Training In Evidence-based Treatments Research Articles

Impact of a Brief Training on Mental Health Stakeholders’ Implementation of Evidence-Based Strategies for Trauma in the Caribbean Within the Context of COVID-19

Abstract. Objective: Lack of governmental funding/infrastructure for mental health has created urgent need for effective training in evidence-based treatments for trauma in the Caribbean for under-resourced providers. Furthermore, impacts of the COVID-19 health crisis on providers’ implementation of skills in this region are currently unknown. Method: We examined impacts of a one-day training workshop for stakeholders in the Caribbean providing psychoeducation on trauma and PTSD and training in short-term interventions. Participants ( n = 46) were surveyed at preworkshop and postworkshop and at 3-month and 6-month follow-up (which coincided with the first 6 months of the COVID-19 pandemic) to assess retention of any changes in perceived knowledge about trauma/effective treatments and subsequent skill implementation. Results: Participants reported significant pre–post workshop increases in perceived knowledge (pre M = 31.61, post M = 44.63) about trauma and its effective treatments ( t[45] = −6.17, p < .001). This perceived knowledge was significantly maintained over time (3M M = 42.66, 6M M = 40.75). Furthermore, participants reported significant use of several of the strategies taught at the workshop at follow-up. Higher reported emotional distress related to the pandemic was associated with lower implementation at 6M, despite significant retention in perceived knowledge from the workshop ( B = −0.02, β = −1.55, p < .05). Conclusions: Brief trauma-focused trainings can be helpful for providers in under-resourced global settings with observable impact on implementation practices over time, but providers’ emotional distress stemming from public health crises can influence practice behaviors. Subsequent impacts on policy/budget allocations are discussed.

How often do community-based mental health providers educate and initiate PTSD treatment following training? Answering the question of reach.

Posttraumatic stress disorder (PTSD) is a significant problem. Clinical practice guidelines recommend evidence-based treatments (EBTs) including cognitive processing therapy (CPT) and prolonged exposure (PE) as first-line treatments. Training in EBTs for PTSD has often been limited to large-scale systems (e.g., U.S. Department of Veterans Affairs). Research has shown that veteran-serving community-based mental health providers have low rates of training and supervision in EBTs for PTSD, suggesting that training initiatives for these community providers are critical to increase accessibility. This study aimed to examine the reach of education about EBTs for PTSD and the initiation of EBT for PTSD treatment among veteran-serving community-based providers participating in a large-scale training initiative. Participants (N = 280) were community-based, licensed mental health providers who received training in CPT (67%) or PE (33%). Provider attitudes toward EBTs were measured with the Perceived Characteristics of Intervention Scale. Reach was calculated from provider self-reported follow-up survey data, including caseload total number of patients with PTSD, number of patients provided education on EBTs for PTSD, and patient initiation of EBT for PTSD. Reach was calculated for both education and EBT initiation. Providers reported positive attitudes toward CPT and PE. Rates of education reach for EBTs for PTSD ranged from 30% to 76%, and rates of EBTs for PTSD initiation ranged from 11% to 35% over the 5-month follow-up period. CPT providers had higher rates of education and initiation earlier in the follow-up period, although differences in initiation rates diminished after 3 months posttraining. Overall, this study examined how large-scale, training programs can be used to increase the education reach and initiation reach of EBTs for PTSD among veteran-serving community-based providers. Future work should examine how best to augment these training programs to reduce the gap between education and implementation of EBTs for PTSD. Posttraumatic stress disorder (PTSD) is a significant problem among veterans. Although there are effective treatments for PTSD, mental health providers in community settings rarely have access to training in these treatments. Training programs are designed to offer providers the necessary training and support to deliver the most effective therapies to their clients. In evaluating these programs, it is important to determine whether they increase the likelihood that providers will deliver the interventions in which they were trained. Valuable outcomes include the percentage of patients who were educated on the specific intervention and who began to receive it. The (STRONG STAR) Training stron Initiative is a large-scale, community-based program that specializes in training providers in two leading PTSD therapies: cognitive processing therapy and prolonged exposure. Participants received a 2-day workshop, online resources, and weekly consultation calls to aid in the delivery of the intervention in which they were trained. Consequently, a large number of clients on provider caseloads are now aware of these PTSD treatments, and many have chosen to receive them. It is clear that the components within the (STRONG STAR) Training Initiative increase providers' competency in delivering therapies that have been widely studied. Therefore, more community members with PTSD will have access to gold-standard care. More funding should be devoted toward competency-based training programs to increase the number of people who receive education about and who engage in delivering effective therapies. This approach will ensure high-quality care and increased quality of life for those seeking treatment from community providers.

