increase access in community settings. METHODS: We conducted 30 1-h semi-structured interviews with leaders in non-participating agencies who did not formally participate in system-wide training initiatives to implement EBPs in the City of Philadelphia, with the goal to understand why they did not participate. RESULTS: We found that despite not participating in training initiatives, most agencies were adopting (and self-financing) some EBP implementation. Leadership from agencies that were implementing EBPs reported relying on previously trained staff to implement EBPs and acknowledged a lack of emphasis on fidelity. Most leaders at agencies not adopting EBPs did not have a clear understanding of what EBP is. Those familiar with EBPs in agencies not adopting EBPs reported philosophical objections to EBPs. When asked about quality assurance and treatment selection, leaders reported being guided by system audits. CONCLUSIONS: While it is highly encouraging that many agencies are adopting EBPs on their own, significant questions about fidelity and implementation success more broadly remain.

The Price per Prospective Consumer of Providing Therapist Training and Consultation in Seven Evidence-Based Treatments within a Large Public Behavioral Health System: An Example Cost-Analysis Metric.

OBJECTIVE: Public-sector behavioral health systems seeking to implement evidence-based treatments (EBTs) may face challenges selecting EBTs given their limited resources. This study describes and illustrates one method to calculate cost related to training and consultation to assist system-level decisions about which EBTs to select. METHODS: Training, consultation, and indirect labor costs were calculated for seven commonly implemented EBTs. Using extant literature, we then estimated the diagnoses and populations for which each EBT was indicated. Diagnostic and demographic information from Medicaid claims data were obtained from a large behavioral health payer organization and used to estimate the number of covered people with whom the EBT could be used and to calculate implementation-associated costs per consumer. RESULTS: Findings suggest substantial cost to therapists and service systems related to EBT training and consultation. Training and consultation costs varied by EBT, from Dialectical Behavior Therapy at $238.07 to Cognitive Behavioral Therapy at $0.18 per potential consumer served. Total cost did not correspond with the number of prospective consumers served by an EBT. CONCLUSION: A cost-metric that accounts for the prospective recipients of a given EBT within a given population may provide insight into how systems should prioritize training efforts. Future policy should consider the financial burden of EBT implementation in relation to the context of the population being served and begin a dialog in creating incentives for EBT use.

A Non-randomized Comparison of Strategies for Consultation in a Community-Academic Training Program to Implement an Evidence-Based Psychotherapy.

Despite the central role of training and consultation in the implementation of evidence-based psychological interventions (EBPIs), comprehensive reviews of research on training have highlighted serious gaps in knowledge regarding best practices. Consultation after initial didactic training appears to be of critical importance, but there has been very little research to determine optimal consultation format or interventions. This observational study compared two consultation formats that included review of session audio and feedback in the context of a program to train clinicians (n = 85) in community mental health clinics to deliver cognitive therapy (CT). A "gold standard" condition in which clinicians received individual feedback after expert consultants reviewed full sessions was compared to a group consultation format in which short segments of session audio were reviewed by a group of clinicians and an expert consultant. After adjusting for potential baseline differences between individuals in the two consultation conditions, few differences were found in terms of successful completion of the consultation phase or in terms of competence in CT at the end of consultation or after a 2 year follow-up. However, analyses did not support hypotheses regarding non-inferiority of the group consultation condition. While both groups largely maintained competence, clinicians in the group consultation condition demonstrated increases in competence over the follow-up period, while a sub-group of those in the individual condition experienced decreases. These findings, if replicated, have important implications for EBP implementation programs, as they suggest that observation and feedback is feasible in community mental health setting, and that employing this method in a group format is an effective and efficient consultation strategy that may enhance the implementation and sustainability of evidence-based psychotherapies.

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.

Implementation of transdiagnostic cognitive therapy in community behavioral health: The Beck Community Initiative.

OBJECTIVE: Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. METHOD: Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. RESULTS: Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). CONCLUSIONS: Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

Applying the Policy Ecology Framework to Philadelphia's Behavioral Health Transformation Efforts.

Raghavan et al. (Implement Sci 3(26):1-9, 2008) proposed that effective implementation of evidence-based practices requires implementation strategies deployed at multiple levels of the "policy ecology," including the organizational, regulatory or purchaser agency, political, and social levels. However, much of implementation research and practice targets providers without accounting for contextual factors that may influence provider behavior. This paper examines Philadelphia's efforts to work toward an evidence-based and recovery-oriented behavioral health system, and uses the policy ecology framework to illustrate how multifaceted, multilevel implementation strategies can facilitate the widespread implementation of evidence-based practices. Ongoing challenges and implications for research and practice are discussed.

