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Racz JI, Bialocerkowski A, Calteaux I, Farrell LJ. Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review. Clin Child Fam Psychol Rev 2024; 27:317-341. [PMID: 38630196 PMCID: PMC11222222 DOI: 10.1007/s10567-024-00478-3] [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] [Accepted: 03/19/2024] [Indexed: 04/28/2024]
Abstract
Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.
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Affiliation(s)
- J I Racz
- School of Applied Psychology, Griffith University, Southport, QLD, Australia.
| | | | - I Calteaux
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
| | - L J Farrell
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
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McLean CP, Cook J, Riggs DS, Peterson AL, Young-McCaughan S, Borah EV, Comtois KA, Dondanville KA, Frick E, Haddock CK, Mann J, Reynolds D, Mistretta M, Neitzer A, Brzuchalski A, Clayton SP, Conforte AM, DuMars TD, Ekundayo K, Flores A, Hein J, Jinkerson J, Keith F, Kim HJ, Link JS, Nofziger D, Pollick K, Ringdahl EN, Waggoner J, Woodworth C, Rosen CS. Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities. Mil Med 2024; 189:721-731. [PMID: 35943175 DOI: 10.1093/milmed/usac240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
| | - Jeffrey Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David S Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | - Elisa V Borah
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX 78712, USA
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Erin Frick
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | | | - Jeffrey Mann
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David Reynolds
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Melissa Mistretta
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Andrea Neitzer
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
| | - Amy Brzuchalski
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
- Kimbrough Ambulatory Care Center, Fort Meade, MD 20755, USA
| | - Spencer P Clayton
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
- Nellis Air Force Base, NV 89191, USA
| | - Allison M Conforte
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
- 3d Marine Division, UNIT 35840, Okinawa FPO AP 96602-5840, Japan
| | - Tyler D DuMars
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Kendra Ekundayo
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
| | - Araceli Flores
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Jessica Hein
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - Jeremy Jinkerson
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Felicia Keith
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
- Spangdahlem Air Base, Spangdahlem 09123, Germany
| | - Hana J Kim
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Jared S Link
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Debra Nofziger
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Kirsten Pollick
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Erik N Ringdahl
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
| | - John Waggoner
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Craig Woodworth
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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DeJesus CR, Trendel SL, Sloan DM. A systematic review of written exposure therapy for the treatment of posttraumatic stress symptoms. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2024:2024-53004-001. [PMID: 38358724 PMCID: PMC11324852 DOI: 10.1037/tra0001659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVE Written exposure therapy (WET) is a brief treatment for posttraumatic stress disorder (PTSD), with an increasing number of studies published over the past several years. The current study conducted a systematic review to evaluate the current state of evidence for WET as a treatment for PTSD symptom severity. METHOD Four databases were searched: PsycInfo, PTSDpubs, MEDLINE, and PubMed. Inclusion criteria included a peer-reviewed study of WET, a PTSD treatment outcome measure at pre- and posttreatment, and full-text available in English. RESULTS Seventeen studies were identified for inclusion, seven of which were randomized controlled trials. Study sample sizes ranged from three to 277, with most studies (88%) examining adults. Five studies used a language translation version of WET, two studies examined a group format, and three studies examined PTSD symptom outcome when WET was delivered via telehealth. Within condition effect sizes for PTSD treatment outcome were moderate to large (d range = 0.48-6.45), and between condition effect sizes were large (d range = 1.05-5.25), except for three studies that included a trauma-focused treatment comparison condition (d range = 0.01-0.31). Dropout rates for WET were generally low, and less when compared with other trauma-focused treatments. CONCLUSIONS The published studies indicate that WET is an efficacious and effective treatment for PTSD symptoms across a variety of samples, settings, and counties. Future work in this area should include investigation of the implementation and dissemination of WET. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | - Stephanie L Trendel
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System
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Saito A, Tsuruta N, Arai Y, Okamoto K, Narisawa T, Nozaki M, Konno N, Asukai N. Effectiveness of prolonged exposure (PE) after implementation at a crime victim support centre. Eur J Psychotraumatol 2024; 15:2302703. [PMID: 38264969 PMCID: PMC10810613 DOI: 10.1080/20008066.2024.2302703] [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: 07/25/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024] Open
Abstract
