A Smartphone App for Parental Management of Adolescent Conduct Problems: Randomized Clinical Trial of iKinnect.

OBJECTIVE: This study evaluates iKinnect, a linked caregiver-teen mobile app system designed to address serious adolescent conduct problems through a focus on key targets of evidence-based treatments for juvenile offending, such as parent expectation setting, monitoring, consistency, and positive reinforcement. Additional gamification and autonomy-supporting features are designed to maximize youth engagement. Digital therapeutics such as mobile apps have great potential to expand access to effective interventions, particularly for youth who engage in serious conduct problems and substance abuse, since most never receive an evidence-based treatment and few apps exist for these concerns. METHODS: This randomized clinical trial used a short-term (12 week) longitudinal design with four time points. Recruited was a U.S. national sample of teens (n = 72, age 13-17, 59.7% male, 68.1% White) receiving services for a serious conduct problem and their primary caregiver. The efficacy of iKinnect, used by parent and teen dyads, was measured against an active control condition, Life360, an app that provided mutual GPS-based location tracking to dyads. RESULTS: Across 12 weeks of app use, youth who used iKinnect showed significantly greater reductions in alcohol use, marijuana use, school delinquency, status offenses, and general delinquency than did controls. Parents who used iKinnect Reported greater improvements in structure/rule clarity and discipline consistency relative to control parents. Teen and parent iKinnect app use and acceptability ratings were high. CONCLUSIONS: Real-world use of iKinnect in future applications can, like other emerging digital health technologies, help to expand the reach of evidence-based interventions to children, youth, and families.Registered at clinicaltrials.gov (NCT03065517).

The Cognitive Walkthrough for Implementation Strategies (CWIS): a pragmatic method for assessing implementation strategy usability.

BACKGROUND: Implementation strategies have flourished in an effort to increase integration of research evidence into clinical practice. Most strategies are complex, socially mediated processes. Many are complicated, expensive, and ultimately impractical to deliver in real-world settings. The field lacks methods to assess the extent to which strategies are usable and aligned with the needs and constraints of the individuals and contexts who will deliver or receive them. Drawn from the field of human-centered design, cognitive walkthroughs are an efficient assessment method with potential to identify aspects of strategies that may inhibit their usability and, ultimately, effectiveness. This article presents a novel walkthrough methodology for evaluating strategy usability as well as an example application to a post-training consultation strategy to support school mental health clinicians to adopt measurement-based care. METHOD: The Cognitive Walkthrough for Implementation Strategies (CWIS) is a pragmatic, mixed-methods approach for evaluating complex, socially mediated implementation strategies. CWIS includes six steps: (1) determine preconditions; (2) hierarchical task analysis; (3) task prioritization; (4) convert tasks to scenarios; (5) pragmatic group testing; and (6) usability issue identification, classification, and prioritization. A facilitator conducted two group testing sessions with clinician users (N = 10), guiding participants through 6 scenarios and 11 associated subtasks. Clinicians reported their anticipated likelihood of completing each subtask and provided qualitative justifications during group discussion. Following the walkthrough sessions, users completed an adapted quantitative assessment of strategy usability. RESULTS: Average anticipated success ratings indicated substantial variability across participants and subtasks. Usability ratings (scale 0-100) of the consultation protocol averaged 71.3 (SD = 10.6). Twenty-one usability problems were identified via qualitative content analysis with consensus coding, and classified by severity and problem type. High-severity problems included potential misalignment between consultation and clinical service timelines as well as digressions during consultation processes. CONCLUSIONS: CWIS quantitative usability ratings indicated that the consultation protocol was at the low end of the "acceptable" range (based on norms from the unadapted scale). Collectively, the 21 resulting usability issues explained the quantitative usability data and provided specific direction for usability enhancements. The current study provides preliminary evidence for the utility of CWIS to assess strategy usability and generate a blueprint for redesign.

Using a Tablet-Based App to Deliver Evidence-Based Practices for Suicidal Patients in the Emergency Department: Pilot Randomized Controlled Trial.

