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Background: Women veterans, compared to civilian women, are especially at risk of experiencing intimate partner violence (IPV), pointing to the critical need for IPV screening and intervention in the Veterans Health Administration (VHA). However, implementing paper-based IPV screening and intervention in the VHA has revealed substantial barriers, including health care providers' inadequate IPV training, competing demands, time constraints, and discomfort addressing IPV and making decisions about the appropriate type or level of intervention., Objective: This study aimed to address IPV screening implementation barriers and hence developed and tested a novel IPV clinical decision support (CDS) tool for physicians in the Women's Health Clinic (WHC), a primary care clinic within the Veterans Affairs Palo Alto Health Care System. This tool provides intelligent, evidence-based, step-by-step guidance on how to conduct IPV screening and intervention., Methods: Informed by existing CDS development frameworks, developing the IPV CDS tool prototype involved six steps: (1) identifying the scope of the tool, (2) identifying IPV screening and intervention content, (3) incorporating IPV-related VHA and clinic resources, (4) identifying the tool's components, (5) designing the tool, and (6) conducting initial tool revisions. We obtained preliminary physician feedback on user experience and clinical utility of the CDS tool via the System Usability Scale (SUS) and semistructured interviews with 6 WHC physicians. SUS scores were examined using descriptive statistics. Interviews were analyzed using rapid qualitative analysis to extract actionable feedback to inform design updates and improvements., Results: This study includes a detailed description of the IPV CDS tool. Findings indicated that the tool was generally well received by physicians, who indicated good tool usability (SUS score: mean 77.5, SD 12.75). They found the tool clinically useful, needed in their practice, and feasible to implement in primary care. They emphasized that it increased their confidence in managing patients reporting IPV but expressed concerns regarding its length, workflow integration, flexibility, and specificity of information. Several physicians, for example, found the tool too time consuming when encountering patients at high risk; they suggested multiple uses of the tool (eg, an educational tool for less-experienced health care providers and a checklist for more-experienced health care providers) and including more detailed information (eg, a list of local shelters)., Conclusions: Physician feedback on the IPV CDS tool is encouraging and will be used to improve the tool. This study offers an example of an IPV CDS tool that clinics can adapt to potentially enhance the quality and efficiency of their IPV screening and intervention process. Additional research is needed to determine the tool's clinical utility in improving IPV screening and intervention rates and patient outcomes (eg, increased patient safety, reduced IPV risk, and increased referrals to mental health treatment)., (©Fernanda S Rossi, Justina Wu, Christine Timko, Andrea L Nevedal, Shannon Wiltsey Stirman. Originally published in JMIR Formative Research (https://formative.jmir.org), 25.09.2024.)

