Skip to main content

Advertisement

SpringerLink
Log in

Clinicians’ Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

  • Original Article
  • Published:
Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

Abstract

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians’ implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians’ perceptions about their patients’ readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  • Benedek, D. M., Friedman, M. J., Zatzick, D., & Ursano, R. J. (2009). Practice guideline for the treatment of patients with acute stress disorder and postratumatic stress disorder. Guideline Watch. Retrieved April 20, 2011 from http://www.psychiatryonline.com/content.aspx?aID=156498&searchStr=post-traumatic+stress+disorder.

  • Berg, A. O., Breslau, N., Goodman, S. N., Lezak, M. D., Matchar, D. B., Mellman, T. A., & Vega, W. A. (2008). Treatment of postraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

    Google Scholar 

  • Chard, K. M., Schumm, J. A., Owens, G. P., & Cottingham, S. M. (2010). A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. Journal of Traumatic Stress, 23(1), 25–32. doi:10.1002/jts.20500.

    PubMed  Google Scholar 

  • Cook, J. M., Schnurr, P. P., & Foa, E. B. (2004). Bridging the gap between posttraumatic stress disorder research and clinical practice: The example of exposure therapy. Psychotherapy: Theory, Research, Practice Training, 41(4), 374–387.

    Article  Google Scholar 

  • Corbin, J., & Strauss, A. (2008). Basics of qualitative research: Tehcniques and procedures for developing grounded theory (3rd ed.). Los Angeles: Sage Publications.

    Google Scholar 

  • Cully, J., Tolpin, L., Henderson, L., Jimenez, D., Kunik, M. E., & Petersen, L. A. (2008). Psychoterhapy in the veterans health administration: Missed opportunities? Psychological Services, 5(4), 320–331.

    Article  PubMed Central  PubMed  Google Scholar 

  • Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 50. doi:10.1186/1748-5908-4-50.

    Article  PubMed Central  PubMed  Google Scholar 

  • Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2003). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice, 10(1), 85–90.

    Article  Google Scholar 

  • Feldstein, A. C., & Glasgow, R. E. (2008). A Practical, Robust Implementation and Sustainility Model (PRISM) for Integrating Research Findings into Practice. Joint Commission on Accreditation of Healthcare Organizations, 34(4), 228–243.

    Google Scholar 

  • Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67(2), 194–200.

    Article  CAS  PubMed  Google Scholar 

  • Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. doi:10.1037/0022-006X.73.5.953.

    Article  PubMed  Google Scholar 

  • Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press.

    Google Scholar 

  • Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59(5), 715–723.

    Article  CAS  PubMed  Google Scholar 

  • Friedman, M. J., Lowry, P., & Ruzek, J. (2010). VA/DoD clinical practice guidelines for the management of post-traumatic stress. Retrieved April 20, 2011 from http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf.

  • Frueh, B. C., Cusack, K. J., Grubaugh, A. L., Sauvageot, J. A., & Wells, C. (2006). Clinicians’ perspectives on cognitive-behavioral treatment for PTSD among persons with severe mental illness. Psychiatric Services, 57(7), 1027–1031. doi:10.1176/appi.ps.57.7.1027.

    Article  PubMed  Google Scholar 

  • Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., & Foa, E. B. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the veterans health administration. Journal of Traumatic Stress,. doi:10.1002/jts.20588.

    PubMed  Google Scholar 

  • Kitson, A. L., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., & Titchen, A. (2008). Evaluating the successful implementation of evidence into practice using the PARIHS framework: Theoretical and practical challenges. Implementation Science, 3, 1. doi:10.1186/1748-5908-3-1.

    Article  PubMed Central  PubMed  Google Scholar 

  • Kussman, M. J. (2008). VHA Handbook 1160.01: Uniform Mental Helath Services in VA Medical Centers and Clinics. Retrieved March 1, 2010 from http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762.

  • Lu, M. W., Plagge, J. M., Marsiglio, M. C., & Dobscha, S. K. (2013). Clinician documentation on receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. The Journal of Behavioral Health Services and Research,. doi:10.1007/s11414-013-9372-9.

    Google Scholar 

  • Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898–907. doi:10.1037/0022-006X.74.5.898.

