Adoption of Technology‐Enhanced Treatments: Conceptual and Practical Considerations

As the efficacy of technology‐enhanced mental health service delivery models (i.e., supportive or adjunctive technological tools) is examined, we must inform and guide clinician decision making regarding acceptance and, in turn, uptake. Accordingly, this review aimed to move beyond traditional discussions of geographic barriers by integrating, reconciling, and extending literatures on dissemination and implementation, as well as technology uptake, in order to anticipate and address organizational and clinician barriers to adoption of technology enhancements. Specifically, a five‐stage model is proposed to address organizational readiness for and clinician acceptance of technology enhancements to evidence‐based treatments, as well as the relevance of current adoption strategies for technology‐enhanced services. Our aim was to provide a guiding framework for future research and practice.     

Evidence‐Based Practice in a Global Context

This commentary examines how the adoption of benchmarking can promote the internationalization of evidence‐based practice. Given the increasing evidence documenting the role of culture and context in the shaping of experiences and expressions of distress, as well as influencing attitudes and conceptions of mental health services, benchmarking may not represent the best approach to addressing global public health agendas. A brief overview of the sequential approach to developing, evaluating, and disseminating treatments in novel cultural contexts is presented, in which benchmarking can play an important, albeit secondary role. It is argued that in a global context, benchmarking's role may better function to promote dissemination within particular contexts, rather than between them.     

Clinical Supervision in Effectiveness and Implementation Research

The role of clinical supervision in the larger‐scale implementation of effective mental health treatments has begun to attract attention in effectiveness research and implementation science. Clinical supervision approaches demonstrated to support the implementation of effective treatments could provide a fruitful basis for adaptation to the contours and implementation of other interventions. The adaptation of the Multisystemic Therapy supervision model to support the implementation of an innovative, experimental mental health service model called Links to Learning is described. An observational study provides the platform for consideration of the extent to which the Links supervision model was implemented as intended and of challenges to Links implementation illuminated by the supervision process. Implications are considered for research on supervision as a tool to effect the implementation and outcomes of effective treatment and service models in community practice contexts.     

Large‐Scale Implementation of Evidence‐Based Treatments for Children 10 Years Later: Hawaii’s Evidence‐Based Services Initiative in Children’s Mental Health

[Clin Psychol Sci Prac 18: 24–35, 2011] This article provides a follow‐up account of efforts associated with a statewide initiative established 10 years ago for identifying and implementing effective treatments for child and adolescent mental health concerns. The manner in which this initiative has evolved and endured within a complex public mental health service infrastructure may provide some important insights and even optimism about the application of science in public sector settings. This 10‐year history illuminates the benefits and challenges of maintaining a community‐based mechanism for the integration of science and practice. As reported here, such collaborative efforts can produce new ways to conceptualize scientific evidence, overcome interdisciplinary barriers, catalyze other progressive initiatives, and generate a guiding vision for public mental health for youth.     

RIPPLE EFFECTS OF IMPLEMENTING EVIDENCE‐BASED MENTAL HEALTH INTERVENTIONS IN A COMMUNITY‐BASED SOCIAL SERVICE ORGANIZATION

Concerns over the quality of mental health services in the United States have led to the creation, dissemination, and implementation of evidence‐based mental health interventions (EBMHIs). Though it is widely acknowledged that interventions have ripple effects, the effects of these interventions on the systems in which they are implemented (i.e., practice settings) are unclear. The purpose of this qualitative pilot study was to explore both practitioner‐ and organization‐level ripple effects of EBMHIs implemented in a community‐based agency. We identified 4 categories of effects on practitioners (work roles and responsibilities, knowledge, thoughts and feelings, and behavior and communication) and 2 categories of effects on the organization (structure, programming). Findings suggest that it is possible to identify ripple effects through qualitative interviews. Implications for future research on mental health intervention effects are discussed.     

Promoting the Internationalization of Evidence‐Based Practice: Benchmarking as a Strategy to Evaluate Culturally Transported Psychological Treatments

In addition to the growing evidence‐based practice movement in psychology, psychological treatments are undergoing increasing adaptation and transportation to other countries and cultures around the world, prompting the need to evaluate treatments in these diverse settings. This article proposes the “benchmarking” strategy as a valuable approach to evaluate the effectiveness of culturally adapted or transported treatments and to promote the internationalization of evidence‐based practice. We first describe the benchmarking concept in clinical research, followed by considerations for the cultural adaptation and transportation of psychological treatments. We then explain how the benchmarking strategy may be used to validate culturally transported and adapted psychological treatments. The article concludes with a discussion of considerations, limitations, and challenges for conducting cross‐cultural benchmarking research.     

