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Ragnarsson EH, Reinebo G, Ingvarsson S, Lindgren A, Beckman M, Alfonsson S, Hedman-Lagerlöf M, Rahm C, Sahlin H, Stenfors T, Sörman K, Jansson-Fröjmark M, Lundgren T. Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis. Clin Psychol Psychother 2024; 31:e3003. [PMID: 38855846 DOI: 10.1002/cpp.3003] [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: 03/19/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 06/11/2024]
Abstract
Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.
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Affiliation(s)
- Emma Högberg Ragnarsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Gustaf Reinebo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Sara Ingvarsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Annika Lindgren
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Maria Beckman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Sven Alfonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Maria Hedman-Lagerlöf
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Christoffer Rahm
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Hanna Sahlin
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Terese Stenfors
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Karolina Sörman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Markus Jansson-Fröjmark
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
| | - Tobias Lundgren
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden
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Becker-Haimes EM, Brady M, Jamison J, Jager-Hyman S, Reilly ME, Patel E, Brown GK, Mandell DS, Oquendo MA. An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER). Implement Sci Commun 2023; 4:148. [PMID: 38001478 PMCID: PMC10675939 DOI: 10.1186/s43058-023-00530-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation. METHODS We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews). DISCUSSION Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes. TRIAL REGISTRATION Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.
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Affiliation(s)
- Emily M Becker-Haimes
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA.
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, USA.
| | - Megan Brady
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Jesslyn Jamison
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Shari Jager-Hyman
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Megan E Reilly
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Esha Patel
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Gregory K Brown
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - David S Mandell
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Maria A Oquendo
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
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Wray TB, Kemp JJ, Adams Larsen M. Virtual reality (VR) treatments for anxiety disorders are unambiguously successful, so why are so few therapists using it? Barriers to adoption and potential solutions. Cogn Behav Ther 2023; 52:603-624. [PMID: 37376984 PMCID: PMC10592498 DOI: 10.1080/16506073.2023.2229017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023]
Abstract
Anxiety disorders are a significant cause of disability globally, yet only one in ten sufferers receives adequate quality treatment. Exposure-based therapies are effective in reducing symptoms associated with a number of anxiety disorders. However, few therapists use exposure techniques to treat these conditions, even when they are adequately trained in them, often because of concerns about provoking distress, drop out, logistical barriers, and other concerns. Virtual reality exposure therapy (VRET) can address many of these concerns, and a large body of research decisively shows that VRET is as efficacious for treating these conditions as in vivo exposures. Yet, use of VRET remains low. In this article, we discuss several factors we believe are contributing to low VRET adoption among therapists and raise potential solutions to address them. We consider steps that VR experience developers and researchers might take, such as leading studies of VRET's real-world effectiveness and treatment optimization trials and continuing to improve the fit of platforms with clinicians' workflows. We also discuss steps to address therapist reservations using aligned implementation strategies, as well as barriers for clinics, and the roles that professional organizations and payers could have in improving care by encouraging adoption of VRET.
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Affiliation(s)
- Tyler B. Wray
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, Providence, RI
| | - Joshua J. Kemp
- Pediatric Anxiety Research Center, Warren Alpert Medical School of Brown University, Providence, RI
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Becker-Haimes EM, Hernandez Rodriguez J, Wolk CB. Editorial: Implementation of evidence-based treatments for child anxiety and related disorders across diverse contexts. Front Psychiatry 2023; 14:1248996. [PMID: 37502811 PMCID: PMC10369350 DOI: 10.3389/fpsyt.2023.1248996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, PA, United States
| | | | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Frank HE, Rifkin LS, Sheehan K, Becker-Haimes E, Crane ME, Phillips KE, Palitz SA, Kemp J, Benito K, Kendall PC. Therapist perceptions of experiential training for exposure therapy. Behav Cogn Psychother 2023; 51:214-229. [PMID: 36805734 PMCID: PMC11006093 DOI: 10.1017/s1352465822000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.
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Affiliation(s)
- Hannah E. Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
- Department of Psychology, Temple University
| | | | - Kate Sheehan
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Emily Becker-Haimes
- Department of Psychiatry, University of Pennsylvania
- Hall Mercer Community Mental Health, University of Pennsylvania Health System
| | | | | | | | - Joshua Kemp
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
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Becker-Haimes EM, Wislocki K, Schriger SH, Kratz HE, Sanchez AL, Clapp D, Frank HE. Preliminary Implementation Outcomes of a Free Online Toolkit to Support Exposure Therapy Implementation for Youth. CHILD & YOUTH CARE FORUM 2023; 52:1-18. [PMID: 36711198 PMCID: PMC9854404 DOI: 10.1007/s10566-023-09732-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/19/2022] [Accepted: 01/07/2023] [Indexed: 01/21/2023]
Abstract
Background Exposure therapy ("exposure") for youth anxiety is highly underutilized in clinical practice. Asynchronous, online implementation strategies such as online toolkits hold promise as pragmatic approaches for extending the sustainability of evidence-based interventions, but their long-term usage, perceived utility, and impact are rarely studied. Objective This study presents three-year preliminary implementation outcomes for a free, online toolkit to support exposure therapy use with youth: the Resource for Exposure for Anxiety Disordered Youth (READY; www.bravepracticeforkids.com). Implementation outcomes of interest included READY usage statistics, adoption, perceived utility, and clinician exposure use. Methods Web analytics characterized usage patterns. A survey of READY users (N = 49; M age = 34.2, 82.9% female, 71% White) assessed adoption, perceived utility, clinician exposure use, and persistent barriers to exposure use. Results In its first three years, READY had 13,543 page views across 1,731 unique users; 442 (25.6%) registered as a site user to access specialized content. Survey data suggested variability in usage and perceived utility across toolkit components. Qualitative analyses highlighted persistent exposure barriers that pointed to potential READY refinements. Conculsions Overall, READY has been accessed by hundreds of clinicians, but its impact was limited by low return to the site. This study highlights strengths and limitations of standalone online implementation supports and identifies additional steps needed to optimally support clinicians to deliver exposure to youth in need.
