Statewide implementation of child trauma-focused practices using the community-based learning collaborative model

Therapist Participation in a Learning Collaborative on Trauma-Focused Cognitive Behavioral Therapy: Impact of COVID-related Stressors and Challenges

The rise in mental health problems during the COVID-19 pandemic amplified the need to improve access to evidence-based treatments (EBT) and necessitated changes in treatment delivery and training of mental health providers (MHPs). There is limited information on how the pandemic may have impacted MHPs' participation in training and treatment delivery. This study included 269 MHPs who participated in a Learning Collaborative (LC) focused on an EBT. Qualitative interviews conducted with 15 MHPs who participated in the LC during the pandemic identified facilitators and barriers to training participation and EBT delivery that included social support, technology challenges, and difficulty completing cases following the transition to telehealth. Quantitative results showed that MHPs in the peri-COVID cohorts completed significantly fewer cases and fewer consultation calls compared to those prior to the pandemic. Findings suggest that providing support to train MHPs and promote EBT delivery may be beneficial during times of heightened stress.

Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care

OBJECTIVES

This study examined diagnostic profiles and trauma history among treatment-seeking young adults with positive PTSD screens in public mental health care.

METHODS

Screening for trauma history and PTSD symptoms was implemented in a community mental health service system. 266 treatment-seeking young adults (aged 18-35) endorsed trauma exposure with a score of at least 45 on the DSM-IV PTSD Checklist, indicating probable PTSD.

RESULTS

Young adults with positive PTSD screens were predominantly female, minority, and diagnosed with mood disorders. Of those with positive screens, only 15% had a chart diagnosis of PTSD; 17.3% (ages 18-24) versus 14.1% (ages 25-35). Variables significantly associated with a decreased likelihood of PTSD detection included a diagnosis of schizophrenia or bipolar disorder, exposure to fewer types of traumatic events, male gender, and white race.

CONCLUSION

Routine PTSD screening for young adults receiving public mental health care should be prioritized to address long-term impacts of trauma.

Comparing In-Person and Synchronous Online Training for an Evidence-Based Treatment

Online trainings in evidence-based treatments (EBT) can be effective platforms and may provide better access to community providers as compared with traditional in-person trainings. However, questions remain as to whether online trainings can achieve similar rates of training engagement and model application to traditional in-person trainings. We compared training engagement and model application (e.g., extent of use, fidelity) between participants attending in-person (n = 127) and synchronous online (n = 277) trainings for an EBT (Alternatives for Families: a Cognitive Behavioral Therapy; AF-CBT). Data were collected through pre- and post-training questionnaires and trainers' records. Chi-square analyses and t-tests were used to test for differences between groups. Engagement regarding attendance at workshops and consultation calls was high for both groups, with no significant differences. A total of 81% and 76% presented at least one case and submitted at least one audio recording of an actual AF-CBT session, respectively. Participants rated the training workshop as high quality (M > 4.5/5), and the consultation calls as medium-to-high quality (M > 4/5) across both modalities, indicating good training engagement. In-person training participants were significantly more likely to submit two or more audio recorded sessions than online training participants. This was the only training requirement outcome that differed between the two groups. In examining model application, there were no significant differences between in-person and online training participants in self-reported delivery of AF-CBT, the number of clients with whom it was implemented, the extent they used the model, or the fidelity with which they delivered it. Both groups reported similar improvements in comfort when working with aggressive families, being directive, and using learning techniques like role plays. Online evidence-based treatment skills training appears to be feasible, efficient, and beneficial, with engagement and performance comparable to in-person training. We discuss potential advantages of online training (e.g., fewer costs, greater flexibility for staff from independent practices) and disadvantages (e.g., less satisfaction).

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

Therapist perceptions of experiential training for exposure therapy

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.

Evidence-based Treatment for Substance Use Disorders in Community Mental Health Centers: the ACCESS Program

A significant gap remains in the availability and accessibility of evidence-based treatments (EBTs) in community substance use disorder (SUD) treatment. This study describes a 2-year statewide training initiative that sought to address this gap by training community-based therapists in motivational enhancement/cognitive behavioral therapy (MET/CBT). Therapists (N = 93) participated in a 2-day MET/CBT workshop followed by bi-weekly clinical consultation, fidelity monitoring, guided readings, and online resources. Therapists completed pre-training and follow-up assessments measuring knowledge, attitudes, confidence, and implementation barriers. Most therapists attended 10 or more consultation calls. Submission of session recordings for feedback was the least utilized training element. Therapists reported increased confidence in their ability to implement MET/CBT for SUD and demonstrated improvement in MI and CBT knowledge. Therapists reported several implementation barriers, including lack of time and opportunity to treat patients with MET/CBT. Recommendations for future training initiatives and addressing the barriers identified in this study are discussed.

