Implementation of Evidence-Based Practices within Treatment-As-Usual and Evidence-Based Practice Initiatives

Publicly funded initiatives are underway to improve implementation of evidence-based practices (EBP) in youth mental health services. However, we know little about the success of these initiatives or about EBP implementation independent of such initiatives. We examined EBP implementation in a treatment as usual (TAU) state and in six states with publicly funded EBP initiatives (EBPIs). In Study 1, we examined providers' use of practices derived from the evidence base (PDEB) and their predictors among 780 providers in a TAU state. In Study 2, we conducted a systematic review of implementation strategies, outcomes, and predictors of EBP use in six state funded EBPIs. Study 1 suggests TAU providers use PDEB alongside practices without consistent research support; provider racial/ethnic minority status, learning theory orientation, and manual use predict greater PDEB use. Study 2 indicates EBPIs employ multiple recommended implementation strategies with variable outcomes across studies and measurement approaches. Predictors of EBP use in EBPIs also varied, though training, setting, and youth age were consistent predictors across studies. While sample differences and inconsistent measurement across studies made direct comparisons somewhat tenuous, rates of PDEB use in the TAU sample appeared similar to those in publicly funded EBPIs. However, two states reported comparisons with TAU samples and found higher EBP implementation under EBPI. Different predictors impacted EBP use in TAU versus EBPIs. Our findings highlight the need for improved evaluation of EBPIs including clear reporting standards for outcomes and more consistent, standardized measurement of EBP use in order to better understand and improve EBPIs.

What parts of PTSD are normal: intrusion, avoidance, or arousal? Data from the Northridge, California, earthquake

The incidence and comorbidity of posttraumatic stress disorder (PTSD) are addressed in a study of 130 Northridge, California, earthquake survivors interviewed 3 months post-disaster. Only 13% of the sample met full PTSD criteria, but 48% met both the re-experiencing and the arousal symptom criteria, without meeting the avoidance and numbing symptom criterion. Psychiatric comorbidity was associated mostly with avoidance and numbing symptoms. For moderately severe traumatic events, re-experiencing and arousal symptoms may be the most "normal," and survivors with a history of psychiatric problems may be those most likely to develop full PTSD. A system that considers people who meet all three symptom criteria to have a psychiatric disorder yet recognizes the distress of other symptomatic survivors may best serve traumatized populations.

Better for it: how people benefit from adversity

Recently, researchers in several different fields have discovered that people who have experienced seriously adverse events frequently report that they were positively changed by the experience. Respondents in these studies typically have reported a variety of different benefits and have reported that they also were harmed by the same experiences. The research suggests several processes that may account for these reports of benefit: purposeful changes in life structure, changes in views of others and the world that result from the experience of vulnerability, the receipt of needed support, and the search for meaning in adversity. Thinking about benefits may help survivors of traumatic events process painful information. This article offers guidance on how to introduce and manage benefit content within a therapeutic relationship and encourages social workers to cautiously reflect clients' unstated benefits, encourage self-assessments in areas where benefits may accrue, explore any benefits discovered, and help clients plan for positive changes. This process converges well with the strengths perspective and constructivist approaches to social work practice.

Psychiatric disorders among survivors of the Oklahoma City bombing

CONTEXT

Disasters expose unselected populations to traumatic events and can be used to study the mental health effects. The Oklahoma City, Okla, bombing is particularly significant for the study of mental health sequelae of trauma because its extreme magnitude and scope have been predicted to render profound psychiatric effects on survivors.

OBJECTIVE

To measure the psychiatric impact of the bombing of the Alfred P. Murrah Federal Building in Oklahoma City on survivors of the direct blast, specifically examining rates of posttraumatic stress disorder (PTSD), diagnostic comorbidity, functional impairment, and predictors of postdisaster psychopathology.

DESIGN, SETTING, AND PARTICIPANTS

Of 255 eligible adult survivors selected from a confidential registry, 182 (71%) were assessed systematically by interviews approximately 6 months after the disaster, between August and December 1995.

