Pilot Study of the MAP Curriculum for Psychotherapy Competencies in Child and Adolescent Psychiatry
Publication: American Journal of Psychotherapy
Abstract
Objective:
This pilot study aimed to evaluate the relevance, feasibility, acceptability, and instructional efficacy of the Managing and Adapting Practice (MAP) curriculum for enhancing the teaching of psychotherapy to child and adolescent psychiatry (CAP) fellows. MAP is a system of resources and decision models that supports practitioners in selecting and implementing psychotherapeutic interventions for children and adolescents. The MAP curriculum includes modules to guide education about psychotherapeutic procedures (e.g., behavioral activation) common in evidence-based treatments for an array of childhood problems and to support development of competencies in assessment, treatment planning, and reflective practice.
Methods:
Curriculum coding was used to examine the relevance of MAP’s core components to the skills articulated in the Accreditation Council for Graduate Medical Education (ACGME) CAP milestones. Feasibility, acceptability, and learning outcomes were examined after delivery of the MAP curriculum to 12 CAP fellows at two sites, with instructional features tailored according to faculty preferences and training program structure.
Results:
Coding suggested that the MAP curriculum was relevant to 95% of the 21 ACGME CAP training subcompetencies. Feasibility was indicated by the successful delivery of 100% of the planned MAP curriculum across the two sites. Acceptability was supported by positive feedback from the CAP fellows, and psychotherapy knowledge increased significantly. Finally, case review scores (mean±SD=2.21±0.15) showed positive posttraining application of MAP to two patients and exceeded scores achieved by other samples of mental health professionals.
Conclusions:
This pilot study demonstrated the potential for the MAP curriculum to support CAP education. MAP’s versatility as a curriculum supports broader adoption, with continuing rigorous empirical evaluation.
Highlights
•
This pilot study suggests that the Managing and Adapting Practice (MAP) curriculum warrants consideration as a formal, coordinated curriculum for teaching youth- and family-focused psychotherapy procedures and integrative reasoning to support evidence-informed decisions in clinical care.
•
A coding analysis suggested that the MAP curriculum has the potential to support learning in the Accreditation Council for Graduate Medical Education’s child and adolescent psychiatry (CAP) competencies and subcompetencies.
•
Preliminary evidence was found for the MAP curriculum’s feasibility, acceptability, and instructional efficacy in supporting the acquisition of therapeutic skills by a pilot sample of 12 CAP fellows at two universities.
Child and adolescent psychiatry (CAP) is the specialty responsible for the diagnosis of psychiatric conditions and for proficient delivery of pharmacological and psychotherapeutic interventions among children and adolescents (1). More than a decade ago, to expand and standardize the educational outcomes of CAP training, the Accreditation Council for Graduate Medical Education (ACGME) formalized psychotherapy and related competencies essential to CAP education, including assessment methods, evidence-based treatments, integrative reasoning, and continuous quality improvement (2, 3).
Similar to other aspects of CAP education, psychotherapy curricula are typically left to individual CAP programs to construct ad hoc (4, 5). In the absence of curricular guidelines, CAP programs are challenged to design efficient and scalable ways to provide rigorous training across the array of competencies. Design and implementation of psychotherapy training demand resources, including the availability of educators with expertise and time to organize a coherent psychotherapy curriculum (4, 6, 7). Curriculum design requires decisions regarding what material to teach (8); how to incorporate emerging science, including trial findings and new manualized treatments (9); how to balance breadth and depth of clinical skills training (10); how to develop competencies in areas such as reflective practice, quality improvement, and research literacy (11–13); how to objectively assess skill development and competence across a variety of domains (14–16); and how to effectively teach cohorts that include individuals who differ in psychotherapy skills (1, 17). Many programs rely on a selection of treatment manuals to teach psychotherapeutic processes and techniques (4, 10). Although straightforward teaching tools (8, 18), manuals typically do not include integrative reasoning, reflective practice, and continuous quality improvement, which are essential to development of skilled child and adolescent psychiatrists.