Objective: This randomized trial tested the effectiveness of Skills Training in Affective and Interpersonal Regulation (STAIR) compared to present-centered therapy (PCT) delivered virtually to women veterans who had experienced military sexual trauma (MST) and screened positive for posttraumatic stress disorder (PTSD)., Method: One hundred sixty-one eligible women veterans were randomized into the study. The primary outcome was clinician-assessed PTSD severity (Clinician-Administered PTSD Scale-5), while secondary outcomes included social support and several other symptom measures at posttreatment through 2- and 4-month follow-up., Results: PTSD severity decreased in both conditions by posttreatment but significantly more ( p = .028, d = 0.39) in STAIR ( d = 1.12 [0.87, 1.37]) than PCT ( d = .78 [0.54, 1.02]). STAIR was also superior in improving social support and emotion regulation and reducing depression and negative cognitions. Improvement in psychosocial functioning was moderate and did not differ between conditions. All changes were maintained through 2- and 4-month follow-ups. Dropout rates were low and did not differ (19.0% and 12.2%, respectively)., Conclusion: STAIR provided superior outcomes compared to PCT regarding PTSD, social support, and multiple types of mental health problems among women veterans with MST. The application of STAIR to other populations with social support and related concerns warrants investigation. The substantial effect sizes for PTSD symptoms in both treatments suggest that they are practical alternatives for individuals who do not wish to participate in trauma-focused therapy and may increase engagement in mental health services. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Numerous guidelines exist to inform decision-making regarding psychological treatment of patients with posttraumatic stress disorder (PTSD). While strides have been made in the implementation of evidence-based psychotherapies (EBPs) for PTSD in the United States. Department of Veterans Affairs (VA), a large population of veterans does not receive such services. Research has been conducted on veterans' decisions to enroll in EBPs; however, less is known about providers' perspectives related to offering trauma-focused therapies to the military and veteran population, particularly outside the United States. This study utilizes baseline data from a larger investigation aimed to support the sustained implementation of cognitive processing therapy (CPT) in U.S. VA and Canadian Operational Stress Injury (OSI) and Department of Defense settings. Providers who trained in CPT ( N = 55) participated in interviews regarding their opinions of CPT, preferred treatments for PTSD, and their process in assessing appropriate PTSD treatments for each patient. A directed content analysis approach was used to identify themes for providers' decision-making to utilize CPT within the context of four Consolidated Framework for Implementation Research (CFIR) domains. In the outer setting domain, providers reported disconnect from policy and leadership as a barrier, and in the inner setting CFIR domain, providers reported multiple facilitators: available resources, leadership support, and compatibility with CPT. The CFIR domain for characteristics of the individuals aligned with a theme of theoretical orientation and training as a facilitator. The intervention characteristics domain aligned with facilitators and barriers; complexity of CPT was a barrier, but relative advantage and perceived strength of evidence were facilitators toward implementation. The systems surrounding and supporting EBP delivery within the U.S. VA, Canada OSI, and Canadian Forces clinics have more similarities than differences regarding barriers and facilitators to delivering CPT. Despite variability in funding and training, provider experiences across all three systems suggest similar themes. Further investigation is needed to determine whether these findings extend to community samples or sites not yet offering EBPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format., Methods: The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness., Discussion: There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program., Trial Registration: ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: The dose-response model of change in psychotherapy posits that each session of therapy is incrementally beneficial across patients. The contrasting good-enough level model suggests that patients improve at different rates in therapy and discontinue treatment when they are satisfied with their improvement. Support for each theory has been mixed, and many prior studies have relied on samples of patients receiving unstructured treatment approaches. We conducted this study to compare these two theories across two manualized treatments for posttraumatic stress disorder (PTSD)., Method: Two hundred eighty-four female veterans and military service members with PTSD ( M age = 44.79; 54.6% White non-Hispanic, 6.7% Black non-Hispanic, 37% other) were randomized to receive 10 sessions of prolonged exposure (PE), a trauma-focused therapy, or present-centered therapy (PCT), a non-trauma-focused therapy. Participants completed the PTSD Checklist (PCL) at even-numbered treatment sessions, and the timing of dropout/treatment completion was monitored., Results: The point of highest risk for dropout differed between the treatments, with risk in PE corresponding to the beginning of imaginal exposures. In the PE condition, but not in PCT, a higher number of sessions completed increased the likelihood of achieving reliable clinically significant improvement. Across treatments, the rate of change in PTSD symptoms did not differ according to the number of sessions completed ( b = 0.06, p = .687)., Conclusions: Findings support the dose-response model of change in psychotherapy. There were notable differences in dropout across the treatment conditions, including rates, timing, and implications for outcomes. These differences likely reflect differences in content between the protocols. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Written Exposure Therapy (WET) for posttraumatic stress disorder (PTSD) has been shown to be efficacious in clinical trials; however, research is needed to determine WET's effectiveness in clinical practice settings. Additionally, research is needed to understand whether patient characteristics or treatment delivery format moderate outcomes., Method: Patient outcomes ( n = 277) were assessed as part of a multisite training and implementation program in the Department of Veterans Affairs (VA). During treatment, patients completed self-report measures of PTSD, depression, and functional impairment. Patient characteristics (i.e., demographics, psychiatric comorbidity, trauma type) and treatment delivery format (i.e., telehealth vs. in-person) were assessed as treatment moderators., Results: Intent-to-treat analyses indicated that WET was effective in reducing PTSD symptoms ( d = .84), depression symptoms ( d = .47), and functional impairment ( d = .36) during treatment. Approximately one quarter of patients dropped out of treatment prematurely. No moderators of PTSD treatment outcome were observed; however, telehealth delivery was associated with lower dropout., Conclusions: WET was an effective approach across a range of patient characteristics in this sample of veterans with PTSD. WET was also effective whether delivered in-person or via telehealth. WET is a promising treatment option for veteran patients in VA clinical care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: The first goal of this study was to assess longitudinal changes in burnout among psychotherapists prior to (T1) and during the COVID-19 pandemic (T2). The second objective was to assess the effects of job demands, job resources (including organizational support for evidence-based psychotherapies, or EBPs) and pandemic-related stress (T2 only) on burnout., Method: Psychotherapists providing EBPs for posttraumatic stress disorder in U.S. Department of Veterans Affairs (VA) facilities completed surveys assessing burnout, job resources, and job demands prior to (T1; n = 346) and during (T2; n = 193) the COVID-19 pandemic., Results: Burnout prevalence increased from 40 % at T1 to 56 % at T2 (p < .001). At T1, stronger implementation climate and implementation leadership (p < .001) and provision of only cognitive processing therapy (rather than use of prolonged exposure therapy or both treatments; p < .05) reduced burnout risk. Risk factors for burnout at T2 included T1 burnout, pandemic-related stress, less control over when and how to deliver EBPs, being female, and being a psychologist rather than social worker (p < .02). Implementation leadership did not reduce risk of burnout at T2., Limitations: This study involved staff not directly involved in treating COVID-19, in a healthcare system poised to transition to telehealth delivery., Conclusion: Organizational support for using EBPs reduced burnout risk prior to but not during the pandemic. Pandemic related stress rather than increased work demands contributed to elevated burnout during the pandemic. A comprehensive approach to reducing burnout must address the effects of both work demands and personal stressors., Competing Interests: Conflict of interest Dr. Rosen reported receiving grants from the U.S. Department of Defense and the U.S. Department of Veterans Affairs. Dr. Kaplan reported no conflicts of interest at the time of publication. Dr. Nelson reported receiving grants from the U.S. Department of Veterans Affairs. Dr. La Bash reported no conflicts of interest at the time of publication. Dr. Chard reported receiving grants from the U.S. Department of Defense, U.S. Department of Veterans Affairs and the Chris Sullivan Foundation. Dr. Eftekhari reported no conflicts of interest at the time of publication. Dr. Kehle-Forbes reported receiving grants from the U.S. Department of Veterans Affairs and the Patient-Centered Outcomes Research Institute. Dr. Wiltsey Stirman reported receiving grants from the U.S. National Institute of Mental Health and the Canadian Institutes of Health Research. Dr. Sayer is the PI of the U.S. Department of Veterans Affairs Health Services Research and Development grant that supported this work., (Published by Elsevier B.V.)

