Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Rinad S. Beidas


Public mental health systems across the U.S. face two competing policy pressures: (1) demands to improve the quality of mental health services by implementing resource-intensive evidence-based interventions (EBIs); and (2) cuts or insufficient increases to public mental health funding. The present research sought to understand the relationship between these conflicting pressures by characterizing the socioeconomic context of patients and clinicians in Philadelphia’s public mental health system. Data from all three studies were collected from the city’s ongoing initiative to increase the delivery of a trauma-informed EBI, trauma-focused cognitive behavioral therapy (TF-CBT). Chapter 1 examined both neighborhood and individual measures of socioeconomic context to characterize the youth seeking treatment in an effectiveness trial of TF-CBT. This study showed that children and adolescents seeking trauma treatment in Philadelphia’s public mental health clinics lived in economically disadvantaged, high‐crime neighborhoods; experienced housing instability; and were predominantly racial/ethnic minorities. Chapter 2 employed qualitative methods from the behavioral insights literature—an interdisciplinary literature examining judgment and decision-making—to understand clinicians’ perspectives implementing TF-CBT in resource-scarce public mental health clinics. Clinicians shared that the decision-making process to use TF-CBT can be complex given patients’ multiple psychosocial stressors and traumas. Clinicians expressed feeling intense, often negative, emotions related to the challenges of helping vulnerable youth; and they felt constrained by the norms and practices at their respective mental health clinics. Chapter 3 surveyed clinicians’ economic and job-related stressors to understand how the experiences of economic precarity and resource scarcity might be related to TF-CBT use at these clinics. Clinicians in public mental health clinics experienced significant economic precarity and job-related stress, which were inversely associated with their TF-CBT use. Collectively, these results suggest that patients and clinicians in Philadelphia’s public mental health system face significant economic strain and stress. Patient and clinician resource scarcity may hinder ongoing efforts to improve the quality of mental health services through EBI implementation efforts. Initiatives to economically and psychologically support patients and the public mental health workforce are needed.


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