Helping Optimize Language Acquisition (HOLA) Online Parent Training Modules for Latinx Parents of Toddlers at Risk for ASD: Protocol for a Pilot Funded by the Organization for Autism Research.

BackgroundCulturally competent parent training in evidence-based intervention for autism spectrum disorder (ASD) can provide young Latinx children from underserved communities with early interventional support while they wait for professional services, thus reducing the impact of intervention delays. Providing parents with brief bilingual training in Pivotal Response Treatment (PRT) is a strategy that can overcome these barriers and is inexpensive to disseminate. Brief PRT training has been shown to significantly improve joint attention, expressive language, responsivity, and adaptive skills in young children with ASD. However, it is unknown whether an interactive, culturally competent online parent training in PRT is effective in a Latinx population.ObjectiveTo this end, we will recruit 24 children (16-36 months old) at risk for ASD and their parent(s) from East and South Los Angeles and provide them with a series of 6 online learning modules in their choice of Spanish or English.MethodsThis pilot study will utilize a single-group, pilot, pre-post design with follow-up assessments 6 weeks later. Linear mixed-effects model analysis will be used to explore most parent-reported and coded outcomes.ResultsBrief online parent training in evidence-based treatments has the capacity to increase access to culturally competent early communication interventions for young children at risk for ASD.ConclusionsThe results of this trial may have particular salience in additional underresourced communities where children have limited access to interventions prior to entering school.International Registered Report Identifier (IRRID)PRR1-10.2196/18004

Teaching evidence-based practice: A comparison of two disciplines

ABSTRACTThe increasing emphasis on research supported treatments in behavioral health requires clinicians to develop knowledge and skills for evidence-based practice. Graduate professional degree programs must address this in preparation for the emerging workforce. In this paper, we synthesize results from two related studies that examined the extent to which master’s level professional degree programs prepare future practitioners to deliver a process of evidence-based practice or specific evidence-based treatments. We compare these results with a previous study of North American administrators and supervisors who hire graduates from Master's level professional degree programs. The first study explored the Masters in Social Work curricula, and the second study examined Marriage and Family Therapy programs. Professionals with these graduate degrees are primary providers of behavioral health treatment. Results demonstrate how both disciplines are changing and offer both rationale and concerns voiced by program deans and directors. Compared with a study of provider perspectives, the collective results indicate institutions of higher education are providing at least modest levels of training in evidence-based treatments. We conclude with suggestions for university partnership with behavioral health and social service programs.

Dialectical behavior therapy guided self-help for binge-eating disorder

ABSTRACTBinge-eating disorder (BED) is a prevalent and serious public health issue. BED is characterized by recurrent out-of-control binge eating episodes in the absence of extreme weight control behavior and is associated with significant psychosocial and physiological impairment. Dialectical Behavior Therapy (DBT), based on the affect regulation model of binge eating, is an evidence-based treatment (EBT) approach for BED. Unfortunately, access to EBTs is often limited due to geographical barriers (i.e., lack of local providers with specialized training in EBTs), lack of financial resources, and/or time constraints. Self-help approaches (via guided and unguided versions) to delivering DBT for BED offer a potentially effective means of more widely disseminating this treatment. Compared to traditional, higher intensity approaches, self-help DBT for BED is less time-consuming, less financially costly, and requires less need for specialized therapist-training. This paper will present how DBT for BED has been adapted for self-help delivery, review the limited but promising research on DBT self-help available to date, and provide directions for future research.

