Digital mental health and peer support: Building a Theory of Change informed by stakeholders' perspectives.

Digital Mental Health and Peer support has the potential to bridge gaps in support through its scalability and accessibility. Despite the increasing use of these platforms, there remains a lack of understanding of how they operate in real life, from initial engagement to longer-term impact. We aimed to explore the key inputs, processes, user interactions, assumptions, barriers, facilitators, outcomes, and impacts associated with the use of DMH and peer support platforms by developing a Theory of Change with stakeholders. Stakeholders (n = 77) contributed to the formulation of the Theory of Change through a series of online workshops, focus groups, interviews, and open-ended survey feedback. Workshops were structured to capture information related to aspects of the Theory of Change and to allow stakeholders to provide feedback to improve the diagram. A thematic framework approach was used to analyze transcripts to enable comparisons of factors reported by members, commissioners, and platform staff. Stakeholders identified a variety of factors contributing to initial inputs, processes, outcomes, and impact. Engagement emerged as the most significant barrier to the use of platforms. Motivations for use included filling in gaps in available support, connecting with others and upskilling. Different member types determined how users would interact with the platform which could influence the social response of others. Outcomes were largely positive including provision of a safe online space, improvement in wellbeing, and feeling connected to others. Stakeholders noted impact was harder to identify due to the preventative nature of these platforms but suggested this related to the knowledge of available support, reduction in waiting for support and in referrals, and increasing engagement and uptake of the platforms. Stakeholders identified assumptions regarding internet access as a significant barrier. The Theory of Change illustrated three distinct pathways in digital mental health and peer support. Further research is needed to improve engagement and factors influencing engagement, the member experience and how impact is measured.

Reconstructing dropout: Building from multiple definitions, therapist effects, and center effects.

Objective: The literature regarding dropout from psychotherapy has suffered from issues of diverse operationalization of the construct. Some have called for a more uniform definition to aid in generalization across research; this study aimed to assess the viability of such a definition by examining the rate of occurrence for three distinct definitions simultaneously. In addition, therapist and center level variances are explored to further understand the differences between definitions.Method: We compared the prevalence rates and overlap of three distinct operationalizations of dropout (based on last session attendance, therapist judgment, and symptom change) using data gathered from a national practice research network (N = 2977). Higher-order therapist and center-level effects were assessed for each definition.Results: There was very little overlap among definitions, with less than one percent of clients simultaneously meeting criteria for all three definitions. Additionally, therapist and center effects were found for each definition, especially notable for therapist-rated and last-session attendance definitions of dropout.Conclusion: Rather than a singular definition of dropout, these results instead suggest that multiple, specific, and unique definitions more accurately depict clinical reality, and future research might benefit from uncovering predictors of different "classes" of dropouts and examining the different practices of therapists and centers.

Predicting future courses of psychotherapy within a grouped LASSO framework.

Objective: There is a paucity of studies examining the experience of clients who undergo multiple courses of psychotherapy. Conducted within a large practice research network, this study demonstrated that returning therapy clients comprise a considerable portion of the clinical population in university counseling settings, and identified variables associated with return to therapy. Method: Utilizing data spanning 2013 to 2017, statistical variable selection for predicting return to therapy was conducted via grouped least absolute shrinkage and selection operator (grouped LASSO) applied to logistic regression. The grouped LASSO approach is described in detail to facilitate learning and replication. The paper also addresses methodological considerations related to this approach, such as sample size, generalizability, as well as general strengths and limitations. Results: Attendance rate, duration of initial treatment course, social anxiety, perceived social support, academic distress, and alcohol use were identified as predictive of return to therapy. Conclusions: Findings could help inform more cost-effective policies for session limits (e.g., extending session limits for clients with social anxiety), referral decisions (e.g., for clients with alcohol use problems), and appointment reminders (based on the association between poor attendance rate and return to therapy). Taking into account the many reasons that can explain why clients do or do not return to therapy, these findings also could inform clinicians' early case conceptualizations and treatment interventions.

Multilevel versus single-level factor analysis: Differentiating within-person and between-person variability using the CCAPS-34.

