Sara J. Landes, PhD National Center for PTSD, VA Palo Alto Health - - PowerPoint PPT Presentation

▶
sara j landes phd national center for ptsd va palo alto
SMART_READER_LITE
LIVE PREVIEW

Sara J. Landes, PhD National Center for PTSD, VA Palo Alto Health - - PowerPoint PPT Presentation

Mar 01, 2024 258 likes •765 views

Sara J. Landes, PhD National Center for PTSD, VA Palo Alto Health Care System Matthew S. Ditty, DSW University of Pennsylvania School of Social Policy and Practice 11 RCTs, 7 independent sites 5 controlled trials SAMHSAs National Registry

slide-1
SLIDE 1

Sara J. Landes, PhD National Center for PTSD, VA Palo Alto Health Care System Matthew S. Ditty, DSW University of Pennsylvania School of Social Policy and Practice

slide-2
SLIDE 2

11 RCTs, 7 independent sites 5 controlled trials SAMHSA’s National Registry of Evidence- based Programs and Practices

slide-3
SLIDE 3
  • Suicidal behavior
  • Non-suicidal self-injury
  • Depression
  • Hopelessness
  • Anger
  • Symptoms of eating disorders
  • Substance dependence
  • Impulsiveness
  • General adjustment
  • Social adjustment
  • Treatment retention
  • Positive self esteem
slide-4
SLIDE 4

Improve client motivation Enhance client capabilities Assure skill generalization Structure environment Improve therapist skills & motivation

slide-5
SLIDE 5

Improve client motivation Enhance client capabilities Assure skill generalization Structure environment Improve therapist skills & motivation

Individual Therapy Group Skills Training Phone Consultation Case Management & Outreach Therapist Consultation Team

slide-6
SLIDE 6
  • 5 days
  • Main content, structure,

& elements of DBT

  • Barriers to

implementation

Part I

  • 6 months
  • Homework
  • Implement program
  • Consultation to teams

Self study

  • 5 days
  • Self study presentations
  • Consultation: barriers to

implementation

  • Others areas as needed

Part II

slide-7
SLIDE 7

What do practice settings require to implement DBT well?

slide-8
SLIDE 8

n = 79 n = 20

All participants were intensively trained > 1 year ago

slide-9
SLIDE 9

 DBT Implementation

Outcomes

 22 CFIR “Inner Setting”

Variables

Program Elements of Treatment Questionnaire (PETQ) Organizational Readiness for Change (ORC)

(Communication and Cohesion subscales)

Team Climate Inventory, Short Version (TCI-14) CFIR-generated questions 8 questions on modes

slide-10
SLIDE 10

Mode % of Respondents Who Implemented it Individual Therapy 96.2 Group Skills Training 98.7 Coaching 87.3 Consult Team 97.5 Individual Skills Training 60.8 DBT Pharmocotherapy 26.6 DBT Case Management 31.7 Support/ Group Process 32.9

slide-11
SLIDE 11

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

slide-12
SLIDE 12

Barriers:

  • Logistical concerns (time, cost)
  • Don’t know how or why to track

It’s still probably the most challenging part in all of this.

slide-13
SLIDE 13

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 *

*

compared to IVs

slide-14
SLIDE 14

Nested within an organization.

*

Moderate significance. Some qualitative support.

>

Stand-alone programs.

slide-15
SLIDE 15

Large team size?

Moderate significance. Conflicting qualitative support.

slide-16
SLIDE 16

Team Cohesion

Strong significance. Clear qualitative support.

slide-17
SLIDE 17

Team Communication

Strong significance. Clear qualitative support.

slide-18
SLIDE 18

Culture/ Climate

Strong significance. Clear qualitative support.

slide-19
SLIDE 19

Supervision

Strong significance. Clear qualitative support.

slide-20
SLIDE 20

Higher % of team members with a doctoral degree?

