Therapist Focus on Parent Involvement in Community-Based Youth Psychotherapy

Parent involvement in the treatment of childhood disruptive behavior problems is a critical component of effective care. Yet little is known about the amount of time therapists are involving parents in treatment and factors that predict therapists' efforts to involve parents in routine care. The purpose of this study is to examine therapists' within-session involvement of parents in community-based outpatient mental health treatment. The data are from a larger longitudinal observational study of psychotherapy for children ages 4-13 with disruptive behavior problems and include videotaped psychotherapy sessions coded for the therapeutic strategies delivered as well as measures of child, parent/family, and therapist characteristics at baseline. Parent involvement is defined as the proportion of time in the session that therapists direct treatment strategies towards parents. Results indicated that therapists directed treatment strategies towards parents an average of 44% of the time within a session. Multilevel modeling was used to examine client-level (child, parent, and family functioning) and provider-level (therapist experience and background) predictors of parent involvement. Therapists involved parents more when the child had higher levels of behavior problems, when the parent reported higher levels of internalized caregiver strain, and when the therapist was more experienced. The results highlight potential areas to target in efforts to increase parent involvement, including training less experienced therapists to increase their focus on directing strategies towards parents.     

A Comparison of Interactions Among Children,Parents, and Therapists in Cognitive Behavior Therapy for Anxiety Disorders in Australia and Japan

Despite growing attention to the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at posttreatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.     

Parent Perspectives of an Evidence-Based Intervention for Children with Autism Served in Community Mental Health Clinics

Research suggests that improvements to community mental health (CMH) care for children with autism spectrum disorders (ASD) are needed. Recent research examining the feasibility of training CMH therapists to deliver a package of evidence-based practice intervention strategies (EBPs) targeting challenging behaviors for school-age children with ASD offers initial support for such efforts to improve care. Specifically, quantitative data from a recent pilot study indicate that CMH therapists with limited ASD experience can deliver an EBP intervention with fidelity and perceive it as useful to their practice. Further, client attendance is high and children demonstrate improvement on standardized measures. To further understand the feasibility and impact of training CMH therapists to deliver EBPs, this mixed-methods study examined parent perspectives of the process and impact of outpatient psychotherapy for 13 parents of children ages 5–13 with ASD whose therapists were trained to deliver the EBP intervention. Results complement and expand previously reported quantitative data on psychotherapy process indicating that parents are highly involved in treatment for their children, perceive a strong therapeutic alliance with their children’s therapist, and highlight that treatment was different once therapists began delivering the intervention. Results also indicate themes related to parents’ perceptions of positive child and parent outcomes that provide important details on the specific gains that were observed during treatment. Study findings underscore the importance of parent perspectives in understanding the process and impact of implementing EBPs in CMH settings for families of children with ASD.     

Client attendance measures in counselling psychology trainees

Counselling supervisors and educators have yet to reach a consensus about standard measures for evaluating the performance of graduate student therapists. Compared to self‐reports and rater judgements, client attendance records provide low‐inference behavioural data partially reflective of clients’ engagement with therapists. This naturalistic study evaluates client attendance data using archival records of 92 doctoral students in beginning and advanced counselling practica who produced data for 771 clients, 3,949 scheduled sessions and 3,186 attended sessions. Providing evidence of the sample representativeness for clinicians, results indicated that the mean number of sessions attended per client for student therapists (5.65) was very similar to that reported in the literature for outpatient therapists (<6). As expected because of structural differences in client assignment, beginning and advanced students evidenced statistically significant differences on attendance variables such as number of clients and scheduled sessions. In contrast, attendance ratios were equivalent across counsellor experience, suggesting that these individual difference variables could be useful for evaluation of therapist competencies related to client engagement.     

Assessing the Key to Effective Coaching in Parent–Child Interaction Therapy: The Therapist-Parent Interaction Coding System

This paper describes the initial evaluation of the Therapist-Parent Interaction Coding System (TPICS), a measure of in vivo therapist coaching for the evidence-based behavioral parent training intervention, parent–child interaction therapy (PCIT). Sixty-one video-recorded treatment sessions were coded with the TPICS to investigate (1) the variety of coaching techniques PCIT therapists use in the early stage of treatment, (2) whether parent skill-level guides a therapist’s coaching style and frequency, and (3) whether coaching mediates changes in parents’ skill levels from one session to the next. Results found that the TPICS captured a range of coaching techniques, and that parent skill-level prior to coaching did relate to therapists’ use of in vivo feedback. Therapists’ responsive coaching (e.g., praise to parents) was a partial mediator of change in parenting behavior from one session to the next for specific child-centered parenting skills; whereas directive coaching (e.g., modeling) did not relate to change. The TPICS demonstrates promise as a measure of coaching during PCIT with good reliability scores and initial evidence of construct validity.     

