Northwest Florida State College 11 Journal Articles Annotated Bibliography Do not worry about formatting, I will take care of all of that.
A written summary (synthesizing) of the key concept(s) of 11 Specific journal articles (provided). Each articles summary should be 200 to 250 words and each one should focus on the following questions:
o Why was the study conducted and/or what themes emerge from the theory/article?
o What was the population studied?
o What did the researcher(s) conclude?
o What other information about this study do you believe is unique or important to recall? (Im looking for limitations in this element.)
The eleven (11) articles are:
Monson, C. M., Shields, N., Suvak, M. K., Lane, J. E. M., Shnaider, P., Landy, M. S. H., Wagner, A. C., Sijercic, I., Masina, T., Wanklyn, S. G., & Stirman, S. W. (2018). A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes. Behaviour Research and Therapy, 110, 3140. doi:10.1016/j.brat.2018.08.007
Peterson, A. L., Resick, P. A., Mintz, J., Young-McCaughan, S., McGeary, D. D., McGeary, C. A., Velligan, D. I., Macdonald, A., Mata-Galan, E., Holliday, S. L., Dillon, K. H., Roache, J. D., Williams Christians, I., Moring, J. C., Bira, L. M., Nabity, P. S., Hancock, A. K., & Hale, W. J. (2018). Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD. Contemporary Clinical Trials, 73, 2735. doi:10.1016/j.cct.2018.08.005
Peterson, A. L., Foa, E. B., Resick, P. A., Hoyt, T. V., Straud, M. C. L. B. A., Favret, J. V., Hale, W. J., Litz, B. T., Rogers, T. E., Stone, J. M., Villarreal, R., Woodson, C. S., & Young-McCaughan, M. S. J. (2020). A Nonrandomized Trial of Prolonged Exposure and Cognitive Processing Therapy for Combat-Related Posttraumatic Stress Disorder in a Deployed Setting. Behavior Therapy. doi:10.1016/j.beth.2020.01.003
Rauch, S. A. M., Koola, C., Post, L., Yasinski, C., Norrholm, S. D., Black, K., & Rothbaum, B. O. (2018). In session extinction and outcome in Virtual Reality Exposure Therapy for PTSD. Behaviour Research and Therapy, 109, 19. doi:10.1016/j.brat.2018.07.003
Silverstein, M. W., Petri, J. M., Kramer, L. B., & Weathers, F. W. (n.d.). An item response theory analysis of the PTSD checklist for DSM-5: Implications for DSM-5 and ICD-11. Journal of Anxiety Disorders, 70. doi:10.1016/j.janxdis.2020.102190
Sripada, R. K., Blow, F. C., Rauch, S. A. M., Ganoczy, D., Hoff, R., Harpaz-Rotem, I., & Bohnert, K. M. (2019). Examining the nonresponse phenomenon: Factors associated with treatment response in a national sample of veterans undergoing residential PTSD treatment. Journal of Anxiety Disorders, 63, 1825. doi:10.1016/j.janxdis.2019.02.001
Sripada, R. K., Ready, D. J., Ganoczy, D., Astin, M. C., & Rauch, S. A. M. (2020). When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy. BEHAVIOR THERAPY, 51(1), 8598. doi:10.1016/j.beth.2019.05.003
Straud, C. L., Siev, J., Messer, S., & Zalta, A. K. (2019). Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis. Journal of Anxiety Disorders, 67. doi:10.1016/j.janxdis.2019.102133
Szafranski, D. D., Smith, B. N., Gros, D. F., Risick, P. A. (2017). High rates of PTSD treatment dropout: A possible red herring? Journal of Anxiety Disorders, 47. doi:10.1016/j.janxdis.2017.01.002
Thorp, S. R., Glassman, L. H., Wells, S. Y., Walter, K. H., Gebhardt, H., Twamley, E., Golshan, S., Pittman, J., Penski, K., Allard, C., Morland, L. A., & Wetherell, J. (2019). A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD. Journal of Anxiety Disorders, 64, 4554. doi:10.1016/j.janxdis.2019.02.003
Trachik, B., Bowers, C., Neer, S. M., Nguyen, V., Frueh, B. C., & Beidel, D. C. (2018). Combat-related guilt and the mechanisms of exposure therapy. Behaviour Research and Therapy, 102, 6877. doi:10.1016/j.brat.2017.11.006 Behaviour Research and Therapy 110 (2018) 3140
Contents lists available at ScienceDirect
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
A randomized controlled e?ectiveness trial of training strategies in cognitive
processing therapy for posttraumatic stress disorder: Impact on patient
Candice M. Monsona, Norman Shieldsb, Michael K. Suvakc, Jeanine E.M. Lanea,
Philippe Shnaidera,d, Meredith S.H. Landya, Anne C. Wagnera, Iris Sijercica, Tasoula Masinaa,
Sonya G. Wanklyna, Shannon Wiltsey Stirmane,f,?