Orientaciones Prácticas para Psicoterapeutas que Atienden a Pacientes con TEPT Después de un Desastre Natural

This article presents information relevant to mental health professionals who work with adult patients with posttraumatic stress disorder (PTSD) in the aftermath of natural disasters and who lack specialized training in evidencebased treatments for PTSD. The article presents orientations based on a review of several international guidelines for working with patients with PTSD and the relevant international scientific literature. These guidelines were reviewed by a panel of Chilean experts. The result, which is presented in this article, consists in a series of practical guidelines aimed at psychotherapists who must work with patients with PTSD after natural disasters. Clinical vignettes are presented to exemplify some of these guidelines.

Implementing an evidence-based psychological intervention for suicidal thoughts and behaviors on an inpatient unit: Process, challenges, and initial findings

ObjectiveBarriers to implementing evidence-based psychological treatments for suicidal thoughts and behaviors in busy hospital settings exist. Transdiagnostic interventions may serve to facilitate training in evidence-based treatment and more efficiently treat individuals with multiple psychiatric comorbidities. We describe the rationale for, process of, and initial data from implementing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) on an inpatient unit for adults with suicidal thoughts and behaviors and affective disorders. MethodWe analyzed clinical intake and outcome data from a subsample of patients admitted during the six months before and six months after UP implementation (n = 133 and n = 61, respectively), and available acceptability and fidelity data from the month following UP implementation. ResultsPatients improved significantly over the course of inpatient treatment before and after UP implementation. Effects for depression, suicidal ideation, anxiety, and emotion regulation were similar before and after UP implementation. Patients generally reported high acceptability of the UP and clinician fidelity to the protocol was variable during the month following UP implementation. ConclusionsThe UP may be a promising evidence-based intervention for inpatient settings that treat individuals with suicidal thoughts and behaviors. Well-controlled, randomized trials are needed to determine efficacy, particularly regarding suicidal behavior after discharge.

Overlooked Ethical Problems Associated With the Research and Practice of Evidence-Based Treatments

Proponents of evidence-based treatments (EBTs) have directed complaints of potential unethical practice against psychotherapists who refrain from using EBTs as first-line interventions for a range of psychiatric disorders on the grounds that these treatments should be given priority because of their exceptional scientific backing. This article counters these claims and highlights core ethical concerns associated with the research and practice of EBT itself; namely, the appropriateness of saturating the field with short-term models of psychotherapy and the questionable assumption that these can yield meaningful and lasting change; the uncertain relevance of the results of EBT investigations for psychotherapists working with real-world clients; the foreclosure of opportunities to address clients’ unmet developmental needs and self-fragility posed by the directive/didactic therapeutic stance inherent in EBTs; and, the reduced quality of psychotherapy offered to the public at large and threats to the clinical competence of early-career mental health professionals caused by overemphasizing training in EBTs over the acquisition of relational skills in graduate schools and postgraduate training sites.

Social Work Training in the Use of Evidence-Based Treatments for Children: What Works?

ABSTRACTDespite the benefits of evidence-based treatments (EBTs) for client outcomes, social service systems have struggled to disseminate EBTs. Effective graduate-level training in EBTs is critical to increase use, given the strong effect of initial training on future practices. This study examined outcomes of a graduate-level training program in EBTs. Questionnaires while in the program and postgraduation were administered to 66 students. Regression analyses indicated an increase in postgraduation use occurred after the program incorporated strategies to support the use of specific EBTs. Consistent with the implementation literature, initial planning with field sites, behavioral rehearsal of specific practice skills, focusing on initiation of EBTs, and targeted support for use of specific practices appear to support graduates’ uptake of EBTs in mental health settings.

