UCLA

Community therapists often adapt evidence-based practices (EBPs) when transported into public systems of care to enhance their fit for the diverse youth and families they serve. Community therapists hold valuable local expertise about what may promote client understanding or engagement in their care contexts, especially when they identify with the communities they serve. This dissertation study employed observational methods to: (1) characterize Augmenting adaptations that community therapists make in sessions of trauma-focused cognitive behavioral therapy (TF-CBT) and factors associated with them; (2) examine associations between Augmenting adaptations and adherence to TF-CBT at the session-level; and (3) examine associations between Augmenting adaptations and client engagement within and across sessions. A sample of 46 community therapists provided 190 TF-CBT session audio recordings delivered to 82 youth (Mean age = 10.30; 67.07% Hispanic/Latine, 21.95% Black, 7.32% Asian American/Pacific Islander, 2.44% White, 1.22% Multiracial). Two observational coding systems were developed and two independent teams of coders were trained to assess the extensiveness of Augmenting adaptations and adherence to TF-CBT (0 = no occurrence, 6 = great extent). Therapist-reported client disengagement and previously observed client engagement behaviors were used to index client engagement outcomes. Multilevel modeling was conducted to investigate the aims. Results indicated that community therapists made Augmenting adaptations in most sessions (n = 119; 62.63%), primarily at modest levels (Mean extensiveness = 2.45; Range = 0–6). Findings revealed session, client, and therapist factors associated with Augmenting adaptations. TF-CBT components were observed in all but two sessions, with acceptable session-level adherence as indicated by the max component score (Mean extensiveness = 4.01, Range = 0–6). No Augmenting adaptations were related to adherence extensiveness. Modify Presentation extensiveness was related to lower odds of therapist-reported client disengagement in a given session, while Integrate extensiveness was related to higher odds of therapist-reported client disengagement. Repeat extensiveness was positively associated with client engagement behaviors. The dissertation data could not support lagged associations between Augmenting adaptations and client engagement in subsequent sessions. While findings suggest meaningful relationships between adaptation and engagement, it is imperative for future work to systematically disentangle the direction of these associations. Implications for EBP practice and implementation within community mental health settings serving structurally minoritized youth and families are discussed.