A comprehensive, multi-pronged effort is required including efforts targeted at every level of the public-sector organization: provider, facility, and system. Proposed strategies for overcoming identified challenges are: set clear goals; nurture broad-based organizational commitment and key stakeholder involvement; implement specialty training efforts to provide information and change attitudes; provide on-going supervision; conduct fidelity monitoring; and ensure accountability to the extent possible. In combination, these strategies support and reinforce one another.
1. Set clear goals
It is important to set goals that are clear, specific, and that are at least somewhat realistic—and to then communicate these goals effectively to relevant change-agents and key stakeholders. These goals should be objectively measurable so that successes and/or failures in particular domains can be tracked, and goals can be revised accordingly. For example, because the empirical evidence for assessment of trauma and PTSD in 1999 was stronger than that for treatment, and because assessment and diagnoses necessarily precede treatment, we prioritized the recognition of PTSD among new patients via routine screening in patients. Our initial two-year goal was to implement standardized screening procedures for 95% of new patients evaluated in at least four community mental health centers across the state.
2. Nurture broad-based organizational commitment and key stakeholder involvement
Successful implementation of any new program within a public-sector setting requires broad-based organizational commitment, including representation and “buy-in” from the full range of key stakeholders, including patients whose voices can be powerful and persuasive. While administrators, clinicians, and other stakeholders are committed to improving patient outcomes, they must be convinced that proposed assessment procedures and interventions can do so cost-effectively.
It is important to convince relevant stakeholders of the importance of addressing PTSD and trauma-related symptoms. To accomplish this it may help to summarize recent data which support the notion that psychotic disorders are conceptually consistent with diathesis-stressor models of mental illness (Corcoran et al., 2003
; Mueser, Rosenberg, Goodman, & Trumbetta, 2002
; Shevlin, Dorahy, & Adamson, 2007
; Walker & Diforio, 1997
). The evidence supporting a conclusion that psychosocial stressors play a critical role in the onset and relapse of psychotic episodes in schizophrenia also suggests that ongoing anxiety and trauma-related symptoms are likely to precipitate increases in symptoms or relapses in vulnerable individuals (Rosenberg et al., 2007
). Turkington et al. propose that the “high levels of arousal arising in posttraumatic stress disorder often maintains and perpetuates psychotic symptoms. In these cases, CBT approaches to posttraumatic stress disorder, including cognitive restructuring and reliving need to be combined with CBT techniques for psychosis (Turkington et al., 2004
, pg. 14).” Empirical data can help demonstrate both the high prevalence of trauma and PTSD among patients with SMI, as well as the availability of effective PTSD interventions for this population.
After obtaining stakeholder “buy-in,” empirical data should guide decisions regarding how PTSD services will be implemented. However, these decision rules should be somewhat flexible to ensure the intervention is appropriate and sensitive to the needs of both patients and providers within a particular facility. Similar to a “bottom-up” approach, provider feedback and concerns regarding the intervention should be solicited and appropriately addressed. Such feedback could alter aspects of the intervention but will ultimately increase the likelihood that the intervention will be successful by promoting a sense of ownership and collaboration among providers (Sullivan et al., 2005
Stakeholders and administrators must also acknowledge that clinicians need training time and resources, on-going clinical supervision, and fidelity monitoring efforts to effectively implement PTSD services. Further, accountability and incentives within the system will be needed to reinforce such efforts. Without appropriate resources, incentives, and accountability, delivering mandated interventions may be viewed as onerous, only adding to a provider’s caseload burden and job-related stress. Thus, involvement of key stakeholders and commitment at multiple organizational levels is necessary for the successful implementation of the multi-pronged efforts required to successfully disseminate EBPs.