BACKGROUND: Emergency departments (EDs) have the potential to provide evidence-based practices for suicide prevention to patients who are acutely suicidal. However, few EDs have adequate time and personnel resources to deliver recommended evidence-based assessment and interventions. To raise the clinical standard of care for patients who are suicidal and seeking psychiatric crisis services in the ED, we developed Jaspr Health, a tablet-based app for direct use by such patients, which enables the delivery of 4 evidence-based practices. OBJECTIVE: This study aims to evaluate the feasibility, acceptability, and effectiveness of Jaspr Health among suicidal adults in EDs. METHODS: Patients who were acutely suicidal and seeking psychiatric crisis services participated in an unblinded pilot randomized controlled trial while in the ED. Participants were randomly assigned to Jaspr Health (n=14) or care as usual (control; n=17) groups. Participants were assessed at baseline, and a 2-hour posttest using self-report measures and a semistructured interview were conducted. RESULTS: Conditions differed significantly at baseline with regard to age but not other demographic variables or baseline measures. On average, participants had been in the ED for 17 hours before enrolling in the study. Over their lifetime, 84% (26/31) of the sample had made a suicide attempt (mean 3.4, SD 6.4) and 61% (19/31) had engaged in nonsuicidal self-injurious behaviors, with an average rate of 8.8 times in the past 3 months. All established feasibility and acceptability criteria were met: no adverse events occurred, participants' app use was high, Jaspr Health app user satisfaction ratings were high, and all participants using Jaspr Health recommended its use for other suicidal ED patients. Comparisons between study conditions provide preliminary support for the effectiveness of the app: participants using Jaspr Health reported a statistically significant increase in receiving 4 evidence-based suicide prevention interventions and overall satisfaction ratings with their ED experience. In addition, significant decreases in distress and agitation, along with significant increases in learning to cope more effectively with current and future suicidal thoughts, were observed among participants using Jaspr Health compared with those receiving care as usual. CONCLUSIONS: Even with limited statistical power, the results showed that Jaspr Health is feasible, acceptable, and clinically effective for use by ED patients who are acutely suicidal and seeking ED-based psychiatric crisis services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03584386; https://clinicaltrials.gov/ct2/show/NCT03584386.

Usability Evaluation for Evidence-Based Psychosocial Interventions (USE-EBPI): A methodology for assessing complex intervention implementability.

Background: Most evidence-based practices in mental health are complex psychosocial interventions, but little research has focused on assessing and addressing the characteristics of these interventions, such as design quality and packaging, that serve as intra-intervention determinants (i.e., barriers and facilitators) of implementation outcomes. Usability-the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction-is a key indicator of design quality. Drawing from the field of human-centered design, this article presents a novel methodology for evaluating the usability of complex psychosocial interventions and describes an example "use case" application to an exposure protocol for the treatment of anxiety disorders with one user group. Method: The Usability Evaluation for Evidence-Based Psychosocial Interventions (USE-EBPI) methodology comprises four steps: (1) identify users for testing; (2) define and prioritize EBPI components (i.e., tasks and packaging); (3) plan and conduct the evaluation; and (4) organize and prioritize usability issues. In the example, clinicians were selected for testing from among the identified user groups of the exposure protocol (e.g., clients, system administrators). Clinicians with differing levels of experience with exposure therapies (novice, n =3; intermediate, n = 4; advanced, n = 3) were sampled. Usability evaluation included Intervention Usability Scale (IUS) ratings and individual user testing sessions with clinicians, and heuristic evaluations conducted by design experts. After testing, discrete usability issues were organized within the User Action Framework (UAF) and prioritized via independent ratings (1-3 scale) by members of the research team. Results: Average IUS ratings (80.5; SD = 9.56 on a 100-point scale) indicated good usability and also room for improvement. Ratings for novice and intermediate participants were comparable (77.5), with higher ratings for advanced users (87.5). Heuristic evaluations suggested similar usability (mean overall rating = 7.33; SD = 0.58 on a 10-point scale). Testing with individual users revealed 13 distinct usability issues, which reflected all four phases of the UAF and a range of priority levels. Conclusion: Findings from the current study suggested the USE-EBPI is useful for evaluating the usability of complex psychosocial interventions and informing subsequent intervention redesign (in the context of broader development frameworks) to enhance implementation. Future research goals are discussed, which include applying USE-EBPI with a broader range of interventions and user groups (e.g., clients). Plain language abstract: Characteristics of evidence-based psychosocial interventions (EBPIs) that impact the extent to which they can be implemented in real world mental health service settings have received far less attention than the characteristics of individuals (e.g., clinicians) or settings (e.g., community mental health centers), where EBPI implementation occurs. No methods exist to evaluate the usability of EBPIs, which can be a critical barrier or facilitator of implementation success. The current article describes a new method, the Usability Evaluation for Evidence-Based Psychosocial Interventions (USE-EBPI), which uses techniques drawn from the field of human-centered design to evaluate EBPI usability. An example application to an intervention protocol for anxiety problems among adults is included to illustrate the value of the new approach.