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

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

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Measuring Evidence-Based Treatment Strategies in Youth Community Mental Health Care: the Evidence-Based Strategies Scale

While there are established measures for fidelity to specific evidence-based treatments, there is no widely accepted, feasible measure of the use of evidence-based treatment strategies in youth mental health (MH) care. This study examined the factor structure of a provider self-report measure of evidence-based treatment strategy use, the Evidence-Based Strategies Scale (EBSS). MH providers completed the EBSS as part of a larger mailed survey. The factor structure of the EBSS was examined using exploratory factor analysis in a national, multidisciplinary sample of MH providers (N = 1092), and confirmatory factor analysis was subsequently conducted to replicate this factor structure in a state-wide, multidisciplinary sample of Medicaid MH providers (N = 780). Findings indicated a three-factor structure, representing working alliance, youth-focused, and family-focused evidence-based treatment strategies factors. The EBSS offers a potential method for measuring the evidence-based treatment strategies being delivered in youth community MH care, though more research is needed.

Predictors of Clinician-Reported Self-Efficacy in Treating Trauma-Exposed Youth

Clinicians' self-efficacy with regard to delivering evidence-based interventions (EBIs) to youth is an important target for both improving EBI use in the community and mitigating the risk of clinician burnout and turnover. Examining predictors of clinician self-efficacy to treat trauma-exposed youth is, therefore, an important step for informing the design of implementation strategies to enhance the mental health workforce's capacity to deliver EBIs in this population. We examined predictors of clinician self-efficacy in working with trauma-exposed youth in a sample of practicing mental health clinicians (N = 258, M age = 34.4 years, 85.0% female). Clinicians were recruited and surveyed as part of a larger study examining how clients' exposure to potentially traumatic events influences clinician decision-making. Results of regression models indicated that training in any trauma treatment model, being trained via a variety of formats (e.g., in-person training, online, supervision), and training in a variety of treatment models were all associated with higher perceived self-efficacy regarding effectively treating trauma-exposed youth. Of the treatment models and training formats examined, receiving in-person training, R2 = .10, and training in trauma-focused cognitive behavioral therapy, R2 = .10, were the strongest predictors of higher self-efficacy ratings. Clinician discipline, R2 = .04, and clinical practice factors, R2 = .20, were also related to self-efficacy. Collectively, the R2 indicated a large effect, with the predictors explaining 25.4% of the variance in self-efficacy ratings. Implications for designing implementation strategies targeting clinician self-efficacy and future research are discussed.

The Urban Youth Trauma Center: A Trauma-Informed Continuum for Addressing Community Violence Among Youth

Contemporary community violence has escalated into a national public health crisis with urban youth, particularly ethnic minorities, suffering disproportionate negative impacts. The Urban Youth Trauma Center (UYTC) promotes a trauma-informed continuum of prevention-to-intervention services that combines community-based and clinic-based manualized protocols designed to reduce and prevent community violence for youth and families. Based on a socio-ecological model, UYTC has the main goals of addressing community violence and related traumatic stress as well as co-occurring conditions of substance abuse and disruptive behavior problems in urban youth by: (1) raising public awareness; (2) disseminating specialized trauma-informed training; and (3) mobilizing service system coalitions. UYTC employs this evidence-based yet flexible structure for disseminating, implementing, and evaluating trauma-informed training as a means of contributing to the reduction and prevention of community violence for low-income urban minority youth and families who bear the biggest burden of this current crisis.

A Causal Model of Children's Vicarious Traumatization

Children may be vicariously traumatized from learning about the trauma of family and friends. To date, a causal model of children's vicarious traumatization has not been empirically validated in the literature. This paper fills the gap in the literature by reporting on the direct effect of vicarious trauma on children independent of caregiving impairment. Data for the study came from the National Survey of Children's Exposure to Violence I (NATSCEV I). This unique dataset features two indicators of vicarious trauma exposure: (1) family victimization and (2) community violence. Hierarchical multiple regression was conducted in order to control for nuisance variables such as caregiver impairment, defined as the degree of warmth or hostility; time elapsed since the trauma occurred and the study taking place; and other trauma exposure (i.e. direct and witnessed trauma). As expected, the study found evidence of a direct and positive relationship between learning about the trauma of close friends and family and children's trauma symptomatology. Both adolescents and young children were found to be vulnerable to experience vicarious traumatization, with gender and ethnicity being contributing factors. Chronological age was not found to be significant in children's vicarious traumatization. These findings support the causal model of vicarious traumatization. They demonstrate that children may be traumatized by exposure to the trauma material of others above and beyond the influence of caregiver impairment. As such, attention should be given to interventions, practices, and policies that intervene in the lives of children exposed to violence.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Partnering for Success: Factors Impacting Implementation of a Cross-Systems Collaborative model Between Behavioral Health and Child Welfare

