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Racz JI, Bialocerkowski A, Calteaux I, Farrell LJ. Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review. Clin Child Fam Psychol Rev 2024:10.1007/s10567-024-00478-3. [PMID: 38630196 DOI: 10.1007/s10567-024-00478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/28/2024]
Abstract
Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.
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Affiliation(s)
- J I Racz
- School of Applied Psychology, Griffith University, Southport, QLD, Australia.
| | | | - I Calteaux
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
| | - L J Farrell
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
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Sayer NA, Wiltsey Stirman S, Rosen CS, Kehle-Forbes S, Spoont MR, Eftekhari A, Chard KM, Kaplan A, Nelson DB. The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration. J Consult Clin Psychol 2023; 91:665-679. [PMID: 37668578 PMCID: PMC10592522 DOI: 10.1037/ccp0000832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVE This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs. METHOD Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs. RESULTS Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery. CONCLUSIONS Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Shannon Wiltsey Stirman
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Craig S Rosen
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Shannon Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Afsoon Eftekhari
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Kathleen M Chard
- Posttraumatic Stress Disorder and Anxiety Disorder Division, Cincinnati Veterans Affairs Medical Center
| | - Adam Kaplan
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
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Frank HE, Rifkin LS, Sheehan K, Becker-Haimes E, Crane ME, Phillips KE, Palitz SA, Kemp J, Benito K, Kendall PC. Therapist perceptions of experiential training for exposure therapy. Behav Cogn Psychother 2023; 51:214-229. [PMID: 36805734 PMCID: PMC11006093 DOI: 10.1017/s1352465822000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.
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Affiliation(s)
- Hannah E. Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
- Department of Psychology, Temple University
| | | | - Kate Sheehan
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Emily Becker-Haimes
- Department of Psychiatry, University of Pennsylvania
- Hall Mercer Community Mental Health, University of Pennsylvania Health System
| | | | | | | | - Joshua Kemp
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
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Pratt KM, Branch LZ, Houston JB. The Practice-Based Implementation (PBI) Network: Technology (Tech) into Care pilot. Transl Behav Med 2021; 11:46-55. [PMID: 31781757 DOI: 10.1093/tbm/ibz174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Technology can support the use of evidence-based behavioral health treatments, as well as serve as a link to care to improve patient engagement and adherence to treatment. While research suggests that mobile applications (apps) specifically have the potential to enhance the delivery of behavioral health treatment, little guidance exists on how clinicians can effectively and safely integrate mobile apps into their clinical practice. The purpose of this paper is to describe the Department of Defense Practice-Based Implementation (PBI) Network's approach to implementation and present the results of the Technology (Tech) into Care pilot. The PBI Network conducted this pilot to address providers' knowledge gaps regarding the integration of mobile apps into behavioral health care within the Military Health System (MHS) and examine the feasibility of widespread dissemination of the practice change in the MHS. A mixed-method design guided by the Promoting Action on Research Implementation in Health Services framework was used to evaluate the approach and identify facilitators and barriers to practice change. Positive preliminary support for the feasibility of the Tech into Care approach was demonstrated in improvements in providers' knowledge, comfort, and perceived level of preparation to integrate mobile apps into care. Organizational challenges including time constraints and staff turnover negatively impacted implementation success. The PBI Network Tech into Care implementation approach is a feasible method to address knowledge gaps related to the integration of mobile apps into clinical practice within the MHS. Contextual factors, such as competing time demands, often impede providers' ability to effectively integrate mobile apps into care.
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Affiliation(s)
- Kimberly M Pratt
- Department of Defense, Psychological Health Center of Excellence, Practice-Based Implementation Network, Silver Spring, MD, USA
| | - LaToya Z Branch
- Department of Defense, Psychological Health Center of Excellence, Practice-Based Implementation Network, Silver Spring, MD, USA
| | - Jorielle B Houston
- Department of Defense, Psychological Health Center of Excellence, Practice-Based Implementation Network, Silver Spring, MD, USA
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Kline AC, Klein AB, Bowling AR, Feeny NC. Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers. Behav Ther 2021; 52:1019-1030. [PMID: 34134819 DOI: 10.1016/j.beth.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/15/2022]
Abstract
Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82-1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55-2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master's degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, University of California San Diego; Case Western Reserve University.
