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Raghavan R, Fitzsimmons-Craft EE, Welch RR, Jo B, Proctor EK, Wilson GT, Agras WS, Wilfley DE. Cost-effectiveness of train-the-trainer versus expert consultation training models for implementing interpersonal psychotherapy in college mental health settings: evidence from a national cluster randomized trial. Implement Sci 2024; 19:55. [PMID: 39075590 PMCID: PMC11287912 DOI: 10.1186/s13012-024-01388-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND This study is a cost-effectiveness study of two implementation strategies designed to train therapists in college and university counseling centers to deliver interpersonal psychotherapy. Costs of implementing a train-the-trainer (TTT) strategy versus an expert consultation strategy were estimated, and their relative effects upon therapist outcomes were calculated and compared. METHODS Twenty four counseling centers were recruited across the United States. These centers were randomized to either a TTT (experimental) condition, in which an in-house therapist trained other center therapists, or an expert consultation condition, in which center therapists participated in a workshop and received 12 months of ongoing supervision. The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, assessed via audio recordings of therapy sessions, and analyzed using linear mixed models. Costs of each condition were quantified using time-driven activity-based costing methods, and involved a costing survey administered to center directors, follow up interviews and validation checks, and comparison of time tracking logs of trainers in the expert condition. Mean costs to produce one therapist were obtained for each condition. The costs to produce equivalent improvements in therapist-level outcomes were then compared between the two conditions. RESULTS Mean cost incurred by counseling centers to train one therapist using the TTT strategy was $3,407 (median = $3,077); mean cost to produce one trained therapist in the control condition was $2,055 (median = $1,932). Therapists in the TTT condition, on average, demonstrated a 0.043 higher adherence score compared to therapists in the control condition; however, this difference was not statistically significant. For the competence outcome, effect size for therapists in the TTT condition was in the large range (1.16; 95% CI: 0.85-1.46; p < .001), and therapists in this condition, on average, demonstrated a 0.073 higher competence score compared to those in the expert consultation condition (95% CI, 0.008-0.14; p = .03). Counseling centers that used the TTT model incurred $353 less in training costs to produce equivalent improvements in therapist competence. CONCLUSIONS Despite its higher short run costs, the TTT implementation strategy produces greater increases in therapist competence when compared to expert consultation. Expanding resources to support this platform for service delivery can be an effective way to enhance the mental health care of young people seeking care in college and university counseling centers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02079142.
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Affiliation(s)
- Ramesh Raghavan
- New York University, Silver School of Social Work, New York, NY, US.
| | | | - R Robinson Welch
- Washington University in St. Louis, School of Medicine, Department of Psychiatry, St. Louis, MO, US
| | - Booil Jo
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA, US
| | - Enola K Proctor
- Washington University in St. Louis, Brown School, St. Louis, MO, US
| | - G Terence Wilson
- Graduate School of Applied and Professional Psychology, Rutgers, The State University of New Jersey, Piscataway, NJ, US
| | - W Stewart Agras
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA, US
| | - Denise E Wilfley
- Washington University in St. Louis, School of Medicine, Department of Psychiatry, St. Louis, MO, US
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2
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Galovski TE, Nixon RDV, Kehle-Forbes S. Walking the line between fidelity and flexibility: A conceptual review of personalized approaches to manualized treatments for posttraumatic stress disorder. J Trauma Stress 2024. [PMID: 38954530 DOI: 10.1002/jts.23073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 07/04/2024]
Abstract
The heterogeneity of the core symptoms of posttraumatic stress disorder (PTSD), high rates of comorbid mental and physical health conditions, and substantial impact of the disorder on functioning and well-being contribute to complex clinical presentations that can be challenging to treat. Despite these challenges, there are excellent manualized treatments for PTSD with significant empirical support. Although the success of frontline treatments for PTSD is evident, there remains room for improvement as indicated by suboptimal response and attrition rates. To address challenges to optimal therapy outcomes (COTOs), researchers have conducted numerous clinical trials designed to (a) enhance the core structure of treatment protocols to increase flexibility or (b) expand the protocols to address comorbid conditions that inhibit recovery. However, it is implausible to ever conduct the number of enhancement and expansion clinical trials necessary to test manual modifications for the universe of possible COTOs. This conceptual review describes the concept of a personalized model of therapy that leverages a case formulation approach to implementing an evidence-based treatment for PTSD. This personalized approach provides guidance for the clinician in assessing the patient's COTOs, monitoring them throughout treatment, and relying on the patient's idiosyncratic data to inform treatment decisions, including how and when to diverge from treatment when clinically indicated and ensuring a clear path to return to trauma-focused work when the COTO is stabilized. This personalized, case formulation approach to treating PTSD provides guidance for adopting a more flexible approach to treating clinically complex patients while ensuring fidelity to the protocol.
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Affiliation(s)
- Tara E Galovski
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Reginald D V Nixon
- College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia
- Flinders University Institute for Mental Health and Wellbeing, Flinders University, Adelaide, Australia
| | - Shannon Kehle-Forbes
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Center for Care Delivery and Outcomes Research, VA Minneapolis Medical Center, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
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3
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Szoke D, Walker E, Christ N, Smith D, Held P. Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program. Cogn Behav Ther 2024; 53:423-435. [PMID: 38477982 DOI: 10.1080/16506073.2024.2329246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
Negative posttraumatic cognitions (NPCs) have been linked to symptoms of PTSD and are an important target of cognitive behavioral treatments for PTSD, including Cognitive Processing Therapy (CPT). Yet to be explored are the different change trajectories of NPCs during CPT. Knowledge of such change trajectories could elucidate common NPC change processes within CPT and their relationship to PTSD symptom severity. We examined NPC change trajectories in a group of 443 veterans who completed a 2-week intensive CPT program. We identified four NPC trajectory groups termed start high end high, start high end moderate, start moderate end low, and start low end low. Most of the groups showed an increase in NPCs at the midpoint of treatment before ultimately decreasing. As predicted, baseline PTSD symptom severity predicted change trajectory group membership. Also, NPC change trajectories were associated with PTSD severity at the end of treatment such that individuals in smaller NPC change groups had higher PTSD symptoms at the end of treatment, and vice versa. Clinicians can use this knowledge to make predictions of a particular client's NPC change trajectory and set expectations for what progress in treatment may look like, including normalizing increases in NPCs from the start of treatment.
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Affiliation(s)
- Daniel Szoke
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Erin Walker
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Nicole Christ
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Dale Smith
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
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Chaple MJ, Kunins HV, Nass MD, Benjamin AC, Viel CR, Bertone P, Marker L, Warren P, Hartzler B. Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers. J Behav Health Serv Res 2024; 51:185-202. [PMID: 38030934 DOI: 10.1007/s11414-023-09871-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.
