Systemic reform is needed to address racism as a root cause of mental health inequities, such as understanding how community mental health (CMH) agencies’ practices and policies may impact care provided to racially minoritized populations. This study described and examined associations between CMH clinicians’ multicultural knowledge and awareness and agency practices and policies to improve care for Clients of Color. CMH clinicians (N = 119) across Washington State reported on their multicultural competence and agencies’ practices and policies in an online survey. Multicultural competence was assessed with the Multicultural Counseling Knowledge and Awareness Scale (MCKAS), which assesses respondents’ knowledge of multicultural counseling frameworks and awareness of multicultural counseling issues. Agency policies were examined with an adapted version of the Multiculturally Competent Service System (MCSS) Assessment Guide, which asked respondents to endorse the degree to which their agencies had taken specific steps to better serve racially and ethnically minoritized populations across 11 domains, including policies, linguistic diversity in services, and quality monitoring and improvement. Multicultural knowledge and awareness were generally high across the sample. Clinicians commonly endorsed that their agencies had mission statements that were committed to cultural competence. Endorsement of concrete steps to improve services for non-English speaking clients was associated with greater multicultural knowledge and awareness, and practices to monitor and improve care provided to Clients of Color were associated with lower scores. Addressing mental health inequities requires multifaceted solutions. Results highlight the potential of examining agency practices and policies as one solution to improve care for Clients of Color.
Introduction A mental health provider's perception of how well an intervention can be carried out in their context (i.e., feasibility) is an important implementation outcome. This article aims to identify determinants of feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) through a case-based causal approach. Method Data come from an implementation-effectiveness study in which lay counselors (teachers and community health volunteers) implemented a culturally adapted manualized mental health intervention, TF-CBT, delivered to teens who were previously orphaned and were experiencing posttraumatic stress symptoms and prolonged grief in Western Kenya. The intervention team identified combinations of determinants that led to feasibility among teacher- and community health volunteer-counselors through coincidence analysis. Results Among teacher-counselors, organizational-level factors (implementation climate, implementation leadership) determined moderate and high levels of feasibility. Among community health volunteer-counselors, a strong relationship between a clinical supervisor and the supervisee was the most influential determinant of feasibility. Conclusion Methodology and findings from this article can guide the assessment of determinants of feasibility and the development of implementation strategies for manualized mental health interventions in contexts like Western Kenya. Plain Language Summary A mental health provider's perception of how easy a therapy is to use in their work setting (i.e., feasibility) can impact whether the provider uses the therapy in their setting. Implementation researchers have recommended finding practices and constructs that lead to important indicators that a therapy will be used. However, limited research to our knowledge has searched and found practices and constructs that might determine feasibility of a therapy. This article uses existing data from a large trial looking at the continued use of a trauma-focused therapy to find practices and constructs that lead to moderate and high levels of feasibility. We found that in settings with a strong organizational structure that organization and leadership support for the therapy led to teachers in Kenya to perceive the therapy as easy to use. On the other hand, in settings with a weaker organizational structure, outside support from a clinical supervisor led to community health volunteers in Kenya perceiving the therapy as easy to use. The findings from this article can guide context-specific recommendations for increasing perceived therapy feasibility at the provider-, organization-, and policy levels.
Introduction: Mobile phones may present a low-tech opportunity to replace or decrease reliance on in-person supervision in task-shifting, but important technical and contextual limitations must be examined and considered. Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision.Methods: Participants were recruited from a large hybrid effectiveness-implementation study in western Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (N=24) and supervisors (N=3) participated in semi-structured interviews in the language of the participants choosing (i.e., English or Kiswahili). The participants included high frequency, average frequency, and low frequency phone users in equal parts. Interviews were transcribed, translated when needed, and analyzed using thematic analysis. Themes were compared across frequency of phone use following a mixed methods data transformation and integration approach. Results: Uses included: clinical updates, scheduling and coordinating, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission, limited relationship building between supervisors and lay counselors, and disrupted communication flows. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can effectively be performed via mobile phones were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Differences emerged in specific themes pertaining to acceptability and feasibility by frequency of use.Conclusion: While mobile phone supervision was acceptable to both lay counselors and supervisors, there were also distinct challenges with feasibility. Researchers considering how digital technology can be used to increase mental and digital health equity must consider limitations to implementing digital health tools and design solutions alongside end-users to increase acceptability and feasibility.