Moderate significance. No qualitative support.

slide-21
SLIDE 21

Office Space

*

Moderate significance. Some qualitative support.

slide-22
SLIDE 22

 Supervision  Team Climate  Team Cohesion  Team Communication

All interpersonal constructs.

slide-23
SLIDE 23 Implementat ion Outcomes DBT Descriptions modification s Implement by doing practice, practice Outcomes & Research denial of tracking don’t know how don’t know what don’t know why logistical concerns Structural characteristi cs Age, size, makeup, etc. age of program agency type size staff turnover Specific structural elements implementa tion team university affiliation Networks and communicati
  • n
Team relationships cohesion commitment communicati
  • n
connecting to team impact Mobilization
  • f others
administratio n ancillary psychiatry community DBT community advocacy Culture and climate Desire for effectiveness BPD empathy benefits of DBT culture of competence/ EBP DBT culture buy-in DBT culture imp. strategies reinforcemen t Competing interests DBT compatibility alternatives policy conflicts legal concerns Safe climate collective energy goals vision therapist stress Readiness for implementat ion Funding, Expenses, Workload funding insurance money
  • verhead
facilities supplies workload time Knowledge and Technology knowledge training books manuals technology clients therapists Leadership bureaucracy/ hierarchy administrati
  • n behaviors
supervision taping Other client characterist ics therapist characterist ics process
slide-24
SLIDE 24

 More technology utilization by clinicians.

slide-25
SLIDE 25

What barriers exist in implementing DBT in the VA? Can we support implementation on a larger level with limited resources?

slide-26
SLIDE 26

n = 39 7 teams

  • 6 VAMCs
  • 1 Vet Center
slide-27
SLIDE 27

 No significant change

in # of barriers

 Top barriers however,

changed over time

slide-28
SLIDE 28

Barrier to Implementation % (n)

Conflict between agency policies and DBT philosophy or practice

78% (29)

Productivity demands

73% (27)

Difficulty meeting with each other/sporadic attendance at consultation meetings

62% (23)

No release time provided for learning and implementing a new program

51% (19)

Lack of support or direct conflict about program with key administrators

49% (18)

slide-29
SLIDE 29

Barrier to Implementation % (n)

Productivity demands 71% (30) Patients accustomed to treatment they have had, and are resistant to change 52% (22) No release time provided for learning and implementing a new program 48% (20) Conflict between agency policies and DBT philosophy or practice 45% (19) Lack of individual therapists 38% (16)

slide-30
SLIDE 30
slide-31
SLIDE 31

Limited resources available Lots being done at grass roots level Many unaware

  • f others’ work

and duplicating efforts Unable to access outside resources (e.g., DBT Wiki site)

slide-32
SLIDE 32
slide-33
SLIDE 33
slide-34
SLIDE 34

 Practical implementation assistance  Online community of practice

slide-35
SLIDE 35
slide-36
SLIDE 36
slide-37
SLIDE 37
slide-38
SLIDE 38
slide-39
SLIDE 39
slide-40
SLIDE 40
slide-41
SLIDE 41
slide-42
SLIDE 42
slide-43
SLIDE 43

Accessed every work day since its launch Materials added from across the country Consults requested Training requested Discussion forum utilized

slide-44
SLIDE 44
  • Average requests per day

165

  • Distinct users

1334

  • Locations of top 5 users

5 VISNs

  • Discussion forum posts

3

slide-45
SLIDE 45
  • Average requests per day

56

  • Distinct users

247

  • Locations of top 5 users

5 VISNs

  • Discussion forum posts

3

slide-46
SLIDE 46
  • 1. What to do – First sessions checklist
  • 2. Diary card
  • 3. Note template – Individual
  • 4. Mindfulness exercise – Sound
  • 5. Handout – Chain analysis
  • 6. Mindfulness exercise – Breath
  • 7. Mindfulness exercise – Physical Sensations
  • 8. Handout – Letting go of emotional suffering
  • 9. What to do – Leading mindfulness practice
  • 10. Handout – Managing distress

…

  • 34. Measure – DERS scoring file
slide-47
SLIDE 47

1.

Handout – DBT summary/notes

2.

Diary card

3.

Handout – Skills summary

4.

Handout – Mindfulness homework

5.

Presentation – Running an effective DBT group

6.

What to do – First sessions checklist

7.

Note template – Skills group

8.

Handout – Treatment overview handout

9.

Presentation slides – Individual DBT: What to do

  • 10. Mindfulness exercises

…

  • 50. Measure – BSL
slide-48
SLIDE 48

DBT SharePoint Sara’s Email Signature Existing DBT Contacts EBP Coordinator List MST List VA Mental Health Intranet Site National Center for PTSD Intranet Site Key VA Folks

slide-49
SLIDE 49

 Social network analysis  Survey of DBT across VA  Training Veteran crisis line staff in DBT skills  Implementation in other settings

  • Residential Trauma Recovery Program
  • Homeless Veterans Rehabilitation Program