Div. 37 Dissertation Award winner: Jonathan Martinez, PhD
By Jonathan Martinez, PhD
In recent decades, there have been important advances in the child mental health (MH) care evidence base, including an understanding of the etiology of child MH problems as well as the proliferation of evidence-based interventions for those problems (National Research Council & Institute of Medicine, 2009). Randomized controlled trials demonstrate that child therapies are efficacious (Weisz & Kazdin, 2010). However, as many as 75-80 percent of U.S. youth in need do not receive MH services (MHS), with the disparity in need and service use highest among racial/ethnic minority and socially disadvantaged families (Kataoka, Zhang, & Wells, 2002). Among families who enter services, over 50 percent fail to complete treatment (Kazdin, 1996), with the majority of families only attending few sessions insufficient to receive an adequate dose of treatment (Armbruster & Fallon, 1994; Harpaz-Rotem, Leslie, & Rosencheck, 2004). There is evidence that racial/ethnic disparities in unmet MH need remain after accounting for a variety of structural barriers (Garland et al., 2002), suggesting that MH literacy barriers related to beliefs and knowledge about youth MH problems and treatments play a role in the underutilization of services (Cauce et al., 2002; Jorm, 2000; Yeh et al., 2005). Thus, despite significant advances in developing evidenced-based interventions for child problems, they are limited in impact due to a lack of family engagement in services.
In child psychotherapy, parents often serve as gatekeepers to child MH services, and their ability to recognize MH problems in their children and be actively involved in treatment is key to successful child outcomes ( Karver, Handelsman, Fields, & Bickman, 2006; Nock & Kazdin, 2005). Active parent engagement in child psychotherapy is critical for the treatment of certain types of child MH problems, such as disruptive behavior problems (Weisz & Kazdin, 2010). However, when y outh and families, particularly those from ethnic minority backgrounds, do initiate care, they often experience significant barriers to engagement in child MH services (Kazdin, 1993; Morrisey-Kane & Prinz, 1999). Poor engagement in services often leads to the ineffectiveness of care (Brannan, 2003), and this may be a particular problem in school-based MH services (SBMHS). SBMHS offer the advantage of increasing access to care (Atkins, 2003), but there appears to be an overreliance on individual counseling (Cerio, 1997; Weist, 1997). Given these factors impacting the MH care for ethnic minority families, this dissertation was comprised of two studies to understand factors impacting parent engagement in child therapy and investigate therapeutic strategies that promote family engagement in child MH care. Psychoeducation , a therapeutic practice used to present factual information about MH problems and treatments (Lukens & McFarlane, 2004), was investigated as a strategy for promoting parent engagement in care.
Study 1 examined therapists' in-session use of psychoeducation and other engagement strategies, and to test if of these therapeutic strategies were prospectively associated with increased parent engagement among an ethnically-diverse sample of families that received community-based MH services. Participants were drawn from the Child System and Treatment Enhancement Projects, a randomized effectiveness trial that included 84 therapists providing treatment to 174 clinically referred youth in community clinic settings in Hawaii and Massachusetts (Weisz et al., 2012) . We focused on a subset of 46 families where t herapists were randomized to provide treatment in an evidenced-based approach (modular treatment; MT) or usual care (UC) treatment for child disruptive behavior problems. A reliable observational coding system was developed to code therapy sessions recordings for therapists' in-session use of psychoeducation and other engagement strategies in the early phase of treatment. Findings revealed that psychoeducation strategies employed by therapists early on uniquely predicted subsequent parent involvement in treatment, over and above the use of other engagement strategies. Additionally, treatment condition (MT vs. UC) predicted parent involvement with MT parents attending a greater proportion of treatment sessions than UC parents, and this difference was mediated by therapists' use of psychoeducation strategies.
Study 2 employed a mixed methods approach to investigate patterns of parent participation in a sample of ethnic minority families who received SBMHS. This study used both quantitative and qualitative methodological approaches to understand the unique values, beliefs, and needs of communities of color. Specifically, administrative data on parent involvement was assessed, and a sample of 20 Latino and Chinese American parents of children that received SBMHS were interviewed to assess their level of participation in services and to document therapist implementation of basic psychoeducation practices in care. Findings from quantitative, administrative data suggested that parent participation in SBMHS was quite low. Qualitative semi-structured interviews suggested that parents were motivated to be involved in their child's services, but encountered barriers to treatment participation, felt uninformed about various aspects of the treatment process, and their participation was often not solicited by therapists. A majority of parents reported that they were uninformed about their child's presenting problems and various aspects of the treatment process, suggesting limited use of even basic psychoeducation by therapists in their child's SBMHS.
Findings from this dissertation are consistent with research that indicates gaps in using evidence-based practices in community MH service settings. An understanding on how specific in-session therapeutic strategies may influence parent engagement further elucidates the therapist's role in promoting client engagement. These results support the need for training community therapists on implementing psychoeducation strategies early in care to promote parent involvement in child MH services, and suggest a major opportunity to implement psychoeducation-based engagement practices to enhance the MH service delivery to ethnic minority families entering care. Furthermore, this research highlights the utility of understanding the MH literacy and perspectives of parents to promote family engagement in care. These findings suggest that to successfully engage families in care, an assessment of parents' beliefs and expectations about treatment is needed so that parent misconceptions can be addressed at the outset of therapy. These results inform the development of a psychoeducation-based engagement intervention at entry into care to target MH literacy barriers to promote family engagement in child MH care.
Jonathan I. Martinez, PhD, completed his doctorate in clinical psychology at the University of California, Los Angeles. His research has been highly informed from his clinical training experiences in providing evidence-based interventions for children and families, particularly underserved Spanish-speaking families. His research focuses on bridging the science to practice gap by implementing evidence-based practices in community mental health settings to reduce disparities in care for culturally diverse children and families. Currently, he is a postdoctoral research fellow at San Diego State University Research Foundation at the Child & Adolescent Services Research Center, where he works on research projects focused on the implementation of evidenced-based practices in community-based child mental health settings in San Diego County . Martinez is honored to have received the Div. 37 Dissertation Award and is looking forward to his new role as the editor of The Advocate starting in 2015.
Jorm, A.F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396-401.
Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status. American Journal of Psychiatry, 159, 1548-1555.
Lukens, E.P., & McFarlane, W.R. (2004). Psychoeducation as evidence-based practice: Considerations for practice, research, and policy. Brief Treatment and Crisis Intervention, 4(3), 205-225.
Morrissey-Kane, E., & Prinz, R. J. (1999). Engagement in Child and Adolescent Treatment: The Role of Parental Cognitions and Attributions. Clinical Child and Family Psychology Review, 2 , 183-198.
Weisz, J.R., Chorpita, B.F., Palinkas, L.A., Schoenwald, S.K., Miranda, J., Bearman, S.K.,…the Research Network on Youth Mental Health (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: a randomized effectiveness trial. Arch Gen Psychiatry, 69(3) , 274-282.