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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [555]-[559]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [555]-[559]
annual dollar limits (and did not require parity in copayments, deductibles, or limits on days or visits), it represented a major policy advance by offering for the first time mental health coverage. The impact of this legislation on service use and costs are being examined (Goldman & Azrin, 2003).
RECENT INITIATIVES ADDRESSING RESEARCH AND SYSTEM FAILURES
There are several significant initiatives currently under way and supported by foundations and federal agencies to reform some of the system failures referenced above.
National Registry of Effective Practices
The Substance Abuse and Mental Health Ser-vices Administration (SAMHSA) has recently launched a new expansion of its National Registry on Effective Practices (NREP) to include mental health. This registry creates a standard set of criteria with which to establish an archive of research-based practices that can be updated to provide assistance to field practitioners on the quality and strength of effective mental health practices. This registry marks a major effort to bring order to the plethora of usages of the term evidence-based practice.
MacArthur Foundation Youth Mental Health Network
A major new 4-year initiative from the MacArthur Foundation, entitled the Youth Mental Health Initiative, under the leadership of John Weisz, is further extending the reach of EBPs by reviewing the evidence for therapies targeted at the most common childhood disorders. A set of studies will address gaps between research-based treatments and their delivery within clinic systems by examining how best to bring effective treatment practices to youth in mental health service settings. Studies of technology transfer in medicine, nutrition, agriculture, and other fields
have shown that effective dissemination requires (a) adaptation of the technologies to fit their intended users, and (b) an understanding of organizational and system barriers to change. This initiative includes two components. A Clinic Treatment Project will test two alternative methods of delivering EBPs within public community-based mental health clinics, using training and supervision procedures designed for the settings and users. A Clinic Systems Project will investigate the organizational, system, and payment issues that influence the ability of providers and clinics to use EBPs. The findings from these two projects are likely to yield answers to significant questions about the readiness of research-based treatments for integration into community practices and the readiness of community practices for adoption of new clinical strategies.
Another new initiative of the Annie E. Casey Foundation is also focusing on disseminating EBPs by melding training and supervisory models across different sets of interventions. The foundation, through its BlueSky Project, has enlisted the involvement of the developers of three evidence-based interventions for youth with disruptive behavior problems who are likely to be involved in the juvenile justice system (Multisystemic Therapy [FFT], Treatment Foster Care, and Functional Family Therapy) to create an integrated training and supervision model. An implementation demonstration program is being planned with two to three states beginning in September 2004.
A group of states are undertaking major efforts to create state-level strategies for disseminating single or, in some cases, multiple EBPs. In several of the states, these efforts also include providing comprehensive training, supervision, or regulatory activities to support the implementation of these EBPs. A brief description of some of the state efforts is provided below.
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New York is implementing a range of EBPs and is engaged in a major effort to evaluate the impact of the implementation processes. For example, FFT, a research-based treatment for youth with antisocial behavior problems and delinquency, is being implemented in approximately 12 sites statewide, following an active process of community involvement that sought stakeholder input about needs and options. Another large-scale implementation effort is being undertaken to carry out and evaluate a set of evidence-based cognitive-behavioral trauma treatments for approximately 600 youth affected by the September 11th World Trade Center disaster. New York State has also created a research bureau specifically focused on EBPs for children and adolescents, to track the implementation of research-based services and to include assessment tools, engagement strategies (McKay, Pennington, Lynn, & McCadam, 2001), and outcomes monitoring (Bickman, Smith, Lambert, & Andrade, 2003). In addition, New York has been awarded one of the NIMH-SAMHSA State Planning Grants to develop a set of tools and methodological approaches for assessing the fit between specific EBP models and organizational and contextual factors within mental health clinics and schools statewide. The focus of this effort is to improve understanding about differences among families, clinicians, administrators, and treatment developers in their perspectives on organizational issues relevant to the adoption of new clinical practices.
A different strategy has been undertaken in Texas, where the state is formulating a benefit design package of selected EBPs, supported through training, supervision, and monitoring. In 2003, a Consensus Conference was convened to assist state policymakers in designing the new benefit package. The Consensus Conference included family advocates, policymakers, clinical practitioners, and treatment and service model developers. The recommended benefit package includes both diagnostic-specific psychothera
pies and comprehensive community-based services to address the full range of mental health needs of youth and families. This benefit design was implemented in 2004.
In Michigan, a state planning process led to the identification of specific interventions to address the most common clinical problems and a statewide initiative to embed a standardized measure of functioning (CAFAS) into clinical practice. A plan was developed to train practitioners to provide cognitive behavior therapy for internalizing disorders, with assistance from UCLA, and parent management training to address externalizing disorders, with assistance from the Oregon Social Learning Center.
