Aboriginal Practitioners Offer Culturally Safe and Responsive CBT: Response to Commentaries

We appreciate the valuable commentaries that have been provided for our paper “Can CBT be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT.” The international authors identify how CBT, with adaptations by culturally responsive practitioners can be of value for non‐Western and Indigenous peoples. The commentary by Australian psychologists Dudgeon and Kelly questions the value of CBT for Indigenous Australians, terming it a “Western therapy” that is “culturally unresponsive” and “culturally blind.” They also critique the methodology of the study. We argue that CBT can be adapted by culturally competent practitioners to be culturally safe in Australia, as elsewhere. Cultural safety is mostly a function of the therapist, not the therapy. In the Bennett‐Levy et al. (2014) study, CBT was delivered in a culturally responsive way by Aboriginal counsellors within their own communities. CBT is a particularly adaptable and versatile therapy, and embodies principles of empowerment and self‐determination that are central to Indigenous social and emotional well‐being. We are concerned that CBT, which has strong empirical support and has been adapted elsewhere for a range of cultures, including Indigenous cultures, may be being denied to Indigenous Australian clients. There is considerable opportunity to evaluate the effectiveness and versatility of CBT, and variations of its mode of delivery, for all Australians.     

Supervision in Community Mental Health: Understanding Intensity of EBT Focus

The goal of the present study was to examine clinician, supervisor, and organizational factors that are associated with the intensity of evidence-based treatment (EBT) focus in workplace-based clinical supervision of a specific EBT, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Supervisors (n = 56) and clinicians (n = 207) from mental health organizations across Washington State completed online self-report questionnaires. Multilevel modeling (MLM) analyses were used to examine the relative influence of nested clinician and supervisor factors on the intensity of EBT focus in supervision. We found that 33% of the variance in clinician report of EBT supervision intensity clustered at the supervisor level and implementation climate was the only significant factor associated with EBT supervision intensity. While individual clinician and supervisor factors may play a role in EBT coverage in supervision, our results suggest that an implementation climate that supports EBT may be the most critical factor for improving intensity of EBT coverage. Thus, implementation efforts that address the extent to which EBTs are expected, rewarded, and supported within an organization may be needed to support greater coverage of EBT during workplace-based supervision.     

Group CBT for Externalizing Disorders in Urban Schools: Effect of Training Strategy on Treatment Fidelity and Child Outcomes

Public schools are an ideal setting for the delivery of mental health services to children. Unfortunately, services provided in schools, and more so in urban schools, have been found to lead to little or no significant clinical improvements. Studies with urban school children seldom report on the effects of clinician training on treatment fidelity and child outcomes. This study examines the differential effects of two levels of school-based counselor training: training workshop with basic consultation (C) vs. training workshop plus enhanced consultation (C +) on treatment fidelity and child outcomes. Fourteen school staff members (counselors) were randomly assigned to C or C +. Counselors implemented a group cognitive behavioral therapy protocol (Coping Power Program, CPP) for children with or at risk for externalizing behavior disorders. Independent coders coded each CPP session for content and process fidelity. Changes in outcomes from pre to post were assessed via a parent psychiatric interview and interviewer-rated severity of illness and global impairment. Counselors in C + delivered CPP with significantly higher levels of content and process fidelity compared to counselors in C. Both C and C + resulted in significant improvement in interviewer-rated impairment; the conditions did not differ from each other with regard to impairment. Groups did not differ with regard to pre- to- posttreatment changes in diagnostic severity level. School-based behavioral health staff in urban schools are able to implement interventions with fidelity and clinical effectiveness when provided with ongoing consultation. Enhanced consultation resulted in higher fidelity. Enhanced consultation did not result in better student outcomes compared to basic consultation. Implications for resource allocation decisions with staff training in EBP are discussed.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group for Individuals with a First Episode of Psychosis

CBT for psychosis has recently been called a best practice, suggesting that studies have demonstrated its efficacy with many populations. Community settings are encouraged to implement best practices such as CBT yet many factors can make the implementation of CBT challenging. Issues such as clinician resistance, setting, as well as client variables (refusal, denial of symptoms, etc.) come into play. Examples of successes and challenges of a community based study of CBT groups for first episodes will be described. The strategies used to overcome these challenges and the successes of the program will be presented.     

Implementation in a Changing Landscape: Provider Experiences During Rapid Scaling of Use of Evidence-Based Treatments

This study examined 133 service providers’ perspectives on a rapid shift to mandated evidence-based treatment delivery, utilizing an inductive coding process to capture themes present in their qualitative feedback. The majority of provider comments were negatively valenced, but attitudes varied considerably across response categories: comments regarding practice context and support were nearly uniformly negative, while comments regarding treatment fit and therapeutic consequences were more balanced. Treatment fit was the most commonly cited category; the fit to therapist (e.g., ease of use) subcategory was predominantly positive in contrast with the fit to client (e.g., flexibility) subcategory, which was predominantly negative. Results illustrate the intended and unintended consequences of large-scale implementation efforts on community providers, and may aid implementation researchers and system decision makers optimize the conditions under which community providers are asked to implement evidence-based treatment.     