Department of Psychology, Ryerson University, 350 Victoria St., Toronto, Ontario, M5B 2K3, Canada
Veterans A?airs Canada Place, 800 Dela Gauchetiere Street, West Montreal, Quebec, Canada
Department of Psychology, Su?olk University, 73 Tremont Street, Boston, MA, 02108, USA
Anxiety Research and Treatment Centre, St. Joseph’s Healthcare, 100 West 5th Street, Hamilton, Ontario, L8N 3K7, Canada
National Center for PTSD, VA Palo Alto Healthcare System, 795 Willow Road (NC-PTSD), Menlo Park, CA, 94025, USA
Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA, 94305, USA
A R T I C LE I N FO
A B S T R A C T
This randomized controlled hybrid implementation/e?ectiveness trial aimed to compare the impact of three
di?erent models of training and consultation by examining the PTSD treatment outcomes achieved by therapists
who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive
Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of
three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on
CPT ?delity, Standard Consultation involving discussion and conceptualization of cases without session audio
review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT
sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically
signi?cant reductions in PTSD symptoms, (d = ?0.95 to ?1.78), comorbid symptoms and functioning
(d = ?0.27 to ?0.51). However, patients of therapists in the Standard Consultation condition (?PTSD = 19.64, d = ?1.78) experienced signi?cantly greater improvement than those in the No Consultation condition
(?PTSD = – 10.54, d = ?0.95, ?DEV = 6.30, ?Parms = 2, p = .043). This study demonstrates that patients who
receive evidence-based psychotherapy for PTSD in routine care settings can experience signi?cant symptom
improvement. Our ?ndings also suggest that to maximize patient bene?t, therapist training should include
consultation, but that audio review of sessions during consultation may not be necessary, at least for structured
protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.
Posttraumatic stress disorder (PTSD) is one of the most common and
debilitating mental health conditions, with substantial morbidity and
mortality (Kessler, 2000). Trauma-focused psychotherapies are frontline recommended treatments, with meta-analyses showing larger
e?ects for psychotherapies compared with pharmacotherapies in controlled studies (Watts et al., 2013). However, concerns have been expressed about the potential for decreased e?ectiveness (Chambers,
Glasgow, & Stange, 2013), or even PTSD symptom exacerbation, when
trauma-focused treatments are implemented in non-research settings
(e.g., van Minnen, Hendriks, & Ol?, 2010). To increase treatment
Abbreviations: CPT, Cognitive Processing Therapy; IS, Implementation Strategy; CQI, Continuous Quality Improvement; VA, Veterans A?airs; OSI, Operational
Stress Injury clinic; MHS, Mental Health System; EBP, Evidence Based Psychotherapy; US, United States; PTSD, Posttraumatic Stress Disorder; DOD, Department of
Defense; PE, Prolonged Exposure; VAC, Veteran A?liated Clinic; TX, Texas; PCL, PTSD Checklist; OQ-45, Outcomes Questionnaire-45
Corresponding author. National Center for PTSD and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road (NC-PTSD 334),
Menlo Park, CA, 94025, USA.
E-mail address: firstname.lastname@example.org (S.W. Stirman).
Received 13 January 2018; Received in revised form 18 June 2018; Accepted 27 August 2018
Available online 30 August 2018
0005-7967/ Published by Elsevier Ltd.
Behaviour Research and Therapy 110 (2018) 3140
C.M. Monson et al.
conducted RCTs to compare di?erent training strategies for substance
abuse interventions and examined ?delity, as measured by independent
ratings of competence in structured role plays with trained actors.
