Search

Delivery of best-practice care for posttraumatic stress disorder (PTSD) is a priority for clinicians working with active duty military personnel and veterans. The PTSD Clinicians Exchange, an Internet-based intervention, was designed to assist in disseminating clinically relevant information and resources that support delivery of key practices endorsed in the Veterans Administration (VA)-Department of Defense (DoD) Clinical Practice Guidelines (CPG) for the Management of Posttraumatic Stress. We conducted a randomized controlled trial to examine the effectiveness of the Clinicians Exchange intervention in increasing familiarity and perceived benefits of 26 CPG-related and emerging practices. The intervention consisted of ongoing access to an Internet resource featuring best-in-class resources for practices, self-management of burnout, and biweekly e-mail reminders highlighting selected practices. Mental health clinicians (N = 605) were recruited from three service sectors (VA, DoD, community); 32.7% of participants assigned to the Internet intervention accessed the site to view resources. Individuals who were offered the intervention increased their practice familiarity ratings significantly more than those assigned to a newsletter-only control condition, d = 0.27, p = .005. From baseline to 12-months, mean familiarity ratings of clinicians in the intervention group increased from 3.0 to 3.4 on scale of 1 (not at all) to 5 (extremely); mean ratings for the control group were 3.2 at both assessments. Clinicians generally viewed the CPG practices favorably, rating them as likely to benefit their clients. The results suggest that Internet-based resources may aid more comprehensive efforts to disseminate CPGs, but increasing clinician engagement will be important.

This study examined aspects of clinicians’ work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians’ appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.

Mobile devices are increasingly used to administer self-report measures of mental health symptoms. There are significant differences, however, in the way that information is presented on mobile devices compared to the traditional paper forms that were used to administer such measures. Such differences may systematically alter responses. The present study evaluated if and how responses differed for a self-report measure, the PTSD Checklist (PCL), administered via mobile device relative to paper and pencil. Participants were 153 trauma-exposed individuals who completed counterbalanced administrations of the PCL on a mobile device and on paper. PCL total scores (d = 0.07) and item responses did not meaningfully or significantly differ across administrations. Power was sufficient to detect a difference in total score between administrations determined by prior work of 3.46 with a d = 0.23. The magnitude of differences between administration formats was unrelated to prior use of mobile devices or participant age. These findings suggest that responses to self-report measures administered via mobile device are equivalent to those obtained via paper and they can be used with experienced as well as naive users of mobile devices.

The authors examined the degree to which provider characteristics, such as profession, treatment orientation, prior experience in treating posttraumatic stress disorder (PTSD), prior experience with prolonged exposure (PE) therapy, and attitudes about PE, were related to the clinical outcomes of veterans receiving care from clinicians participating in the national Department of Veterans Affairs (VA) PE Training Program. Positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience treating PTSD, and prior PE training experience. With 1,105 providers and 32 predictors (13 provider variables), power was at least 90% power to detect an effect of β = .15. Profession was the only provider characteristic significantly related to outcomes, but the mean effect (a 2 point difference on the PTSD Checklist) was too small to be clinically meaningful. The results support the intensive training model used in the VA PE training program and demonstrate that clinicians of varying backgrounds can be trained using interactive training workshops followed by case consultation to deliver PE effectively.

