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

Cognitive-Behavioral Treatment for Posttraumatic Stress Disorder in Children and Adolescents

A number of Cognitive Behavioral Therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). Similar to other CBT treatments, particularly those for anxiety disorders, these treatments all include common elements (e.g., psychoeducation, relaxation and affective modulation skills, exposure). The goals of this review are to: 1) delineate common elements in CBT approaches for treating child and adolescent PTSD; 2) provide a detailed review of two CBT approaches with substantial evidence of effectiveness; and 3) describe “Promising Practices,” in the area of CBT approaches to treating child and adolescent PTSD. The two treatments reviewed in detail are Trauma-focused Cognitive Behavioral Therapy (TF-CBT) and Cognitive Behavioral Intervention for Trauma in Schools (CBITS). For these treatments, we describe the research evidence to date, specific elements of the treatment model, and discuss implementation and cultural considerations. In the “Promising Practices” section, other CBT approaches are reviewed that include many of the common elements; however, these approaches have accumulated less evidence of effectiveness to date. Research on CBT approaches to treating PTSD is ongoing, with a growing focus on explicit consideration of the multiple systems in which youth exposed to trauma are involved, and ways to better address co-occurring difficulties (e.g. serious behavior problems, substance use). Future directions for the field are discussed. These include further study of promising practices, cultural applicability of CBT approaches to treating PTSD, and strategies to enhance implementation and dissemination efforts to improve access to high-quality, evidence-based care for children and adolescents with PTSD

Caseworker assessments of risk for recurrent maltreatment: Association with case-specific risk factors and re-reports

This article focuses on caseworkers’ assessments of risk of maltreatment recurrence among families in contact with social services. Specifically, the article has two primary goals: 1) to examine the association between caseworkers’ risk assessments and demographic, child, parent and family-level risk factors; and 2) to examine agreement between caseworkers’ risk assessments and any subsequent report, or reports, of maltreatment

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])

The degree of microbiome complexity influences the epithelial response to infection

<p>Abstract</p> <p>Background</p> <p>The human microflora is known to be extremely complex, yet most pathogenesis research is conducted in mono-species models of infection. Consequently, it remains unclear whether the level of complexity of a host's indigenous flora can affect the virulence potential of pathogenic species. Furthermore, it remains unclear whether the colonization by commensal species affects a host cell's response to pathogenic species beyond the direct physical saturation of surface receptors, the sequestration of nutrients, the modulation of the physico-chemical environment in the oral cavity, or the production of bacteriocins. Using oral epithelial cells as a model, we hypothesized that the virulence of pathogenic species may vary depending on the complexity of the flora that interacts with host cells.</p> <p>Results</p> <p>This is the first report that determines the global epithelial transcriptional response to co-culture with defined complex microbiota. In our model, human immortalized gingival keratinocytes (HIGK) were infected with mono- and mixed cultures of commensal and pathogenic species. The global transcriptional response of infected cells was validated and confirmed phenotypically. In our model, commensal species were able to modulate the expression of host genes with a broad diversity of physiological functions and antagonize the effect of pathogenic species at the cellular level. Unexpectedly, the inhibitory effect of commensal species was <it>not </it>correlated with its ability to inhibit adhesion or invasion by pathogenic species.</p> <p>Conclusion</p> <p>Studying the global transcriptome of epithelial cells to single and complex microbial challenges offers clues towards a better understanding of how bacteria-bacteria interactions and bacteria-host interactions impact the overall host response. This work provides evidence that the degree of complexity of a mixed microbiota <it>does </it>influence the transcriptional response to infection of host epithelial cells, and challenges the current dogma regarding the <it>potential </it>versus the <it>actual </it>pathogenicity of bacterial species. These findings support the concept that members of the commensal oral flora have evolved cellular mechanisms that directly modulate the host cell's response to pathogenic species and dampen their relative pathogenicity.</p

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

Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers

Background: Recent global mental health research suggests that mental health interventions can be adapted for use across cultures and in low resource environments. As evidence for the feasibility and effectiveness of certain specific interventions begins to accumulate, guidelines are needed for how to train, supervise, and ideally sustain mental health treatment delivery by local providers in low- and middle-income countries (LMIC). Model and case presentations: This paper presents an apprenticeship model for lay counselor training and supervision in mental health treatments in LMIC, developed and used by the authors in a range of mental health intervention studies conducted over the last decade in various low-resource settings. We describe the elements of this approach, the underlying logic, and provide examples drawn from our experiences working in 12 countries, with over 100 lay counselors. Evaluation: We review the challenges experienced with this model, and propose some possible solutions. Discussion: We describe and discuss how this model is consistent with, and draws on, the broader dissemination and implementation (DI) literature. Conclusion: In our experience, the apprenticeship model provides a useful framework for implementation of mental health interventions in LMIC. Our goal in this paper is to provide sufficient details about the apprenticeship model to guide other training efforts in mental health interventions

A Mixed Methods Study of Individual and Organizational Factors that Affect Implementation of Interventions for Children with Autism in Public Schools

Background: The significant lifelong impairments associated with autism spectrum disorder (ASD), combined with the growing number of children diagnosed with ASD, have created urgency in improving school-based quality of care. Although many interventions have shown efficacy in university-based research, few have been effectively implemented and sustained in schools, the primary setting in which children with ASD receive services. Individual- and organizational-level factors have been shown to predict the implementation of evidence-based interventions (EBIs) for the prevention and treatment of other mental disorders in schools, and may be potential targets for implementation strategies in the successful use of autism EBIs in schools. The purpose of this study is to examine the individual- and organizational-level factors associated with the implementation of EBIs for children with ASD in public schools. Methods: We will apply the Domitrovich and colleagues (2008) framework that examines the influence of contextual factors (i.e., individual- and organizational-level factors) on intervention implementation in schools. We utilize mixed methods to quantitatively test whether the factors identified in the Domitrovich and colleagues (2008) framework are associated with the implementation of autism EBIs, and use qualitative methods to provide a more comprehensive understanding of the factors associated with successful implementation and sustainment of these interventions with the goal of tailoring implementation strategies. Discussion: The results of this study will provide an in-depth understanding of individual- and organizational-level factors that influence the successful implementation of EBIs for children with ASD in public schools. These data will inform potential implementation targets and tailoring of strategies that will help schools overcome barriers to implementation and ultimately improve the services and outcomes for children with ASD