In 2020, researchers at University of Michigan completed a clustered, sequential, multiple-assignment randomized trial (SMART) to examine adaptive implementation supports for increasing cognitive behavioral therapy (CBT) skill delivery by Michigan-based high-school mental health providers. A collaboration with the TRAILS program, this study aimed to determine whether technical assistance (access to training and intervention materials), technical assistance and coaching (one-to-one support in implementing the intervention), technical assistance and facilitation (one-to-one assistance in overcoming barriers to implementation among providers at slow-responding schools), or technical assistance, coaching, and facilitation led to differential improvements in the amount of CBT that providers delivered at schools. Primary outcomes from that study (Smith et al., 2022) indicated that facilitation significantly increased CBT delivery at slow responding schools. However, this initial paper did not look at the type or quality of CBT that was delivered.
A new publication (Meyer et al., 2024) examines provider fidelity to CBT and how it relates to implementation supports. Within this trial, fidelity was defined as being adherent to the CBT manual and having high levels of CBT competence. Adherence was defined as providers delivering at least two full courses of the study manual, operationalized as provider delivery of all study CBT skills in the following frequencies: Psychoeducation about CBT (2), Psychoeducation about mental health (2), Relaxation (2), Cognitive coping (4), Behavioral activation (2), and Exposure (4). CBT competence was operationalized as provider scores on the CBT Competency Scale (Rodriguez-Quintana et al., 2021).
Approximately one quarter (27.8%) of study providers met the adherence criteria. This result was primarily driven by Exposure, as only 30.8% of providers met criteria for this skill alone. Providers who met adherence criteria also had significantly higher CBT competence scores at the end of the study. When looking at adherence and competence across different implementation conditions, differential effects emerged, such that adherence was higher among providers randomized to facilitation, and competence was higher among providers who received coaching. Taken together, these findings suggest that implementation supports for school-based delivery may have unique impacts on delivery outcomes. For providers to deliver sufficient quantities of the full range of CBT skills, facilitation may be most important, whereas coaching may be most helpful in improving provider CBT competence and the quality of skill delivery. These results have important implications for researchers, providers, families, and communities dedicated to improving youth access to effective mental health services.