Some authors (18–21) have suggested that CAP education could benefit from innovation regarding how evidence-based practice is conceptualized and taught. Indeed, other health professions, such as psychology (22, 23), primary care (24, 25), and social work (26, 27), have recognized these challenges and have engaged in conversations to find feasible and nimble methods for teaching evidence-based psychotherapeutic interventions and to promote integrative reasoning and data fluency amid a growing evidence base.
In this pilot study, we evaluated the potential of the Managing and Adapting Practice (MAP) curriculum to support CAP training (28). MAP is not a treatment manual; rather, it is a system of resources and decision models incorporating concepts and methods from hundreds of treatment protocols for youths’ emotional and behavioral health problems. MAP was developed for mental health professionals from all fields to support coordination of multiple evidence-based practices, use of evidence for clinical reasoning, and quality improvement. MAP has demonstrated applicability, scalability, effectiveness, cost-effectiveness, and sustainability in youth mental health service contexts (28–31).
We chose to study the MAP curriculum for CAP because its design addresses some of the challenges in psychotherapy education. The curriculum includes self-contained modules that guide delivery of psychotherapeutic procedures (e.g., behavioral activation, cognitive restructuring, exposure) common in treatments for an array of childhood problems (e.g., anxiety, autism, disruptive behavior, traumatic stress). In one coherent curriculum, MAP includes modules to support competencies in assessment, treatment planning, integrative reasoning, reflective practice, and continuous quality improvement, all educational targets for CAP fellows. The curriculum’s modularity allows delivery tailored according to instructor, learner, and other contextual needs and preferences, making it a flexible educational tool. Finally, the basic curriculum is available for free after registration on the publisher’s website (www.practicewise.com), and supplemental materials are available for paid subscribers.
In 2014, Kataoka and colleagues (32) trained CAP fellows in MAP and illustrated the curriculum’s relevance to the ACGME competency of practice-based learning and improvement (PBLI; proficiency in reflective practice and continuous quality improvement). In this study, we built on Kataoka and colleagues’ qualitive description by applying curriculum coding analysis to all ACGME subcompetencies and by quantitatively evaluating the MAP curriculum delivered to CAP fellows at two sites. In accordance with the goals of pilot studies (33–35), the purpose of this study was to evaluate the feasibility, acceptability, and preliminary impact of the MAP curriculum on psychotherapy education. We were interested in gathering evidence regarding MAP’s potential as a curriculum to support CAP training programs, with the intention of conducting a more rigorous empirical study in the future.
Methods
Curriculum Coding
We created a codebook of 18 codes, one for each MAP component: seven core concepts (e.g., evidence-based services system model) that serve as models for making key decisions in treatment delivery, six resources (e.g., clinical dashboard) to help integrate case knowledge to inform key treatment decisions, four applications (e.g., assessment) representing direct use of a process, and one code representing the entirety of the MAP system. The codebook included the description and purpose of each code (Table 1), as described in existing materials and publications (9).
| Component | Description and purpose |
|---|---|
| Concepts | |
| Evidence-based services system model | Coordinates multiple sources of evidence and relevant decision makers related to common questions that guide service delivery and quality improvement |
| Consider, answer, respond, evaluate (CARE) process | A cycle of problem solving in which the individual considers evidence relevant to a defined problem, answers the central question(s) posed by the problem, responds by implementing a solution, and evaluates the effect of the response |
| Map (flowchart of decisions) | Applies the CARE process to a set of common clinical decisions related to client outcomes |
| Connect-cultivate-consolidate | Guides organization of therapeutic practices across a progression of early (connect, focus on treatment engagement), middle (cultivate, focus on skill development), and late (consolidate, focus on generalization and maintenance) phases of care |
| Focus-interference framework | Helps distinguish between prioritized targets for intervention and anticipated sources of clinical interference (e.g., comorbidity, psychosocial stressors, crises) |
| Session planner | Guides planning about the progression of a single treatment session as well as important preparatory and postsession activities |
| Embracing diversity | Describes dimensions of process and content that may be adapted for clients of diverse characteristics, backgrounds, and identities |
| Resources | |