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings., (© 2022. The Author(s).)

Background: The US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD)., Methods: This study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30-45-min semi-structured interviews with a purposive subsample of these therapists ( n = 32)., Findings: Combining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review., Conclusion: Healthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wiltsey Stirman, La Bash, Nelson, Orazem, Klein and Sayer.)

Objective: Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials., Method: We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants ( n = 183) completed self-report measures of PTSD symptoms at each session., Results: Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment., Conclusions: The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective: Uptake of Evidence-Based Psychotherapies (EBPs) by mental health (MH) clinicians, especially in community settings, remains highly variable. This formative pilot study aimed to understand the attitudes and practices of Veterans Health Administration community-based MH clinicians regarding EBPs and to identify multi-level factors that enable and hinder EBP implementation in this unique context., Methods: Semi-structured interviews were conducted with MH clinicians (N = 40) working in community-based outpatient clinics (CBOCs) in metro/urban (n = 20) and non-metro/rural (n = 20) locations. Interviews were guided by the Consolidated Framework for Implementation Research and were analyzed using rapid content analysis. Results were organized by system-, clinician-, patient-, and innovation-levels., Results: EBPs were consistently perceived as important to delivering quality MH care, with most clinicians having received training in at least one VHA EBP. However, limited EBP training and consultation opportunities, inadequate autonomy to schedule EBP sessions, high and complex caseloads, and feelings of isolation at CBOCs decreased EPB use. Social workers perceived disparities in EBP training access relative to psychologists. Some barriers were more salient in non-metro/rural settings (e.g., patient-level privacy concerns)., Conclusions: Increased EBP training opportunities- particularly for social workers-, greater flexibility over schedules and caseloads, and more mechanisms for consultation and professional development may increase EBP uptake in community-based clinics., (Published by Elsevier Inc.)

