Clinicians’ Perspectives on Cognitive Therapy in Community Mental Health Settings: Implications for Training and Implementation

  • Shannon Wiltsey Stirman
  • Ana Gutiérrez-Colina
  • Katherine Toder
  • Gregory Esposito
  • Frances Barg
  • Frank Castro
  • Aaron T. Beck
  • Paul Crits-Christoph
Original Article

Abstract

Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.

Keywords

Evidence-based psychosocial treatments Cognitive therapy Dissemination and implementation 

References

  1. Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence-based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6(2), 61–74. doi:10.1023/B:MHSR.0000024351.12294.65.PubMedCrossRefGoogle Scholar
  2. Aarons, G. A. (2006). Transformational and transactional leadership: Association with attitudes toward evidence-based practice. Psychiatric Services, 57(8), 1162–1169. doi:10.1176/appi.ps.57.8.1162.PubMedCrossRefGoogle Scholar
  3. Aarons, G., Cafri, G., Lugo, L., & Sawitzky, A. (2010). Expanding the domains of attitudes towards evidence-based practice: The Evidence based practice attitude scale-50. Administration and Policy in Mental Health and Mental Health Services Research. doi: 10.1007/s10488-010-0302-3
  4. Aarons, G., Hurlburt, M., & Horwitz, S. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 4–23. doi:10.1007/s10488-010-0327-7.PubMedCrossRefGoogle Scholar
  5. Aarons, G. A., & Palinkas, L. A. (2007). Implementation of evidence-based practice in child welfare: Service provider perspectives. Administration and Policy in Mental Health Services Research, 34, 411–419. doi:10.1176/appi.ps.62.3.255.CrossRefGoogle Scholar
  6. Aarons, G. A., & Sawitzky, A. (2006). Organizational climate partially mediates the effect of culture on work attitudes and staff turnover in mental health services. Administration and Policy in Mental Health and Mental Health Services Research, 33(3), 289–301. doi:10.1007/s10488-006-0039-1.PubMedCrossRefGoogle Scholar
  7. Aarons, G. A., Sommerfeld, D. H., Hecht, D. B., Silovsky, J. F., & Chaffin, M. J. (2009). The impact of evidence-based practice implementation and fidelity monitoring on staff turnover: Evidence for a protective effect. Journal of Consulting and Clinical Psychology, 77(2), 270–280. doi:10.1037/a0013223.PubMedCrossRefGoogle Scholar
  8. Beck, A. T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62(9), 953–959. doi:10.1001/archpsyc.62.9.953.PubMedCrossRefGoogle Scholar
  9. Becker, K. D., & Stirman, S. W. (2011). The science of training in evidence-based treatments in the context of implementation programs: Current status and prospects for the future. Administration and Policy in Mental Health and Mental Health Services Research, 38, 317–322. doi:10.1007/s10488-011-0361-0.Google Scholar
  10. Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology: Science and Practice, 17(1), 1. doi:10.1111/j.1468-2850.2009.01187.x.CrossRefGoogle Scholar
  11. Borntrager, C., Chorpita, B. F., MacMillan-Higa, C., & Weisz, J. (2009). Provider attitudes towards evidence based practices: Are the concerns with the evidence or the manuals? Psychiatric Services, 60, 677–681. doi:10.1176/appi.ps.60.5.677.PubMedCrossRefGoogle Scholar
  12. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. doi:10.16/jcpr2005.07.003.PubMedCrossRefGoogle Scholar
  13. Cohen, J. (1968). Weighted kappa: Nominal scale agreement provision for scaled disagreement or partial credit. Psychological Bulletin, 70(4), 213–220. doi:10.1037/h0026256.PubMedCrossRefGoogle Scholar
  14. Cook, J. M., Biyanova, T., & Coyne, J. C. (2009). Barriers to adoption of new treatments: An internet study of practicing community psychotherapists. Administration and Policy in Mental Health and Mental Health Services Research, 36(2), 83–90. doi:10.1007/s10488-008-0198-3.PubMedCrossRefGoogle Scholar
  15. Corrigan, P. W., Kwartarini, W. Y., & Pramana, W. (1992). Staff perception of barriers to behavior therapy at a psychiatric hospital. Behavior Modification, 16(1), 132–144. doi:10.1177/01454455920161007.PubMedCrossRefGoogle Scholar
  16. Corrigan, P. W., McCracken, S. G., Kommana, S., Edwards, M., & Simpatico, T. (1996). Staff perceptions about barriers to innovative behavioral rehabilitation programs. Cognitive therapy and research, 20(5), 541–551. doi:10.1177/01454455980224006.CrossRefGoogle Scholar