A novel engagement of suicidality in the emergency department: Virtual Collaborative Assessment and Management of Suicidality.

OBJECTIVE: A novel avatar system (Virtual Collaborative Assessment and Management of Suicidality System; V-CAMS) for suicidal patients and medical personnel in emergency departments (EDs) was developed and evaluated. V-CAMS facilitates the delivery of CAMS and other evidence-based interventions to reduce unnecessary hospitalization, readmissions, and suicide following an ED visit. METHOD: Using iterative user-centered design with 24 suicidal patients, an avatar prototype, "Dr. Dave" (based on Dr. Jobes) was created, along with other patient-facing tools; provider-facing tools, including a clinical decision support tool were also designed and tested to aid discharge disposition. RESULTS: Feasibility tests supported proof of concept. Suicidal patients affirmed the system's overall merit, positive Perception of Care, and acceptability; medical providers (n = 21) viewed the system as an efficient, effective, and safe method of improving care for suicidal ED patients and reducing unnecessary hospitalization. CONCLUSIONS: Technology tools including a patient-facing avatar and e-caring contacts, along with provider-facing tools may offer a powerful method of facilitating best-practice suicide prevention interventions and point-of-care tools for suicidal patients seeking ED services and their medical providers. Future directions include full development of V-CAMS and integration into a health electronic medical record and a rigorous randomized controlled trial to study its effectiveness.

Digital apothecaries: a vision for making health care interventions accessible worldwide.

Evidence-based psychological interventions are growing in number but are not within reach of many individuals who could benefit from them. The recent revolution in digital technologies now makes it possible to reach people around the globe with digital interventions in the form of web sites, mobile applications, wearable devices, and so on. Although a plethora of digital interventions are available online few are evidence-based and individuals have little guidance to decide among the multitude of options. We propose the development of "digital apothecaries," that is, online repositories of evidence-based digital interventions. As portals to effective interventions, digital apothecaries would be useful to individuals who could access evidence-based interventions directly, to health care providers, who could identify specific digital tools to suggest to or use with their patients, and to researchers, who could study a range of tools with large samples, enabling comparative tests and evaluation of moderators of effects. We present a taxonomy of types of in-person and digital interventions ranging from traditional therapy without the use of digital tools to totally automated self-help interventions. This taxonomy highlights the potential of blending digital tools into health care systems to expand their reach. Digital apothecaries would provide access to evidence-based digital interventions (both free and paid versions), provide data on effectiveness (including effectiveness for diverse populations), and encourage the development and testing of more such tools. Other issues discussed include: criteria for inclusion of interventions into digital apothecaries; how digital tools could enhance health care for diverse populations; and cautionary notes regarding potential negative unintended consequences of the adoption of digital interventions into the health care system. In particular, we warn about the potential misuse of evidence-based digital interventions to justify reducing access to live providers. Digital apothecaries bring with them the promise of reducing health disparities by reaching large numbers of individuals across the world who need health interventions but are not currently receiving them. The health care field is encouraged to mindfully develop this promise, while being alert not to cause inadvertent harm.

A randomized controlled trial of an online, modular, active learning training program for behavioral activation for depression.

OBJECTIVE: This randomized-controlled trial assessed the efficacy of a trainer-led, active-learning, modular, online behavioral activation (BA) training program compared with a self-paced online BA training with the same modular content. METHOD: Seventy-seven graduate students (M = 30.3 years, SD = 6.09; 76.6% female) in mental health training programs were randomly assigned to receive either the trainer-led or self-paced BA training. Both trainings consisted of 4 weekly sessions covering 4 core BA strategies. Primary outcomes were changes in BA skills as measured by an objective role-play assessment and self-reported use of BA strategies. Assessments were conducted at pre-, post-, and 6-weeks after training. A series of longitudinal mixed effect models assessed changes in BA skills and a longitudinal model implemented with generalized estimating equations assessed BA use over time. RESULTS: Significantly greater increases in total BA skills were found in the trainer-led training condition. The trainer-led training condition also showed greater increases in all core BA skills either at posttraining, follow-up, or both. Reported use of BA strategies with actual clients increased significantly from pre- to posttraining and maintained at follow-up in both training conditions. CONCLUSIONS: This trial adds to the literature on the efficacy of online training as a method to disseminate BA. Online training with an active learning, modular approach may be a promising and accessible implementation strategy. Additional strategies may need to be paired with the online BA training to assure the long-term implementation and sustainability of BA in clinical practice. (PsycINFO Database Record

