TREATMENT FOCUS DIFFUSION AND CLIENT OUTCOMES IN PUBLIC MENTAL HEALTH CARE FOR YOUTH

Abstract

Research conducted in public mental health care (PMHC) suggests that therapists often divide treatment focus across several co-occurring issues (both diagnostic and non-diagnostic) over the course of treatment. This spreading of treatment focus across multiple concerns is referred to as treatment focus diffusion (TFD). There is emerging evidence that maintaining a central focus in treatment is an important element of effective services and that higher levels of TFD are associated with poorer client outcomes. Additional research is needed in order to determine the robustness and generalizability of TFD as a predictor of clinical and system outcomes. The program of research described in this dissertation aims to investigate the extent of TFD as it occurs in different service formats in PMHC settings (e.g., standards-based in- and out-of-home services and implemented evidence-based therapies) and its association with relevant outcomes. Data collected as part of routine quality assurance initiatives in a local state-wide child and adolescent mental health care system were examined using multi-level linear and logistic regression analyses including statistical controls for potential covariates.The following dissertation includes an introductory chapter to orient the reader to the theoretical and empirical background relevant to all four subsequent studies. Chapters two through five include four separate studies in manuscript submission format. The first study showed that in implemented Multisystemic Therapy (MST), an evidence-based treatment package, therapists reported a significantly lower average TFD level than those in a standards-based intensive in-home (SB-IIH) service format when accounting for other indicators of case complexity. The first, second, and third studies found that higher TFD was related to poorer outcomes in these two service formats, whether measured by therapist reported progress ratings, change in functional impairment, or longer-term subjective indicators of return to services and cost to the system. Across all three of these studies, the relationship between higher TFD and poorer outcomes tended to be stronger in the implemented MST service format than in the SB-IIH format. In the final study (Chapter 5) we examined TFD’s relationship to all previously identified outcomes in an out-of-home, community-based residential (CBR) service and in Functional Family Therapy (FFT), another implemented evidence-based treatment. This study found that CBR therapists reported relatively high levels of TFD while FFT therapists reported relatively low TFD. Second, more TFD was significantly related to poorer immediate outcomes (monthly average progress ratings and functional improvement over the course of the study episode) in the CBR service format. In FFT, higher TFD was significantly related to higher odds of returning to services. Across all four service formats, all but one of the TFD/outcomes relationships were in the expected direction. These results suggest that TFD might be a useful early indicator of later treatment success in PMHC. These services generally have a high rate of use and are often utilized by historically underserved clientele. Thus, it is important to deepen our understanding of treatment elements related to clinical outcomes in PMHC that might be amenable to improvement such as TFD.