This study provides the first detailed data on the type and variability of psychotherapeutic treatment strategies observed in mental health care delivered to children with disruptive behavior problems, the most common presenting problems in mental health. Results reflect heterogeneity in amount and type of treatment, including treatment duration (0–70 sessions in 16 months), additional service use, and within-session psychotherapeutic strategies observed.
Although treatment duration varied widely, the mean number of sessions attended (22.4) is somewhat consistent with limited available data on duration of community-based care, with reported total treatment session averages ranging from 17 (31
) to 23 sessions (32
). Most EB treatment models for children with DBPs require a minimum of 12 weekly visits (23
). In addition to out-patient sessions, the majority of patients reportedly received other types of mental health services. Almost two-thirds of these 4 to 13 year olds received some psychoactive medication, which stands in contrast to 38% of a somewhat similar sample of youths with DBPs receiving UC treatment in the Netherlands (33
). The majority of children in our sample also received some type of school-based psycho-educational services, and a minority received more intensive services, including hospitalization for psychiatric reasons (9%), during the 16-month study period. Combined with the fact that 28% of children were still in treatment after 16 months, these data reflect a substantial volume of mental health services for families who engaged in UC. The extent to which these services were coordinated across treatment modalities is not known.
Within and across treatment sessions, therapists were observed delivering a wide array of clinical strategies, which is consistent with limited research indicating that UC therapists prefer an eclectic approach to psychotherapy (10
). Although only 26% of the therapists in this study endorsed “Eclectic” as their primary theoretical orientation, the observational data indicate that eclecticism is the norm rather than the exception. The findings that almost half of sessions did not include a single therapeutic strategy delivered at high intensity, and that the mean intensity rating across all observed strategies was relatively low reflect a cursory and/or incomplete application of the treatment strategy with limited follow-through. Explanations for low intensity are largely speculative but may reflect variability in therapist training, interference of patient crises and case management challenges, assumptions or perceptions of patients’ responsiveness, and/or pragmatic constraints (e.g., not enough time). Overall, the UC psychotherapy we observed could be characterized as reflecting great breadth, but not depth, in therapeutic approaches.
Parents participated in at least part of the majority of treatment sessions, and similar therapeutic techniques were observed frequently being delivered to both children and parents (e.g., assessing problems/events, psychoeducation, establishing/reviewing goals). However, therapists were observed addressing different therapeutic content areas with parents vs. children. Specifically, two of the most common content areas addressed with parents were “child’s external care” (i.e., case management or coordination of extra-therapeutic services) and parental psychosocial issues, but these were not common with children. These findings are consistent with anecdotal reports from UC therapists who indicate that the complex, multi-determined needs of families in public sector care require significant case management, which can interfere with delivery of EB psychotherapeutic approaches such as child skill-building or parent management training. While our data do confirm that therapists are spending a great deal of time with parents on case management, the data cannot address the necessity of this case management emphasis, nor the impact on outcomes.
The second aim of this study was to examine the extent to which UC therapists employed strategies conceptually consistent with pre-determined common elements of EB treatment for this patient population. Results indicate that while several strategies common to EB practices were observed in a majority of sessions (e.g., affect education, problem solving skills, use of positive reinforcement, psychoeducation), other strategies common in EB treatment were observed relatively infrequently. Even when observed, several EB strategies were usually rated at low intensity, thus not consistent with expectations in EB treatment models. Similar observations were reported in other work comparing observational and therapist self-report methods for characterizing psychotherapy practice (34
Many of the infrequently observed EB treatment strategies, such as assigning/reviewing homework, role-play/behavioral rehearsal, and modeling, are characterized as more directive psychotherapeutic techniques (35
), and these strategies are at the core of virtually all EB treatment models for children with DBPs. We have found that therapists in UC clinics generally have positive attitudes about many of these psychotherapeutic techniques (36
), yet they do not employ them often. Research on adult psychotherapy similarly finds that directive therapeutic approaches are not observed as frequently in UC compared to EB treatment models (35
). Given that more directive treatment approaches have been associated with greater improvement in specific behavioral outcomes (37
), more attention to this discrepancy is warranted.
