Outcomes of student trainee-delivered cognitive-behavioral therapy (CBT) on internalizing symptoms, CBT skills, and life satisfaction.

Increased quality of life (QoL) is rated by patients as a primary factor in determining recovery from psychopathology. Cognitive-behavioral therapies (CBTs) are the most well-researched psychotherapies for internalizing disorders and appear effective at reducing symptoms even when delivered by trainees. Existing research suggests that the effects of CBTs on QoL are more modest than their effects on symptoms. However, little is known about the effects of trainee-delivered CBT on life satisfaction, a subjective measure of QoL. We analyzed data from 93 clients treated by students (n=23) in a graduate-level training clinic using an intent-to-treat approach, completers case analyses, and random forest imputation. Across methods of handling missing data, improvements in anxiety, depression, and CBT skills were more marked than improvements in QoL. Exploratory analyses suggested baseline life satisfaction was the strongest predictor of end-of-treatment life satisfaction. Future research should explore alternatives to "standard" CBT for clients with low life satisfaction.

Mental health needs in a large urban school district: Findings from a web-based survey.

OBJECTIVE: To explore the mental health needs of students, and the professional development and support needs of teachers and school health professionals, as a way to foster community engagement and help set priorities for a comprehensive school mental health system in the Detroit Public Schools Community District (DPSCD). SETTING: The study team surveyed all DPSCD staff in June 2019 and all students in grades 8-12 between October and December 2019. STUDY DESIGN: A descriptive study based on anonymous, web-based surveys focused on student trauma exposure and mental health symptoms, student mental health resource utilization, staff burnout, and professional development needs. DATA COLLECTION: All students (grades 8-12) and district staff were eligible to participate; the student survey was made available in six languages. Parents/guardians could opt children out; schools could exclude children unable to complete the survey independently. Student surveys were administered in school; staff surveys were sent via email. PRINCIPAL FINDINGS: Thirty-four percent of DPSCD students reported moderate/severe depression symptoms; 22% had seriously considered suicide in the past year. Rates exceed national averages; 37% of students with severe depression and 34% of those with suicidal ideation had not accessed mental health supports. Staff indicated high levels of burnout and substantial interest in learning about self-care strategies or coping with vicarious trauma. Over 75% of teachers and school mental health professionals expressed interest in learning about best practices for supporting students impacted by trauma or mental illness. CONCLUSIONS: A large number of DPSCD students are experiencing symptoms of depression and anxiety, and many students who need care are not accessing it. Addressing the mental health needs of students is a high priority for staff, but they need more training and support, as well as support for their own vicarious trauma and high levels of burnout.

Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase.

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic-community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Implementation of the Wolverine Mental Health Program, Part 3: Sustainment Phase.

Sustaining the implementation of an evidence-based practice (EBP) is the ultimate goal of often years of significant personnel and financial investment. Some conceptualize sustainment as a distinct phase following an active implementation period where the contextual factors, processes, and supports are bolstered to ensure continued EBP delivery. This study provides an overview of the sustainment strategies deployed to embed cognitive-behavioral therapy (CBT) in a Midwestern residential treatment facility serving youth with complex mental health needs. Seven key strategies and their outcomes are described: use of CBT teams, new hire orientation plans, monthly campaigns, change in job descriptions and performance evaluations, development of a behavioral reinforcement system for youth, and a pathway to CBT certification. This study provides a window into how one might sustain an EBP by addressing barriers unique to this phase of work.

Implementation of the Wolverine Mental Health Program, Part 1: Adoption Phase.

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS's readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.

Developing a statewide network of coaches to support youth access to evidence-based practices.

Background: A national shortage of mental health providers for youth exists in the United States. Implementation support for mental health services in schools, where students are most likely to access care, can help to fill these gaps. Coaching consists of in vivo modeling and support during service delivery and is effective in supporting the implementation of evidence-based practices (EBPs). This implementation report describes the recruitment and training of community providers to become coaches as a part of a modified train-the-trainer model of implementation support. Method: An EBP implementation program, Transforming Research into Action to Improve the Lives of Students (TRAILS), trained community providers in Michigan to increase knowledge of cognitive behavioral therapy (CBT) and position them as coaches in schools. The development of the coach network involved five stages prior to the initiation of a randomized controlled trial: (1) recruitment, (2) a one-day clinical training, (3) 12 weeks of individualized consultation, (4) evaluation, and (5) training in the coaching protocol. Results: A total of 347 individuals attended an initial training, and 187 were paired with a consultant. Eighty-six clinicians from 47 of Michigan's 83 counties successfully became coaches by completing all required elements of training. Coaches showed significant improvements in the use and knowledge of CBT across consultation. Conclusion: Statewide networks of trained mental health professionals can address gaps in mental healthcare for youth. This article demonstrates one strategy for strengthening and leveraging community expertise to support the implementation of EPBs in schools. Plain Language Summary: Although youth face many barriers in accessing effective mental health care, schools are one setting where they can more easily receive treatment. Research shows that training and supports are needed for school mental health professionals to provide effective care. Coaching, which involves in vivo support for school mental health professionals, is one helpful strategy. We describe the process of recruiting and training community clinicians to become coaches. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program successfully recruited and trained a network of 86 community clinicians to become coaches. Clinicians attended two day-long trainings and participated in 12 weeks of personalized consultation. Clients to whom these clinicians provided CBT showed significant symptom improvement. Clinicians also reported that they increased their knowledge and use of core CBT strategies, including psychoeducation, exposure, and behavioral activation. Community mental health professionals who are trained as coaches can address gaps in access to care for youth. We demonstrate one strategy for strengthening and leveraging clinicians' knowledge of CBT to support the school-based implementation of CBT.