Diffusion of Mental Health and Substance Abuse Treatments: Development, Dissemination, and Implementation

Theory and research regarding the diffusion of innovations and technology transfer have advanced our understanding of how new ideas and technologies are developed, disseminated, adopted, and implemented by individuals and organizations. Although diffusion has been studied in other fields, it is not often applied to mental health and substance abuse treatment. However, findings from diffusion-of-innovations research can assist in bridging research-practice gaps that lead to clients receiving treatments whose effectiveness has not been assessed or to clients not receiving the most effective treatments. This article reviews theory and research regarding the diffusion of innovations and highlights areas for application to mental health treatment, including the transportability of treatments into real-world settings, strategies to disseminate treatments, attributes of treatments that affect their adoption, and organizational change factors that affect implementation.     

Closing the research-practice gap: factors affecting adoption and implementation of a children's mental health program.

Despite the availability of effective interventions, they are not widely used in community mental health centers. This study examined the adoption and implementation of The Arson Prevention Program for Children (TAPP-C), a program for juvenile firesetters developed at a teaching hospital and disseminated to community settings. Questionnaire data from mental health professionals were used to evaluate the roles of adopter, innovation, and dissemination characteristics in TAPP-C adoption and implementation. Results indicate that different factors are important at different diffusion stages. Moreover, they suggest that innovation characteristics may be particularly important to adoption, whereas adopter and dissemination characteristics may be more influential in implementation.     

Adapting empirically supported treatments in the era of integrated care: A roadmap for success

The emerging era of integrated care represents a major opportunity for clinical psychology to migrate empirically supported treatments (ESTs) into the mainstream of public health. To succeed will require us to modify current ESTs to make them brief, cost‐effective, patient‐centered and acceptable to and easily learned by both the mental health and health‐care professionals that will deliver them. Changes to the recently modified standards for designating ESTs are proposed that will facilitate adoption of a population health model of treatment development and testing, designed to promote rapid dissemination of empirically supported interventions that are a “good fit” for integrated settings. Defining characteristics of the “new look” for ESTs are examined.     

School‐Based Mental Health Checkups: Ready for Practical Action?

Fox, Halpern, and Forsyth (2008) offer a compelling case for school-based mental health checkups for children at risk for developing anxiety and depressive disorders. Although the concept of universal mental health screening has obvious merits, a number of important issues in clinical science, practice, and training need to be addressed in order to promote successful implementation. With regard to clinical science, issues pertaining to risk assessment, screening implementation, and prevention effects for anxiety and depression deserve additional attention. Many of the challenging issues involved in the dissemination and utilization of evidence-based treatments, including current training of school-based clinicians, apply to screening and prevention efforts. We highlight some of what needs to be done in order to transport the concept of mental health checkups into school-based practice.     

Social Contexts of Mental Weil-Being in Later Life

Extending the preceding review, this commentary argues for serious attention to the social contexts of mental health of older adults in research and practice. Social gerontology research focuses primarily on summative or aggregate variables with little focus on mechanism, despite growing evidence that mechanisms as diverse as immunosuppression and expressed emotion influence mental health. Increased linkages between the macro-level and microlevel data are required to provide the theoretical models needed to shape practice. Current evidence is deemed sufficient, however, to alter the frameworks we use for both diagnosis and treatment.     

Making the Translation from Research to Its Application: The Je Ne Sais Pas of Evidence-Based Practices

Moving evidence-based treatments into practice settings is an important new direction for the field of children's mental health., but is fraught with many unknowns. This commentary discusses scientific conundrums that surround that transportability of research-based interventions, including issues of definition (e.g., differences among treatments, preventive interventions, services); diagnostic reification and the absence of markers; the value and status of combination treatments (including pharmacologic) for conceptualizing the evidence base; and differences between evidence-based practices and evidence-based treatments. Suggestions are made for a disciplined approach to advancing a yoked research and policy agenda for children's mental health.     

Poverty and Mental Health: How Do Low‐Income Adults and Children Fare in Psychotherapy?

Poverty is associated with an increased risk for psychological problems. Even with this increased risk for mental health problems and need for care, many low‐income adults and families do not receive treatment because of logistical, attitudinal, and systemic barriers. Despite significant barriers to obtaining care, research suggests that low‐income individuals show significant benefit from evidence‐based mental healthcare. In this article, we review the link between poverty and mental health, common barriers to obtaining mental health services, and treatment studies that have been conducted with low‐income groups. Finally, we discuss the implications of the research reviewed and offer recommendations for clinicians working with low‐income children or adults, highlighting the importance of evidence‐based care, extensive outreach, and empathic respect.     