Notably, recent research has indicated that ?delity measured via role
play does not correspond with therapist competence in sessions with
their patients (Decker, Carroll, Nich, Canning-Ball, & Martino, 2013). A
later study established that Internet-based training plus Internet-based
supervision resulted in greater competence (as measured by independent ratings of therapists’ psychotherapy session recordings) than
delayed training or an Internet-based training with a consultation
worksheet (Rakovshik et al., 2016). Although uncontrolled patient-level
program evaluation data from implementation programs has been reported (Eftekhari et al., 2013; Ehlers et al., 2013; Karlin et al., 2012), to
our knowledge, there are no RCTs evaluating patient-level outcomes for
di?erent training strategies when implemented in routine care settings.
In light of numerous state and national-level policy initiatives to
train therapists to deliver EBPs (Clark, 2011; Eftekhari et al., 2013;
McHugh & Barlow, 2010), guidance on scalable strategies that yield
optimal patient-level outcomes is overdue. Thus, this RCT employed a
hybrid type III implementation-e?ectiveness design (Curran, Bauer,
Mittman, Pyne, & Stetler, 2012) to compare the e?ects of three di?erent
approaches to training clinicians to deliver Cognitive Processing
Therapy (CPT; Resick, Monson, & Chard, 2017) for patients with PTSD
in routine clinical practice. In this trial, a national sample of therapists
were randomized to receive one of three post-workshop support strategies: 1) standard expert-led group consultation without review of
session audio (Standard Consultation); 2) expert-led group consultation
including review of session audio (Consultation Including Audio Review); or 3) No Consultation. We hypothesized that reviewing segments
of audiorecorded therapy sessions in the context of group consultation
would yield better patient outcomes than consultation without audio
review or no consultation.
e?ectiveness and access, it is essential to understand how best to prepare providers to deliver these treatments e?ectively in clinical settings.
Thus, this study tested the e?ects of three di?erent post-workshop
learning conditions on patient treatment outcomes.
Previous research indicates that the use of manuals, web-based
trainings, or workshops alone are insu?cient to achieve the level of
treatment ?delity (i.e., adherence to, and competence in delivering,
essential elements) found in randomized control trials (RCTs; Herschell,
Kolko, Baumann, & Davis, 2010). Systematic reviews have concluded
that, to achieve acceptable ?delity in clinical settings, some form of
follow-up consultation or support is necessary (Herschell et al., 2010).
The emphasis on feedback in supervision and consultation models
(Edmunds, Beidas, & Kendall, 2013; James, Milne, Marie-Blackburn, &
Armstrong, 2007), combined with ?ndings that clinicians are not always able to accurately assess their level of skill or adherence to a
psychotherapy protocol (Brosan, Reynolds, & Moore, 2008; Tracey,
Wampold, Lichtenberg, & Goodyear, 2014), suggest that observation
and feedback may be necessary when training clinicians. Some previous
comparisons of training strategies support this possibility, with therapists who received consultation that included feedback on session recordings demonstrating higher levels of competence and other key
process variables (e.g., eliciting change talk) at the end of their training
(Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Sholomskas et al.,
2005). In fact, researchers have considered observation of full sessions
and feedback to be a gold standard for psychotherapy training (Lewis,
Scott, & Hendricks, 2014), and an essential element of training and
monitoring psychotherapists in clinical trials (Perepletchikova, Treat, &
Although the larger literature on consultation and training suggests
the importance of observation and feedback, it is unclear whether this
intensive and costly level of review is necessary to achieve good outcomes. To date, studies have typically compared workshops or webbased trainings alone to workshops or web-based trainings with consultation (Beidas, Edmunds, Marcus, & Kendall, 2012; Miller et al.,
2004; Ruzek et al., 2014; Sholomskas et al., 2005). Only one study, a
study of Motivational Interviewing, included a condition that provided
any form of observation and feedback based on session recordings
(Miller et al., 2004). However, feedback was written, limited to two
clinician-selected 20-min recordings, and fewer than half of the participants provided recordings in the study.
