Inquiry in the Department of Veterans Affairs

Saturday 10:30 – 11:45 Breakout D2

Presentor: Sara J. Landes

Sara J. Landes, National Center for PTSD, VA Palo Alto Health Care System; Brandy N. Smith, National Center for PTSD, VA Palo Alto Health Care System; Allison L. Rodriguez, National Center for PTSD, VA Palo Alto Health Care System; Lindsay R. Trent, National Center for PTSD, VA Palo Alto Health Care System; Monica M. Matthieu, Saint Louis University, School of Social Work; Central Arkansas Health Care System, Mental Health Quality Enrichment Research Initiative (QUERI)


Dialectical Behavior Therapy (DBT; Linehan, 1993) is an evidence-based psychotherapy designed to address suicidal behavior and emotion dysregulation. DBT is effective among female veterans with Borderline Personality Disorder (Koons, et al., 2001) and helpful in reducing VA healthcare costs of veterans (Meyers, Landes, & Thuras, 2014). DBT has been implemented locally across VA.  However, DBT suffers from sporadic funding, limited training resources, and lack of evaluation of its spread. Given this, there is a pressing need to document implementation of DBT across VA to inform strategic planning and advocacy.

Using the PARIHS model (Kitson, et al., 1998) as a conceptual framework, the current study is using sequential quantitative and qualitative methods (Creswell & Plano Clark, 2007; Palinkas, et al., 2011) to characterize DBT implementation.  Interviews are being conducted with clinicians and administrators at 16 sites.  These sites include high and low adopters of DBT (determined by number of components implemented).

This presentation will focus on qualitative data examining the process of implementation and highlight how sites have utilized evidence to make decisions, what contextual factors were barriers or facilitators, and what factors facilitated the process of implementation.  Information that is likely generalizable to other interventions will be highlighted.


‘Successful’ Usual Care: Therapeutic Interventions and Contextual Factors

Saturday 10:30 – 11:45 Breakout D2

Presentor: Julia Revillion Cox

Julia Cox, Virginia Commonwealth University; Meghan Smith, Virginia Commonwealth University; Michael Southam-Gerow, Virginia Commonwealth University; Bryce McLeod, Virginia Commonwealth University



In some effectiveness trials, usual care (UC) therapists have demonstrated ‘successful’ treatment outcomes (e.g., diagnostic remission, reduced symptoms) on par with therapists delivering evidence-based treatments. The goal of the present study is to characterize one such sample of UC therapists by describing (1) the therapeutic interventions delivered and (2) the context in which such interventions were delivered, including therapist characteristics (e.g., training level), child characteristics (e.g., severity of psychopathology), and level of family engagement (e.g., attendance). Therapy process and contextual data were obtained from the UC condition of a randomized controlled trial of CBT for youth anxiety (Southam-Gerow et al., 2010); therapists treated a diverse sample of children, aged 8-15, in community clinics (N=24, 56% female, 38% Caucasian). The extensiveness of interventions delivered was double coded on a 7-point scale using the Therapy Process Observational Coding System of Child Psychotherapy – Revised Strategy Scale (TPOCS-RS; Mean ICC= 0.77; McLeod, Smith, Southam-Gerow, Weisz, & Kendall, 2014). We will describe the delivery of different therapeutic strategies interventions along with the contextual factors described above. Findings may help inform future dissemination and implementation efforts, including training, supervision, consultation, and effective measurement of treatment integrity within community-based mental health settings.

Learning from Implementation as Usual in Children’s Mental Health

Saturday 10:30 – 11:45 Breakout D2

Presentor: Byron J. Powell

Byron J. Powell, University of Pennsylvania; Enola K. Proctor, Washington University in St. Louis



To ensure that implementation strategies are feasible, acceptable, sustainable, and scalable, efforts to identify and develop implementation strategies need to be grounded by a thorough understanding of real-world service systems and what constitutes “implementation as usual.??? The aim of this multiple case study was to identify and characterize the strategies used in six children’s mental health organizations, and to evaluate the extent to which implementation as usual reflects best practices specified in the implementation literature. Semi-structured interviews and focus groups were conducted with organizational leaders (n=27) and clinicians (n=58) respectively. Interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Across organizations, provider-focused strategies (e.g., training, supervision) were dominant; however, these strategies were not offered at the frequency and intensity required to implement EBTs effectively. Multiple areas of implementation were not well addressed, including process, client, organizational, financial, and policy levels. Several problematic trends related were identified, such as the inconsistent provision of training and supervision, monitoring fidelity in unhelpful ways, and failing to measure or appropriately utilize clinical outcome data. We suggest how these results can inform the development of implementation strategies that will be practical and effective, and discuss implications for practice, policy, and research.