The results of this study provide valuable information about a generally representative sample of community-based therapists' attitudes towards a variety of treatment strategies, including those that are common across evidence-based interventions for children with disruptive behavior problems and other strategies that are not emphasized in the evidence-based, individual youth skills training or parent training manualized protocols. Therapists were asked to rate how valuable (i.e., important) they consider individual strategies to their practice because perceived value has been identified as an important predictor of behavior (Casper 2007
). Overall, therapists highly value many different types of treatment techniques and therapeutic content in their work with this group of children and their caregivers. While there was variability in the Likert ratings, on average, therapists endorsed most of the therapeutic strategies as “fairly valuable” or “very valuable” to their practice. These findings are consistent with previous research indicating that therapists may use a variety of different strategies (Baumann et al. 2006
) and prefer an “eclectic” approach to treatment, utilizing a variety of techniques (Kazdin et al. 1990
The results also indicate that therapists highly value many strategies that are common in EBP protocols for this population. Overall, composite scores of average value ratings of strategies common in evidence-based interventions were higher than composite scores of average value ratings of all other strategies that are not emphasized in the majority of EBPs. In particular, EBP strategies that therapists rated as highly valued in their practice with this population included delivering positive reinforcement, modeling, problem-solving/social skills, and affect education. EBP strategies that therapists rated as highly valued in their practice with caregivers of children with disruptive behavior problems included modeling, psychoeducation, parent-child relationship, and principles of positive reinforcement. This finding is promising, as it indicates that therapists highly value treatment approaches common to EBPs. Interestingly, the composite scores of average value ratings for EBPs and all other strategies were not significantly different for strategies delivered to children ages 9–13. This finding may be related to therapists' perceptions that there are developmental differences in the applicability in common elements of EBP for children with disruptive behavior problems, such that they consider other strategies such as improved communication and cognitive restructuring more valuable with older children than with younger children. It is important to mention that cognitive restructuring is a strategy that was not identified as common to EBPs for disruptive behavior problems, but it may be commonly used in EBPs for internalizing disorders. Overall, the distributions of value ratings for content strategies delivered to children appears slightly different between the two age groups, however, the distribution of value ratings for therapeutic techniques delivered is relatively consistent. It is likely that many of the active techniques, such as modeling and role-play/practice, are applicable to a wide range of content areas addressed in psychotherapy and are applicable to children of different developmental levels. Additional research on how children's developmental level impacts treatment planning and treatment provided would be interesting to pursue (Eyberg et al. 1998
In our exploratory analyses of associations between therapist characteristics and EBP value ratings, no significant associations were identified, and effect sizes were generally small. This lack of other associations between therapist characteristics and attitudes towards treatment strategies, particularly self-report of theoretical orientation, is notable. One might expect, for example, that therapists who endorse behavioral or cognitive behavioral theoretical orientations might value EBP strategies more than therapists of other orientations, as most of the EBPs for youths with disruptive behavior problems are behavioral or cognitive behavioral. Further, previous research indicates that interns, in contrast to licensed professionals and those with higher educational status, may hold more positive attitudes towards EBPs (Aarons 2004
). The lack of significant associations between therapist characteristics and value ratings may be due to the way that attitudes about treatment were measured. Specifically, differences between therapists may be minimized when the focus is on attitudes towards individual treatment strategies rather than towards the concept of manualized treatment or “empirically supported treatments” more generally.
This study adds to the literature in a number of ways. First, while there are a growing number of studies reporting therapists' attitudes toward EBPs, they have typically measured attitudes towards specific EBPs or manualized interventions in general. This line of research suggests that therapists may have different definitions of, and exposure to, manuals, making it challenging to assess their attitudes towards them (Baumann et al. 2006
). In the current study, therapists were asked about their attitudes towards individual treatment strategies. The terms “evidence-based practice” and “manual” are not included in the survey instrument, although it includes strategies that have been identified as common to EBPs for children ages 4–13 years with disruptive behavior problems (Garland et al. 2008
). It also includes strategies that are not emphasized in EBPs, but that our therapist partners indicate are important to their practice (e.g., identifying client's strengths, assessing problems and events) and may be implicit in EBPs. Focusing on individual strategies provides a common language to assess attitudes, as previous research indicates that there may be significant variability in familiarity with EBPs or manualized interventions (e.g., Aarons 2004
; Addis and Krasnow 2000
; Baumann et al. 2006
). Further, it highlights that therapists may be more positive about EBP strategies when the emphasis is on individual treatment strategies rather than on manualized interventions. Future research might examine how attitudes towards EBPs or manualized interventions more generally are associated with attitudes toward individual treatment strategies.
Another strength of this study is that it assessed attitudes of a generally representative sample of therapists providing community-based mental health services to children in one, large and diverse county and provides a description of the characteristics of therapists practicing in six, representative, community-based, outpatient mental health clinics serving a group of racially/ethnically and diagnostically diverse children and their families. Almost all therapists practicing in six, publicly-funded agencies in a large urban area responded to the survey. The therapists were diverse in their professional discipline, self-reported primary theoretical orientation, and level of experience. While there was some racial/ethnic diversity, the majority were Caucasian. Therapists were mostly masters-level, having practiced five years on average, and over one-third were unlicensed trainees. Therapists represented multiple professional disciplines with approximately one half of the respondents trained in the Marriage and Family Therapy discipline and twenty percent each from the Social Work and Psychology disciplines. The most frequently reported primary theoretical orientations were behavioral and cognitive behavioral. Data from a recent national survey of 1200 clinicians from 100 clinical sites across the United States provides a good comparison sample to the sample of clinicians surveyed in the current study (Glisson et al. 2008
). In the national sample, clinicians were primarily female (76%) and Caucasian, with the majority holding a master's degree (67%). This study supports the representativeness of our sample in terms of basic demographics and educational level. Studies including a diverse, representative sample of therapists contribute to our understanding of usual care practice.
