A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic stress disorder

Implementation Science

Candice M Monson⁴  Marta M Maslej⁴  Jennifer M Belus¹  Meredith SH Landy⁴  Josh Deloriea⁴  Norman Shields²  Shannon Wiltsey Stirman³ 

[1] Department of Psychology, University of North Carolina, 209 South Rd., Chapel Hill, NC 27599, USA;Veterans Affairs Canada, Operational Stress Injuries National Network (OSINN), 305 Boul des Anciens-Combattants, Sainte-Anne-de-Bellevue, QC H9X 1Y9, Canada;Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston University, 150 South Huntington Ave (116B3), Boston, MA 02130, USA;Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada

关键词: Cognitive processing therapy;    PTSD;    Psychotherapy;    Consultation;    Implementation;    Training;   

Others  :  813480
DOI  :  10.1186/1748-5908-8-82

 received in 2013-04-12, accepted in 2013-07-26,  发布年份 2013

【 摘 要 】

Background

Posttraumatic Stress Disorder (PTSD) is a serious mental health condition with substantial costs to individuals and society. Among military veterans, the lifetime prevalence of PTSD has been estimated to be as high as 20%. Numerous research studies have demonstrated that short-term cognitive-behavioral psychotherapies, such as Cognitive Processing Therapy (CPT), lead to substantial and sustained improvements in PTSD symptoms. Despite known benefits, only a minority of clinicians provide these therapies. Transferring this research knowledge into clinical settings remains one of the largest hurdles to improving the health of veterans with PTSD. Attending a workshop alone is insufficient to promote adequate knowledge transfer and sustained skill; however, relatively little research has been conducted to identify effective post-training support strategies.

Methods

The current study investigates whether clinicians receiving post-workshop support (six-month duration) will deliver CPT with greater fidelity (i.e., psychotherapy adherence and competence) and have improved patient outcomes compared with clinicians receiving no formal post-workshop support. The study conditions are: technology-enhanced group tele-consultation; standard group tele-consultation; and fidelity assessment with no consultation. The primary outcome is independent assessment (via audio-recordings) of the clinicians’ adherence and competence in delivering CPT. The secondary outcome is observed changes in patient symptoms during and following treatment as a function of clinician fidelity. Post-consultation interviews with clinicians will help identify facilitators and barriers to psychotherapy skill acquisition. The study results will inform how best to implement and transfer evidence-based psychotherapy (e.g., CPT) to clinical settings to attain comparable outcomes to those observed in research settings.

Discussion

Findings will deepen our understanding of how much and what type of support is needed following a workshop to help clinicians become proficient in delivering a new protocol. Several influences on clinician learning and patient outcomes will be discussed. An evidence-based model of clinical consultation will be developed, with the ultimate goal of informing policy and influencing best practice in clinical consultation.

