The California Institute for Mental Health (CIMH) is working with a wide range of partner agencies to engage in the model adherent implementation of evidence-based practices. Informed by experiences of county mental health departments and other public agencies, non-profit community-based organizations, and foundations CIMH has created an approach designed to support the full and sustained implementation of practices and programs – The Community Development Team (CDT) Model. A detailed description of the CDT Model is available: Community Development Team Model: Supporting the Model Adherent Implementation of Programs and Practices.
The Community Development Team (CDT) Model is a multilevel training and technical assistance strategy that has grown out of the CIMH’s effort to promote innovation in services and operations of mental health programs. CDTs are designed to promote high-adherence adoption of program and/or operational innovations by publicly operated/administered agencies and nonprofit community-based organizations. The CDT structure is designed so that participants are able to develop a realistic and concrete implementation plan, learn and apply clinical or technical information about a specific innovation, and overcome barriers to change.
A CDT is composed of a group of counties or agencies that are committed to implementing a new practice. Each participating agency/county has a team of participants including consumers, administrators, managers/supervisors, and direct service staff. Training and technical assistance is provided through a series of multi-agency meetings and augmented by individualized agency specific assistance as needed. CDT meetings involve four sets of activities:
- Clinical or Technical Training —Typically didactic with discussion, activities and role-playing presented by a “content-expert,” usually program developers.
- Planning—Provides an opportunity for the team of individuals from each agency/county to integrate the new information and develop or amend plans for local implementation. CDT trainers assist with county planning activities and assist the counties to develop strategies to overcome barriers to adoption, for example federal, state and county regulation, funding, and so forth.
- Peer-to-peer support —Provides opportunities for counties to share their plans for local implementation. This peer-to-peer component is a distinguishing characteristic of the CDT approach. Participating /agencies benefit from learning about the strategies being used by other counties/agencies and by receiving feedback from their peers about their own strategies.
- Outcome and Evaluation Support
Publication: Community Development Team Model: Supporting the Model Adherent Implementation of Programs and Practices.
Practice Description – The following practices are currently supported by CIMH Values Driven Evidence-based Practices Implementation Projects.
Multi-Dimensional Treatment Foster Care (MTFC) was developed in the 1980’s to assist youth with stabilization and reunification with a parent, relative or other permanent caregiver. It has been subject to numerous random assignment clinical studies in which youth participating in MTFC showed significantly better outcomes than control groups, including youth in group care. Youth involved with MTFC often show emotional and behavioral problems that present a challenge for adults. The project focuses on decreasing problem behaviors and increasing developmentally appropriate social skills and behaviors, to help youth experience success at home, at school and in the community. This is accomplished by providing:
- Close supervision
- Fair and consistent limits
- Predictable rewards and sanctions for following or breaking rules
- A supportive relationship with at least one mentoring adult
- Reduced exposure to delinquent peers
- Emphasis on school performance
The intervention is multifaceted and occurs in multipole settings. The intervention components include:
- Behavioral parent training and support for MTFC foster parents and biological parents (or other after-care resources)
- Skills training for the youth
- Family therapy for biological families (or other after-care resources)
- Supportive therapy for the youth and involved adults
- School-based behavioral interventions and academic support
- Psychiatric consultation and medication management when needed.
Functional Family Therapy (FFT) is a multi-phased family intervention targeting youth (11-18 years of age) and their families, including youth with problems such as conduct disorder, violent acting-out, and substance abuse. FFT intervention ranges from, an average of 8 to 12 one-hour sessions, up to 30 sessions of direct service for more difficult situations. FFT is conducted both in clinic settings as an outpatient therapy and as a home-based model. It is a treatment technique that is appealing because of its clear identification of specific phases, which organize intervention in a coherent manner, thereby allowing clinicians to maintain focus in the context of considerable family and individual disruption. Each phase includes specific goals, assessment foci, specific techniques of intervention, and therapist skills necessary for success
FFT was developed by James Alexander and his colleagues from the University of Utah. FFT has a number of studies demonstrating positive outcomes including reductions in criminal behavior (from 25-60%) and improved family relationships and school performance. FFT has been successfully adopted by numerous diverse communities throughout the nation.
