Clinical and Administrative Insights From Delivering Massed Trauma-Focused Therapy to Service Members and Veterans

Despite strong evidence of their effectiveness in reducing symptoms of posttraumatic stress disorder (PTSD), prolonged exposure therapy (PE) and cognitive processing therapy (CPT) remain challenging for some service members and veterans to access and complete. Delivering PE and CPT in time-condensed or “massed” formats may reduce barriers to receiving care. PE and CPT have now been implemented across a range of tempos (e.g., multiple sessions per day across 1 week, one session per day for 3 weeks) and to multiple target populations, in a variety of contexts from individual therapy alone to full intensive outpatient programs. A massed format of treatment delivery has advantages for both patients and providers, including quicker time to recovery, less opportunity for avoidance, and improved treatment completion rates. The time-limited nature of massed treatment also creates accompanying challenges, such as less time to practice homework and greater impact when factors delay or disrupt progress. This paper discusses lessons learned from providers across diverse settings who are experienced in both delivering massed PE and CPT and managing such programs, primarily with military populations.     

Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series

Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.     

Massed Cognitive Processing Therapy in Active-Duty Military: A Case Series

Despite consistent evidence that Cognitive Processing Therapy (CPT) is an efficacious treatment for posttraumatic stress disorder (PTSD), the effects among active-duty service members and veterans have been smaller than for civilians. Modifications to standard delivery may be needed to increase treatment engagement and completion, which could improve outcomes in this population. Delivering CPT in a massed format may reduce barriers to care and enable more rapid symptom reduction, yet clinicians and patients may have concerns about the tolerability and practicality of such interventions. This case series describes a course of CPT delivered in 5 days in a mixed group and individual format among 4 active-duty military service members as part of a larger randomized clinical trial. Although the pattern of symptom change differed between patients, most demonstrated clinically significant reductions in PTSD and depression symptoms during the 5-day treatment. Patients reported that the pace was tolerable and that the mixed group and individual format was beneficial. Although further research is needed to understand the longer-term outcomes of massed CPT, this therapy format has important implications for the future delivery of treatments for PTSD.     

The Current State of Intervention Research for Posttraumatic Stress Disorder Within the Primary Care Setting

Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.     

Parent engagement in an original and culturally adapted evidence-based parenting program,Legacy for Children™

Legacy for Children™ (Legacy) is an evidence-based program focused on promoting sensitive, responsive parenting for socioeconomically disadvantaged families. Legacy has recently been culturally and linguistically adapted for Spanish-monolingual Latino families and is being piloted in partnership with an early childhood education program. We conducted a mixed methods study to identify barriers and facilitators to engagement, using program monitoring data sources from both participant and group leader perspectives. We conducted qualitative analyses of open-ended data to identify distinct barriers (e.g., employment challenges, health-related challenges and appointments) and facilitators (e.g., other mothers in group, interest in program topics) to engagement that emerged across English and Spanish language curriculum versions; curriculum-specific barriers and facilitators were also documented. We interpret these findings in light of quantitative data on measures of engagement, showing that participants in the Spanish curriculum evidenced comparable levels of parent–group leader relationship quality relative to the English group, and higher levels of parent's group support/connectedness and overall satisfaction. These results offer promising considerations for optimizing families’ engagement in parenting programs in the context of early care and education settings.     

Perceived Barriers and Preliminary PTSD Outcomes in an Open Pilot Trial of Written Exposure Therapy With Latinx Immigrants

