Evidence based psychotherapies (EBPs) are available for a wide range of mental health disorders, yet remain underutilized in routine clinical practice. Although pressure to use EBPs has come from many arenas, significant organizational and practitioner barriers to EBP implementation remain. Among the organizational hurdles to be crossed are convincing administrators and other key stakeholders of the advantages of EBP adoption (e.g., improved client outcomes, consistency of care) and addressing concerns about how training and implementation can fit within existing organizational practices.
Although training approaches utilizing the internet and other forms of technology hold promise for greatly expanding training opportunities for clinicians to learn EBPs, to what extent such strategies can address the many significant barriers to implementation that have been reviewed remains an empirical question. This study developed and tested the implementation of a web-based, interactive training plus weekly telephone supervision for the Broadening Recovery by Improving Goals, Habits, and Thoughts intervention (BRIGHT). BRIGHT is a manualized, 16- session CBT group depression treatment for individuals with Substance Use Disorders (SUDs). Hepner et al. (2011) found that addiction counselors with little/no prior mental health experience could be effectively trained to deliver BRIGHT after undergoing a 2-day in-person training and receiving weekly clinical group supervision with a CBT therapist. We were interested in exploring the feasibility of replacing the in-person BRIGHT training with a self-paced, online training and utilizing distance supervision.
Objective 1: To develop and test a web-based training program for addiction therapists to be trained in CBT for depression.
Objective 2: To develop and test a distance supervision plan to accompany the web training.
We sought to assess 1) feasibility of the trainings and subsequent implementation of the BRIGHT groups, 2) satisfaction of the counselors and programs with the training and implementation of the groups supported by distance supervision, and 3) barriers to routine implementation and sustainability of the online trainings accompanied by distance supervision.
Development of Modules and Supervision Plan:
The Instructional Systems Design (ISD) model was used to translate the BRIGHT therapy manuals into three media rich, interactive web-based training modules: 1) CBT Basic Concepts, 2) Introduction to BRIGHT, 3) BRIGHT Session Essentials. CBT Basic Concepts is a short (2 hours) conceptual introduction to CBT for depression. Introduction to BRIGHT is a detailed presentation of the BRIGHT manuals along with extensive instructions on group leadership (10 hours). BRIGHT Session Essentials collects 16 short training exercises (15 minutes each) with tips and strategies for each BRIGHT session.
The "story boards" (mock-ups of web pages), supervision plan for the counselors, and the prototype web products were iteratively derived (see Figure 2). The following stakeholders were involved: 1) Subject Matter Experts (SMEs), two clinical psychologist experts who developed and tested the BRIGHT manual (Drs. Hepner and Woo); 2) Instructional Design Experts (IDEs), a masters'-trained instructional designer and a PhD-level psychologist with instructional design expertise (Dr. Weingardt); 3) End Users, 3 current or former counselors in SUD treatment programs; and 4) a VA Panel of representatives from multiple disciplines (psychiatry, psychology, nursing, social work) and members of the EES. The SMEs first selected BRIGHT manual and training content from their prior work and submitted to the IDs for development into storyboards. The content documents and subsequent initial storyboards were extensive, including key concepts and CBT strategies, video scenarios, "characters" to be developed in the videos, and interactive exercises. The story boards went through four major iterations. The prototype web trainings and associated videos were created by private companies under contract. The iterative process produced a decision to pursue group supervision over the phone, with 3-4 counselors at a time.
The PI described the study to all VA regional mental health managers, asking them to recommend programs and directors within their region to contact. He contacted a total of 16 program directors, and 12 programs agreed to hear more about the study. Eight counselors from seven sites volunteered to participate.
All data were collected over the phone: a short demographic questionnaire, a "pre-test" examining knowledge about depression and basic CBT concepts, and two qualitative interviews-- following the completion of the online modules and the implementation of one complete BRIGHT group. Interview guides were developed with input from the study team, including the SMEs and IDEs. Topics covered in the post-training and post-implementation interviews were: the participants' experiences with the trainings, barriers and facilitators to completing the training, recommendations for modifying the trainings, thoughts on how proving depression care fit into their scope of practice, experiences implementing the BRIGHT groups in their clinics, modifications or adjustments they made during implementation, experiences in group supervision, and recommendations for implementing the trainings and groups (including the supervision plan) in "real world" conditions. A template approach is being used for qualitative data analyses (King, 1998; Crabtree and Miller, 1992), in which a list of codes, or template, is produced representing themes identified in the data, some of which are defined a priori, and some of which emerge from the data. The PI is the sole coder.
The following themes are emerging in the post-training interviews:
1) Barriers/facilitators to completing the trainings
Barriers: lack of protected time to complete trainings, technical difficulties (especially
offsite), the length of the trainings (and the 16-group session format) is causing some
counselors to not volunteer.
Facilitators: supervisor support, dedication of counselors to learn new material, belief that
treating depression within scope of practice, positive beliefs about the quality and utility of
2) Positive/negative experiences and reactions to training content
Positive: Majority were positive/very positive about the experience, all found the video
clips and skills building exercises informative, most found the instruction of running groups
Negative: No universal dislikes; one counselor found the group leaders in the video "too
touchy feely", another had problems with the test questions, and another thought that they
were too advanced for this course and "got bored."
3) Recommendations to improve the trainings: "Require" that a supervisor provide large blocks
of protective time so the trainings could be completed quickly and without the need to go back
over material, offer varying levels of training based on experience or a pre-test.
The following themes are emerging in the post-implementation interviews:
1) Barriers/facilitators to implementing the groups
Barriers: No other groups are two hours so scheduling was challenging, some counselors
struggled to find enough patients, turnover of program leadership, coverage for groups
Facilitators: Supportive leadership, having intern or some other co-facilitator for the group,
positive reactions of patients and improving outcomes.
2) Positive/negative experiences and reactions to implementing the groups
Positive: Some groups leaders saw vast improvement in clients, some counselors found
this to be the best training they ever had, many continuing BRIGHT groups post-study.
Negative: Patients missing groups was a challenge, patients not doing homework hard to
deal with, facilitating the group along was challenging for some.
3) Recommendations to improve the implementation of the groups: Allow counselors to reduce
group length and select some topics to be under-emphasized, allow counselors to run two 1-
hour groups peer week, have 2 counselors per site at least trained for coverage, "strongly
recommend" to have 2 people co-facilitate (at least at first).
We believe the study provided a look at implementation in semi-real-world conditions and the data resulted in highly useful recommendations for supporting a national roll-out.
The three training products are now available on TMS and providers from around the country are taking them. We will propose an additional small QUERI study to follow the spread during the first year after they are "advertised" by OMS, then consider an implementation study based on implementation needs. This study will contribute to the literature on implementation of EBPs for complex clinical presentations and will address the strengths and limitations of web-based and distance training technologies in supporting the implementation of EBPs.
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