Expanding access to evidence-based psychotherapy in VA settings: implementation of the brief cognitive behavioral therapy for depression program.

Introduction: Evidence-based psychotherapies (EBPs) are effective for mental health conditions, but access to these services remains limited and rural Veterans are particularly underserved. Specialized implementation and dissemination programs are needed to improve access to known EBPs. Methods: The current project sought to improve access to a known EBP-brief Cognitive Behavioral Therapy for depression (Brief CBT). Diverse Veterans and those from rural settings were a focus of this work. Aligned with the RE-AIM framework, a multifaceted implementation program was used to train and support VHA providers in their use of Brief CBT in VHA mental health settings, with specific outreach efforts made to providers at VHA Community-Based Outpatient Clinics (CBOCs) where rural Veterans often receive care. Evaluation included all facets of RE-AIM with a particular focus on adoption, effectiveness, and maintenance. Results: During the first two years, over 40 VHA facilities adopted the program across four regional networks. Eighty-three providers were approached, and 54 (65.1%) providers completed the training and are delivering the intervention. A total of 688 Veterans, 174 rural (25.7%), received 2,186 sessions (average of 3.5 sessions per Veteran). Veterans receiving Brief CBT with elevated depression scores who completed three or more sessions were found to have significant symptom reductions of 4.6 points (first to last available evaluations). Discussion: Implementation efforts of Brief CBT resulted in rapid uptake and significant clinical impact on Veterans. Rural outreach efforts, including targeted training for CBOC providers and use of tele-mental health, enhanced availability of EBP services for rural Veterans.

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).

Case Mis-Conceptualization in Psychological Treatment: An Enduring Clinical Problem.

Case conceptualization, an integral component of mental health treatment, aims to facilitate therapeutic gains by formulating a clear picture of a client's psychological presentation. However, despite numerous attempts to improve this clinical activity, it remains unclear how well existing methods achieve their purported purpose. Case formulation is inconsistently defined in the literature and implemented in practice, with many methods varying in complexity, theoretical grounding, and empirical support. In addition, many of the methods demand a precise clinical acumen that is easily influenced by judgmental and inferential errors. These errors occur regardless of clinicians' level of training or amount of clinical experience. Overall, the lack of a consensus definition, a diversity of methods, and susceptibility of clinicians to errors are manifestations of the state of crisis in case conceptualization. This article, the 2nd in a series of 5 on thematic mapping, argues the need for more reliable and valid models of case conceptualization.

The Process of Thematic Mapping in Case Conceptualization.

This article, the 4th in a series of 5, introduces the 3-stage process of thematic mapping: theme identification, theme interpretation, and theme intervention. Theme identification is based on inductive reasoning, in which clinicians seek to discover and describe behavioral patterns in emotionally charged episodes. Theme interpretation subsequently initiates a process of deductive reasoning, wherein clinicians distill the generalized pattern into dominant and subthemes. Each theme is then labeled with a compelling metaphor that is representative of the theme interpretation. In the 3rd stage, theme intervention, clinicians seek to change the dysfunctional dominant and subthemes through collaboration with the clients. The process unfolds within 5 overarching parameters: a focus on comprehensiveness, simplification, maximal objectivity/impartial subjectivity, observation and inference, and an idiographic approach. Alternative models of case formulation are offered in comparison to thematic mapping.

Exploratory factor analysis in Rehabilitation Psychology: a content analysis.

OBJECTIVE: Our objective was to examine the use and quality of exploratory factor analysis (EFA) in articles published in Rehabilitation Psychology. DESIGN: Trained raters examined 66 separate exploratory factor analyses in 47 articles published between 1999 and April 2014. The raters recorded the aim of the EFAs, the distributional statistics, sample size, factor retention method(s), extraction and rotation method(s), and whether the pattern coefficients, structure coefficients, and the matrix of association were reported. RESULTS: The primary use of the EFAs was scale development, but the most widely used extraction and rotation method was principle component analysis, with varimax rotation. When determining how many factors to retain, multiple methods (e.g., scree plot, parallel analysis) were used most often. Many articles did not report enough information to allow for the duplication of their results. CONCLUSION: EFA relies on authors' choices (e.g., factor retention rules extraction, rotation methods), and few articles adhered to all of the best practices. The current findings are compared to other empirical investigations into the use of EFA in published research. Recommendations for improving EFA reporting practices in rehabilitation psychology research are provided.

WISC-IV profile in high-functioning autism spectrum disorders: impaired processing speed is associated with increased autism communication symptoms and decreased adaptive communication abilities.

Changes in the Wechsler Intelligence Scales for Children-IV (WISC-IV) may affect the IQ profile characteristic of autism spectrum disorders (ASD). Moreover, the association of particular component cognitive abilities (unlike overall IQ) with symptomatology and adaptive functioning in ASD remains unclear. This archival study characterizes the WISC-IV IQ profile among 56 high-functioning (IQ > 70) children with ASD and correlates WISC-IV performance with ASD and ADHD symptomatology and adaptive functioning. The ASD WISC-IV profile included strengths on Matrix Reasoning and Similarities, weaknesses on Comprehension (which correlated negatively with social symptoms) and the subtests comprising the Processing Speed Index (Coding, Symbol Search). Processing speed task performance correlated negatively with communication symptoms and positively with communication abilities, indicating its importance to functional outcomes in ASD.