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Affiliation(s)
- Michael J Chaple
- New York State Psychiatric Institute, Division on Substance Use Disorders, Columbia University Irving Medical Center, New York, NY, USA.
| | | | - M D Nass
- Bureau of Alcohol and Drug Use Prevention Care and Treatment, NYC Department of Health and Mental Hygiene, New York, NY, USA
| | - Ajani C Benjamin
- Bureau of Alcohol and Drug Use Prevention Care and Treatment, NYC Department of Health and Mental Hygiene, New York, NY, USA
| | - Carl R Viel
- Bureau of Alcohol and Drug Use Prevention Care and Treatment, NYC Department of Health and Mental Hygiene, New York, NY, USA
| | - Paula Bertone
- New York State Psychiatric Institute, Division on Substance Use Disorders, Columbia University Irving Medical Center, New York, NY, USA
| | - Lauren Marker
- New York State Psychiatric Institute, Division on Substance Use Disorders, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Warren
- New York State Psychiatric Institute, Division on Substance Use Disorders, Columbia University Irving Medical Center, New York, NY, USA
| | - Bryan Hartzler
- Center for Advancing Addiction Services, Addiction, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA
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Zaccari B, Sherman ADF, Higgins M, Ann Kelly U. Trauma Center Trauma-Sensitive Yoga Versus Cognitive Processing Therapy for Women Veterans With PTSD Who Experienced Military Sexual Trauma: A Feasibility Study. J Am Psychiatr Nurses Assoc 2024; 30:343-354. [PMID: 35833676 PMCID: PMC9839891 DOI: 10.1177/10783903221108765] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is a common sequela to military sexual trauma (MST) among women veterans. Yoga has shown promise in research examining its benefit for symptoms and sequela of PTSD. AIMS The objective of this study was to evaluate the feasibility of a randomized controlled trial (RCT) of Trauma Center Trauma-Sensitive Yoga (TCTSY) for women veterans with PTSD related to MST. METHOD In this feasibility study, the final sample included women veterans (n = 41) with PTSD related to MST accessing health care in a Veterans Affairs Health Care System in the southeast United States; the majority were African American (n = 33; 80.5%). Interventions used established protocols of 10 weekly sessions of group TCTSY versus 12 weekly sessions of group Cognitive Processing Therapy (CPT). PTSD was assessed via clinical interview and participant report. Additional data collection included multiple participant-reported outcomes commonly associated with PTSD and psychophysiological measures. We also collected data regarding participant satisfaction and feasibility-related feedback from participants and providers. RESULTS Feasibility and acceptability were evaluated via demand, practicality, fidelity, and acceptability. This was measured by expressed interest, attendance, program completion, barriers to care and satisfaction with treatment, and satisfaction with interventions and data collection. CONCLUSIONS Results indicate the RCT design and TCTSY implementation were feasible; a full-scale RCT was subsequently conducted to determine efficacy of the experimental intervention. Recommendations for successful research strategies are provided.
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Affiliation(s)
- Belle Zaccari
- Belle Zaccari, PsyD, Veterans Affairs Portland Health Care System, Portland, OR, USA
- Belle Zaccari, PsyD, Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Athena D F Sherman
- Athena D. F. Sherman, PhD, PHN, RN, CNE, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Melinda Higgins
- Melinda Higgins, PhD, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Ursula Ann Kelly
- Ursula Ann Kelly, PhD, APRN, ANP-BC, PMHNP-BC, FAANP, FAAN, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
- Ursula Ann Kelly, PhD, APRN, ANP-BC, PMHNP-BC, FAANP, FAAN, Atlanta VA Health Care System, Atlanta, GA, USA
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6
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Steil R, Weiss J, Müller-Engelmann M, Dittmann C, Priebe K, Kleindienst N, Fydrich T, Stangier U. Is adherence to dialectic behaviour therapy for post-traumatic stress disorder (PTSD) and cognitive processing therapy related to treatment outcome in PTSD after childhood abuse? Eur J Psychotraumatol 2023; 14:2260293. [PMID: 37860858 PMCID: PMC10591525 DOI: 10.1080/20008066.2023.2260293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 07/04/2023] [Indexed: 10/21/2023] Open
Abstract
Background: Literature on the association between therapist adherence and treatment success in the treatment of post-traumatic stress disorder (PTSD) is scarce, and the results are mixed.Objective: To examine the relationship between therapist adherence to dialectical behaviour therapy for PTSD (DBT-PTSD) and cognitive processing therapy (CPT) on treatment outcome in women with PTSD and emotion regulation difficulties after interpersonal childhood abuse.Method: Videotaped therapy sessions from 160 female participants of a large randomized controlled trial [Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse. JAMA Psychiatry, 77(12), 1235. jamapsychiatry.2020.2148] were rated. Adherence to CPT and DBT-PTSD was assessed using two specifically developed rating scales.Results: Higher therapist adherence was associated with a greater reduction of clinician-rated PTSD symptom severity. This effect was more pronounced in the CPT group than in the DBT-PTSD group. Adherence was also related to a greater reduction of self-rated PTSD symptoms, borderline symptoms, and dissociation intensity.Conclusion: Our results indicate that higher therapist adherence can lead to better treatment outcomes in PTSD treatments, especially in CPT.
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Affiliation(s)
- Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Judith Weiss
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Meike Müller-Engelmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
- Department of Psychology, Medical School Hamburg, Faculty Human Sciences, Hamburg, Germany
| | - Clara Dittmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Kathlen Priebe
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolaus Kleindienst
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Thomas Fydrich
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany
| | - Ulrich Stangier
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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7
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Sripada RK, Peterson CL, Dziak JJ, Nahum-Shani I, Roberge EM, Martinson AA, Porter K, Grau P, Curtis D, McElroy S, Bryant S, Gracy I, Pryor C, Walters HM, Austin K, Ehlinger C, Sayer N, Wiltsey-Stirman S, Chard K. Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment. Trials 2023; 24:676. [PMID: 37858262 PMCID: PMC10588087 DOI: 10.1186/s13063-023-07669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format. METHODS The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness. DISCUSSION There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program. TRIAL REGISTRATION ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA.
| | - Cassaundra L Peterson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - John J Dziak
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, USA
| | - Inbal Nahum-Shani
- University of Michigan Institute for Social Research, Ann Arbor, USA
| | - Erika M Roberge
- VA Salt Lake City Health Care System, University of Utah School of Medicine, Salt Lake City, USA
| | | | | | - Peter Grau
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA
| | - Diana Curtis
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Sarah Bryant
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Isabel Gracy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Cosette Pryor
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Heather M Walters
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Karen Austin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Nina Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA
| | | | - Kathleen Chard
- Cincinnati VA Medical Center, University of Cincinnati, Cincinnati, USA
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8
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Steil R, Weiss J, Müller-Engelmann M, Dittmann C, Priebe K, Kleindienst N, Fydrich T, Stangier U. Does treatment specific-, disorder specific- or general therapeutic competence predict symptom reduction in posttraumatic stress disorder? Eur J Psychotraumatol 2023; 14:2257434. [PMID: 37753639 PMCID: PMC10538459 DOI: 10.1080/20008066.2023.2257434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/13/2023] [Indexed: 09/28/2023] Open
Abstract
Background: Literature on the association between therapist competence and treatment success in posttraumatic stress disorder (PTSD) treatments is scarce and results are mixed.Aims/Objective: The relationship between different types of therapeutic competence, therapeutic alliance, and PTSD symptom reduction in patients treated with Dialectical Behaviour Therapy for PTSD (DBT-PTSD) or Cognitive Processing Therapy (CPT) was assessed. Competence types were PTSD-specific competence, treatment specific competence, and general competence in cognitive behaviour therapy (CBT).Method: Videotaped therapy sessions from N = 160 women with PTSD and emotion regulation difficulties after child abuse participating in a large randomised controlled trial (Bohus et al., 2020) were rated. Three therapeutic competence-types were assessed using specifically developed rating scales. Alliance was assessed via patient ratings with the Helping Alliance Questionnaire (HAQ). PTSD symptoms were assessed at pre- and post-treatment via clinician rating with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and via self-rating with the PTSD-Checklist for DSM-5 (PCL-5).Results: No significant association between competence and clinician or self-rated PTSD symptoms was found. PTSD specific competence predicted clinician rated PTSD symptom severity on a trend level. Alliance predicted both clinician and self-rated PTSD symptom reduction.Conclusion: Our results provide a starting point for future research on different competence types and their association with PTSD treatment gains. Therapists were highly trained and received weekly supervision, hence a restricted competence range is a possible explanation for non-existing associations between competence and PTSD symptom reduction in our sample. More research in naturalistic settings, such as dissemination studies, is needed.
