Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications

Frequency of, Confidence in, and Educational Satisfaction With Mental Illness Recognition and Referral Among Certified Athletic Trainers

CONTEXT

Mental illness recognition and referral are required components of professional athletic training education. However, athletic trainers (ATs) often report feeling underprepared to assist patients with mental health emergencies.

OBJECTIVE

To determine ATs' frequency of and confidence in psychosocial skill use and their satisfaction with education related to mental illness recognition and referral.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 226 ATs (86 men, 140 women; age = 35.5 ± 9.9 years, years of practice = 11.9 ± 9.0).

MAIN OUTCOME MEASURE(S)

The independent variables were professional athletic training program, professional psychosocial courses, highest education level, psychosocial continuing education units, clinical practice setting, and years of experience. For each skill, individuals identified the average frequency with which the skill was performed each year, rated their confidence in performing the skill, and rated their satisfaction with professional education related to the skill.

RESULTS

Anxiety was reported as the symptom most frequently recognized and referred. Most respondents felt moderately or extremely confident in managing patients with anxiety, panic attacks, depression, suicidal ideation, or eating disorders but less confident or unconfident in managing those with psychosis or substance use disorder. The majority of respondents felt dissatisfied or only slightly satisfied with their education related to mental health recognition and referral. Years of clinical practice and self-reported frequency of referral were significantly associated for managing patients with anxiety disorder (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({\rm{\chi }}_{87}^2\) = 117.774, P = .016) and suicidal thoughts or actions (\({\rm{\chi }}_{87}^2\) = 179.436, P < .001). For confidence, significant positive associations were present between years of practice and self-reported recognition of patients with anxiety disorders (\({\rm{\chi }}_{145}^2\) = 195.201, P = .003) and referral for those with anxiety disorders (\({\rm{\chi }}_{145}^2\) = 15.655, P = .048) or panic attacks (\({\rm{\chi }}_{145}^2\) = 19.790, P = .011). Significant associations were also noted between the number of continuing education units and self-reported confidence in recognizing suicide (\({\rm{\chi }}_{15}^2\) = 26.650, P = .032), referring for suicidal concerns (\({\rm{\chi }}_{18}^2\) = 40.456, P = .002), recognizing substance use (\({\rm{\chi }}_{18}^2\) = 33.649, P = .014), and referring for substance use (\({\rm{\chi }}_{18}^2\) = 30.918, P = .029). No significant associations were related to satisfaction.

CONCLUSIONS

The ATs with fewer years of clinical practice (ie, who had completed professional programs more recently) expressed higher confidence in mental health recognition and referral than those who had completed professional programs longer ago. We recommend that real-time interactions with individuals who have mental health concerns or emergencies be incorporated into professional education programs and that increased emphasis be placed on continuing education related to these topics.

Interdisciplinary Trauma-focused Therapy and Return-to-work Support for A Police Officer with Work-related PTSD: A Case Study

Police officers carry a high risk of exposure to traumatic events in their everyday work duties and are at an increased risk for work-related posttraumatic stress disorder (PTSD). Practitioners lack clear guidance on how to support these individuals to facilitate both mental health recovery and return to work, particularly for those receiving treatment in the context of a claim with a workers’ compensation board. The following case study describes the treatment of a female police officer who had experienced numerous traumatic events over the course of her career, and subsequently filed a claim with the workers’ compensation board of British Columbia. She was referred to an interdisciplinary program that involved both psychology and occupational therapy interventions, including a trauma-focused cognitive behaviour therapy intervention followed by a gradual return to work. The outcome suggests that intensive, interdisciplinary trauma-focused treatment is a promising approach for supporting police officers with their recovery and return to work.

Stakeholder Preferences on Transdiagnostic Psychosocial Treatment for Trauma-Exposed Veterans

While modular and transdiagnostic approaches may address implementation challenges, there remains limited investigation into the fit within large healthcare systems. The current study examines qualitative interviews from patients, clinicians and administrative stakeholders in the Veterans Administration about experiences with, and views of, the Unified Protocol (UP; Barlow et al. in The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide, Oxford University Press, New York, 2011) to understand potential for implementation. Qualitative interviews were conducted based on an established implementation framework and speak to implementation of transdiagnostic treatment in veterans, including insight into barriers, facilitators, intervention characteristics, patient characteristics, and system level variables. The UP demonstrated promise for improving efficiency, satisfaction and personalizing mental healthcare.

The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions

BACKGROUND

This paper describes the process and results of a refinement of a framework to characterize modifications to interventions. The original version did not fully capture several aspects of modification and adaptation that may be important to document and report. Additionally, the earlier framework did not include a way to differentiate cultural adaptation from adaptations made for other reasons. Reporting additional elements will allow for a more precise understanding of modifications, the process of modifying or adapting, and the relationship between different forms of modification and subsequent health and implementation outcomes.

DISCUSSION

We employed a multifaceted approach to develop the updated FRAME involving coding documents identified through a literature review, rapid coding of qualitative interviews, and a refinement process informed by multiple stakeholders. The updated FRAME expands upon Stirman et al.'s original framework by adding components of modification to report: (1) when and how in the implementation process the modification was made, (2) whether the modification was planned/proactive (i.e., an adaptation) or unplanned/reactive, (3) who determined that the modification should be made, (4) what is modified, (5) at what level of delivery the modification is made, (6) type or nature of context or content-level modifications, (7) the extent to which the modification is fidelity-consistent, and (8) the reasons for the modification, including (a) the intent or goal of the modification (e.g., to reduce costs) and (b) contextual factors that influenced the decision. Methods of using the framework to assess modifications are outlined, along with their strengths and weaknesses, and considerations for research to validate these measurement strategies.

CONCLUSION

The updated FRAME includes consideration of when and how modifications occurred, whether it was planned or unplanned, relationship to fidelity, and reasons and goals for modification. This tool that can be used to support research on the timing, nature, goals and reasons for, and impact of modifications to evidence-based interventions.