Objective: Although most self-report measures of distress are intended to assess time-varying constructs, they are usually developed using between-person data. They are therefore vulnerable to misspecification due to measurement nonequivalence at the between-person and within-person levels. In recent years, multiple studies have found that self-report distress may not be the same when considered over time versus between people: what changes over time may not be the same as what makes individuals different from one another. Method: In this study, we present a multilevel factor analysis (MFA) of a widely used multidimensional self-report measure of psychological symptoms, the Counseling Center Assessment of Psychological Symptoms-34 (CCAPS-34), in two samples (Ns: 1,223 and 757) of individuals with 10 or more observations each. We compare the results to traditional factor analysis. Results: Single-level factor analyses converged with the established seven-factor structure, regardless of sample or data subset. The MFA largely, but not entirely, recovered the existing factor structure of the CCAPS-34 at the within-person level in both samples, but not at the between-person level. The between-person factor structure was simpler than the within-person factor structure, particularly in the nonclinical sample in which only two factors were sufficient. Conclusions: The factors of this instrument that change over time appear to be narrow, while differences between people are broader. This argues against using general distress measures when assessing treatment outcomes. MFA is a promising method for measure development, even in data with relatively few observations per person. This method may clarify how self-report psychopathology manifests over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Suicide among college students in psychotherapy: Individual predictors and latent classes.

This study sought to identify predictors of suicidal behavior among college students who are psychotherapy clients, as well as to determine underlying classes of clients with suicidal ideation. Data were gathered from 101,570 clients, 391 of whom engaged in suicide behavior during treatment. Regression analyses revealed that suicide behavior was positively associated with 3 pretreatment variables: depression, prior suicide behavior, and prior nonsuicidal self-injury. Four latent classes of clients with suicidal ideation were identified that were named "prior ideation," "extensive risk," "prior treatment," and "circumscribed depression." The number of clients in each class varied widely, as did the relative risk of suicide behavior. Implications for treatment, suicide assessment, and suicide prevention are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Development of the Counseling Center Assessment of Psychological Symptoms-Japanese version: Pilot study.

There is currently no reliable and valid multidimensional instrument for measuring psychological symptoms among Japanese university students. The purpose of this pilot study was to translate the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62) into Japanese and evaluate its validity and reliability. Following robust translation procedures, the CCAPS-Japanese was created. In the validation study, 2,758 undergraduate students from 11 universities (mean age = 19.08 ± 1.85 years) completed the CCAPS-Japanese. The results of confirmatory factor analysis supported the theoretical eight-factor structure model of the CCAPS-Japanese with the exclusion of seven items. The decision to retain/remove items was made by evaluating factor loadings and model fit indices while considering cultural equivalence and structural validity. Using the finalized 55-item CCAPS-Japanese, further analyses demonstrated that the eight subscales had acceptable to good internal consistencies (α = .61-.89). Thus, the tool's validity and reliability were established. The CCAPS-Japanese may be appropriate for assessing the psychological concerns of Japanese university students.

Effectiveness of routine psychotherapy: Method matters.

OBJECTIVE: Though many studies have shown that psychotherapy can be effective, psychotherapy available in routine practice may not be adequate. Several methods have been proposed to evaluate routine psychological treatments. The aim of this paper is to demonstrate the combined utility of complementary methods, change-based benchmarking, and end-state normative comparisons, across a range of self-reported psychological symptoms. METHOD: Benchmarks derived from randomized controlled trials (RCTs) and normative comparisons were used to evaluate the effectiveness of psychotherapy in a large (N = 9895) sample of clients in university counseling centers (UCCs). RESULTS: Overall, routine psychotherapy was associated with significant improvement across all symptoms examined. For clients whose initial severity was similar to RCT participants, the observed pre-post effect sizes were equivalent to those in RCTs. However, treatment tended to lead to normative end-state functioning only for those clients who were moderately, but not severely, distressed at the start of psychotherapy. CONCLUSIONS: This suggests that although psychotherapy is associated with an effective magnitude of symptom improvement in routine practice, additional services for highly distressed individuals may be necessary. The methods described here comprise a comprehensive analysis of the quality of routine care, and we recommend using both methods in concert. Clinical or methodological significance of this article: This study examines the effectiveness of routine psychotherapy provided in a large network of counseling centers. By comparing multiple established methods to define outcomes in this sample we provide a detailed understanding of typical outcomes. The findings show that, across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress. However, there is room to improve, especially by increasing the number of clients who return to normal functioning by the end of treatment. Using distinct methods provides complementary answers to the question: How effective is routine psychotherapy?

Assessing and investigating clinicians' research interests: Lessons on expanding practices and data collection in a large practice research network.