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Affiliation(s)
- Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Judith Weiss
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Meike Müller-Engelmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
- Faculty Human Sciences, Department Psychology, Medical School Hamburg, Germany
| | - Clara Dittmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Kathlen Priebe
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolaus Kleindienst
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Thomas Fydrich
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany
| | - Ulrich Stangier
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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9
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Steil R, Weiss J, Renneberg B, Gutermann J, Rosner R. Effect of therapeutic competence, adherence, and alliance on treatment outcome in youth with PTSD treated with developmentally adapted cognitive processing therapy. CHILD ABUSE & NEGLECT 2023; 141:106221. [PMID: 37178528 DOI: 10.1016/j.chiabu.2023.106221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/06/2023] [Accepted: 04/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Developmentally adapted cognitive processing therapy (D-CPT) is an effective treatment for posttraumatic stress disorder (PTSD) in adolescents and young adults. It is unclear if therapeutic adherence and competence in D-CPT are associated with higher PTSD treatment gains. OBJECTIVE To assess if higher therapeutic adherence and competence in D-CPT are associated with higher symptom reduction of PTSD in adolescents and young adults, while controlling for therapeutic alliance. PARTICIPANTS AND SETTING Participants were 38 patients (aged 14-21 years; M = 17.61 years, SD = 2.42 years) of a multicenter randomized controlled trial in which the efficacy of D-CPT was compared to a waitlist with treatment advice. METHODS Videotaped therapy sessions were rated using validated ratings scales to assess adherence and competence. Therapeutic alliance was assessed via weekly patient ratings. We used hierarchical linear modelling to assess the relationship of adherence and competence on PTSD symptoms being measured by both clinician and patient while controlling for alliance. RESULTS Neither adherence nor competence were related to treatment outcomes in clinician or patient rated PTSD symptom severity. Higher alliance was associated with a lower symptom severity at 12 months posttreatment in both clinician and patient rated PTSD symptoms. CONCLUSIONS In this study of young adults with PTSD, who were treated with D-CPT by well-trained therapists, therapeutic adherence and competence were not related to treatment outcome. This might be explained by a lack of range in therapist adherence and competence. Therapeutic alliance had a positive effect on PTSD symptom severity.
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Affiliation(s)
- Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Judith Weiss
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Babette Renneberg
- Department of Clinical Psychology and Psychotherapy, Freie Universitaet Berlin, Berlin, Germany
| | - Jana Gutermann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstätt-Ingolstadt, Eichstätt, Germany
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10
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Alpert E, Carpenter JK, Smith BN, Woolley MG, Raterman C, Farmer CC, Kehle-Forbes SM, Galovski TE. Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion. J Trauma Stress 2023; 36:397-408. [PMID: 36987703 PMCID: PMC10228524 DOI: 10.1002/jts.22924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.
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Affiliation(s)
- Elizabeth Alpert
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Joseph K. Carpenter
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Brian N. Smith
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
| | - Mercedes G. Woolley
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | | | - Shannon M. Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Center for Care Delivery & Outcomes Research at Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tara E. Galovski
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University Chobanian & Avedisian School of Medicine Department of Psychiatry, Boston, Massachusetts, USA
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11
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Powers KE, das Nair R, Phillips J, Farrin A, Radford KA. Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4694. [PMID: 36981601 PMCID: PMC10048688 DOI: 10.3390/ijerph20064694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualising intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early stroke specialist vocational rehabilitation intervention (ESSVR), and stroke survivor return-to-work (RTW) outcomes. Thirty-nine OTs were surveyed about their experience and knowledge of stroke and vocational rehabilitation and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Fidelity scores ranged from 30.8 to 100% (Mean: 78.8%, SD: 19.2%). Only OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05-0.53, p < 0.05). Increased fidelity (OR = 1.06, 95% CI = 1.01-1.1, p = 0.01) and increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI = 1.02-1.35) was significantly associated with positive stroke survivor RTW outcomes. Findings of this study suggest that mentoring OTs may increase fidelity of delivery of ESSVR, which may also be associated with positive stroke survivor return-to-work outcomes. The results also suggest that OTs with more experience of stroke rehabilitation may be able to support stroke survivors to RTW more effectively. Upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.
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Affiliation(s)
- Katie E. Powers
- Injury, Inflammation & Recovery Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK
| | - Roshan das Nair
- Health Division, SINTEF, 7465 Trondheim, Norway
- Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Julie Phillips
- Injury, Inflammation & Recovery Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9JT, UK
| | - Kathryn A. Radford
- Injury, Inflammation & Recovery Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK
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12
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Held P, Splaine CC, Smith DL, Kaysen D. Examining trauma cognition change trajectories among initial PTSD treatment non-optimal responders: a potential avenue to guide subsequent treatment selection. Eur J Psychotraumatol 2023; 14:2237361. [PMID: 37564032 PMCID: PMC10424629 DOI: 10.1080/20008066.2023.2237361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/17/2023] [Accepted: 06/20/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Despite their general effectiveness, 14-50% of individuals do not fully respond to evidence-based treatments for posttraumatic stress disorder (PTSD). Although changes in negative posttrauma cognitions (NPCs) are considered a likely PTSD treatment mechanism, less is known about how NPCs change among individuals who continue to be symptomatic following treatment (non-optimal responders). OBJECTIVE The objective of this study was to examine NPC change trajectories among individuals who were determined to be non-optimally responsive to intensive PTSD treatment. METHOD Using a 3-week Cognitive Processing Therapy-based intensive PTSD treatment sample (ITP; N = 243), the present study examined the number of distinct NPC change trajectories among non-optimal responders via Group Based Trajectory Modeling and assessed predictors of non-optimal responders' NPC change trajectory membership. Analyses were replicated in a separate 2-week ITP sample (N = 215). RESULTS In both non-optimal responder samples, two trajectories emerged; a no NPC change group which represented those with an overall lack of NPC change throughout treatment and an NPC change group which represented those with an overall reduction of NPCs occurring primarily later in treatment. Changes in PTSD symptom severity during treatment was the only consistent predictor of NPC change trajectory group membership among treatment non-optimal responders across ITPs. CONCLUSIONS Findings suggest NPC change among non-optimal responders is nuanced and may inform subsequent intervention selection, resulting in testable hypotheses for future research.
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Affiliation(s)
- Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Cailan C. Splaine
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Dale L. Smith
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
- Department of Psychiatry, University of Illinois – Chicago, Chicago, IL, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, CA, USA
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13
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LoSavio ST, Holder N, Wells SY, Resick PA. Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Keefe JR, Hernandez S, Johanek C, Landy MSH, Sijercic I, Shnaider P, Wagner AC, Lane JEM, Monson CM, Stirman SW. Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes. Behav Ther 2022; 53:763-775. [PMID: 35987537 DOI: 10.1016/j.beth.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/04/2021] [Accepted: 12/07/2021] [Indexed: 11/02/2022]
Abstract
Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1-3 and one session from Sessions 4-7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18-0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.