Enhancing Cognitive‐Behavioural Therapy (CBT) Skill Acquisition Through Experiential and Reflective Learning: A Commentary on Studies Examining the Impact of Self‐Practice and Self‐Reflection in CBT

Self‐practice and self‐reflection (SP/SR) is a targeted training tool that is intended to increase CBT competency in therapists. The four articles reviewed in this commentary examine the benefits of SP/SR with various types of therapists, and survey the significant obstacles faced in implementing this tool with clinicians. Collectively, these articles conclude that SP/SR is a valuable tool in improving CBT skill acquisition and preventing burnout, particularly with difficult patients, but that most therapists elect not to use it largely because of the time involved in engaging in it. In this commentary, I suggest that empirical studies with larger samples and controlled designs are needed to build on the wealth of qualitative data collected to date in order to assess the value added by SP/SR compared with other training methods, and in order to determine its impact on a range of therapeutic outcomes. I also suggest that future studies should examine the efficacy of required SP/SR engagement, isolate its critical ingredients, and assess if there are clients and therapists for whom SP/SR is comparably more effective.     

Sustainability of Teacher Implementation of School-Based Mental Health Programs

Evidence-based prevention and intervention programs are increasingly being implemented in schools and it therefore is becoming increasingly important to understand the complexities of program implementation under real-world conditions. Much research has focused on the contextual factors that influence program implementation but less work has attempted to provide an integrated understanding of mechanisms (e.g., teacher-training processes) that affect teachers' program implementation. In this paper, we review literature on factors related to teachers' implementation of school-based prevention and intervention programs, then from this review abstract what we believe are four basic ingredients that characterize potentially sustainable teacher-implemented classroom programs. Finally, we present a sequential model, based on these ingredients, of the naturalistic processes underlying sustainability of teachers' program implementation and describe how this sustainability can be enhanced through provision of teacher training and performance feedback from a classroom consultant.     

Integrating Behavioral Aspects into Community Preparedness and Response Systems

Summary

This article examines the role of psychosocial and behavioral dimensions of terrorism that influence community preparedness and homeland defense efforts. Public health interventions will fail if people do not follow the recommendations. A broader public health model is applied to help identify the interactions between risk and safety appraisals, social factors, and behavioral response to uncertain and stressful situations. Community preparedness would benefit by linking disparate programmatic and advocacy initiatives that already exist. It stands to reason that improving the cohesiveness of existing systems of social organization would strengthen community resilience and serve as effective countermeasures for terrorism.     

The School and Community Study: Characteristics of Students Who Have Emotional and Behavioral Disabilities Served in Restructuring Public Schools

We present selected initial results from a study investigating the effects of school restructuring and reform activities on outcomes for students who are identified as having serious emotional and behavioral disabilities. A review of the literature revealed six key areas of reform for investigation: accountability, governance, parent involvement, includedness, curriculum and instruction, and pro-social discipline. Ten schools (five elementary, two K-8, one middle, and two high schools) actively engaged in school restructuring and reform efforts were selected to participate in the study, and their status related to these six areas is presented. Characteristics of the students identified as having emotional and behavioral disabilities and served in these schools in special education settings (N = 116) are described. Results from the administration of standardized assessments revealed that these students have significant levels of emotional and behavioral disabilities that impair their functioning at school and at home. Further, school staff are providing the majority of counseling services to these students during the school day, with non-school professionals providing services to 25% of the students.     

Online Cognitive Behavioural Therapy Training for Therapists: Outcomes,Acceptability, and Impact of Support

The objectives of the present study were to assess the effects of online cognitive behavioural therapy (CBT) training for therapists on measures of CBT knowledge, skills, confidence, and utilisation; to determine what differences might exist between a group supported by regular telephone contact and an independent group who undertook online training without additional support; and to determine the acceptability of CBT online training among rural and remote mental health professionals. Mental health practitioners were randomly allocated to a supported training group (six sessions of 15‐min support) or an independent group. They undertook a 12‐week online CBT training program. The two groups showed similar gains on an objective test of knowledge of CBT, and on self‐report measures of knowledge, skills, confidence levels, and utilisation of skills. However, the supported training group had a significantly higher program completion rate than the independent group. Participants evaluated the program favourably. The results suggest that online CBT training represents a promising and cost‐effective approach to training the mental health workforce, and may be particularly attractive for those who live in regional, rural, and remote communities. A challenge is to determine the most cost‐effective ways to enhance program completion rates and trainee skills.     