The psychological study of resilience has increasingly underscored the need for children and families to access material and psychological resources to positively adapt to significant stress. Redistributive policies-policies that downwardly reallocate society's social and economic resources-can offer economically disadvantaged families sustained access to these resources and mitigate the harmful impacts of adversity. This conceptual article builds upon and integrates insights from psychological and policy research to develop a unifying multilevel resilience framework, which we call the Social Determinants of Resilience. We examine four U.S. redistributive policies that have been extensively studied for their effects on child and family outcomes as case studies: (1) Medicaid expansion; (2) the Earned Income Tax Credit; (3) childcare subsidies; and (4) Temporary Assistance for Needy Families. Informed by a scoping review of each policy, we propose that redistributive policies promote children's resilience through three mechanisms by (1) increasing families' resource and service access; (2) reducing family stress; and (3) enhancing adaptive cognitions, emotions, behaviors, and interpersonal processes that protect against the development of psychopathology and promote positive mental health outcomes. Highlighting current evidence for these resilience mechanisms as well as gaps in knowledge, we conclude by setting a multidisciplinary research agenda that can leverage this conceptual framework to advance the science on how redistributive policies enable children and families to thrive. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
There is a pervasive mental health treatment gap for children across the globe. Engaging stakeholders in child mental health evidence-based treatment (EBT) implementation projects may increase the likelihood of successful EBT implementation, thereby better addressing the treatment gap. However, little is known about the extent of stakeholder engagement to inform the implementation of child mental health EBTs.We conducted a scoping review to characterize stakeholder engagement in child mental health EBT implementation projects, including what stakeholders are engaged, how they are engaged, when they are engaged, where they are engaged (i.e., location of projects), why they are engaged, and the reported impacts of stakeholder engagement. We searched seven databases: MEDLINE, PsycInfo, Embase, ERIC, CINAHL Complete, Scopus, and Web of Science Core Collection. To be included, studies had to report on some form of stakeholder engagement that was undertaken to inform or explain the implementation of a child mental health EBT. We performed data extraction and synthesis to describe key study and stakeholder characteristics, stakeholder engagement methods and rationales, reported impacts of stakeholder engagement, and quality of reporting on stakeholder engagement.In total, 122 manuscripts met our inclusion criteria, from which we identified a total of 103 unique child mental health EBT implementation projects. Projects spanned 22 countries, which included low-, lower-middle, upper-middle, and high-income countries. The largest number of projects was in the USA and conducted in public mental health settings. Most projects engaged EBT providers during the active implementation phase and with limited depth, often gathering information from stakeholders without sharing decision-making power in implementation efforts. Across projects, impacts of stakeholder engagement spanned all of Proctor and colleague's implementation outcomes.Given that stakeholder engagement is often shallow and with limited shared decision-making, additional effort should be made to increase engagement to preempt challenges to EBT implementation and ensure implementation success. Such efforts may ensure the just distribution of power in EBT implementation efforts.All procedures were pre-registered on the Open Science Framework prior to conducting the literature search (DOI 10.17605/OSF.IO/GR9AP ).
The present study investigated the acceptability, feasibility, and potential effectiveness of using theater as an interdisciplinary tool to train mental health clinicians to discuss race and racism with Black youth clients. The training was developed using findings from a statewide survey of clinicians' perceived barriers and facilitators to discussing race and racism. Development survey data were analyzed to generate didactic content that addressed common misperceptions and to develop scripted performances of interactions between a therapist and two Black youth clients. Mental health clinicians and clinical supervisors (N = 23) from community mental health organizations viewed and responded to the videos of the scripted scenes before the training. Black clinician collaborators co-presented didactic information and facilitated small-group breakouts. Trained actors improvised participant suggestions in the large group, and breakouts allowed for debriefing, discussing, and practicing through improvisation with actors. The training was evaluated with a pre- and posttraining survey. Training significantly improved multicultural counseling self-efficacy (measured by the Multicultural Counseling Self-Efficacy Scale—Racial Diversity form; t[13] = –5.83, p < .001), decreased concerns about counseling Black clients (measured by the Concerns About Counseling Racial Minority Clients scale; t[13] = 7.05, p < .001), and improved intentions to discuss race and racism with Black clients specifically, t(13) = –6.11, p < .001, as well as all clients of color, t(13) = –3.16, p = .008. Qualitative and quantitative measures converged to suggest that the training was highly acceptable (M = 4.7, SD = 0.6) and appropriate (M = 4.7, SD = 0.6). We end with clinical implications.
The present study examined relations between supervisory alliance and fidelity to the trauma narrative component of Trauma-Focused Cognitive Behavioral Therapy, as well as how supervisory alliance might moderate the effect of behavioral rehearsals (i.e., role plays) on fidelity. Forty-two supervisors and 124clinicians from 28 different community-based mental health offices across Washington State participated.Clinicians were randomized to receive one of two supervision conditions—symptom and fidelity monitoring or symptom and fidelity monitoring with behavioral rehearsal. Supervisory alliance alone did not predict adherence or extensiveness of the trauma narrative. One aspect of alliance, client focus, significantly altered the effect of supervision condition on adherence (p=0.05); however, this effect was only seen in 43.5% of clinicians. A second aspect of alliance, rapport, altered the effect of condition on trauma narrative extensiveness with moderate significance (p=0.09). Future research should investigate strategies to improve supervisory alliance or match supervision strategies to specific supervisor-clinician dyads.
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