Latinx immigrants experience substantial disparities in mental health treatment access, particularly for posttraumatic stress disorder (PTSD). The availability of brief, flexible interventions in Spanish may assist in reducing these disparities. Written Exposure Therapy (WET) is a five-session PTSD intervention that appears as effective as longer, gold-standard interventions, but has yet to be tested among Latinx immigrants. To test the acceptability and preliminary effectiveness of WET, 20 Spanish-speaking, Latinx immigrants conducted structured interviews at pretreatment, were offered WET, and completed posttreatment structured interviews. Open thematic coding of pre- and posttreatment interview questions examined perceived barriers and benefits of WET. Quantitative components examined symptom change across PTSD (PCL-IV-C) and depression (PHQ-9). Quantitative results indicated clinically meaningful and statistically significant change in PTSD symptoms using intent-to-treat analyses (M_diff = 17.06, SD_diff = 9.97, range = 0–29, t(15) = 6.84, p < .001). Open thematic coding identified four barrier-related themes and three benefit-related themes at pretreatment. At posttreatment, three barrier-related themes and two benefit-related themes were identified. Qualitative results largely suggested that perceived barriers were common to other PTSD interventions (e.g., exposure components). Only one participant identified barriers specific to WET. Results suggested WET may reduce PTSD symptoms among Latinx immigrants. WET also appeared to be acceptable and primarily viewed as beneficial among this population. WET is a promising intervention with Latinx immigrants and warrants further testing larger trials, including testing implementation strategies that may improve access to care.     

Work potential of road accident survivors with post-traumatic stress disorder

Work potential in adult survivors of road accidents with and without post-traumatic stress disorder (PTSD) was examined at a mean of 8.6 months (SD = 3.77) post-accident. All participants were working prior to their accident. Results showed that survivors with PTSD had significantly less work potential post-accident than survivors without PTSD. Specific barriers to employability for survivors with PTSD identified by this study included high levels of depression, reduced time-management ability, and an over-concern or anxiety with physical injuries. Respondents with PTSD, however, reported significantly greater extrinsic motivation to work than those without PTSD. Early intervention and referral to occupational rehabilitation programs that: (1) help address these barriers to employability and stimulate the existing motivation to return to work, and (2) work alongside clinical treatment programs, may assist in the reduction of poor work outcomes that people with PTSD following road accidents often experience.     

Cultural Considerations for Treating PTSD in Latinx Sexual Assault Survivors With Prolonged Exposure

There is growing interest in the implementation of culturally responsive mental health care that balances treatment fidelity and cultural fit (Castro et al., 2004). Prolonged exposure (PE) is a first-line, evidence-based treatment for posttraumatic stress disorder (PTSD) and has been successfully implemented in low-income and ethnoracial minority samples (Feske, 2008) and with Latinx individuals specifically (Vera et al., 2011). However, cultural and systemic factors may contribute to Latinx individuals experiencing higher conditional risk for PTSD (Alcántara et al., 2013), disparities in mental health care utilization (Alves-Bradford et al., 2020), and challenges with PTSD treatment delivery (Valentine et al., 2017). Culturally responsive implementation of PE with Latinx clients involves making culturally informed but person-specific assessments of clients, with adaptations as needed. We propose several culturally responsive strategies for therapists to consider when conducting PE with Latinx sexual assault survivors, such as building trust and rapport early on, conducting culturally informed assessment, investing in psychoeducation, optimizing imaginal exposure and in vivo exposure, and problem-solving barriers to homework engagement. Therapists are encouraged to approach this work with cultural humility (Fisher-Borne et al., 2015; Tervalon & Murray-Garcia, 1998) through open listening, critical self-reflection, and consideration for the way in which Latinx identity intersects with other important identity characteristics that can impact treatment relevance and engagement.     

Barriers and Facilitators to Implementing Attachment-based Family Therapy into a Child Welfare Setting: A Qualitative Process Evaluation

Child welfare systems (CWSs) worldwide show increased interest in adopting empirically informed clinical strategies to increase treatment effectiveness. Many empirically supported treatments (ESTs) exist, but little is known about EST implementation barriers and facilitators in CWS. This study explored CWS providers’ experiences of implementing attachment-based family therapy (ABFT) in home-based services of the Flemish CWS (in Belgium). Sixteen CWS providers (twelve counselors and four supervisors) involved in three home-based services were interviewed. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection, coding, and analysis of interview data. Findings revealed that implementation success was related to ABFT's fit with the CWS's mission, philosophy, and existing practices. CWS providers’ belief in the compatibility between ABFT and CWS increased investment in implementation efforts and persistence to overcome challenges and setbacks. Some barriers pertained to the learning of ABFT and some barriers pertained to systems level challenges such as lack of leadership and support, poor coordination with referral sources and other youth care partners, and lack of policy support. For successful expansion of ESTs into CWS settings, various barriers at multiple systemic levels need to be addressed.     

