Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings

Abstract

Background-The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families. Objective-The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists' self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children's mental health services. Method-One hundred and three therapists reported on two types of engagement challenges-Limited Client Engagement and Expressed Client Concerns-in 702 sessions with 274 clients. Results-Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. Both types of engagement challenges were negatively associated with therapists' report of their ability to carry out intended activities in the same session.

How community therapists describe adapting evidence‐based practices in sessions for youth: Augmenting to improve fit and reach

“…We did not examine associations between adaptations and treatment plans or outcomes in the current study. Our findings, combined with those of Gellatly et al (2018) using the same sample of therapists, pose an interesting phenomenon in which therapists are not significantly more likely to adapt via Augmenting or Reducing in the face of an engagement challenge, yet therapists report being derailed from planned session activities during such sessions. Perhaps modifying presentation or repeating elements are some ways therapists could prevent sessions derailment.…”

“…In prior examinations with the current therapist sample, therapists' reports of limited client engagement and expressed client concerns were negatively associated with therapists' reports of their own ability to carry out intended activities in the same session (Gellatly et al, 2018). That is, when therapists perceived an engagement challenge, they also perceived that the session did not go as planned.…”

“…Rates of Augmenting and Reducing adaptations did not significantly differ by client gender. Previous studies have suggested that boys have higher rates of disruptive behaviors, which may lead to more disruptions in treatment sessions, difficulty with client engagement, and derailed treatment delivery (Gellatly et al, 2018). Our analyses controlled for expressed client concerns and limited client engagement behaviors in session, which may explain why we did not see gender emerge as a client‐level factor associated with adaptation.…”

“…In the current study, therapists reported on four items to indicate whether each engagement challenge had occurred. The Limited Engagement in Therapy Activities subscale included two items: “Demonstrated apathetic or disinterested behavior” and “Avoided participating in therapy activities.” The Expressed Client Concerns subscale included two items: “Expressed about the relevance/acceptability/helpfulness of an intervention strategy” and “Expressed difficulty mastering skills presented in therapy.” The reliability of the engagement challenges items and subscales were previously supported through analyses of the prospective correlations between mean occurrence of therapist‐reported engagement challenges across sessions with a given client over a study period, and their subsequent retrospective reports of challenges encountered over the previous 2‐month period with that client (Gellatly et al, 2018).…”

Community providers’ experiences with evidence-based practices: The role of therapist race/ethnicity.

“…However, there is little evidence bearing on how therapist race/ethnicity may be associated with perceptions of challenges in engaging diverse clients in EBP delivery. Previous studies have led to mixed findings, ranging from no significant racial/ethnic differences in therapists' reports of clients expressing concerns/doubts about treatment or levels of engagement in sessions (Gellatly et al, 2019) to results suggesting that Latinx therapists report fewer instances of clients not participating in sessions compared with White therapists (Lau et al, 2018). Given these inconsistent results, mixed-methods analyses may be useful to understand how diverse therapists perceive and respond to client-engagement challenges within community EBP implementation.…”