  17. Corrigan, P. W., Williams, O. B., McCracken, S. G., Kommana, S., Edwards, M., & Brunner, J. (1998). Staff attitudes that impede the implementation of behavioral treatment programs. Behavior Modification, 22(4), 548–562. doi:10.1177/01454455980224006.PubMedCrossRefGoogle Scholar
  18. Corry, R., & Jewell, T. C. (2002). Implementation of psychiatric rehabilitation strategies in real-life treatment settings for adults with severe mental illness. Psychiatric Rehabilitation Skills, 6(3), 335–354. doi:10.1080/10973430208408442.CrossRefGoogle Scholar
  19. Costa, A., Roe, R., & Taillieu, T. (2001). Trust within teams: the relation with performance effectiveness. European journal of work and organizational psychology, 10, 225–244. doi:10.1080/13594320143000654.CrossRefGoogle Scholar
  20. Crits-Christoph, P., Siqueland, L., Chittams, J., Barber, J. P., Beck, A. T., Frank, A., et al. (1998). Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence. Journal of Consulting and Clinical Psychology, 66(3), 484–492. doi:10.1037/0022-006X.66.3.484.PubMedCrossRefGoogle Scholar
  21. Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Tata, P., Murray, H., et al. (2006). The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of Personality Disorders, 20(5), 450–465. doi:10.1521/pedi.2006.20.5.450.PubMedCrossRefGoogle Scholar
  22. DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., & Gallop, R. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62(4), 409. Retrieved at http://archpsyc.ama-assn.org/cgi/content/full/62/4/417.
  23. Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., & Mayou, R. (2003). A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Archives of General Psychiatry, 60(10), 1024. Retrieved at http://archpsyc.ama-assn.org/cgi/content/full/60/10/1024.
  24. Gittelsohn, J., Steckler, A., Johnson, C. C., Pratt, C., Grieser, M., Pickrel, J., et al. (2006). Formative research in school and community-based health programs and studies: “State of the art” and the TAAG approach. Health Education & Behavior, 33(1), 25–39. doi:10.1177/1090198105282412.CrossRefGoogle Scholar
  25. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine Publishing Company.Google Scholar
  26. Glisson, C., Schoenwald, S. K., Hemmelgarn, A., Green, P., Dukes, D., Armstrong, K. S., et al. (2010). Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. Journal of Consulting and Clinical Psychology, 78(4), 537. doi:10.1037/a0019160.PubMedCrossRefGoogle Scholar
  27. Glisson, C., Schoenwald, S. K., Kelleher, K., Landsverk, J., Hoagwood, K. E., Mayberg, S., et al. (2008). Therapist turnover and new program sustainability in mental health clinics as a function of organizational culture, climate, and service structure. Administration and Policy in Mental Health and Mental Health Services Research, 35(1–2), 124. doi:10.1007/s10488-007-0152-9.PubMedCrossRefGoogle Scholar
  28. Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N., & Beck, A. T. (2011). A randomized trial to evaluate the efficacy of cognitive therapy for low functioning patients with schizophrenia. Archives of General Psychiatry, 69(2), 121–127. doi:10.1001/archgenpsychiatry.2011.129.PubMedCrossRefGoogle Scholar
  29. Gray, M., Elhai, J. D., & Schmidt, L. O. (2007). Trauma professionals’ attitudes towards and utilization of evidence-based practice. Behavior Modification, 31, 732–748. doi:10.1177/0145445507302877.PubMedCrossRefGoogle Scholar
  30. Helfrich, C. D., Damschroder, L. J., Hagedorn, H. J., Daggett, G. S., Sahay, A., Ritchie, M., et al. (2010). A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implementation Science, 5, 82. doi:10.1186/1748-5908-5-82.PubMedCrossRefGoogle Scholar
  31. Hemmelgarn, A. L., Glisson, C., & James, L. R. (2006). Organizational culture and climate: Implications for services and interventions research. Clinical Psychology: Science and Practice, 13(1), 73–89. doi:10.1111/j.1468-2850.2006.00008.x.CrossRefGoogle Scholar
  32. Henggeler, S. W. (2004). Decreasing effect sizes for effectiveness studies: Implications for the transport of evidence-based treatments: Comments on Curtis, Ronan, and Borduin. Journal of Family Psychology, 18, 420–423. doi:10.1037/0893-3200.18.3.420.PubMedCrossRefGoogle Scholar
  33. Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review, 30(4), 448–466. doi:10.1016/j.cpr.2010.02.005.PubMedCrossRefGoogle Scholar