Background: Recent practice guidelines strongly recommend evidence-based psychotherapies (EBPs) as the first-line treatment for post-traumatic stress disorder (PTSD). However, previous studies found barriers to the implementation of EBPs and a relatively high dropout rate in clinical settings. After proving the efficacy of prolonged exposure (PE) in Japan [Asukai, N., Saito, A., Tsuruta, N., Kishimoto, J., & Nishikawa, T. (2010). Efficacy of exposure therapy for Japanese patients with posttraumatic stress disorder due to mixed traumatic events: A randomized controlled study. Journal of Traumatic Stress, 23(6), 744-750. https://doi.org/10.1002/jts.20589], we began implementing PE in a real-world clinical setting at the Victim Support Center of Tokyo (VSCT).Objective: We aimed to investigate the effectiveness and benefit of PE for crime-induced PTSD among VSCT clients and what causes dropout from treatment.Method: Of 311 adult clients who received counselling from clinical psychologists at VSCT due to violent or physical crime victimization from April 2008 through December 2019, 100 individuals received PE and participated in this study. Their PTSD symptoms were evaluated before and after treatment using the Impact of Event Scale-Revised and the Clinician-Administered PTSD Scale for DSM-IV.Results: A total of 93 participants completed PE and seven dropped out after six sessions or less. The completers group improved in PTSD symptoms with significant score differences between pre- and post-treatment in IES-R and CAPS-IV. Participants' symptoms did not exacerbate after treatment. Forty of 49 completers who left their workplace or college/school after victimization returned to work or study shortly after treatment. Compared to the completers, all dropout participants were women and younger. The majority were rape survivors, with significantly shorter intervals between victimization and treatment. The reasons for dropout were difficulty scheduling treatment between work/study schedules and manifestation of bipolar disorder or physical illness.Conclusions: PE can be implemented with significant effectiveness and a low dropout rate in a real-world clinical setting if advantages in the system and policies, local organizational context, fidelity support and patient engagement are fortified.
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Affiliation(s)
- Azusa Saito
- Faculty of Human Sciences, Department of Psychology, Sophia University, Tokyo, Japan
- Victim Support Center of Tokyo, Tokyo, Japan
| | | | - Yoko Arai
- Victim Support Center of Tokyo, Tokyo, Japan
| | - Kaori Okamoto
- Victim Support Center of Tokyo, Tokyo, Japan
- Faculty of Human Studies, Department of Psychology, Seisen Jogakuin College, Nagano, Japan
| | - Tomomi Narisawa
- Victim Support Center of Tokyo, Tokyo, Japan
- Faculty of Human Sciences, Department of Human Sciences, Musashino University, Tokyo, Japan
| | - Mari Nozaki
- Victim Support Center of Tokyo, Tokyo, Japan
| | | | - Nozomu Asukai
- Victim Support Center of Tokyo, Tokyo, Japan
- Aoki Hospital, Tokyo
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Ackland PE, Koffel EA, Goldsmith ES, Ullman K, Miller WA, Landsteiner A, Stroebel B, Hill J, Wilt TJ, Duan-Porter W. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:792-812. [PMID: 37326899 DOI: 10.1007/s10488-023-01279-6] [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] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Benjamin Stroebel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica Hill
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
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McLean CP, Cook J, Riggs DS, Peterson AL, Young-McCaughan S, Haddock CK, Rosen CS. Policy Recommendations for Increasing the Use of Evidence-Based Psychotherapy for Posttraumatic Stress Disorder in the Military Health System. Mil Med 2023; 188:183-186. [PMID: 36617250 DOI: 10.1093/milmed/usac429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023] Open
Abstract
Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
| | - Jeffrey Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David S Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | | | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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LoSavio ST, Hale W, Straud CL, Wachen JS, Mintz J, Young-McCaughan S, Vacek SN, Yarvis JS, Sloan DM, McGeary DD, Taylor DJ, Keane TM, Peterson AL, Resick PA. Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
LAY SUMMARY Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.
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Affiliation(s)
- Stefanie T. LoSavio
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Willie Hale
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Jennifer Schuster Wachen
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Sarah N. Vacek
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Jeffrey S. Yarvis
- School of Social Work, Tulane University, New Orleans, Louisiana, United States
| | - Denise M. Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Daniel J. Taylor
- Department of Psychology, University of Arizona, Tucson, Arizona, United States
| | - Terence M. Keane
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, United States
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8
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Kosonogov VV, Efimov KV, Rakhmankulova ZK, Zyabreva IA. Review of Psychophysiological and Psychotherapeutic Studies of Stress Using Virtual Reality Technologies. NEUROSCIENCE AND BEHAVIORAL PHYSIOLOGY 2023; 53:81-91. [PMID: 36969359 PMCID: PMC10006560 DOI: 10.1007/s11055-023-01393-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/20/2022] [Indexed: 03/13/2023]
Abstract
This review addresses the use of virtual reality technologies in the psychophysiology and psychotherapy of stress. Studies using virtual reality both to introduce subjects into a state of stress and to help reduce stress reactions are reviewed. Methods developed for treating patients suffering from stress-related disorders (in particular, PTSD and phobias) are described. In many cases, reductions in stress reactions with the help of virtual reality systems are achieved not only at the self-report (experiential) level, but also at the level of central and peripheral nervous system measures. This allows virtual reality to be regarded as a modern, inexpensive, and effective method, firstly, for introducing subjects into a state of stress with the aim of testing various hypotheses in psychophysiology and, secondly, to reduce stress reactions.
