As several researchers have suggested (e.g., Southam-Gerow, Chorpita, Miller, & Gleacher, 2008
; Southam-Gerow, Weisz, & Kendall, 2003
; Weisz, Donenberg, Han, & Weiss, 1995
; Weisz, 2004
), there are many differences between the contexts in which EBTs are usually tested and the contexts of everyday clinical care. Bridging all these differences may not be a simple process. This point is made clear in a recent review of research on the implementation of tested programs in practice settings (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
). Fixsen et al. report that many implementation efforts have not succeeded, despite evidence that the programs have worked well within controlled trials; by contrast, a few studies have shown successful implementation in practice settings when extensive, multilevel procedures are used, including careful selection of the “implementers,” thorough training, and active coaching/supervision.
The complex array of findings reviewed by Fixsen et al. (2005)
suggests that extensive research will be needed to understand what implementation procedures work in any particular domain (see also Southam-Gerow, Austin, & Marder, 2008
). The present study was one step toward such a body of research, focused on a specific form of treatment for depression in children and adolescents (here referred to as “youth”), as implemented in clinical practice.
The need for this research is underscored by questions about whether skilled and effective use of EBTs can be achieved in the limited time available to many practitioners. Many of the most skilled users of EBTs have built their skills over several years of graduate or postdoctoral training. Such training often occurs in specialized training clinics that focus on one treatment protocol, or a few related ones, for a narrow range of clients, and with faculty mentors and peers all concentrating on a similar skill set (see e.g., Southam-Gerow & Kendall, 2006
). Such extended, intensive, and highly focused skill-building is not likely to be feasible for most practitioners, given their mandate to serve a broad array of clients and given the time constraints, work demands, and productivity pressures of everyday clinical care. Similarly, the procedures used in many clinical trials—including selection of only the most talented therapists, extensive training, skill-building through practice cases, and assigning study cases only after high skill levels are achieved in practice cases—may not be feasible in practice contexts, given the service mandates and financial and time constraints under which clinics and clinicians must now operate.
These implementation challenges are quite relevant to cognitive-behavioral therapy (CBT) for depression. CBT is widely recommended for youth depression by professional groups (e.g., American Academy of Child and Adolescent Psychiatry—see Birmaher et al., 1998
), and has the most extensively replicated success in clinical trials for youth depression (see Weisz, McCarty, & Valeri, 2006
). However, preparation for a CBT trial often involves extensive therapist preparation. For example, CBT therapists in an RCT by Brent et al. (1997)
were required to (a) have six months of intensive training on the specific CBT treatment manual, (b) “treat two cases in adherence to the treatment model before becoming a therapist for the study” (p. 878), and (c) after passing a and b, receive 1 hour of group and 1 hour of individual supervision per week throughout their work as therapists. Because such an extensive time commitment would not be feasible for most clinicians employed in everyday practice, an important implementation question arises: Can clinicians employed in practice settings learn sufficient skills in CBT, in the time that is available to them, to be successful in treating youth depression?
Two recent studies suggest that it may be difficult to train practitioners to use CBT in ways that outperform the usual interventions provided in everyday youth mental health care. In one study, Clarke et al. (2002)
compared usual care (UC) for youth depression in the Kaiser Permanente HMO (e.g., outpatient visits plus psychotropic medication) to UC plus CBT. The depressed offspring of depressed parents were treated using the Coping with Depression Course for Adolescents (CWD-A), a CBT protocol that had shown beneficial effects in two previous efficacy trials. Therapists received initial training in the CWD-A followed by supervision every other week. At the end of the study, “the authors were unable to detect any significant advantage of the CBT program over usual care” (Clarke et al., 2002
, p. 305).
In another study, Kerfoot, Harrington, Rogers, and Verduyn (2004)
randomly assigned social workers and other community support workers to receive training and supervision in CBT or to continue their usual care (UC) procedures, with both groups treating depressed adolescents. At the end of treatment, the adolescents in both groups had shown similar reductions on depression symptom self-report measures, with no significant difference between CBT and UC. Kerfoot et al. concluded from these findings that “training community-based social workers in [CBT] is neither practical nor effective in improving the outcomes of their clients” (p. 92).