Center for Mental Health Services System of Care and EBPs in Kentucky, Ohio, and California
The Center for Mental Health Services (CMHS) is funding implementation initiatives of specific EBP models in several states, including Kentucky, Ohio, and California. In conjunction with Kentucky's Children's Services Grant Program, CMHS is supporting formal implementation of parent–child interaction treatment (PCIT) in a system-of-care site in eastern Kentucky. Although many randomized clinical trials of PCIT have been conducted, this is the first one conducted outside of academia. The PCIT is being randomized to schools and will also be implemented in a large county in Oregon where mental health centers will be the locus of treatment. Through the Center on Innovative Practices, Ohio is implementing Multisystemic Therapy, intensive home-based services, and wraparound services. Through the California Institute of Mental Health, the state of California is implementing Treatment Foster Care, FFT, and Webster-Stratton's Incredible Years.
An ambitious dissemination approach has been undertaken in Hawaii, called the Hawaii Experi
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ment (Chorpita, Yim, Donkervoet, Arensdorf, Amundsen et al., 2002). The combination of a 14-month review of the research literature on psychosocial treatments for youth by a group of stakeholders, including families, policymakers, researchers, and practitioners, identified a set of treatments that have been systematically deployed into Hawaii schools. A partnership between academia and the state led to the implementation effort. A process of distillation of EBPs into core practice components, has enabled more clinician flexibility in selecting treatments that fit with parent, child, and clinical needs. This statewide initiative is being carefully evaluated and a set of clinical practice guidelines and tools are being developed (Chorpita, Daleiden, & Weisz, in press).
RESEARCH ON ORGANIZATIONAL CONTEXT AND ITS IMPACT ON SERVICE DELIVERY
During the past decade, a series of studies originally conducted within business and industry has been applied to human service agencies, most recently including mental health (Glisson, 2002; Glisson & James, 2002; Schoenwald, Sheidow, Letourneu, & Liao, 2003). This application has arisen because it has become apparent that theory and constructs about organizational behavior have much to offer as interpretive frameworks within which to understand the capacity of mental health systems to change, adapt, or adopt new technologies, including EBPs. In the mental health field, organizations or organizational systems refer to the range of service delivery settings where treatments or mental health services are delivered (e.g., clinics, schools, group homes, or other work environments). Much of the new thinking about the application of organizational theory to mental health service delivery is derived from the diffusion of innovation literature, generally ascribed to Everett Rogers ( 1995). Rogers delineated different stages of adoption that characterize the uptake of new technologies and identified characteristics of the diffusion process that lead to their sustainability over time (Van de Ven, Polly, Garud, & Ventkataraman, 1999). For example, Rogers ( 1995) noted that the characteristics and moti
vations of adopters tend to differ among those adopting at the beginning, middle, and end periods of an innovation, and he identified attributes of innovations that can be used to design new technologies for their later successful diffusion. These characteristics include the extent to which an innovation is believed to be better than the current model of care, the degree to which an innovation is perceived to be consistent with existing values, the ease with which an innovation can be used, and the extent to which results of an innovation are visible to others. Empirical studies from the diffusion of innovation literature indicate that organizations and systems are not equally innovative and that some are much more open than others to adopting and implementing new practices. The factors that affect the capacity of an organizational system to change, adapt, or take up new innovations have been examined in a series of studies mostly outside of the human services field. These studies have identified a core group of dimensions along which work environments or service systems vary. In recent work, most notably by Glisson ( 2002) and Schoenwald et al. ( 2003), key factors within mental health agencies have been identified that affect delivery of services. Some of the key constructs within the organizational literature found to influence the behavior of providers are summarized below.
Organizational Culture and Climate
The constructs of organizational culture and climate have been measured in tandem and recently found to be discrete (Glisson & James 2002; Verbeke, Volgering, & Hessels, 1998). In general, organizational theorists define climate as the way people perceive their work environment, and culture as the way things are done in an organization (Verbeke et al., 1998). In other words, climate is defined as a property of the individual and culture as a property of the organization. Climate is further subdivided into psychological climate and organizational climate (Glisson & James, 2002; James & James, 1989; Jones, James, & Bruni, 1975; James, James, & Ashe, 1990). Psychological climate is defined as an
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individual's perception of the psychological impact of their work environment on their well-being (James & James, 1989). Organizational climate occurs when employees in the same organizational unit have the same perceptions about their work environment (Jones & James, 1979; Joyce & Slocum, 1984). Some of the core components of the psychological climate of a work environment include emotional exhaustion, depersonalization, and role conflict. A general psychological climate factor (PCg), reflecting the workers' overall perception of the positive or negative valence within the organization, is believed to constitute the core features underlying this construct (James & James, 1989; James et al., 1990; Brown & Leigh, 1996; Glisson & Hemmelgarn, 1998; Glisson & James, 2002). Culture is described as a “deep” construct that reflects the normative beliefs and shared behavioral expectations in an organization or work unit (Cooke & Szumal, 1993). These beliefs and expectations provide a guiding framework by which the priorities of the organization are made explicit. These priorities or values include conformity, consensus, and motivation. According to Glisson ( 2000), organizational culture is often described as layered, with behavioral expectations and norms representing an outer layer and values and assumptions representing an inner layer (Rousseau, 1990). Hofstede ( 1998) described behavior as the visible part of culture and values as the invisible part.
