Shannon Wiltsey Stirman received her PhD in Clinical Psychology from the University of Pennsylvania. She completed an internship at the VA Palo Alto Healthcare System, and returned to Philadelphia for postdoctoral training, where she received an NIMH-funded K99/R00 award to study implementation and sustainability of CBT in a partnership between Penn and the City of Philadelphia’s Department of Behavioral Health and disAbility Services to implement cognitive therapy across the city’s network of providers. In 2009, Dr. Stirman joined the Women's Health Sciences Division of the VA National Center for PTSD and the Department of Psychiatry at Boston University. She was a Fellow of the NIMH and VA-funded Implementation Research Institute, and later served as an expert faculty member. In 2015, Dr. Stirman transitioned to the Dissemination and Training Division of the National Center for PTSD, where she currently serves as Acting Deputy Director, and joined the Stanford faculty in 2016. She was awarded the Association of Behavior and Cognitive Therapy's Mid-Career Innovator award in 2018 and serves on the board of the Society for Implementation Research Collaboration. Her research has been funded by the National Institute of Mental Health and the Canadian Institute for Health Research.
Associate Professor - Med Center Line, Psychiatry and Behavioral Sciences
Acting Deputy Director, Dissemination and Training Division, National Center for PTSD (2018 - Present)
Boards, Advisory Committees, Professional Organizations
Senior Leader, Dissemination and Implementation Special Interest Group, Association for Behavioral and Cognitive Therapy (2018 - Present)
Board of Directors, Chair of the Established Network of Expertise, Society for Implementation Research Collaboration (2018 - Present)
Community and International Work
Sonoma County Wildfire Mental Health Collaborative
Healthcare Foundation Northern Sonoma County
Individuals impacted by wildfires in Sonoma County
Opportunities for Student Involvement
Current Research and Scholarly Interests
The overarching goal of my program of research is to determine how to facilitate the high quality delivery of evidence-based psychosocial interventions (EBPs) in public sector mental health settings. Areas of emphasis include training and consultation, treatment fidelity and adaptation, and the identification of strategies that promote sustained implementation of EBPs. In my early work, I examined the degree to which the randomized controlled trial (RCT) literature included individuals with characteristics like those seen in routine care settings. This work highlighted some gaps in the literature, but largely demonstrated that the RCT literature may be more applicable to typical clients in routine care settings than previously assumed.
This early work also led me to become interested in developing and studying strategies to promote the implementation and sustained use of EBPs in public sector settings. My research group’s systematic review of research on sustainability suggested that EBPs are often fully or partially discontinued a short time after they are introduced into routine care settings. Identification of factors associated with sustained implementation is therefore an important step in promoting the long-term success of implementation efforts. Through my recently completed K99/R00 award, I used qualitative and quantitative methods to examine system, organizational, clinician, and patient-level influences on the long-term trajectory of clinicians’ use of cognitive therapy.
The degree of fidelity (adherence to the protocol and skill of delivery) with which EBPs are delivered, and adaptations to EBPs made in routine care, are key implementation outcomes. Without time- and cost-intensive direct observation, these outcomes are difficult to assess. I received an R21 to develop a strategy for assessing EBP fidelity that uses materials generated during routine sessions. If this effort is successful, the burden associated with fidelity assessment and support in both clinical trials and in implementation initiatives could be reduced dramatically.
As a first step toward understanding the implications of different types of adaptations to EBPs, my colleagues and I also developed a framework for identifying and classifying adaptations that are made to EBPs in routine care. This framework makes it possible to determine whether specific types of adaptations lead to different clinical or implementation outcomes. Using the framework, we have identified evidence that clinicians do make changes to EBPs in their own practice, and that certain clinician characteristics predict the use of adaptations that are inconsistent with the protocol.
While the work described above is based on observation of implementation efforts and has laid important groundwork for future research, my larger goal is to develop and test strategies to facilitate high-quality implementation of EBPs in routine care settings. Beyond the growing recognition that workshops, web-based trainings, and manuals alone are insufficient, little is known about strategies to train and prepare clinicians to deliver EBPs with fidelity in public sector mental health settings. My collaborators and I recently completed data collection for a fully-powered hybrid implementation/effectiveness RCT that compares consultation alone, consultation combined with observation, and a fidelity-monitoring alone strategy for training clinicians to deliver Cognitive Processing Therapy (CPT) for PTSD.
The next step is to find ways to sustain the use of EBPs after initial training and implementation. In one of the first studies of strategies to promote sustainment of EBPs, my collaborators and I are following up with a study that compares a fidelity-oriented learning collaborative strategy to a continuous quality improvement-oriented learning collaborative to support the ongoing use of an EBP in three large mental health systems.
Sustaining and Improving Clinicians' Use of Evidence-Based Psychotherapy (EBP) for PTSD
The purpose of the study is to compare the impact of two strategies to sustain and improve the delivery of an evidence-based psychotherapy for PTSD, Cognitive Processing Therapy (CPT) in three different mental health systems. These approaches are based on two different theories of what is necessary to promote successful implementation. We will examine whether these strategies lead to improved patient outcomes, clinician skill, proportion of clients who receive CPT, and other outcomes that are relevant to the implementation of evidence-based psychosocial treatments. By examining these questions in 3 different mental health systems, we will also examine whether the implementation strategies yield different results in different systems.