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Affiliation(s)
| | | | | | | | | | | | | | - Jeanine E M Lane
- Ryerson University, Toronto; Ontario Shores Center for Mental Health Sciences, Whitby, Ontario
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15
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Held P, Kovacevic M, Petrey K, Meade EA, Pridgen S, Montes M, Werner B, Miller ML, Smith DL, Kaysen D, Karnik NS. Treating posttraumatic stress disorder at home in a single week using 1-week virtual massed cognitive processing therapy. J Trauma Stress 2022; 35:1215-1225. [PMID: 35338534 PMCID: PMC9357038 DOI: 10.1002/jts.22831] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 01/03/2023]
Abstract
Posttraumatic stress disorder (PTSD) treatments are increasingly delivered in massed formats and have shown comparable results to standard, weekly treatment. To date, massed cognitive processing therapy (CPT), delivered daily, has been delivered primarily in combination with adjunctive services and among veteran populations, but it has not been rigorously evaluated as a standalone intervention. The present study evaluated 1-week massed CPT delivered virtually (i.e., via telehealth) to a community sample of trauma-exposed individuals (N = 24). Using a single-arm open-label design, participants received CPT twice per day for 5 days. The results indicated that most participants completed treatment (n = 23, 95.8%), and no adverse events were reported. Participants exhibited large reductions in clinician-rated, d = 2.01, and self-reported PTSD symptoms, d = 2.55, as well as self-reported depressive symptoms, d = 1.46. On average, participants reported a 5-point PTSD symptom reduction and 1-point reduction in depressive symptoms for each treatment day. Reductions in PTSD and depressive symptoms were maintained at 3-month follow-up. Overall, 1-week massed CPT delivered virtually was shown to be feasible and to result in rapid symptom reductions that were sustained over time. Virtual massed CPT has the potential to increase access to effective treatments and help trauma survivors restore aspects of their lives in short amounts of time.
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Affiliation(s)
- Philip Held
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Merdijana Kovacevic
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Kelsey Petrey
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Enya A. Meade
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Sarah Pridgen
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Mauricio Montes
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Brianna Werner
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
| | - Michelle L. Miller
- Department of PsychiatryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Dale L. Smith
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA,Department of Behavioral SciencesOlivet Nazarene UniversityBourbonnaisIllinoisUSA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral SciencesStanford University School of MedicineStanfordCaliforniaUSA,National Center for PTSDVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA
| | - Niranjan S. Karnik
- Department of Psychiatry and Behavioral SciencesRush University Medical CenterIllinoisUSA
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16
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Understanding why people with OCD do what they do, and why other people get involved: supporting people with OCD and loved ones to move from safety-seeking behaviours to approach-supporting behaviours. COGNITIVE BEHAVIOUR THERAPIST 2022. [DOI: 10.1017/s1754470x22000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
The distress inherent in obsessive compulsive disorder (OCD) can often lead to partners, family members and friends becoming entangled with the OCD in terms of being drawn into performing certain behaviours to try and reduce the distress of their loved one. In the past this has often been referred to somewhat pejoratively as collusion, or more neutrally as accommodation. In this paper we emphasise that this is usually a natural human response to seeing a loved one in distress and wanting to help. This paper provides detailed clinical guidance on how to understand this involvement and how to include others in the treatment of OCD along with practical tips and hints around potential blocks that may require troubleshooting. It also details the relatively recently introduced concept of approach-supporting behaviours, and provides guidance on how to distinguish these from safety-seeking behaviours. The ‘special case’ of reassurance seeking is also discussed.
Key learning aims
(1)
To illustrate the importance of understanding the person’s OCD beliefs ‘from the inside’ including the internal logic that leads to specific behaviours.
(2)
To understand the ways that key individuals in the lives of people with OCD can become entangled with the OCD (through the best of intentions) and to provide practical clinical guidance for CBT therapists around how to engage and work with these individuals in the lives of people with OCD.
(3)
To explain and delineate the idea of approach-supporting behaviours, distinguishing these from safety-seeking behaviours.
(4)
To distinguish the interpersonal component of reassurance from the neutralisation component and provide guidance on how we can help family members to replace reassurance with something that is equally or more supportive whilst not maintaining the OCD.
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17
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Morris KL, Schwartz C, Galovski TE, Dondanville KA, Schuster Wachen J. Massed Cognitive Processing Therapy in Active-Duty Military: A Case Series. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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18
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Holder N, Batten AJ, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Patterson OV, DuVall SL, Maguen S. Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same? Cogn Behav Ther 2022; 51:456-469. [PMID: 35475499 DOI: 10.1080/16506073.2022.2058996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI95: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.
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Affiliation(s)
- Nicholas Holder
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Adam J Batten
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Applied Statistics Unit, AB Evergreen Analytics LLC, Seattle, WA, USA
| | - Brian Shiner
- Mental Health Service, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Executive Division Hanover, New Hampshire, USA.,Executive Division, National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
| | - Yongmei Li
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Erin Madden
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Integrative Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Departments of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
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19
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Chapman JE, Schoenwald SK, Sheidow AJ, Cunningham PB. Performance of a Supervisor Observational Coding System and an Audit and Feedback Intervention. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:670-693. [PMID: 35230600 DOI: 10.1007/s10488-022-01191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2022] [Indexed: 10/19/2022]
Abstract
Workplace-based clinical supervision is common in community based mental health care for youth and families and could be a leveraged to scale and improve the implementation of evidence-based treatment (EBTs). Accurate methods are needed to measure, monitor, and support supervisor performance with limited disruption to workflow. Audit and Feedback (A&F) interventions may offer some promise in this regard. The study-a randomized controlled trial with 60 clinical supervisors measured longitudinally for 7 months-had two parts: (1) psychometric evaluation of an observational coding system for measuring adherence and competence of EBT supervision and (2) evaluation of an experimental Supervisor Audit and Feedback (SAF) intervention on outcomes of supervisor adherence and competence. All supervisors recorded and uploaded weekly supervision sessions for 7 months, and those in the experimental condition were provided a single, monthly web-based feedback report. Psychometric performance was evaluated using measurement models based in Item Response Theory, and the effect of the SAF intervention was evaluated using mixed-effects regression models. The observational instrument performed well across psychometric indicators of dimensionality, rating scale functionality, and item fit; however, coder reliability was lower for competence than for adherence. Statistically significant A&F effects were largely in the expected directions and consistent with hypotheses. The observational coding system performed well, and a monthly electronic feedback report showed promise in maintaining or improving community-based clinical supervisors' adherence and, to a lesser extent, competence. Limitations discussed include unknown generalizability to the supervision of other EBTs.
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20
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Vittorio LN, Murphy ST, Braun JD, Strunk DR. Using Socratic Questioning to promote cognitive change and achieve depressive symptom reduction: Evidence of cognitive change as a mediator. Behav Res Ther 2022; 150:104035. [PMID: 35016095 DOI: 10.1016/j.brat.2022.104035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/08/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023]
Abstract
Socratic questioning has long been thought to play a critical role in cognitive behavioral therapy (CBT) for depression. Though use of Socratic questioning is theorized to achieve symptom reduction by promoting cognitive change, research has yet to investigate this pathway. In a sample of 123 clients participating in CBT for depression, we tested cognitive change as a mediator of the relation between Socratic questioning and symptom change in early treatment sessions. We found evidence of a significant indirect effect, consistent with cognitive change mediating the effect of Socratic questioning on change in depressive symptoms. Further analyses showed that pre-treatment CBT skills moderated the effect of Socratic questioning on cognitive change, with this relationship being stronger for clients who started treatment with lower CBT skills. These findings provide support for the view that Socratic questioning contributes to therapeutic gains in CBT through cognitive change. This study also provides initial evidence to suggest the use of Socratic questioning is particularly important for clients who begin treatment with particularly low CBT skills.
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Affiliation(s)
- Lisa N Vittorio
- The Ohio State University, Department of Psychology, The Ohio State University, Columbus, OH, United States
| | - Samuel T Murphy
- The Ohio State University, Department of Psychology, The Ohio State University, Columbus, OH, United States
| | - Justin D Braun
- The Ohio State University, Department of Psychology, The Ohio State University, Columbus, OH, United States
| | - Daniel R Strunk
- The Ohio State University, Department of Psychology, The Ohio State University, Columbus, OH, United States.
