Demystifying the virtualization process: A call for standard reporting of virtual modifications to evidence-based psychotherapies, using the FRAME model.

The sudden onset of the coronavirus disease led to a rapid expansion of video telehealth to deliver mental healthcare. Although video telehealth was not a new clinical practice, there was limited guidance on how best to modify evidence-based psychotherapies (EBPs) for virtual delivery (a process also referred to as virtualization). The virtualization process for EBPs remains unclear as newly emerging reports on this topic do not consistently report modification decisions. This commentary calls attention to the need to improve documentation practices to allow a greater understanding of modifications needed to maximize the positive effects of EBPs transported to a virtual format. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to capture details about the nature, process, and outcomes of intervention modifications across a given clinical setting or population. To illustrate the use of the FRAME, we present a case example describing our experiences with transporting a 1-day in-person Acceptance and Commitment Therapy group workshop to a virtual format. Workshop modifications primarily involved changes to the delivery format, administration procedures, and content. The case example walks through how, why, and by whom specific modifications were made as well as the degree to which fidelity was maintained. In the wake of the telemedicine revolution, further investigation into the virtualization process for EBPs is warranted. Improving reporting practices by using the FRAME or a similar adaptation framework will promote a more rigorous study of virtual modifications to EBPs that inform future guidelines and best practices.

Video telehealth rapidly expanded during COVID-19 as a preferred method for delivering mental health treatment. The sudden, unexpected onset of the pandemic left healthcare systems and individual clinicians little time to shift their services to this virtual format. In addition, there was and remains limited information on the most effective ways to modify evidence-based psychotherapies for virtual delivery (a process known as virtualization). To fill this knowledge gap, this commentary calls for improved documentation and evaluation of the virtualization process. We provide a case example demonstrating how to use the Framework for Reporting Adaptations and Modifications-Expanded­a comprehensive system to detail the nature and process of treatment modifications within a given context. Routine use of this or similar adaptation models within the field of behavioral and social sciences will provide a better understanding of changes needed to ensure the continuity and integrity of evidence-based psychotherapies modified for video telehealth delivery.

Narrowing the Treatment Gap: A Call to Increase Use of Direct-to-Consumer Marketing in Psychotherapy Practice and Research.

A mental health treatment gap exists in which individuals who would benefit from evidence-based psychotherapies (EBPs) do not receive them. It is critical to take effective actions so that individuals with unmet mental health needs feel empowered to seek treatment. Direct-to-consumer (DTC) marketing meets this objective. DTC marketing is an effective, patient-centered approach that creates patient demand for a product or service by influencing patient behaviors, attitudes, and preferences. While primarily used in the United States and New Zealand to promote prescription drugs, uses and practices for DTC marketing with nonpharmaceutical EBPs are less established. This article highlights the value of leveraging this marketing approach to increase awareness and use of EBPs. Additionally, an illustrative example is presented that describes the use of social marketing and marketing mix principles to develop effective DTC marketing campaigns in psychotherapy practice.

Leveraging the ExpandNet framework and operational partnerships to scale-up brief Cognitive Behavioral Therapy in VA primary care clinics.

Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research-operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy - brief Cognitive Behavioral Therapy (brief CBT) - in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization's ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).

A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans.

Exposure and response prevention (ERP) is the gold-standard, evidence-based psychotherapy for obsessive-compulsive disorder (OCD), but few receive it. Video telehealth can increase access to ERP for OCD and may enhance the salience of exposures. This study examined the feasibility, acceptability, and preliminary effectiveness of video telehealth-delivered ERP. We conducted a pilot open trial with 11 Veterans, using mixed quantitative and qualitative methods. Treatment completers (n = 9) had significantly reduced OCD and posttraumatic stress disorder symptoms posttreatment. Patients expressed greater comfort in engaging in ERP at home than in clinics. Therapists reported that seeing patients' home environments helped them understand their symptoms and identify relevant OCD exposures. Results suggest that video telehealth-delivered ERP is feasible and acceptable to patients and therapists and promising for reducing OCD symptoms. Future research should compare its effectiveness to usual care and evaluate patients' preferences for treatment delivery. Abbreviations: ERP: exposure and response prevention; GAD-7: Generalized Anxiety Disorder-7 scale; OCD: obsessive-compulsive disorder; OCI-R: Obsessive-Compulsive Inventory, Revised; PCL-5: PTSD Checklist; PHQ-9: Patient Health Questionnaire; PTSD: posttraumatic stress disorder; VA: epartment of Veterans Affairs; Y-BOCS: Yale-Brown Obsessive Compulsive Scale, self report form.

