Modular Psychotherapy for Youth with Internalizing Problems: Implementation with Therapists in School-Based Health Centers

Article excerpt

An estimated 70%-80% of all mental health care for children and adolescents is delivered in school settings, making school the most common point of entry and receipt of mental health services (Burns et al., 1995; Farmer, Burns, Phillips, Angold, & Costello, 2003). Despite the general accessibility of school mental health care and its documented ability to reduce service access disparities (Kataoka, Stein, Nadeem, & Wong, 2007), experts have suggested that the effectiveness of mental health interventions offered in schools could be improved through increased use of evidence-based practices (EBP) (Evans & Weist, 2004; Rones & Hoagwood, 2000).

Many barriers stand in the way of successful implementation of EBP by school-based practitioners. For instance, the training and support resources required for implementation typically exceed those available in schools (Evans & Weist, 2004). Translation of evidence-based mental health treatments to the school context is challenging, as most have been developed for delivery in a predictable sequence of multiple (e.g., 12-14) 50-min sessions in outpatient clinical settings. As in other delivery settings, schools, districts, and school-based providers vary in their openness to change as well as resources available to allocate to change initiatives. These factors make it difficult for direct service providers and school administrators to develop effective mental health programs. Empirically informed adaptations of intervention and training practices to fit the school context are needed, and frameworks driving adaptation decisions must be feasible for use by clinicians, administrators, and researchers alike. This article reports on an initial effort to adapt and pilot an evidence-based modular treatment approach for use by therapists working within school-based health centers.

The school-based health center (SBHC) is a specific education-sector service delivery model operating in nearly 2,000 schools across the United States (Strozer, Juszczak & Ammerman, 2010). Eighty-nine percent of SBHCs provide primary health care, and 72% have mental health professionals on staff (Strozer et al., 2010). SBHCs typically provide services to students regardless of their insurance status and represent a proven structure in which service-access disparities based on ethnicity or socioeconomic status are reduced (Kaplan et al., 1999; Wade, Mansour, Line, Huentelman, & Keller, 2008). Although relatively little is known about the quality of mental health services delivered by SBHC therapists, care provided to youth across mental health sectors is known to fall short of adequately integrating EBP (Garland et al., 2010; Herschell, McNeil, & McNeil, 2004).

Emerging implementation models attend closely to characteristics of the settings in which new practices are delivered, with the intent of facilitating the adaptation, adoption, and ongoing application of evidence-based care (e.g., Damschroder et al., 2009; Mendel, Meredith, Schoenbaum, Sherbourne, & Wells, 2008). Although the field of implementation science is in its infancy, implementation research specifically focused on school mental health is particularly underdeveloped (Lyon, McCauley, & Vander Stoep, 2011). The education sector is ripe for the development of new service models. Implementation of new practices in schools necessitates careful, upfront evaluation of unique aspects of the educational context (Ringeisen, Henderson, & Hoagwood, 2003). This may include preimplementation data collection surrounding the most prevalent client characteristics and presenting problems, as well as characteristics of the service providers and the organizational features of the school setting.

The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) provides one model for conceptualizing program implementation that identifies essential factors for successful adoption of new practices. …