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial.

BACKGROUND: Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation. METHODS: To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS. DISCUSSION: It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs. TRIAL REGISTRATION: NCT02449421 . Registered 02/09/2015.

Increasing psychotherapists' adoption and implementation of the evidence-based practice of progress monitoring.

Evidence-based practices (EBPs) reach consumers slowly because practitioners are slow to adopt and implement them. We hypothesized that giving psychotherapists a tool + training intervention that was designed to help the therapist integrate the EBP of progress monitoring into his or her usual way of working would be associated with adoption and sustained implementation of the particular progress monitoring tool we trained them to use (the Depression Anxiety Stress Scales on our Online Progress Tracking tool) and would generalize to all types of progress monitoring measures. To test these hypotheses, we developed an online progress monitoring tool and a course that trained psychotherapists to use it, and we assessed progress monitoring behavior in 26 psychotherapists before, during, immediately after, and 12 months after they received the tool and training. Immediately after receiving the tool + training intervention, participants showed statistically significant increases in use of the online tool and of all types of progress monitoring measures. Twelve months later, participants showed sustained use of any type of progress monitoring measure but not the online tool.

User-Centered Design for Psychosocial Intervention Development and Implementation.

The current paper articulates how common difficulties encountered when attempting to implement or scale-up evidence-based treatments are exacerbated by fundamental design problems, which may be addressed by a set of principles and methods drawn from the contemporary field of user-centered design. User-centered design is an approach to product development that grounds the process in information collected about the individuals and settings where products will ultimately be used. To demonstrate the utility of this perspective, we present four design concepts and methods: (a) clear identification of end users and their needs, (b) prototyping/rapid iteration, (c) simplifying existing intervention parameters/procedures, and (d) exploiting natural constraints. We conclude with a brief design-focused research agenda for the developers and implementers of evidence-based treatments.

Investigating bang for your training buck: a randomized controlled trial comparing three methods of training clinicians in two core strategies of dialectical behavior therapy.

The present study examined the efficacy of online training (OLT), instructor-led training (ILT), and a treatment manual (TM) in training mental health clinicians in two core strategies of Dialectical Behavior Therapy (DBT): chain analysis and validation. A randomized controlled trial compared OLT, ILT, and TM among clinicians naïve to DBT (N=172) who were assessed at baseline, post-training, and 30, 60, and 90 days following training. Primary outcomes included satisfaction, self-efficacy, motivation, knowledge, clinical proficiency, and clinical use. Overall, ILT outperformed OLT and TM in satisfaction, self-efficacy, and motivation, whereas OLT was the most effective method for increasing knowledge. The conditions did not differ in observer-rated clinical proficiency or self-reported clinical use, which both increased to moderate levels after training. In addition, ILT was particularly effective at improving motivation to use chain analysis, whereas OLT was particularly effective at increasing knowledge of validation strategies. These findings suggest that these types of brief, didactic trainings may be effective methods of increasing knowledge of new treatment strategies, but may not be sufficient to enable clinicians to achieve a high level of clinical use or proficiency. Additional research examining the possible advantages of matching training methods to types of treatment strategies may help to determine a tailored, more effective approach to training clinicians in empirically supported treatments.

Practice-oriented research: what it takes to do collaborative research in private practice.

The goal of this paper is to describe the authors' experience conducting research in and for private practice. Based on two distinct research programs (one guided by a scientist practitioner leading various groups of clinicians and another from a network of practitioners and researchers), a number of practice-oriented studies are presented. Lessons learned from these collaborative projects are discussed in terms of challenges and strategies to deal with them, as well as benefits that can be earned from conducting empirical studies within clinical routine. General recommendations are then offered to foster the engagement of clinicians in their own working environment and to facilitate partnerships between researchers and practitioners in developing and implementing valid, feasible, and informative clinical studies.

