Supervising EBT: What Content Do Workplace-Based Supervisors Cover and What Techniques Do They Use?

Workplace-based clinical supervision in public mental health is an underutilized resource for supporting evidence- based treatments (EBTs) [1], despite the fact that supervisors may offer a cost-effective way to support clinician fidelity to EBT. Very little, however, is known about the content and techniques used by workplace-based supervisors [2]; particularly in the context of EBT implementation [3]

Objective Coding of Content and Techniques in Workplace-Based Supervision of an EBT in Public Mental Health

BACKGROUND: Workplace-based clinical supervision as an implementation strategy to support evidence-based treatment (EBT) in public mental health has received limited research attention. A commonly provided infrastructure support, it may offer a relatively cost-neutral implementation strategy for organizations. However, research has not objectively examined workplace-based supervision of EBT and specifically how it might differ from EBT supervision provided in efficacy and effectiveness trials. METHODS: Data come from a descriptive study of supervision in the context of a state-funded EBT implementation effort. Verbal interactions from audio recordings of 438 supervision sessions between 28 supervisors and 70 clinicians from 17 public mental health organizations (in 23 offices) were objectively coded for presence and intensity coverage of 29 supervision strategies (16 content and 13 technique items), duration, and temporal focus. Random effects mixed models estimated proportion of variance in content and techniques attributable to the supervisor and clinician levels. RESULTS: Interrater reliability among coders was excellent. EBT cases averaged 12.4 min of supervision per session. Intensity of coverage for EBT content varied, with some discussed frequently at medium or high intensity (exposure) and others infrequently discussed or discussed only at low intensity (behavior management; assigning/reviewing client homework). Other than fidelity assessment, supervision techniques common in treatment trials (e.g., reviewing actual practice, behavioral rehearsal) were used rarely or primarily at low intensity. In general, EBT content clustered more at the clinician level; different techniques clustered at either the clinician or supervisor level. CONCLUSIONS: Workplace-based clinical supervision may be a feasible implementation strategy for supporting EBT implementation, yet it differs from supervision in treatment trials. Time allotted per case is limited, compressing time for EBT coverage. Techniques that involve observation of clinician skills are rarely used. Workplace-based supervision content appears to be tailored to individual clinicians and driven to some degree by the individual supervisor. Our findings point to areas for intervention to enhance the potential of workplace-based supervision for implementation effectiveness. TRIAL REGISTRATION: NCT01800266 , Clinical Trials, Retrospectively Registered (for this descriptive study; registration prior to any intervention [part of phase II RCT, this manuscript is only phase I descriptive results])

Improving practice in community-based settings: a randomized trial of supervision – study protocol

Background: Evidence-based treatments for child mental health problems are not consistently available in public mental health settings. Expanding availability requires workforce training. However, research has demonstrated that training alone is not sufficient for changing provider behavior, suggesting that ongoing intervention-specific supervision or consultation is required. Supervision is notably under-investigated, particularly as provided in public mental health. The degree to which supervision in this setting includes ‘gold standard’ supervision elements from efficacy trials (e.g., session review, model fidelity, outcome monitoring, skill-building) is unknown. The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practices and test the impact of systematic implementation of gold standard supervision strategies on treatment fidelity and clinical outcomes. Methods/Design The study has two phases. We will conduct an initial descriptive study (Phase I) of supervision practices within public mental health in Washington State followed by a randomized controlled trial of gold standard supervision strategies (Phase II), with randomization at the clinician level (i.e., supervisors provide both conditions). Study participants will be 35 supervisors and 130 clinicians in community mental health centers. We will enroll one child per clinician in Phase I (N = 130) and three children per clinician in Phase II (N = 390). We use a multi-level mixed within- and between-subjects longitudinal design. Audio recordings of supervision and therapy sessions will be collected and coded throughout both phases. Child outcome data will be collected at the beginning of treatment and at three and six months into treatment. Discussion This study will provide insight into how supervisors can optimally support clinicians delivering evidence-based treatments. Phase I will provide descriptive information, currently unavailable in the literature, about commonly used supervision strategies in community mental health. The Phase II randomized controlled trial of gold standard supervision strategies is, to our knowledge, the first experimental study of gold standard supervision strategies in community mental health and will yield needed information about how to leverage supervision to improve clinician fidelity and client outcomes. Trial registration ClinicalTrials.gov NCT0180026

Sexual assault, sexual abuse, and harassment: Understanding the mental health impact and providing care for survivors: An International Society for Traumatic Stress Studies Briefing Paper