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21
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Steil R, Müller-Engelmann M, Stangier U, Priebe K, Fydrich T, Weiß J, Dittmann C. Scales for assessing therapeutic adherence and competence in dialectical behaviour therapy for PTSD: development and analysis of psychometric properties. Eur J Psychotraumatol 2022; 13:2055293. [PMID: 35386730 PMCID: PMC8979536 DOI: 10.1080/20008198.2022.2055293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The assessment of therapeutic adherence and competence is essential to understand mechanisms that contribute to treatment outcome. Nevertheless, their assessment is often neglected in psychotherapy research. AIMS/OBJECTIVE To develop an adherence and a treatment-specific competence rating scale for Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD), and to examine their psychometric properties. Global cognitive behavioural therapeutic competence and disorder-specific therapeutic competence were assessed using already existing scales to confirm their psychometric properties in our sample of patients with PTSD and emotion regulation difficulties. METHOD Two rating scales were developed using an inductive procedure. 155 videotaped therapy sessions from a multicenter randomised controlled trial were rated by trained raters using these scales, 40 randomly chosen videotapes involving eleven therapists and fourteen patients were doubly rated by two raters. RESULTS Both the adherence scale (Patient-level ICC = .98; αs = .65; α p = .75) and the treatment-specific competence scale (Patient-level ICC = .98; αs = .78; α p = .82) for DBT-PTSD showed excellent interrater - and good reliability on the patient level. Content validity, including relevance and appropriateness of all items, was confirmed by experts in DBT-PTSD for the new treatment-specific competence scale. CONCLUSION Our results indicate that both scales are reliable instruments. They will be useful to examine possible effects of adherence and treatment-specific competence on DBT-PTSD treatment outcome.
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Affiliation(s)
- Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Meike Müller-Engelmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Ulrich Stangier
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Kathlen Priebe
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Fydrich
- Department of Psychology, Faculty of Life Sciences, Humboldt-University of Berlin, Berlin, Germany
| | - Judith Weiß
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Clara Dittmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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22
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Cooper G, Zink A, Jordan SE. Dialectical Behavior Therapy and Cognitive Processing Therapy Delivered Sequentially to a Woman Veteran: A Promising Alternative to Concurrent Dialectical Behavior Therapy–Prolonged Exposure. Clin Case Stud 2021. [DOI: 10.1177/15346501211049452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD) are complex and chronic conditions that result in impairment across a number of clinically significant domains. Although the two diagnoses reflect distinct clinical syndromes, they often present comorbidly. Furthermore, the comorbidity of the two diagnoses predicts increased symptomatology and may also result in treatment difficulties that would not arise when treating PTSD without a concurrent BPD diagnosis. The challenging nature of comorbid PTSD and BPD diagnoses has led to an increased interest in integrative approaches to treating both diagnoses together. Recent research has suggested that the integration of prolonged exposure (PE; an evidence-based therapy for PTSD) and dialectical behavior therapy (DBT; an evidence-based therapy for BPD) into one treatment approach (CBT–PE) can offer superior outcomes when compared to treating each diagnosis separately. However, at this time, the literature does not document any such examinations with regards to cognitive processing therapy (CPT), another evidence-based therapy for PTSD. This paper reflects a first step towards exploring the integration of CPT and DBT. In this case, a female-identified military Veteran seeking care at a Veterans Affairs healthcare system was treated utilizing integrated, though sequential, CPT and DBT. The clinical results of this case are discussed, as are the implications for other clinicians considering integrating CPT and DBT.
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Affiliation(s)
- Graham Cooper
- Santa Rosa Mental Health and Wellness, Kaiser Permanente Northern California, Santa Rosa, CA, USA
| | - Alycia Zink
- Department of Veterans Affairs, James Haley VA Medical Center, Tampa, FL, USA
| | - Shiloh E. Jordan
- Department of Veterans Affairs, VA Pacific Islands Health Care System, Honolulu, HI, USA
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23
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Dondanville KA, Fina BA, Straud CL, Finley EP, Tyler H, Jacoby V, Blount TH, Moring JC, Pruiksma KE, Blankenship AE, Evans WR, Zaturenskaya M. Launching a Competency-Based Training Program in Evidence-Based Treatments for PTSD: Supporting Veteran-Serving Mental Health Providers in Texas. Community Ment Health J 2021; 57:910-919. [PMID: 32666417 DOI: 10.1007/s10597-020-00676-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Community mental health providers play an essential role in delivering services to veterans who either have limited access to U.S. Department of Veterans Affairs (VA) facilities or who prefer to seek care outside of the VA. However, there are limited training opportunities in evidence-based treatments for posttraumatic stress disorder (PTSD) outside of the VA. In 2017, the STRONG STAR Training Initiative was established to develop competency-based training in two evidence-based therapies for PTSD and to provide that training for mental health providers serving veterans and their families in community settings in Texas. This article describes the program's development and implementation, baseline characteristics of participating clinicians, and lessons learned toward the scale-up and extension of this competency-based training effort to include other interventions and locations.
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Affiliation(s)
- Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, 78249, USA
| | - Erin P Finley
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, USA
| | - Hannah Tyler
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Vanessa Jacoby
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Tabatha H Blount
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - John C Moring
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Abby E Blankenship
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Wyatt R Evans
- VA North Texas Health Care System, 4500 S Lancaster Rd, Dallas, TX, USA
| | - Mariya Zaturenskaya
- James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL, USA
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24
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Stirman SW, Gutner CA, Gamarra J, Suvak MK, Vogt D, Johnson C, Wachen JS, Dondanville KA, Yarvis JS, Mintz J, Peterson AL, Young-McCaughan S, Resick PA. A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy. Behav Ther 2021; 52:656-672. [PMID: 33990240 DOI: 10.1016/j.beth.2020.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 11/28/2022]
Abstract
Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.
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Affiliation(s)
- Shannon Wiltsey Stirman
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Healthcare System & Stanford University.
| | - Cassidy A Gutner
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | | | | | - Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | - Clara Johnson
- Dissemination and Training Division, National Center for PTSD
| | - Jennifer Schuster Wachen
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | | | | | - Jim Mintz
- University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; University of Texas at San Antonio
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25
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Cognitive Bias and Medication Use Moderate the Relation of Socratic Questioning and Symptom Change in Cognitive Behavioral Therapy of Depression. COGNITIVE THERAPY AND RESEARCH 2021. [DOI: 10.1007/s10608-021-10224-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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26
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Sijercic I, Lane JEM, Gutner CA, Monson CM, Stirman SW. The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 47:8-18. [PMID: 31463667 DOI: 10.1007/s10488-019-00966-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.
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Affiliation(s)
| | | | | | | | - Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System & Stanford University, 795 Willow Road, NC-PTSD 334, Menlo Park, CA, 94025, USA.