| Clinical dashboard | Visual summary of case context information, progress measures, and practice history in a single display intended to organize multiple sources of information to provide feedback and promote reflective practice |
| Practice guides | Library of two-page summaries of common clinical procedures to assist with performing and evaluating delivery of clinical practice |
| Practice-wise evidence-based services database | Searchable database that provides a synthesis of effective treatments from the research literature for youths according to user-defined search parameters, such as treatment targets, diagnoses, youth characteristics, and service characteristics (e.g., settings, format) |
| Supervisor curriculum | Set of concepts and resources for individuals in supervisory or consultant roles |
| Therapist portfolio | Tracking of a learner’s continually evolving learning experience and expertise related to each MAP component as well as the individual’s experience implementing MAP with patients |
| Treatment pathways | Sequence of practices for a specific set of characteristics, such as treatment focus, client age, or service setting |
| Applications | |
| Assessment | Use of multiple measures across multiple domains to generate case-specific evidence |
| Monitoring | Consideration and comparison of expected results (e.g., treatment progress) and actual results to promote evidence-informed care that is reliable, accountable, and self-correcting |
| Planning | Integration of available information to devise a course of action and evaluation of outcomes for a patient |
| Practice delivery | Actual performance of clinical practices during therapeutic interactions |
| MAP system | The entirety of MAP’s components and the ways in which they work together |
We applied the MAP codes to the ACGME milestones for CAP (2). These milestones consist of six competencies (patient care [PC], medical knowledge [MK], system-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills), 21 subcompetencies (e.g., PC1: psychiatric evaluation, PC2: psychiatric formulation and differential diagnosis), and 334 indicators corresponding to skill levels 1 through 5 of each subcompetency (e.g., “PC1–1.1: for adolescents, acquires accurate history and mental status examination findings, customized to the patient’s complaints”). We applied the MAP codes to all 334 indicators because psychotherapy competencies are nested within multiple milestones and subcompetencies (e.g., both PC and MK), and selection of only certain milestones or indicators might have artificially inflated the relevance of MAP to certain competencies. Additionally, the MAP curriculum covers competencies beyond psychotherapy procedures (e.g., reflective practice, consultation); thus, we believed it would be instructive to examine the relation of MAP resources to each indicator.
Three raters evaluated the extent to which each of the 18 MAP components could support the development of each subcompetency. Each rater held a doctorate in psychology and had expertise in evidence-based treatments, mental health service design, and MAP (i.e., E.L.D. and B.F.C. jointly developed the MAP system; K.D.B. has extensive training in the design and application of MAP). The scoring scale ranged from 0, “MAP component is not generally expected to contribute to the development of the subcompetency being rated,” to 4, “MAP component has the potential to make a direct, significant contribution to the development of the subcompetency being rated.” There were 4,676 ratings per rater and 14,028 ratings across the three raters. Interrater reliability for the 18 MAP components across the three raters was calculated by using two-way mixed absolute agreement intraclass correlations, which ranged from 0.49 to 0.80, representing fair to excellent agreement (36).
Training Demonstrations
Training demonstrations were conducted at two urban university-affiliated CAP training programs; each program included a yearlong outpatient CAP rotation serving youths who had a variety of clinical presentations. The faculty at both sites included MAP experts, and the training director and core CAP faculty at both sites discussed MAP’s potential value to psychiatric education and how best to integrate MAP into the existing training program.
At the University of Maryland, Baltimore (UMB), six CAP fellows (four women, two men) received the MAP curriculum over the course of 40 hours spread across 10 months, from July through May of the first fellowship year. Table 2 shows content sequencing and instruction time at both sites. The curriculum was taught by a clinical psychologist (K.D.B.) with MAP expertise who was on the faculty in the Division of Child and Adolescent Psychiatry. This faculty member also provided 12 hours of clinical supervision, focused on the application of MAP with CAP patients, to each fellow (in group or individual sessions). Another clinical psychologist (A.D.) attended class meetings so the fellows could reinforce the use of clinical procedures and MAP resources during their own instruction and supervision. The institutional review board at UMB approved all study procedures.
