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FSRC Update Publications

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• Highlighted article or topic
• Transport Findings Update and Summary
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Sonja Schoenwald, Ph.D. January 14, 2009
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MST Transport Implementation Research

• Thanks to
• Office of Juvenile Justice and Delinquency
  Prevention
• National Institute of Mental Health
• National Institute of Drug Abuse
• Family Services Research Center
• Charles Glisson
• Don Hedeker
• David Mackinnon
• Service systems, organizations, clinicians, and
  families

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Transporting New Treatments MST as Test Case

• Funded by
• National Institute of Mental Health
• MH59138
• 1999 2004
• National Institute of Drug Abuse
• DA018107
• 2005 2007
• Schoenwald, PI

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MST Transportability Study Aims

• To Examine Relations Between
• MST therapist adherence and outcomes
• Organizational climate and structure, adherence,
  outcomes
• Supervision, adherence, outcomes
• Impact of clinician training experience on
  adherence
• A mediation model of transport

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Social Ecological Model of Treatment
Transportability

• Extra-Organizational Context
• (Referral, Reimbursement, Disposition)
• Organization Clinician Child
• (Structure,Climate,) Adherence
  Outcomes
• MST Supervision (Behavior, functioning,
• criminal activity)
• Clinician Variables
• Professional Training Experience

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Design

• Prospective, uncontrolled study
• Children nested within therapists nested within
  organizations within service systems
• Repeated measures
• Youth Pre, post, 6 12 months post-treatment
  lifetime pre through 1-year post criminal charges
• Clinicians TAM monthly SAM bimonthly
• Organizations biannually
• Service system biannually, per case

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Participants

• 45 MST programs in 12 states and Canada
• 452 therapists 73 female, 73 Caucasian,
  15 African American, 6 Asian/PI, 2 Hispanic
• 64 masters (social work, counseling, psychology)
• 1979 youths and their caregivers
• Youths were 15.5 years old, 65 male,
  58 Caucasian, 19 African American, 6
  Asian, 4 Hispanic, 13 Biracial

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• MST Transportability Study
• Published Findings Redux

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Predictors of Post-Treatment Change

• Therapist Adherence (Schoenwald, Sheidow,
  Letourneau, Liao, 2003 FSRC Pub. 235)
• Select Organizational Climate Structure Scales
  (Schoenwald et al., 2003 same as above)
• Consultant Adherence (Schoenwald, Sheidow,
  Letourneau, 2004 FSRC Pub. 242)

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Organizational Factors Assessed

• Climate
• Psychological impact of work environment
• Validated measure, OCQ, has 10 scales
• Structure
• Formal features of organization
• Hierarchy of Authority
• Procedural Rule Specification
• Participation in Decision-making
• Fit of work with structure is more important
  than structure per se

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Organizational Predictors

• Select climate and structure factors predicted
  short-term outcomes, some in unexpected
  directions.
• Climate structure did not predict adherence.
• Adherence moderated relations between climate and
  structure and outcomes.

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• Findings at Long-Term Follow-Up

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Youth Change Over Time

• Significant reductions in behavior and
  functioning problems through 1-year
  post-treatment
• Significant reductions in criminal charges
  through 4-year post-treatment

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Did Adherence Predict Longer-Term Post-Treatment
Change?

• Reductions in behavior problems one-year
  post-treatment differed significantly as function
  of therapist adherence ratings
• Schoenwald, S. K., Carter, R. E., Chapman, J. E.,
  Sheidow, A. J. (2008). Therapist adherence and
  organizational effects on change in youth
  behavior problems one year after Multisystemic
  Therapy. Administration and Policy in Mental
  Health and Mental Health Services Research, 35,
  379-394 FSRC Pub 326)

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Adherence Criminal Outcomes

• At the highest level of adherence, the annualized
  rate of post-treatment charges for youth was 47
  lower than at the lowest level of adherence.
• When therapist adherence scores were one SD above
  the mean, annualized rate of post-treatment
  charges was 29 lower than when therapist
  adherence scores were one SD below the mean.
• Schoenwald, S.K., Chapman, J.E., Sheidow,
  A.J., Carter, R.E. (in press). Long-term youth
  criminal outcomes in MST transport The impact of
  therapist adherence and organizational climate
  and structure. Journal of Clinical Child and
  Adolescent Psychology.

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Structure Climate Findings

• Higher Therapist Adherence Was Predicted By
• Greater organizational average levels of Growth
  Advancement
• Therapist perception of greater Growth
  Advancement and Job Satisfaction
• Lower Therapist Adherence Predicted By
• Therapist perception of greater Emotional
  Exhaustion

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Structure Climate Findings (2)

• Greater reductions in youth Externalizing
  behavior were predicted by
• Higher organizational average levels of Growth
  Advancement
• Lower organizational average levels of Hierarchy
  of Authority
• Therapist perceptions of greater Participatory
  Decision making

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Structure Climate Findings (3)

• However,
• When therapist adherence was added to the
  statistical models, the effects of these
  organizational climate and structure factors on
  youth outcomes weakened.

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Structure Climate Findings (4)

• Youth Criminal Charges (on average 4 years
  post-treatment) Were Predicted By
• Therapist perceptions of greater Job
  Satisfaction, Growth Advancement
• Higher organizational average Participatory
  Decision making
• But,
• These effects washed out when therapist adherence
  was included in the model

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What Does This Mean For Your Work?

• When adherence is good, but youth long-term
  outcomes are not, it may be that select aspects
  of organizational climate or structure are
  affecting the outcomes.
• BUT Depending on the outcome in question, those
  organizational effects are either weak or wash
  out compared to the effects of adherence
• SO Keep focusing on adherence

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Supervisor Adherence

• Supervisor Adherence Measure (SAM)
• Subscales
• Supervision structure process (SP)
• Promotion of MST principles (AP)
• Promotion of MST analytic process (ANP)
• Supervisor development of clinicians skills and
  competencies (CD)

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Supervisor Adherence Findings

• Greater supervisor average focus on Adherence to
  Principles predicted therapist adherence.
• Greater supervisor adherence to the Structure and
  Process (SP) of supervision during a youths
  treatment episode predicted greater reductions in
  youth behavior and functioning problems.
• Greater average focus on Clinician Development
  predicted a lesser decrease in youth functioning
  problems.
• Schoenwald, S.K., Sheidow, A.J.,
  Chapman, J.E. (in press). Clinical supervision in
  treatment transport Effects on adherence and
  outcomes. Journal of Consulting and Clinical
  Psychology.

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Empirically Supported Fidelity Links

Organization
Consultant
Supervisor
Therapist
Outcomes
CAM Therapist Report
SAM Therapist Report
TAM Parent Report
Behaviors Function Criminal Activity