Innovative Methods to Assess Psychotherapy Practices (imAPP), National Center for PTSD and Stanford University
Compares strategies to assess what occurs in CBT sessions for Depression, Anxiety, and PTSD. Recruiting clinicians, interns/externs and postdoctoral fellows from VA Palo Alto, VA Boston, MGH, Penn and the Beck Community Initiative, as well as clinicians in private and group practices. Clinicians who practice cognitive behavioral treatments are eligible.
More information can be found at http://med.stanford.edu/fastlab/research/imapp.html
Various Locations in the US (Philadelphia, PA, Boston, MA, Palo Alto, CA, and private/group practices in the US)
Improving and Sustaining CPT for PTSD in Mental Health System, National Center for PTSD, Stanford University
This study compares two strategies for supporting clinicians and treatment programs that have previously trained in/implemented cognitive processing therapy for PTSD.
VA treatment programs, mental health clinics in Texas, and treatment programs in Canada are being recruited for participation. More information can be found here: http://med.stanford.edu/fastlab/research/cpt-sustainability-study.html
Texas, U.S. VA programs, Canada
A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes
BEHAVIOUR RESEARCH AND THERAPY
2018; 110: 31–40
This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.
View details for DOI 10.1016/j.brat.2018.08.007
View details for Web of Science ID 000447581300004
View details for PubMedID 30218837
Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD.
2018; 49 (5): 741–55
We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.
View details for DOI 10.1016/j.beth.2017.12.001
View details for PubMedID 30146141
Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study
2018; 13: 69
Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions.To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity.Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes.ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.
View details for DOI 10.1186/s13012-018-0756-3
View details for Web of Science ID 000433162700001
View details for PubMedID 29789017
View details for PubMedCentralID PMC5964900
A Pragmatic Approach to Guide Implementation evaluation Research: strategy Mapping for Complex Interventions
FRONTIERS IN PUBLIC HEALTH
2018; 6: 134
Greater specification of implementation strategies is a challenge for implementation science, but there is little guidance for delineating the use of multiple strategies involved in complex interventions. The Cardiovascular (CV) Toolkit project entails implementation of a toolkit designed to reduce CV risk by increasing women's engagement in appropriate services. The CV Toolkit project follows an enhanced version of Replicating Effective Programs (REP), an evidence-based implementation strategy, to implement the CV Toolkit across four phases: pre-conditions, pre-implementation, implementation, and maintenance and evolution. Our current objective is to describe a method for mapping implementation strategies used in real time as part of the CV Toolkit project. This method supports description of the timing and content of bundled strategies and provides a structured process for developing a plan for implementation evaluation.We conducted a process of strategy mapping to apply Proctor and colleagues' rubric for specification of implementation strategies, constructing a matrix in which we identified each implementation strategy, its conceptual group, and the corresponding REP phase(s) in which it occurs. For each strategy, we also specified the actors involved, actions undertaken, action targets, dose of the implementation strategy, and anticipated outcome addressed. We iteratively refined the matrix with the implementation team, including use of simulation to provide initial validation.Mapping revealed patterns in the timing of implementation strategies within REP phases. Most implementation strategies involving the development of stakeholder interrelationships and training and educating stakeholders were introduced during the pre-conditions or pre-implementation phases. Strategies introduced in the maintenance and evolution phase emphasized communication, re-examination, and audit and feedback. In addition to its value for producing valid and reliable process evaluation data, mapping implementation strategies has informed development of a pragmatic blueprint for implementation and longitudinal analyses and evaluation activities.We update recent recommendations on specification of implementation strategies by considering the implications for multi-strategy frameworks and propose an approach for mapping the use of implementation strategies within complex, multi-level interventions, in support of rigorous evaluation. Developing pragmatic tools to aid in operationalizing the conduct of implementation and evaluation activities is essential to enacting sound implementation research.
View details for DOI 10.3389/fpubh.2018.00134
View details for Web of Science ID 000435423000001
View details for PubMedID 29868542
View details for PubMedCentralID PMC5968102
In rape trauma PTSD, patient characteristics indicate which trauma-focused treatment they are most likely to complete
DEPRESSION AND ANXIETY
2018; 35 (4): 330–38
Dropout rates for effective therapies for posttraumatic stress disorder (PTSD) can be high, especially in practice settings. Although clinicians have intuitions regarding what treatment patients may complete, there are few systematic data to drive those judgments.A multivariable model of dropout risk was constructed with randomized clinical trial data (n = 160) comparing prolonged exposure (PE) and cognitive processing therapy (CPT) for rape-induced PTSD. A two-step bootstrapped variable selection algorithm was applied to identify moderators of dropout as a function of treatment condition. Employing identified moderators in a model, fivefold cross-validation yielded estimates of dropout probability for each patient in each condition. Dropout rates between patients who did and did not receive their model-indicated treatment were compared.Despite equivalent dropout rates across treatments, patients assigned to their model-indicated treatment were significantly less likely to drop out relative to patients who did not (relative risk = 0.49 [95% CI: 0.29-0.82]). Moderators included in the model were: childhood physical abuse, current relationship conflict, anger, and being a racial minority, all of which were associated with higher likelihood of dropout in PE than CPT.Individual differences among patients affect the likelihood they will complete a particular treatment, and clinicians can consider these moderators in treatment planning. In the future, treatment selection models could be used to increase the percentage of patients who will receive a full course of treatment, but replication and extension of such models, and consideration of how best to integrate them into routine practice, are needed.
