207 Assessing Barriers to Care and Readiness for Cognitive Behavioral Therapy in Early Acute Care PTSD Interventions Sarah Geiss Trusz, Amy W. Wagner, Joan Russo, Jeff Love, and Douglas F. Zatzick Cognitive Behavioral Therapy (CBT) interventions are efficacious in reducing posttraumatic stress disorder (PTSD) but are challenging to implement in acute care and other non-specialty mental health settings. This investigation identified barriers impacting CBT delivery through a content analysis of interventionist chart notes from an acute care PTSD prevention trial. Only 8.5% of all inter- vention patients were able to complete CBT. Lack of engagement, clinical and logistical barriers had the greatest impact on CBT entry. Treatment preferences and stigma only prevented entry when more primary barriers resolved. Patients with prior diagnosis of alcohol abuse or dependence were able to enter CBT after six months of sobriety, Based on the first trial, we developed a CBT readiness assessment tool. We implemented and evaluated the tool in a second early inter- vention trial. Lack of engagement emerged again as the primary impediment to CBT entry. Patients who were willing to enter CBT treatment but demonstrated high rates of past trauma or diagnosis of PTSD were also the least likely to en- {gage in any PTSD treatment one month post-discharge. Findings support the need for additional investigations into engagement and alternative delivery strategies, including those which dismantle traditional office-based, multi-session CBT into stepped, deliverable components. Surah Geiss Tass, BA, is Reseach Coosdinator, Department of Psychiatry and Behavioral Sciences atthe Univer- sity of Washington School of Medicine in Seattle, and PsyD student ia clinical psychology ar Antioch University- Seale. Amy W. Wagner, PAD, is Staff Psychologist at the Porland VA Medical Center and Associate Professor at (Oregon Health and Science University in Portland. Jam Russo, PAD, i Associate Research Professos, Department of Psychiatry and Behavioral Sciences at the University of Washiagton School of Medicine in Seat. eff Love, BA, is Reseach Seudy Coordinator, Depastment of Psjchitey and Behavioral Sciences, at University of Washington School of Medicine in Seale. Douglas E Zatzck, MD, is Profesor, Department of Psychiatry and Behavioral Sei- ‘ences atthe Univesity of Washington School of Medicine in Seat “The authors wish to acknowledge KrisAnn Schmitz, MSW, fr her contributions 10 the CBT seadines assessment development, Megan Pet, BA, foe assistance in coondinating the Wal, and Jin Wang, PAD, for support with sta tistical analyses. “The research was supported by rants RO1/MHO73613 and K24/MHOS6814 fom the National Insta of Mental Health A peciminary abstact of this manuscri was presented at the 26% annual meeting of the International Society of Traumatic Sess Studies in Monteal, Canada, on November 5, 2010. Addeess corespondence to Sarah *Grin” Geiss Tras, Harborview Medical Center, Box 359911, 325 Ninth Avenue, Seale, WA 98104, Email: steusz@uwedu (© 2011 Guilford Pobliations, tne208 Effective trauma-focused early inter- ventions delivered in acute care medical set- tings incorporate both patient-centered sup- portive care to address immediate concerns and evidence-based treatment targeting spe- cific disturbances such as posttraumatic stress disorder (PTSD) (Brymer et al., 2006; Hob- foll et al., 2007; National Institute of Men- tal Health, 2002; van Ommeren, Saxena, & Saraceno, 2005). Cognitive Behavioral Ther- apy (CBT) is the evidence-based treatment ‘modality for PTSD most consistently recom- ‘mended by best practice treatment guidelines (Bisson & Andrew, 2007; Department of Veterans Affairs, 2003; Foa, Keane, Fried- ‘man, & Cohen, 2009; Institute of Medicine, 2007; National Collaborating Centre for ‘Mental Health, 2005; Ursano et al., 2004), ‘A growing body of research documents that CBT may be an effective early PTSD-preven- tive intervention for sub-populations of trau- macexposed patients recruited into efficacy trials (Roberts, Kitchiner, Kenardy, & Bis- son, 2009a; Roberts, Kitchiner, Kenardy, & Bisson, 2009b); however, ongoing dialogue in the dissemination research field suggests that multi-session CBT can be challenging to implement in real-world posttraumatic contexts (Glasgow, Lichtenstein, & Marcus, 2003; Jaycox et al., 2010; Kerner, Rimer, & Emmons, 2005; Lovell & Richards, 2000; Street, Niederehe, & Lebowitz, 20005 Zatz- ick & Galea, 2007). Commentary has raised questions regarding whether trauma survi- vors are able to enter CBT in non-specialty early intervention settings, such as acute care, combat zones, and postdisaster con- texts (Koepsell, Zatzick, & Rivara; Raphael, 2007; Rose, 1992; Tuma, 2007; Weisaeth, Dyb, & Heit, 2007; Zatzick, Koepsell, & Ri- vara, 2009). In an initial acute care study of a ‘behavioral activation early CBT intervention (Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007) similar to other CBT intervention tri- als (Bradley, Greene, Russ, Dutra, & Westen, 2005; Roberts et al., 200%), less than 1% of trauma survivors symptomatic for PTSD received CBT (Zatzick, Koepsell, & Rivara, 2009). The few patients who were able to en- Assessing CBT Barriers and Readiness ter CBT suggest there were significant deliv- ery barriers and that CBT may have limited reach as a preventative intervention in non- specialty mental health settings. Stepped-caredelivery modelshave been introduced into acute post-trauma contexts to assist front-line providers in reducing bar- tiers to PTSD treatment by first addressing primary concerns in care management before “stepping-up” to complex treatments like trauma-focused CBT (Zatzick, Kang, Hinton et al., 2001; Zatzick, Ray-Bymne, Russo et al., 2004). Although stepped-care interven- tions are effective at treating and preventing PTSD, few tools have been developed to as- sist providers in determining when to step up care to CBT. Acute care providers who triage to specialty mental health may ben- efit from an assessment of potential barriers and characteristics that increase likelihood of CBT completion. In trials where patients ‘were ambivalent to enter treatment, ongo- ing assessments of readiness (Prochaska & DiClemente, 1986; Prochaska, Velicer, Fava, Rossi, & Tsoh, 2001) were key to determin: ing progression through the therapeutic pro- cess from early engagement to more complex treatments (Brogan, Prochaska, & Prochas- ka, 1999; Knight, McGowan, Dickens, 8 Bundy, 2006; Medley & Powell, 2010). In contexts with limited resources oF trained providers to deliver CBT, a comprehensive assessment of barriers and patient readiness to enter treatment may be crucial to assist providers and increase the likelihood that those who are able and ready to enter CBT receive treatment. The aim of the current investigation was to identify current barriers impacting CBT delivery and accessibility, and to de- velop and implement a CBT readiness assess- ‘ment tool for use in early intervention set- tings with acutely injured trauma survivors at risk for development of PTSD. Once de- veloped, we conducted preliminary tests of validity, reliability, and acceptability of the CBT readiness assessment tool with front- line providers working in acute care medi- cal settings. We also explored the extent toGeiss Truse etal which domains of the assessment tool were associated with patient clinical characteris- tics, such as prior trauma and PTSD symp- toms, and what characteristics were associat- ed with low engagement in CBT treatment. ‘METHOD Design Overview To identify factors that impacted CBT treatment delivery, entry, and completion, we conducted a qualitative content analy” sis (Creswell, 1998; Miles & Huberman, 1994) of clinician logs and field notes from a stepped collaborative care early PTSD pre- vention trial in the acute care setting (Study 1) (Zatzick et al., 2004). The notes reflected clinician attempts to offer trauma-focused CBT to trauma survivors with PTSD in the intervention arm of the study. We identified specific factors impeding CBT entry and clas- sified them into more broad CBT readiness domains. Domains were possible indepen- dent measures of a CBT readiness construct derived from a review of CBT intervention trials and treatment implementationidissemi- nation literature. We considered the domains with the most impact on CBT completion to be independent measures of a global CBT readiness construct and included them in our preliminary CBT readiness assessment tool ‘An interdisciplinary team of clinical experts provided feedback regarding face validity of the tool, ‘We implemented the CBT readiness assessment tool as part of the baseline inter- vention component of a second randomized control PTSD prevention tril (Study Il) (Za- trick et al., 2010). Frontline clinicians as- sessed the feasibility of implementation. We assessed the interrater reliability, discrimi- nant and convergent validity, and explored associations between clinical and demo- ‘graphic patient characteristics and decreased engagement in CBT. 209 Setting and Patient Populations for Studies I and If Our sample included trauma survivors from Studies T and Ml (Zatzick et al., 2004; Zatzick et al., 2010) that were recruited from Harborview Medical Center (Harbor- view), a Level I trauma center managed by the University of Washington (UW) in Se- attle, Washington. Each year, Harborview admits approximately 6,000 survivors of in- tentional and unintentional injuries. In order to recruit a representative acute care trauma survivor population, we used few exclusion criteria. Eligible patients were English-speak- ng trauma survivors ages 18 and older who lived within 50 to 100 miles of the trauma center. We recruited intervention patients for Study I (n= 59) between March 30, 2001, and January 10, 2002, and Study Il (1 = 106) between March 21, 2006, and September 30, 2009. To assess the representativeness of ncluded patients, we compared the clinical and demographic characteristics of inter- vention patients in Studies I and II with the trauma registry data of all other trauma pa- tients admitted during the time period of the nvestigations. The UW institutional review board approved all procedures prior to the initiation of both studies. Both studies’ early