Development of a Brief Group CBT Intervention to Reduce COVID-19 Related Distress Among School-Age Youth.

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.

The Cognitive Behavioral Therapy Competence Scale (CCS): initial development and validation.

Background: Nearly one-third of youth are affected by a mental health disorder, and the majority do not receive adequate care. To improve clinical outcomes among youth, efforts have been made to train providers in evidence-based mental health practices, such as cognitive behavioral therapy (CBT). Such efforts call for valid assessment measures that can inform and evaluate training activities. Aims: This study presents the development and validation of the CBT Competence Scale (CCS), a brief self-report measure to assess provider competence for CBT delivery. Method: Participants were 387 school mental health professionals (SMHPs) working with students in Michigan, USA. Initial items (n=59) were developed to evaluate competence in delivering common elements of CBT, with competence conceptualized as covering domains of knowledge, perception, and use of CBT techniques. CCS validation proceeded in three steps: using item response theory to select the most important items for assessing knowledge, evaluating the factor structure using exploratory and then confirmatory factor analyses, and examining reliability and validity of the resultant measure. Results: The validated CCS measure consists of four dimensions of CBT competence across 33 items: Non-behavioral skills, Behavioral skills, Perceptions, and Knowledge. The CCS demonstrated excellent internal consistency and good construct-based validity. Conclusions: The CCS holds promise as a valid, informative measure of CBT competence appropriate for the school setting, with potential for application in other environments such as mental health clinics.

In Search of Reliability: Expert-Informed Training Methods for Conducting Observational Coding of Cognitive Behavioral Therapy Fidelity.

BACKGROUND: Observational coding is the gold standard for measuring treatment fidelity; however, the intensive training needed for reliable and valid measurement has not been carefully scrutinized. A systematic review concluded there is a lack of information in published studies on how to approach training raters, and the available content suggests widely variable approaches are taken across research teams. The quality and comparability of the data produced from these treatment fidelity measures is undermined by heterogeneous training approaches occurring both within and between coding teams. No guidance for training teams to do observational coding for fidelity is currently available. The aims of the current study were to: (a) characterize expert-informed processes for observational coding regarding training, coding, and achieving reliability, and (b) generate expert recommendations for training and conducting observational coding. METHOD: A semi-structured interview was used to explore international CBT expert's (N = 11) perspectives and experiences regarding observational coding training processes. A qualitative content analysis approach was used to analyze the data. RESULTS: Experts in the study provided information about their training, coding, and reliability processes. CONCLUSION: Results from this study informed recommendations on how to: (a) introduce scale items, (b) anchor ratings, and (c) drift prevention.

A placebo prognostic index (PI) as a moderator of outcomes in the treatment of adolescent depression: Could it inform risk-stratification in treatment with cognitive-behavioral therapy, fluoxetine, or their combination?

Introduction: Researchers have proposed that predicting who is a likely placebo responder may help guide treatment allocations to treatment regimens that differ in intensity. Methods: We used data from the Treatment of Adolescent Depression Study (TADS) in which adolescents (n = 439) were randomized 1:1:1:1 to placebo, cognitive-behavioral therapy (CBT), medications (MEDs), or their combination (COMB). We developed a prognostic index (PI) in the placebo group to predict self-reported (RADS) and observer-rated (CDRS) depression outcomes using elastic net regularization. We explored whether the PIs moderated outcomes in the treatment conditions. Results: PI-CDRS was predicted by multiple variables but it did not moderate outcomes. PI-RADS was predicted by baseline severity, age, sleep problems, expectations, maternal depression, and the action stage of change. It moderated outcomes such that there were treatment differences for less placebo-responsive patients. For participants prone to placebo response, type of treatment had no statistically significant impact on outcomes. Baseline depression severity accounted for this effect: treatment differences were small and non-significant for patients with milder depression but larger in more severely depressed patients. Discussion: Future work should investigate whether multiple variable explain outcomes beyond severity as well as complex interactions between severity and other variables.