Conducted in naturalistic settings, practice-oriented research (POR) is aimed at building stronger connections between the science and practice of psychotherapy. Promoting the principles of POR, this article has 2 aims: (a) presenting the results of a survey assessing the interests of members of a large practice research network in topics that could guide future research conducted as part of clinical routine, and (b) describing difficulties in implementing a study in line with such interests. Despite the significant interest in and perceived clinical significance of two relationship constructs (alliance and countertransference), there were unique obstacles faced in their empirical investigation within an already operationally functional practice research network. Challenges in this process included resource-related difficulties (such as changes in staff and the time required to set up the study and administer the measures), logistics-related issues, and effectively incorporating the assessment procedure into an existing clinical system. The article also describes strategies to address these obstacles, with differing degrees of success, including the role of a "local champion" at each site, the importance of a personal/professional relationship between the researcher and participating centers, as well as the pragmatic assistance to sites during the preparation, coordination, and implementation process (e.g., providing templates and feedback on institutional review board applications, and technological assistance on how to incorporate the measures into existing center software). The article concludes with general recommendations and future directions for POR. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Treatment-seeking college students with disabilities: Presenting concerns, protective factors, and academic distress.

Students with disabilities are a growing population on college campuses and have unique challenges that put them at risk for early departure, creating complexity in efforts to address their personal and academic needs. PURPOSE: The purpose was to explore academic and other sources of distress among college students with disabilities to identify possible areas where enhanced supports might benefit this population. Research Method and Design: Researchers analyzed cross-sectional data from the Center for Collegiate Mental Health to compare subsamples of students with (n = 1,774) and without disabilities (n = 1,774) on presenting concerns, and to determine significant predictors of academic distress among students with disabilities. RESULTS: Results indicated that students with disabilities have many similar treatment concerns with their peers, but showed greater concerns in depression and self-harm; academic performance; anxiety and obsessions/compulsions; and fewer concerns in relationship problems. Significant predictors of academic distress for students with disabilities included attention deficit-hyperactivity disorder (ADHD), depression and self-harm, trauma or victimization, stress and academic performance, and social support from family and peers. CONCLUSIONS/IMPLICATIONS: These results suggest the importance of several factors in understanding the presenting concerns of treatment-seeking students with disabilities and mitigating academic distress for this population. Additional areas for research are presented. (PsycINFO Database Record

Are we in crisis? National mental health and treatment trends in college counseling centers.

The current state of college student mental health is frequently labeled a "crisis," as the demand for services and severity of symptomatology have appeared to increase in recent decades. Nationally representative findings are presented from the Center for Collegiate Mental Health, a practice research network based in the United States, composed of more than 340 university and college counseling centers, in an effort to illuminate trends in symptom severity and patterns in treatment utilization for the campus treatment seeking population. Clinical data collected over 5 academic years (2010-2015) showed small but significantly increasing trends for self-reported distress in generalized anxiety, depression, social anxiety, family distress, and academic distress, with the largest effect sizes observed for generalized anxiety, depression, and social anxiety. On the other hand, a significantly decreasing trend was observed for substance use. No significant changes were observed for eating concerns and hostility. Utilization data over 6 years indicated a gradual yet steady increase in the number of students seeking services (beyond the rate expected with increasing institutional enrollment), as well as increases in the number of appointments scheduled and attended, with great variation between centers. Within the context of changing national trends, we conclude that it is advisable to consider the specific needs of local centers to best accommodate distinct student bodies. (PsycINFO Database Record

Presenting concerns in counseling centers: The view from clinicians on the ground.

Despite growing evidence that a greater number of students are seeking counseling in college and university counseling centers throughout the United States, there is a dearth of empirical information about (a) the presenting concerns for which students seek treatment and (b) how these concerns differ according to client demographic factors. The purpose of this descriptive and exploratory study was to explore how counseling center clinicians categorize client presenting concerns, and how these concerns vary according to client demographics. Given the importance of client suicide within the field of college counseling, the frequency of suicidality as an identified presenting concern was also explored. A sample of 1,308 clinicians from 84 counseling centers rated the presenting concerns of 53,194 clients using the Clinician Index of Client Concerns (CLICC) after an initial consultation. Results of descriptive and nonparametric analyses indicated that the most prevalent concerns were anxiety, depression, stress, family, and academic performance, and that clients who belong to different demographic groups frequently present to counseling with broadly similar types of concerns. Furthermore, suicidality represented an area of concern for 8.4% of all clients, and it ranked 20 of 44 as a clinician-rated concern. Comparable rates emerged across the range of client demographic groups examined, although rates were notably higher for a handful of groups. The findings offer one of the largest and most generalizable descriptions of why college students seek counseling services, as determined by clinicians' evaluations of presenting concerns. Implications for research and clinical applications of the findings are discussed. (PsycINFO Database Record

The relationship between students' counseling center contact and long-term educational outcomes.