View details for DOI 10.1002/da.22731
View details for Web of Science ID 000429322100006
View details for PubMedID 29489037
A comparison of two learning collaborative strategies to support newly trained clinicians in delivering cognitive processing therapy
BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428649900060
Adaptation in dissemination and implementation science
BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428649900092
The effect of message board correspondence on therapist fidelity and adaptation in cognitive processing therapy for PTSD
BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428649900089
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 (2): 131–39
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).Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT.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.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
View details for DOI 10.1037/tra0000220
View details for Web of Science ID 000427747400001
View details for PubMedID 27893265
View details for PubMedCentralID PMC5446934
- Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems PSYCHIATRIC SERVICES 2018; 69 (3): 286–92
Impact of age of onset of psychosis and engagement in higher education on duration of untreated psychosis
JOURNAL OF MENTAL HEALTH
2018; 27 (3): 257–62
The average age of onset of psychosis coincides with the age of college enrollment. Little is known about the impact of educational engagement on DUP in a college-aged population.To determine DUP, and the impact of educational engagement, for college-aged participants of the RAISE study (n = 404).We conducted secondary data analyses on the publicly available RAISE dataset. Subsamples were analyzed to determine the impact of age and educational engagement on DUP.DUP was significantly shorter (p < 0.02) for participants who were college-aged (18-22 years, n = 44) and engaged in post-secondary education (median = 12 weeks, mean = 29 weeks) compared with participants who were college-aged and not engaged in higher education (n = 92, median = 29 weeks, mean = 44 weeks).Educational engagement appears to be associated with a shorter DUP. This may be partially explained by the presence of on-site wellness centers in college settings. However, even among young people who engaged in post-secondary education DUP was still at, or beyond, the upper limit of WHO recommendations in this group. Future research exploring how colleges could improve their capacity to detect and refer at risk students for treatment at an earlier stage is recommended.
View details for DOI 10.1080/09638237.2018.1466047
View details for Web of Science ID 000432901400009
View details for PubMedID 29707996
The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care
ANNUAL REVIEW OF PUBLIC HEALTH, VOL 39
2018; 39: 55–76
There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.
View details for DOI 10.1146/annurev-publhealth040617-014731
View details for Web of Science ID 000433066200004
View details for PubMedID 29328872
Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions
CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE
2017; 24 (4): 396–420
This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.
View details for DOI 10.1111/cpsp.12218
View details for Web of Science ID 000417250500007
View details for PubMedID 29593372
View details for PubMedCentralID PMC5866913
Therapist Report of Adaptations to Delivery of Evidence-Based Practices Within a System-Driven Reform of Publicly Funded Children's Mental Health Services.
Journal of consulting and clinical psychology
This study examined clinical adaptations reported by community therapists to multiple evidence-based practices (EBPs) currently implemented in children's mental health services. Based on an item set informed by Stirman and colleagues' model (2015), 2 factors emerged describing Augmenting adaptations and Reducing/Reordering adaptations. We used multilevel modeling to examine therapist- and practice-level predictors of therapist reports of each type of adaptation.Data were drawn from an online survey, including a novel therapist report measure of EBP adaptations, completed by 572 therapists (89.2% female, Mage = 37.08 years, 33.4% non-Hispanic White) delivering EBPs in the context of a system-driven, fiscally mandated implementation effort.Analyses revealed that the 2 types of therapist adaptations (Augmenting and Reducing/Reordering) could be readily discriminated, with therapists reporting significantly more Augmenting than Reducing/Reordering adaptations. Therapists of Hispanic/Latino ethnicity and with fewer years of experience reported more extensive Augmenting adaptations, but no therapist background characteristics were associated with Reducing/Reordering adaptations. Therapists' general attitudes that EBPs diverged from their personal approach to therapy were associated with reporting more Augmenting and Reducing/Reordering adaptations. In contrast, negative perceptions toward the specific EBP predicted Reducing/Reordering adaptations, but not Augmenting adaptations.Community therapist reports suggest that most adaptations undertaken involve engaging with the practice to augment the fit of the EBPs for local contexts; however, when practices were perceived negatively, therapists were more likely to make adaptations reducing or rearranging components. (PsycINFO Database Record
View details for DOI 10.1037/ccp0000215
View details for PubMedID 28471210
View details for PubMedCentralID PMC5501960
Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial.
2017; 12 (1): 32-?
Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.NCT02449421 . Registered 02/09/2015.
View details for DOI 10.1186/s13012-017-0544-5
View details for PubMedID 28264720
View details for PubMedCentralID PMC5339953
Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems.
Psychiatric services (Washington, D.C.)