Recruiting and Retaining High-Risk Adolescents into Family-Based HIV Prevention Intervention Research

The purpose of this study was to examine the effectiveness of evidence-based recruitment and retention strategies for a longitudinal, family-based HIV prevention intervention study targeting adolescents in psychiatric care by (1) determining consent rate (recruitment), rate of participation at the first intervention session (retention), and follow-up attendance rate (retention); and (2) examining socio-demographic factors, family-level processes, sexual risk-related indices, and intervention factors (i.e., treatment arm) associated with study retention. Only one-third of the families contacted ultimately enrolled in the study. 81% of those enrolled participated in the workshop and 72% attended the booster sessions with no significant differences between families on any variable based on attendance. Retention over 1?year was 85% and did not differ by treatment arm. Strategies employed were successful at retaining families once they were enrolled. Findings highlight barriers to enrollment for adolescents in psychiatric care and suggest that it may be critical to integrate HIV prevention programs within community-based mental health services in order to counteract recruitment challenges.     

Community Implementation of MI-Enhanced Behavior Therapy for Adolescent ADHD: Linking Fidelity to Effectiveness

Evidence-based behavior therapy for adolescent ADHD faces implementation challenges in real-world settings. The purpose of this trial was to investigate the relationship between implementation fidelity and outcomes among adolescents receiving services in the active treatment arm (N = 114; Motivational Interviewing [MI]-enhanced parent-teen behavior therapy) of a community-based randomized trial of adolescent ADHD treatment. Participants received therapy from community clinicians (N = 44) at four agencies in a large, ethnically diverse metropolitan setting. Therapists provided self-report of session-by-session adherence to content fidelity checklists and audio recordings of sample sessions that were coded for MI integrity. Parents provided report of ADHD symptoms and family impairment at baseline, posttreatment, and follow-up, while academic records were obtained directly from the local school district. Results indicated that content fidelity significantly waned across the 10 manualized sessions (d = -1.23); these trends were steepest when therapy was delivered outside the office-setting and parent attendance was low. Community therapist self-report of content fidelity predicted significantly greater improvements in academic impairment from baseline to follow-up. MI delivery quality was not associated with improved outcomes; contrary to hypotheses, lower MI relational scores predicted significantly greater improvements in family impairment over time. Findings indicate that community-based outcomes for evidence-based ADHD treatment are enhanced when treatment is implemented with fidelity. Future work should revise community-based implementation strategies for adolescent ADHD treatment to prevent declines in fidelity over time, thereby improving outcomes.     

The alliance in a friendship coaching intervention for parents of children with ADHD

The alliance between parent and therapist was observed in a group-based parent-training intervention to improve social competency among children with attention-deficit/hyperactivity disorder (ADHD). The intervention, called Parental Friendship Coaching (PFC), was delivered to 32 parents in small groups as part of a randomized clinical trial. PFC was delivered in eight, 90-minute sessions to parents; there was no child treatment component. Observed parent–therapist alliance recorded among 27 of the parents was measured using the Therapy Process Observational Coding System—Alliance scale (TPOCS-A; McLeod, 2005). Early alliance and change in alliance over time predicted improvements in several parenting behaviors and child outcomes, including peer sociometrics in a lab-based playgroup. These preliminary findings lend support to the importance of examining the parent–therapist alliance in parent-training groups for youth social and behavioral problems.     

Effects of a Workplace Intervention on Parent–Child Relationships

This study tested whether effects of a workplace intervention, aimed at promoting employees’ schedule control and supervisor support for personal and family life, had implications for parent–adolescent relationships; we also tested whether parent–child relationships differed as a function of how many intervention program sessions participants attended. Data came from a group randomized trial of a workplace intervention, delivered in the information technology division of a Fortune 500 company. Analyses focused on 125 parent–adolescent dyads that completed baseline and 12-month follow-up home interviews. Results revealed no main effects of the intervention, but children of employees who attended 75 % or more program sessions reported more time with their parent and more parent education involvement compared to adolescents whose parents attended <75 % of sessions, and they tended to report more time with parent and more parental solicitation of information about their experiences compared to adolescents whose parents were randomly assigned to the usual practice condition.     

