Table 1 Code book

Proficiency^a

“Proficient cultures are characterized by expectations that service providers will place the wellbeing of each client first and by expectations that individual service providers will be competent and have up-to-date knowledge. Representative items include ‘Members of my organizational unit are expected to be responsive to the needs of each client’ and ‘Members of my organizational unit are expected to have up-to-date knowledge.’ The Proficiency scale consists of both competency and responsiveness items. Competency describes the emphasis that is placed on training, up-to-date knowledge, and expectations of excellence in skills and abilities. Responsiveness describes the extent to which service providers are expected to meet the unique needs of individual clients.”

“One of the therapists was talking about participating in a motivational interviewing training today.”

“The practice principles of the Department of Behavioral Health and Intellectual disAbility Services were in the waiting room as well. We were in a conference room upstairs. There was a large rectangular table that we sat around. It was quiet. Core values of the agency were listed on the walls (effective communication, commitment, quality of services, trust, respect, professionalism (knowledge), and empowerment). There was also a determination poster and an accreditation (expired) certificate on the wall.”

“Certain therapists seemed to have a difficult time understanding what they were being asked to do.”

“Therapist said that she felt like therapists were just hired to fill empty spots, not based on merit or on their attitude towards evidence-based practices. She said in her interview for this job, they basically just asked if she had worked with kids and didn’t ask much about what kinds of therapy they do.”

Rigidity^a

“Rigid cultures are characterized by service providers having less discretion and flexibility in their work; limited input into key management decisions; and being controlled by many bureaucratic rules, and regulations. Representative items include ‘I have to ask a supervisor or coordinator before I do almost anything’ and ‘The same steps must be followed in processing every piece of work.’ The rigidity scale includes both centralization and formalization. Centralization indicates the degree to which power and decision making are in the hands of relatively few while formalization characterizes the level of procedural specifications that guide work-related interactions among members of an organizational unit. Organizations that are highly centralized and highly formalized emphasize control with little individual autonomy or participative decision making.”

“Both therapists checked everything off on the training survey. At first it seemed like they didn’t understand, but then the second therapist reported worries that it would get back to the higher ups that she hadn’t heard of certain practices. We assured her that we would be careful about what information we reported.”

“One therapist got up and left after he realized that it was a voluntary study.”

“Another therapist said he ‘wanted to keep his job’ and wanted to know if I would be sharing results with administration. I said no but that he didn’t have to fill anything out that he didn’t want to.”

“One male therapist sat with his arms crossed at the table. When I asked him if he wanted to participate, he said that he did not, and I told him he could leave.”

Resistance^a

“Resistant cultures are characterized by expectations that service providers will show little interest in change or in new ways of providing service, and that service providers will suppress any opportunity for change. Representative items include, ‘Members of my organizational unit are expected to not make waves’ and ‘Members of my organizational unit are expected to be critical.’ Resistance includes items to assess apathetic and suppressive behavioral expectations. Apathetic items assess the level of resignation and inactivity towards change while suppression items mark expectations of criticism and opposition that undermine openness and innovation.”

“[Participant] thinks people implementing evidence-based practices are not giving other treatments a chance (mainly psychodynamic)…Said the reason that we haven’t found that psychodynamic treatment is effective is a) we haven’t done enough research, b) it can’t be measured in the same way as cognitive-behavioral therapy.”

“Likes evidence-based practices a lot. Is getting training on his/her own in several. He/she thinks that some of the older therapists don’t like evidence-based practices because the treatments are new and seem complicated and are too structured.”

Engagement^a

“Engaged agencies are characterized by employee perceptions that they are able to personally accomplish many worthwhile things in their work, remain personally involved in their work, and be concerned about their clients. Representative items include, ‘I feel I treat some of the clients I serve as impersonal objects (reverse coded)’ and ‘I have accomplished many worthwhile things in this job.’ These items include both personalization and personal accomplishment items. Personalization items indicate the degree to which organizational members feel connected and involved with their clients. Personal accomplishment assesses perceptions of efficacy in dealing with clients and positive emotions related to success with clients.”

“Therapist said that she had a case load of ‘75-85’ clients. Said that she was really stressed out, that she ‘loved her kids’ but felt overwhelmed.”

“[Participant] said his supervision isn’t from psychologists or psychiatrists (they have them in the building) and doesn’t focus on how to best treat children and families. Said the supervision is focused on them making more money, getting in their paperwork, and seeing clients. Said that he has told them that he can’t see any more, but they don’t care. Said that when he shares with his supervisor that a client has shown improvement, she doesn’t really care if it means that he didn’t make the client quota for the week.”

Functionality^a

“Functional climates are characterized by employee perceptions that they receive the cooperation and help from coworkers and administration required to do their job, have a clear understanding of how they fit in, and can work successfully within their organizational unit. Representative items include, ‘This agency provides numerous opportunities to advance if you work for it,’ ‘My job responsibilities are clearly defined,’ and ‘There is a feeling of cooperation among my coworkers.’ The functional scale includes items for growth and advancement, role clarity, and workgroup cooperation. These include perceptions that continual development and advancement will occur, that expectations for one’s work behavior are clearly presented, and that organizational unit members will assist and aid in one’s work when needed.”