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Creed TA, Crane ME, Calloway A, Olino TM, Kendall PC, Stirman SW. Changes in Community Clinicians' Attitudes and Competence following a Transdiagnostic Cognitive Behavioral Therapy Training. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2. [PMID: 34541540 PMCID: PMC8444627 DOI: 10.1177/26334895211030220] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Although the literature suggest that attitudes toward evidence-based practices (EBPs) are associated with provider use of EBPs, less is known about the association between attitudes and how competently EBPs are delivered. This study examined how initial attitudes and competence relate to improvements in attitudes and competence following EBP training. Methods Program evaluation data was collected during implementation of an EBP in a large community mental health network. Clinicians (N=891) received intensive training in cognitive behavioral therapy followed by six months of consultation. Attitudes were assessed using the Evidence-Based Practice Attitude Scale, and competence was assessed using the Cognitive Therapy Rating Scale. Data were analyzed by fitting three latent change score models to examine the relationship between changes in attitudes and competence across the training and within its two phases (workshop phase, consultation phase). Results Latent change models identified significant improvement in attitudes (Ms latent change≥1.03, SEs≤ 0.18, zs≥6.55, ps< .001) and competence (Ms latent change ≥14.16, SEs≤3.10, zs≥2.82, ps<.001) across the full training and in each phase. Higher pre-workshop attitudes predicted significantly greater change in competence in the workshop and across training (bs≥1.62, SEs≤0.90, z≥1.09, p<.04, β≥0.10); however, contrary to our hypothesis, post-workshop attitudes did not significantly predict change in competence in consultation (b=1.62, SE=0.86, z=1.87, p=.06, β=0.09). Change in attitudes and change in competence in the training period and within the two phases were not significantly correlated. Conclusions Results indicate that pre-training attitudes about EBPs present a target for implementation interventions, given their relation to changes in both attitudes and competence throughout training. Following participation in in itial training workshops, other factors such as subjective norms, implementation culture, or system-level policy shifts may be more predictive of change in competence through consultation.
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Affiliation(s)
- Torrey A Creed
- Perelman School of Medicine, University of Pennsylvania, 3535 Market Street Suite 3046, Philadelphia, PA, USA
| | - Margaret E Crane
- Department of Psychology, Temple University, Weiss Hall, 1701 N. 13th Street, Philadelphia, PA, USA
| | - Amber Calloway
- Perelman School of Medicine, University of Pennsylvania, 3535 Market Street Suite 3046, Philadelphia, PA, USA
| | - Thomas M Olino
- Department of Psychology, Temple University, Weiss Hall, 1701 N. 13th Street, Philadelphia, PA, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Weiss Hall, 1701 N. 13th Street, Philadelphia, PA, USA
| | - Shannon Wiltsey Stirman
- National Center for PTSD and Stanford University, 795 Willow Road NC-PTSD, Menlo Park, CA, 94025, USA
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Becker-Haimes EM, Byeon YV, Frank HE, Williams NJ, Kratz HE, Beidas RS. Identifying the organizational innovation-specific capacity needed for exposure therapy. Depress Anxiety 2020; 37:1007-1016. [PMID: 32390315 PMCID: PMC7822059 DOI: 10.1002/da.23035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/15/2019] [Accepted: 04/20/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. METHODS We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. RESULTS In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. CONCLUSIONS Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients' access to effective treatment for anxiety disorders.