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Affiliation(s)
- V. V. Kosonogov
- Institute of Cognitive Neurosciences, HSE University, Moscow, Russia
| | - K. V. Efimov
- Institute of Cognitive Neurosciences, HSE University, Moscow, Russia
| | | | - I. A. Zyabreva
- Institute of Cognitive Neurosciences, HSE University, Moscow, Russia
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Henrich D, Glombiewski JA, Scholten S. Systematic review of training in cognitive-behavioral therapy: Summarizing effects, costs and techniques. Clin Psychol Rev 2023; 101:102266. [PMID: 36963208 DOI: 10.1016/j.cpr.2023.102266] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/09/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
With the steadily growing importance of psychotherapeutic care, there is also an increasing need for high-quality training. We analyze the literature published between 2009 and 2022 on the effectiveness of training in cognitive behavioral therapy. The review addresses current gaps in the literature by focusing on the description of specific training components and their associated costs, as well as examining therapist-level predictors of training effectiveness. Our findings confirm the effect of additional supervision on both therapist competence and patient outcomes. Instructor-led training and self-guided web-based training seem to moderately increase competence, especially when targeting specific and highly structured treatments or skills. The level of prior training and experience of a therapist appears to predict the strength of training-related gains in competence. Few studies analyzed the differential effect of certain elements of training (e.g., the amount of active learning strategies) and training costs were generally not reported. Future studies should replicate or expand the existing evidence on active ingredients and therapist-level predictors of training effectiveness. Costs should be systematically reported to enhance the comparability of different training strategies.
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Affiliation(s)
- Dominik Henrich
- Department of Clinical Psychology and Psychotherapy, RPTU Kaiserslautern-Landau, Germany.
| | - Julia A Glombiewski
- Department of Clinical Psychology and Psychotherapy, RPTU Kaiserslautern-Landau, Germany
| | - Saskia Scholten
- Department of Clinical Psychology and Psychotherapy, RPTU Kaiserslautern-Landau, Germany
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10
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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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11
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Bonfils KA, Tennity CL, Congedo BA, Dolowich BA, Hammer LA, Haas GL. Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis. J Anxiety Disord 2022; 89:102576. [PMID: 35580437 DOI: 10.1016/j.janxdis.2022.102576] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/24/2022] [Accepted: 04/27/2022] [Indexed: 01/08/2023]
Abstract
People with posttraumatic stress disorder (PTSD) experience a wide array of symptoms, often accompanied by significant functional and quality of life impairments. Evidence-based psychotherapies are effective for alleviating symptoms in this group, but functional outcomes following psychotherapy are understudied. This study aimed to synthesize existing work on functional outcomes of psychotherapy to conduct a meta-analytic investigation examining whether people with PTSD experience significant improvements in functioning and quality of life following a course of psychotherapy. A literature search was conducted for studies reporting results of randomized clinical trials of psychotherapies for people diagnosed with PTSD that included a functional or quality of life outcome measured at pre- and post-intervention. Both between-groups and within-groups analyses were conducted using a random effects model. Fifty-six independent samples were included. Results suggest that, on average, people with PTSD experience significant, moderate improvement in functional outcomes after a course of psychotherapy. Taken together, this meta-analysis represents a substantial advance in our understanding of functional outcomes of psychotherapy for people with PTSD. Findings suggest that psychotherapy is one vehicle through which functional outcomes may be improved for this group, though notably to a lesser degree than symptom improvement.
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Affiliation(s)
- Kelsey A Bonfils
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States; VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States.
| | - Cassidy L Tennity
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Benjamin A Congedo
- VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States.
| | - Benjamin A Dolowich
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Lillian A Hammer
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States; Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213, United States.
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12
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Frank HE, Milgram L, Freeman JB, Benito KG. Expanding the reach of evidence-based mental health interventions to private practice: Qualitative assessment using a policy ecology framework. FRONTIERS IN HEALTH SERVICES 2022; 2:892294. [PMID: 36925863 PMCID: PMC10012822 DOI: 10.3389/frhs.2022.892294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022]
Abstract
Background Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research. Methods Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy. Results Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice. Conclusions Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.