Therapist effects and the dissemination of cognitive behavior therapy for chronic fatigue syndrome in community-based mental health care

ObjectiveThe purpose of the present study was to explore the role of the therapist in the dissemination of manualized cognitive behavior therapy (CBT) for chronic fatigue syndrome (CFS) outside specialized treatment settings.MethodWe used the routinely collected outcome data of three community-based mental health care centers (MHCs) which implemented and sustained CBT for CFS during the course of the study. Ten therapists, who all received the same training in CBT for CFS, and 103 patients with CFS were included.ResultsRandom effects modeling revealed a significant difference in mean post-treatment fatigue between therapists. The effect of the therapist accounted for 21% of the total variance in post-treatment fatigue in our sample. This effect could be explained by the therapists’ attitude toward working with evidence-based treatment manuals as well as by the MHC where CBT for CFS was delivered.ConclusionThe context in which CBT for CFS is delivered may play an important role in the accomplishment of established therapy effects outside specialized treatment settings. Due to the small sample size of MHCs and the different implementation scenarios in which they were engaged, our findings should be interpreted as preliminary results which are in need for replication.     

Dyadic Treatment,Reflective Functioning,and Videofeedback: Fostering Attachment with Families in the Foster Care System

The Building Blocks Program encourages parent-child bonding, attachment, and reflective functioning based on theories of nonverbal communication and mentalization. In the Building Blocks Program, young children who are in foster care or at risk of being in foster care are seen in dyadic sessions with their birth parents in a clinical setting. The parents come in with traumatic histories, including adverse childhood experiences, disrupted connections, mental illness, ongoing exposure to poverty and violence, and have little social support. The children have significant medical, emotional, and/or cognitive challenges. In this article, all aspects of the Building Blocks Program are described, including training for therapists, treatment for parents and children in supervised play/visitation sessions, Reflective Supervision with therapists in group and individual sessions, and the model of Nested Mentalization. Using video and videofeedback as a vehicle for positive change, therapists promote emotional healing and parent-child attachment. In Reflective Supervision, supervisors make every effort to understand the thoughts and feelings of the therapists. A holding environment is provided for the therapists who, in turn, hold the parent, who can then hold the child. Two cases are described that demonstrate the many layers of complexity in the Building Blocks model, and how the multifaceted levels of complicated systems are addressed.     

Impact of Location and Availability of Behavioral Health Services for Children

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2?C12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children??s hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; ??² = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.     

Research to Practice: Implementation of Family School Success for Parents of Children With ADHD

“Family-School Success” (FSS) is an efficacious intervention improving the home and school functioning of children with ADHD in grades 2–6. An extension of this intervention designed for a younger population also showed positive effects for kindergarten and first grade students in a pilot study. Following the completion of these trials, FSS was implemented in a fee-for-service tertiary care ADHD center. The implementation process included adapting the manual and treatment procedures to be feasible outside the structure and support of a federally funded randomized control trial (RCT). The current study examines the process of adapting the treatment protocol and examines the acceptability and effectiveness of the adapted FSS, as well as predictors of family treatment response including parent engagement in treatment (as measured by attendance and homework adherence). A case study illustrates the adaptations to the intervention and its implementation in the clinic-based setting. In line with findings from clinical trials, families reported high satisfaction with the adapted FSS intervention and showed significant improvement in parental self-efficacy, child academic homework performance, and reduction in child impairment. Additionally, as in the initial FSS RCT, parental attendance in the adapted FSS program predicted child attention to academic homework, controlling for parental adherence to between-session homework. Furthermore, controlling for attendance at FSS sessions, parent adherence to between-session homework assignments predicted improvements in parent self-efficacy as well as child’s homework productivity. These results replicate those of the original RCT and confirm that both session attendance and between-session homework completed are important for improvement during the program. Overall, this study provides support for the acceptability and effectiveness of this treatment model and suggests that future work toward dissemination to community-based settings would be worthwhile.     

„Beyond efficacy“:

In this study, treatment efficacies of 30 short and long-term treatments with adolescents were presented from the perspective of the afflicted adolescent, the parents and the therapists. Assessments were made 3 times over 1.5 years after 97 therapy sessions on average. Short-term psychotherapy did not significantly contribute to symptom reduction. In the long-term treatments, therapists reported a strong reduction in symptomatology and in communicative disturbances with parents, siblings and friends over time. However, parents perceived less change in symptomatology compared to their children. The quality of the therapists' work with parents did not impact psychotherapy outcome. Tendentially, the type of treatment and the experience of the therapist were relevant for treatment efficacy.     

The incremental validity of the MMPI-2: when does therapist access not enhance treatment outcome?