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Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Young Vivian Byeon
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah E. Frank
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | | | - Hilary E. Kratz
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cook JM, Simiola V, Thompson R, Mackintosh MA, Rosen C, Sayer N, Schnurr PP. Implementation Patterns of Two Evidence-Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five-Point Longitudinal National Investigation. J Trauma Stress 2020; 33:432-442. [PMID: 32583606 PMCID: PMC7719091 DOI: 10.1002/jts.22557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/06/2020] [Accepted: 04/08/2020] [Indexed: 11/06/2022]
Abstract
The present study examined the patterns of adoption of two evidence-based psychotherapies (EBPs)-prolonged exposure (PE) and cognitive processing therapy (CPT)-in U.S. Department of Veterans Affairs (VA) residential posttraumatic stress disorder (PTSD) treatment programs. A total of 526 providers from 39 programs nationwide completed online quantitative surveys and qualitative interviews, collected at five assessment points between 2008 and 2015, concerning the use of PE and CPT. By the midpoint of the study period, responders from most programs reported having adopted one or both EBPs as either core components of their programs or "tracks" for certain patients within their programs, adoption rates were 52.8% of programs at Time 3, 61.0% at Time 4, and 66.7% at Time 5. Evaluation of adoption patterns over time suggested that CPT was used in more programs and with more patients within programs compared to PE. At Time 5, respondents from half of the programs reported little or no adoption of PE, whereas the CPT adoption rate was reported to be "little or none" for one-fifth of the programs. The adoption of PE was generally slower compared to CPT adoption. The slower rate of adoption may be related to the resource-intensive nature of implementing PE on an individual basis in a residential setting as compared to the multiple ways CPT can be delivered: individually or in group settings, and with or without the inclusion of the trauma narrative. Strategies to improve sustainability measurement and implications for implementation science are discussed.
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Affiliation(s)
- Joan M. Cook
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA,National Center for PTSD, West Haven, Connecticut, USA
| | - Vanessa Simiola
- Center for Integrated Health Care Research, Kaiser Permanente, Honolulu, Hawaii, USA
| | - Richard Thompson
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, USA
| | | | - Craig Rosen
- National Center for PTSD, West Haven, Connecticut, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Nina Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA,Departments of Medicine, Psychiatry, and Psychology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paula P. Schnurr
- National Center for PTSD, West Haven, Connecticut, USA,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, McColl E, Steen IN, Cook C, Vernazza CR, Mackintosh N, Sharma S, Barbery G, Steele J, Rapley T. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol 2018; 18:135. [PMID: 30442094 PMCID: PMC6238372 DOI: 10.1186/s12874-018-0591-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 10/29/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Successful implementation and embedding of new health care practices relies on co-ordinated, collective behaviour of individuals working within the constraints of health care settings. Normalization Process Theory (NPT) provides a theory of implementation that emphasises collective action in explaining, and shaping, the embedding of new practices. To extend the practical utility of NPT for improving implementation success, an instrument (NoMAD) was developed and validated. METHODS Descriptive analysis and psychometric testing of an instrument developed by the authors, through an iterative process that included item generation, consensus methods, item appraisal, and cognitive testing. A 46 item questionnaire was tested in 6 sites implementing health related interventions, using paper and online completion. Participants were staff directly involved in working with the interventions. Descriptive analysis and consensus methods were used to remove redundancy, reducing the final tool to 23 items. Data were subject to confirmatory factor analysis which sought to confirm the theoretical structure within the sample. RESULTS We obtained 831 completed questionnaires, an average response rate of 39% (range: 22-77%). Full completion of items was 50% (n = 413). The confirmatory factor analysis showed the model achieved acceptable fit (CFI = 0.95, TLI = 0.93, RMSEA = 0.08, SRMR = 0.03). Construct validity of the four theoretical constructs of NPT was supported, and internal consistency (Cronbach's alpha) were as follows: Coherence (4 items, α = 0.71); Collective Action (7 items, α = 0.78); Cognitive Participation (4 items, α = 0.81); Reflexive Monitoring (5 items, α = 0.65). The normalisation scale overall, was highly reliable (20 items, α = 0.89). CONCLUSIONS The NoMAD instrument has good face validity, construct validity and internal consistency, for assessing staff perceptions of factors relevant to embedding interventions that change their work practices. Uses in evaluating and guiding implementation are proposed.