| Topic sequencing | Content and practicesa | Instruction time, duration, and frequency |
|---|---|---|
| University of Maryland, Baltimore | ||
| MAP concepts and resources | Included all MAP components except supervisor curriculum | 14 hours: two (extra) 4-hour seminars, followed by three (existing) weekly 2-hour seminars |
| Engaging youths and caregivers in services | Engagement with caregivers, goal setting, motivational enhancement | 2 hours: one (extra) 2-hour seminar |
| Treating disruptive behavior | Psychoeducation about disruptive behavior, self-monitoring, monitoring, attending, praise, rewards, response cost, commands, time out, active ignoring, antecedent and/or stimulus control, communication skills, assertiveness skills | 10 hours: five (existing) weekly 2-hour seminars |
| Treating anxiety | Psychoeducation about anxiety, self-monitoring, monitoring, exposure, relaxation, cognitive skills, social skills, maintenance and relapse prevention | 8 hours: four (existing) weekly 2-hour seminars |
| Treating depression | Psychoeducation about depression, self-monitoring, monitoring, problem solving, activity selection, cognitive skills | 6 hours: three (existing) weekly 2-hour seminars |
| University of California, Los Angeles | ||
| MAP concepts and resources | Included all MAP components except supervisor curriculum | 10 hours: 8 hours on workshop day 1, plus 2 hours on day 2 |
| Treating anxiety | Psychoeducation about anxiety, self-monitoring, monitoring, exposure | 6 hours on workshop day 2 |
| Treating traumatic stress | Psychoeducation about traumatic stress, self-monitoring, monitoring, trauma narrative, personal safety skills | 3 hours on workshop day 3 |
| Treating depression | Psychoeducation about depression, self-monitoring, monitoring, problem solving, activity selection, relaxation, cognitive skills, social skills, maintenance and relapse prevention | 5 hours on workshop day 3 |
| Treating disruptive behavior | Psychoeducation about disruptive behavior, self-monitoring, monitoring, attending, praise, rewards, response cost, commands, time out, active ignoring, antecedent and/or stimulus control, communication skills, assertiveness skills | 8 hours on workshop day 4 |
| Integration of MAP concepts, resources, and practices | Included review of the entire workshop curriculum along with a series of case application exercises | 8 hours on workshop day 5 |
a
Managing and Adapting Practice (MAP) curriculum concepts and resources were included with case application exercises and discussion in each instructional session.
At the University of California, Los Angeles (UCLA), a previous cohort of CAP fellows had received the MAP curriculum during a 5-day workshop, as summarized in a proof-of-concept description (32) of the application of MAP to CAP. The present study examined the delivery of the MAP curriculum to a subsequent CAP cohort (four women, two men) who received the MAP curriculum in a 40-hour workshop over 5 days in the September of their second fellowship year. The CAP fellows attended the workshop as part of a course offered annually by the Department of Psychology and attended by clinical psychology graduate students (N=7) and postdoctoral fellows (N=2). The workshop was led by one of the developers of MAP (B.F.C.), a clinical psychologist and professor of psychology at UCLA; the UMB MAP faculty member (K.D.B.) served as a joint instructor (see Table 2 for curriculum information). Core faculty (K.M.B.) also participated in the MAP workshop to reinforce the use of clinical procedures and MAP concepts and resources after the workshop and throughout the training year.
Study procedures were exempt from review by the institutional review board at UCLA, because they were considered an educational evaluation and did not include collection of identifying information.
Curriculum and materials.
Instructors used the MAP curriculum resources available with registration. Resources included ready-to-use instructional slides with teaching notes and training activities. Although not required for the curriculum, each training program also purchased subscription access to additional online MAP resources (e.g., PracticeWise Evidence-Based Services [PWEBS] database, practitioner guides, clinical dashboards) for each CAP trainee to facilitate use of the learned skills in patient care. Each subscription cost about the same as a textbook.
Measures.
Indicators of MAP’s feasibility included the percentage of the planned MAP curriculum delivered to CAP fellows and the percentage of CAP fellows who completed the curriculum.
