Relationship Between Supervisor Factors and Therapist Knowledge, Attitudes, and Use of EBP in a Large Public Behavioral Health System

TO THE EDITOR: Research has identified the importance of supervisors in implementation processes, given their ongoing support of therapists’ skill development and competence in evidence-based practice (EBP) (1,2). It is therefore crucial to understand the specific supervisor characteristics that facilitate or hinder implementation of EBP. Findings from the organizational and management fields suggest that supervisor understanding of and commitment to innovation may affect staff knowledge of and attitudes toward EBP (3). Two supervisor characteristics that may reflect supervisor understanding of and commitment to innovation include supervisor knowledge of and attitudes toward EBP. Given the limited research in this area, we examined whether supervisor knowledge of and attitudes toward EBP are related to therapist implementation factors (knowledge of and attitudes toward EBP) and implementation outcomes (the self-reported use of EBP).

Quantitative survey data were collected from therapists (N=114) and their direct clinical supervisors (N=35) within 22 organizations who participated in at least one of four cognitive-behavioral therapy (CBT)–focused EBP implementation initiatives in Philadelphia. The selection of organizations for participation in the EBP initiatives has evolved from a nonuniform selection of organizations to a competitive process where organizations apply for participation through a request-for-applications process. Organizations and participating therapists were provided with gold-standard training and ongoing consultation with expert treatment developers (4); organizations implementing one of the EBPs were provided an enhanced financial rate for the provision of that EBP.

Participants were recruited from the aforementioned publicly funded community behavioral health organizations that were implementing EBP. Between January and June 2015, potential participants attended a one-time meeting where research staff presented an overview of the research study, obtained informed consent, and administered measures assessing supervisor and therapist knowledge of and attitudes toward EBP, therapist use of cognitive, behavioral, and family therapy modalities, and information about the supervisory context.

Using PROC MIXED in SAS 9.0, we conducted nine mixed-effects linear regression models to test the relationship between supervisor characteristics (knowledge and attitudes) and therapist implementation factors (knowledge and attitudes) and outcomes (CBT use). Random intercepts for organization were included to account for nesting of therapists within organizations.

Contrary to our expectations, supervisor knowledge of and attitudes toward EBP were not predictive of therapist knowledge, attitudes, or self-reported CBT use. This was surprising in that previous literature documents the relationship between supervision and successful implementation of EBP in community settings (5). One explanation for the null findings may be supervision content and delivery methods. Although supervisors reported that nearly all clinicians were receiving supervision, less than 15% (N=4) of supervisors reported using active learning methods (such as audio recording), which are evidence-based supervisory strategies (5). In addition, perhaps supervisors do not exert influence on individual therapists but rather inculcate an environment at the organizational level to facilitate innovation implementation (2). Further qualitative and quantitative research is needed to better understand the role of supervisors in facilitating EBP implementation in community settings.