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Affiliation(s)
- Tracy L. Finch
- Department of Nursing, Midwifery and Health, Northumbria University, Coach Lane, Newcastle-upon-Tyne, NE7 7XA UK
| | - Melissa Girling
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Frances S. Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, Upper Floor 3, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Ian Nicholas Steen
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Clare Cook
- School of Law and Business, University of Northumbria, City Campus East 1, Newcastle upon Tyne, NE1 8ST UK
| | - Christopher R. Vernazza
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW UK
| | - Nicola Mackintosh
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH UK
| | - Samridh Sharma
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW UK
| | - Gaery Barbery
- International Business and Asian Studies, Griffith University, QLD, Gold Coast, 4222 Australia
| | - Jimmy Steele
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW UK
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Coach Lane, Newcastle-upon-Tyne, NE7 7XA UK
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Cook JM, Thompson R, Simiola V, Wiltsey Stirman S, Schnurr PP. Provider general attitudes versus specific perceptions of evidence-based psychotherapies for PTSD. Psychol Serv 2018; 17:46-53. [PMID: 30265069 DOI: 10.1037/ser0000280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study examined the role of attitudes toward evidence-based psychotherapies (EBPs) in predicting use of prolonged exposure (PE) and cognitive processing therapy (CPT), two EBPs for posttraumatic stress disorder (PTSD) among PTSD treatment providers within the Department of Veterans Affairs. Providers' general attitudes toward EBPs, as well as their specific perceptions of PE and CPT, were examined as potential predictors of use. One hundred fifty-nine providers from 38 Department of Veterans Affairs' residential PTSD programs across the United States completed an online survey that included the predictors listed as well as self-reported use of PE on an individual basis and CPT on an individual and on a group basis. Although general attitudes toward EBPs were related to use of individually administered CPT, they were not related to use of PE or group-administered CPT. For each of the 3 treatments, however, specific positive perceptions were related to use. In examination of other training, skill, and delivery-related variables, general attitudes appear more in line with perceptions and delivery of CPT than PE. Perhaps this is because of the unique exposure component of PE. Assessing provider perceptions of specific EBPs may help providers in guiding their own practice as well as aid treatment developers, trainers, and administrators to more effectively tailor dissemination and implementation efforts. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Cook JM, Simiola V, McCarthy E, Ellis A, Wiltsey Stirman S. Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications. ACTA ACUST UNITED AC 2018; 3:153-167. [PMID: 30906873 DOI: 10.1037/pri0000070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.
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Affiliation(s)
- Joan M Cook
- Department of Psychiatry Yale School of Medicine and National Center for PTSD, West Haven, Connecticut
| | - Vanessa Simiola
- Department of Psychiatry, Yale School of Medicine and Kaiser Permanente, Honolulu, Hawaii
| | | | - Amy Ellis
- Institutional Center for Scientific Research, Albizu University, Miami, Florida
| | - Shannon Wiltsey Stirman
- Department of Psychiatry and Behavioral Sciences, National Center for PTSD, Palo Alto, California and Stanford University of Medicine
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Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 44:904-918. [PMID: 28597238 PMCID: PMC5640758 DOI: 10.1007/s10488-017-0809-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.
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Gutner CA, Pedersen ER, Drummond SPA. Going direct to the consumer: Examining treatment preferences for veterans with insomnia, PTSD, and depression. Psychiatry Res 2018; 263:108-114. [PMID: 29524908 PMCID: PMC5911221 DOI: 10.1016/j.psychres.2018.02.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/28/2022]
Abstract
Inclusion of consumer preferences to disseminate evidence-based psychosocial treatment (EBPT) is crucial to effectively bridge the science-to-practice quality chasm. We examined this treatment gap for insomnia, posttraumatic stress disorder (PTSD), depression, and comorbid symptoms in a sample of 622 young adult veterans through preference in symptom focus, treatment modality, and related gender differences among those screening positive for each problem. Data were collected from veteran drinkers recruited through targeted Facebook advertisements as part of a brief online alcohol intervention. Analyses demonstrated that veterans reported greater willingness to seek insomnia-focused treatment over PTSD- or depression-focused care. Notably, even when participants screened negative for insomnia, they preferred sleep-focused care to PTSD- or depression-focused care. Although one in five veterans with a positive screen would not consider care, veterans screening for both insomnia and PTSD who would consider care had a preference for in-person counseling, and those screening for both insomnia and depression had similar preferences for in-person and mobile app-based/computer self-help treatment. Marginal gender differences were found. Incorporating direct-to-consumer methods into research can help educate stakeholders about methods to expand EBPT access. Though traditional in-person counseling was often preferred, openness to app-based/computer interventions offers alternative methods to provide veterans with EBPTs.