Structure refers to the formal organization of an agency or unit. This construct has the longest history and has been studied in greater depth and detail than the other organizational constructs. Core components of organizational structure include the centralization of power and the formalization of responsibilities and position in an organization. Structural functions such as participation in decision making, hierarchy of authority, ways in which roles are divided, and the procedural specifications that guide the division of labor all comprise elements of an organization's structure (Glisson, 2002).
Job satisfaction and organizational commitment have been studied since 1976 and appear to comprise features associated with work attitudes (Glisson & Durick, 1988). The distinction between satisfaction and commitment inheres in the difference between attachment to an organization and positive acceptance of one's duties within it (Mowday, Porter, and Steers, 1982; Williams & Hazer, 1986).
The characteristics of effective leadership have been identified largely through studies of staff perceptions about this quality. In these studies, three types of skills have been identified (Glisson & Durick, 1988): the extent to which a leader is perceived as willing to make key decisions and comfortable with this responsibility; the extent to which a leader is perceived as using the power to make decisions without authoritarianism; and the perceptions of the leader as intelligent. These dimensions are believed to comprise a single factor reflecting overall staff perceptions of a leader's capabilities (Glisson & Durick, 1998).
Organizational Readiness to Change
The construct of readiness to change is a recent addition to the dialogue within the organizational literature. It is a construct that has arisen within the substance abuse literature and includes aspects of culture, climate, structure, leadership, and work attitudes (Simpson, 2002). It has been examined with reference to the question as to why some organizations are more apt to adopt innovations than others (Simpson, 2002). Debate currently exists as to whether readiness to change is a separate dimension from the other constructs or whether it constitutes a whole subsumed within which are the other dimensions of organizational behavior. One of the research projects being undertaken in New York state is targeted at constructing a typology for or
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ganizational readiness, which will reflect multiple stakeholder perspectives, including, importantly, families and consumers. This typology will be used to assess for policy-planning purposes the readiness for uptake of a set of specific EBPs for youth (Hoagwood et al., in press).
Studies of Organizational Effectiveness
Recent work by Glisson and colleagues suggests that considerable variation exists among organizations in their capacity to accept innovations and to implement new technologies. These studies have demonstrated that an organization's structure and leadership affect the extent to which work environments allow experimentation with innovations or the adoption of new technologies. Studies from literatures within business and industrial organizational research suggest that work environments vary considerably along the dimension of innovativeness and openness to adoption. Structure and leadership are known to be important dimensions of organizations, but other variables—notably organizational culture, climate, and work attitudes—are also factors that predict innovation. These studies suggest that flexible structures, strong leadership, constructive cultures, nonrestrictive climates, and positive work attitudes contribute to innovation in organizations and the adoption of cutting-edge technologies (Glisson & James, 2002). In addition, Glisson has identified four organizational requirements for effective work environments ( 2002): use of assessments and treatment interventions that are appropriate, valid, and effective for the populations targeted by the service system; assurance that adherence to the protocols is obtained; positive alliances between the clinicians and the clients; and finally, provision of services that are available, responsive, and characterized by continuity. Glisson has found that these characteristics can be modeled and that they improve the culture and climate of child welfare and juvenile justice systems (Glisson, 2002). Whether this will hold true for mental health–care agencies remains to be determined.
Summary of Organizational Research Findings
Characteristics of organizations that promote adoption, adherence, alliance, and service responsivity have been identified in relatively global ways. Yet a specific understanding of the complex relationships that coexist among culture, climate, structure, leadership, attitudes, and the complex therapeutic process of alliance, adherence, and fidelity has yet to be delineated. According to Glisson, constructive and non-defensive organizational cultures, less centralized and formalized organizational structures, safe organizational climates, and positive work attitudes promote these attributes of service delivery. In identifying ways to improve health-care delivery and quality, it is likely that attention to issues of the specific fit among organizational elements and therapeutic processes will need to be identified if EBPs are to be sustained.
SUMMARY AND RECOMMENDATIONS
Create a Context for Constant Empirical Inquiry in Routine Practice
Current approaches to the implementation of EBPs within state and local service systems are largely characterized as unidirectional: research-based models are taken off the academic shelf and put into place within routine practice settings. An alternative approach is to encourage routine practice settings to become the seat of empirical inquiry—to become empirically driven centers for both delivering and examining practices and their link to outcomes (Kazdin, 2004). Such normalization of research-based approaches to practice would demystify the scientific enterprise and create services that could be constantly reevaluated, refined, and improved. This kind of revolution in thinking could lead to the creation of service clinics that construct locally relevant evidence. This approach could be used to create a context for empiricism within routine service settings, leading ultimately to improvements in quality.
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doi:10.1093/9780195173642.003.0029
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