A critical barrier to the widespread use of individual feedback on
therapy provision is its feasibility (Rakovshik & McManus, 2010).
Direct observation or audio review of full therapy sessions, which is the
standard for clinical trials and training in academic contexts, is impractical in lower-resourced, routine care settings (Ruzek & Rosen,
2009). In addition, it is possible that full session review may not be
necessary to produce good outcomes. In a recent non-randomized
comparison of individual consultation with full session review context
of group consultation that included review of segments of sessions,
participants in group consultation were able to achieve a level of
competence that was non-inferior to those for whom full session review
was provided (Stirman et al., 2017). A potential advantage to this
model is that providers are exposed to a broader sample of case material
and peer examples than they would be in individual consultation, with
more speci?c and accurate feedback than they could receive in a form
of consultation that does not include any form of observation.
Meanwhile, research on training in evidence-based psychotherapies
(EBPs) has largely focused on outcomes at the therapist level (e.g., ?delity to the treatment protocol) rather than on patient-level outcomes
(Carpenter et al., 2012; Creed, 2016; Godley, Garner, Smith, Meyers, &
Godley, 2011; Herschell et al., 2010; Rakovshik, McManus, VazquezMontes, Muse, & Ougrin, 2016), likely due to the logistical challenges
associated with collecting patient-level data in studies of this nature.
For example, Sholomskas et al. (2005), and Miller et al. (2004),
2.1.1. Recruitment and enrollment
Mental health therapists from Veterans A?airs Canada Operational
Stress Injury Clinics, Canadian Forces mental health services, and the
broader Canadian community were eligible to participate in the study if
they: attended a standardized CPT workshop provided by the ?rst author; were licensed mental health therapists with psychotherapy in
their scope of practice; were currently providing psychotherapy to individuals who were therapist-assessed to have PTSD; consented to be
randomized to one of the study conditions; and were willing to provide
audiorecordings of therapy sessions, and measures of PTSD symptoms
and psychosocial functioning from consenting patients. Therapists were
invited to participate prior to, or at, the standardized workshops
teaching the CPT protocol (Resick, Monson, & Chard, 2017). After
completing the workshop, therapists who provided informed consent
were randomized to one of the three post-workshop consultation conditions. Full participation in the study required therapists to provide
recordings of all CPT sessions with at least two patients for use in
consultation or for ?delity ratings, and to collect patient outcome
measures. To incentivize participation, therapists who uploaded the
required number of session recordings and patient symptom measures
were eligible to become Quality-rated CPT Providers and placed on a
public roster of CPT providers if they met a minimum threshold for
competence (www.cptforptsd.com). After the 6-month post-workshop
phase was completed and all data were collected, all therapists (including those assigned to No Consultation) received written feedback
on their ?delity to CPT.
Consistent with other studies on EBP training (Miller et al., 2004;
Behaviour Research and Therapy 110 (2018) 3140
C.M. Monson et al.
agreement ? = 0.94, study team observers’ agreement ? = 0.74). Adherence to the procedures speci?ed for the consultation conditions was
high and di?erentiation between conditions was possible: No audio was
played in the Standard Consultation meetings, only 5% of the Consultation Including Audio Review sessions did not include audio review
due to technical di?culties.
Eftakhari et al., 2013), participating therapists facilitated recruitment
by identifying eligible patients, who provided informed consent for all
study procedures before beginning CPT. To participate, patients had to
be diagnosed with PTSD by their therapist according to the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV;
American Psychiatric Association, 2000) criteria, and have a score of ?
50 on the Posttraumatic Stress Disorder Checklist – Fourth Edition (PCLIV; Weathers, Litz, Herman, Huska, & Keane, 1993). Patients also
consented to participate in CPT, and have their sessions audiorecorded
and reviewed by independent ?delity raters, as well as potentially other
therapists during consultation. Consistent with the evidence base for
CPT, patients were ineligible if they had current uncontrolled psychosis
or bipolar disorder, substance dependence (abuse was permitted), imminent suicidality or homicidality, or signi?cant cognitive impairment
(mild to moderate traumatic brain injury was permitted).