3. Implement specialty training efforts to provide information and change attitudes
Clearly, there is need for additional specialty training and clinical supervision to help clinicians keep up with advances in the PTSD field and address identified knowledge deficits (Frueh et al., 2001
; Frueh et al., 2006
; Hanson et al., 2002
). Available empirical data can be used to persuade stakeholders to accept the need for developing or changing PTSD-related clinical practices, and to provide direction on how those practices might be structured. For example, introducing specific measures or treatment manuals that are relatively user friendly and providing resources and instruction on their use can be extremely helpful to well-intentioned clinicians who want to change their practice but are unsure of where to begin. It is also important to include relevant case vignettes and other instructional materials that are tailored to specific audiences. Further, the use of multi-channel approaches to clarify and reinforce key points over time is important to facilitate and consolidate learning. These can include video, distance learning or videoconferences, websites, readings, didactic presentations, role-modeling, and opportunities to practice and role-play. It may even be helpful to invite patients to discuss their relevant experiences and perceptions. In combination, these training efforts can help to increase knowledge, expand skill sets, dispel common trauma myths, and more generally “demystify” trauma. At the same time, it is important not to go beyond the available data, inflate the impact of trauma exposure, or “oversell” the efficacy of available treatments.
4. Provide on-going supervision and peer-review
It is not sufficient to merely provide education and training to clinicians. On-going clinical supervision is an essential component of effective dissemination efforts (Corrigan, Steiner, McCracken, Blaser, & Barr, 2001
; Torrey et al., 2001
), and is likely to be especially critical to helping relatively inexperienced, reluctant, or fearful clinicians work with trauma survivors suffering PTSD and SMI. The broader dissemination literature suggests that single or compressed training sessions in public-sector settings seldom result in meaningful or lasting changes. Furthermore, data from providers who treat patients with SMI indicates that they actually prefer to receive their training over time through ongoing supervision and other activities (Torrey et al., 2001
). Due to high caseloads and standards for contact hours, however, few clinicians are in environments that include “clinical” supervision. Instead, supervision often consists of checking-in and receiving updates on administrative issues. Therefore, this component should also include teaching supervisory staff how to provide clinical supervision and “leaders” should be identified to ensure accountability. If clinical supervisors are unavailable, distance learning techniques such as web based tutorials and supervision via teleconference technology may be effective and efficient (Rosenberg & Rosenberg, 2006
5. Conduct fidelity monitoring
It has long been recognized that fidelity monitoring is essential to ensure effective long-term implementation of EBPs (e.g., Backer, Liberman, & Kuehnel, 1986
; McGrew, Bond, Dietzen, & Salyers, 1994
). Without such monitoring, protocol deviations inevitably occur, including the introduction of theoretically incompatible or inert/unsupported treatment strategies. For example, we found that clinicians being trained in the use of cognitive-behavioral treatment for PTSD were often tempted to fall back on “old habits” (e.g., avoiding discussion of trauma exposure details or PTSD symptoms) or to use elements of other PTSD interventions they learned about (e.g., “trust exercises,” “journaling”). However, fidelity efforts will be most effective if they are relatively quick, user-friendly, and cost-efficient (Schoenwald & Henggeler, 2003
). Strategies could include checklists to ensure session content areas were covered, peer-review, and formal supervision in group or individual format, which includes review of audio or videotaped sessions.
6. Ensure accountability to the extent possible
The final, and perhaps most difficult to implement, component of dissemination is accountability at all levels of the organization. Once an organization has made the decision to change, has implemented new procedures and services, and clinicians are trained and prepared to implement PTSD-related EBPs, accountability is what keeps the engine on the tracks. Two pieces are critical to introducing practice accountability: (1) developing familiarity and comfort with ongoing assessment of protocol adherence (e.g., fidelity monitoring) and clinical outcomes, which can be used to help ensure accountability; and (2) dedicated ongoing supervision and fidelity monitoring to help address problems with client progress and success. Further, strategies must be developed to incorporate goal-obtainment accountability at provider, facility, and system levels. This should include both incentives for success; and feedback, guidance, and ultimately consequences if goals are not met. Quite frankly, this may be the most difficult challenge to surmount in publicly-funded agencies, and requires committed and creative leadership throughout the system.