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose., (Published 2021. This article is a U.S. Government work and is in the public domain in the USA.)

[Correction Notice: An Erratum for this article was reported online in Psychological Services on May 12 2022 (see record 2022-63047-001). In the original article, the columns in Table 3 were misaligned such that the data presented in the columns did not correspond with the correct variable. Additionally, for clarity, the table should have presented a separate column "n" for sample size and displayed total scores for the Personal Progress Scale (PPS) as opposed to mean scores. None of these errors impacted the results or conclusions. All versions of this article have been corrected.] This article describes the rationale, development, and preliminary examination of a brief, variable-length (up to six sessions), modular-based counseling intervention for women who experience intimate partner violence (IPV). Recovering from IPV through Strengths and Empowerment (RISE) is an empowerment and skills-focused treatment that incorporates Motivational Interviewing. RISE was developed to fill the gap in interventions for women who disclose IPV within integrated healthcare settings such as the Veterans Health Administration (VHA). Fifteen women Veterans with past-year IPV participated in an open trial at two VHA hospitals to evaluate the potential helpfulness, feasibility, and acceptability of RISE using a mixed-methods approach to assessment. Qualitative feedback from women Veterans and five RISE clinicians (psychologists and social workers) was collected posttreatment. Descriptive analyses of quantitative psychosocial outcomes before and after the intervention provide evidence of support for RISE as potentially helpful in improving psychosocial well-being. High retention and high satisfaction ratings, along with positive qualitative feedback from both IPV survivor participants and clinicians, supported intervention feasibility and acceptability. Overall, this pilot study offers feasibility and acceptability data for RISE as a potentially helpful intervention for women experiencing past-year IPV. Refinements to RISE based on the open trial and subsequent testing of the clinical effectiveness of the intervention are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Veterans Health Administration (VHA) recommends that patients with posttraumatic stress disorder (PTSD) receive either of the 2 frontline evidence-based psychotherapies, cognitive processing therapy (CPT) and prolonged exposure (PE). However, VHA providers have reported low use of these treatments, and voiced their concerns over exposing patients to distress in PE and their patients not understanding CPT. In the current study, we surveyed VHA providers ( N = 225) in PTSD clinical teams across the United States on their graduate school training experience in structured cognitive-behavioral therapy protocols, agreement with the 2 provider concerns, and use of the 2 treatments. Results from our mediation analyses indicated that graduate school training in structured protocols led to lower discomfort of exposing patients to distress during PE, and in turn, greater PE utilization. However, there was no significant relationship between graduate school training and CPT utilization. Findings suggest an important role for graduate training in the uptake of guideline recommended treatment for PTSD at VHA. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