    Article  PubMed  Google Scholar 

  • Mott, J. M., Hundt, N. E., Sansgiry, S., Mignogna, J., & Cully, J. A. (2014). Changes in psychotherapy utilization among veterans with depression, anxiety, and PTSD. Psychiatric Services, 65(1), 106–112. doi:10.1176/appi.ps.201300056.

    Article  PubMed  Google Scholar 

  • Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867–879.

    Article  PubMed Central  PubMed  Google Scholar 

  • Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756.

    Article  CAS  PubMed  Google Scholar 

  • Ronconi, J. M., Shiner, B., & Watts, B. V. (2014). Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD. Journal of Psychiatric Practice, 20(1), 25–37.

    Article  PubMed  Google Scholar 

  • Rosen, C. S., Nguyen, T., Bernardy, N. C., Hamblen, J. L., Ruzek, J. I., & Friedman, M. J. (2012). Evaluation of a mentoring program for PTSD clinic managers in the U.S. Department of Veterans Affairs. Psychiatric Services, 63(10), 1047–1050. doi:10.1176/appi.ps.201100446.

    Article  PubMed  Google Scholar 

  • Rycroft-Malone, J. (2004). The PARIHS framework–A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19(4), 297–304.

    Article  PubMed  Google Scholar 

  • Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., & Estabrooks, C. (2002). Ingredients for change: Revisiting a conceptual framework. Quality and Safety in Health Care, 11(2), 174–180.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  • Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA, 297(8), 820–830. doi:10.1001/jama.297.8.820.

    Article  CAS  PubMed  Google Scholar 

  • Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren, L., & Marmar, C. R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23(1), 5–16. doi:10.1002/jts.20493.

    PubMed  Google Scholar 

  • Shiner, B., D’Avolio, L. W., Nguyen, T. M., Zayed, M. H., Young-Xu, Y., Desai, R. A., & Watts, B. V. (2013). Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Administration and Policy in Mental Health, 40(4), 311–318. doi:10.1007/s10488-012-0421-0.

    Article  PubMed  Google Scholar 

  • Spoont, M. R., Murdoch, M., Hodges, J., & Nugent, S. (2010). Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric Services, 61(1), 58–63. doi:10.1176/appi.ps.61.1.58.

    Article  PubMed  Google Scholar 

  • Stein, B. D., Celedonia, K. L., Kogan, J. N., Swartz, H. A., & Frank, E. (2013). Facilitators and barriers associated with implementation of evidence-based psychotherapy in community settings. Psychiatric Services, 64(12), 1263–1266. doi:10.1176/appi.ps.201200508.

    Article  PubMed Central  PubMed  Google Scholar 

  • Stetler, C. B., Damschroder, L. J., Helfrich, C. D., & Hagedorn, H. J. (2011). A guide for applying a revised version of the PARIHS framework for implementation. Implementation Science, 6, 99. doi:10.1186/1748-5908-6-99.

    Article  PubMed Central  PubMed  Google Scholar 

  • Stirman, S. W., Gutierrez-Colina, A., Toder, K., Esposito, G., Barg, F., Castro, F., & Crits-Christoph, P. (2013). Clinicians’ perspectives on cognitive therapy in community mental health settings: Implications for training and implementation. Administration and Policy In Mental Health, 40(4), 274–285. doi:10.1007/s10488-012-0418-8.

    Article  PubMed Central  PubMed  Google Scholar 

  • Tucker, P., Zaninelli, R., Yehuda, R., Ruggiero, L., Dillingham, K., & Pitts, C. D. (2001). Paroxetine in the treatment of chronic posttraumatic stress disorder: Results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry, 62(11), 860–868.

    Article  CAS  PubMed  Google Scholar 

  • Tuerk, P. W., Yoder, M., Grubaugh, A., Myrick, H., Hamner, M., & Acierno, R. (2011). Prolonged exposure therapy for combat-related posttraumatic stress disorder: An examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq. Journal of Anxiety Disorders, 25(3), 397–403. doi:10.1016/j.janxdis.2010.11.002.

    Article  PubMed Central  PubMed  Google Scholar 

  • Van Minnen, A., Hendricks, L., & Olff, M. (2010). When do trauma experts choose exposure thearpy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy, 48, 312–320.

    Article  PubMed  Google Scholar 

  • VirginiaTech. (2013). Reach Effectiveness Adoption Implementation Maintenance (RE-AIM). Retrieved December 26, 2013 from www.re-aim.org.

