by Joye C. Anestis
Attempts to disseminate empirically-supported treatments (ESTs) have been rife with serious obstacles. It is no small task changing the practice of mental health care providers, and EST dissenters have voiced many complaints about the feasibility of widespread EST implementation. Among these complaints is the question of therapist training. Because clinical psychology as a field does not have a regulatory system that demands students be trained in science-based practices, many clinical psychologists receive their degrees with no or limited knowledge of ESTs and the evidence-based approach to client conceptualization. If ESTs are to become standard clinical practice for all mental health care professionals, than many therapists will have to undergo new training to learn how to implement these treatments. As you can imagine, this is a daunting idea! In order to understand how best to train therapists in ESTs, a research question imperative to the dissemination movement is how much training is necessary for therapists to undergo in order to be able to effectively implement a new treatment. A few (very few) studies have begun to answer this question.
A new study published in the Journal of Consulting and Clinical Psychology attempted to expand upon the EST training literature by examining the effect of the degree of intensity in EST training. Degree of intensity has rarely been examined in the treatment literature, but it makes sense to think that therapists who have received more intense training would implement the treatment more effectively. As always though, it is never safe to rely on clinical judgment and our own intuition when making treatment decisions. Lucky for us, this is one of the rare instances when clinical judgment has been verified by scientific data. Prior to the newest study by Lochman and colleagues discussed here, only one other study examined the role of EST training intensity on outcome. Henggeler, Melton, Brondino, Schere, & Hanley (1997) investigated therapist training in multisystemic therapy (MST), a comprehensive and incredibly effective treatment for conduct disordered adolescents and even juvenile offenders. Henggeler et al. (1997) looked at differences in outcomes produced by therapists trained in the standard MST training, which involves intense workshops and ongoing weekly consultation versus a more cost-effective training model without the weekly consultation. The cost-effective version of training did produce an overall reduction in incarceration rates; however, it did not impact a subset of clients, namely the serious juvenile offenders, a subset who were successfully treated by the therapists that received the more intensive training. So, a little preliminary evidence suggests that training intensity seems to have an impact on treatment/therapist effectiveness. Some studies have looked at training in cognitive-behavioral procedures and found similar results. Sholomskas, Syracuse-Siewert, & Rounsaville (2005) found that cognitive-behavioral training workshops, without any other techniques or supports, were not effective in establishing clinical competency. However, if the training workshops were supplemented by continuing supports (e.g., supervision), then competent implementation was greatly improved. Finally, Weisz et al. (1995) noted that, based on a meta-analytic review of child treatment literature, degree of structure provided (through treatment manuals) and the degree of monitoring (in this case, review of session tapes) were directly related to increased intervention effectiveness.
Building upon this literature base, John Lochman and colleagues examined the role of training intensity on an evidence-based prevention program for aggressive children, Coping Power. Coping Power includes a 34-session child component (in this case, 50-60 minute group sessions) and a 16-session parent component (90-minute sessions). The data reported are part of a field trial of the program within five public school districts (57 schools). Existing school staff (school counselors) were trained in the use Coping Power with children at high-risk during the transition to middle school (thus, the study also examined the ability of community caregivers to implement an EST). The counselors were randomly assigned to one of three study conditions (19 schools per condition):
- Coping Power - training plus feedback (CP-TF): This was the most intensive training condition, and it involved 4 training components. First, counselors received 3 initial workshop training days. They also participated in monthly ongoing training sessions (2 hours) which included training for upcoming sessions, a debriefing for previous sessions, and problem-solving for difficulties that which arose during implementation. Individual problem-solving was also available to these counselors via a technical assistance component (i.e., e-mail access to implementation staff and a telephone hotline to reach trainers). Finally, trainers provided supervisory feedback based on the rate of completion of session objectives. Qualitative feedback was also given based on the trainer's review of the session tapes.
- Coping Power - basic training (CP-BT): These counselors received the first 2 components given to the CP-TF counselors, 3 workshop training days and monthly ongoing training sessions.
- a comparison group: Counselors in the comparison group provided services as usual.
Children were selected to receive the treatment via an extensive selection process which included teacher ratings of aggressive behavior and investigator screening. The counselors had varied levels of education and experience (degrees ranged from Bachelor's degrees to PhDs) and about three quarters of the counselors reported never using an intervention similar to Coping Power before.
This study had 2 different aims: 1) to provide continued empirical support for the Coping Power program and 2) to examine differences in training intensity. In terms of goal 1, the CP-TF condition resulted in significantly better outcomes (e.g., decrease in externalizing behaviors, increase in most of the positive skills targeted by the intervention) for the children than the comparison condition. Interestingly, the CP-BT condition did not provide significantly better outcomes than the control condition. So, intensity of training seems to make a difference. Goal 2 more specifically examined the effect of training intensity by directly comparing outcomes for CP-TF and CP-BT. Lochman and colleagues found that the children treated by the more intensely trained counselors (CP-TF) were significantly different at post-test than those in the CP-BT condition, including lower levels of teacher & parent-rated externalizing behaviors, lower rates of child-reported assualtive behaviors, and reductions in their beliefs that aggressive behaviors would lead to good outcomes.
Although this was a very well-done study, it is certainly not without its limitations. Two are of primary concern to me. First of all, they did not follow-up with the students over an extended period of time. It would be important to know if the advantages garnered by the more intensive training were sustained over time. Second, we still do not know the minimum level of training needed to evince the treatment gains. Some sort of dismantling study would be interesting to see, one that pulls apart each component of the extended training protocol to determine if any one piece or combination of pieces produces the best results.
The Lochman study indicates that the amount of training received by a mental health care provider has a direct impact on therapist effectiveness. The counselors in the more intensive condition had greater access to their trainers and received direct feedback on their performance. These components seemed to have really influenced the quality of care provided by the counselors. As the EST community learns about such findings, we need to begin brainstorming ways to make this process more accessible and feasible to clinicians working in the community. The evidence continues to grow suggesting that standard training workshops are not sufficient. Investments of more money and time are needed in order for therapists to become fully competent in a treatment protocol and to implement it effectively. While the need for these more intensive programs may be expensive and time-consuming, as always the primary concern needs to be the best interest of the client...the more expensive method is preferred if it is significantly better for the client. I am hopeful that more research like this is being conducted to help the clinical psychology community know exactly what we need to do to become better at implementing these powerful treatments. Soon we will know exactly the type of training needed to build up our therapeutic muscles.
Joye Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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