A randomized controlled trial for symptoms of anxiety and depression: Effects of a 1-day acceptance and commitment training workshop.

BACKGROUND: Cognitive-behavioral therapies often are recommended for anxiety disorders. However, treatment adherence and compliance are major barriers for these treatments, which are often delivered in 10 to 12 sessions over several months. This randomized controlled trial (trial registration NCT02915874 at www.clinicaltrials.gov) examined the effectiveness and feasibility of a 1-day cognitive-behavioral intervention for mixed anxiety. METHODS: A total of 72 adults with moderate-to-high anxiety were randomized into a 1-day acceptance and commitment therapy (ACT) work-shop (n = 44) or treatment as usual (n = 28). Follow-up assessments were conducted 6 and 12 weeks after the workshop. Clinical outcomes were anxiety (primary) and depressive (secondary) symptoms, as measured by the Beck Anxiety Inventory and Beck Depression Inventory-II, respectively. Proposed mediators of ACT-psychological flexibility and commit-ted action-also were examined. RESULTS: Participants assigned to the ACT workshop showed significant improvements in anxiety (beta = -1.13; P = .02) and depression (beta = -1.09; P = .02) after 12 weeks. Consistent with the theoretical model, these clinical improvements were mediated by psychological flexibility and committed action. Notable limitations included the sample size, inability to blind to treatment condition, and a racially and ethnically homogeneous sample. CONCLUSIONS: Our 1-day ACT workshop was effective for anxiety with co-occurring depressive symptoms. One-day interventions are a promising alternative to weekly treatments.

Improving the transition of patients with mental health disorders back to primary care: A protocol for a partnered, mixed-methods, stepped-wedge implementation trial.

The current study protocol regards a partnered, mixed-methods, cluster-randomized stepped wedge trial of the implementation and effectiveness of the FLOW program. FLOW (not an acronym) is a collection of resources and strategies to assist in determining which recovered or stabilized specialty mental health (SMH) patients should transition back to primary care (PC) and tools to make the transition seamless. Transitioning appropriate patients to PC can increase access and timeliness of mental health care for newly referred mental health patients. Nine sites in one US region will be randomized to one of three waves in which they will receive implementation-facilitation to implement the FLOW program. Primary outcomes will include the reach of FLOW, provider adoption of the program, effectiveness in increasing access in SMH, implementation fidelity, and maintenance over time. A mixed-methods analysis of implementation factors associated with implementation success will also be conducted, including the following as possible predictors: staffing ratios, site resources, leadership and provider support for the program, and local champion characteristics. This study's results will provide evidence for the effectiveness of FLOW in increasing access and may provide generalizable information about characteristics of sites that are likely to be successful with implementing similar programs.

One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol.

OBJECTIVE: Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning. METHODS: Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months. RESULTS: The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population. CONCLUSIONS: The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.

The moderating effect of psychological flexibility on event centrality in determining trauma outcomes.

OBJECTIVE: Emerging research shows that event centrality, or the degree to which trauma is perceived as integral to one's worldviews and personal identity, has a substantial impact on trauma recovery. Given that high centrality fosters both distress and growth, additional research on potential moderators that could better distinguish the course of adjustment is needed. This study examined whether differences in psychological flexibility (or the ability to persist in a behavior despite urges to do otherwise) impacted posttraumatic stress symptoms (PTS) and perceived posttraumatic growth (PTG) as event centrality increased. METHOD: One-hundred and 25 college students (52% female) with a history of trauma exposure were recruited from a large Midwestern university. Participants completed an electronic survey for course credit. RESULTS: There was a significant interaction between event centrality and psychological flexibility on PTS severity (B = 2.10, p = .003). A simple slopes analysis revealed that low psychological flexibility was associated with greater PTS severity as event centrality increased. Although event centrality and psychological flexibility independently predicted perceived PTG, no interaction effect was observed (B = -4.68, p = .080). CONCLUSION: This suggests that while differences in psychological flexibility may influence PTS severity following highly centralized traumatic experiences it has a more complicated relationship with perceived PTG that requires further investigation. Clinical implications are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Cumulative Trauma and Adjustment in Women Exposed to a Campus Shooting: Examining the Role of Appraisals and Social Support.