  34. James, I. A., Blackburn, I. M., Milne, D. L., & Reichfelt, F. K. (2001). Moderators of trainee therapists’ competence in cognitive therapy. British Journal of Clinical Psychology, 40(2), 131–141. doi:10.1348/014466501163580.PubMedCrossRefGoogle Scholar
  35. Jensen-Doss, A., Hawley, K. M., Lopez, M., & Osterberg, L. D. (2009). Using evidence-based treatments: The experiences of youth providers working under a mandate. Professional Psychology: Research and Practice, 40(4), 417. doi:10.1037/a0014690.CrossRefGoogle Scholar
  36. Kauth, M. R., Sullivan, G., Blevins, D., Cully, J. A., Landes, R. D., Said, Q., et al. (2010). Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study. Implementation Science, 5, 75. doi:10.1186/1748-5908-5-75.PubMedCrossRefGoogle Scholar
  37. Kilmer, B., Eibner, C., Ringel, J. S., & Pacula, R. L. (2011). Invisible wounds, visible savings? Using microsimulation to estimate the costs and savings associated with providing evidence-based treatment for PTSD and depression to veterans of operation enduring freedom and operation Iraqi freedom. Psychological Trauma: Theory, Research, Practice, and Policy, 3(2), 201. doi:10.1037/a0020592.CrossRefGoogle Scholar
  38. Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., & Sham, P. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Archives of General Psychiatry, 60(2), 145. Retrieved from http://archpsyc.ama-assn.org/cgi/reprint/60/2/145.
  39. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33(1), 159–174. doi:10.2307/2529310.PubMedCrossRefGoogle Scholar
  40. Lehman, W. E., Greener, J. M., & Simpson, D. D. (2002). Assessing organizational readiness for change. Journal of Substance Abuse Treatment, 22(4), 197–209. doi:10.1016/S0740-5472(02)00233-7.PubMedCrossRefGoogle Scholar
  41. Levitt, J. T., Malta, L. S., Martin, A., Davis, L., & Cloitre, M. (2007). The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack. Behaviour Research and Therapy, 45(7), 1419–1433. doi:10.1016/j.brat.2007.01.004.PubMedCrossRefGoogle Scholar
  42. Lundgren, L., Amodeo, M., Cohen, A., Chassler, D., & Horowitz, A. (2011). Modifications of evidence-based practices in community-based addiction treatment organizations: A qualitative research study addictive behaviors. Addictive Behaviors, 36(6), 630–635. doi:10.1016/j.addbeh.2011.01.003.PubMedCrossRefGoogle Scholar
  43. Malik, N., Kingdon, D., Pelton, J., Mehta, R., & Turkington, D. (2009). Effectiveness of brief cognitive-behavioral therapy for schizophrenia delivered by mental health nurses: relapse and recovery at 24 months. The Journal of Clinical Psychiatry, 70(2), 201–207. doi:10.4088/JCP.07m03990.PubMedCrossRefGoogle Scholar
  44. McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. American Psychology, 65(2), 73–84. doi:10.1037/a0018121.CrossRefGoogle Scholar
  45. Mendel, P., Meredith, L. S., Schoenbaum, M., Sherbourne, C. D., & Wells, K. B. (2008). Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research. Administration and Policy in Mental Health and Mental Health Services Research, 35(1), 21–37. doi:10.1007/s10488-007-0144-9.PubMedCrossRefGoogle Scholar
  46. Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050–1062. doi:10.1037/0022-006X.72.6.1050.PubMedCrossRefGoogle Scholar
  47. Palinkas, L., Aarons, G., Horwitz, S., Chamberlain, P., Hurlburt, M., & Landsverk, J. (2010). Mixed method designs in implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 44–53. doi:10.1007/s10488-010-0314-z.CrossRefGoogle Scholar
  48. Palinkas, L. A., Schoenwald, S. K., Hoagwood, K., Landsverk, J., Chorpita, B. F., & Weisz, J. R. (2008). An ethnographic study of implementation of evidence-based treatments in child mental health: First steps. Psychiatric Services, 59(7), 738–746. doi:10.1176/appi.ps.59.7.738.PubMedCrossRefGoogle Scholar
  49. Podsakoff, P. M., MacKenzie, S. B., Lee, J.-Y., & Podsakoff, N. P. (2003). Common method biases in behavioral research: A critical review of the literature and recommended remedies. Journal of Applied Psychology, 88(5), 879–903. doi:10.1037/0021-9010.88.5.879.PubMedCrossRefGoogle Scholar
  50. Raghavan, R., Bright, C., & Shadoin, A. (2008). Toward a policy ecology of implementation of evidence-based practices in public mental health settings. Implementation Science, 3(1), 26. doi:10.1186/1748-5908-3-26.PubMedCrossRefGoogle Scholar