Trial registration

ClinicalTrials.gov: NCT01861769

【 授权许可】

   
2013 Wiltsey Stirman et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Van Ameringen M, et al.: Post-traumatic stress disorder in Canada. CNS Neurosci Ther 2008, 14(3):171-181.
• [2]Kessler RC, et al.: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005, 62(6):617.
• [3]Tanielian T, Jaycox L: Invisible wounds of war : psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica: RAND Corporation; 2008.
• [4]Schell TL, Marshall GN: Survey of individuals previously deployed for OEF/OIF, in invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Edited by Tanielian T, Jaycox LH. Santa Monica: RAND Center for Military Health Policy Research; 2008:87-115.
• [5]Sareen J, et al.: Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosom Med 2007, 69(3):242-248.
• [6]Sareen J, et al.: The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey. Depress Anxiety 2005, 21(4):193-202.
• [7]Schnurr PP, et al.: Predictors and outcomes of PTSD in World War II veterans exposed to mustard gas. J Consult Clin Psychol 2000, 68(2):258-268.
• [8]Sibai AM, Fletcher A, Armenian HK: Variations in the impact of long-term wartime stressors on mortality among the middle-aged and older population in Beirut, Lebanon, 1983–1993. Am J Epidemiol 2001, 154(3):128-137.
• [9]Schnurr P, Green BL: Understanding relationships among trauma, post-traumatic stress disorder, and health outcomes. Adv Mind Body Med 2004, 20(1):18-29.
• [10]Kessler RC: Posttraumatic Stress Disorder: The burden to the individual and to society. J Clin Psychiatry 2000, 61(suppl 5):4-12.
• [11]Hoge CW, Auchterlonie JL, Milliken CS: Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. J Am Med Assoc 2006, 295:1023-1032.
• [12]Wolfe J, et al.: Posttraumatic stress disorder and war-zone exposure as correlates of perceived health in female Vietnam War veterans. J Consult Clin Psychol 1994, 62(6):1235-1240.
• [13]Schnurr PP, et al.: PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis 2000, 188(8):496-504.
• [14]Walker EA, Newman E, Koss M: Costs and health care utilization associated with traumatic experiences, in Trauma and health: Physical health consequences of exposure to extreme stress. Edited by Schnurr P, Green BL. Washington, DC: American Psychological Association; 2004:43-69.
• [15]Dobie JD, et al.: Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med 2004, 164(4):394-400.
• [16]Resick PA, Monson CM, Gutner C: Psychosocial treatments for PTSD., in handbook of PTSD: science and practice. Edited by Friedman MJ, Keane TM, Resick PA. NY: Guilford; 2007:330-358.
• [17]Foa EB, et al.: Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). 2nd edition. New York, NY US: Guilford Press; 2009. [Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies]
• [18]Group, V.A.D.o.D.T.M.o.P.-T.S.W: VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. 2010.
• [19]Resick MC, Chard KM: Cognitive processing therapy veteran/military version: Therapist and patient materials manual. 2008.
• [20]Resick PA, et al.: A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol 2008, 76(2):243-258.
• [21]Resick PA, et al.: Long term outcomes of cognitive behavioral treatments for posttraumatic stress disorder among female rape survivors. J Consult Clin Psychol 2012, 80(2):210-212.
• [22]Schulz PM, et al.: The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. Cognitive and Behavioral Practice 2006, 13:322-331.
• [23]Resick PA, et al.: A comparison of cognitive processing therapy, prolonged exposure and a waiting condition for the treatment of posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002, 70(4):867-879.
• [24]Monson CM, et al.: Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol 2006, 74(5):898.
• [25]Thomas TL, Kang HK, Dalager NA: Mortality among women Vietnam veterans, 1973–1987. Am J Epidemiol 1991, 134:973-980.
• [26]Chard KM: Cognitive processing therapy for sexual abuse: a treatment outcome study. J Consult Clin Psychol 2005, 73:965-971.
• [27]Galovski TE, et al.: Does cognitive-behavioral therapy for PTSD improve perceived health and sleep impairment? J Trauma Stress 2009, 22(3):197-204.
• [28]Alvarez J, et al.: The comparative effectiveness of cognitive processing therapy for male veterans treated in a VHA posttraumatic stress disorder residential rehabilitation program. J Consult Clin Psychol 2011, 79(5):590-599.
• [29]Resick PA, Schnicke MK: Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol 1992, 60(5):748-756.
• [30]Chard KM, et al.: A comparison of OEF and OIF veterans and vietnam veterans receiving cognitive processing therapy. J Trauma Stress 2010, 23(1):25-32.
• [31]Chard KM, et al.: Dissemination and experience with cognitive processing therapy. JARD 2012, 49(5):667-678.
• [32]Ahrens J, Rexford L: Cognitive processing therapy for incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma 2002, 6(1):201-216.
• [33]Schulz PM, et al.: The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. Cognitive and Behavioral Practice 2006, 13(4):322.
• [34]Chard KM: An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol 2005, 73(5):965-971.
• [35]McHugh RK, Barlow DH: The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. American Psychology 2010, 65(2):73-84.
• [36]Insel TR: Devising prevention and treatment strategies for the nation’s diverse populations with mental illness. Psychiatr Serv 2007, 58(3):395.
• [37]Weissman MM, et al.: National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry 2006, 63(8):925-934.
• [38]Karlin BE, et al.: Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the veterans health administration. J Trauma Stress 2010, 23(6):663-673.