In response to recommendations from the Special Committee on posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs, Veterans Health Administration (VHA) chartered a workgroup to identify strategies for improving the reach and fidelity of evidence-based psychotherapies (EBPs) implemented by VHA through clinician training initiatives. The workgroup, which comprised stakeholders in a variety of roles within the VHA, used an Intervention Mapping process, a practical approach to designing change strategies based on theory, evidence, and stakeholder input. High-level recommendations centered around implementation of recent VHA/Department of Defense (VA/DoD) treatment guidelines. In addition to recommended first-line and suggested second-line treatments, the guidelines include measurement-based care and shared decision making around EBPs and their alternatives to ensure that care is goal-oriented and patient-centered. To support increased reach and fidelity, the workgroup made four broad recommendations: (a) enhancing leadership support; (b) alignment of policies, programs, and processes that influence reach of EBPs as recommended in clinical practice guidelines, including implementation support to accompany EBP trainings; (c) use of clinical data to inform decision making at multiple levels, and to provide fidelity support when outcomes are lower than expected or desired; and (d) increasing veteran and stakeholder education and awareness of guideline recommendations and availability of EBPs. These recommendations accompanied a more detailed set of recommended steps for implementation. This article describes the Intervention Mapping process and a summary of resulting workgroup recommendations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective: Although efforts to implement evidence-based psychotherapies (EBPs) require understanding how providers view and initiate these interventions, little is known regarding provider treatment selection in posttraumatic stress disorder (PTSD) care. The current study examines how specialty PTSD clinic providers within the Veterans Health Administration (VHA) describe reasons for selecting specific psychotherapies in PTSD treatment planning., Method: VHA psychotherapists in specialty PTSD care clinics completed a national online survey of treatment attitudes and practices, including an open-ended item inquiring about treatment selection. Thematic analysis was used to develop a framework describing factors in VHA providers' PTSD treatment selection., Results: Of 250 survey participants, 219 provided description of their treatment selection process. Providers identified four domains of factors impacting treatment planning: (1) provider factors (e.g., training), (2) perceived characteristics of the intervention (e.g., structural features), (3) patient factors (e.g., characteristics of the patient and symptom presentation), and (4) organizational context (e.g., VHA policy). Assessment of appropriate treatments for an individual patient was described as resulting from interaction across these domains, particularly perceived fit between patient needs and specific treatments., Conclusions: Provider decision making has been understudied in implementation science. Although prior research has emphasized the role of organizational context in EBP reach, our findings suggest that other factors are salient when decisions are made at the level of the individual patient. Results suggest that increased attention to treatment selection and focused training in use of decision aids and shared decision making may have utility in increasing uptake, reach, and sustainment of EBPs among VHA PTSD specialty providers. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

To better understand VA providers' approaches to and perspectives on providing care to women Veterans, providers (n = 97) in primary care and mental health settings were interviewed about women's perceived treatment needs, types of care provided, and perceptions of evidence-based treatments (EBTs) for this population. Providers perceived that women Veteran VA users are often diagnostically complex and require a coordinated approach to treatment planning. They struggled with decisions about how to offer services such as EBTs and collaborative care in light of comorbidity and psychosocial stressors, and endorsed the belief that a tailored approach and consideration of these factors is essential in providing care.

While modular and transdiagnostic approaches may address implementation challenges, there remains limited investigation into the fit within large healthcare systems. The current study examines qualitative interviews from patients, clinicians and administrative stakeholders in the Veterans Administration about experiences with, and views of, the Unified Protocol (UP; Barlow et al. in The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide, Oxford University Press, New York, 2011) to understand potential for implementation. Qualitative interviews were conducted based on an established implementation framework and speak to implementation of transdiagnostic treatment in veterans, including insight into barriers, facilitators, intervention characteristics, patient characteristics, and system level variables. The UP demonstrated promise for improving efficiency, satisfaction and personalizing mental healthcare.

Introduction: Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation., Methods: Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation., Results: Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified., Discussion: Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.

Objective: To determine whether childhood abuse predicts health symptoms and health care use among female veterans., Methods: Participants were 369 female patients at Veterans Affairs hospitals in New England who completed a mail survey. Multiple regression analyses were conducted to determine the differential impact of childhood physical abuse and childhood sexual abuse on health symptoms and health care use, while accounting for age, race, military branch, and military sexual trauma (MST)., Results: In our sample, 109 (29%) female veterans reported experiencing childhood abuse. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, and greater depressive and post-traumatic stress disorder symptoms. No significant association was found between childhood sexual abuse and poor physical or mental health status. After adjusting for other factors, childhood physical abuse was associated with more frequent use of medical health care. Childhood sexual abuse was not a predictor for health care use., Conclusions: Childhood physical abuse remains an important contributor to physical health and mental health, even after adjusting for the more proximate experience of MST. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment among female veterans., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

Little is known about client attitudes, especially veterans', toward the types of structured interventions that are increasingly being offered in public sector and U.S. Department of Veterans Affairs mental health clinics, nor is the possible impact these attitudes may have on treatment engagement well understood. Previous work indicates that attitudes of African Americans and European Americans toward treatment may differ in important ways. Attitudes toward treatment have been a proposed explanation for lower treatment engagement and higher dropout rates among African Americans compared with European Americans. Yet to date, the relationship between race and attitudes toward treatment and treatment outcomes has been understudied and the findings inconclusive. The purpose of this study was to explore African American and European American veteran attitudes toward mental health care, especially as they relate to structured treatments. Separate focus groups were conducted with 24 African American and 37 European American military veterans. In general, both groups reported similar reasons for seeking 0treatment and similar thoughts regarding the purpose of therapy. Differences emerged primarily regarding therapist preferences. In both groups, some participants expressed favorable opinions of structured treatments and others expressed negative views; treatment preferences did not appear to be influenced by race., ((c) 2015 APA, all rights reserved).)