These important studies highlight the challenge of moving CBT into community service settings, particularly when the task includes training professionals in their first-ever use of CBT, and when CBT is pitted against UC in which professionals use familiar procedures and do their best to help their young clients improve. The research to date has taken valuable steps toward investigating whether there are training and supervision procedures through which CBT might produce more beneficial effects than UC. As a next step, we set out to (a) use a more complete effectiveness design than has been tried thus far, (b) use a fully randomized experimental procedure, and (c) avoid built-in dose differences that might favor CBT. Given these goals, our study design differed from Clarke et al. (2002)
and Kerfoot et al. (2004)
in significant ways:
1. Complete effectiveness design
We used clinically representative treatment settings, youths, and therapists. All sessions took place within routine outpatient care in public mental health clinics; we included only youths who had been referred through normal pathways, contacting them only after their families had called the clinics to seek services; and we included only clinicians who were already employed as therapists in those clinics. By contrast, the setting for CBT in Clarke et al. was a research center, with UC done in HMO offices; and in Kerfoot et al. both CBT and UC were done in various community social service settings. Youths in Clarke et al. were recruited from an HMO database, and Kerfoot et al. had study therapists recruit their own cases. Clinicians in Clarke et al. were research center staff for CBT and HMO clinical staff for UC; clinicians in Kerfoot et al. were social workers and community support workers.
2. Balanced, double-randomization
Our experimental design was structured to create as fair and balanced a comparison as possible between CBT and UC; we randomized therapists to CBT or UC, then randomized youths to CBT or UC. By contrast, Clarke et al. (2002)
randomized youths but not therapists; and Kerfoot et al. (2004)
randomized social workers to CBT or UC, but youths were then recruited by the therapists, precluding youth randomization.
3. No built-in dose differences
We also sought to avoid built-in dose differences that would favor CBT over UC (we tracked treatment duration, but left it free to vary). By contrast, the CBT condition in Clarke et al. (2002)
was CBT plus usual HMO services (including medication)—a design that offers advantages but does create a built-in dose difference favoring CBT over UC.
4. Practice-oriented skill-building model
To minimize conflict with clinic productivity rules, we limited initial CBT training to one day and stressed learning via weekly case supervision. By contrast, Clarke et al. and Kerfoot et al. mainly emphasized initial training—30 hours in Clarke et al., three days in Kerfoot et al. After training, Clarke et al. provided supervision every other week for 30 minutes in year 1, 15 minutes in year 2, with most supervision focused on attendance issues (personal communication, G. Clarke, 3/23/07). After their training, Kerfoot et al. offered voluntary supervision but had poor clinician participation (median number of supervision meetings attended was three; almost a third of therapists attended none or one).
The CBT program in the present study was Primary and Secondary Control Enhancement Training (PASCET; Weisz, Thurber, Sweeney, Proffitt, & LeGagnoux, 1997
). A previous RCT (Weisz et al., 1997
) had shown beneficial effects of PASCET with elementary to middle school youths who had elevated depression symptoms, and PASCET was especially appropriate for this study because (a) it included the most common core elements of CBT [e.g., activity selection, cognitive restructuring, relaxation training], (b) it was designed to fit the relatively broad age range needed in this study, (c) it was designed to accommodate the variations in pace and session attendance often seen in outpatient care, and (d) its focus on surveying multiple depression coping skills and then identifying and practicing a few “best fit” skills appeared to fit the array of different forms of youth depression seen in outpatient settings (see e.g., Weiss et al., 1991
To encompass outcomes across a relatively broad spectrum, we built on the assessment model of Hoagwood, Jensen, Petti, and Burns (1996)
, examining CBT vs. UC group differences on clinical outcomes, consumer response (i.e., therapeutic alliance), treatment duration, use of additional clinical services beyond psychotherapy, and cost. Our study appears to be the first trial of CBT for youth depression to encompass all three major effectiveness trial dimensions (i.e., clinically representative treatment setting, referred youths, and psychotherapists); the rigor of a fully randomized design (i.e., with both therapists and
youths randomized to CBT or UC); and broad assessment encompassing, clinical process, clinical outcome, and cost. We tested the hypotheses that CBT would prove superior to UC on clinical outcomes and therapeutic alliance, with lower cost and less need for additional services than UC. The primary study outcome was depression symptomatology, assessed via youth- and parent-report measures.