All participants provided voluntary informed consent after a clear
description of the Research Ethics Board (REB)-approved study procedures. Approval for this study was obtained from the parent REB at
Ryerson University. Eleven REBs from sites across Canada with which
therapists were a?liated also provided approval for the study.
2.2.1. Therapist demographic characteristics and experience
A pre-workshop questionnaire was administered to assess relevant
therapist demographic information (i.e., age, sex, education), therapist
experience [i.e., years of licensed practice, hours of formal training in
cognitive-behavioral therapy (CBT), hours of supervised post-graduate
CBT training, prior CPT training experience (workshop hours and supervision hours), experience treating patients with PTSD (number of
patients), and caseload size].
2.2.2. Fidelity ratings from audio-recorded CPT sessions
To assess the therapists’ ?delity to the CPT protocol, audiorecorded
therapy sessions were randomly selected at four timepoints across the
6-month consultation period for each clinician. Trained independent
raters evaluated audio recordings with a modi?ed version of the CPT
?delity measure that has been used in previous clinical trials (Resick
et al., 2008). The CPT ?delity measure examines therapists’ adherence
to speci?c CPT interventions (4-point Likert-type scale, with 0 = incomplete, 1 = slightly complete, 2 = mostly complete, and 3 = fully
complete) as prescribed in each session, and their competence or skill in
delivering them (7-point Likert-type scale, from 0 = not competent to
6 = outstanding competence). A mean score of all unique and essential
items per session was calculated to determine adherence and competence scores. Two studies have assessed the reliability of this measure
and found 97% agreement between two raters across all items for adherence in one study (agreement was not reported for competence
scores; Resick, Nishith, Weaver, Astin, & Feuer, 2002), and 100%
agreement for adherence and competence in another (Resick et al.,
2.1.2. Post-workshop support strategies
Therapists in all conditions attended a standard 2-day CPT workshop provided by the ?rst author, received the CPT manual and related
materials, and had access to resources available through the free CPTweb online training (https://cpt.musc.edu/index). Participants in the
two consultation conditions received 6 months of weekly 1-h group
consultation with a CPT expert via a web-based program that allowed
therapist participants to access consultation meetings through the
Internet or to use their phones to dial in. Both consultation conditions
included 46 therapists per meeting. Consultation meetings included
discussion about provision of the CPT protocol, challenging cases,
treatment obstacles, and speci?c issues raised by participants within
each group. In the Consultation Including Audio Review condition, one
or two therapists per meeting presented segments of their audio recordings (typically 510 min) from a recent session and received feedback from other group members, as well as from the expert consultants.
Participants were asked to play segments that re?ected their use of a
speci?c CPT intervention from that session or to play a segment in
which they struggled to deliver CPT. In later sessions, consultants were
encouraged to ask therapists to play random segments of their session if
they did not identify speci?c parts that were challenging for them.
Therapists who did not present session content in a given week had the
opportunity to provide a brief check-in about the progress of their
current cases, and received input and feedback. All therapists who
submitted audio, including those in the No Consultation condition,
received feedback on their ?delity to two sessions after they had
completed the six-month post-workshop phase and completed all required study measures.
Experienced CPT consultants, originally trained to provide CPT
training and consultation by the treatment developers, led consultation
meetings across both consultation conditions to control for any consultant-related e?ects. They were trained in study consultation procedures for each condition by study team members prior to beginning
consultation meetings. The prescribed and proscribed activities for each
consultation condition are described in manuals (Chard, 2009; Stirman
& Monson, 2011). Study investigators reviewed self-reported consultation checklists, and also reviewed recordings of consultant meetings on a monthly basis to ensure that consultant ?delity to the consultation condition was maintained. Consultants received oversight and
feedback on their ?delity to the consultation condition from the principal investigators every 46 weeks, and as needed throughout the
study. Study team members reviewed 15% of the consultation session
recordings and rated the adherence checklists (Consultant-Observer
2.2.3. Patient characteristics
Patient information, including gender, age, race, ethnicity, diagnostic information, military status, and education level, were reported
by clinicians upon the patient’s enrollment in the study.
2.2.4. Patient outcome measures
Posttraumatic Stress Disorder Checklist (PCL-IV Weathers et al.,
1993) is a well-validated, 17-item, self-report questionnaire of the severity of di…
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