Training therapists in evidence-based mental health interventions: What works and what holds promise for the future?

“Jenna” was an adolescent who presented for treatment at a specialty clinic after having been in therapy for several years. During that time, she had been having several panic attacks per day and met criteria for multiple anxiety disorders. She had dropped out of school, had increasing depression symptoms, and had been hospitalized several times for suicidality. By the time she presented to the specialty clinic, she had seen a number of therapists and had little hope for improvement, stating that “nothing worked before.” However, despite all her years of psychosocial intervention, she had never received evidence-based interventions for her anxiety.

Unfortunately, people like Jenna are not as uncommon as we would hope. Although evidence-based interventions exist for a wide variety of mental health disorders, they are rarely used in routine clinical practice. Many factors influence the types of mental health treatments individual clinicians use, but one major contributor to this research-to-practice gap is a lack of effective training for therapists. Evidence-based interventions are complex and can be challenging to implement – ensuring therapists know how to implement these complex interventions is critical to closing the research-to-practice gap. Prior work from nearly a decade ago reviewed the literature related to the impact of training strategies to facilitate therapist evidence-based intervention use. These early reviews concluded that self-study (e.g., reading a treatment manual) and brief workshops (less than one day) had limited impact on therapists’ actual behavior (Beidas & Kendall, 2010; Herschell, Kolko, Baumann, & Davis, 2010; Rakovshik & McManus, 2010). In contrast, more intensive trainings models, such as multi-day trainings and ongoing consultation, demonstrated promise in increasing therapist use of the targeted intervention, although much remained unknown about how to maximize the effects of training strategies.

Since these early reviews, many studies examining therapist training in evidence-based interventions have been published. Our recently published article in Clinical Psychology: Science and Practice (Frank, Becker-Haimes, & Kendall, 2020), provides an update on the past decade of literature by systematically reviewing the results of 76 unique studies published since 2010. We describe findings across five approaches to therapist training: 1) workshops alone, 2) workshops followed by consultation, 3) online training, 4) train-the-trainer models (in which expert therapists provide training to select therapists who in turn train other therapists), and intensive training (defined as 20 or more hours of training and two or more additional training components).

There are several key takeaways. First, consistent with the earlier reviews, there is limited support for low-intensity training approaches (in-person workshops, online workshops) to change therapist behavior, although these approaches do increase therapist knowledge and improve attitudes toward evidence-based interventions. Interestingly, we did find some differences between in-person workshops and online workshops, with in-person workshops leading to better outcomes when the target intervention was more complex; for simpler interventions, online and in-person workshops yielded similar outcomes.

Second, our review confirms prior findings that providing ongoing consultation on how to deliver a specific intervention after attending a workshop can yield better outcomes. The recent research on this topic also suggests that consultation following online training is just as important and effective as it is for in-person training.

Third, train-the-trainer models show promise as a cost-effective and efficient model. After receiving training from experts, community therapists were able to provide proficient levels of training to other community therapists. In turn, therapists who received training from their colleagues demonstrated adequate competence in the intervention. However, more work is needed to determine whether patients receive the same benefits from treatment when therapists are trained in this model.

Fourth, intensive training models, which included many hours of training, consultation, and supervisor feedback, consistently resulted in increases in therapist competence and use of the intervention. These models are expensive and time-consuming, but apparently worth it. The “active” ingredients of these intensive training approaches warrant further research.

Finally, our review highlighted that there is still a lot that we do not yet know about how best to train therapists to deliver evidence-based interventions.  Methodologically, many studies had critical limitations in how they measured the success of training, making firm conclusions challenging. In addition, it was often unclear exactly what educational strategies were employed in the various trainings, making it difficult to understand why one training may have yielded better outcomes than another. It is also not clear how sustainable or cost-effective the more intensive training models are; given the harsh fiscal reality of the mental health landscape, this is an important area we hope that researchers will continue to develop.

In conclusion, results of our review suggest that more intensive training approaches are most likely to lead to therapists increasing their use of evidence-based interventions. However, there is much that we do not yet know about how to optimize training and how to combine training with other strategies (e.g., policy mandates) to improve therapist use of evidence-based interventions. Future work is needed to identify key elements of training to optimize the success of implementation efforts and ensure that treatment seeking-individuals receive effective care.

Reference Article

Frank, H.E., Becker-Haimes, E.M, & Kendall, P.C. (2020). Therapist training in evidence-based interventions for mental health: A systematic review of training approaches and outcomes. Clinical Psychology: Science and Practice.

About the Authors

Hannah Frank, M.A. is a clinical psychology intern at the Alpert Medical School of Brown University and a doctoral candidate at Temple University. She currently conducts clinical work and research in the Pediatric Anxiety Research Center (PARC) at Bradley Hospital. Hannah has received federal funding to support her research on a novel experiential approach for training clinicians in evidence-based interventions for anxiety and related disorders.

Emily M. Becker-Haimes, Ph.D. is an Assistant Professor at the University of Pennsylvania’s Center for Mental Health. She is also the clinical director of the Pennsylvania Hospital Anxiety Treatment for Children/Adolescents at Hall Mercer (PATCH) program, which is the only specialty anxiety clinic in Philadelphia dedicated to serving youth in the public mental health system. She is an implementation scientist and clinical psychologist whose work is dedicated to improving mental health service quality in specialty mental health settings for youth.  She has expertise in the implementation of exposure therapy across settings and the application of exposure therapy for youth with complex comorbidities.

Philip C. Kendall, Ph.D. is a Distinguished University Professor and Laura H. Carnell Professor of Psychology at Temple University.  His CV lists over 750 publications, including over 25 books and over 20 treatment manuals and workbooks. His treatment for anxiety in youth has been translated into a dozen languages. He has had 35 years of grant support from various agencies (e.g., NIMH; MacArthur). Having received many thousands of citations annually, he was identified as a “Most Highly-Cited” individual in all of the social and medical sciences (top 1%). His recent H Index is 127. Dr. Kendall was twice a Fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford, won the Research Recognition Award from the Anxiety Disorders Association of America and was awarded the Aaron T. Beck Award for “Significant and Enduring Contributions.” ABCT awarded him its Lifetime Achievement Award (2019).  Dr. Kendall has contributed as a scientist, teacher/mentor, and leader. His overall contributions include cognitive-behavioral theory and an understanding of the psychopathology and treatment of children and adolescents. Dr. Kendall is known for his rigorous research methodology, creative and integrative approaches, and commitment to graduate mentoring. An avid completer of the NY Times crossword puzzle (every day except Saturday), Dr. Kendall plays basketball twice a week, tennis, and enjoys opportunities to spend time in the ocean and with his family.

References

Beidas, R. S., & Kendall, P. C. (2010). Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective. Clinical Psychology: Science and Practice, 17(1), 1-30. doi:10.1111/j.1468-2850.2009.01187.x

Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review, 30(4), 448-466. doi:10.1016/j.cpr.2010.02.005

Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516. doi:https://doi.org/10.1016/j.cpr.2010.03.004

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