Despite potential advantages in scalability and efficiency of web-based training for trauma providers, few controlled trials of feasibility and effectiveness of web-based mental health training have been performed. Our study compared web-based training in 3 intervention skills (motivation enhancement [ME], goal setting [GS], behavioral task assignment [BTA]) with web-based training plus telephone consultation, and a no-training control. The primary outcome measures included objective measures of skills acquisition (standardized patient assessments). Results showed significant differences among the training conditions. The overall tests of differences among the groups were statistically significant for ME and BTA skills (p < .001 and p = .005, respectively), but not for GS (p = .245). The web training plus consultation group improved in ME skills by 0.35 units compared to 0.12 units in the web only group (p < .001) and no change in the control group (p = .001). For BTA skills, the web training plus consultation improved by 0.27 units compared to 0.17 units in the web only group (p = .175) and no change in the control group (p = .004). Overall, these findings support the use of web-based dissemination for large-scale training programs for trauma providers in health care delivery systems. Further studies are needed to clarify the specific role of consultation as an adjunct to web-based training. Resumen A pesar de las ventajas potenciales en escalabilidad y eficiencia de los entrenamientos basados en la web para proveedores de trauma, pocas investigaciones controladas de la factibilidad y efectividad de entrenamiento basado en la web en salud mental han sido realizadas. Nuestro estudio compara el entrenamiento basado en la web en 3 habilidades de intervencion (aumento de la motivacion (AM), establecimiento de objetivos (EO), asignacion de tareas conductuales (ATC) con entrenamiento basado en la web mas consulta telefonica y un control sin entrenamiento. Las principales medidas resultantes incluyeron mediciones objetivas de la adquisicion de habilidades (evaluaciones estandarizadas de los pacientes). Los resultados muestran diferencias significativas entre las condiciones de entrenamiento. Las pruebas generales de diferencias entre grupos fueron estadisticamente significativas para habilidades AM y ATC (p

This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.

Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed.

Aggressive and unsafe driving was examined in 474 male veterans receiving Veterans Affairs residential treatment for posttraumatic stress disorder (PTSD). Specifically, the authors evaluated if PTSD was associated with aggressive and unsafe driving and if Iraq and Afghanistan War veterans were at higher risk than other war veterans. Approximately two thirds of the sample reported lifetime aggressive driving and one third reported current aggressive driving. Posttraumatic stress disorder severity was associated with aggressive driving, but not other forms of unsafe driving. Iraq and Afghanistan veterans endorsed higher rates of and more frequent aggressive driving than did other veterans. After accounting for PTSD severity, age, income, and marital status being an Iraq and Afghanistan War veteran predicted aggressive driving frequency and infrequent seatbelt use.

Trauma recovery Web sites are proliferating with limited supportive evidence for effectiveness. In this article, the authors review the current very early studies on trauma recovery Web sites highlighting the different approaches, the empirical support provided, and the critical development issues facing this exciting frontier. An example site based on social cognitive theory is also reviewed.

Mental health is seen as an important aspect in the community response to crisis and disaster. Research offers limited guidance to what interventions are likely to be effective in preventing postdisaster mental health problems. This article reviews recommended elements of mental health responses to community disasters. Different factors influencing response are illustrated by using 9/11 and Hurricane Katrina as examples. Clinical suggestions for community planning and actions of individual psychologists conclude the article. Language: en

Many combat veterans with PTSD have co-occurring symptoms of other forms of psychopathology; however, there have been limited studies examining personality disorders among this population. The few extant studies typically have assessed only two or three personality disorders or examined a small sample, resulting in an incomplete picture and scope of comorbidity. This study assessed all DSM-III-R personality disorders in 107 veterans in a specialized, inpatient unit. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, 79.4% of the participants were diagnosed with at least one personality disorder: 29.9% received only one diagnosis, 21.5% had two, 15.9% had three, and 12.1% had four or more. The most frequent single diagnoses were Avoidant (47.2%), Paranoid (46.2%), Obsessive-Compulsive (28.3%), and Antisocial (15.1%) personality disorders.

In times of disaster, emergency mental health services must be delivered in the field. This chapter reviews the current state of the literature and future trends in disaster mental health.

Although individual therapy involving imaginal experiencing of the traumatic event has been found to be effective in treating PTSD, there is evidence that few trauma therapists actually use the technique. Moreover, symptom improvement has been found to favor intrusive symptoms, whereas avoidance and hyperarousal have been less affected. Additionally, there are several published reports documenting difficulties in implementing the treatment, ranging from client refusal, adverse reactions, and therapist inexperience. In this article we outline an alternative group form of exposure therapy, manualized trauma focus group therapy (TFGT), designed to overcome some of these implementation obstacles and to enhance the effects of imaginal exposure to include those chronic PTSD symptoms of avoidance and social isolation. We describe the cognitive behavioral and developmental models from which the approach was derived, present clinical guidelines and an illustrative session, discuss complications we have encountered in TFGT pilot studies, and offer suggestions for improving future implementation. © 1997 John Wiley & Sons, Inc.