Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists.

OBJECTIVE: Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS: This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS: VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS: Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.

The challenges of improving statistical practice in alcohol treatment research.

BACKGROUND: This commentary discusses the paper by Hallgren and Witkiewitz (2013) which evaluated 5 methods for addressing missing data in clinical trials of interventions for alcohol use disorders. The authors conclude that commonly used methods (e.g., complete case analysis, single imputation methods) can produce misleading results and that better alternatives exist (e.g., multiple imputation [MI]). The problems of using inferior approaches are well-known and well-illustrated by the analysis in this paper, which serves as an educational reminder to use more statistically justified practices. METHODS: Findings of this paper are put in context of the broader statistical literature. Strategies to promote common usage of superior missing data methods are discussed. RESULTS: Solving the poor uptake of statistically justified missing data methods will require a multilevel diagnosis of the problem and likely a multifaceted response, perhaps including the establishment, publication, and enforcement of standards by scientific funding and regulatory agencies, scientific journals, and graduate program accreditation bodies. CONCLUSIONS: Little disagreement exists regarding the importance of addressing missing data in a statistically justified manner (e.g., with MI or other maximum likelihood methods). However, as with the implementation of other evidence-based practices, knowing what should be done does not alone make it happen.

Anxiety sensitivity and sleep quality: independent and interactive predictors of posttraumatic stress disorder symptoms.

A cardinal feature of posttraumatic stress disorder (PTSD) is decreased sleep quality. Anxiety sensitivity (AS) is one factor that has shown early theoretical and empirical promise in better understanding the relation between sleep quality and PTSD outcomes. The current study is the first to test the independent and interactive effects of sleep quality and AS on PTSD symptoms. Consistent with hypotheses, AS and sleep quality were found to be independent and interactive predictors of PTSD symptom severity in our sample of male military veterans seeking treatment for PTSD. Slope analyses revealed that AS was differentially related to PTSD symptom severity as a function of quality of sleep. The veterans with good sleep quality and relatively lower levels of AS had the lowest level of PTSD symptoms, whereas the veterans with poor sleep quality and low AS evidenced severity of PTSD symptoms similar to those with high AS.

Emotional clarity and attention to emotions in cognitive behavioral group therapy and mindfulness-based stress reduction for social anxiety disorder.

We examined (1) differences between controls and patients with social anxiety disorder (SAD) in emotional clarity and attention to emotions; (2) changes in emotional clarity and attention to emotions associated with cognitive-behavioral group therapy (CBGT), mindfulness-based stress reduction (MBSR), or a waitlist (WL) condition; and (3) whether emotional clarity and attention to emotions moderated changes in social anxiety across treatment. Participants were healthy controls (n = 37) and patients with SAD (n = 108) who were assigned to CBGT, MBSR, or WL in a randomized controlled trial. At pretreatment, posttreatment, and 12-month follow-up, patients with SAD completed measures of social anxiety, emotional clarity, and attention to emotions. Controls completed measures at baseline only. At pretreatment, patients with SAD had lower levels of emotional clarity than controls. Emotional clarity increased significantly among patients receiving CBGT, and changes were maintained at 12-month follow-up. Emotional clarity at posttreatment did not differ between CBGT and MBSR or between MBSR and WL. Changes in emotional clarity predicted changes in social anxiety, but emotional clarity did not moderate treatment outcome. Analyses of attention to emotions were not significant. Implications for the role of emotional clarity in the treatment of SAD are discussed.

A comprehensive examination of delay discounting in a clinical sample of Cannabis-dependent military veterans making a self-guided quit attempt.

Delay discounting (DD), an index of impulsivity, reflects individuals' preference for smaller immediate rewards to larger delayed rewards. The current study examined (a) relations between DD and quantity, frequency, and severity of Cannabis use, as well as several other measures of co-occurring substance use and clinical severity, and (b) whether DD predicted Cannabis-cessation outcomes. Cannabis-dependent United States (U.S.) veterans (N = 72; 95% male) who were interested in making serious self-quit attempts were evaluated prior to their cessation attempts, during which they completed a computerized DD task, and were followed throughout six months postattempt. Results indicated that higher DD was significantly correlated with higher compulsive craving for Cannabis (ρ = .29, p < .05), younger age of first Cannabis use (r = -.32, p < .01), earlier commencement of regular Cannabis smoking (r = -.25, p < .05), and seeking professional help for a previous Cannabis quit attempt (ρ = .27, p < .05). DD did not significantly predict any Cannabis-cessation outcomes in the first week postattempt or during the 6-month follow-up. These results add to the literature on DD, which has focused on users of tobacco, alcohol, opioids, and cocaine, by demonstrating that DD is sensitive to developmental trajectories of Cannabis dependence, but does not reliably predict cessation outcomes. Results also suggest that DD may carry less relevance for Cannabis than for other substances of abuse.

A randomized controlled trial of a web-delivered brief alcohol intervention in Veterans Affairs primary care.

OBJECTIVE: This study sought to examine whether a web-delivered brief alcohol intervention (BAI) is effective for reducing alcohol misuse in U.S. military veterans presenting to primary care. METHOD: Veterans (N = 167) screening positive for alcohol misuse during a routine primary care visit were randomized to receive a BAI plus treatment as usual (TAU) or TAU alone. An assessment of alcohol-related outcomes was conducted at baseline and 3 and 6 months after treatment. RESULTS: Veterans in both study conditions showed a significant reduction in alcohol quantity and frequency and alcohol-related problems at 6-month follow-up. No differential treatment effects on outcomes were observed between the two treatment groups. CONCLUSIONS: This study is the first to explore whether a web-delivered BAI using normative feedback is effective for veterans with alcohol misuse. Our findings suggest that BAIs using normative feedback may not have any additional benefit beyond TAU for older veterans with high rates of comorbid mental health concerns.