Disseminating evidence-based treatments for PTSD in organizational settings: A high priority focus area

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Abstract

Dissemination of evidence-based treatments for PTSD has become an important focus of activity in the aftermath of recent terrorist attacks (e.g., London underground and U.S. 9/11 attacks), natural disasters (e.g., Indian Ocean tsunami and Hurricane Katrina), and wars (e.g., in Iraq and Afghanistan). This has become a high priority need for all mental health training and service delivery organizations. Researchers and educators have begun to examine clinician and client perceptions and preferences regarding PTSD treatment processes, and health care systems are organizing more comprehensive efforts at training and system change. As this evolution of services moves forward, effective dissemination should be a major focus of health policy research for the next decade or more.

This review critically evaluates the PTSD-related research and emerging theory related to four major sets of variables that affect dissemination: (1) Practitioner factors, (2) Training methods, (3) The practice innovation(s) being disseminated; and (4) Organization or system factors. We evaluate findings from recent studies in light of emerging models of dissemination, and in the final section of the paper, we consider five broad topics with particular implications for dissemination of PTSD-specific treatments. They are: (1) The content of dissemination (i.e., which treatment protocols or intervention methods should be prioritized); (2) Strict adherence versus flexibility in the use of treatment manuals and the role of fidelity assessment; (3) The need for collaboration with user audiences; (4) The potential role of web-based technologies in increasing the effectiveness and efficiency of dissemination; and (5) Development of dissemination infrastructures within organizations.

Introduction

The task of providing adequate training in evidence-based interventions to providers of treatment services for trauma survivors is one of the foremost challenges in mental health service delivery today. With increasing recognition of the impact of traumatic stress exposure and its emotional and behavioral sequelae, and with increasing availability of safe and effective cognitive-behavioral treatments for posttraumatic stress disorder (PTSD; Friedman et al., 2007, Follette and Ruzek, 2006), the demand for empirically-supported treatment services in this area is growing rapidly.

Although evidence-based practice guidelines have been published and made widely available, application of empirically-based treatments remains sparse and inconsistent, and best practices in the management of PTSD have not yet been widely disseminated or implemented (Rosen et al., 2004). Moreover, limited attention is being given at present to systematic, long-term evaluation of training programs and dissemination initiatives. Development of effective, replicable procedures to speed the adoption and enable sustained implementation of best practices in the treatment of PTSD and other trauma-related problems is an important public health priority. In his review of current mental health initiatives and priorities, Insel (2009) observes that despite better effectiveness outcomes for psychosocial interventions compared to drug therapy for chronic anxiety and mood disorders, “psychosocial interventions have received much less marketing attention than pharmacological treatments” (Insel, 2009; p. 129). This imbalance urgently needs to be addressed.

This review focuses on dissemination in organizational settings, for several reasons. Dissemination of evidence-based PTSD care is a current focus of several key organizations, such as the Veterans Healthcare Administration (VHA; Karlin, Ruzek, & Chard, 2009) in the United States and the National Health Service (NHS) in the United Kingdom. There is a growing body of literature on the role of organizational factors in best practices dissemination, which will inform our presentation here. Perhaps most important, organizations can systematically address the variety of factors that are likely to affect the success of dissemination efforts.

Section snippets

PTSD-related dissemination research in organizational settings

Dissemination projects or interventions are typically derived, either explicitly or implicitly, from a conceptual model or theoretic approach (Durlak and DuPre, 2008, Fixsen et al., 2005, Greenhalgh et al., 2004, Wandersman et al., 2008). The range of variables that should be considered when undertaking dissemination includes staff selection, pre-service and in-service training, ongoing consultation and coaching, staff and program evaluation, facilitative administrative support, and systems

What to disseminate?

At the present time, evidence-based treatments for PTSD are usually manualized treatments that combine specific interventions or intervention components to produce client change. However, it is useful to distinguish between evidence-based programs and practices, in that the goal of dissemination should be to implement only those elements of a program that are necessary and sufficient for effective behavior change (Fixsen et al., 2005). Information is lacking on the critical determinants of

Conclusion: the road forward in organizational implementation

There is an accelerating focus among organizations on dissemination of evidence-based PTSD assessment and treatment practices. The limitations of traditional training approaches are more widely recognized and training workshops are more frequently supplemented with post-training consultation/supervision. Researchers and educators are beginning to examine clinician and client perceptions and preferences regarding PTSD treatment processes, and health care systems are organizing more comprehensive

Acknowledgments

Supported by Department of Defense grant # PT074889.

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