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Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd floor, 19104 Philadelphia, PA USA
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, USA
| | - Katherine Wislocki
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd floor, 19104 Philadelphia, PA USA
- Department of Psychological Science, University of California Irvine, Irvine, USA
| | | | - Hilary E. Kratz
- Department of Psychology, La Salle University, Philadelphia, USA
| | - Amanda L. Sanchez
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd floor, 19104 Philadelphia, PA USA
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, USA
- Department of Psychology, George Mason University, Fairfax, VA USA
| | - Douglas Clapp
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, USA
- Department of Psychology, La Salle University, Philadelphia, USA
| | - Hannah E. Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, USA
- Bradley Hospital, Lifespan Health System, Providence, USA
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7
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Kemp J, Benito K, Herren J, Brown Z, Frank HE, Freeman J. Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation. Front Psychiatry 2023; 14:1096259. [PMID: 36873204 PMCID: PMC9975163 DOI: 10.3389/fpsyt.2023.1096259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Exposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs. METHODS The study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training. ANTICIPATED RESULTS It is hypothesized that the E2E training condition will produce greater reductions in therapists' negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients. CONCLUSION Implementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.
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Affiliation(s)
- Joshua Kemp
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States.,Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States.,Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
| | - Jennifer Herren
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States.,Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
| | - Zoe Brown
- Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
| | - Hannah E Frank
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States.,Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
| | - Jennifer Freeman
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States.,Pediatric Anxiety Research Center at Bradley Hospital, Riverside, RI, United States
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Kennedy SM, Wilkie DP, Henry L, Moe-Hartman J, President K, Townson K, Anthony LG, Hawks JL. The Unified Protocols for Children and Adolescents in Partial Hospitalization: Using Implementation Science Frameworks to Guide Adaptation. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Meza RD, AlRasheed R, Pullmann MD, Dorsey S. Clinical supervision approach predicts evidence-based trauma treatment delivery in children's mental health. Front Psychiatry 2022; 13:1072844. [PMID: 36699474 PMCID: PMC9869035 DOI: 10.3389/fpsyt.2022.1072844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Observational studies of practices used in clinical supervision-as-usual can be leveraged to advance the limited research on workplace-based supervision as an evidence-based treatment (EBT) implementation strategy. This exploratory observational study examined the presence of supervision approaches (comprised of supervision techniques) and whether these predicted clinicians' EBT technique delivery. METHODS Participants included 28 supervisors, 70 clinician supervisees, and 60 youth clients and guardians from 17 public mental health organizations. Data included audio recorded supervision-as-usual sessions over 1 year, audio recorded Trauma-focused Cognitive Behavioral Therapy (TF-CBT) treatment sessions with youth for 6 months, and youth-reported post-traumatic stress severity scores. Audio recordings of 438 supervision sessions were coded for session duration and the presence of 13 supervision techniques and intensity of their coverage. Audio recordings of 465 treatment sessions were coded for presence and intensity of coverage of TF-CBT practice elements. Agglomerative hierarchical cluster analysis examined the presence of clusters of supervision technique use, termed supervision approaches. Generalized estimating equations estimated the relation between supervision approaches and delivery of TF-CBT elements. RESULTS Two supervision approaches were identified- Supportive-Directive and Supportive- that discriminated between use of five supervision techniques. Clinicians who received a higher proportion of supportive-directive supervision sessions had greater odds of delivering the trauma narrative with a client. CONCLUSION Findings suggest that patterns of supervision techniques can be identified and may shape EBT delivery. Supervision approaches show some evidence of being tailored to individual clinicians. Implications for the development of supervision implementation strategies and future directions are discussed.
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Affiliation(s)
- Rosemary D Meza
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Rashed AlRasheed
- Department of Psychology, University of Washington, Seattle, WA, United States
| | - Michael D Pullmann
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, United States
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10
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Last BS, Schriger SH, Timon CE, Frank HE, Buttenheim AM, Rudd BN, Fernandez-Marcote S, Comeau C, Shoyinka S, Beidas RS. Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making. Implement Sci Commun 2021; 2:6. [PMID: 33431032 PMCID: PMC7802291 DOI: 10.1186/s43058-020-00105-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians' use of TNs. The behavioral insights literature-an interdisciplinary field studying judgment and decision-making-offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants. METHODS Through semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the "Easy Attractive Social Timely" framework, a behavioral insights design approach. RESULTS We generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation. CONCLUSIONS Our study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.
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Affiliation(s)
- Briana S Last
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Simone H Schriger
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Carter E Timon
- College of Liberal and Professional Studies, University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Frank
- Department of Psychology, Temple University, Philadelphia, PA, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alison M Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany N Rudd
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Carrie Comeau
- Department of Behavioral Health and Intellectual Disability Services, Philadelphia, PA, USA
| | - Sosunmolu Shoyinka
- Department of Behavioral Health and Intellectual Disability Services, Philadelphia, PA, USA
| | - Rinad S Beidas
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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