Evaluating transdiagnostic, evidence-based mental health care in a safety-net setting serving homeless individuals

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

Biopsychosocial Model of Traumatic Stress Symptoms in Women Experiencing Homelessness: A Qualitative Descriptive Study

Trauma is nearly ubiquitous among women experiencing homelessness (WEH). WEH develop post-traumatic stress disorder (PTSD) at rates far exceeding the general population. The consequences of untreated PTSD can cascade, exacerbating existing physical, mental, and social health inequities, placing this population at risk for disproportionate biopsychosocial health adversity. Despite the outsized impact of PTSD, WEH are less likely to access or receive appropriate trauma-focused services. Understanding the unique and intersecting factors that contribute to the disproportionate PTSD toll on WEH may elucidate risk and protective factors, as well as possible intervention pathways to address the disparate trauma burden. This study employed a qualitative descriptive approach to develop understanding of the determinants of trauma risk, exposure, and outcomes among WEH. Semi-structured interviews were completed with 10 WEH, six shelter staff, four mental health professionals. Six deductively biopsychosocial model-derived themes were identified, alongside supporting categories. Themes/categories highlighted the role of biological, psychological, and socio-environmental determinants in shaping risk for and actualization of traumatic events and adverse outcomes. Trauma played an outsized role in shaping the health of WEH participants in this study, and the need for and interest in tailored trauma screening, treatment, psychoeducation options was highlighted. Recursive relationships between biopsychosocial determinants and trauma impact were identified. Participants emphasized population tailored trauma-focused interventions, specifically brief co-designed and community partner implemented interventions that address substance use behaviors, while leveraging the strengths of WEH. Addressing the marked trauma burden in WEH shows promise in promoting measurable biopsychosocial health improvements in this resilient yet overlooked population.

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.

The Role of Stressful Life Events among Women Experiencing Homelessness: An Intragroup Analysis

The aim of this study is to examine stressful life events (SLEs) among homeless women and how SLEs were related to patterns and trajectories of homelessness. Specifically, the study aimed to replicate and build upon by Muñoz et al. (2005) by using cluster and discriminant analysis in a sample of 116 homeless women. The sample was classified based on SLEs, and the relationship between the resulting subgroups and sociodemographic characteristics, homeless trajectories, physical and mental health, and social support was examined. The results suggest that the three-cluster solution was theoretically and structurally meaningful: (a) the "Shorter homelessness trajectories and best health and mental health" subgroup was characterized by low levels of SLEs, a shorter homeless trajectory, lower prevalence of physical and mental health problems, and lower rates of alcohol and substances consumption; (b) the "Early onset of homelessness and poorer health and poorer mental health" subgroup was characterized by a higher prevalence of childhood and adolescence SLEs, an early onset of homelessness and greater chronification, mental health problems, and alcohol consumption; and (c) the "Chronic homelessness and poorest health and mental health" subgroup was mainly characterized by a higher prevalence of typically adulthood SLEs, as well as some SLEs that may be unique to women, a greater number of periods of homelessness, physical health problems, disabilities, and substance misuse. Increased knowledge about the different subgroups and trajectories of homeless women, as well as their specific characteristics and needs, will help us design social services and policies sensitive to all these differences.

Initial Effectiveness Evaluation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Homeless Women

The purpose of this study is to evaluate the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders adapted for homeless women (UPHW). Eighty-one homeless women participated in this single-blinded quasi-experimental clinical trial, involving up to 12 sessions of group treatment, and 3-and 6-month follow-ups. The participants received either immediate treatment with the UPHW (n = 46) or delayed treatment, following a 12-week wait-list control period (WLC; n = 35). Primary outcomes included depression and anxiety. Secondary measures comprised positive and negative affect, psychological well-being, health perception, and social support. The UPHW resulted in significant improvement on measures of anxiety, depression and negative affect. Improvements in anxiety and depression were maintained over a 3-month follow-up period, but not at 6-month. The reliability of the clinical changes showed significant differences between UPHW and WLC for depression. Moreover, the inter-session assessment in the UPHW group showed a linear trend reduction for depression and anxiety scores along the 12 sessions. The clinical implications on the UPHW in social settings are also discussed.