Using a Learning Collaborative Model to Disseminate Cognitive Processing Therapy to Community-Based Agencies

Although effective treatments for posttraumatic stress disorder exist, their use in community settings is disappointingly low. Training alone does not necessarily lead to adoption. To address this problem, we trained community clinicians in cognitive processing therapy, an evidence-based treatment for posttraumatic stress disorder, using a Learning Collaborative, an intensive training methodology focused on both clinical training and developing sustainability. Sixty clinicians within 18 agencies began the year-long, team-based Learning Collaborative. Clinicians attended three in-person Learning Sessions, received weekly consultation, and submitted audio-recorded sessions to be rated for fidelity. Clinicians were rostered as approved treatment providers if they completed all training requirements. Additionally, we engaged leadership from each agency to build a sustainable practice. Clinicians trained through the Learning Collaborative demonstrated a high degree of fidelity to the treatment (average competence ratings “satisfactory” to “good”), and most (68%) were rostered as approved treatment providers. Patients treated by clinician trainees exhibited significant symptom reductions (d = 1.68 and 1.28 for posttraumatic stress and depression symptoms, respectively, among treatment completers). At a 6-month follow-up, 95% of rostered clinicians and 100% of agencies with rostered clinicians were still providing the treatment. These results suggest that the Learning Collaborative model is a promising approach for the dissemination and implementation of evidence-based treatments for adult posttraumatic stress disorder.     

效率至上还是忠实优先:学前儿童模仿学习机制探讨

模仿是儿童学习的一种重要机制,但学前儿童在模仿他人行为的过程中,是注重效率原则而有选择性地模仿,还是注重忠实原则不加辨别地模仿?这一问题成为近10年来发展心理学,比较心理学和进化人类学中的争论问题。争论双方提供了大量实验证据支持各自观点,并提出种种假设以解释学前儿童的模仿学习机制。如基于因果关系推理角度提出自动因果编码假设和意图不清假设;基于社会交往角度提出社会依存假设和自然教育法假设等。迄今为止,尚无一个假设能解释所有证据。因此,在整合相关实验证据的基础上,提出了解释这一争论的新视角——"损益权衡"假设,即学前儿童模仿策略选择是特定情境下权衡利益与损失的过程。     

Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.     

中国当前的医疗危机与医护人员的专业责任和使命

分析了导致当前国内医患关系恶化的种种宏观与微观的因素,认为其中最重要的原因是医患关系中出现不应存在的利益冲突,最终导致医患关系出现一种诚信危机。以此为讨论起点,分析了西方国家的信托模式的七种特征,论证医患关系的本质为何是一种信托关系,并指出忠诚与守信是信托关系和医疗专业精神的核心价值。在结论中特别指出,这种认知明确了医疗专业在当前的医患危机中应该扮演的角色和担当的责任。     

To stay or to leave? Decision rules for partner species relocation in two symbiotic pairs of desert beetles

Four nocturnal Kalahari desert tenebrionid beetles live in closely associated species pairs. The larger member of each pair, Parastizopus and Gonopus, are the primary burrowers while their smaller associates, Eremostibes and Herpiscius, inhabit the burrows with them and feed on detritus the larger beetles carry in. During summer drought, the two large species have different emergence times, surface activity patterns (vagilities) and different probabilities that burrows will be reoccupied before sunrise or remain empty for longer periods. Because their partners leave the burrows, the smaller species must make a decision either to stay in the expectation of a burrow being reinhabited, or leave and locate a new partner. The vagility and burrow fidelity of the associating species were studied using marked individuals in free-living populations. Field inclusion/exclusion experiments to test what influences the decision process showed that neither continual partner presence nor food induced the smaller beetles to remain. Different percentages, depending on species, left overnight. For both associates, these proportions corresponded exactly to the probability that the burrow would not be inhabited by their partner species the next day. Neither species predicted the probability of burrow reoccupation after a short vacancy and adopted a “waiting” strategy. Received: 13 January 1998 / Accepted after revision: 20 May 1998     

The Development and Validation of the Memory Support Treatment Provider Checklist