Experiencing repeated trauma can have increasingly detrimental effects on psychosocial functioning after subsequent stressors. These effects may be intensified for victims of interpersonal traumas given that these events are often associated with heightened risk for adverse outcomes. To better understand this relationship, the present study prospectively examined the effect of pre-shooting trauma exposure (i.e., interpersonal vs. non-interpersonal trauma) on psychological functioning (i.e., posttraumatic stress symptoms, depression) following a mass campus shooting. Based on previous research, it was expected that negative appraisals and social support would mediate this relationship. A sample of 515 college women reporting prior trauma exposure was assessed at four time points following the shooting (i.e., pre-shooting, 1-month, 6-months, and 12-months post-shooting). Bootstrap analyses with bias-corrected confidence intervals were conducted. Contrary to expectation, pre-shooting trauma exposure was unrelated to 12-month post-shooting outcomes and neither negative appraisals nor social support at 6-months post-shooting emerged as mediators. Interestingly, a history of non-interpersonal trauma was associated with greater post-shooting family and friend support than a history of interpersonal trauma. Ad hoc analyses showed that pre-shooting symptom severity and level of exposure to the shooting had indirect effects on post-shooting outcomes via post-shooting negative appraisals. These findings support that cumulative trauma, regardless of type, may not have an additive effect unless individuals develop clinically significant symptoms following previous trauma. Trauma severity also appears to play a meaningful role.

Treatment Use Among College Women Following a Campus Shooting.

Despite increases in campus shootings, there is limited research on treatment utilization after these tragic events. The present study prospectively examined the prevalence and predictors of treatment use among college women following a campus shooting. Predictors included age, race/ethnicity, education level, severity of exposure to shooting, and post-shooting sequelae (i.e., social support, posttraumatic stress disorder [PTSD] severity, depression severity). Present data were obtained from 516 women on campus at the time of the shooting. They completed electronic and online surveys across three time points - pre-shooting (T1), 1-month post-shooting (T2), and 6-months post-shooting (T3). As expected, few participants (14.4%) sought any treatment. Of note, 77.5% of participants endorsed at least one risk factor for PTSD. Prevalence rates of probable PTSD significantly decreased from 51.8% of the full sample at T2 to 12.9% at T3. Results showed that a significantly higher proportion of participants with probable PTSD at T3 sought treatment than those participants at minimal to no risk for PTSD. Psychotherapy was sought at higher rates than medication or combined treatment across risk groups. No reliable predictors of treatment use were observed for at-risk participants or those with probable PTSD. Research and clinical suggestions for optimizing post-disaster recovery and improving treatment utilization among students following campus shootings are discussed.

A proposal for augmenting the measurement of index events in PTSD assessment using event centrality.

BACKGROUND: Standard practice in assessing and diagnosing posttraumatic stress disorder (PTSD) entails identifying a single "worst" index event as the basis for symptom inquiry. Determining a single event can be challenging for clinicians and clients when multiple traumas are considered equally distressing. Additionally, it can be difficult to distinguish potential index events based on distress given the cumulative effect of repeated trauma exposure. This calls for the development of approaches that build on existing selection methods (e.g., worst event method). OBJECTIVE/CONCLUSIONS: In this article, we propose an innovative approach for identifying and measuring index events that utilizes the construct of event centrality to expand the parameters by which index events are selected. Event centrality assesses the degree to which traumatic events are perceived as integral to one's personal identity and worldviews. Given its role in the etiology and maintenance of PTSD symptoms, this construct also approximates the emotional impact of trauma. Incorporating validated measures of event centrality into PTSD assessments would provide an objective strategy for identifying index events in a way that may increase the reliability of diagnosis. Our proposed strategy may also have a positive impact on the therapeutic process and treatment outcomes.

Video to Home Delivery of Evidence-Based Psychotherapy to Veterans With Posttraumatic Stress Disorder.

