Table 4 Mixed-method results demonstrating conversion and expansion of findings with representative quotes

1. Fit of practice with client clinical needs

+ Fit with client needs across symptom, family, ethnic-racial diversity.

 a. “We don’t see it as fitting in our program because it’s so superficial…not really addressing the issues that we have. And a lot of the time Seeking Safety is linked to substance use and we’re not having a lot of clients disclosing substance use. And even if they are, we have a specialized program we refer them out to for substance abuse treatment.”

 b. “So Seeking Safety doesn’t really fit age-wise. Especially our more intensive field-based programs. They see younger kids there more seldom, so they use it less.”

 c. “I would imagine that many of them couldn’t read anything that complicated. So it just didn’t work out.”

 d. “And you also need a place where – like if you have one child or two children it’s one thing; when you’ve got five kids screaming and yelling at each other, how do you really target the one child who’s our client? It just didn’t work out.”

 e. “They didn’t wanna watch it [video resources] … It’s white. There is not a single African American person on it. There’s no diversity….it might help if you had a more diverse …, culturally meaningful video to show people that they [clients] could relate to.”

 f. “Traumas with API [Asian/Pacific Islander] is too [much] full self-disclosure to have in a group setting…so that’s why it’s not working out.”

2. Fit of practice PEI Implementation requirements

+ Client fit with PEI eligibility requirements.

 a. “there just weren’t enough clients that met the criteria”

 b. “So now we’re able to look at what [practice] clients fit, what clients don’t, which is great”

+ Allowable billing and reimbursements.

 c. “We’re using it less and less, with the PEI piece, a lot of the clients here have been in treatment for a long time and so then they don’t fit the PEI criteria, and so then we can’t bill to PEI TF-CBT…that’s why it’s used less.”

 d. “from when I started to now, DMH has gotten stricter in terms of length of sessions. So, people [therapists] are not using it as much. Like in the beginning, I think it was overused, and they were using it for over a year…And now they know it’s six months or less, people don’t wanna’ use it.”

+ Compliance with training and certification protocols.

 e. “TF-CBT specifically, there’s not a lot of ongoing support for the model…specific supervision or meetings on ongoing trainings around this particular model. I think it was more like you do the training requirements and then that’s it…”

 f. “The certification within the year…I think we have definitely tried to abide by those principles more closely than when we first started out.”

3. Practice modality fit

+ Logistics with group modality.

 a. “Some staff were recently trained in [another parenting practice], but, again, the logistics of getting groups—they’re hard to get started. So, I think that’s probably why CBITS and Incredible Years have not done as well.”

+ Client and family disinterest in groups.

 b. “We had some referrals but actually the biggest concern was that it was going to be in a group and the kids didn’t want to do it in the group or the parents didn’t want them to do it in the group and, rather, wanted individual services.”

 c. “We tried doing Seeking Safety in group, we ran a couple of groups. They were older kids. They would stick around for a little bit, and then they’d just drop out. We de-adopted that model.”

4. Therapist attitudes

General and wide-spread attitudes.

 a. “It TF-CBT was probably used more than in the beginning. I think especially when it was first rolled out. And when staff are first trained, they’re probably excited about doing it and they want to do it right away. And then, I think, after time maybe that excitement fizzles away and they use it a little bit less.”

 b. “And I think our staff loves CPP. So that helps that you don’t have to talk them into that it’s a good model. They feel like it fits very well with their theoretical orientation. It kind of forced us to do it. We picked enough variety of choices [EBPs] that we could make it work for us without it feeling alien or like we’re being made to do things that don’t fit our kids.”

 c. “Just the openness of the therapists wanting to learn something new, and the support from upper management has been great with implementing MAP.”

+ Therapist practice-specific attitudes toward practice.

 d. “I think those that enjoyed it like it because it’s one of the simple ones.”

 e. “The thing about MAP is that’s been the one that actually has stuck because of the flexibility.”

 f. “So, I think it was partly the model Triple P. It is very short-term.”

5. Developing the workforce

+ Workforce infrastructure and staff turnover.

 a. “…Initially I had case managers who were trained in the model and they felt quite uncomfortable. They didn’t embrace it. Felt that the model didn’t fit the acuity of the clients that they were seeing at the time…”

 b. “Well, we lost the three people – there were four of us trained, so we lost three of them. Now we have to get trained again. It’s very difficult when you’re a small agency”. [moderate]

 c. “The director happened to be not only overseeing the intensive programs but she was overseeing training. So she took over my position. And so when I lost her—she went out of state—I lost the person who was kind of championing for all the directors and everybody. So there goes the groups.” [moderate]

 d. “we do have turnaround because people get licensed and they have other opportunities that obviously pay more than a non-profit so that’s been huge” [large]

 e. “I’ve noticed that many people are interested in coming to our agency because we do have a lot of EBPs and they know that there’s training that will be done” [large]

+ Developing champions/leaders.

 f. “Getting individuals who love the model, know the model well enough that they become kind of these informal point people that other clinicians can go to them and ask questions about it.”

 g. “We probably utilize it TF-CBT more because we recognize the need to have champions so that we could train people internally. It [training] was external and now we’ve had, now probably five people trained as champions. That helps.”

Strategic professional development.

 h. “Those that we’ve brought in, we’ve made sure that they’re individuals who truly embrace the model. So, I have got some clinicians that just love Triple P and would love additional training in it. So, they become almost our champions for those causes.”

 i. “Here there’s no development plan per clinician, but there’s all these weird opportunities…I don’t feel there’s a unified plan that’s related with quality management…So I’m afraid in this agency we have already lost Triple P.”

 j. “Well, I think the clinicians that get trained as supervisors are usually clinicians that we are trying to provide additional professional developmental opportunities for and that’s in an effort to retain them” [large]

6. Available training and ongoing supports

+ Availability of internal and external training and covering initial training through post-certification supports.

 a. “I don’t know what happened, but for some reason there’s not as many trainings” and “The decrease Triple P is because of lack of trainings.”

 b. “If it’s [consultation, train the trainer] not there, they [practices] disappear. It’s like Triple P. Nobody is doing Triple P here anymore. Not because they didn’t like it, but there’s no ongoing structure once you finish the training.”

 c. “With TF-CBT you don’t have internal trainers, so that also creates a barrier of entrance.”

 d. “We’ll have the staff demonstrate how ‘people searches’ are working with their clients. For instance, a 12-year-old with anxiety. What’s the gender? Specific ethnicity? Then go over the result and to compare with the treatment model we are providing right now to see if there’s anything they already incorporated or they need to incorporate. After I started, I sort of promoted this idea. I would say we, every one or two months, will have some discussion around this.”

 e. “We probably utilize it more because we recognize the need to have champions so that we could train people internally. So, it was external and now we’ve had, now probably five people trained as champions that helps” [large]

 f. “So, they become almost our champions for those causes and, ideally, we want to be able to get individuals who love the model, know the model well enough that they become kind of these informal point people that other clinicians can go to them and ask questions about it…Those that we’ve brought in, we’ve made sure that they’re individuals who truly embrace the model.” [moderate]

 g. “We also have invested a significant amount of resource here in building the capacity to do internal training in TF-CBT. And we’ve done that because A) we have this deep training commitment, and B) because there’s turnover. And so, if we’re going to continue to provide TF-CBT over time effectively, we need to have a trained workforce who has the knowledge and skills to provide TF-CBT. And it’s most cost effective if we can train and support those people internally’) [large]