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National Trainers’ Perspectives on Challenges to Implementation of an Empirically-Supported Mental Health Treatment

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Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

Abstract

This study examined perceived challenges to implementation of an empirically supported mental health treatment for youth (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT) and explored the potential use of technology-based resources in treatment delivery. Thematic interviews were conducted with 19 approved national TF-CBT trainers to assess their perspectives about challenges to implementation of TF-CBT and to explore their perceptions about the potential value of innovative, technology-based solutions to enhance provider fidelity and improve quality of care. These data offer some important insights and implications for training in evidence-based treatments, provider fidelity and competence, and patient engagement, particularly for those interventions targeting trauma-related symptoms among youth.

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Acknowledgments

This study was supported by the South Carolina Clinical and Translational Research (SCTR) Institute (NIH Grants UL1 RR029882 and UL1 TR000062). Dr. Hanson is partly supported by Grant 1790-SP from the Duke Endowment and Substance Abuse and Mental Health Services Administration Grant No. 1U79SM061269-01 (PI: Hanson). Preparation of this article was supported in part by the Implementation Research Institute at the George Warren Brown School of Social Work, Washington University, through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service (QUERI). Drs. Hanson, Davidson, Gros, and Ruggiero are supported by NIMH Grant R01 MH081056 (PI: Ruggiero). Drs. Hanson, Ruggiero, and Davidson are also supported by National Institute of Mental Health Grant No. 1 R34 MH096907-01 (PI: Ruggiero). Views expressed herein are those of the authors and do not necessarily reflect those of VA or NIMH or respective institutions. This paper has not been presented or published previously. The authors wish to acknowledge Kyle Brown, Danna Lewsky and Amy Oliver for their assistance in manuscript preparation.

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Correspondence to Rochelle F. Hanson.

Appendices

Appendix

Semi-Structured Interview of Approved TF-CBT National Trainers

Thank you for participating in our survey. The survey should take about 30–45 min. First, we will ask you questions about who you are and your experience as a TF-CBT Train-the-Trainer. Next, we will tell you about our plans to develop a technology-based resource designed to help providers deliver TF-CBT with high fidelity and competence and to promote child/caregiver engagement in treatment. We will then ask you a series of questions to get some ideas from you about how we can make this tool most helpful for providers in their work with abused or traumatized children and their families. This interview will be audiotaped so that we don’t miss anything. Do you have any questions?

Section A. About You and Where You Work

A01:

OK, let’s start. These first questions will address your experience providing treatment to children and adolescents. First, how long have you been conducting therapy with children?

A02:

How long have you been conducting therapy with children who have experienced a traumatic event (such as sexual abuse, physical abuse, witnessed violence, natural or man-made disaster)? (months or years)

A03:

Please estimate how many abused/traumatized children you have treated in the past year. If UNSURE, give ranges: (a) 1–5, (b) 6–10, (c) 11–20, (d) more than 20. If number is high and/or seems like a large part of caseload, what percentage of your caseload would you estimate is comprised of abused/traumatized children?

A04:

What is your primary role? (Supervisor, Provider, Administrator, Other [specify])

A05:

Next, a few more questions about your background for statistical purposes. What is your discipline? Are you a clinical psychologist, social worker, counselor, physician, or something else [specify]?

A06:

What degrees do you hold? (MD, PhD, MSW, EdD, LMSW, LISW, PsyD, Other)

A07:

Are you licensed? (Yes, No)

A08:

[Interviewer circle gender—do not ask: male, female]

A09:

Would you mind telling me your age? [If REFUSE, move on]

A10:

Would you mind telling me what ethnicity/race do you identify with? [If REFUSE, move on]

A11:

What state do you live in?

A12:

In what year did you complete the TTT training?

A13:

What type of TF-CBT specific training activities do you provide? (check all that apply: in-person 1-day workshop; 2-day initial/beginner workshop; 2 day advanced/booster workshop; telephone consultation calls; other—specify)

A14:

Approximately how many TF-CBT workshops have you provided in the past year?

A15:

Approximately how many providers have you trained in TF-CBT over the past year?