Background: The Veterans Health Administration (VHA) has pioneered the implementation of video to home (VTH) technology to increase access to mental health treatments for Veterans facing barriers to receiving in-person care, particularly for posttraumatic stress disorder (PTSD). Randomized controlled trials have established the noninferiority of evidence-based psychotherapies (EBPs) for PTSD delivered through VTH, compared to in-person delivery. Less is known about the use of VTH to deliver EBPs for PTSD in routine clinical practice. Objective: We examined the provision of EBPs for PTSD delivered via VTH at a large Southwestern VHA PTSD outpatient clinic. Methods: Data were obtained from chart review of the electronic medical records of Veterans receiving at least one session of Cognitive Processing Therapy or Prolonged Exposure via VTH in the VHA PTSD clinic during the study time frame. Results: Fourteen providers (including six psychology trainees) delivered EBPs for PTSD via VTH between 2016 and 2018. Providers treated 74 Veterans (33.8% women) from diverse sociocultural backgrounds who ranged in age from 25 to 79. Each provider treated about 3.08 (± 2.18) Veterans using VTH, not including one provider who saw more than 30. A hybrid approach, in which VTH-delivery was coupled with in-person delivery, was used with 70.3% of Veterans across treatment (including sessions completed before initiation and after termination of the EBP). This demonstrates the versatility of VTH for meeting individual patient needs. Most EBP sessions (85.4%) were conducted over VTH. Despite Veterans attending an average of 6.85 (± 4.88) EBP sessions, 50% terminated before session 7. This dropout rate is consistent with national and local EBP completion averages within the VHA. Veterans receiving Cognitive Processing Therapy via VTH were more likely to complete treatment than those receiving Prolonged Exposure. No other patient factors predicted attrition. Conclusions: This study highlights the use of VTH as "tool in the toolbox" that expands the scope of practice for providers and increases opportunities for Veterans to receive EBPs for PTSD. We describe other potential advantages of using VTH to deliver EBPs for PTSD.

Barriers to self-compassion for female survivors of childhood maltreatment: The roles of fear of self-compassion and psychological inflexibility.

Preliminary evidence has demonstrated the benefits of targeting self-compassion in the treatment of posttraumatic stress disorder (PTSD). However, survivors of childhood maltreatment may present with unique challenges that compromise the effectiveness of these and other PTSD treatments. Specifically, childhood maltreatment victims often exhibit a marked fear and active resistance of self-kindness and warmth (i.e., fear of self-compassion). Victims may also attempt to control distressing internal experiences in a way that hinders engagement in value-based actions (i.e., psychological inflexibility). Research suggests that psychological inflexibility exacerbates the negative effects of fear of self-compassion. The present study expanded on previous research by examining the relations among childhood maltreatment, fear of self-compassion, psychological inflexibility, and PTSD symptom severity in 288 college women. As expected, moderate to severe levels of childhood maltreatment were associated with greater fear of self-compassion, psychological inflexibility, and PTSD symptom severity compared to minimal or no childhood maltreatment. A mediation analysis showed that childhood maltreatment had a significant indirect effect on PTSD symptom severity via fear of self-compassion, although a conditional process analysis did not support psychological inflexibility as a moderator of this indirect effect. A post hoc multiple mediator analysis showed a significant indirect effect of childhood maltreatment on PTSD symptom severity via psychological inflexibility, but not fear of self-compassion. These findings highlight the importance of addressing fear of self-compassion and psychological inflexibility as barriers to treatment for female survivors of childhood maltreatment.

Examining Minority Attrition Among Women in Longitudinal Trauma Research.

Research suggests that racial and ethnic minorities are more likely to attrit from longitudinal trauma studies than non-Hispanic Whites. Yet, little is known about how the loss of minority participants influences longitudinal findings as well as internal and external validity of study findings. Thus, the present study examined the effects of race/ethnicity on attrition in a longitudinal trauma study of women (minority = 223, non-Hispanic White or majority = 459) exposed to a campus shooting. Survival analyses were used to compare the attrition rates of minority participants to majority participants and assess the extent to which race/ethnicity, among other variables, predicted attrition. Minority participants were more likely to attrit than majority participants, hazard ratio (HR) = 0.69, 95% CI [0.48, 0.99], even after adjusting for study variables. A main effect was also found for age, HR = 1.06, 95% CI [1.01, 1.12]. Race/ethnicity did not interact with other study variables to influence attrition. The findings underscored the importance of assessing the effects of attrition on longitudinal findings and external validity.