To evaluate the acceptability of MAP at UMB, CAP fellows completed the Supervision Evaluation Form (SEF), which included 17 items (e.g., “I am confident that I can use the MAP system successfully”) (37). Items were scored on a scale ranging from 1, strongly disagree, to 4, strongly agree, with higher scores reflecting a more positive supervision experience. The SEF has excellent internal consistency and correlates significantly with subsequent on-the-job performance as measured by case quality reviews (α=0.91) (38). UCLA CAP fellows completed an evaluation that included eight items assessing their satisfaction with the MAP workshop (e.g., “I learned things that I can apply in my work right away”). Items were scored on a scale ranging from 1, strongly disagree, to 5, strongly agree, and higher scores represented greater satisfaction. The measure included one open-ended question that asked fellows what was helpful about the workshop and one open-ended question about what could be improved.
CAP fellows at both sites completed knowledge tests before and after training in each clinical procedure to assess their understanding of the practices taught (e.g., activity selection, communication skills, trauma narrative). The tests included a mix of multiple choice and true or false items.
At UMB, CAP fellows submitted case materials (i.e., clinical dashboard, treatment literature summary from the PWEBS) for two patients of their choosing for review by independent evaluators as part of an established certification process for the MAP system. Evaluators were not aware that these case materials were submitted by CAP fellows. Each fellow received a case review score for each case. Scores could range from 0 to 3, with a score of 1.7 representing the minimum score for competence. At UCLA, in accordance with faculty preferences, the CAP follows did not participate in the case review process.
Results
Curriculum Coding
We examined the potential for each of the 18 MAP curriculum components to support the development of each of the 21 ACGME subcompetencies. At least one MAP component was rated as having the potential to contribute to the development of almost all (N=20, 95%) subcompetencies. Only MK3 (clinical neuroscience and genetics) did not have support from any MAP component. A mean±SD of 5.33±3.69 MAP components were rated as having the potential to contribute to the development of each ACGME subcompetency. The MAP curriculum provided the greatest support for PC3 (treatment planning and management; N=14 MAP components rated as supportive), PC4 (psychotherapy; N=10 components), and MK4 (psychotherapy knowledge; N=12 components). (A chart showing comprehensive results of the curriculum coding analysis is available in the online supplement to this article.)
Training Demonstrations
Feasibility.
At both sites, 100% of the planned MAP curriculum was delivered to CAP fellows. All CAP fellows who began the MAP curriculum completed it. Those who missed portions of the in-person training viewed recorded lectures online for missed class content.
Acceptability.
Ratings on the SEF by CAP fellows at UMB were high (3.68±0.32 of 4.0) and matched or exceeded benchmark values from another sample of clinicians who received MAP training from their supervisors (38).
CAP fellows from UCLA rated their training satisfaction as very positive (4.91±0.30 of 5.0). Fellows noted the utility of the rehearsal and case application exercises. One recommendation was to schedule the training to correspond with the onset of the second fellowship year (July rather than September). Another recommendation was to divide the training group by level of prior experience to support differentiated instruction.
Knowledge.
Analysis of the knowledge assessments revealed a significant effect of time. On the pretraining assessment, CAP fellows correctly answered approximately two-thirds of the test items (67.86%±13.74%), and on the posttraining assessment, they responded correctly to significantly more items (73.53%±13.25%, F=20.47, df=1, 10, p=0.001).
Skills.
All six CAP fellows at UMB exceeded the minimum competence score for their case reviews. The mean case review score (2.21±0.15) exceeded scores achieved by other samples of mental health professionals evaluated independently after being trained by MAP-certified trainers (2.15±0.27) (38) or by in-agency supervisors (2.10±0.21) (28). Of note, many CAP fellows applied MAP skills to help patients with complex conditions, including those who had comorbid medical conditions (e.g., diabetes, seizure disorder) and/or were receiving concurrent pharmacological treatment.
Discussion
The ratings of the expert raters in this pilot study suggested that the MAP components have the potential to support the development of nearly all ACGME subcompetencies and that most of the subcompetencies are supported by multiple MAP components. Our results showed the MAP curriculum’s potential as a resource for CAP educators and fellows to develop skills consistent with ACGME subcompetencies, including competencies outside the realm of psychotherapeutic procedures.