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Affiliation(s)
- Hannah E Frank
- Warren Alpert Medical School of Brown University, Providence, RI, United States.,Bradley Hospital, East Providence, RI, United States
| | - Lauren Milgram
- Warren Alpert Medical School of Brown University, Providence, RI, United States.,Bradley Hospital, East Providence, RI, United States
| | - Jennifer B Freeman
- Warren Alpert Medical School of Brown University, Providence, RI, United States.,Bradley Hospital, East Providence, RI, United States
| | - Kristen G Benito
- Warren Alpert Medical School of Brown University, Providence, RI, United States.,Bradley Hospital, East Providence, RI, United States
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Vianez A, Marques A, Simões de Almeida R. Virtual Reality Exposure Therapy for Armed Forces Veterans with Post-Traumatic Stress Disorder: A Systematic Review and Focus Group. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010464. [PMID: 35010723 PMCID: PMC8744859 DOI: 10.3390/ijerph19010464] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
Virtual reality exposure therapy (VRET) is an emerging treatment for people diagnosed with Post-Traumatic Stress Disorder (PTSD) due to the limited accessibility of psychotherapies. This research aims to determine the guidelines for developing a Virtual Reality–War Scenario program for Armed Forces veterans with PTSD and encompasses two studies: Study 1, a systematic electronic database review; Study 2, a focus group of twenty-two Portuguese Armed Forces veterans. Results showed a positive impact of VRET on PTSD; however, there were no group differences in most of the studies. Further, according to veterans, new VRET programs should be combined with the traditional therapy and must consider as requirements the sense of presence, dynamic scenarios, realistic feeling, and multisensorial experience. Regardless, these findings suggest VRET as a co-creation process, which requires more controlled, personalized, and in-depth research on its clinical applicability.
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Affiliation(s)
- Ana Vianez
- Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal;
| | - António Marques
- Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal;
- Correspondence:
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Woodard GS, Triplett NS, Frank HE, Harrison JP, Robinson S, Dorsey S. The impact of implementation climate on community mental health clinicians’ attitudes toward exposure: An evaluation of the effects of training and consultation. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2. [PMID: 36210960 PMCID: PMC9536473 DOI: 10.1177/26334895211057883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Most evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) and anxiety disorders include exposure; however, in community settings, the implementation of exposure lags behind other EBT components. Clinician-level determinants have been consistently implicated as barriers to exposure implementation, but few organizational determinants have been studied. The current study examines an organization-level determinant, implementation climate, and clinician-level determinants, clinician demographic and background factors, as predictors of attitudes toward exposure and changes in attitudes following training. Method: Clinicians (n = 197) completed a 3-day training with 6 months of twice-monthly consultation. Clinicians were trained in cognitive behavioral therapy (CBT) for anxiety, depression, behavior problems, and trauma-focused CBT (TF-CBT). Demographic and background information, implementation climate, and attitudes toward exposure were assessed in a pre-training survey; attitudes were reassessed at post-consultation. Implementation climate was measured at the aggregated/group-level and clinician-level. Results: Attitudes toward exposure significantly improved from pre-training to post-consultation (t(193) = 9.9, p < .001; d = 0.71). Clinician-level implementation climate scores did not predict more positive attitudes at pre-training (p > .05) but did predict more positive attitudes at post-consultation (ß = −2.46; p < .05) and greater changes in those attitudes (ß = 2.28; p < .05). Group-level implementation climate scores did not predict attitudes at pre-training, post-consultation, or changes in attitudes (all ps > .05). Higher frequency of self-reported CBT use was associated with more positive attitudes at pre-training (ß = −0.81; p < .05), but no other clinician demographic or background determinants were associated with attitudes at post-consultation (all p > .05) or with changes in attitudes (all p > .05). Conclusions: Clinician perceptions of implementation climate predicted greater improvement of attitudes toward exposure following EBT training and consultation. Findings suggest that organizational determinants outside of training impact changes in clinicians’ attitudes. Training in four EBTs, only two of which include exposure as a component, resulted in positive changes in clinicians’ attitudes toward exposure, which suggests non-specialty trainings can be effective at changing attitudes, which may enable scale-up. Exposure is highly effective for treating trauma symptoms and anxiety-based disorders, but it is not commonly used in community mental health settings. Clinicians who endorsed higher expectations, support, and rewards for using exposure in their agency had more positive attitudes toward exposure after training and consultation. Additionally, clinicians who endorsed that exposure is expected, supported, and rewarded in their agency showed a greater improvement in attitudes throughout the training process. Organizational culture can affect clinicians’ attitude changes in the training process, and therefore should become a focus of training efforts.
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Affiliation(s)
- Grace S. Woodard
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Noah S. Triplett
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Hannah E. Frank
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
| | - Julie P. Harrison
- Department of Psychiatry, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Sophia Robinson
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, USA
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