Recent events including revelations of the systematic cover-up of widespread childhood sexual abuse in the Catholic Church, sexual assault and harassment accusations involving many prominent individuals in the entertainment and other industries in the U.S., Canada, Europe, Australia, and Japan, global coverage of cases of violent rape and rape-murder of girls and young women in India, and the #metoo movement, have served to increase public consciousness internationally regarding the pervasiveness of various forms of sexual victimization worldwide. In response, the International Society for Traumatic Stress Studies (ISTSS) commissioned this briefing paper to inform its membership, policymakers, and global stakeholders about the prevalence, impact, and barriers faced by survivors of various forms of sexual victimization including attempted and completed rape, sexual abuse in childhood, and sexual harassment in workplace and educational settings. This paper outlines the research evidence regarding (1) the prevalence of different forms of sexual victimization worldwide including childhood sexual abuse, various forms of sexual assault in adulthood, and sexual harassment in workplace and educational settings, (2) the prevalence of various forms of sexual victimization among several marginalized groups, (3) the psychological, behavioral, and physical health impacts of sexual victimization in childhood and adulthood, (4) evidence-based interventions for survivors of sexual victimization, and (5) barriers to treatment seeking commonly faced by survivors of different forms of sexual victimization. Recommendations are also made in the areas of policy, practice, research, and for professional organizations. Research conducted throughout the world continues to document the alarmingly high prevalence of various forms of sexual victimization throughout the lifespan, including the sexual abuse of children, sexual assault of adults, and sexual harassment within individuals’ place of employment and in educational settings. Although all individuals are vulnerable to experiences of sexual victimization, sexual assault, abuse, and harassment are gendered crimes, such that women and girls are more likely to be victims of these forms of sexual violence. In addition, members of a number of marginalized groups face substantially increased vulnerability to sexual victimization. These include individuals with disabilities, sexual and gender minorities, homeless individuals, individuals engaging in various kinds of sex work, and members of indigenous populations. Further, the impact of sexual victimization is both broad and targeted, with various forms of sexual victimization, including experiences of childhood sexual abuse and sexual assault in adulthood, associated with a host of negative outcomes including the development of posttraumatic stress disorder, depression, anxiety, substance use disorders, eating disordered pathology, suicidality, dissociation, and high risk sexual behaviors. Further, sexual victimization is associated with risk for a number of negative physical health outcomes including obesity, gastrointestinal disorders, chronic pelvic pain, and reproductive health issues. There exists a robust evidence base supporting the efficacy of psychological treatment for PTSD symptomology among adult survivors of childhood sexual abuse and sexual assault. Of extant treatments, cognitive-behavioral based treatments have the strongest evidence for their efficacy. Similarly, cognitive-behavioral treatments, such as trauma-focused CBT, have demonstrated efficacy in treating PTSD and depressive symptomology among children and adolescents who have experienced sexual abuse. There is also some evidence supporting the efficacy of psychopharmacological treatment in reducing PTSD symptomology among adult survivors of sexual abuse or assault. Conversely, there is far more limited research examining the efficacy of psychological treatments for PTSD in other cultural contexts, with the vast majority of research involving United States samples. There is also much less evidence regarding the impact of trauma-focused treatments on other outcomes besides PTSD symptomology and depression, or examining how to treat additional behavioral and mental health issues among survivors of sexual victimization. Finally, almost no research has evaluated the efficacy of psychological treatments for individuals who have experienced sexual harassment in their workplace. Further, research documents that survivors of various forms of sexual victimization often face substantial barriers to disclosing their experience or seeking formal help. These barriers include issues related to defining the experience as a victimization, concerns about not being believed or taken seriously, and feelings of stigma, shame, or embarrassment. Other barriers include concerns about whether the experience will be reported to authorities, mistrust of formal support systems, and prior negative experiences following disclosure of a sexual victimization experience. Many survivors also may be unaware of services that are available to them, may believe that available services are not appropriate for them, and may also face substantial barriers to accessing the care that is available, and available care may be inadequate for addressing their needs in many parts of the world. Finally, it is important to note that many individuals who experience sexual victimization face ongoing issues related to poverty, socioeconomic disadvantage, ongoing personal and community violence, and belong to marginalized groups. Given the prevalence, impact, and substantial barriers to care faced by individuals who experience sexual victimization, including childhood sexual abuse, sexual assault, and sexual harassment, it is clear that concerted, international, and collaborative efforts involving policymakers, researchers, clinicians, professional organizations, and other global stakeholders is imperative

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science

It is well documented that the majority of adults, children and families in need of evidence-based behavioral health interventionsi do not receive them [1, 2] and that few robust empirically supported methods for implementing evidence-based practices (EBPs) exist. The Society for Implementation Research Collaboration (SIRC) represents a burgeoning effort to advance the innovation and rigor of implementation research and is uniquely focused on bringing together researchers and stakeholders committed to evaluating the implementation of complex evidence-based behavioral health interventions. Through its diverse activities and membership, SIRC aims to foster the promise of implementation research to better serve the behavioral health needs of the population by identifying rigorous, relevant, and efficient strategies that successfully transfer scientific evidence to clinical knowledge for use in real world settings [3]. SIRC began as a National Institute of Mental Health (NIMH)-funded conference series in 2010 (previously titled the “Seattle Implementation Research Conference”; $150,000 USD for 3 conferences in 2011, 2013, and 2015) with the recognition that there were multiple researchers and stakeholdersi working in parallel on innovative implementation science projects in behavioral health, but that formal channels for communicating and collaborating with one another were relatively unavailable. There was a significant need for a forum within which implementation researchers and stakeholders could learn from one another, refine approaches to science and practice, and develop an implementation research agenda using common measures, methods, and research principles to improve both the frequency and quality with which behavioral health treatment implementation is evaluated. SIRC’s membership growth is a testament to this identified need with more than 1000 members from 2011 to the present.ii SIRC’s primary objectives are to: (1) foster communication and collaboration across diverse groups, including implementation researchers, intermediariesi, as well as community stakeholders (SIRC uses the term “EBP champions” for these groups) – and to do so across multiple career levels (e.g., students, early career faculty, established investigators); and (2) enhance and disseminate rigorous measures and methodologies for implementing EBPs and evaluating EBP implementation efforts. These objectives are well aligned with Glasgow and colleagues’ [4] five core tenets deemed critical for advancing implementation science: collaboration, efficiency and speed, rigor and relevance, improved capacity, and cumulative knowledge. SIRC advances these objectives and tenets through in-person conferences, which bring together multidisciplinary implementation researchers and those implementing evidence-based behavioral health interventions in the community to share their work and create professional connections and collaborations