Implementation of the Wolverine Mental Health Program,Part 1: Adoption Phase

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS’s readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.     

Stress-enhanced fear learning in rats is resistant to the effects of immediate massed extinction

Enhanced fear learning occurs subsequent to traumatic or stressful events and is a persistent challenge to the treatment of post-traumatic stress disorder (PTSD). Facilitation of learning produced by prior stress can elicit an exaggerated fear response to a minimally aversive event or stimulus. Stress-enhanced fear learning (SEFL) is a rat model of PTSD; rats previously exposed to the SEFL 15 electrical shocks procedure exhibit several behavioral responses similar to those seen in patients with PTSD. However, past reports found that SEFL is not mitigated by extinction (a model of exposure therapy) when the spaced extinction began 24?h after stress. Recent studies found that extinction from 10?min to 1?h subsequent to fear conditioning "erased" learning, whereas later extinction, occurring from 24 to 72?h after conditioning did not. Other studies indicate that massed extinction is more effective than spaced procedures. Therefore, we examined the time-dependent nature of extinction on the stress-induced enhancement of fear learning using a massed trial's procedure. Experimental rats received 15 foot shocks and were given either no extinction or massed extinction 10?min or 72?h later. Our present data indicate that SEFL, following traumatic stress, is resistant to immediate massed extinction. Experimental rats showed exaggerated new fear learning regardless of when extinction training occurred. Thus, post-traumatic reactivity such as SEFL does not seem responsive to extinction treatments.     

TIES that BIND: an introduction to domain mapping as a visualization tool for virtual rehabilitation.

The application of virtual reality (VR) to rehabilitation is a young, interdisciplinary field where clinical implementation very rapidly follows scientific discovery and technological advancement. Implementation is often so rapid that demonstration of intervention efficacy by investigators, and establishment of research and development priorities by funding bodies tend to be more reactive than proactive. An examination of the dynamic unfolding of the history of our young discipline may help us recognize the facilitators of current practice and identify the barriers that limit greater progress. This paper presents a first step towards the examination of the past and future growth of VR-based rehabilitation by presenting the use of concept maps to explore the publication history of application of VR to rehabilitation.     

Assessing daily fluctuations in posttraumatic stress disorder symptoms and substance use with Interactive Voice Response technology: protocol compliance and reactions

PTSD symptoms and substance use commonly co-occur, but information is limited regarding their interplay. We used ecological momentary assessment (EMA) to capture fluctuations in PTSD symptoms and drinking within and across days. Fifty Iraq and Afghanistan War veterans completed four daily Interactive Voice Response (IVR) assessments of PTSD and substance use with cell phones for 28 days. The aims of this study were to (1) describe participant compliance and reactions to the protocol and (2) identify participant characteristics and protocol reactions that predict compliance. Protocol compliance was high, with participants completing an average of 96 out of a total of 112 IVR assessments (86%). While some participants perceived that the IVR assessments increased their drinking (21%) and PTSD symptoms (60%), self-report measures showed significant decreases in PTSD symptoms and nonsignificant decreases in drinking over the assessment period. Analyses revealed demographic (e.g., older than 24, full-time employment, more education), clinical (e.g., less binge drinking, less avoidance symptoms), and perceived benefit from participation predicted better protocol compliance. Results can guide future research on participant predictors of compliance with intensive EMA methods.     