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

OBJECTIVES: Community mental health clinics are increasingly utilizing independent contractors to provide clinical services. At the same time, many organizations are participating in initiatives intended to increase implementation of evidence-based practices (EBPs). The primary aim of this study was to understand the associations of utilizing independent contractors with clinician knowledge and attitudes toward EBPs and organizational culture and climate. The study also sought to understand the potential impact of using independent contractors on mental health services delivery from the perspective of organizational leadership. METHODS: Quantitative data were collected from 130 therapists in 23 organizations; qualitative data were collected from executive administrators in nine of the 16 organizations participating in EBP initiatives sponsored by the City of Philadelphia. Regression with random effects was used to estimate the associations between worker status (contractor or employee) and clinician attitudes toward EBPs, knowledge of EBPs, and organizational culture and climate. Qualitative inquiry was used to understand the impact of reliance on independent contractors on organizational participation in EBP initiatives. RESULTS: Independent contractors endorsed less positive attitudes toward EBPs and scored lower on knowledge of EBPs. Interviews revealed four main themes: reasons for using independent contractors, general consequences of using independent contractors, specific impact of independent contractors on participation in EBP initiatives, and suggestions for alternatives. CONCLUSIONS: A growing number of community mental health clinics rely on independent contractors. There may be consequences of this shift that deserve exploration.

Therapist- and Client-Level Predictors of Use of Therapy Techniques During Implementation in a Large Public Mental Health System.

OBJECTIVE: Many youths receiving community mental health treatment do not receive evidence-based interventions. Research suggests that community mental health therapists use a broad range of therapeutic techniques at low intensities. This study examined the relationship between therapist- and client-level predictors of community-based therapists' report of cognitive, behavioral, psychodynamic, and family techniques within the context of implementation efforts. METHODS: A total of 130 therapists participated from 23 organizations in an urban, publicly funded behavioral health system implementing evidence-based practices. Therapist-level predictors included age, gender, clinical experience, licensure status, and participation in evidence-based practice initiatives. Child-level predictors included therapist-reported child primary disorder (externalizing, internalizing, or other) and child age. Therapists completed the Therapist Procedures Checklist-Family Revised, a self-report measure of therapeutic techniques used. RESULTS: Unlicensed therapists were more likely than licensed therapists to report using psychodynamic and behavioral techniques. Therapists who did not participate in an evidence-based practice initiative were less likely to report use of cognitive techniques. Those with clients with externalizing disorders were more likely to report use of behavioral and family techniques. Therapists with the youngest clients (ages three to seven years) were most likely to report use of behavioral techniques and less likely to report use of cognitive and psychodynamic techniques. CONCLUSIONS: Results suggest that both therapist and client factors predict self-reported use of therapy techniques. Participating in an evidence-based practice initiative was associated with increased reports of using cognitive techniques. Therapists reported using behavioral and family techniques more than other techniques when working with youths with externalizing disorders and using fewer cognitive and psychodynamic techniques with young clients.

The Perfect Storm: Collision of the Business of Mental Health and the Implementation of Evidence-Based Practices.

Financing has been hypothesized to be an important driver of the implementation of evidence-based practices (EBPs), yet there has been little systematic investigation of financing as a factor in EBP implementation. This column presents findings from a qualitative study of the effects of financial factors on the implementation of EBPs in a large urban publicly funded mental health system. Interviews with 33 agency leaders and 16 policy makers identified financial distress in community mental health agencies, leading to concerns about complex and expensive implementation of EBPs. Stakeholders agreed that the cost of EBP implementation should be shared between the agencies and the system; however, the stakeholders did not agree on how EBPs should be financed.

Beyond the Label: Relationship Between Community Therapists' Self-Report of a Cognitive Behavioral Therapy Orientation and Observed Skills.

Policy-makers, payers, and consumers often make decisions based on therapists' reported theoretical orientations, but little is known about whether these labels represent actual or potential skills. Prior to CBT training, therapists (n = 321) reported theoretical orientations. Experts rated CBT competency using the Cognitive Therapy Rating Scale Therapy at pre-, mid-, and post-training. CBT- and non-CBT identified therapists showed equivalent, non-competent baseline CBT skills. CBT-identified therapists showed greater CBT skills at mid-training, but by end of training, groups evidenced equivalent achieved competency. Baseline CBT orientations were neither valid, nor useful markers of later competency. Policy, clinical and research implications are discussed.