Use of expert-led workshops plus consultation has been established as an effective strategy for training community mental health (CMH) clinicians in evidence-based practices (EBPs). Because of high rates of staff turnover, this strategy inadequately addresses the need to maintain capacity to deliver EBPs. This study examined knowledge, competency, and retention outcomes of a two-phase model developed to build capacity for an EBP in CMH programs.In the first phase, an initial training cohort in each CMH program participated in in-person workshops followed by expert-led consultation (in-person, expert-led [IPEL] phase) (N=214 clinicians). After this cohort completed training, new staff members participated in Web-based training (in place of in-person workshops), followed by peer-led consultation with the initial cohort (Web-based, trained-peer [WBTP] phase) (N=148). Tests of noninferiority assessed whether WBTP was not inferior to IPEL at increasing clinician cognitive-behavioral therapy (CBT) competency, as measured by the Cognitive Therapy Rating Scale.WBTP was not inferior to IPEL at developing clinician competency. Hierarchical linear models showed no significant differences in CBT knowledge acquisition between the two phases. Survival analyses indicated that WBTP trainees were less likely than IPEL trainees to complete training. In terms of time required from experts, WBTP required 8% of the resources of IPEL.After an initial investment to build in-house CBT expertise, CMH programs were able to use a WBTP model to broaden their own capacity for high-fidelity CBT. IPEL followed by WBTP offers an effective alternative to build EBP capacity in CMH programs, rather than reliance on external experts.
View details for DOI 10.1176/appi.ps.201700029
View details for PubMedID 29137558
The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings.
Current opinion in psychology
2017; 14: 61–66
In recent years, the implementation of trauma-focused treatments has expanded across settings that vary widely in the availability of resources, infrastructure, and personnel. The present review aims to inform researchers, policy makers, trainers, and administrators about this diverse range of research. Taking a global health perspective, this review of effectiveness trials and implementation studies compares strategies used in high-income countries to those in low- and medium-income countries. A primary difference between studies in high-income and low- and medium-income countries is the relative emphasis placed on fidelity or adaptation. Adaptations used in low- and medium-income countries might offer useful ideas for increasing the portability, impact, and accessibility of evidence-based interventions in high-income countries.
View details for DOI 10.1016/j.copsyc.2016.11.007
View details for PubMedID 28713852
View details for PubMedCentralID PMC5507619
Implementation of Transdiagnostic Cognitive Therapy in Community Behavioral Health: The Beck Community Initiative
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2016; 84 (12): 1116-1126
Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP.Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity.Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other).Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record
View details for DOI 10.1037/ccp0000105
View details for Web of Science ID 000389304500008
View details for PubMedID 27379492
View details for PubMedCentralID PMC5125881
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
2016; 43 (6): 957-977
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.
View details for PubMedID 27474040
Cognitive Processing Therapy for Spanish-speaking Latinos: A Formative Study of a Model-Driven Cultural Adaptation of the Manual to Enhance Implementation in a Usual Care Setting.
Journal of clinical psychology
As part of a larger implementation trial for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in a community health center, we used formative evaluation to assess relations between iterative cultural adaption (for Spanish-speaking clients) and implementation outcomes (appropriateness and acceptability) for CPT.Qualitative data for the current study were gathered through multiple sources (providers: N = 6; clients: N = 22), including CPT therapy sessions, provider fieldnotes, weekly consultation team meetings, and researcher fieldnotes. Findings from conventional and directed content analysis of the data informed refinements to the CPT manual.Data-driven refinements included adaptations related to cultural context (i.e., language, regional variation in wording), urban context (e.g., crime/violence), and literacy level. Qualitative findings suggest improved appropriateness and acceptability of CPT for Spanish-speaking clients.Our study reinforces the need for dual application of cultural adaptation and implementation science to address the PTSD treatment needs of Spanish-speaking clients.
View details for DOI 10.1002/jclp.22337
View details for PubMedID 27378013
Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program.
journal of continuing education in the health professions
2016; 36 (2): 96-103
Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation.Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation.Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified.Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.
View details for DOI 10.1097/CEH.0000000000000073
View details for PubMedID 27262152
Avoidance as an obstacle to preventing depression among urban women at high risk for violent trauma.
Archives of women's mental health
2016; 19 (1): 63-70
The impact of depression interventions is often attenuated in women who have experienced trauma. We explored whether psychological avoidance could explain this phenomenon. We synthesized two pilot randomized trials of problem-solving education (PSE) among a total of 93 urban mothers. Outcomes included depressive symptoms and perceived stress. Mothers with avoidant coping styles experienced an average 1.25 episodes of moderately severe depressive symptoms over 3 months of follow-up, compared to 0.40 episodes among those with non-avoidant coping (adjusted incident rate ratio [aIRR] 2.18; 95 % CI 1.06, 4.48). PSE tended to perform better among mothers with non-avoidant coping. Among mothers with non-avoidant coping, PSE mothers experienced an average 0.24 episodes, compared to 0.58 episodes among non-avoidant controls (aIRR 0.27; 95 % CI 0.05, 1.34). Among mothers with avoidant coping, PSE mothers experienced an average 1.26 episodes, compared to 1.20 episodes among avoidant controls (aIRR 0.76; 95 % CI 0.44, 1.33). This trend toward differential impact persisted when avoidance was measured as a problem-solving style and among traumatized mothers with and without avoidant PTSD symptoms. Further research is warranted to explore the hypothesis that psychological avoidance could explain why certain depression treatment and prevention strategies break down in the presence of trauma.
