Practice Corner: Community Therapist Reports of Client Engagement Challenges During the Implementation of Multiple EBPs in Children’s Mental Health

Practice Corner Authors:

Christopher Gomez, University of California, Los Angeles

Kenny Le, University of California, Los Angeles

Morgan Crawley, University of California, Los Angeles

Joyce Lui, University of California, Los Angeles

Article Title: Community Therapist Reports of Client Engagement Challenges During the Implementation of Multiple EBPs in Children’s Mental Health

Article Authors: Lau, A.S., Gonzalez, J.C., Barnett, M.L, Kim, J.J., Saifan, D., & Brookman-Frazee, L.

Why is this article relevant to your practice?

• Community mental health therapists may encounter difficulty engaging their clients due to the complexity of the populations served.
• Few studies examine engagement challenges encountered in community mental health.
• This article provides insight into the frequency and predictors of client engagement challenges when delivering evidence-based practices (EBPs) to diverse families in the community.

What are the key takeaways from the article?

• This study occurs in the context of a system-driven implementation of multiple EBPs in community mental health services. Data was part of a larger study, 4KEEPS (Lau & Brookman-Frazee, 2016).
• 668 therapists from community-based mental health agencies reported on client engagement challenges for a given case over the past two months.
• Two types of client engagement challenges were identified:
  • Expressed Client Concerns: Practical barriers, difficulty mastering skills, relevance/acceptability/helpfulness, lack of familiarity of concepts
  • Limited Client Engagement: Apathetic/disinterested, avoiding participation, veering off topic
• 4% of therapists reported encountering at least one engagement challenge in the past 2 months.
• Several child- and therapist- factors predicted client engagement challenges (Table 3):
  • Client Expressed Concerns were more common in therapists with positive EBP attitudes and in those delivering parent-training EBPs.
  • Limited Client Engagement was more common in children with externalizing behavior, burned out therapists, and therapists with negative EBP attitudes, but less common in Latinx therapists.
• Only Limited Client Engagement was negatively related to therapist-reported ability to carry out the EBP over the previous 2 months (Table 4). Expressed Client Concerns were not associated with this implementation outcome.
  • In the context of parent training interventions, expressed challenges may actually be indicators of positive engagement in psychotherapy process.

What do the authors say are the limitations of the article?

• This study cannot infer causality or directionality between variables because of the cross-sectional design.

• Therapists were primarily unlicensed, and mostly ethnic minority, which is representative of the community mental health system under study, but findings may not generalize to other contexts.
• Authors were not able to determine whether therapists’ reports were representative of their full caseload, or whether they reported on cases that were more successful.
• Results were derived from therapists’ self-reports of implementation processes and outcomes, multi-method data should be examined.

Link to the article:

Full article reference: Lau, A.S., Gonzalez, J.C., Barnett, M.L, Kim, J.J., Saifan, D., & Brookman-Frazee, L. (2018). Community therapist reports of client engagement challenges during the implementation of multiple EBPs in children’s mental health. Evidence-Based Practice in Child and Adolescent Mental Health, 3(3), 197-212. doi:10.1080/23794925.2018.1455545

Additional Resources: Lau AS, Brookman-Frazee L. The 4KEEPS study: identifying predictors of sustainment of multiple practices fiscally mandated in children’s mental health services. Implement Sci. 2016. doi:10.1186/s13012-016-0388-4.