Numerous studies have demonstrated that counseling centers deliver a positive impact on the emotional and social development of college students who receive services. These healthy outcomes, in turn, can lead to increased academic success, such as improved performance, retention, and persistence. While these short-term academic outcomes have been widely investigated, very few studies have explored the relationship between counseling center services and longer-term educational outcomes, such as final grade point average (GPA), time spent at the university, and degree completion. In the current study, counseling center usage, including appointments that were attended, cancelled, and no showed, as well as distal educational variables were examined within 2 cohorts of first-time full-time students over a 6-year period. Findings revealed that both users and nonusers of counseling center services spent a similar amount of time to degree completion and achieved comparable final semester GPAs as well. However, students who utilized counseling services graduated at a significantly lower rate (79.8%) than those who did not use services (86.2%) across the 6-year time span. Post hoc analyses indicated that among students who used counseling services, those who did not graduate scheduled significantly more services than those who graduated, suggesting that students who use the counseling center, and have more chronic and severe mental health problems, may be graduating at a lower rate. Implications are discussed. (PsycINFO Database Record

Therapist effects and the impacts of therapy nonattendance.

Although dropout from psychotherapy has received substantial attention, the impacts of nonattendance on client outcome across a course of psychotherapy have not been well researched. All in-person psychotherapy treatments require clients to actually attend sessions to generate positive symptomatic results, and missed sessions have at least a time and financial cost. Furthermore, it is plausible that therapist differences exist for client attendance rates. The present study examined impacts of nonattendance, particularly early in a course of treatment, comparing the effects of canceled and no-showed appointments on overall symptom reduction and rate of change while accounting for therapist effects. Using multilevel hierarchical regression, the impact of nonattendance on symptom reduction and rate of change was modeled on 5,253 clients (67.2% female, 72.3% white) across 83 therapists gathered from a practice research network. Results suggested that no-shows, but not cancellations, had negative impacts on the magnitude and rate of symptom change, with larger effects when occurring before the third session. Therapist effects on attendance also were identified; therapists varied greatly on nonattendance percentages of their clients after the third attended session. (PsycINFO Database Record

Therapist effects on dropout from a college counseling center practice research network.

Dropout has been a pervasive and costly problem in psychotherapy, particularly for college counseling centers. The present study examined potential predictors of dropout using a large data set (N = 10,147 clients, 481 therapists) that was gathered through a college counseling center practice research network as a replication and extension of recent findings regarding therapist effects on dropout. The final model resulted in a dropout rate of 15.9% and a therapist effect of 9.51% on dropout variance. Therapist demographic variables were investigated, though none were found to be significant. Variables found to be predictive of increased likelihood of dropping out included higher levels of general presenting concerns, alcohol-related distress, and current financial stress. Ultimately, this study showed that therapists may play an important role in the likelihood of client dropout, and that additional research should be conducted to identify additional predictors, particularly at the therapist and center level. (PsycINFO Database Record

Mental health and professional help-seeking among college students with disabilities.

OBJECTIVE: Research has demonstrated that providing appropriate supports and services on campus can improve both mental health and academic outcomes for students with disabilities (Emerson, Honey, Madden, & Llewellyn, 2009; Stumbo, Martin, & Hedrick, 2009), but little is known about the specific mental health needs of this population. The purpose of this exploratory study, therefore, was to identify the mental health needs of college students with various types of disabilities. METHOD: Researchers analyzed data, collected by the Center for Collegiate Mental Health, of 5,696 students with, and without, disabilities who utilized counseling services on campuses in the 2013-14 academic year. A nonclinical (students not in counseling) sample of 1,620 students with, and without, disabilities was also explored. RESULTS: Compared to students without disabilities, students with disabilities report more anxiety and academic-related distress, as well as higher rates of suicide ideation, suicide attempts, and nonsuicidal self-injury among both students in counseling and not in counseling. CONCLUSIONS: Although in certain areas students with disabilities show similar levels of distress as students without disabilities, students with disabilities have higher levels of distress in areas which could impact their academic success. Self-harming tendencies are higher for students with disabilities overall, but more so for specific disability types. (PsycINFO Database Record

Psychotherapists' outcomes with White and racial/ethnic minority clients: First, the good news.

The purposes of this study were to (a) investigate whether psychotherapists differ in their effectiveness with clients, (b) determine whether disparities exist within therapists' caseloads in their outcomes with White and racial and ethnic minority (REM) clients, (c) explore therapist factors that might contribute to observed therapist effects, and (d) identify whether treatment outcomes varied for REM and White clients. A sample of 3,825 clients seen by 251 therapists at 45 college counseling centers completed the Counseling Center Assessment of Psychological Symptoms at the beginning and end of individual psychotherapy. Therapists differed in their effectiveness at reducing general distress across clients, and evidence was found for disparities within therapists' caseloads in their effectiveness with REM and White clients. Effect sizes were small. Disparities within therapists' caseloads were not a function of any therapist variable that was studied. Therapy outcomes were similar for White and REM clients. Therapist multicultural competence can, and should, be considered in terms of measurable outcomes across client racial/ethnic groups. It is possible to identify multiculturally expert therapists who evidence competence with both REM and White clients and who might serve as models from whom the field could learn.