Cross-system implementation efforts can support needed mental health (MH) service utilization among children involved in the child welfare (CW) system. The Partnering for Success (PfS) initiative is one such effort that promotes greater collaboration between the CW and MH providers by building capacity within and across each system. Frontline CW providers learn to accurately identify child MH treatment targets, link families to locally-provided evidence-based treatments (EBTs), and monitor treatment progress. Concurrently, local MH providers are trained along with CW workers to utilize Cognitive Behavioral Therapy plus Trauma-Focused CBT (CBT +), a common elements training and consultation approach focusing on typical MH issues for CW-involved children: Anxiety, Depression, Behavioral Problems, and Traumatic Stress. Finally, agency leadership receive support around promoting implementation and sustainment. This paper examines factors identified by participating CW and MH staff which impacted PfS implementation. Twenty-nine frontline, supervisory, and executive CW and MH providers were interviewed via audio-recorded web-based calls in six focus groups and 10 individual interviews. Factors facilitating implementation success included training/consultation, support from supervisors and agency leadership, improved referral processes, high quality relationships and communication between CW and MH frontline staff, PfS tools and resources, opportunities to use PfS, as well as buy-in from providers and families. Implementation barriers included poor communication between CW and MH providers, conflicts over role expectations, workload and turnover challenges, lack of buy-in, as well as provider (e.g., not aligned with CBT +) and client characteristics (e.g., frequent crises).

Making Implementation Last: The Impact of Training Design on the Sustainability of an Evidence-Based Treatment in a Randomized Controlled Trial

Although advances have been made in facilitating the implementation of evidence-based treatments, little is known about the most effective way to sustain their use over time. The current study examined the sustainability of one evidence-based treatment, Parent-Child Interaction Therapy (PCIT), following a statewide implementation trial testing three training methods: Cascading Model, Learning Collaborative, and Distance Education. Participants included 100 clinicians and 50 administrators from 50 organizations across Pennsylvania. Clinicians and administrators reported on sustainability at 24-months, as measured by the number of clients receiving PCIT and the continued use of the PCIT protocol. Multi-level path analysis was utilized to examine the role of training on sustainability. Clinicians and administrators reported high levels of sustainability at 24-months. Clinicians in the Cascading Model reported greater average PCIT caseloads at 24-months, whereas clinicians in the Learning Collaborative reported greater full use of the PCIT protocol at 24-months. Attending consultation calls was associated with delivering PCIT to fewer families. Implications for the sustainable delivery of PCIT beyond the training year as well as for the broader field of implementation science are discussed.

Disseminating Trauma-Focused Cognitive Behavioral Therapy with a Systematic Self-care Approach to Addressing Secondary Traumatic Stress: PRACTICE What You Preach

This pilot study evaluated the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training programs augmented with a systematic "PRACTICE What You Preach" (PWYP) self-care focus, which has trainees personally utilize the coping skills they teach their clients. Participants were 115 clinicians/supervisors who completed a PWYP TF-CBT training program. Pre- to post-training analyses documented significant increases in participants' competency and fidelity in implementing TF-CBT (ps < .001), significantly more frequent use of coping skills including instrumental social support (p < .01), active coping (p < .001), humor (p < .01), and restraint (p < .01), and significant decreases in secondary traumatic stress (STS; p < .001). Children's symptoms of PTSD (ps < .001) and behavior problems (p < .05) also decreased significantly. This preliminary evidence suggests that training augmented with PWYP may enhance clinicians'/supervisors' personal coping and reduce their levels of STS without compromising treatment implementation efforts and client outcomes.

Training During a Pandemic: Successes, Challenges, and Practical Guidance From a Virtual Facilitated Learning Collaborative Training Program for Written Exposure Therapy

In response to COVID-19, continued workforce training is essential to ensure that evidence-based treatments are available on the frontline to meet communities' ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID-19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence-based treatment for posttraumatic stress disorder, included virtual workshop training, phone-based clinical consultation, implementation-focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID-19-related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.

Preaching to the Choir? Predictors of Engagement in a Community-Based Learning Collaborative

This study examined predictors of engagement among 283 professionals from 34 agencies participating in three community-based learning collaboratives (CBLCs) on trauma-focused cognitive-behavioral therapy (TF-CBT). Only 50.2% of participants completed the CBLC, primarily due to not attending consultation calls or completing training cases. While higher engagement was associated with being trauma-informed and using more of the TF-CBT components prior to the CBLC, most predictors were not significant, perhaps due to ceiling effects. Positive attitudes and high organizational support were not sufficient to ensure engagement. Future research using longitudinal measurement of a wider range of predictors is needed.