Our training demonstration suggested that variations in instructional delivery (frequency, duration, intensity) were feasible and were received positively by the 12 fellows across the two sites. Consistent with psychiatric pedagogy’s emphasis on active learning, MAP’s curricular emphasis on experiential exercises (e.g., role-play, case application) appealed to the CAP fellows. The MAP curriculum was associated with increased knowledge of psychotherapy procedures and competence in the application of MAP with patients.
The curriculum coding was limited in that MAP experts may have been biased to overestimate MAP’s alignment with ACGME subcompetencies. Other individuals with greater knowledge of the ACGME subcompetencies may have coded the alignment of MAP components and ACGME subcomponents differently than did the raters. Future coding of the alignment between components in treatment manuals and ACGME subcompetencies would yield a context for interpreting MAP’s relative relevance to the ACGME subcompetencies.
In the training demonstrations, our reliance on convenience samples and the absence of a control group did not allow us to determine whether outcomes were at least comparable to or better than training as usual. Although MAP was taught to fellows in typical outpatient CAP rotations, it cannot be known without further study whether the findings would generalize to other clinic rotations or CAP programs.
Additionally, at UMB, gains might not have been solely attributable to MAP, because the curriculum was delivered across the entire year of training. Pre- and post-ACGME subcompetency ratings were not assessed and thus were not available to evaluate learning. The focus of a pilot study, however, is to examine feasibility, acceptability, and the potential for an effect (33–35). We believe we have established all for MAP but recognize that these results do not represent a definitive evaluation of the curriculum. Future research is required to compare the effect of the MAP curriculum with other CAP curricula, such as specific manualized interventions, on trainee outcomes that represent local standards for competencies (e.g., the ACGME milestones). In addition, a more rigorous trial in the future, including random assignment of fellows within sites and delivery of the MAP curriculum by nonexperts, would be useful.
These results suggest the potential utility of the MAP curriculum to support CAP training beyond the PBLI milestone explored by Kataoka and colleagues (32). The pilot study’s success was due, in large part, to conversations with the training directors and core faculty and to subsequent tailoring of the curriculum delivery to the preferences and needs of each site. Those considering the MAP curriculum are encouraged to first review the curriculum materials to examine their relevance to the needs of their own training context. This study examined two possible arrangements for curriculum delivery; MAP’s modularity permits other variations in content, sequencing, and format (e.g., asynchronous or hybrid models) at the educator’s discretion. Although this study’s educators were MAP experts, nonexperts have taught the curriculum successfully (27, 31, 32). Educators who have experience teaching psychotherapy likely would find the modules and instructional scripts for specific clinical techniques and related competencies (e.g., assessment) easy to deliver. For those who would like to teach MAP-specific resources (e.g., PWEBS database), curricular support (e.g., narrated instruction for how to teach MAP and narrated lectures for MAP resources and clinical procedures) are available for free online from the publisher. The potential benefits of having a coordinated curriculum with a flexible arrangement outweigh the initial time investment in becoming familiar with the materials, especially when one considers the challenges inherent in organizing and delivering a coherent curriculum based on a collection of other psychotherapy resources.
Conclusions
The MAP curriculum was designed to enhance clinical education by providing practical resources delivered within a developmental framework (from simple to more advanced skills and concepts), including metacognitive support for self-assessment and reflective practice, and incorporating active and effective teaching strategies. These findings support further consideration of the MAP curriculum to assist in the development of independent practitioners who have the practical psychotherapeutic and metacognitive skills integral to effective care.
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Information & Authors
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Published In
History
Received: 2 March 2021
Revision received: 27 May 2021
Revision received: 10 August 2021
Accepted: 25 August 2021
Published online: 2 November 2021
Published in print: June 15, 2022
Keywords
Authors
Funding Information
This work was funded in part by a grant from the Betty Huse Foundation to Dr. Becker.Dr. Becker is a consultant for and Drs. Daleiden and Chorpita are co-owners of PracticeWise, a private behavioral health consulting company that owns the intellectual property for the Managing and Adapting Practice curriculum and system described in this article. The other authors report no financial relationships with commercial interests.
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