  • Wagner, T. H., Sinnott, P., & Siroka, A. M. (2011). Mental health and substance use disorder spending in the department of veterans affairs, fiscal years 2000–2007. Psychiatric Services, 62(4), 389–395. doi:10.1176/appi.ps.62.4.389.

    Article  PubMed  Google Scholar 

  • Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541–e550. doi:10.4088/JCP.12r08225.

    Article  PubMed  Google Scholar 

  • Watts, B. V., Shiner, B., Zubkoff, L., Carpenter-Song, E., Ronconi, J. M., & Coldwell, C. M. (2014). Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics. Psychiatric Services,. doi:10.1176/appi.ps.201300176.

    Google Scholar 

  • Zayfert, C., & Becker, C. B. (2000). Implementation of empirically supported treatments for PTSD: Obstacles and innovations. The Behavior Therapist, 23(8), 161–168.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. White River Junction VA Medical Center, 215 N. Main Street (10A4B1), White River Junction, VT, 05009, USA

    Lisa Zubkoff, Brian Shiner, Julia M. Ronconi & Bradley V. Watts

  2. Geisel School of Medicine at Dartmouth, Hanover, NH, USA

    Lisa Zubkoff, Elizabeth Carpenter-Song, Brian Shiner & Bradley V. Watts

  3. VA National Center for Patient Safety, White River Junction, VT, USA

    Lisa Zubkoff, Brian Shiner & Bradley V. Watts

Authors
  1. Lisa Zubkoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth Carpenter-Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Brian Shiner
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Julia M. Ronconi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bradley V. Watts
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lisa Zubkoff.

Appendix: Interview protocol

Appendix: Interview protocol

Mental health chief

How do therapists care for people with PTSD and how often do they adhere to that model?

What training have therapists had in evidence-based practices?

Did therapists on the PCT have prior training in PE and CPT before they came to the VA?

  Did therapist attend and complete VA PE and CPT training?

What are the roles of the chief of staff, the mental health service line director, the psychology director, and the PCT director in determining what happens in the PCT clinic?

  Are the roles real?

How do therapists respond to requests to offer treatments they may not believe in? What is the response of therapist to requests to adhere to treatments they may not believe in?

  Do they do the treatments?

  Do they tell people they did the treatments?

  Do they ignore the requests altogether?

PCT chief

How do you care for people with PTSD and how often do you adhere to that model?

What are the roles of the chief of staff, the mental health service line director, the psychology director, and the PCT director in determining what happens in the PCT clinic?

  Are the roles real?

Do you feel that you actually have the ability to deliver PE and CPT to patients whenever these treatments are indicated?

Where and when do staff meetings occur (PCT, psychologists, MH All-Staff)?

 

  What aspects of PTSD care are discussed in staff meetings?

Psychologists/therapists: doctoral-level,

masters-level

Do you use measurement in your practice (e.g., individual-level outcomes)?

  How is the information used?

  Do they aggregate and report the information to anyone?

What are your general thoughts on evidence-based practice rollouts?

  What was your experience?

  Did you want to go?

  Did the teaching work for you?

    pedagogical style (i.e., lecture-style, interactive)

    perceived positives/negatives of the style used in training

  Were teachers viewed as experts

  Was there adequate support during the training?

  Was there adequate technical support after the training?

Did you attend and complete VA PE and CPT training?

  If so, where and when?

  How did you view VA PE and CPT training?

  Was it professional or punitive?

  Did the teachers have expertise?

  Did they provide adequate technical support after the training?

What are the key facilitators and barriers to your ability to deliver PE and CBT?

  What do you feel helps you to deliver PE and CPT?

    Time?

    Training?

    Appropriate Patients?

    Other Supports?

  What do you feel you lack in delivering PE and CPT

    Time?

    Training?

    Appropriate Patients?

    Other Supports?

How do you respond to requests to offer treatments you may not believe in?

  Do you do the treatments?

  Do you tell people you did the treatments?

  Do you ignore the requests altogether?

How do you care for people with PTSD and how often do you adhere to that model?

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zubkoff, L., Carpenter-Song, E., Shiner, B. et al. Clinicians’ Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?. Adm Policy Ment Health 43, 250–258 (2016). https://doi.org/10.1007/s10488-015-0635-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10488-015-0635-z

Keywords

Search

Navigation