• [39]Canadian Institutes of Health Research: Health Research Roadmap: Creating innovative research for better health and health care. 2013. http://www.cihr-irsc.gc.ca/e/documents/strat_plan_2009_e.pdf webcite
• [40]National Institute of Mental Health: Dissemination and Implementation Research Workshop: Harnessing Science to Maximize Health. Available from: http://www.nimh.nih.gov/research-priorities/scientific-meetings/2007/dissemination-and-implementation-research-workshop-harnessing-science-to-maximize-health.shtml webcite
• [41]Rakovshik SG, McManus F: Establishing evidence-based training in cognitive behavioral therapy: a review of current empirical findings and theoretical guidance. Clin Psychol Rev 2010, 30(5):496-516.
• [42]Beidas RS, Kendall PC: Training therapists in evidence-based practice: a critical review of studies from a systems-contextual perspective. Clin Psychol Sci Pract 2010, 17(1):1.
• [43]Herschell AD, et al.: The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations. Clin Psychol Rev 2010, 30(4):448-466.
• [44]Shaw BF, et al.: Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. J Consult Clin Psychol 1999, 67(6):837-846.
• [45]Hogue A, et al.: Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. J Consult Clin Psychol 2008, 76(4):544-555.
• [46]DeRubeis RJ, et al.: Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am J Psychiatry 1999, 156(7):1007-1013.
• [47]Strunk DR, Brotman MA, DeRubeis RJ: The process of change in cognitive therapy for depression: predictors of early inter-session symptom gains. Behav Res Ther 2010, 48(7):599-606.
• [48]Strunk DR, et al.: Therapist competence in cognitive therapy for depression: predicting subsequent symptom change. J Consult Clin Psychol 2010, 78(3):429-437.
• [49]Schoenwald SK, et al.: Therapist adherence and organizational effects on change in youth behavior problems one year after multisystemic therapy. Adm Policy Ment Health 2008, 35(5):379-394.
• [50]Decker SE, Jameson MT, Naugle AE: Therapist training in empirically supported treatments: a review of evaluation methods for short- and long-term outcomes. Adm Policy Ment Heath 2011, 38:254-286.
• [51]Brosan L, Reynolds S, Moore RG: Self evaluation of cognitive therapy performance: Do therapists know how competent they are? Behav Cogn Psychother 2008, 36(5):581-587.
• [52]Miller WR, et al.: A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol 2004, 72(6):1050-1062.
• [53]Ruzek JI, Rosen RC: Disseminating evidence-based treatments for PTSD in organizational settings: a high priority focus area. Behav Res Ther 2009, 47(11):980-989.
• [54]Resick PA, Nishith, and M.C. Astin: Empirically based therapy for posttraumatic stress disorder. , in Effective Interventions in Mental Health: Cognitive Behavior Therapy Introduced. Edited by Bilsen HV. Wellington, New Zealand: Central Institute of Technology Press; 1999.
• [55]Resick PA, et al.: A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol 2008, 76(2):243.
• [56]Resick PA, et al.: 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. J Consult Clin Psychol 2002, 70(4):867.
• [57]Vallis TM, Shaw BF, Dobson K: The cognitive therapy scale: psychometric properties. J Consult Clin Psychol 1986, 54:381-385.
• [58]Stirman S, et al.: Development of a framework and coding system for modifications made to evidence-based programs and interventions. Implement Sci 2013, 8:65. BioMed Central Full Text
• [59]Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA: Psychometric properties of the PTSD checklist (PCL). Behavioral Research & Therapy 1996, 34:669-673.
• [60]Lambert MJ, et al.: The reliability and validity of the outcome questionnaire. Clin Psychol Psychother 1996, 3:249-258.
• [61]Ware JE, Kosinski M, Keller SD: A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996, 34(3):220-233.
• [62]Lehman WE, Greener JM, Simpson DD: Assessing organizational readiness for change. J Subst Abuse Treat 2002, 22(4):197-209.
• [63]Hoagwood K, Schoenwald SK, Chapman JE: Dimensions of Organizational Readiness-Revised (DOOR-R). 2003. Unpublished instrument
• [64]Aarons G, et al.: Expanding the Domains of Attitudes Towards Evidence-Based Practice: The Evidence Based Practice Attitude Scale-50. 2010., 1 [Administration and policy in mental health and mental health services research]
• [65]Marsh DR, et al.: The power of positive deviance. BMJ 2004, 329(7475):1177.
• [66]Stirman SW, et al.: Perspectives on training and consultation in a cognitive therapy implementation program: implications for implementation. Depression Research and Treatment 2012, 2012:11.
• [67]Damschroder LJ, et al.: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009, 4:50. BioMed Central Full Text
• [68]Cohen J: Statistical Power Analysis for the Behavioral Sciences (Second ed.). Hillsdale, NJ: Erlbaum; 1988.
• [69]Schulz KF, Altman DG, Moher D: CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 2010, 152(11):726-W.293.
• [70]Pope C, Ziebland S, Mays N: Qualitative research in health care. Analysing qualitative data. BMJ Research 2000, 320(7227):114-116.
• [71]Palinkas L, et al.: Mixed Method Designs in Implementation Research. Administration and Policy in Mental Health and Mental Health Services Research 2010, 38(1):44-53.
• [72]Spillane J, et al.: Mixing methods in randomized controlled trials (RCTs): validation, contextualization, triangulation, and control. Educ Assess Eval Account 2010, 22(1):5-28.
• [73]Proctor EK, et al.: Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research 2009, 36(1):24-35.
• [74]Baer JS, et al.: An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug Alcohol Depend 2004, 73(1):99-106.
• [75]Simons AD, et al.: Training and dissemination of cognitive behavior therapy for depression in adults: a preliminary examination of therapist competence and client outcomes. J Consult Clin Psychol 2010, 78(5):751-756.