A Quantitative Test of an Implementation Framework in 38 VA Residential PTSD Programs.

This study examines the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs residential Posttraumatic Stress Disorder treatment programs. Two hundred and one providers from 38 programs completed an online survey concerning implementation of PE delivered on an individual basis and CPT delivered in individual and group formats. For PE, a supportive organizational context (dedicated time and resources, and incentives and mandates) and overall positive view of the treatment were related to its implementation. For both group and individual CPT, only the supportive organizational context was significantly associated with outcome. Implications for implementation efforts are discussed.

Evaluation of an implementation model: a national investigation of VA residential programs.

This national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs' (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers' existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.

Post-traumatic stress disorder in older adults: a systematic review of the psychotherapy treatment literature.

OBJECTIVES: Older adults represent the fastest growing segment of the US and industrialized populations. However, older adults have generally not been included in randomized clinical trials of psychotherapy for post-traumatic stress disorder (PTSD). This review examined reports of psychological treatment for trauma-related problems, primarily PTSD, in studies with samples of at least 50% adults aged 55 and older using standardized measures. METHODS: A systematic review of the literature was conducted on psychotherapy for PTSD with older adults using PubMed, Medline, PsychInfo, CINAHL, PILOTS, and Google Scholar. RESULTS: A total of 42 studies were retrieved for full review; 22 were excluded because they did not provide at least one outcome measure or results were not reported by age in the case of mixed-age samples. Of the 20 studies that met review criteria, there were: 13 case studies or series, three uncontrolled pilot studies, two randomized clinical trials, one non-randomized concurrent control study and one post hoc effectiveness study. Significant methodological limitations in the current older adult PTSD treatment outcome literature were found reducing its internal validity and generalizability, including non-randomized research designs, lack of comparison conditions and small sample sizes. CONCLUSION: Select evidence-based interventions validated in younger and middle-aged populations appear acceptable and efficacious with older adults. There are few treatment studies on subsets of the older adult population including cultural and ethnic minorities, women, the oldest old (over 85), and those who are cognitively impaired. Implications for clinical practice and future research directions are discussed.

Residential Treatment for Posttraumatic Stress Disorder in the Department of Veterans Affairs: A National Perspective on.

Thirty-eight U.S. Department of Veterans Affairs's (VA) residential treatment programs for posttraumatic stress disorder took part in a formative evaluation of their programmatic services, including perceptions of effective treatment. From July 2008 through March 2011, face-to-face qualitative interviews were conducted with over 250 VA residential staff. A wide variety of perceived effective treatment elements were noted. The most frequently mentioned elements were evidence-based treatments, frequency and intensity of milieu, staff cohesion, varied programming, and individualized treatment. Implications for VA managers and policy-makers as well as non-VA health care systems and health care providers are discussed.

VA Residential Provider Perceptions of Dissuading Factors to the Use of Two Evidence-Based PTSD Treatments.

Providers (N = 198) from 38 Department of Veterans Affairs residential posttraumatic stress disorder treatment programs across the United States completed qualitative interviews regarding implementation of 2 evidence-based treatments: prolonged exposure and cognitive processing therapy. As part of this investigation, providers were asked how they decide which patients are appropriate for these treatments. Many indicated that they did not perceive any patient factors that dissuade their use of either evidence-based treatment. However, 3 broad categories emerged surrounding reasons that patients were perceived to be less suitable candidates for the treatments: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation. Interestingly, providers' perceived reasons for limited or nonuse of a treatment did not correspond entirely to those espoused by treatment developers. Possible solutions to address provider concerns, including educational and motivational interventions, are noted.

Trauma-informed care: a paradigm shift needed for services with homeless veterans.

PURPOSE OF STUDY: Exposure to traumatic events is a highly prevalent, although often overlooked, aspect in the lives of homeless veterans. In this study, the prevalence and correlates of potentially traumatic events, including posttraumatic stress disorder, in the homeless veteran population are presented. FINDINGS/CONCLUSIONS: Presently, there exists a lack of trauma-informed case management services for homeless veterans. Failing to recognize the association between trauma and homelessness may lead to further victimization, exacerbate mental health symptomology, and hinder a provider's ability to effectively intervene on behalf of homeless veterans. IMPLICATIONS FOR CASE MANAGEMENT: Subgroups of homeless veterans such as those who served in the Vietnam and post-Vietnam era, more recent returnees from Iraq and Afghanistan, women, rural-residing veterans, and those who are justice involved, are discussed for unique trauma histories and service needs. Barriers to receiving trauma-informed care among homeless veterans are reviewed. Information to assist providers in assessing trauma histories and current best practices in the treatment of posttraumatic stress disorder are noted. Suggestions for how this document can be used in varied organizational settings are made.

Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation.

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs' residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.

Prevalence of physical and sexual assault and mental health disorders in older women: findings from a nationally representative sample.

OBJECTIVES: This study presents prevalence and characteristics of physical and sexual assaults, and their relationship to posttraumatic stress disorder (PTSD), and mood and anxiety disorders in a nationally representative sample of older women. DESIGN AND SETTING: Face-to-face interviews conducted with adult participants from wave 2 of the National Epidemiological Survey on Alcohol and Related Conditions. PARTICIPANTS: A total of 3,354 community-residing women of age 65 years and older. MEASUREMENT: Alcohol Use Disorder and Associated Disabilities Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, current mood and anxiety disorders. RESULTS: Almost 14% of participants reported a history of physical or sexual assault or both during their lifetimes. Assaults were often repeated rather than isolated events. Although the majority of participants did not identify interpersonal violence as their "worst" traumatic event, those who experienced interpersonal violence were generally more likely than those without such history to meet the criteria for past-year and lifetime PTSDs, depression, and anxiety. CONCLUSIONS: Some women who have been physically or sexually assaulted decades earlier continue to report significant levels of mood and anxiety disorders into late adulthood. Several ways to increase the identification and treatment of older female trauma survivors by healthcare providers are suggested.

Iraq and Afghanistan veterans: national findings from VA residential treatment programs.

A quality improvement effort was undertaken in Department of Veterans Affairs' (VA) residential treatment programs for Posttraumatic Stress Disorder (PTSD) across the United States. Qualitative interviews were conducted with over 250 directors, providers, and staff during site visits of 38 programs. The aims of this report are to describe clinical issues and distinctive challenges in working with veterans from Iraq and Afghanistan and approaches to addressing their needs. Providers indicated that the most commonly reported problems were: acute PTSD symptomatology; other complex mental health symptom presentations; broad readjustment problems; and difficulty with time demands of and readiness for intensive treatment. Additional concerns included working with active duty personnel and mixing different eras in therapy. Programmatic solutions address structure (e.g., blended versus era-specific therapy), content (e.g., physical activity), and adaptations (e.g., inclusion of family; shortened length of stay). Clinical implications for VA managers and policy makers as well as non-VA health care systems and individual health care providers are noted.

A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs.

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced-based treatments (EBTs). Face-to-face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.

Measurement of a model of implementation for health care: toward a testable theory.

BACKGROUND: Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.'s model by providing background, rationale, working definitions, and measurement of key constructs. METHODS: A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model's broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus. RESULTS: The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported. CONCLUSION: Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.

Older women survivors of physical and sexual violence: a systematic review of the quantitative literature.

BACKGROUND: This systematic review synthesizes the quantitative empirical literature concerning older women survivors of physical and sexual assault. METHODS: A literature search was conducted using a range of scholarly databases. Information is presented here on the prevalence, correlates, and consequences of these types of interpersonal violence in older women. Additionally, age-related differences in prevalence, psychiatric distress, and characteristics of violence, including information on perpetrators, are reviewed. RESULTS: Overall, older women report lower lifetime and past year rates of physical and sexual assault and associated negative psychologic consequences compared to younger and middle-aged women. Additionally, older women who experienced interpersonal violence report greater psychiatric distress, including posttraumatic stress disorder (PTSD), than older women who have not experienced such events. CONCLUSIONS: Some women who have been physically or sexually assaulted decades earlier in life continue to report significant levels of PTSD well into older adulthood. Gaps in the literature, including lack of information on ethnicity and culture, are presented, and future research directions are proposed.

Responses of a Sample of Practicing Psychologists to Questions About Clinical Work With Trauma and Interest in Specialized Training.

This study reports on selected findings from a survey conducted by the American Psychological Association Practice Organization, which assessed the number of hours per month that practicing psychologists estimated they spent treating trauma survivors and their interest in additional clinical training on trauma-related issues and topics. Respondents reported 14.3 mean number of hours spent working with trauma survivors over the past month. Of the 76% of the sample who treated any trauma patients, the mean was 16.9 hours. Although trauma psychology is not currently an integral component of the standard curricula in graduate-level education, generalist psychology practitioners are treating trauma-related concerns in their clinical practices. It is imperative therefore to ascertain if they are adequately trained in specialized trauma recognition, assessment, and treatment. The fact that almost 64% of survey respondents expressed interest in participating in educational endeavors to learn more about trauma-related clinical topics suggests that such a need exists and that more training opportunities, including ongoing continuing education offerings, should be organized.