The Role of Lean Process Improvement in Implementation of Evidence-Based Practices in Behavioral Health Care.

To effectively implement evidence-based practices (EBP) in behavioral health care, an organization needs to have operating structures and processes that can address core EBP implementation factors and stages. Lean, a widely used quality improvement process, can potentially address the factors crucial to successful implementation of EBP. This article provides an overview of Lean and the relationship between Lean process improvement steps, and EBP implementation models. Examples of how Lean process improvement methodologies can be used to help plan and carry out implementation of EBP in mental health delivery systems are presented along with limitations and recommendations for future research and clinical application.

What must you know and do to get good outcomes with DBT?

Because little research has been conducted on which therapist-client interactions lead to intermediate and end-point improvements in Dialectical Behavior Therapy (DBT), we have a small evidence-base from which to specify what therapists must know and do in order to obtain good outcomes using DBT. As with other evidence-based practices, dissemination of DBT has defaulted to assumptions and methods from the "psychotherapy technology model," which emphasizes transfer of the validated treatment package from the research clinic to routine settings with high fidelity (Morgenstern & McKay, 2007). However, serious limitations of the psychotherapy technology model require pursuit of alternative complementary models to guide dissemination. One complementary approach is to use well-designed practice-based training research. In this approach, therapists learn modular competencies linked to a highly structured yet flexible clinical decision-making framework. Modular training of therapist competencies emphasizes the continuity of the component therapist strategies across evidence-based protocols rather than emphasizing the packages or manuals as separate and distinct. Key hypotheses about the change processes responsible for client change and the associated treatment strategies used to influence these change processes should be specified and measured at the level of client, therapist, and service delivery setting. Adopting this approach may offer advantages that apply to the dissemination and implementation of DBT and other evidence-based practices (EBPs).

Developing an online, modular, active learning training program for behavioral activation.

The current study reports on two sequential studies that developed and provided a pilot evaluation of a Behavioral Activation (BA) training package based on an online, modular, active learning model for community mental health providers. In the first study, training outcomes were assessed with a within-subjects design by measuring trainees' (N = 8) reported implementation of learned BA skills in clinical practice and their satisfaction with the training at pretraining baseline and throughout the training. The results showed that trainees reported increased implementation of BA techniques in actual sessions. Several improvements were made in the second study, including incorporating more active learning strategies to the training protocol and including a role-play Behavioral Activation Skills Assessment (BASA) for an objective rather than self-report measure of trainees' (N = 9) performance before, after, and 6 weeks after training. Results suggested that skill at implementing two of the three core BA techniques (providing the rationale and activity scheduling) increased significantly, and overall performance was maintained at follow-up. Furthermore, trainees reported high satisfaction with the training in both studies.

Preliminary data from a randomized pilot study of web-based functional analytic psychotherapy therapist training.

Therapists of many persuasions emphasize the therapy relationship in their work, a priority backed by strong empirical evidence. Training in how to maximize the power and potential of the therapy relationship, however, has lagged behind. A novel approach to using the therapy relationship and to training therapists in its use is provided by Functional Analytic Psychotherapy (FAP). FAP training involves eight 2-hr weekly training sessions conducted online using web-conferencing technology. The training integrates behavioral principles with a focus on trainee-trainer and trainee-trainee relationships in a highly structured course that evokes the desirable FAP therapist-trainee behaviors and collectively shapes the behaviors through reinforcement by the trainer and other trainees. In a preliminary study, 16 therapist-trainees were randomly assigned to receive either immediate FAP training or training after a waitlist period. Significant and large effects of training were found on both self-reported and observer-assessed measures for the first training group, and the waitlist training group replicated the first training group with significant within-subject change over the course of training. Finally, qualitative feedback from therapists indicated high satisfaction with the primary elements of the training protocol. Several important limitations to this preliminary study are discussed.

Training research: practical recommendations for maximum impact.

This review offers practical recommendations regarding research on training in evidence-based practices for mental health and substance abuse treatment. When designing training research, we recommend: (a) aligning with the larger dissemination and implementation literature to consider contextual variables and clearly defining terminology, (b) critically examining the implicit assumptions underlying the stage model of psychotherapy development, (c) incorporating research methods from other disciplines that embrace the principles of formative evaluation and iterative review, and (d) thinking about how technology can be used to take training to scale throughout all stages of a training research project. An example demonstrates the implementation of these recommendations.

