(PS5-C60) Does Theoretical Orientation Predict the Use of Empirically Supported Strategies? Results from Observational Coding of Routine Youth Psychotherapy

Research across five decades has produced manualized empirically supported treatments (ESTs) that outperform usual care (UC) for youth in community mental health settings (Weisz et al., 2006; 2013). Observational coding of UC therapy with youth suggests that therapists deliver practice elements consistent with ESTs but with significantly lower competence than therapists in research trials (McLeod et al., 2019), and often leave out key elements of ESTs (Garland et al., 2010). Given these findings, Implementation Scientists have sought to better understand factors associated with the use of ESTs in routine practice settings. Therapist characteristics, such as therapeutic orientation, may be associated with the delivery of ESTs. Therapists report using a mix of cognitive-behavioral, psychodynamic, and other strategies, regardless of self-reported theoretical orientation (Stewart et al., 2012; 2018). Self-report survey data from mental health providers indicates that those who identify as cognitive-behavioral report greater use of ESTs (Becker et al., 2013; Cho et al., 2019; Nelson & Steele, 2007). The current study seeks to extend these findings by examining whether self-reported therapeutic orientation predicts the actual use of elements from ESTs using observational coding of UC therapy sessions in youth outpatient settings.

This study uses therapy process observational coding data (Therapist Integrity to Evidence-Based Interventions; Bearman et al., 2012) of 158 UC sessions from a randomized controlled effectiveness trial in youth outpatient mental health clinics. Coding data were aggregated by therapist (N = 21). Linear regression analyses were performed to examine whether orientation predicts adherence (percentage of session time a therapist uses specified practice elements) and competence (skillfulness with which practice elements were delivered) to practice elements from ESTs.

Therapists reported that their orientation was cognitive-behavioral (n = 9), eclectic (n = 5), psychodynamic (n = 3) and other (n = 4). Seventeen therapists (80.95%) used some practice elements from ESTs. On average, therapists spent 17.46% of their sessions utilizing any EST practice element, and these were delivered with competence rated between “insufficient” and “adequate but not optimal” (M = 1.61). Theoretical orientation did not predict adherence to practice elements from ESTs, R² = .023, F(1, 156) = 3.70, p = 0.56 or competent delivery, R² =.003, F(1, 72) = .23, p = .633.Similarly, orientation did not predict adherence to practice elements prescribed by problem area (e.g., exposure for anxiety) or the competence with which they were delivered.

Consistent with prior research, UC therapists utilized some EST practice elements, but delivered them with relatively low competence (McLeod et al., 2019). While self-reported use of evidence-based practices has been shown to correlate with a cognitive-behavioral orientation (Becker et al., 2013; Cho et al., 2019; Nelson & Steele, 2007), current results suggest that therapeutic orientation did not predict the actual delivery of such practices. Results will be discussed in the context of quality improvement efforts and targeted training for youth mental health in routine care settings.