Background: In 2008, the Veterans Health Administration (VHA) implemented the use of safety planning for suicide prevention. A safety plan is a list of strategies, developed collaboratively with a provider, for a patient to use when suicide risk is elevated. Despite the use of safety plans in VHA, little is known about implementation fidelity, the extent to which safety plans are delivered as intended, or patient-level outcomes of safety planning., Aims: This study aimed to explore the implementation fidelity of safety planning in a regional VHA hospital and examine the associations between safety plan quality and completeness with patient outcomes., Method: A comprehensive chart review was conducted for patients who were flagged as high risk for suicide (N = 200). Completeness and quality were coded, as well as information about patient and provider interactions regarding safety plan use., Results: Safety plans were mostly complete and of moderate quality, although variability existed, particularly in quality. Limited evidence of follow-up regarding safety planning was found in the medical charts. Higher quality was associated with fewer subsequent psychiatric hospitalizations., Conclusion: Variability in implementation fidelity and infrequent follow-up suggest a need for additional training and support regarding the use of safety plans for suicide prevention.

Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings., (© 2014 Wiley Periodicals, Inc.)

ObjectiveThe purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD).MethodThe present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment.ResultsOn average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program.ConclusionsThe present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Women in the United States continue to experience intimate partner violence (IPV) at unprecedented rates, necessitating the development and implementation of personalized, effective healthcare-based interventions. Methods of developing patient-centered interventions for IPV should elicit the voice of the target population (i.e., women who experience IPV) while assuring that outcomes identified as important are incorporated into the refined intervention. This pilot study is part of a multiphase, larger study aiming to refine an IPV intervention and clinical outcome measurements prior to formal evaluation of the effectiveness of the intervention. Specifically, this study elucidates patient-centered outcomes identified by women who have experienced IPV. Women patients of the Veterans Health Administration (VHA) in New England participated in focus groups to provide feedback and desired outcomes of a new IPV intervention. Patient-centered outcomes were defined by the participants. Focus groups were transcribed and analyzed using conventional content analysis and matrix analysis. A total of 25 women participated in focus groups (n = 5) at two large VHA facilities. Participant feedback revealed five common themes related to desired outcomes. Women opined increased feelings of empowerment as a key outcome of engaging in an IPV intervention. Women desired increased social connectedness and support to be gained during treatment, citing providers and other survivors of IPV as exemplary sources. Self-esteem was viewed as critical to enhancing recovery, as was increased knowledge across domains of IPV (e.g., warning signs, the link between mental and physical health for self and children). Finally, women identified valued action and goal setting, such as achieving more independence, as an optimal outcome. Addressing IPV against women requires patient-centered interventions that specifically target the types of outcomes deemed important by the end users: women who experience IPV. Findings have implications for tailoring treatments for IPV and selecting measures that tap into women's desired outcomes. [ABSTRACT FROM AUTHOR]

Background: Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.Methods: To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.Discussion: It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.Trial Registration: NCT02449421 . Registered 02/09/2015. [ABSTRACT FROM AUTHOR]

Female Veterans experience intimate partner violence (IPV) at alarming rates. The Veterans Health Administration (VHA) requires foundational research to guide the development of policy and programs to detect IPV among women Veterans and provide interventions. This pilot study reports findings from in-depth qualitative interviews conducted with 12 VHA primary care providers treating female Veterans in the New England region. Although most providers indicated that they were not currently routinely screening for IPV, they expressed positive attitudes and beliefs about screening in VHA primary care settings. Themes also included the importance of a comprehensive health care response to IPV, such as interdisciplinary coordination of care and team-based approaches to detection and intervention. Barriers to routine screening were identified, as well as recommendations for training programs and clinical tools to inform the successful implementation of a standardized IPV screening and response program in VHA. Although preliminary, these findings represent an initial step in an essential line of research. [ABSTRACT FROM AUTHOR]