Couineau Anne-Laure

Barriers to providing evidence-based treatments for veterans

Limited use of effective treatment: the example of PTSD

Only 17- 25% of practitioners deliver the most researched EPB

Delays and adaptation of

therapy common

Mixed results of sustained

dissemination in veteran

services in U.S.

Cook et al. (2013); Minnen, Hendriks & Olff(2010), Rosen et al. (2005), Tanielian & Jaycox, (2008)

Best practice and complexity

– Co-morbid & complex clinical issues

– Structured protocols or manuals

– Context (funding, organisational support)

– Client considering change (AND the therapist when EPB use is new or infrequent)

Framework used to understand barriers

System readiness

Compatibility with policy Patient needs and access Healthcare settings Time and resources

Adoption of EBP

individual practitioners

Attitudes toward EBP Belief in self-efficacy Knowledge and skills Therapeutic orientation Experience Client-clinician relationship

Intervention characteristics

Degree of evidence Adaptability Cost

Implementation processes

Training and supervision Clinical decision-making

support & reminders Use of opinion leaders

Based on CFIR model (Damschroder et al., 2009)

Asking doesn’t always lead to an answer: the issue with self report

• Almost no research links self-reported barriers to clinical behaviour.

• When measures of adoption included, attitudes towards EBP had an impact on intent but not on clinical behaviour

(Gray, Elhai, & Schmidt, 2007; Hrisos et al., 2009)

copyleft Nina Paley

What the research says about barriers

• General self-report: lack of organisational support, access to training, service-related resourcing, client complexity not addressed by research, fear of causing harm, self-efficacy (e.g. Becker, Zayfert, & Anderson, 2004; Couineau & Forbes, 2011; Peterson et al., 2011; Rauch et al., 2009; Ruzek & Rosen, 2009)

• Treating practitioners about clinical decision to delay or not provide EBT in implementation studies: crises, clinical considerations, client engagement and preferences, practical considerations (e.g. Couineau et al., 2016; Kartal et al., 2016, Lu et al., 2016)

• Veterans in treatment: Delays and ambivalence frequent-fear and avoidance more than lack of information (e.g. Hundt et al., 2015)

How are barriers being addressed

Client

Practitioner

System

• Training• Supervision• Guidelines• Leadership• Organisational

support• Incentives• Requirements

• Funding models

• Organisational culture and mission

• Decision making aides

• partnerships

Impact on clinical outcomes

• Therapist individual characteristics not linked to clinical outcomes (e.g. Eftekhari et al. 2015)

• No clear understanding of links between contextual factors (e.g. funding, leadership targeting EPB), clinician behaviours and clinical outcomes

• Fidelity and adaptation matter (e.g., Cohen et al., 2008; Cook et al., 2013; Couineau et al., 2016; Galovski, et al., 2012; Wiltsey Stirmanet al., 2013)

Example: implementation of CPT in VVCS

• CPT systematically implemented through training, clinical support, leadership support and changes to data collection system (outcome data and intake screening)

• What will support long term use of CPT?

• Mixed method approach that combines quantitative and qualitative data from service system data, staff surveys, end of treatment summary data including client outcomes.

Treatment provided for PTSD

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CBT PE EMDR CPT ACT SupportiveTherapy

Non-PTSDtreatment

Other PTSDtreatment

Hun

dred

s

Post-implementation May-15 May-16

Reasons for not offering CPT

0 20 40 60 80

Does not fit with my preferred orientationCPT not flexible enough

Unable to deliver CPT as often as requiredI did not have sufficient support

Believe that CPT will be ineffectiveI did not have sufficient skills

I did not feel confident enoughColleagues reported negative consequences

CPT likely to increase my client's distressUsed in the past with negative consequences

My client would not be open to itOffered but client said no*

Client needs stabilising before PTSD treatment*Client's co-occuring clinical/social issues

Post-implementation May-15 May-16

Clinical Outcomes for CPT Clients

• PCL at first session: m=54.85, SD=15

• PCL at last session:m=40.63, SD=20.47

• Clinically significant drop of 14 points.

• Paired t-test found statistically significant difference (t(55)=6.809, p<.001, g=.824).

0

10

20

30

40

50

60

PCL scores

Mean PCL at First and Last CPT Session

T1 First session T2 Last session

CPT Treatment Fidelity and Clinical Outcomes

• Out the 80 CPT clients, 40% (n=36) received a CPT protocol that incorporated other treatments

• Incorporating non-protocol sessions into CPT did not significantly impact client outcomes

30

35

40

45

50

55

60

65

First session Last session

PCL

Scor

es

CPT protocol group CPT non-protocol group

Adopting evidence-based approach

Maintaining skills

Clinical decision-making

Adaptation fidelity

Organisational support, resourcingand client support

Implications for clinicians

When considering your own use of EPBs or adoption at an organisational or system level, take into account:• The timing of using EPBs with clients

• Clinical decision-making in context of complexity, the role of therapist (e.g. “following the client”)

• The role of champions and leaders, team or therapeutic community.

• And the client- how do you make collaborative decisions about care that include an effective approach? What do clients need to participate?

Selected References

Cohen, D. J., Crabtree, B. F., Etz, R. S., Balasubramanian, B. A., Donahue, K. E., Leviton, L. C., . . . Green, L. W. (2008). Fidelity versus flexibility: translating evidence-based research into practice. American Journal of Preventive Medicine, 35(5 Suppl), S381-389. doi: 10.1016/j.amepre.2008.08.005Cook, J., Cook, C., O'Donnell, S., Dinnen, N., Bernardy, R., Rosenheck, R., & Hoff. (2013). A formative evaluation of two evidence-based psychotherapies for PTSD in VA residentialtreatment programs. Journal of traumatic stress, 26(1), 56-63.Couineau, A.-L., & Forbes, D. (2011). Using predictive models of behavior change to promoteevidence-based treatment for ptsd. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 266-275.Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4, 50. doi: 10.1186/1748-5908-4-50Eftekhari, A., Crowley, J. J., Ruzek, J. I., Garvert, D. W., Karlin, B. E., & Rosen, C. S. (2015). Training in the implementation of prolonged exposure therapy: provider correlates of treatment outcome. J Trauma Stress, 28(1), 65-68. doi: 10.1002/jts.2198Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968.Gray, M. J., Elhai, J. D., & Schmidt, L. O. (2007). Trauma Professionals' Attitudes Toward and Utilization of Evidence-Based Practices. Behavior Modification, 31(6), 732-748. doi: 10.1177/0145445507302877Lu, M., Plagge, J., Marsiglio, M., Dobscha, S., Lu, M. W., Plagge, J. M., & ... Dobscha, S. K. (2016). Clinician Documentation on Receipt of Trauma-Focused Evidence-Based Psychotherapies in a VA PTSD Clinic. Journal Of Behavioral Health Services & Research, 43(1), 71. doi:10.1007/s11414-013-9372-9Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., . . . Karlin, B. E. (2014). Factors related to clinician attitudes toward prolonged exposure therapy for PTSD. Journal of Traumatic Stress, 27(4), 423-429.Wiltsey Stirman, S, Calloway, A., Toder, K., Miller, C., DeVito, A., Meisel, S., & … Crits-Christoph, P. (2013). Community mental health provider modifications to Cognitive Therapy: Implications for sustainability PSYCHIATRIC SERVICES, 64(10), 1056-1059.

Acknowledgements

The Department of Veterans’ Affairs

The Veterans and Veterans’ Families Counselling Service