Which training method works best? A randomized controlled trial comparing three methods of training clinicians in dialectical behavior therapy skills.

This study evaluated the efficacy of three methods of training community mental health providers (N = 150) in Dialectical Behavior Therapy skills, including a written treatment manual; an interactive, multimedia online training (OLT); and a two-day instructor-led training workshop (ILT). A hybrid design was utilized that incorporated aspects of efficacy and effectiveness trials. Assessments were completed at baseline, post-training, and 30- and 90-days following training. The results indicate that learner satisfaction with the training was highest in OLT and ILT, and both resulted in significantly higher satisfaction ratings than the manual. OLT outperformed ILT and the manual in increasing knowledge of the treatment, whereas ILT and the manual did not differ. All three training methods resulted in comparable increases in clinicians' ability to apply course content in clinical simulations. Overall, the results provide strong support for the efficacy of technology-based OLT methods in disseminating knowledge of empirically supported treatments to community mental health providers, suggesting that OLT may be a high-quality, easily accessible, and affordable addition to traditional training methods.

Liver lesions in demersal fishes near a large ocean outfall on the San Pedro Shelf, California.

The prevalence of toxicopathic liver lesions in demersal fish on the San Pedro Shelf, California was determined for a 15-year period (1988-2003). Fish livers were sampled at fixed locations as part of the Orange County Sanitation Districts (OCSD) ocean monitoring program. Histopathological examination of selected fish liver tissues was studied to determine whether the wastewater discharge had affected fish health. The prevalence of toxicopathic lesion classes neoplasms (NEO), preneoplastic foci of cellular alteration (FCA), and hydropic vacuolation (HYDVAC) varied among species and locations. For all species sampled, severe lesions occurred in 6.2% of the fish examined (n=7,694). HYDVAC (4.1%) was the most common toxicopathic lesion type followed by FCA (1.4%) and NEO (0.7%). HYDVAC occurred only in white croaker (Genyonemus lineatus), accounting for 84.8% of the toxicopathic lesions for this species. Prevalence of HYDVAC, NEO, and FCA in white croaker was 15.2, 2.0, and 0.7%, respectively. The prevalence of HYDVAC and NEO in white croaker increased with age and size but there was no sexual difference. A linear regression model was used for hypothesis testing to account for significant differences in fish size (and age for croakers) at the different sampling locations. This analysis showed that for HYDVAC there was no spatial or location effect for lesion rate or size/age of onset. For NEO, the model predicted that white croaker near the wastewater outfall may acquire these lesions at a smaller size/younger age, and at a higher rate, than at other sites. However, this result may be biased due to the unequal size frequency distributions and the low prevalence of NEO in white croaker at the different sampling sites. Bigmouth sole (Hippoglossina stomata) had a prevalence of FCA and NEO of 1.3 and 0.35%, respectively, but the prevalence and distribution of lesions was too few for statistical testing. There was no sexual difference for lesion prevalence in hornyhead turbot (Pleuronichthys verticalis) and the prevalence of FCA and NEO was 3.4 and 0.37%, respectively. FCA prevalence increased with size in hornyhead turbot and there were no significant spatial differences for lesion rates and fish size at lesion onset. Overall, consistent spatial differences for lesion prevalence were not demonstrated and highlight the analytical difficulties of detecting a possible point source impact when the effect is rare, correlated with the size/age structure of the population, and may be caused by exposure to unknown multiple sources. Thus, the usefulness of liver histopathology as a point-source monitoring tool is best applied to where the spatial scale of impact generally exceeds the home range of the target species.

Implementing dialectical behavior therapy.

Dialectical behavior therapy (DBT) is a cognitive-behavioral approach to treating borderline personality disorder. Early empirical results are promising, although they are not sufficient to establish DBT as an evidence-based practice in community settings. Nevertheless, the treatment has been widely implemented by mental health authorities, program leaders, and clinicians. The authors describe DBT's four stages of treatment, the functional areas addressed, and the treatment modes used as well as the reasons for the appeal of DBT to practitioners. They review barriers encountered by those who have implemented the model and present strategies that have been developed to overcome the barriers.