Perceived confidence, competence and training in evidence-based treatments for eating disorders: a survey of clinicians in an Australian regional health service.

Eating disorders (EDs) are challenging to treat and contribute to considerable morbidity and mortality. This study sought to identify the educational preparedness, competence and confidence of clinicians to work with people with EDs; and to identify how services might be improved. Clinicians who worked in the emergency department, medical, paediatric wards and mental health services were invited to complete an online survey. From the 136 surveys returned, 73% of respondents reported little or no confidence working with EDs. There was a strong linear correlation between perceived confidence and competence and hours of education. Those with 70 or more hours of self-reported training were 2.7 times more likely to rate themselves as both confident and competent. Improving services for people with eating disorders included the provision of appropriate training, improving access to services including psychotherapy, and facilitating consistency in and continuity of care. To increase the confidence and competence of the workforce, regular training around EDs should be undertaken. The establishment of a specialist team to provide services across the continuum of care for people with severe or complex EDs appears warranted in a regional health service.

An Interdisciplinary University-Based Initiative for Graduate Training in Evidence-Based Treatments for Children’s Mental Health

States and jurisdictions are under increased pressure to demonstrate the use of evidence-based treatments (EBTs) for children’s mental health, increasing the demand for a workforce trained in these practices. Universities are a critical pipeline for this workforce. This article describes the genesis and evolution of a university-based initiative for training in EBTs for children, youth, and families. Given both the need to make training in EBTs available to future providers in a range of disciplines and that mental health providers increasingly find themselves on interdisciplinary teams (despite university-based training being relatively siloed along disciplinary lines), the initiative has had an interdisciplinary focus. Two tracks are described: (a) Practitioner Track, a course series in which students learn a specific EBT, and (b) Referral Track, a monthly lecture series designed to engage a wider university and community audience. Results of the program evaluation component of this initiative revealed that students can significantly increase their skills and self-efficacy in components of EBT delivery through participation in the active, skill-focused courses. Furthermore, the results of the lecture series evaluation appear to meet an important need for community-based providers and other supportive individuals in transferring useful knowledge about best practices. Implications and future directions are discussed.

Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment.

Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making. Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory. MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making. This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.

Nationwide dissemination of contingency management: the Veterans Administration initiative.

Contingency management (CM) is an empirically validated intervention but one not often applied in practice settings in the US. The aim of this article is to describe the Veterans Administration (VA) nationwide implementation of CM treatment. In 2011, the VA called for integration of CM in its intensive outpatient substance abuse treatment clinics. As part of this initiative, the VA funded training and ongoing implementation support, and it provided direct funds for reinforcers and other intervention costs. Over 100 clinics received this funding in 2011, and CM has been implemented in over 70 substance abuse treatment clinics since August 2011. This training and implementation experience has been highly successful and represents the largest scale training in evidence-based treatments for substance use disorders in the VA health care system to date. This program may serve as a model for training in evidence-based treatments.

National trainers' perspectives on challenges to implementation of an empirically-supported mental health treatment.

This study examined perceived challenges to implementation of an empirically supported mental health treatment for youth (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT) and explored the potential use of technology-based resources in treatment delivery. Thematic interviews were conducted with 19 approved national TF-CBT trainers to assess their perspectives about challenges to implementation of TF-CBT and to explore their perceptions about the potential value of innovative, technology-based solutions to enhance provider fidelity and improve quality of care. These data offer some important insights and implications for training in evidence-based treatments, provider fidelity and competence, and patient engagement, particularly for those interventions targeting trauma-related symptoms among youth.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

The Science of Training in Evidence-Based Treatments in the Context of Implementation Programs: Current Status and Prospects for the Future