Group Cognitive-Behavioral Therapy via Telebehavioral Health for Those With Psychotic Spectrum Disorders: A Case Series

Telebehavioral health emerged as an important practice during the coronavirus disease 2019 (COVID-19) pandemic as an opportunity for continued evidence-based mental health intervention, while minimizing exposure to coronavirus contagion. Though preliminary research suggests feasibility and positive outcomes of telebehavioral health practice for people with schizophrenia spectrum and other psychotic disorders, there is limited research about implementation and effectiveness of this practice (Kasckow et al., 2014). This case series highlights the transition from in-person to telebehavioral health practice of a Cognitive Behavioral Social Skills Training for Schizophrenia group due to the COVID-19 pandemic. This article summarizes: (a) the staff procedures needed to transition the group from in-person to telebehavioral health, (b) participant outcome data, (c) session attendance data, and (d) survey results from facilitators and participants about barriers and facilitators of the transition to telebehavioral health, and about how the virtual platform altered the therapeutic relationship and engagement. Participant outcome and engagement data suggest that, not only were two participants able to transition to telehealth and complete the program, but both participants also showed notable improvement in treatment engagement, goal progress, and skill acquisition. Surveys of six facilitators and one participant highlight how the transition to telebehavioral health had treatment advantages (e.g., therapeutic relationship, treatment engagement, group dynamics). Though survey results highlighted several implementation challenges in using the new virtual platform (e.g., technological connectivity, confidential space for engagement), no survey respondents reported that participation in this program resulted in harm to facilitators or participants. All facilitators and one participant agreed that the transition from in-person to virtual services was easy and reduced transportation barriers. Given the limited treatment engagement for this population (Lora et al., 2012) and the importance of early intervention to maximize clinical outcomes (Black et al., 2001; Bottlender et al., 2003), unanimous facilitator and participant report about improved patient attendance and participation in treatment after the transition to telebehavioral health was critically important. Though results of this case study are promising in suggesting telebehavioral health could be a viable modality for providing psychosocial treatment to people with schizophrenia spectrum and other psychotic disorders, more rigorous study is needed.     

Facilitators and Barriers to HIV Activities in Religious Congregations: Perspectives of Clergy and Lay Leaders from a Diverse Urban Sample

This paper examines facilitators and barriers to HIV activities within religious congregations, the relative internal or external sources of these influences, and suggestive differences across congregational types. Results are based on in-depth interviews with clergy and lay leaders (n = 57) from 14 congregations in Los Angeles County, California, purposively selected to reflect diversity in racial-ethnic composition, denomination, size, and HIV activity level. Many common facilitators and barriers were related to norms and attitudes, only a few of which appeared overtly associated with theological orientations. Clergy support was a facilitator particularly prevalent among congregations having higher HIV activity levels, indicating its importance in sustaining and expanding HIV programs. Resource issues were also prominent, with material resource barriers more frequently mentioned by smaller congregations and human resource barriers more among larger congregations. Organizational structure issues were mostly centered on external linkages with various social service, public health, and faith-based entities. Analysis of internal versus external sources highlights the roles of different stakeholders within and outside congregations in promoting HIV activities. Potential differences across congregational types represent fruitful areas for future research.     

Improving Health Education for Women Who Carry an <Emphasis Type="Italic">FMR1</Emphasis> Premutation

Women who carry an FMR1 (i.e., fragile X) premutation have specific health risks over their lifetime. However, little is known about their experience understanding these risks and navigating their health needs. The aim of this study was to use qualitative analysis to uncover both barriers and facilitators to personal healthcare using a framework of the Health Belief Model. Five focus groups were conducted with a total of 20 women who carry the FMR1 premutation using a semi-structured discussion guide. All sessions were transcribed verbatim and independently coded by two researchers. The coders used a deductive – inductive approach to determine the prominent themes related to the participants’ experiences seeking healthcare for premutation-related conditions. Salient barriers to personal healthcare included difficult clinical translation of research findings, lack of knowledge among healthcare providers and among the women themselves, different priorities, and shortage of premutation-specific support and targeted educational materials. Facilitators included family members, national and community support organizations, research studies, compassionate physicians, and other premutation carriers. Addressing barriers to personal healthcare through up-to-date educational materials can help diminish misperceptions regarding health risks. Targeted educational materials will aid in information sharing and awareness for women who carry the FMR1 premutation and their physicians.     