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Affiliation(s)
- Cassidy A Gutner
- National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
| | | | - Sean P A Drummond
- Monash Institute for Cognitive and Clinical Neuroscience, School of Psychological Sciences, Monash University, Australia
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Landes SJ, Rodriguez AL, Smith BN, Matthieu MM, Trent LR, Kemp J, Thompson C. Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration. Transl Behav Med 2018; 7:832-844. [PMID: 28168608 DOI: 10.1007/s13142-017-0465-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.
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Affiliation(s)
- Sara J Landes
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA. .,University of Arkansas for Medical Sciences, 4301 W. Markham St., #755, Little Rock, AR, 72205, USA. .,Central Arkansas VA Health Care System, VISN 16 South Central Mental Illness Research Education and Clinical Center (MIRECC), NW, Washington, DC, USA.
| | - Allison L Rodriguez
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Brandy N Smith
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Monica M Matthieu
- Central Arkansas VA Health Care System, 2200 Fort Roots Drive, Building 58, North Little Rock, AR, 72114, USA.,College for Public Health and Social Justice, School of Social Work, Saint Louis University, Tegeler Hall, Suite 300, 3550 Lindell Blvd., Saint Louis, MO, 63103, USA
| | - Lindsay R Trent
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road Suite 3217, Stanford, 94305-5719, USA
| | - Janet Kemp
- VISN 2 Center of Excellence for Suicide Prevention, NW, Washington, DC, USA
| | - Caitlin Thompson
- Office for Suicide Prevention, Mental Health Service, US Department of Veterans Affairs, NW, Washington, DC, 20420, USA
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Thompson R, Simiola V, Schnurr PP, Stirman SW, Cook JM. VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2018; 10:131-139. [PMID: 27893265 PMCID: PMC5446934 DOI: 10.1037/tra0000220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT). METHOD Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT. RESULTS Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment. CONCLUSIONS These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record
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Affiliation(s)
| | | | - Paula P. Schnurr
- National Center for PTSD and Geisel School of Medicine at Dartmouth
| | | | - Joan M. Cook
- Yale School of Medicine and National Center for PTSD
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Post-training Beliefs, Intentions, and Use of Prolonged Exposure Therapy by Clinicians in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 44:123-132. [PMID: 26487392 DOI: 10.1007/s10488-015-0689-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
To examine how changes in beliefs during the training process predict adoption of prolonged exposure therapy (PE) by veterans health administration clinicians who received intensive training in this evidence-based treatment. Participants completed a 4-day PE workshop and received expert consultation as they used PE with two or more training cases. Participants were surveyed prior to the workshop, after the workshop, after case consultation (n = 1.034), and 6 months after training (n = 810). Hierarchical regression was used to assess how pre-training factors, and changes in beliefs during different stages of training incrementally predicted post-training intent to use PE and how many patients clinicians were treating with PE 6 months after training. Post-training intent to use PE was high (mean = 6.2, SD = 0.81 on a 1-7 scale), yet most participants treated only 1 or 2 patients at a time with PE. Pre-training factors predicted intent to use and actual use of PE. Changes in beliefs during the workshop had statistically significant yet modest effects on intent and use of PE. Changes in beliefs during case consultation had substantial effects on intent and actual use of PE. Pre-training factors and changes in beliefs during training (especially during case consultation) influence clinicians' adoption of PE. Use of PE was influenced not only by its perceived clinical advantages/disadvantages, but also by contextual factors (working in a PTSD specialty clinic, perceived control over one's schedule, and ability to promote PE to patients and colleagues).
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17
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Powell BJ, Beidas RS. Advancing Implementation Research and Practice in Behavioral Health Systems. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:825-833. [PMID: 27591772 DOI: 10.1007/s10488-016-0762-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105C McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599-7411, USA.
| | - Rinad S Beidas
- Center for Mental Health Policy and Services Research, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3015, Philadelphia, PA, 19104, USA
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18
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Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, Chard KM, Crowley J, Eftekhari A, Finley EP, Hamblen JL, Harik JM, Kehle-Forbes SM, Meis LA, Osei-Bonsu PE, Rodriguez AL, Ruggiero KJ, Ruzek JI, Smith BN, Trent L, Watts BV. A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:957-977. [PMID: 27474040 DOI: 10.1007/s10488-016-0755-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.