View details for DOI 10.1007/s00737-015-0521-4
View details for PubMedID 25833808
Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion
BEHAVIOUR RESEARCH AND THERAPY
2016; 77: 68-77
Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.
View details for DOI 10.1016/j.brat.2015.12.009
View details for Web of Science ID 000370899200009
View details for PubMedID 26731171
Bridging the gap between research and practice in mental health service settings: An overview of developments in implementation theory and research
View details for DOI 10.1016/j.beth.2015.12.001
Delivering cognitive processing therapy in a community health setting: The influence of Latino culture and community violence on posttraumatic cognitions.
Psychological trauma : theory, research, practice and policy
2016; 8 (1): 98-106
Despite the applicability of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) to addressing sequelae of a range of traumatic events, few studies have evaluated whether the treatment itself is applicable across diverse populations. The present study examined differences and similarities among non-Latino, Latino Spanish-speaking, and Latino English-speaking clients in rigid beliefs-or "stuck points"-associated with PTSD symptoms in a sample of community mental health clients. We utilized the procedures of content analysis to analyze stuck point logs and impact statements of 29 participants enrolled in a larger implementation trial for CPT. Findings indicated that the content of stuck points was similar across Latino and non-Latino clients, although fewer total stuck points were identified for Latino clients compared to non-Latino clients. Given that identification of stuck points is central to implementing CPT, difficulty identifying stuck points could pose significant challenges for implementing CPT among Latino clients and warrants further examination. Thematic analysis of impact statements revealed the importance of family, religion, and the urban context (e.g., poverty, violence exposure) in understanding how clients organize beliefs and emotions associated with trauma. Clinical recommendations for implementing CPT in community settings and the identification of stuck points are provided. (PsycINFO Database Record
View details for DOI 10.1037/tra0000044
View details for PubMedID 25961865
- Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy IMPLEMENTATION SCIENCE 2015; 10
System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network.
2015; 66 (7): 734-742
The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system.Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach.Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge.Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.
View details for DOI 10.1176/appi.ps.201400147
View details for PubMedID 25828878
View details for PubMedCentralID PMC4490058
Hormone therapy use in women veterans accessing veterans health administration care: a national cross-sectional study.
Journal of general internal medicine
2015; 30 (2): 169-175
The majority of women Veterans using VA (Veterans Administration) care fall in the 45-65 year-old age range. Understanding how menopause is managed in this group is of importance to optimizing their health.National population estimates showed a prevalence of hormone therapy (HT) use by women over 45 years of 4.7 % (2009-2010). Our study described the frequency of HT use among women Veterans in VA, and examined whether mental health (MH) was predictive of HT use.This was a cross-sectional analysis of national VA administrative data for fiscal year 2009.Women Veterans over the age of 45 (N = 157,195) accessing VA outpatient care were included in the analysis.Logistic regression analyses using HT use as the dependent variable.Mean age was 59.4 years (SD =12.2, range =46-110), and 16,227 (10.3 %) of all women used HT. Hysterectomy (OR 3.99 [3.53, 4.49]) and osteoporosis (1.34 [1.27, 1.42]) were the strongest medical indicators of HT use. A total of 49,557 (31.5 %) women in the sample received at least one primary diagnosis of a MH disorder and were more likely to use HT than women with no MH diagnoses (unadjusted OR 1.56, 95 % CI [1.50, 1.61]). Women Veterans with a mood disorder (depression/bipolar) or anxiety disorder [post-traumatic stress disorder (PTSD), other anxiety diagnoses] were more likely to use HT after controlling for demographics and medical comorbidity.The prevalence of HT use among women Veterans using VA is more than twice that of the general population. Prior work suggested that women Veterans were discontinuing HT at comparable rates, but these data demonstrate that decline in VA HT use has not kept pace with that of civilian medical care. The association of MH diagnosis with HT use suggests that MH plays an important role in VA rates. Further study is needed to understand contributing patient and provider factors.
View details for DOI 10.1007/s11606-014-3073-9
View details for PubMedID 25373833
- Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System CRISIS-THE JOURNAL OF CRISIS INTERVENTION AND SUICIDE PREVENTION 2015; 36 (6): 433-439
Women Veterans' Preferences for Intimate Partner Violence Screening and Response Procedures Within the Veterans Health Administration
RESEARCH IN NURSING & HEALTH
2014; 37 (4): 302-311
Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings.
View details for DOI 10.1002/nur.21602
View details for Web of Science ID 000340665400006
View details for PubMedID 24990824
Community Mental Health Provider Modifications to Cognitive Therapy: Implications for Sustainability
2013; 64 (10): 1056-1059
This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client's needs or to the clinician's therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.