Our findings raise natural questions about factors associated with therapist variability in practice. In related research, we have tested for therapist characteristics that may be associated with delivery of treatment relatively more or less consistent with elements of EB practice; few significant effects were found (38
). For example, therapist experience (months practiced), discipline, and staff versus trainee status have not been significantly associated with observed intensity of delivery of EB practice elements in our sample of therapists, which includes many therapists with few years of accumulated experience. Thus, explanations for variability in practice likely require more complex investigation of training and supervision experiences. Accordingly, our results have implications for therapist training (as discussed below).
The current study findings need to be interpreted in the context of some additional strengths and limitations of the study. Representativeness of the therapist and patient sample is critical for the generalizability of these findings. The patient sample is comparable to several other clinical samples of children in publicly-funded care. Specifically, the 2:1 male to female ratio is consistent across many studies (12
), as is the over-representation of some racial/ethnic minority youth relative to general population estimates (12
), and the most common diagnoses (conduct disorder/ODD, ADHD, and mood disorders) (39
). The therapist sample is also very comparable to a recent national sample of 1200 providers in children’s mental health care in terms of distribution by educational level, gender, and ethnicity (41
). Trainees with limited experience are somewhat over-represented in our study, but other studies of community-based UC also report high representation of trainees (42
). Our sample also includes a large representation of therapists trained in the Marriage & Family Therapy (MFT) discipline, which represents a rapidly growing segment of the workforce across the U.S., but is over-represented in California (43
). Of course, the extent to which the participating therapists represent therapists in other types of service sectors (e.g., private practice) or geographic regions is unknown.
The strengths of the study methods reflect a balance of relevance and rigor. We achieved adequate inter-rater reliability on our observational measure (PRAC-TPOCS-S), which also benefited from collaborative input from practicing therapists to assure ecological validity and comprehensiveness (29
). Use of such qualitative methodology to support the validity of practice measures has been strongly reinforced in previous studies (10
). Despite these strengths, the resulting measure did not capture all possible therapeutic interventions. The data reflect only the observable behavior of the therapist, and do not capture therapists’ intentions, goals, or decision-making processes, patients’ responses to different intervention strategies, or additional therapeutic contacts such as communication outside the office. Finally, we do not know how observing practice may have impacted practice itself, although we attempted to minimize this effect by establishing videotaping as routine in the clinics and by using small, unobtrusive cameras.
In the context of recent reports of the extraordinarily high cost of mental health treatment for children and discouraging data on effectiveness, this study offers timely detail regarding the types of care being delivered in one large public system. The study provides the first glimpse into UC psychotherapy practice offices, and thus provides essential contextual data for the development of tailored efforts to improve care, as well as providing baseline data for change efforts. Our results highlight some areas of relative convergence between EB practice and UC, as well as significant discrepancies between EB treatment elements and UC. Areas of convergence may represent “common ground” upon which to build and discrepancies represent potentially potent targets for improving care. For example, training efforts designed to increase the delivery of infrequently observed directive EB treatment strategies for children and parents, such as role-playing, modeling, and assigning/reviewing homework, are needed. These efforts must also address needed improvements in intensity of treatment. Mental health clinician training is most effective when training interventions are tailored to address the existing service context (44
). Further, it may be important to infuse EB training into graduate programs preparing master’s level therapists since they represent a significant proportion of the providers of community-based mental health services.
Critical next steps in this practice-based research program include examination of UC child/family outcome trajectories to determine how specific practice patterns may be associated with different clinical outcomes. More detailed analyses can examine potential moderating effects of patient characteristics (demographic and/or clinical factors), as well as therapist characteristics. Analyses of the mediating role of perceived therapeutic alliance are also needed as previous research supports the role of alliance in outcomes. Richer information about UC practice will provide essential contextual data for ongoing efforts to improve the translation of EB interventions into practice, balancing the emphasis on evidence-based practice with attention to practice-based evidence.