Teaching Prosocial Skills (including Aggression Replacement Training™ curriculum) is a multi-component cognitive-behavioral treatment to promote pro-social behavior by addressing factors that contribute to aggression in children and adolescents including limited interpersonal social and coping skills, impulsiveness, over-reliance on aggression to meet daily needs, and egocentric and concrete values. Teaching Prosocial Skills (TPS) utilizes Aggression Replacement Training™ curriculum and has consistently shown positive outcomes across a number of quasi-experimental studies including:
- Reduced criminal behavior
- Decreased conduct problem behaviors
- Increased pro-social behaviors
- Improved anger control
TPS is a group intervention (6-8 youth per group) that consists of three components: Skillstreaming, Anger Control Training, and Moral Reasoning Training. Skillstreaming, developed by Arnold Goldstein, teaches youth pro-social skills. Anger Control Training by Eva Feindler and her colleagues teaches youth how to manage angry feelings. Moral Reasoning Training, through social perspective taking opportunities, teaches youth higher levels of moral reasoning, characterized by mutuality (treating others as you would hope they would treat you), and interdependence and cooperation for the sake of society.
Multidimensional Family Therapy (MDFT) is an intensive community- and home-based program that primarily targets substance abusing juvenile offenders and at-risk youth (12-18 years of age). Appropriate for youth residing in their homes but at-high risk of out-of-home placement.
MDFT was developed by Howard Liddle and his colleagues from the University of Miami School of Medicine. MDFT has been subject to numerous random clinical trails and shows positive outcomes including reductions in use of drugs and alcohol and affiliations with antisocial peers, and improvements in family relationships and school performance. MDFT research has focused upon African – American and Latino youth and has been successfully adopted by numerous diverse communities throughout the nation.
Depression Treatment Quality Improvement (DTQI) is a clinic-based cognitive-behavioral intervention that utilizes quality improvement processes to guide the provision of therapeutic services to adolescents who have depression.
This model was developed and studied by Joan Asarnow PhD, UCLA and Margaret Mason-Rea PhD, UCD and has been successfully implemented in Michigan. In Michigan-based studies comparing youth receiving DTQI to those receiving usual care reported that 80% of adolescents receiving DTQI service experienced meaningful change, and faired significantly better than adolescents receiving usual care with:
- Reductions in depressive symptoms;
- Improved quality of life ratings
- Higher participation in mental health services.
The Wraparound approach to treatment began in the 1980s with efforts to help families with the most challenging children function more effectively. It is a definable planning process resulting in a unique set of community services and natural supports individualized for a child and family. Wraparound has been implemented in mental health, education, child welfare and juvenile justice sectors. CIMH is partnering with the National Wraparound Initiative (NWI) to support the model adherent implementation of Wraparound as a strategy for improving outcomes. The following outlines key Wraparound elements:
- Wraparound must be community-based.
- Wraparound must be a team-driven process involving the child, family, natural supports, agencies and community services collaborating to develop, implement and evaluate an individualized plan.
- Families must be full and active partners in every level of the Wraparound process.
- Services and supports must be individualized and built on strengths, meeting the needs of children and families across life domains to promote success, safety and permanence in home school and community.
- The process must be culturally competent, building on the unique values, preferences and strengths of children and families and their communities.
- Wraparound child and family teams must have flexible approaches and adequate/flexible funding.
- Wraparound plans must balance formal services and informal community andfamily supports.
- There must be an unconditional commitment to serve children and their families.
- The plans should be developed and implemented based on an interagency community—based collaborative process.
- Outcomes must be determined and measured for the system for the program and for the individual child and family.
(adapted from Burchard, J.D., Bruns, E.J., & Burchard, S.N. (2002) The Wraparound Process. In B.J. Burns & K Hoagwood, Community-based Treatment for youth. Oxford:Oxford University Press.)