View details for DOI 10.1176/appi.ps.201200456
View details for Web of Science ID 000327278200029
View details for PubMedID 24081406
Longitudinal course of anxiety sensitivity and PTSD symptoms in cognitive-behavioral therapies for PTSD
JOURNAL OF ANXIETY DISORDERS
2013; 27 (7): 728-734
Anxiety sensitivity (AS) has been conceptualized as trait-like vulnerability and maintenance factor for PTSD. Although recent literature has demonstrated its malleability during treatment, few have examined its influence on and effect from PTSD treatment. Using multilevel regression analyses we examined: (a) changes in AS during treatment and (b) whether pre-treatment AS predicted PTSD treatment response, in sample of female victims of interpersonal trauma receiving one of three treatments (cognitive processing therapy, cognitive processing therapy-cognitive, and written accounts). Participants exhibited reductions in total ASI scores from pre- to post-treatment. Growth curve modeling revealed slightly different trajectories of PTSD symptoms as a function of pre-treatment AS, and overall decreases in PTSD symptoms during treatment were not associated with pretreatment AS. Pretreatment AS dimensions impacted PTSD total scores and symptoms clusters differentially. Clinical and theoretical implications for these results are discussed.
View details for DOI 10.1016/j.janxdis.2013.09.010
View details for Web of Science ID 000327685600014
View details for PubMedID 24176804
- A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic stress disorder IMPLEMENTATION SCIENCE 2013; 8
Clinicians' Perspectives on Cognitive Therapy in Community Mental Health Settings: Implications for Training and Implementation
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2013; 40 (4): 274-285
Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.
View details for DOI 10.1007/s10488-012-0418-8
View details for Web of Science ID 000320338600004
View details for PubMedID 22426739
- Research Setting Versus Clinic Setting: Which Produces Better Outcomes in Cognitive Therapy for Depression? COGNITIVE THERAPY AND RESEARCH 2013; 37 (3): 605-612
Developing the next generation of dissemination and implementation researchers: insights from initial trainees
Dissemination and implementation (D&I) research is a relatively young discipline, underscoring the importance of training and career development in building and sustaining the field. As such, D&I research faces several challenges in designing formal training programs and guidance for career development. A cohort of early-stage investigators (ESI) recently involved in an implementation research training program provided a resource for formative data in identifying needs and solutions around career development.Responses outlined fellows' perspectives on the perceived usefulness and importance of, as well as barriers to, developing practice linkages, acquiring additional methods training, academic advancement, and identifying institutional supports. Mentorship was a cross-cutting issue and was further discussed in terms of ways it could foster career advancement in the context of D&I research.Advancing an emerging field while simultaneously developing an academic career offers a unique challenge to ESIs in D&I research. This article summarizes findings from the formative data that outlines some directions for ESIs and provides linkages to the literature and other resources on key points.
View details for DOI 10.1186/1748-5908-8-29
View details for Web of Science ID 000318418300001
View details for PubMedID 23497462
Recruiting older men for geriatric suicide research
2013; 25 (1): 88-95
Clinical research is required to develop and evaluate suicide prevention interventions in the elderly. However, there is insufficient information available about how to best recruit suicidal older adults for such research. This study evaluated the success and efficiency of five recruitment strategies for a clinical trial on the efficacy of cognitive therapy for suicidal older men.For each strategy, the numbers of individuals approached, screened, and enrolled were calculated, and the expenses and time associated with each enrollment estimated. Men who were 60 years or older and who had a desire for suicide over the past month were eligible for the trial.Of 955 individuals considered for trial, 33 were enrolled. Most enrollments were sourced from the Veterans Affairs Behavioral Health Laboratory. Recruiting form this source was also the most time and cost efficient recruitment strategy in the study.Recruitment strategies are effective when they are based on collaborative relationships between researchers and providers, and utilize an existing infrastructure for involving patients in ongoing research opportunities.
View details for DOI 10.1017/S104161021200138X
View details for Web of Science ID 000312528400011
View details for PubMedID 22929086
- VA primary care providers’ perspectives on screening female Veterans for intimate partner violence: A preliminary assessment Journal of Family Violence 2013; 37: 302-311
- Development of a framework and coding system for modifications made to evidence-based programs and interventions Implementation Science 2013
A critical evaluation of the complex PTSD literature: Implications for DSM-5
JOURNAL OF TRAUMATIC STRESS
2012; 25 (3): 241-251
Complex posttraumatic stress disorder (CPTSD) has been proposed as a diagnosis for capturing the diverse clusters of symptoms observed in survivors of prolonged trauma that are outside the current definition of PTSD. Introducing a new diagnosis requires a high standard of evidence, including a clear definition of the disorder, reliable and valid assessment measures, support for convergent and discriminant validity, and incremental validity with respect to implications for treatment planning and outcome. In this article, the extant literature on CPTSD is reviewed within the framework of construct validity to evaluate the proposed diagnosis on these criteria. Although the efforts in support of CPTSD have brought much needed attention to limitations in the trauma literature, we conclude that available evidence does not support a new diagnostic category at this time. Some directions for future research are suggested.
View details for DOI 10.1002/jts.21699
View details for Web of Science ID 000305576500003
View details for PubMedID 22729974
- A Qualitative Investigation of Practicing Psychologists' Attitudes Toward Research-Informed Practice: Implications for Dissemination Strategies PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2012; 43 (2): 100-109
The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research
The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.
View details for DOI 10.1186/1748-5908-7-17
View details for Web of Science ID 000302479300001
View details for PubMedID 22417162
Perspectives on Cognitive Therapy Training within Community Mental Health Settings: Implications for Clinician Satisfaction and Skill Development.