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27
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Mallard Swanson K, Song J, Beristianos M, Aajmain S, Lane JE, Landy MS, Suvak MK, Shields N, Monson CM, Stirman SW. A Glimpse into the "Black Box": Which Elements of Consultation in an EBP are Associated with Client Symptom Change and Therapist Fidelity? IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2:26334895211051791. [PMID: 37090000 PMCID: PMC9978606 DOI: 10.1177/26334895211051791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Consultation is an implementation strategy that improves delivery and clinical outcomes for Cognitive Processing Therapy (CPT), an evidence-based practice (EBP) for posttraumatic stress disorder (PTSD). However, little is known about the specific components of consultation that influence the fidelity of treatment delivery or clinical outcomes. Methods: The current study examined whether specific activities performed during CPT consultation meetings were associated with better fidelity to the CPT protocol among 60 newly trained therapists or improved clinical outcomes among 135 clients treated by these therapists. Consultation activities that fall under three broad categories (discussion of the application of CPT to individual cases, review/feedback on fidelity, and technical difficulties) were measured by consultant checklists for each consultation session. Treatment fidelity (adherence to the protocol and competence of delivery) was rated by trained observers for a random sample of therapists' CPT sessions following consultation. The self-reported PTSD Checklist-IV assessed PTSD symptom change. Results: Multilevel regression analyses indicated that higher therapist consultation attendance predicted a greater decrease in their clients' PTSD symptoms and that attendance was not associated with observer-rated treatment fidelity. Discussion of the application of specific CPT strategies was the only consultation activity that was significantly associated with greater improvement in PTSD symptoms. Lastly, no consultation activities were significantly associated with treatment fidelity. Conclusions: Our findings suggest that specific consultation strategies such as emphasizing the discussion of the application of specific CPT strategies to individual cases during consultation meetings may be effective in improving the clinical outcomes of CPT.
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Affiliation(s)
| | - Jiyoung Song
- National Center for PTSD and Stanford University, Menlo Park, CA,
USA
| | | | - Syed Aajmain
- National Center for PTSD and Stanford University, Menlo Park, CA,
USA
| | - Jeanine E.M. Lane
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | | | | | - Norman Shields
- Royal Canadian Mounted
Police, Divisional Psychologist Occupational Health and Safety
Services, Ottawa, Ontario, Canada
| | - Candice M. Monson
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
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28
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Dardis CM, Kraft KM, Gidycz CA. "Miscommunication" and Undergraduate Women's Conceptualizations of Sexual Assault: A Qualitative Analysis. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:33-61. [PMID: 29294880 DOI: 10.1177/0886260517726412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Approximately 60% of legally defined rape victims do not label their experiences as "rape," most of whom label the experience as "a serious miscommunication." However, little research has examined why women choose this label. Labeling rape as a miscommunication could be problematic if chosen due to stereotypical conceptions that one's experience is not "real" rape. The present study used a mixed-methodological approach to understand why women might refer to rape as a "miscommunication," and how their reasons for labeling might differ from those who label their experiences and those who are nonlabeled (i.e., unequivocally state that they were "not victimized"). Participants included 123 undergraduate women who experienced rape. Participants responded to how they labeled rape and answered questions regarding assault characteristics, disclosure, reporting, and self- and perpetrator blame. Chi-square analyses assessed labeling group differences. Responses to an open-ended question about factors contributing to their labeling decision were content analyzed. Whereas miscommunication-labeled and nonlabeled victims reported similar assault characteristics in the quantitative analyses, qualitative content analyses revealed varying reasons for labeling rape as miscommunication, not victimization, and rape. Over three quarters of miscommunication-labeled victims reported that one or more of the following factors influenced their labeling: victim and perpetrator substance use, sexual activity prior to the rape, and perceptions that one did not express nonconsent strongly enough and that the perpetrator "did not realize" their lack of desire. Whereas miscommunication-labeled and nonlabeled victims reported similar assault characteristics, the extent to which those assault characteristics affected their labeling differed. Those who labeled their experiences as miscommunication gave reasons for their label that centered on factors which reflect inconsistencies between their experiences and "stereotypical rape." Misperceptions of rape can be addressed via prevention programming and clinical work.
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Affiliation(s)
- Christina M Dardis
- VA Boston Healthcare System, Boston, MA, USA
- Boston University, Boston, MA, USA
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29
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What works in the Socratic debate? An analysis of verbal behaviour interaction during cognitive restructuring. Behav Cogn Psychother 2020; 49:513-525. [PMID: 33292882 DOI: 10.1017/s1352465820000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cognitive restructuring is one of the most complex application procedures in psychotherapy. It is widely used by psychologists from different orientations. However, the guidelines on how to apply it do not usually have empirical evidence and there is a lack of knowledge about the mechanisms of change that explain it. AIMS The analysis of verbalizations that therapists emit during the Socratic method could help to better understand the functioning and strategies of effective debates. METHOD In this study, specific verbal interaction sequences were analysed using observational methodology. The sample consisted of 113 Socratic questioning fragments belonging to 18 clinical cases, treated by behavioural therapists. RESULTS Among other findings, it was found that using questioning together with certain previous verbalizations directed the client's response more effectively and those successful debates were characterized by using the aversive component in a frequent and contingent way. CONCLUSION This study shows the most effective way to establish such an interaction in the Socratic method (following a style closer to Ellis's argumentative debate), which entails relevant practical applications in therapy.
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30
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Pace BT, Song J, Suvak MK, Shields N, Monson CM, Stirman SW. Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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31
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Alpert E, Hayes AM, Barnes JB, Sloan DM. Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content. Behav Ther 2020; 51:774-788. [PMID: 32800305 PMCID: PMC7431675 DOI: 10.1016/j.beth.2019.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 12/30/2022]
Abstract
Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.
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Affiliation(s)
| | - Adele M. Hayes
- University of Delaware, Department of Psychological and Brain Sciences
| | - J. Ben Barnes
- University of Delaware, Department of Psychological and Brain Sciences
| | - Denise M. Sloan
- VA Boston Healthcare System, National Center for PTSD,Boston University School of Medicine
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32
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Valenstein-Mah H, Greer N, McKenzie L, Hansen L, Strom TQ, Wiltsey Stirman S, Wilt TJ, Kehle-Forbes SM. Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review. Implement Sci 2020; 15:40. [PMID: 32460866 PMCID: PMC7251851 DOI: 10.1186/s13012-020-00998-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/07/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes. METHODS We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus. RESULTS Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes. LIMITATIONS The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies. CONCLUSIONS EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable. TRIAL REGISTRATION The protocol for this review is registered in PROSPERO (CRD42018093381).
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Affiliation(s)
- Helen Valenstein-Mah
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, 2450 Riverside Avenue, F282/2A West, Minneapolis, MN, 55454, USA.
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Lauren McKenzie
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Lucas Hansen
- Minneapolis VA Health Care System, Minneapolis, MN, USA.,University of St. Thomas, Minneapolis, MN, USA
| | - Thad Q Strom
- Oscar G. Johnson VA Medical Center, Iron Mountain, MI, USA
| | - Shannon Wiltsey Stirman
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Stanford University, Palo Alto, CA, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Shannon M Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.,National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA
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33
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Held P, Klassen BJ, Small CF, Brennan MB, Horn RV, Karnik NS, Pollack MH, Zalta AK. A Case Report of Cognitive Processing Therapy Delivered over a Single Week. COGNITIVE AND BEHAVIORAL PRACTICE 2020; 27:126-135. [PMID: 33041618 PMCID: PMC7543987 DOI: 10.1016/j.cbpra.2019.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.
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Affiliation(s)
- Philip Held
- Rush University Medical Center, Chicago, IL 60612
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34
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Waltman SH. Targeting Trauma-Related Beliefs in PTSD with Behavioral Experiments: Illustrative Case Study. JOURNAL OF RATIONAL-EMOTIVE AND COGNITIVE-BEHAVIOR THERAPY 2020. [DOI: 10.1007/s10942-020-00338-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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35
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Sripada RK, Ready DJ, Ganoczy D, Astin MC, Rauch SAM. When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy. Behav Ther 2020; 51:85-98. [PMID: 32005342 DOI: 10.1016/j.beth.2019.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research VA Ann Arbor Health Care System; University of Michigan.