Community psychology values and the culture of graduate training: A self-study

In this self-study of an M.A. program in community psychology, the authors focused on evaluation of training goals related to the values of collaboration, empowerment, and diversity. Employing quantitative and qualitative methods, the evaluator, a thesis student in the program, cooperated with a stakeholder committee and other student, staff, and faculty members of the program to construct the methods and interpret the findings. Although the converging sources of data showed that the program was meeting its process goals to some extent, several key issues in the culture of training, such as the status of women, the psychological sense of community, and a supportive learning environment, needed improvement. The authors interpret the findings in terms of the impact of the university system and patriarchal norms on training in community psychology. This study is based on the first author's M.A. thesis, which the second author supervised. Judit Alcalde works in health promotion with the Regional Municipality of Waterloo, Community Health Department. She presented an earlier version of this work at the conference of the Canadian Psychological Association, Calgary, Alberta, June 1991. We are grateful to the thesis committee members for their support and guidance, to our colleagues for their participation, to Paul Davock, and to the reviewers and editor for their helpful comments.     

Parent-School and Community Partnerships in Children's Mental Health: Networking Challenges, Dilemmas, and Solutions

Inter-agency collaboration, service coordination, and the creation of successful partnerships among parents, teachers, and human services professionals continues to be a challenge for the development of responsive community-based systems of care for at-risk youth and their families. We explore how one inner-city neighborhood struggles to create successful community partnerships through traditional networking strategies. Our findings identify networking strategies that appear to work and those that do not. Recommendations for improving communication are provided.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

Guidelines for Cognitive Behavioral Training Within Doctoral Psychology Programs in the United States: Report of the Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education

The Association for Behavioral and Cognitive Therapies initiated an interorganizational task force to develop guidelines for integrated education and training in cognitive and behavioral psychology at the doctoral level in the United States. Fifteen task force members representing 16 professional associations participated in a yearlong series of conferences, and developed a consensus on optimal doctoral education and training in cognitive and behavioral psychology. The recommendations assume solid foundational training that is typical within applied psychology areas such as clinical and counseling psychology programs located in the United States. This article details the background, assumptions, and resulting recommendations specific to doctoral education and training in cognitive and behavioral psychology, including competencies expected in the areas of ethics, research, and practice.     

Community implementation of PMTO™: Impacts on referrals to specialist services and schools

Sigmarsdóttir, M. & Björnsdóttir, A. (2012). Community implementation of PMTO?: Impacts on referrals to specialist services and schools. Scandinavian Journal of Psychology 53, 506–511. In 2000, the city of Hafnarfjörður, Iceland, implemented Parent Management Training – Oregon Model (PMTO^?) to prevent and treat behavioral problems among children. This paper describes the implementation and findings regarding impacts in the community. As hypothesized, findings showed that the number of referrals to specialist services decreased in Hafnarfjörður following PMTO implementation and increased in two comparison communities not implementing the method. Within the Hafnarfjörður community, recorded instances of behavior problems reduced in elementary schools working in line with PMTO. The results presented are the first such findings in Iceland and suggest the kinds of systematic changes communities may experience following the implementation of an evidence‐based program.     

Disorder-specific Effects of CBT for Anxious and Depressed Youth: A Meta-analysis of Candidate Mediators of Change

The commonalities between anxiety and depression have been discussed before, but few have delineated the potentially different mechanisms through which treatments work for these populations. The current study conducted a comprehensive review of child and adolescent randomized clinical trials that tested cognitive-behavioral therapy (CBT) for anxiety or depression. All studies were required to have assessed both treatment outcomes and at least one theory-specific process target, including behavioral, physiological, cognitive, and coping variables. Using a meta-analytic approach, CBT demonstrated positive treatment gains across anxiety, depression, and general functioning outcomes. CBT for anxiety also produced moderate to large effects across behavioral, physiological, cognitive, and coping processes, with behavioral targets demonstrating potentially the greatest change. CBT for depression produced small effects for cognitive processes but nonsignificant effects for behavioral and coping variables. Findings were generally consistent with CB theory but suggest potentially different mediators in the treatment of anxiety and depression. Results are discussed in terms of implications for mechanisms research, theories of change, and treatment development.     

Challenges in Disseminating Model Programs: A Qualitative Analysis of the Strengthening Washington DC Families Program

This article discusses the challenges faced when a popular model program, the Strengthening Families Program, which in the past has been implemented on a smaller scale in single organizations, moves to a larger, multiorganization endeavor. On the basis of 42 interviews conducted with program staff, the results highlight two main themes that address program and organizational characteristics. The themes relate to the cultural relevance of the program, the accessibility of program partners, the organization of program services, and the coordination of program activities. The article also offers a discussion of how to better prepare sites for program delivery. This discussion focuses explicitly on the need for good communication among program partners, extensive community outreach, and the ability to secure additional resources.