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Affiliation(s)
- C S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA. .,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
| | - M M Matthieu
- School of Social Work, Saint Louis University, Saint Louis, MO, USA
| | - S Wiltsey Stirman
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J M Cook
- Evaluation Division, National Center for PTSD, VA Connecticut Health Care System, West Haven, CT, USA.,Yale School of Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT, USA
| | - S Landes
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - N C Bernardy
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - K M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Crowley
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - A Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - E P Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA.,The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - J L Hamblen
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - J M Harik
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA
| | - S M Kehle-Forbes
- Women's Health Sciences Division at VA Boston Healthcare System, National Center for PTSD, Boston, MA, USA.,Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - L A Meis
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - P E Osei-Bonsu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - A L Rodriguez
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - K J Ruggiero
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - J I Ruzek
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,Palo Alto University, Palo Alto, CA, USA
| | - B N Smith
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - L Trent
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - B V Watts
- Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Veterans Affairs Medical Center, White River Junction, VT, USA
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19
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Shiner B, Leonard Westgate C, Simiola V, Thompson R, Schnurr PP, Cook JM. Measuring Use of Evidence-Based Psychotherapy for PTSD in VA Residential Treatment Settings with Clinician Survey and Electronic Medical Record Templates. Mil Med 2018; 183:e539-e546. [PMID: 29547909 PMCID: PMC6115864 DOI: 10.1093/milmed/usy008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/22/2017] [Accepted: 01/12/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Available studies on implementation of evidence-based psychotherapy (EBP) for patients attending Department of Veterans Affairs (VA) residential post-traumatic stress disorder (PTSD) programs rely on therapist self-report of EBP delivery. Patient-level data on receipt of EBP are needed both to corroborate therapist self-report and to understand patient factors that predict receipt of EBPs for PTSD. MATERIALS AND METHODS We identified 159 therapists from 38 VA residential PTSD programs who responded to a survey about EBP implementation during the 2015 fiscal year (FY15). Therapists self-reported their use of two EBPs, including prolonged exposure delivered in an individual format (PE-I) and cognitive processing therapy delivered in individual and group formats (CPT-I and CPT-G). Using electronic medical record (EMR) templates mandated for EBP documentation in FY15, we measured contemporaneous patient-level receipt of EBPs for PTSD. We assessed the degree of correlation between therapist self-reported EBP delivery and patient receipt of EBT as measured by EMR templates using polychoric correlation coefficients. We determined patient and therapist factors that predicted the receipt of EBPs with multivariable logistic regression, using random effects and robust standard error estimation, and controlling for site. The Veterans IRB of Northern New England provided a waiver of informed consent; as this was a retrospective review, no patients or therapists were contacted, and all data were stored, transmitted, and analyzed on secure VA servers. The VA Connecticut Health Care System Human Research Protection Program approved secondary use of therapist survey data for this project. RESULTS When EMR template use became mandated in FY15, the proportion of patients in residential PTSD programs who received at least one EBP session that was recorded with an EMR template increased dramatically from 8.8% to 33.9%. There was adequate correlation and between survey-based and EMR-based measures of EBP receipt, with polychoric correlation values of 0.77 for PE-I, 0.69 for CPT-I, and 0.82 for CPT-G. Multiple patient factors were positive (e.g., female gender) and negative (e.g., depressive disorders) predictors of receipt of EBPs, even after controlling for site. Among therapist factors, only EBP consultant or trainer status was a positive predictor of EBP provision and only therapist race was a negative predictor of EBT provision after controlling for site. CONCLUSION Following a FY15 mandate, EMR templates documenting EBP delivery were widely used by therapists working in VA residential PTSD programs. EBP receipt measured using EMR templates was consistent with therapist self-report of EBT delivery. There were several patient-level predictors of EBP receipt and therapist-level predictors of EBP delivery. However, therapists most likely to deliver EBPs were clustered at a limited number of sites.
