According to traditional diagnostic viewpoints represented in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision; American Psychiatric Association, 2000), a disorder is: enduring pattern of inner experience and that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (p. 685). We review issues relevant to a behavioral perspective and the DSM-IV-TR approach to disorders below, followed by assessment and treatment issues for disorders (both at the nomothetic and idiographic levels), and examples of borderline and avoidant disorders. A central thesis of this paper is that a behavioral approach to assessment and treatment can compliment and expand upon a diagnostic approach, for example, by targeting covarying response classes characteristic of the different disorders. concept of personality has historically been eschewed by behaviorists, who focus on external (i.e., environmental), rather than internal, causes of behavior. purpose of this paper is to present our view that basic behavioral principles can be successfully applied to disorders, which have been conceptualized by many as characterological in nature and that a behavioral view can fully integrate the DSM concept of disorders. Hayes et al. (2006) supported this emphasis on theory by noting that a focus on basic behavioral treatment principles (not just the techniques themselves) makes it easier to confront a wide array of clinical problems. Although one such treatment package for disorders does exist, it is designed only for borderline disorder. Further, some personality-disordered clients show resistance to the structure of a manualized treatment, leaving much room for uncertainty in the treatment of this population. It is our position that a focus on basic behavioral assessment and treatment principles can aid greatly in clinical decision-making for clients with disorders. As this population presents unique and difficult clinical challenges, this approach is likely to be successful in the absence of readily available treatment packages. Relationship between Behavioral Assessment and the DSM system Prior to presenting a behavioral view on the assessment of disorders, we describe the relationship between behavioral assessment and the DSM system. It is our contention that recent versions of the DSM can be useful to behavioral assessors. This viewpoint has been presented previously, in relation to psychopathology in general (Nelson & Barlow, 1981; Nelson-Gray & Paulson, 2004). Behavioral assessment and psychiatric diagnosis developed on two parallel tracks. Behavioral assessment began informally, as a means of quantifying outcome measures while therapy or modification initially demonstrated its efficacy. various series of case studies that demonstrated the effectiveness of specific therapy techniques included outcome measures, showing changes in particular target behaviors (e.g., Eysenck, 1976; Ullmann & Krasner, 1965). Even when the case study dealt with a classic diagnosable disorder (e.g., depression), therapists were content with selecting a few salient target behaviors to demonstrate improvements that resulted from behavioral interventions (e.g., very slow speech rate in a chronically depressed man; Robinson & Lewinsohn, 1973). In these early case studies utilizing therapy, no mention was made of formal diagnosis or of changes in covarying behaviors that comprise the diagnostic syndrome. Eventually, behavioral assessment developed as a discipline in its own right, with this stated goal: The goal of behavioral assessment is to identify meaningful response units and their controlling variables for the purposes of understanding and of altering behavior (Nelson & Hayes, 1979, p. …
This study explored rates of non-attendance (i.e., non-initiation, inconsistent attendance, early discontinuation) in cognitive processing therapy (CPT) and other posttraumatic stress disorder (PTSD) focused individual and group psychotherapies (i.e., interventions with at least some PTSD and/or trauma-related content) and characterized veterans' self-reported reasons for non-attendance in these treatments. Baseline and 6-month follow-up data from the Telemedicine Outreach for PTSD study, a pragmatic randomized effectiveness trial conducted in 11 Veterans Health Administration community-based outpatient clinics, was examined (N = 265 veterans). Over 90% of veterans with a scheduled psychotherapy appointment attended at least one appointment by 6-month follow-up. Self-reported treatment completion was higher for veterans attending individual CPT (25%) than for those attending PTSD-focused individual (4.4%) and group psychotherapy (15.5%). However, rates of inconsistent attendance (13.3%) and early discontinuation (18.3%) were also higher in veterans attending CPT when compared to other forms of PTSD-focused psychotherapy (inconsistent attendance-individual: 2.2%, group: 6.9%; early discontinuation-individual: 14.6%; group: 10.3%). Issues with scheduling appointments was one of the most frequently reported reasons for non-attendance across treatments (> 20%). Logistical barriers, including transportation (CPT), therapy taking too much time (PTSD-focused individual psychotherapy) and not being able to afford counseling (PTSD-focused group psychotherapy), were also commonly cited (i.e., > 15%). Those scheduled to attend CPT (26%) or PTSD-focused individual psychotherapy (11%) also cited treatment efficacy concerns as a reason for non-attendance. Findings suggest logistical barriers, particularly scheduling convenient appointments, and beliefs about treatment may be important to address when engaging veterans in psychotherapy for PTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Prior single-site and regional studies have documented difficulties in implementing prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) into practice in Veterans Affairs (VA) Medical Centers, estimating that between 6% and 13% of VA patients with PTSD receive PE or CPT (Lu, Plagge, Marsiglio, & Dobscha, 2016; Mott et al., 2014; Shiner et al., 2013). However, these studies examined data from fiscal years 2008-2012, and therefore may not reflect more recent utilization patterns. Beginning in 2007, the VA invested heavily in increasing implementation of PE and CPT, including nationwide training rollouts and consultation. Given the length of time required for successful implementation of new practices, it is important to evaluate use of PE and CPT over time. We examined current use of PE and CPT at 1 VA medical center PTSD specialty clinic and compared this to prior rates for the same clinic. Chart reviews for all patients receiving a PTSD clinic initial evaluation between January 1, 2015, and May 31, 2015, indicated that 52% of patients began a course of PE or CPT within the 1-year follow-up period, representing a 5-fold increase from 2008 to 2012. We discuss changes in clinic structure, processes, training, and clinician support that might account for the successful implementation of PE and CPT in this clinic. We also present data on alternative referrals provided to patients not engaging in PE and CPT, and predictors of engagement in PE and CPT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. ClinicalTrials.gov, NCT01149772
As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans.The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire.The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder.Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.
COVID-19 called attention to the challenges postdoctoral fellows in health research face when they have times of prolonged disruption or changes in work conditions; this disruption revealed key insights on how mentors, fellows, and their institutions can work together to ensure training continuity. To prepare strong scientists, postdoctoral fellowships need mentoring, training, and networking opportunities to enhance fellows’ professional and skill development. In this article we outline potential solutions to minimize the impact of disruptions while promoting adaptable postdoctoral fellowship experiences by addressing how mentors and fellows alike can intervene on three key aspects of fellowships in health research: mentorship, training, and networking.
This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.
Purpose The purpose of study was to assess the impact of an online training program for a brief cognitive-behavioral therapy (CBT) that integrated physical health management designed for use by mental health providers in the primary care setting. Design/methodology/approach In total, 19 providers from two Veterans Health Administration (VHA) medical centers completed online training as part of a larger trial. Statistical analyses compared provider self-reported CBT knowledge and abilities at pretraining, posttraining, and long-term follow-up. Additionally, data were collected on providers’ experiences of the training. Findings Providers’ baseline to post-training scores improved on general CBT knowledge and ability, as well as across 11 CBT principles and techniques. Post-training scores were maintained over time. Research limitations/implications A small sample size, sole focus on VHA data, and reliance on self-report measures are limitations of the study. Practical implications Qualitative data suggested training was feasible, acceptable, and potentially scalable; however, a one-size-fits-all approach may not be ideal. Originality/value Online training has potential for providing wider access to providers with limited access to traditional face-to-face training.
