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Harrison JP, Deblinger E, Pollio E, Cooper B, Steer RA. TF-CBT Training Augmented with a Self-Care Focus: Understanding Facilitators and Barriers to Treatment Implementation. Community Ment Health J 2023; 59:1409-1421. [PMID: 37145337 PMCID: PMC10160727 DOI: 10.1007/s10597-023-01130-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023]
Abstract
Clinicians working with youth exposed to trauma may be at increased risk for experiencing elevated levels of stress and symptoms of secondary traumatic stress, which can negatively impact clinician wellbeing and ultimately contribute to reduced access to quality care for clients. An innovative Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training incorporating self-care practices (i.e., Practice What You Preach; PWYP) was developed to help facilitate the implementation of TF-CBT and to enhance clinicians' coping and decrease stress. The primary purpose of this study was to determine whether the PWYP-augmented training met three Objectives: (1) increase clinicians' feelings of TF-CBT competency; (2) improve clinicians' coping abilities/reduce clinicians' stress; and (3) increase clinicians' insight into the benefits and/or challenges clients may experience in treatment. An exploratory aim was also developed to identify additional facilitators and barriers of TF-CBT implementation. The written reflections of 86 community-based clinicians who participated in the PWYP-augmented TF-CBT training were examined using qualitative methods. The majority of clinicians indicated increased feelings of competency and improved coping abilities and/or stress levels; almost half mentioned increased insight into clients' experiences. The most frequently mentioned additional facilitators were related to elements of the TF-CBT treatment model. Anxiety/self-doubt was the barrier most frequently mentioned, though all clinicians who mentioned this barrier indicated it lessened or resolved over the course of the training. Incorporating self-care strategies into trainings may serve as a facilitator for TF-CBT implementation by enhancing the competency and well-being of clinicians. The additional insights into barriers and facilitators can be used to further improve the PWYP initiative and future training and implementation efforts.
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Affiliation(s)
- Julie P Harrison
- CARES Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA.
| | - Esther Deblinger
- CARES Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Elisabeth Pollio
- CARES Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Beth Cooper
- CARES Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Robert A Steer
- Department of Psychiatry, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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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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Last BS, Johnson C, Dallard N, Fernandez-Marcote S, Zinny A, Jackson K, Cliggitt L, Rudd BN, Mills C, Beidas RS. Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231199467. [PMID: 37790185 PMCID: PMC10496473 DOI: 10.1177/26334895231199467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background: In 2012, Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) developed an initiative to implement an evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health system. This report evaluates the initiative's 10-year implementation and effectiveness outcomes. Method: The Exploration, Preparation, Implementation, and Sustainment framework guided our implementation evaluation. The implementation outcomes include adoption, reach, and sustainment; these were obtained during regular evaluation data collection from publicly funded behavioral health agencies participating in the TF-CBT initiative. We analyze effectiveness outcomes (i.e., changes in PTSD symptoms) from a subset of patients receiving TF-CBT, which were collected in 6-month intervals by our research team between 2013 and 2021. Results: From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for potentially traumatic events and PTSD symptoms, and 7,550 youths received TF-CBT. Through the TF-CBT initiative, the city expanded the network of TF-CBT providers from 3 to 20 agencies. DBHIDS sustained this network by maintaining the participation of 16 behavioral health agencies over the course of a decade. The subset of 202 youths who were evaluated to assess TF-CBT effectiveness was drawn from 94 therapists and 20 agencies across Philadelphia. All participating youths completed a baseline assessment, and 151 (75%) completed at least one follow-up assessment. Linear mixed-effects models accounting for observations nested within participants and nested within clinicians found that treatment significantly reduced PTSD symptoms. Conclusion: Between 2012 and 2021, DBHIDS successfully implemented and sustained TF-CBT across the city's behavioral health system. Adoption, reach, and sustainment of TF-CBT were high. Despite the considerable adverse experiences faced by youths seeking treatment in Philadelphia's behavioral health system, TF-CBT was effective. Future directions to improve TF-CBT implementation in the next iteration of the initiative are described.
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Affiliation(s)
- Briana S. Last
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Natalie Dallard
- Community Behavioral Health, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA
| | - Sara Fernandez-Marcote
- Community Behavioral Health, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA
| | - Arturo Zinny
- Community Behavioral Health, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA
- Center for Nonviolence and Social Justice, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Kamilah Jackson
- Community Behavioral Health, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA
- Talawa International Consultants, Philadelphia, PA, USA
| | - Lauren Cliggitt
- Hall-Mercer Community Mental Health Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany N. Rudd
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Chynna Mills
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rinad S. Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Milgram L, Freeman JB, Benito KG, Elwy AR, Frank HE. Clinician-Reported Determinants of Evidence-Based Practice Use in Private Practice Mental Health. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2022. [DOI: 10.1007/s10879-022-09551-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Becker-Haimes EM, Klein CC, Frank HE, Oquendo MA, Jager-Hyman S, Brown GK, Brady M, Barnett ML. Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary. FRONTIERS IN HEALTH SERVICES 2022; 2:833214. [PMID: 36382152 PMCID: PMC9648711 DOI: 10.3389/frhs.2022.833214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/16/2022] [Indexed: 11/13/2022]
Abstract
This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.
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Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, PA, United States
| | - Corinna C. Klein
- Department of Counseling, Clinical, and School Psychology, University of California, Santa Barbara, Santa Barbara, CA, United States
| | - Hannah E. Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Bradley Hospital, Lifespan Health System, Riverside, RI, United States
| | - Maria A. Oquendo
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Shari Jager-Hyman
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Gregory K. Brown
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Megan Brady
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Miya L. Barnett
- Department of Counseling, Clinical, and School Psychology, University of California, Santa Barbara, Santa Barbara, CA, United States
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