“Everyone was very friendly, from the receptionist to the therapists. Everyone interacted nicely with one another and there seemed to be an atmosphere of collegial respect. Therapists were all very chatty and jovial.”

“Overall, the atmosphere was quite collegial and people seemed to enjoy being in the same room together. There was a lot of laughter and engagement among the staff.”

“Therapists were mostly on time and respectful of one another. They joked about their days and seemed to interact nicely as colleagues. Talked about their kids openly with us and joked about their clients. Everyone from the security guards to our contact person were very welcoming.”

Stress^a

“Stressful climates are characterized by employee perceptions that they are emotionally exhausted from their work, pulled in different directions, and unable to get the necessary things done. Representative items include, ‘I feel like I am at the end of my rope,’ ‘Interests of the clients are often replaced by bureaucratic concerns (e.g., paperwork),’ and ‘The amount of work I have to do keeps me from doing a good job.’ Stress is identified by emotional exhaustion, role conflict, and role overload items. Respectively, these include perceptions of feeling overwhelmed, of experiencing multiple conflicting demands, and having impossible amounts of work to accomplish.”

“Also she told us that there used to be six therapists here when she started (five years ago), but now there are only three.”

“People asked a few questions but were generally quiet during the data collection process. The intercom was bothering a few of the therapists who felt frustrated that it kept going off and interrupting them. One therapist said she wanted to go home so that she didn’t have to deal with it anymore.”

“Subway shook the building and made a lot of sound periodically.”

Leadership^b

Leadership refers to interactions with leaders at the agencies such as supervisors, clinical directors, and executive directors. Typically, this will refer to references around therapist behavior when leaders leave the room or references to how frequently therapists interact with leadership. Note, simply mentioning the leader is not enough (i.e., the clinical director was welcoming); it should refer to an interaction between the researcher and the leaders or the leaders and staff. This interaction could be hypothetical (i.e., I never meet one on one with my executive director) or actual (i.e., leader encourages staff to be honest on the questionnaires).

“When I brought up that they would be rating their executive director, many of them said they had only met [her] once or had never interacted with her.”

“Once the clinical director left the room, the therapists were much rowdier and were calling out numbers on the Organizational Social Context measure saying that they were funny.”

“The therapists were playful with one another and their supervisor. They were less talkative when the other administrators joined us.”

“Many of them noted that they had no relationship with their executive director and didn’t even know what her name was. One person said, ‘I wouldn’t know who she was if she walked in this room.’”

Physical space^b

Physical space refers to any mention of the building, room, or part of the city that the agency is in.

“The agency was well lit and sunny and the waiting room was inviting. The receptionists were friendly. The training room had a TV, computer, and projector set up, and we were all seated at a big boardroom table with chairs. Walls look freshly painted. Conference room had long square table with nice leather chairs. Had abstract paintings.”

“Outside of building was brick and looked a bit run down. Inside was clean and looked like parts of the building had been updated somewhat recently. We held the meeting on the 2nd floor main conference room. It was a clean, nicely lit room with large windows on one side. There was a long, rectangular table with approximately enough seating for 20. There was also a kitchen to the side and a projector system.”

Culture/diversity^b

Culture/diversity refers to mention of cultural impacts on the agency visit. This does not refer to organizational culture, rather it refers to situations such as agencies that primarily serve a particular cultural group (e.g., Latino/a) or where language barriers were evident.

“Staff seemed to be segregated by language in terms of cliques.”

“There was also a language barrier. Most of the therapists in this agency were [non-English speaking], and had difficulty understanding the questionnaires.”

Affect^b

Affect refers to observations around participant affect during the agency visit. For example, often therapists laughed during completion of the OSC or seemed anxious around completion of leadership ratings. Any emotion words (“laughter, hesitant, anxious”) would qualify.

“Lots of laughter around Organizational Social Context question about fatigue. Said they were always tired.”

“Supervisor pulled me aside and was almost tearful and asked if she could mail in her forms and that she was feeling overwhelmed after completing the measures because she has been in meetings all day. She also told me the Organizational Social Context measure made her feel depressed and burnt out.”

“Therapists were quiet in the beginning but became much rowdier as the clinical director left the room. One therapist was especially talkative and stated, ‘The Organizational Social Context measure makes me think I should reconsider the field I am in.’”

Distrust^b

Distrust refers to observations or statements about participant distrust. This distrust could be targeted at the researcher, Department of Behavioral Health and Intellectual disAbility Services, or the leadership at their agency.

“Also they asked me several times if I really wanted them to be honest.”

“Lots of hesitation around agreeing to consent for the study. One therapist in general had a lot of questions regarding confidentiality and risk management (e.g., suicidality of participants). Seemed like none of them wanted to sign the consents until everyone else did.”

“Another therapist said he ‘wanted to keep his job’ and wanted to know if I would be sharing results with administration. I said no but that he didn’t have to fill anything out that he didn’t want to.”

Initiatives^b

Any mention of city initiatives (i.e., Beck Initiative, Prolonged Exposure, Trauma Initiative, Evidence-Based Practice and Innovation Center; EPIC) would qualify.

“No one had heard of EPIC.”

“They also noted they did the Beck [Cognitive Therapy] training two years ago.”

“Everyone had heard of EPIC and was excited for us to be visiting.”

“One of the supervisors hadn’t heard of any initiatives.”