Enhancing feedback for clinical use: Creating and evaluating profiles of clients seeking counseling.

The current study explored the reliability and clinical utility of a method designed to identify latent classes of students seeking counseling, based on 8 symptom domains and their interactions. Participants were over 50,000 college students in counseling, assessed with the CCAPS-62 and -34 as part of routine clinical care. Latent profile analysis was used to group an exploratory and confirmatory sample of students by reported symptoms across the 8 CCAPS subscales. Profiles were evaluated for reliability and clinical utility, in particular for risk assessment and the prediction of treatment duration and success. Nine reliably stable latent profiles, or groups of profiles, emerged from analysis. Profiles differed significantly in reported symptoms, demographic makeup, psychosocial history, and diagnoses. Additionally, profiles appeared to capture meaningful differences between clients that had implications for relative risk of suicide, self-harm, and violence toward others as well as significant differences in the number of sessions in treatment and the effect size of treatment. Latent profiles of patients appear to capture meaningful, stable differences that could be implemented in an automated system of evaluation and feedback, and that might be useful to clinicians, administrators, and researchers.

The Counseling Center Assessment of Psychological Symptoms (CCAPS): Merging clinical practice, training, and research.

The goal of this article is to present information about a standardized multidimensional measure of psychological symptoms, the Counseling Center Assessment of Psychological Symptoms (CCAPS; Locke et al., 2011; Locke, McAleavey, et al., 2012; McAleavey, Nordberg, Hayes, et al., 2012), developed to assess difficulties specific to college students' mental health. We provide (a) a brief review and summary of the psychometric and research support for the CCAPS; (b) examples of the use of the CCAPS for various purposes, including clinical, training, policy, and counseling center advocacy; and (c) implications of the integration of routine outcome monitoring and feedback for the future of training, research, and clinical practice. In particular, the article emphasizes how the assimilation of and symbiotic relationship between research and practice can address the scientist-practitioner gap.

Building a practice research network: obstacles faced and lessons learned at the Center for Collegiate Mental Health.

OBJECTIVE: The Center for Collegiate Mental Health (CCMH) was created through a grass-roots initiative among university and college counseling centers to standardize assessment procedures, conduct empirical studies, and advocate clinical services. METHOD: At present, CCMH has over 240 college counseling center members and oversees a research infrastructure based on these centers' routine services, describing approximately 90,000 individual clients annually. These data are used to provide clinical tools, which can be useful for ongoing clinical services as well as program evaluation, quality assurance, and advocacy on behalf of the counseling centers and clients. RESULTS: There have been substantial obstacles to overcome, and there remain numerous challenges in day-to-day operations. This article provides a brief overview of the challenges and current solutions. CONCLUSIONS: Large-scale collaborations between researchers and practitioners are possible, and some recommendations can be made based on the experience of CCMH.

Clinical validity of the counseling center assessment of psychological symptoms-62 (CCAPS-62): further evaluation and clinical applications.

Self-report instruments of psychological symptoms are increasingly used in counseling centers but rely on rigorous evaluation of their clinical validity. Three studies reported here (total N = 26,886) investigated the validity of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62; Locke et al., 2011) as an assessment and screening instrument. In Study 1, initial evidence regarding the concurrent validity of the CCAPS-62 was replicated and extended in a naturalistic clinical sample of clients from 16 counseling centers. Using this sample, convergent validity of the subscales was examined in counseling center clients, the range of sensitivity of the subscales was investigated using item-response theory, and the presence of 2nd-order factors was preliminarily examined. In Study 2, 7 of the 8 CCAPS-62 subscales statistically significantly differentiated between students in counseling and those who were not, using data collected from a large national survey, although most differences were small and the groups' distributions overlapped considerably. Cut scores based on the differences between these clinical and nonclinical populations showed limited utility due to overall similarities between these broadly defined groups. In Study 3, therapist-rated diagnoses collected from 5 university counseling centers were used to further examine the validity of subscale scores. In addition, cut points for diagnostic screening using receiver operating characteristic curves were evaluated. Overall, these studies support the use of the CCAPS-62 as an initial measure of psychological symptoms in college counseling settings, provide additional information about its psychometric performance, develop cut scores, and illustrate the potential for collaboration between practitioners and researchers on a large scale.