Factors Facilitating and Inhibiting the Use of Research to Inform Interpretation Practice: A Case Study of Australian Protected Area Management Agencies

ABSTRACT

Interpretation research can be and is used to inform and improve interpretation policymaking and planning undertaken by practitioners such as those who work for Australian protected area management (PAM) agencies. This study explores perceptions of the extent to which interpretation research is undertaken and used by these agencies, and the facilitators and constraints to doing so. In-depth telephone interviews were conducted with senior interpretation planners and managers in all Australian PAM agencies. The findings indicate that interpretation research is usually prompted by a crisis or a short-term need such as a specific project and that most research is site-specific and content-focused, while respondents see a need for more longitudinal and evaluation-focused research. Two-thirds of the respondents reported that their agency made poor or no use of research findings for improving interpretation practice. Stated barriers to undertaking and using research included lack of funding, lack of time and that research was not considered an agency priority. Underpinning these were perceptions consistent with diffusion of innovation theory (e.g., that doing or using research is perceived as being too complex, not compatible with agency goals or not offering relative advantage). Strategies for removing these perceptual barriers to undertaking and using interpretation research and research findings are presented.     

Caregiver perceptions of Parent Peer Support Services within the Wraparound Service Delivery Model

This qualitative study examined caregivers’ perceptions of Parent Peer Support (PPS) services, embedded in the Wraparound service delivery model for youth with severe emotional and behavioral disturbances (SEBD), to identify potential engagement facilitators and barriers. Wraparound is a holistic process involving multiple formal and informal providers to collectively implement an individualized, family-centered plan of care focused on maintaining youth with SEBD within the community. PPS are frequently referred to caregivers involved in Wraparound to provide additional support. Caregivers (n?=?35) previously involved in an evaluation of one state’s Wraparound model participated in a single 30–60-min interview. Interview questions examined caregivers’ expectations about PPS, reasons for accepting or refusing PPS, and caregivers’ perceived impact of PPS. Transcribed interviews were analyzed using strategies from grounded theory methodology. Perceived need, as well as desire for shared experiences, knowledge, and assistance in accessing resources, facilitated accepting the PPS service. Barriers included inaccurate expectations of PPS, time limitations on Wraparound services, escalating youth behavior requiring more restrictive placements, scheduling difficulties, perceived unresponsiveness, and caregivers feeling overwhelmed by the number of providers. Caregivers indicated that PPS provided several benefits for themselves, youth in the care, and their families. However, potential barriers to ongoing engagement included perceived intrusiveness, as well as misalignment between services offered and caregivers’ needs.     

An examination of the construct validity of posttraumatic stress disorder with veterans using a revised criterion set

Ongoing concerns exist in the literature regarding the construct of posttraumatic stress disorder (PTSD) and how to best conceptualize and measure this disorder. We compared the traditional DSM-IV PTSD symptom criteria (i.e., symptoms from clusters B, C, and D) to a revised criterion set that omits overlapping mood and other anxiety symptoms on PTSD prevalence, PTSD diagnostic caseness, associated psychiatric comorbidity, functional status, and structural validity using a cross-sectional, multi-site primary care sample of 747 veterans. After removing items theorized to overlap with mood and other anxiety disorders, PTSD prevalence was identical using both criterion sets (i.e., 12%). Overall, there were few statistically significant differences in PTSD caseness, associated psychiatric comorbidity, functional status, and structural validity across the two diagnostic criterion sets. These data provide further support that removing items that overlap with other psychiatric disorders does not significantly impact the prevalence of PTSD, its associated comorbidity and functional impairment, or its structural validity. Although the revised criterion set represents a more parsimonious model, the current study findings generally support the strong construct validity of PTSD. The implications of these study findings for research and clinical practice are discussed.