  51. Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496–516. doi:10.1016/j.cpr.2010.03.004.PubMedCrossRefGoogle Scholar
  52. Resick, P. A., Galovski, T. E., Uhlmansiek, M. O. B., Scher, C. D., Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76(2), 243. doi:10.1037/0022-006X.76.2.243.PubMedCrossRefGoogle Scholar
  53. Riggs, S., Stirman, S. W., & Beck, A. T. (2012). Training community mental health agencies in cognitive therapy for schizophrenia. The Behavior Therapist, 35, 34–39. Retrieved from http://www.abct.org/docs/PastIssue/35n2.pdf
  54. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47(1), 81–90.PubMedCrossRefGoogle Scholar
  55. Schoenwald, S. K., Chapman, J. E., Kelleher, K., Hoagwood, K. E., Landsverk, J., Stevens, J., et al. (2008). A survey of the infrastructure for children’s mental health services: Implications for the implementation of empirically supported treatments (ESTs). Administration and Policy in Mental Health and Mental Health Services Research, 35(1–2), 84–97. doi:10.1007/s10488-007-0147-6.PubMedCrossRefGoogle Scholar
  56. Sensky, T., Turkington, D., Kingdon, D., Scott, J. L., Scott, J., Siddle, R., et al. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57(2), 165–172. doi:10.1001/archpsyc.57.2.165.PubMedCrossRefGoogle Scholar
  57. Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t train in vain: A dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 73(1), 106–115. doi:10.1037/0022-006X.73.1.106.PubMedCrossRefGoogle Scholar
  58. 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(1), 99–112. doi:10.1186/1748-5908-6-99.PubMedCrossRefGoogle Scholar
  59. Stetler, C., Legro, M., Rycroft-Malone, J., Bowman, C., Curran, G., Guihan, M., et al. (2006a). Role of “external facilitation” in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implementation Science, 1(1), 23–32. doi:10.1186/1748-5908-1-23.PubMedCrossRefGoogle Scholar
  60. Stetler, C. B., Legro, M. W., Wallace, C. M., Bowman, C., Guihan, M., Hagedorn, H., et al. (2006b). The role of formative evaluation in implementation research and the QUERI experience. Jounal of General Internal Medicine, 21, S1–8. doi:10.1111/j.1525-1497.2006.00355.x.CrossRefGoogle Scholar
  61. Stewart, R. E., Wiltsey Stirman, S., & Chambless, D. L. (in press). A qualitative investigation of practicing psychologists’ attitudes toward research-informed practice: Implications for dissemination strategies. Professional Psychology: Research & Practice.Google Scholar
  62. Stirman, S. W., Bhar, S. S., Spokas, M., Brown, G. K., Creed, T. A., Perivoliotis, D., et al. (2010). Training and consultation in evidence-based psychosocial treatments in public mental health settings: The access model. Professional Psychology: Research and Practice, 41(1), 48–56. doi:10.1037/a0018099.CrossRefGoogle Scholar
  63. Turkington, D., Dudley, R., Warman, D. M., & Beck, A. T. (2006). Cognitive-behavioral therapy for schizophrenia: A review. Focus, 4(2), 223–233. Retrieved from http://psychiatryonline.org/article.aspx?articleid=50577 Google Scholar
  64. Vos, T., Corry, J., Haby, M. M., Carter, R., & Andrews, G. (2005). Cost effectiveness of cognitive-behavioural therapy and drug interventions for major depression. Australian and New Zealand Journal of Psychiatry, 39(8), 683–692. doi:10.1111/j.1440-1614.2005.01652.x.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2012

Authors and Affiliations

  • Shannon Wiltsey Stirman
    • 1
    • 2
  • Ana Gutiérrez-Colina
    • 3
  • Katherine Toder
    • 4
  • Gregory Esposito
    • 5
  • Frances Barg
    • 6
    • 7
  • Frank Castro
    • 1
    • 2
  • Aaron T. Beck
    • 4
  • Paul Crits-Christoph
    • 4
  1. 1.Women’s Health Sciences Division, National Center for PTSDVA Boston Healthcare SystemBostonUSA
  2. 2.Department of PsychiatryBoston UniversityBostonUSA
  3. 3.Department of PsychologyUniversity of GeorgiaAthensUSA
  4. 4.Department of PsychiatryUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.University of PennsylvaniaPhiladelphiaUSA
  6. 6.Department of Family Medicine and Community Health, School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  7. 7.Department of AnthropologyUniversity of PennsylvaniaPhiladelphiaUSA

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