MAIN OUTCOME MEASURES

Diagnosis of 8 psychiatric disorders, demographic data, level of functioning, treatment, exposure to the event, involvement of family and friends, and physical injuries, as ascertained by the Diagnostic Interview Schedule/Disaster Supplement.

RESULTS

Forty-five percent of the subjects had a postdisaster psychiatric disorder and 34.3% had PTSD. Predictors included disaster exposure, female sex (for any postdisaster diagnosis, 55% vs 34% for men; chi2 = 8.27; P=.004), and predisaster psychiatric disorder (for PTSD, 45% vs 26% for those without predisaster disorder; chi2 = 6.86; P=.009). Onset of PTSD was swift, with 76% reporting same-day onset. The relatively uncommon avoidance and numbing symptoms virtually dictated the diagnosis of PTSD (94% meeting avoidance and numbing criteria had full PTSD diagnosis) and were further associated with psychiatric comorbidity, functional impairment, and treatment received. Intrusive reexperience and hyperarousal symptoms were nearly universal, but by themselves were generally unassociated with other psychopathology or impairment in functioning.

CONCLUSIONS

Our data suggest that a focus on avoidance and numbing symptoms could have provided an effective screening procedure for PTSD and could have identified most psychiatric cases early in the acute postdisaster period. Psychiatric comorbidity further identified those with functional disability and treatment need. The nearly universal yet distressing intrusive reexperience and hyperarousal symptoms in the majority of nonpsychiatrically ill persons may be addressed by nonmedical interventions of reassurance and support.

The status of older adolescents at exit from out-of-home care

Administrative data and case record reviews were used to assess the exit status of a sample of older youths leaving out-of-home care in one midwestern state. Results show that most left without a job or a high school diploma, and that many left with neither. The most common living arrangement at the time of exit was with relatives, some through planned reunification and some through unplanned reunification. The majority of the youths exited out-of-home care in unplanned ways. The number of placements and the completion of high school predicted employment status. High school completion was associated with age and a history of inpatient psychiatric care, running away, and mental retardation. Implications for independent living programs for older youths are discussed.

Perceived benefit and mental health after three types of disaster

The study of growth and perceived benefit after traumatic events has been hailed as one of the most promising directions for stress research. This research, however, has been limited by several methodological limitations. These limitations are addressed in this prospective study, which examines perceived benefit and mental health adjustment after 3 different types of disaster. Survivors of a tornado in Madison, Florida, had the highest rates of perceived benefit, followed by survivors of a mass killing in Killeen, Texas, and survivors of a plane crash in Indianapolis, Indiana. Perceived benefit 4-6 weeks postdisaster predicted posttraumatic stress disorder 3 years later. Perceived benefit moderated the effect of severity of disaster exposure on mental health diagnosis change over time. Without perceived benefit, as exposure severity increased, the amount of recovery decreased. If benefit was perceived, as exposure severity increased, the amount of recovery increased. Implications for clinical interventions and future research are discussed.

A practice model for enhancing effective coping in child welfare families

Some degree of stress is of necessity associated with child welfare interventions. This stress adds to that already present in service consumers' situations. This article offers help to child welfare students and beginning practitioners in understanding and reducing the kinds of stress involved in child welfare interventions.

Perceived benefit and mental health after three types of disaster

The study of growth and perceived benefit after traumatic events has been hailed as one of the most promising directions for stress research. This research, however, has been limited by several methodological limitations. These limitations are addressed in this prospective study, which examines perceived benefit and mental health adjustment after 3 different types of disaster. Survivors of a tornado in Madison, Florida, had the highest rates of perceived benefit, followed by survivors of a mass killing in Killeen, Texas, and survivors of a plane crash in Indianapolis, Indiana. Perceived benefit 4-6 weeks postdisaster predicted posttraumatic stress disorder 3 years later. Perceived benefit moderated the effect of severity of disaster exposure on mental health diagnosis change over time. Without perceived benefit, as exposure severity increased, the amount of recovery decreased. If benefit was perceived, as exposure severity increased, the amount of recovery increased. Implications for clinical interventions and future research are discussed.