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System
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36
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Dimitropoulos G, Lock JD, Agras WS, Brandt H, Halmi KA, Jo B, Kaye WH, Pinhas L, Wilfley DE, Woodside DB. Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study. EUROPEAN EATING DISORDERS REVIEW 2020; 28:55-65. [PMID: 31297906 PMCID: PMC6925617 DOI: 10.1002/erv.2695] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 05/16/2019] [Accepted: 05/27/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa. METHOD One hundred and ninety recorded FBT sessions from 68 adolescents with anorexia nervosa and their families were recruited across multiple sites (N = 6). Each site provided 1-4 tapes per family over four treatment time points, and each was independently rated for therapist adherence. RESULTS There were differences in adherence scores within and between sites. ANOVA produced a main effect for site, F(5, 46) = 8.6, p < .001, and phase, F(3, 42) = 12.7, p < .001, with adherence decreasing in later phases. Adherence was not associated to end of treatment percent ideal body weight after controlling for baseline percent ideal body weight (r = .088, p = .48). CONCLUSIONS Results suggest that FBT can be delivered with adherence in phase one of treatment. Adherence was not associated with treatment outcome as determined using percent ideal body weight.
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Affiliation(s)
| | - James D Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | | | - Harry Brandt
- The Center for Eating Disorders, Sheppard Pratt Health System, Baltimore, MD
| | - Katherine A Halmi
- Department of Psychiatry, Weill Medical College, Cornell University, New York, NY
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Walter H Kaye
- Centre for Eating Disorders, Department of Psychiatry, University of California, San Diego, CA
| | - Leora Pinhas
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada
| | - Denise E Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - D Blake Woodside
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW This article reviews recent evidence related to public health epidemiology and intervention for traumatic stress and PTSD. Recent evidence is presented regarding incidence of traumatic stress worldwide, as well as most frequent types of traumas, indicators of the public health burden of PTSD, and prevalence, predictors, and correlates of PTSD. Public health perspectives on intervention and treatment are delineated, and innovations in both psychosocial and psychopharmacological interventions are highlighted. RECENT FINDINGS PTSD has been associated with substantial medical and economic burden. Recent public health preventive innovations include integrated medical/behavioral health care, acute CBT and attention interventions, modifications to CBT protocols, use of novel and augmentative psychopharmacological agents, and use of technology. Recent research regarding the scope and impact of traumatic stress, as well as prevention strategies for PTSD, have resulted in an improved understanding of its impact and more effective public health interventions.
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Affiliation(s)
- Patricia Watson
- Department of Veterans Affairs (116D), National Center for PTSD, Executive Division, 215 N. Main ST, White River Junction, VT, 05009, USA.
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38
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Holder N, Holliday R, Wiblin J, LePage JP, Surís A. Predictors of dropout from a randomized clinical trial of cognitive processing therapy for female veterans with military sexual trauma-related PTSD. Psychiatry Res 2019; 276:87-93. [PMID: 31030005 DOI: 10.1016/j.psychres.2019.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 04/19/2019] [Accepted: 04/21/2019] [Indexed: 12/30/2022]
Abstract
Many veterans do not complete evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Veterans with military sexual trauma (MST)-related PTSD were shown to have higher than average rates of dropout from PTSD treatment in a national study of EBT implementation. Although predictors of dropout from EBTs have been identified, these factors are largely unmodifiable (e.g., age, service era). The purpose of the present study was to identify dynamic psychosocial predictors of dropout among female veterans from cognitive processing therapy (CPT). Data were utilized from 56 female veterans who participated in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD. Dropout was defined continuously (i.e., number of sessions attended) and dichotomously (i.e., attending six or more sessions). Potential predictors included sociodemographic factors, psychotherapist fidelity, PTSD-related service connection, psychiatric symptom severity (i.e., PTSD, depression), trauma-related negative cognitions (about self, self-blame, world), and treatment expectations. Higher trauma-related negative cognitions about self-blame and lower trauma-related negative cognitions about self were protective against dropout. The current study generated testable hypotheses for further research on dynamic predictors of dropout from CPT in female veterans with MST-related PTSD. With replication, results may assist with identifying pre-treatment strategies to reduce dropout in this clinical population.
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Affiliation(s)
- Nicholas Holder
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA.
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, 1700N Wheeling St (G-3-116M), Aurora, CO 80045, USA; University of Colorado Anschutz Medical Campus, Building 500, Mail Stop F546, 13001 East 17th Place, Aurora, CO 80045, USA
| | - Jessica Wiblin
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - James P LePage
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Alina Surís
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
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Marques L, Valentine SE, Kaysen D, Mackintosh MA, Dixon De Silva LE, Ahles EM, Youn SJ, Shtasel DL, Simon NM, Wiltsey-Stirman S. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. J Consult Clin Psychol 2019; 87:357-369. [PMID: 30883163 DOI: 10.1037/ccp0000384] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes. METHOD Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications. RESULTS Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms. CONCLUSIONS The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Luana Marques
- Department of Psychiatry, Massachusetts General Hospital
| | | | - Debra Kaysen
- Department of Global Health, University of Washington
| | | | | | - Emily M Ahles
- Department of Psychiatry, Massachusetts General Hospital
| | - Soo Jeong Youn
- Department of Psychiatry, Massachusetts General Hospital
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Sippel LM, Holtzheimer PE, Friedman MJ, Schnurr PP. Defining Treatment-Resistant Posttraumatic Stress Disorder: A Framework for Future Research. Biol Psychiatry 2018; 84:e37-e41. [PMID: 29752073 DOI: 10.1016/j.biopsych.2018.03.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 03/28/2018] [Accepted: 03/31/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Lauren M Sippel
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Paul E Holtzheimer
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Matthew J Friedman
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Paula P Schnurr
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Cook JM, Simiola V, McCarthy E, Ellis A, Wiltsey Stirman S. Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications. ACTA ACUST UNITED AC 2018; 3:153-167. [PMID: 30906873 DOI: 10.1037/pri0000070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.
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Affiliation(s)
- Joan M Cook
- Department of Psychiatry Yale School of Medicine and National Center for PTSD, West Haven, Connecticut
| | - Vanessa Simiola
- Department of Psychiatry, Yale School of Medicine and Kaiser Permanente, Honolulu, Hawaii
| | | | - Amy Ellis
- Institutional Center for Scientific Research, Albizu University, Miami, Florida
| | - Shannon Wiltsey Stirman
- Department of Psychiatry and Behavioral Sciences, National Center for PTSD, Palo Alto, California and Stanford University of Medicine
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42
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Wiltsey Stirman S, Marques L, Creed TA, Gutner CA, DeRubeis R, Barnett PG, Kuhn E, Suvak M, Owen J, Vogt D, Jo B, Schoenwald S, Johnson C, Mallard K, Beristianos M, La Bash H. Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study. Implement Sci 2018; 13:69. [PMID: 29789017 PMCID: PMC5964900 DOI: 10.1186/s13012-018-0756-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/19/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND 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. METHODS 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. DISCUSSION 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. TRIAL REGISTRATION ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Luana Marques
- Harvard Medical School and Massachusetts General Hospital, 70 Everett Ave., Chelsea, MA 02150 USA
| | - Torrey A. Creed
- University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 3038, Philadelphia, PA 19104 USA
| | - Cassidy A. Gutner
- National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave., Boston, MA 02130 USA
| | - Robert DeRubeis
- School of Arts and Sciences, University of Pennsylvania, 425 S. University Ave., Philadelphia, PA 19104 USA
| | - Paul G. Barnett
- Palo Alto Veterans Institute for Research, 3801 Miranda Ave., Palo Alto, CA 94304 USA
| | - Eric Kuhn
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Michael Suvak
- Suffolk University, 73 Tremont Street, Boston, MA 02108 USA
| | - Jason Owen
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave., Boston, MA 02130 USA
| | - Booil Jo
- Stanford University, 401 Quarry Rd, Stanford, CA 94305 USA
| | | | - Clara Johnson
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Kera Mallard
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
| | | | - Heidi La Bash
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
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Heiniger LE, Clark GI, Egan SJ. Perceptions of Socratic and non-Socratic presentation of information in cognitive behaviour therapy. J Behav Ther Exp Psychiatry 2018; 58:106-113. [PMID: 29055854 DOI: 10.1016/j.jbtep.2017.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/07/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Abstract
Socratic Method is a style of inquiry used in cognitive behavioural therapy (CBT) that encourages clients to reflect on their problems and draw conclusions from newly-gained insights. However, assumptions about the superior efficacy of Socratic Method over non-Socratic (didactic) approaches remain largely untested. The aim of this study was to compare the perceived helpfulness of therapists' questions, autonomy supportiveness, likelihood of engaging in therapeutic tasks and preference for Socratic Method versus a didactic approach using a video analogue and ratings of lay observers. The mediating effects of therapeutic alliance and empathy were also examined. Participants (N = 144, mean age = 37, SD = 13) completed an online survey where they rated two videoed therapy analogues. Socratic Method had higher mean scores on perceived helpfulness of therapists' questions, autonomy supportiveness, and likelihood of engaging in therapeutic tasks and preference than didactic presentation. Perceived helpfulness and preference ratings were higher for Socratic Method after accounting for potential confounders. Perceived therapeutic alliance and empathy both mediated the effect of therapy condition on autonomy and engagement. The findings support the use of Socratic Method in CBT.