Patient memory for the contents of treatment is staggeringly poor, and poor memory for treatment is associated with worse treatment outcome. Accordingly, the Memory Support Intervention was developed to improve patient memory for treatment as an adjunct to treatment as usual. As plans to disseminate the Memory Support Intervention are developed, it is important to have efficient, accurate methods of measuring fidelity to the intervention. However, the existing method of assessing fidelity to the Memory Support Intervention, the Memory Support Rating Scale (MSRS), is burdensome and requires trained independent-raters to spend multiple hours reviewing session recordings, which is not feasible in many routine mental health care settings. Hence, a provider-rated measure of fidelity to the MSI has been developed. The goal of this study is to examine the reliability and validity of scores on this measure—the Memory Support Treatment Provider Checklist. A sample of Memory Support Treatment Provider Checklists (N = 319) were completed by providers (N = 8) treating adults with depression (N = 84). Three metrics of the Memory Support Treatment Provider Checklist were evaluated: (a) the internal consistency and structural validity using confirmatory factor analysis based on prior research on the MSRS and the Memory Support Intervention, (b) construct validity, and (c) predictive validity. Results indicate that the Memory Support Treatment Provider Checklist yields reliable and valid scores of fidelity to the Memory Support Intervention. Overall, this checklist offers a viable, brief method of evaluating fidelity to the Memory Support Intervention.     

Enhancing Therapeutic Gains: Examination of Fidelity to the Model for the Intensive Mental Health Program

Given that the development of treatment fidelity assessment protocol is an integral but too frequently ignored aspect of clinical trials for psychological treatments, the Intensive Mental Health Program (IMHP) sought to build fidelity activities into training, program evaluation, and clinical recordkeeping from the outset of a 3 year study period. We describe (a) operational definitions and measurement of the IMHP treatment model, (b) planned fidelity-promoting activities, (c) evaluation methods, and (d) fair to appreciable accomplishment of IMHP fidelity targets. Discussion of the circumstances and processes possibly hindering better fidelity for several IMHP treatment features accompanies presentation of fidelity data. We summarize pitfalls and compensatory strategies identified during IMHP program evaluation and offer practical suggestions to enhance accountability and evaluative activity in future clinical research.     

An analysis of instructor- and tablet-presented conditional discriminations: Fidelity and rapidity

Matching-to-sample arrangements are commonly used to teach conditional discriminations. In these arrangements, instructors must systematically arrange instruction to ensure that a learner's response comes under the intended sources of stimulus control. Given the multitude of instructional considerations, the instructors' procedural fidelity has been a significant concern. Recently, LeBlanc et al. found that brief training and access to enhanced data sheets produced high levels of fidelity with experienced service providers. The current study extended LeBlanc et al. by examining the effects of a similar training on the fidelity and instructional pacing by participants with and without previous experience. The participants' performance was also compared when using a flashcard or binder (i.e., printed) arrays and relative to a tablet-delivered instructional program. High levels of fidelity were observed following training, although pacing was slow. Slight differences in performance were observed across comparison arrays; nevertheless, the tablet-based program outperformed instructors.     

Does knowing translate to doing? Practitioners’ experiences of Circle of Security-Parenting (COS-P) training and implementation

This study sought to understand how practitioners perceive and experience the Circle of Security-Parenting (COS-P) training, and further, how they integrate and implement it into practice, and how these experiences influence their use and understanding of the program and its underlying model. A thematic analysis of semistructured interviews at two time points (shortly after training and 3–6 months after training) was used to explore 12 practitioners’ experiences of COS-P training and subsequent implementation. Three main themes were identified; clinical salience, personal salience, and partial use of the program. The findings reflected participants’ common perception that the model is relevant and generalizable to a wide variety of contexts. It also highlighted potential barriers to implementation, particularly practitioners’ experiences using only components of the COS-P program in isolation. The results suggest practitioners’ assumptions about client complexities, vulnerabilities, and/or incapacities, can prompt practitioners to withhold the use of COS-P (in part or whole), thereby potentially neglecting key components required for client change. The only participants who implemented the COS-P training in full had additional training in Circle of Security.