Training plays a critical role within the broader implementation research agenda involving evidence-based treatments (EBTs). EBTs, interventions that have demonstrated client improvement within the context of controlled trials (Kazdin 2008), tend to be complex, multisession treatment packages that hinge largely on the provider’s execution of a set of interventions with a satisfactory level of fidelity (Carroll et al. 2010; Chorpita and Regan 2009; Herschell et al. 2010). Although training alone is not sufficient to guarantee successful implementation, there is evidence that adequate training can reduce variations in provider behavior, improve fidelity, and ultimately, increase the quality of service delivery (Aarons et al. 2011; Feldstein et al. 2008; Fixsen et al. 2005; Stirman et al. 2004) above and beyond that provided by therapy as usual (Schoener et al. 2006; Simons et al. 2010). In light of the central role training plays in the implementation of EBTs in mental health service delivery settings (Karlin et al. 2010; McHugh and Barlow 2010), efforts to scientifically examine the impact of training and to establish best practices in training are essential (Herschell et al. 2010). Our field is fortunate to be at the point at which EBTs have been designed, tested, and refined with much success; however, dissemination and implementation initiatives are still in their relative infancy (Becker et al. 2009). This early stage of evidence-based training development renders the field at a crossroads. One possible path parallels the traditional stage model of EBT development (Onken et al. 1997), with training methods developed and tested in university-based settings with tightly controlled conditions to demonstrate efficacy prior to testing effectiveness. As demonstrated by highly controlled studies of training (Miller et al. 2004; Sholomskas et al. 2005), this approach has merit inasmuch as information regarding necessary and sufficient training components, and optimal dosage, sequencing, and spacing of training can be identified (see Rakovshik and McManus 2010 for a review of these factors in the training of cognitive behavioral therapy). However, as the stage model of psychotherapy development has demonstrated, the needs of the field, in terms of understanding effective, efficient treatment strategies that can be deployed in less tightly controlled settings, easily outpace the stages of research (Institute of Medicine 2001). Similarly, given that advances in EBTs have outpaced the development of implementation supports (i.e., evidencebased training) (Fixsen et al. 2005), the ‘‘research-topractice gap’’ (McHugh and Barlow 2010) is at risk of continuing to widen, leaving a workforce with insufficient training and support in the very treatments that may have the best chance of improving the conditions of patients in need. An alternative path to promoting the science of training involves fitting the training program into the existing mental health delivery system (Stirman et al. 2010) to K. D. Becker (&) Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD 21205, USA e-mail: kbecker@jhsph.edu

A Roadmap to Computer-Based Psychotherapy in the United States

Computers can be used to deliver self-guided interventions and to provide access to live therapists at remote locations. These treatment modalities could help overcome barriers to treatment, including cost, availability of therapists, logistics of scheduling and traveling to appointments, stigma, and lack of therapist training in evidence-based treatments (EBTs). EBTs could be delivered at any time in any place to individuals who might otherwise not have access to them, improving public mental health across the United States. In order to fully exploit the opportunities to use computers for mental health care delivery, however, advances need to be made in four domains: (1) research, (2) training, (3) policy, and (4) industry. This article discusses specific challenges (and some possible solutions) to implementing computer-based distance therapy and self-guided treatments in the United States. It lays out both a roadmap and, in each of the four domains, the milestones that need to be met to reach the goal of making EBTs for behavioral health problems available to all Americans.

Evidence-Based Psychotherapies for Depression in Older Adults.

We conducted an evidence-based review of psychological treatments for geriatric depression using coding criteria, and we identified six treatments to be beneficial: behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychody-namic therapy, and reminiscence therapy. Other interventions were found to be promising but were lacking replication. These findings suggest that (a) there are several treatment choices for consumers and practitioners across a relatively broad range of theoretical orientations and modalities, (b) there needs to be a recognition of the viability of psychological treatments for depressed elders by other disciplines, and (c) there is an opportunity to provide training in evidence-based treatments for present and future providers to the growing number of older adults.