Therapist Delivery of Evidence Based Practice (EBP) Strategies in a System-Driven Implementation of Multiple EBPs for Children

Examples of system-driven implementation of multiple evidence-based practices (EBPs) are becoming more frequent in efforts to improve community mental health care, but there is limited understanding of how these efforts change community therapist practice. Within one such implementation effort in the Los Angeles County Department of Mental Health, this observational study sought to: (1) examine observer ratings of therapist delivery of EBP strategies in sessions where therapists claimed reimbursement to one of six youth mental health EBPs; and (2) explore factors associated with extensiveness of EBP strategy delivery. Data were drawn from 680 sessions with 273 youth delivered by 103 therapists in 14 agencies. Sessions were audio recorded and rated by trained observers for extensiveness of therapist delivery of EBP technique and content strategies. Therapists were observed to use EBP techniques (Structuring Treatment Techniques and Skill Building Techniques) in the majority of sessions. Consistent with expectations, use of specific EBP content strategies were more targeted and less commonly observed at every session. Finally, the following factors were associated with higher observed EBP strategy extensiveness: sessions completed in a non-English language (compared with sessions completed in English), sessions using an EBP with a prescribed session content/order (compared with sessions using an EBP without a prescribed session content/order), higher levels of therapist reported self-efficacy with the EBP being delivered, older client age, and therapists with a cognitive behavioral theoretical orientation (compared with therapists with an orientation other than cognitive behavioral). Patterns of therapist EBP strategy delivery followed expected patterns, with techniques strategies used in the majority of sessions and specific content strategies used in a more targeted fashion. Given the dearth of observational measurement of EBP implementation-as-usual, these findings contribute to our understanding of key outcomes of scale-up efforts. Predictors of EBP strategy use have implications for targeting efforts to promote sustainment, such as improving provider EBP self-efficacy.