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Affiliation(s)
- Louise E Heiniger
- Department of Psychology, School of Behavioural, Cognitive and Social Sciences, University of New England, Australia
| | - Gavin I Clark
- Department of Psychology, School of Behavioural, Cognitive and Social Sciences, University of New England, Australia.
| | - Sarah J Egan
- School of Psychology and Speech Pathology, Curtin University, Australia
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Dittmann C, Müller-Engelmann M, Stangier U, Priebe K, Fydrich T, Görg N, Rausch S, Resick PA, Steil R. Disorder- and Treatment-Specific Therapeutic Competence Scales for Posttraumatic Stress Disorder Intervention: Development and Psychometric Properties. J Trauma Stress 2017; 30:614-625. [PMID: 29178338 DOI: 10.1002/jts.22236] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 11/05/2022]
Abstract
Although the assessment of therapeutic competence in psychotherapy research is essential for examining its possible associations with treatment outcomes, it is often neglected due to high costs and a lack of valid instruments. This study aimed to develop two therapeutic competence scales that assess disorder-specific and treatment-specific therapeutic competence, and to examine these scales' psychometric properties along with those of the already established Cognitive Therapy Scale (CTS) in a posttraumatic stress disorder (PTSD) sample. Using an inductive procedure, two rating scales for assessing disorder-specific and treatment-specific competence were constructed. The psychometric properties of these scales and those of the CTS were assessed in a sample of 30 videotaped sessions of eight patients from a multicenter study in which PTSD related to child abuse was treated using cognitive processing therapy. Two raters assessed therapeutic competence in 30 videotaped psychotherapy sessions. Interrater reliability, internal consistency, and content validity were determined. The scales (all items and total scores) demonstrated good to excellent interrater reliability, intraclass correlation coefficients (ICCs) = .67 to .97, and internal consistency, Cronbach's α = .73 to .92. The PTSD experts' ratings confirmed good internal validity. We found statistically significant associations with therapeutic adherence, r = .62 to .85; p < .001; and therapeutic alliance, r = .47, p < .001. These preliminary data imply that the two newly developed competence scales and the CTS can be reliably used to assess different types of therapeutic competence in PTSD samples and may be useful as possible predictors of treatment outcomes.
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Affiliation(s)
- Clara Dittmann
- Goethe University, Department of Clinical Psychology and Intervention, Institute of Psychology, Frankfurt am Main, Germany
| | - Meike Müller-Engelmann
- Goethe University, Department of Clinical Psychology and Intervention, Institute of Psychology, Frankfurt am Main, Germany
| | - Ulrich Stangier
- Goethe University, Department of Clinical Psychology and Intervention, Institute of Psychology, Frankfurt am Main, Germany
| | - Kathlen Priebe
- Humboldt-Universität, Department of Psychotherapy and Somatopsychology, Berlin, Germany
| | - Thomas Fydrich
- Humboldt-Universität, Department of Psychotherapy and Somatopsychology, Berlin, Germany
| | - Nora Görg
- Institute for Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sophie Rausch
- Institute for Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Patricia A Resick
- Duke University, Department of Psychiatry and Behavioral Sciences, Durham, North Carolina, USA
| | - Regina Steil
- Goethe University, Department of Clinical Psychology and Intervention, Institute of Psychology, Frankfurt am Main, Germany
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45
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Holder N, Holliday R, Williams R, Mullen K, Surís A. A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD. Cogn Behav Ther 2017; 47:76-89. [DOI: 10.1080/16506073.2017.1357750] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Nicholas Holder
- Research Service, Veterans Affairs North Texas Health Care System, 4500 S. Lancaster Rd. Research Service (151), Dallas, TX 75216, USA
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Ryan Holliday
- Research Service, Veterans Affairs North Texas Health Care System, 4500 S. Lancaster Rd. Research Service (151), Dallas, TX 75216, USA
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Rush Williams
- Columbia Health, Columbia University in the City of New York, Lerner Hall, 2920 Broadway, 8th Fl, New York, NY 10027, USA
| | - Kacy Mullen
- Departments of Mental Health and Chief of Staff, Veterans Affairs Southern Oregon Rehabilitation Center & Clinics, 8495 Crater Lake Hwy, White City, OR 97503, USA
| | - Alina Surís
- Research Service, Veterans Affairs North Texas Health Care System, 4500 S. Lancaster Rd. Research Service (151), Dallas, TX 75216, USA
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
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46
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Wiltsey Stirman S, Finley EP, Shields N, Cook J, Haine-Schlagel R, Burgess JF, Dimeff L, Koerner K, Suvak M, Gutner CA, Gagnon D, Masina T, Beristianos M, Mallard K, Ramirez V, Monson C. Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial. Implement Sci 2017; 12:32. [PMID: 28264720 PMCID: PMC5339953 DOI: 10.1186/s13012-017-0544-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/28/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND 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. METHODS 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. DISCUSSION 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. TRIAL REGISTRATION NCT02449421 . Registered 02/09/2015.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Erin P. Finley
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Norman Shields
- Divisional Psychologist Occupational Health and Safety, Royal Canadian Mounted Police, 4225 Dorchester, Westmount, QC Canada
| | - Joan Cook
- Department of Psychiatry, Yale University, 950 Campbell Avenue, West Haven, CT 06516 USA
| | | | - James F. Burgess
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veterans Affairs Boston Healthcare System, Boston, MA USA
| | - Linda Dimeff
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Kelly Koerner
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Michael Suvak
- Suffolk University, 73 Tremont Street, Boston, MA 01331 USA
| | - Cassidy A. Gutner
- National Center for PTSD, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA 02130 USA
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118 USA
| | - David Gagnon
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
| | - Tasoula Masina
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
| | - Matthew Beristianos
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Kera Mallard
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Vanessa Ramirez
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Candice Monson
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
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47
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Nixon RDV, Sloan DM. Treating PTSD: Innovations and Understanding Processes of Change. Behav Ther 2017; 48:143-146. [PMID: 28270325 DOI: 10.1016/j.beth.2016.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | - Denise M Sloan
- National Center for PTSD, VA Boston Healthcare System, and Boston University School of Medicine
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