RELATIONSHIP OF EVIDENCE‐BASED PRACTICE AND TREATMENTS: A SURVEY OF COMMUNITY MENTAL HEALTH PROVIDERS

Evidence‐based treatments (EBTs) are interventions that have been proven effective through rigorous research methodologies. Evidence‐based practice (EBP), however, refers to a decision‐making process that integrates the best available research, clinician expertise, and client characteristics. This study examined community mental health service providers’ knowledge of EBP and perceived advantages, disadvantages, reasons for not implementing full EBT protocols, and attitudes toward EBTs. Qualitative examination of mental health service providers’ definitions of EBP reveals confusion between the terms EBP and EBT. Service providers indicated several advantages and disadvantages of using EBTs. Analysis suggests that many perceived EBT disadvantages would be eliminated if EBTs are implemented as part of the EBP approach, thus allowing for clinician expertise and patient characteristics to be combined with EBTs. Alternatively, distinguishing between EBP and EBT may be more confusing than useful for most community mental health practitioners, which indicates new terminology may be needed.     

Proposing a mechanistic model of clinician training and consultation

To make evidence‐based treatments deliverable, effective, and scalable in community settings, it is critical to develop a workforce that can deliver evidence‐based treatments as designed with skill. However, the science and practice of clinician training and consultation lag behind other areas of implementation science. In this paper, we present the Longitudinal Education for Advancing Practice (LEAP) model designed to help span this gap. The LEAP model is a mechanistic model of clinician training and consultation that details how training inputs, training and consultation strategies, and mechanisms of learning influence training outcomes. We first describe the LEAP model and then discuss how key implications of the model can be used to develop effective training and consultation strategies.     

Dissemination and Implementation of Evidence–Based Practices: Training and Consultation as Implementation Strategies

To provide effective treatment for individuals with mental health needs, there is a movement to deploy evidence‐based practices (EBPs) developed in research settings into community settings. Training clinicians in EBPs is often used as the primary implementation strategy in these efforts, despite evidence suggesting that training alone does not change therapist behavior. A promising implementation strategy that can be combined with training is consultation, or ongoing support. This article reviews the literature on consultation following initial training. A model of consultation is presented as well as preliminary findings regarding effective consultation techniques. Future directions are offered.     

Practice‐based evidence: benchmarking NHS primary care counselling services at national and local levels

There are a number of problems for evidence‐based practice (EBP) including limited generalizability of efficacy research results, the consequent lack of confidence in the relevance of such research, and the conceptual distance of most practitioners from the research process. The result is that EBP, although sound in principle, often fails to achieve its aim of improving practice. Practice‐based evidence (PBE) provides a complementary bridge for the gap between research and practice to offset some of these problems, promoting collaboration between mental health services and academic institutions. This paper presents the initial results of such a collaboration via three phases: (1) the development of a referential database for primary care counselling services, (2) ‘practitioner‐friendly’ feedback on grouped data to services, and (3) the combination of the two to build an evidence base for work with ethnic minorities—an area in which research trials are not well adapted to provide much evidence. Copyright © 2003 John Wily & Sons, Ltd.     

What Happens After the Innovation Is Identified?

Although the identification of efficacious and effective mental health treatments represents a potentially important synthesis of research literatures, such identification is but a first step in the transport of evidence-based treatments to field settings. Based on multidisciplinary research on the diffusion of innovation articulated by Rogers, this commentary briefly describes characteristics of the innovation and of the social system that may influence the adoption of mental health innovations.     

The biomedical model of mental disorder: A critical analysis of its validity,utility, and effects on psychotherapy research

The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities. A biologically-focused approach to science, policy, and practice has dominated the American healthcare system for more than three decades. During this time, the use of psychiatric medications has sharply increased and mental disorders have become commonly regarded as brain diseases caused by chemical imbalances that are corrected with disease-specific drugs. However, despite widespread faith in the potential of neuroscience to revolutionize mental health practice, the biomedical model era has been characterized by a broad lack of clinical innovation and poor mental health outcomes. In addition, the biomedical paradigm has profoundly affected clinical psychology via the adoption of drug trial methodology in psychotherapy research. Although this approach has spurred the development of empirically supported psychological treatments for numerous mental disorders, it has neglected treatment process, inhibited treatment innovation and dissemination, and divided the field along scientist and practitioner lines. The neglected biopsychosocial model represents an appealing alternative to the biomedical approach, and an honest and public dialog about the validity and utility of the biomedical paradigm is urgently needed.     

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.