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.
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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.
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.
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.
Corbin, J., & Strauss, A. (2008). Basics of qualitative research: Tehcniques and procedures for developing grounded theory (3rd ed.). Los Angeles: Sage Publications.
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.
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.
Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2003). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice, 10(1), 85–90.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Zayfert, C., & Becker, C. B. (2000). Implementation of empirically supported treatments for PTSD: Obstacles and innovations. The Behavior Therapist, 23(8), 161–168.
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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? |
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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
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DOI: https://doi.org/10.1007/s10488-015-0635-z