Depression research and treatment
2012; 2012: 391084-?
Despite the mounting evidence of the benefits of cognitive therapy for depression and suicidal behaviors over usual care, like other evidence-based psychosocial treatments (EBTs), it has not been widely adopted in clinical practice. Studies have shown that training followed by intensive consultation is needed to prepare providers to an appropriate level of competency in complex, multisession treatment packages such as cognitive therapy. Given the critical role of training in EBT implementation, more information on factors associated with the success and challenges of training programs is needed. To identify potential reasons for variation in training outcomes across ten agencies in a large, urban community mental health system, we explored program evaluation data and examined provider, consultant, and training program administrator perspectives through follow-up interviews. Perceptions of cognitive therapy, contextual factors, and reactions to feedback on audio recordings emerged as broad categories of themes identified from interviews. These factors may interact and impact clinician efforts to learn cognitive therapy and deliver it skillfully in their practice. The findings highlight experiences and stakeholder perspectives that may contribute to more or less successful training outcomes.
View details for DOI 10.1155/2012/391084
View details for PubMedID 23056933
Changes in Psychotherapy Utilization Among Consumers of Services for Major Depressive Disorder in the Community Mental Health System
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2011; 38 (6): 495-503
The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.
View details for DOI 10.1007/s10488-011-0336-1
View details for Web of Science ID 000300092700006
View details for PubMedID 21298475
- The Science of Training in Evidence-Based Treatments in the Context of Implementation Programs: Current Status and Prospects for the Future ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2011; 38 (4): 217-222
Participation Bias among Suicidal Adults in a Randomized Controlled Trial
SUICIDE AND LIFE-THREATENING BEHAVIOR
2011; 41 (2): 203-209
Although individuals who attempt suicide have poor compliance rates with treatment recommendations, the nature and degree of participation bias in clinical treatment research among these individuals is virtually unknown. The purpose of this study was to examine participation bias by comparing the demographic and diagnostic characteristics of adult suicide attempters who participated in a randomized controlled trial to a sample of nonparticipants. Results indicated that males and individuals with a diagnosis of substance abuse or dependence were more likely to be participants in the randomized controlled trial. The implications of these findings for suicide intervention research are discussed.
View details for DOI 10.1111/j.1943-278X.2010.00011.x
View details for Web of Science ID 000289247800009
View details for PubMedID 21470296
- Developing the mental health workforce: Review and application of training strategies from multiple disciplines Administration and Policy in Mental Health and Mental Health Services Research 2011: 238-253
The clinical effectiveness of cognitive therapy for depression in an outpatient clinic
JOURNAL OF AFFECTIVE DISORDERS
2010; 125 (1-3): 169-176
Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N=217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.
View details for DOI 10.1016/j.jad.2009.12.030
View details for Web of Science ID 000281377100023
View details for PubMedID 20080305
New psychotherapies for mood and anxiety disorders.
Canadian journal of psychiatry. Revue canadienne de psychiatrie
2010; 55 (4): 193-201
To discuss psychotherapies for depression and anxiety that have emerged in recent years and to evaluate their current level of empirical support.An electronic and a manual literature search of psychotherapies for mood and anxiety disorders were conducted.Five new therapies for mood disorders and 3 interventions for posttraumatic stress disorder with co-occurring substance abuse met criteria for inclusion in this review. Fewer psychotherapies have been developed for other anxiety disorders. Although research for some of the psychotherapies has demonstrated superiority to usual care, none have firmly established efficacy or specific benefits over other established psychotherapies.A plurality of the new psychotherapies introduced and established in the past 5 years have been different assimilations of previously established cognitive-behavioural, interpersonal, or psychodynamic models. While initial results are promising for some, more rigorous efficacy trials and replications are necessary before conclusions can be drawn regarding their relative benefits.
View details for PubMedID 20416142
- Training and Consultation in Evidence-Based Psychosocial Treatments in Public Mental Health Settings: The ACCESS Model PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2010; 41 (1): 48-56
- Developing research and recruitment while fostering stakeholder engagement in an IP-RISP for Depression Progress in Community Health Partnerships: Research, Education, and Action 2010: 299-303
Engagement and Retention of Suicide Attempters in Clinical Research Challenges and Solutions
CRISIS-THE JOURNAL OF CRISIS INTERVENTION AND SUICIDE PREVENTION
2010; 31 (2): 62-68
High attrition rates in longitudinal research can limit study generalizability, threaten internal validity, and decrease statistical power. Research has demonstrated that there can be significant differences between participants who complete a research study and those who drop out prematurely, and that treatment outcomes may be dependent on retention in a treatment protocol.The current paper describes the challenges encountered when implementing a randomized controlled trial of cognitive therapy for the prevention of suicide attempts and the solutions developed to overcome these problems.Problems unique to suicide attempters are discussed, and strategies successfully implemented to boost retention rates are provided.The methods implemented appeared to increase retention rates in the randomized controlled trial.Many steps can be taken to work with this difficult population, and researchers are encouraged to be as involved and flexible with participants as possible.
View details for DOI 10.1027/0227-5910/a000018
View details for Web of Science ID 000277094400002
View details for PubMedID 20418211
Unique and Common Mechanisms of Change Across Cognitive and Dynamic Psychotherapies
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2009; 77 (5): 801-813
The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.
