When the Unexpected Arises: Characterizing Emergent Life Events and Their Impact during Community Implementation of Evidence-Based Psychotherapy
Community mental health providers frequently express that emergent life events (ELEs) - acute stressors reported in psychotherapy that negatively impact the client and his/her family - interfere with their ability to implement evidence-based psychosocial treatments (EBTs). Examples of ELEs include death in the family, eviction, and suspension from school. Preliminary data suggest that in a diverse community sample, providers report at least one ELE over the course of treatment for the majority of clients. Furthermore, in sessions with an ELE, providers have significant difficulty carrying out their planned EBT activities.
Building upon these preliminary findings, the goal of this dissertation is to provide an in-depth investigation of ELEs in order to assess the extent to which they disrupt community implementation of EBTs. In Study 1, an observational coding system for ELEs is applied to a large sample of EBT recordings to provide a detailed description of their occurrence and subsequent provider behavior in session. Results demonstrate that ELEs are prevalent and unpredictable, and they often negatively impact providers’ adherence to EBT content. Study 2 uses an observational coding system to investigate how ELEs and other potential barriers to EBT implementation (i.e., barriers to engagement and caregiver participation) are expressed by caregivers in treatment sessions for a collaborative, caregiver-mediated intervention. Findings indicate that ELEs, barriers, and participation may capture a common construct of caregivers speaking up in therapy. Hispanic caregivers were less likely to speak up in therapy, which may have reduced providers’ adherence to the EBT. Finally, Study 3 uses provider- and client-report data to examine associations between ELEs and longer-term outcomes (i.e., provider adherence in later sessions and clinical progress). Results reveal that ELEs negatively impact provider adherence to planned EBT for at least two sessions. Each ELE for which no EBT content is covered significantly reduces youths’ rate of clinical improvement. The collective findings from these studies provide a wealth of information on the complex nature and impact of ELEs. They suggest that in order to optimize the benefits of existing EBTs, structured guidance is needed to assist providers in effectively responding to ELEs.