Section B. Orienting Participants to Project Goals and Website Content

(Orient participants to the broad purpose of our project using the two items below.) [Briefly cover these issues (30–60 s)]

B1:

The goal of our project is to explore the usefulness of technology-based resources for TFCBT to enhance provider fidelity to the treatment model and increase child/caregiver interest and engagement

B2:

These resources would be used by providers in session to assist in engaging children and their caregivers, and to help them stay on protocol

Section C. Semi-Structured Interview

C1:

What TF-CBT components do you believe are the most challenging for providers to deliver with high degree of fidelity and competence? (provide list of components for TF-CBT- PRACTICE)

[If participant only provides vague descriptions of TF-CBT, prompt them to tell you what specific PRACTICE component(s) appear to present the most challenge for providers]

C1a:

[For each component selected] In your opinion, why do you think these components present the most challenge for providers?

[If participant needs prompting provide these examples: provider discomfort; provider lack of familiarity with procedures; lack of congruence between the treatment model and the provider’s theoretical orientation or prior experience; limited experience with traumatized youth, or youth more broadly]

C1b:

[For each component NOT selected] So, to verify, it is your opinion that providers generally do not have too much difficulty administering the following TF-CBT components with fidelity and competence?

[If answer is no, seek clarity on other components that present challenges and why]

C2:

Keeping children engaged in treatment is a common obstacle to completing treatment and staying on protocol. In your experience, which TF-CBT components are most challenging in terms of actively engaging the child? Which components are most challenging in terms of engaging the caregiver? (Provide list of components for TF-CBT PRACTICE)

[If participant only provides vague descriptions of TF-CBT, prompt them to tell you what specific PRACTICE component(s) appear to present the most challenge for client engagement]

C2a:

[For each component selected] In your opinion, why do you think these components present the most challenge for client engagement?

[If participant needs prompting provide these examples: client discomfort/avoidance; boredom; lack of perceived relevance; provider enthusiasm; provider competence]

C2b:

[For each component NOT selected] So, to verify, it is your opinion that providers generally do not have too much difficulty engaging children and/or caregivers in the following TF-CBT components with fidelity and competence?

[If answer is no, seek clarity on other components that present challenges and why]

C3:

One of the goals of our project is to develop technology-based tools to help providers deliver a high quality of care and keep families actively engaged in TF-CBT components, particularly those that are known to be the most challenging to deliver. The tools would be available on a tablet such as an iPad, and would include things such as interactive educational games, a trauma narrative writing tool, and video demonstrations to show caregivers specific behavior management skills. In your opinion, how can we make sure that this toolkit adequately addresses the challenges that providers experience in delivering TF-CBT?

[Follow-up prompts:]

C3a:

What features would be most important for this toolkit to be engaging to children?

C3b:

Caregivers?

C3c:

If the toolkit is going to be useful, providers will need to find it valuable. How can we make this valuable to them in their practice?

C4:

Do you think that a technology-based toolkit has potential to enhance provider fidelity or competence?

C4a:

Why or why not? [will it reduce providers’ discomfort with delivery of certain treatment components? Which ones?]

C4b:

How do you think it could affect the therapeutic relationship? Is it likely to help it? Hurt it? Not affect it at all?

C4c:

Do you think the toolkit would be useful in addressing challenges to successfully completing TF-CBT?

C5:

What types of concerns or challenges do you think are important to consider in developing this web-based resource to facilitate delivery of TF-CBT?

[Follow-up prompt]:

C5a:

Do you think there is a potential for harm? [if YES] Why?

C5b:

IF YES: Can you think of some solutions to these challenges? How can we address these issues that you mentioned? [Follow-up prompt]:

C5c:

What are some key barriers to using the resource that providers will have? (aside from cost/accessibility)

C5d:

Web-security concerns?

C5e:

Privacy concerns?

C5f:

IF YES TO ANY OF ABOVE: Can you think of some solutions to these challenges? How can we address these issues that you mentioned?

D. Completion of Interview

That completes the questions I had for you. We appreciate your time and thoughts. If you have questions or comments, please feel free to call. Do you have any questions before we wrap up?

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Hanson, R.F., Gros, K.S., Davidson, T.M. et al. National Trainers’ Perspectives on Challenges to Implementation of an Empirically-Supported Mental Health Treatment. Adm Policy Ment Health 41, 522–534 (2014). https://doi.org/10.1007/s10488-013-0492-6

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