Incredible Years (IY) is a three component curriculum for children 2-12 years old who have, or are at risk for, behavior and conduct problems. The three components include parent training (BASIC and ADVANCED), teacher training (Classroom Management Training and Dina Dinosaur Classroom Curriculum), and a child small group program (Dina Dinosaur). The BASIC Parenting Program is required in implementing IY, and the others are optional. All programs rely upon video vignettes to guide group discussion.
Developed and researched by Carolyn Webster-Stratton PhD, IY has been subject to numerous random clinical trials. Outcomes for the various components include:
- Increases positive parental behavior (for ex., praise) and reduced use of criticism and negative commands.
- Increases in parent use of effective limit-setting by replacing spanking and harsh discipline with non-violent discipline techniques and increased monitoring of children.
- Reductions in parental depression and increases in parental self-confidence.
- Increases in positive family communication and problem-solving.
- Reduces conduct problems in children’s interactions with parents and increases in their positive affect and compliance to parental commands.
- Increases in teacher use of praise and encouragement and reduced use of criticism and harsh discipline.
- Increases in children’s positive affect and cooperation with teachers, positive interactions with peers, school readiness and engagement with school activities.
- Reductions in peer aggression in the classroom.
- Increases in children’s appropriate cognitive problem-solving strategies and more prosocial conflict management strategies with peers.
- Reductions in conduct problems at home and school.
Trauma Focused Cognitive Behavioral Therapy (TF CBT)
The goal of TF-CBT is to help address the unique biopsychosocial needs of children with Post Traumatic Stress Disorder (PTSD) or other problems related to traumatic e life experiences, and their parents or primary caregiver. TF-CBT is a time limited (12-16 weeks) model of psychotherapy that combines trauma sensitive interventions with cognitive behavioral therapy. Children and parents are provide knowledge and skills related to processing the trauma; managing distressing thoughts, feelings and behaviors; and enhancing safety, parenting skills and family communication.
TF – CBT has demonstrated effectiveness in randomized controlled trials superior to nondirective play therapy and supportive therapy in children (ages 3-14) who haeve experienced multiple traumas. TF CBT has proven effective improving PTSD, depression, anxiety, externalizing behaviors, sexualized behaviors, and feelings of shame and mistrust.
(Adapted from the Trauma-Focused Cognitive Behavioral Therapy Fact Sheet. National Child Traumatic Stress Network. www.NCTSNet.org. )
Multisystemic Therapy (MST)
MST is a pragmatic and goal-oriented treatment that specifically targets factors of each youth’s social network that are contributing to his or her antisocial behavior. Thus, MST interventions typically aim to improve caregiver discipline practices, enhance family affective relations, decrease youth association with deviant peers, increase youth association with prosocial peers, improve youth school or vocational performance, engage youth in prosocial recreational outlets, and develop an indigenous support network of extended family, neighbors, and friends to help caregivers achieve and maintain such changes. Specific treatment techniques used to facilitate these gains are integrated from those therapies that have the most empirical support, including cognitive behavioral, behavioral, and the pragmatic family therapies.
MST services are delivered in the natural environment (e.g., home, school, community). The treatment plan is designed in collaboration with family members and is, therefore, family-driven rather than therapist-driven. The ultimate goal of MST is to empower families to build an environment, through the mobilization of indigenous child, family, and community resources, that promotes health. The typical duration of home-based MST services is approximately 4 months, with multiple therapist-family contacts occurring each week.
The first controlled study of MST with juvenile offenders was published in 1986, and since then, numerous randomized clinical trials with violent and chronic juvenile offenders have been conducted. In these trials, MST has demonstrated:
- reduced long-term rates of criminal offending in serious juvenile offenders,
- decreased recidivism and rearrests,
- reduced rates of out-of-home placements for serious juvenile offenders,
- extensive improvements in family functioning,
- decreased behavior and mental health problems for serious juvenile offenders,
- favorable outcomes at cost savings in comparison with usual mental health and juvenile justice services.
(adapted from the MST Services Website at http://www.mstservices.com)