View details for DOI 10.1037/a0016596
View details for Web of Science ID 000270564400001
View details for PubMedID 19803561
Public-academic partnerships: the Beck Initiative: a partnership to implement cognitive therapy in a community behavioral health system.
2009; 60 (10): 1302-1304
The Beck Initiative is a partnership between researchers and clinicians at a large university and an urban behavioral health managed care system. Both partners share a commitment to ensuring that consumers in the community have access to competently delivered, individualized, evidence-based mental health care and that the providers who serve them have the support they need to deliver high-quality evidence-based treatments. Central features of the program are individualized training and consultation in cognitive therapy for each provider agency and policies to promote the sustainability of the initiative and its continuing evolution to meet the needs of providers and consumers.
View details for DOI 10.1176/appi.ps.60.10.1302
View details for PubMedID 19797367
Suicide Risk Factors and Mediators Between Childhood Sexual Abuse and Suicide Ideation Among Male and Female Suicide Attempters
JOURNAL OF TRAUMATIC STRESS
2009; 22 (5): 467-470
The current study examined the manner in which childhood sexual abuse (CSA) history relates to risk factors for suicidal behavior among recent suicide attempters (n = 166). Men who recently attempted suicide and endorsed a CSA history had higher scores on measures of hopelessness and suicide ideation than men without a CSA history. Men with a CSA history were also more likely to have made multiple suicide attempts and meet diagnostic criteria for posttraumatic stress disorder and borderline personality disorder. In contrast, there were fewer group differences as a function of CSA history among the female suicide attempters. Hopelessness was a significant mediator between CSA history and suicide ideation in both men and women.
View details for DOI 10.1002/jts.20438
View details for Web of Science ID 000271493000016
View details for PubMedID 19711488
- CHANGES IN POSITIVE QUALITY OF LIFE OVER THE COURSE OF PSYCHOTHERAPY PSYCHOTHERAPY 2008; 45 (4): 419-430
The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population
JOURNAL OF PSYCHIATRIC PRACTICE
2008; 14 (4): 199-208
The extent to which the results of randomized controlled trials can be expected to generalize to clinical populations has been the subject of much debate. To examine this issue among a population of individuals diagnosed with posttraumatic stress disorder (PTSD), the clinical characteristics of Veterans Affairs (VA) patients with PTSD were compared to the eligibility criteria for clinical trials of psychosocial treatments for PTSD. Administrative data for 239,668 patients who received a diagnosis of PTSD within the VA healthcare system during the 2003 fiscal year were compared with inclusion and exclusion criteria of 31 clinical trials for PTSD. Based on available data, all patients appeared to be eligible for at least one study, and half (50%) were eligible for between 16 and 21 (50% or more) of the 31 studies examined. The studies for which the most veterans with PTSD would have been eligible targeted combat-related trauma or did not specify type of trauma in their eligibility criteria. Veterans who exhibited psychotic symptoms (3% of the sample) were ineligible for most, but not all, of the studies. However, most veterans with comorbid Axis I conditions, such as depression, anxiety disorders, and substance use disorders, were eligible for multiple studies. These findings, which indicate that the existing literature on the efficacy of psychosocial treatment may inform the treatment of the majority of veterans who present with PTSD, have applications for the design of future clinical trials and for consultation of the literature regarding appropriate treatments for veterans with PTSD.
View details for Web of Science ID 000258110500002
View details for PubMedID 18664888
- The applicability of randomized controlled trials of psychosocial treatments for Post-traumatic Stress Disorder to a Veteran population Journal of Psychiatric Practice 2008; 14: 199-208
Can the randomized controlled trial literature generalize to nonrandomized patients?
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2005; 73 (1): 127-135
To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.
View details for DOI 10.1037/0022.006X.73.1.127
View details for Web of Science ID 000227000400014
View details for PubMedID 15709839
- Achieving successful dissemination of empirically supported adult psychotherapies: A synthesis of dissemination theory Clinical Psychology: Science and Practice 2004; 11: 343-359
Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2003; 71 (6): 963-972
To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.
View details for DOI 10.1037/0022-006X.71.6.963
View details for Web of Science ID 000186693600001
View details for PubMedID 14622071
Word use in the poetry of suicidal and nonsuicidal poets
2001; 63 (4): 517-522
The purpose of this study was to determine whether distinctive features of language could be discerned in the poems of poets who committed suicide and to test two suicide models by use of a text-analysis program.Approximately 300 poems from the early, middle, and late periods of nine suicidal poets and nine nonsuicidal poets were compared by use of the computer text analysis program, Linguistic Inquiry and Word Count (LIWC). Language use within the poems was analyzed within the context of two suicide models.In line with a model of social integration, writings of suicidal poets contained more words pertaining to the individual self and fewer words pertaining to the collective than did those of nonsuicidal poets. In addition, the direction of effects for words pertaining to communication was consistent with the social integration model of suicide.The study found support for a model that suggests that suicidal individuals are detached from others and are preoccupied with self. Furthermore, the findings suggest that linguistic predictors of suicide can be discerned through text analysis.
View details for Web of Science ID 000170119800001
View details for PubMedID 11485104