There are a number of limitations to this study that should be noted. First, we did not include a measure of observed behavior for the current sample, so we can not say whether the strategies therapists' rate as highly valuable are the strategies that they most frequently use in practice. As part of our larger PRAC research study, however, we are collecting observational data on therapists sampled from the same clinics as the TSS sample (57% of therapists in the current sample are also in the PRAC observational study sample). Preliminary examination of the PRAC observational psychotherapy process data suggests there are a number of consistencies and inconsistencies between therapists' attitudes about the value of treatment strategies and their observed use of treatment strategies. For example, observational data suggests that therapists do use a wide range of treatment strategies, which is consistent with the large number of strategies rated as highly valuable in this study. However, the strategies considered the most valuable are not necessarily the strategies observed most frequently (e.g., modeling was a strategy that was rated as highly valuable, however, it is observed in less half of videotaped psychotherapy sessions). This discrepancy indicates that while therapists may consider certain strategies very important in their work, there may be barriers to implementing these strategies frequently or intensively. Future research will specifically examine these patterns.
Another limitation of this study relates to the measure used to assess therapists' attitudes towards psychotherapeutic strategies. Given our purpose of assessing therapists' attitudes towards individual psychotherapeutic strategies (including those common in EBPs and those that therapists report are common practice) that are consistent with the strategies used in our observational coding system, we did not use one of the few measures with established psychometric properties such as the EBPAS (Aarons 2004
; Aarons et al. 2007
) or the TPC (Weersing et al. 2002
). Instead, we adapted a self-report measure based on the observational measure (PRAC-TPOCS) used in the PRAC study. Thus, the psychometrics of our TSS measure are not well established and further validation of the measure is needed in the future. However, we do have some support for the test-retest reliability, and the two measurement methods lend some support to the validity. A related limitation is that we designated treatment strategies as “common in EBPs” based on one method of identifying these elements (Garland et al. 2008
). Other methods might yield additional or different common elements of EBPs. Lastly, this study was conducted in one urban area and, therefore, may not generalize to other areas.
In the current study, we differentiated strategies based on whether they had been identified as a common treatment element in EBPs for children with disruptive behavior problems, and conducted analyses to identify therapist characteristics associated with a composite of EBP elements. In future research, we may examine naturally occurring groups of strategies through exploratory factor analyses and identify therapist characteristics associated with these empirically determined groups of strategies.
It is important to note that we may expect different results if we surveyed therapists regarding their attitudes towards strategies used with a different clinical populations such as children with internalizing problems. This study reports therapists' attitudes towards strategies used with children with disruptive behavior problems. We argue that our emphasis on strategies for children with disruptive behavior problems is important, as it is applicable to the largest portion of patients receiving community-based care (Garland et al. 2001
). This study paves the way for researchers to examine therapist attitudes towards elements of treatment targeting other diagnostic groups or presenting problems.
While our therapist sample is likely representative of therapists in other communities based on experience and level of experience (Glisson et al. 2008
), certain characteristics of our sample may not be representatives of therapists practicing in other geographic areas. For example, approximately half of therapists in our sample were trained as martial and family therapists (MFTs). While this discipline is very common in California, it may not be as common in other states. Further, the distribution of therapist primary orientation may not be representative of providers in other communities. Fewer than ten percent of therapists in the current sample self-identified as dynamic, differing from certain studies of practicing providers that report approximately one quarter of therapists identifying as dynamic (e.g., Norcross et al. 2002
; Stewart and Chambless 2007
; Weersing et al. 2002
). However, these studies included doctoral-level psychologists only, many of whom were in private practice, rather than a multidisciplinary sample of therapists practicing in publicly-funded settings. Our sample is similar in theoretical orientation distribution to another sample of multidisciplinary therapists working in community-based child welfare practice (Baumann et al. 2006
). Overall, distribution of therapist discipline and orientation may vary by geographic location and service setting (community-based care vs. private practice).
Despite these limitations, the results of this study have important implications for the implementation of evidence-based interventions in community-based practice. In particular, these findings have implications for tailoring training efforts in EBP protocols based on the knowledge gained about attitudes towards individual components of EBPs. New research suggests that sustainable changes in mental health providers' behavior are more likely to be achieved when training interventions are tailored to preexisting attitudes and values regarding practice (Casper 2007
). Our finding that therapists do value many elements of EBPs indicates that a training approach incorporating attitudes toward select treatment strategies may be effective in addressing potentially ambivalent attitudes toward manualized interventions in general. Understanding therapists' attitudes provides information on characteristics that influence the treatment decision-making process. Given that there may already be “buy in” on individual treatment strategies such as delivering positive reinforcement, training could focus on providing specific feedback on the intensity, timing and generalized use of this strategy. In contrast, more time and effort might be needed to provide a stronger rationale for strategies that therapists did not highly value that are core to EBPs (e.g., assigning/reviewing homework and anticipating setbacks) in order to facilitate training. Essentially, knowledge about therapists' attitudes can provide a roadmap for effective training efforts for individual EBP treatment protocols or proposed common elements approaches (Garland et al. 2008
In sum, findings from the current study indicate that, when asked about individual treatment strategies used with children with disruptive behavior problems in outpatient, community-based mental health settings, therapists highly value a number of different therapeutic strategies. Further, they value those strategies that are common in EBPs for this population at least a much as strategies not emphasized in EBPs. Differences in attitudes towards EBP strategies cannot be accounted for by differences in therapist demographics, professional discipline, level of training, or primary theoretical orientation. Understanding therapists' attitudes has the potential to significantly improve implementation of EBPs in community-based care.