(WITHDRAWN) A Mixed Methods Investigation of Factors Affecting the Implementation of Trauma-Focused Cognitive Behavioral Therapy

Background and Purpose: A number of evidence-based treatments (EBTs), such as Trauma-focused Cognitive-Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006), have demonstrated their ability to reduce posttraumatic stress reactions in youth. However, efforts to disseminate TF-CBT and other EBTs into community settings have encountered many challenges (Allen, Gharagozloo, & Johnson, 2012), prompting identification and examination of factors that affect implementation (Bond et al., 2014). This presentation presents findings from a large-scale implementation initiative that sought to disseminate trauma-focused EBTs for youth into community settings. Specifically, the purpose of the study was to (1) examine whether variations in training format and/or the use of problem-solving models during TF-CBT training were associated with five implementation outcomes (engagement in the training process, confidence in delivering the intervention, fidelity to intervention model, individual-level sustainability, and organizational-level sustainability), and (2) explore clinicians’ experiences with implementing specific TF-CBT components.

Methods: A concurrent mixed methods design was utilized to analyze survey data from mental health professionals (N=85) who received TF-CBT training in one of three training formats: in person training only, in-person training with monthly consultation calls, or a learning collaborative (in-person training with monthly consultation calls and additional in-person training sessions). The survey queried participants about their experiences with implementation, and included closed- and open-ended questions. For the qualitative strand, thematic analysis (Braun & Clark, 2006) explored responses to open-ended questions. Researchers adopted an inductive, open-coding approach and utilized prolonged engagement, data triangulation, researcher triangulation, and diagramming to promote trustworthiness and rigor. For the quantitative strand, chi square and independent t tests analyses helped determine whether more extended training formats or the use of problem solving models were associated with more favorable implementation outcomes.

Results: Clinicians perceived the same three components of TF-CBT as most difficult regardless of the type of training they received. Thematic analysis of qualitative survey data yielded themes and several sub-themes relating to provider (difficulty with certain therapeutic skills, indirect trauma exposure, and lack of buy-in to intervention model), youth (difficulty with youth engagement, managing avoidance, and implementing TF-CBT with younger youth), caregiver (difficulty with promoting caregiver engagement and caregiver difficulty adopting parenting skills), and organizational (modifications for various settings) factors. Bivariate analyses revealed more extended training formats and the use of problem-solving models were associated with higher levels of all five implementation outcomes.

Conclusions and Implications: Findings suggest that perceived difficulty of TF-CBT components did not vary by training format or agency setting, but more extended training formats and the use of problem-solving models were associated with greater implementation success. Results suggest adoption of enhanced training models and the inclusion of problem-solving models during the training process may bolster implementation outcomes. Findings also indicate an explicit focus on certain clinical skills and challenges during training may help clinicians to manage implementation barriers and promote sustainability.