The present study examined whether therapist access to the Minnesota Multiphasic Personality Inventory (MMPI-2) predicted favorable treatment outcome, above and beyond other assessment measures. A manipulated assessment design was used, in which patients were randomly assigned either to a group in which therapists had access to their MMPI-2 data or to a group without therapist access to such information. Illness severity, improvement ratings, number of sessions attended, and premature termination were indicators of therapy outcome. Results indicated that therapist access to the MMPI-2 data did not add to the prediction of positive treatment outcome beyond that predicted by other measures in this setting. Findings from this initial study suggest that, compared with other resources, perhaps in clinical settings with an emphasis on diagnosis-based and evidence-based treatment, the MMPI-2 may not provide incrementally valid information. However, these effects warrant replication across different settings and samples. Guidelines for future studies are discussed.     

Preliminary Evaluation of Sleepwise Program for Children With Sleep Disturbance and Developmental Delay

Sleep disturbances are very prevalent in children with developmental delay. Parental-assisted behavioral strategies have been used effectively in school-aged children; however, multimodal treatment for preschool-aged children is lacking. The current study is a preliminary investigation of the effectiveness of a parent group program called Sleepwise designed for young children with developmental delay and incorporating behavioral, communicative, and sensory strategies. Six parents attended three workshop sessions and implemented individualized treatment plans. Initial results revealed significant posttreatment reductions in child sleep disturbances and behavioral problems, with high treatment acceptability ratings by parents. Outcomes were generally maintained at 1-month follow-up.     

Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial

Efforts to improve the implementation of evidence-based treatments (EBT) have recently made important strides. One such example is understanding the vital role that weekly consultation plays as therapists learn to deliver an EBT. Because mechanism-based research can further support EBT implementation, the present study sought to examine the potential relationship between therapist self-efficacy in relation to treatment fidelity and outcomes.We examined therapist self-efficacy ratings from 80 therapists working with 188 patients. These data were collected as part of a randomized controlled implementation trial testing cognitive processing therapy (CPT). Across post-workshop training conditions, we ran multilevel models to assess (1) changes in therapist self-efficacy, (2) therapist self-efficacy in relation to treatment fidelity, and (3) therapist-self-efficacy in relation to patient PTSD symptom outcomes.We found that therapist self-efficacy significantly improved over the course of 6 months of CPT training. Baseline therapist self-efficacy was differentially associated with client outcomes based on post-workshop training condition. Specifically, therapists with low self-efficacy that did not receive post-workshop consultation tended to have poorer outcomes than therapists with low self-efficacy that received consultation. In the present sample, therapist self-efficacy was not related to treatment fidelity.As this was the first study to examine therapist self-efficacy in the implementation of an evidence-based treatment, our findings suggest that self-efficacy may be an important implementation factor in treatment outcomes and worthy of ongoing research.     

Child and family therapy: A collaborative approach

Abstract

When a child is the identified patient, people often expect individual sessions to be a part of treatment. Yet, family therapists routinely violate this expectation by working with children solely in the context of the family. This article discusses how the therapeutic process can be facilitated by conducting at least a small number of individual sessions with children. Such behavior by the therapist communicates to children, parents, and involved referral sources a respect for their opinions and lays the groundwork for cooperation. The advantages and disadvantages of such an approach are discussed.     

A Feasibility Study of Behavioral Activation for Major Depressive Disorder in a Community Mental Health Setting

Behavioral activation (BA) is a well-supported treatment approach, but little research has been conducted on the effectiveness of this treatment within publicly funded community mental health settings. We examined the feasibility of conducting a randomized trial examining the effectiveness of nine sessions of BA as a treatment for major depressive disorder (MDD) in a community mental health clinic (CMHC) setting. Following adaptation of a BA manual and training of BA therapists, 80 patients seeking treatment at a CMHC were randomized, with a 3:1 randomization rate of BA to nine sessions of treatment as usual (TAU). Feasibility assessments indicated that only one eligible patient refused randomization and, of patients who attended at least one session, the median number of sessions was six for the BA group and eight for the TAU group. Of three postbaseline monthly assessments, 71.3% (171/240) were successfully obtained. On average, patients in the BA condition completed homework assignments 83.9% of the time. Treatment fidelity ratings indicated that substantially more BA techniques were delivered in the BA group compared to the TAU group (d = 2.11). Measures of BA mechanisms improved significantly over time and these changes were significantly associated with change in depressive symptoms. These results indicate that it is feasible to conduct a randomized study of BA for MDD in a CMHC setting. In addition, the study reconfirmed the potential importance of theory-relevant BA mechanism variables. Following these findings, further investigation into the effectiveness of BA in this setting is needed.     

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).