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Affiliation(s)
- Brian Shiner
- VA Medical Center, 215 North Main Street, White River Junction, VT,Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH,National Center for PTSD, Executive Division, 215 North Main Street, White River Junction, VT
| | | | | | | | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH,National Center for PTSD, Executive Division, 215 North Main Street, White River Junction, VT
| | - Joan M Cook
- Yale School of Medicine, 333 Cedar Street, New Haven, CT,National Center for PTSD, Evaluation Division, 950 Campbell Avenue, West Haven, CT
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Sripada RK, Bohnert KM, Ganoczy D, Pfeiffer PN. Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2017; 45:353-361. [DOI: 10.1007/s10488-017-0828-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Organizational readiness for change: Preceptor perceptions regarding early immersion of student pharmacists in health-system practice. Res Social Adm Pharm 2017; 13:1028-1035. [DOI: 10.1016/j.sapharm.2017.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 11/20/2022]
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22
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Rosen CS, Eftekhari A, Crowley JJ, Smith BN, Kuhn E, Trent L, Martin N, Tran T, Ruzek JI. Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training. J Trauma Stress 2017; 30:63-70. [PMID: 28103401 DOI: 10.1002/jts.22153] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 11/05/2022]
Abstract
This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.
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Affiliation(s)
- Craig S Rosen
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Afsoon Eftekhari
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Jill J Crowley
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Brandy N Smith
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Eric Kuhn
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lindsay Trent
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nicole Martin
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Thuy Tran
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
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Ross DF, Ionita G, Stirman SW. System-Wide Implementation of Routine Outcome Monitoring and Measurement Feedback System in a National Network of Operational Stress Injury Clinics. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 43:927-944. [DOI: 10.1007/s10488-016-0749-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Cook JM, Simiola V, Hamblen JL, Bernardy N, Schnurr PP. The influence of patient readiness on implementation of evidence-based PTSD treatments in Veterans Affairs residential programs. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2016; 9:51-58. [PMID: 27348065 DOI: 10.1037/tra0000162] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Mental health provider perceptions of patient readiness for trauma-focused evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) have been found to impact outpatient care in the Department of Veterans Affairs (VA). METHOD One hundred and 72 mental health directors and providers from 36 VA residential PTSD treatment programs completed qualitative interviews regarding implementation of two EBTs, Prolonged Exposure (PE), and Cognitive Processing Therapy (CPT). Perceptions of patients' "readiness" for PE and CPT, including how to define and assess this construct and how it influences implementation of these EBTs, were discussed. RESULTS Patient readiness was identified as having three components: psychological and psychiatric stability, general readiness to change, and specific skills to manage trauma-focused EBTs (e.g., distress tolerance, affect regulation skills). Providers indicated that some patients who are deemed not ready are either screened out prior to entry or helped to get ready prior to or during their residential stay. Providers expressed difficulties predicting who is actually ready and described what they saw as differences between readiness for PE as compared with CPT. CONCLUSIONS The concept of readiness for trauma-focused EBTs impacted admission and access to services in the programs. Future research directions, such as empirically measuring readiness and formally assessing veterans' perceptions of and willingness to participate in these EBTs, are considered. (PsycINFO Database Record
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Affiliation(s)
- Joan M Cook
- Department of Psychiatry, Yale School of Medicine
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25
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Abstract
The Perceived Characteristics of Intervention Scale (PCIS), a 20-item assessment measure, was developed to assess health care providers’ views of interventions. Two hundred and fifteen Department of Veterans Affairs’ residential treatment providers from 38 programs across the United States completed an online survey that included the PCIS as well as self-reported use of two evidence-based treatments. The PCIS was anchored to ask about two evidence-based psychotherapies for posttraumatic stress disorder, prolonged exposure, and cognitive processing therapy. The PCIS is a reliable measure of perceived characteristics of interventions, with some preliminary support for its validity. Consideration of providers’ perceptions of particular evidence-based treatments may serve as an aid to improve their dissemination, implementation, and sustained use.
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Affiliation(s)
- Joan M. Cook
- Yale School of Medicine, West Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | | | - Paula P. Schnurr
- National Center in White River Junction, CT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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