PTSD_interven- tion included a stepped-care protocol with ‘case management that led up to multisession trauma-focused CBT. The CBT interven- tion included psychoeducation, controlled breathing, cognitive restructuring, and gead- ed exposure (Bryant, Creamer, O'Donnell, Silove, & McFarlane, 2009; Bryant & Har vey, 1998; Wagner, 2003). Identifying Factors Impacting CBT Delivery We conducted a comprehensive it- erature review (Gray & Acierno, 2003; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004) to identify CBT readiness210 domains (ie., independent measures of CBT readiness construct) that prevented patients’ successful progression through treatment from early engagement to CBT completion in other trials. The scope of the review included literature on barriers, preferences, stigma, and retention in CBT treatment (Brogan et al., 1999; Jaycox et al., 2010; Jaycox & Foa, 1996; Lovell & Richards, 2000; Mancebo, Pinto, Rasmussen, & Eisen, 2008; Monson et al., 2006; Schnurr et al., 2007; al., 2004; Waller & Gilbody, 2009; Wierz- bicki & Bekarik, 1993; Zayfert & Black Becker, 2000; Zoellner, Feeny, & Bittinger, 2009), health services research on access, reach, delivery, and utilization of trauma-fo- cused mental health treatment in acute care settings (Aday & Andersen, 1974; Elhai, North, & Fruch, 2005; Liang, Goodman, ‘Tummala-Narra, & Weintraub, 2005; Wong & Marshall, 2010; Wong et al., 2009; Za- tick, 2003), and literature related to treat- ‘ment engagement, readiness for entry, and drop-outattrition (Ghesquiere et al., 2004; Grote et al., 2007; McKay, Nudelman, 8 McCadam, 1996; McKay & Bannon 2004; Walker et al., 2007). Following previously described procedures for content analyses, wwe developed a coding manual to define do- ‘mains that encompassed individual factors impacting delivery (Zatzick et al., 2001) We then conducted a qualitative content analysis (Creswell, 1998; Miles & Huberman, 1994) of clinician case manage- ‘ment logs and field notes that documented attempts at CBT delivery to an acute care trauma population (Study I Zatzick et al., 2004), In addition to reflecting content of care management sessions and attempts to engage patients in treatment, the logs de- tailed collaborative care meetings where the team and primary therapist reached consen- sus on why patients were unable to enter CBT, problem-solved barrier resolution, and conducted treatment planning. Two coders (DZ and KAS) reviewed the intervention pa- tient chart notes with the aim of identifying all factors that influenced treatment progres- sion and impeded entry to CBT. If a patient Assessing CBT Barriers and Readiness had multiple impeding factors, a single “pri- ‘mary factor” for non-completion was identi- fied in the chart notes. ‘The primary factor ultimately prevented progression to CBT entry or completion, regardless of the pres- ence or absence of any other factors (e.8.y lack of engagement with therapist precludes CBT entry despite patient initially expressing preference to participate in CBT). The fac- tors that impeded CBT entry were iteratively classified according to the codebook of do- ‘mains developed from the literature review. For example, “no transport to treatment center” would be categorized under “logis- tic barriers,” a domain identified across CBT trials that impacted treatment completion. A third rater (SGT) performed a com- prehensive review of the case notes, and de- screpancies were discussed with other raters. Raters then modified the coding manual un- til all factors impeding CBT entry identified in Study I could be classified within, and thereby provide applied examples of, each domain. Similar factors were collapsed into ‘more general factors (e.g., “attrition due to second surgery” collapsed under “recurrent surgeries”), and each factor was categorized into only one domain. Similar domains with overlapping factors (e.g., alcohol and am- phetamine substance abuse) were merged into broader domains (e.., clinical barrier of substance use). Development and Implementation of CBT Readiness Assessment Tool ‘The coding team considered the final domains that captured all factors impacting CBT delivery for inclusion in the assessment tool. We ranked the domains based on their impact on CBT completion. The domains ‘with the highest percentage of primary fac- tors, those which impeded entry regardless of all other factors, were considered to have the greatest impact on preventing CBT pro- gression and thus were ranked first in the assessment. Members of an interdisciplinary research team from trauma surgery, nursing,Geiss Truse etal social work, and critical care that included clinical psychologists (AW), psychiatrists, and practitioners reviewed the readiness as- sessment. Team members judged the tool to hhave adequate face validity; the assessment represented a global construct of CBT readi- ness and captured many reasons that patients did not progress to CBT entry and comple- It demonstrated. sufficient purpose, framework, and comprehensibility. Domains were retained, and the format of the assess- ment was adjusted based on feedback from the expert panel. In Study Il, front-line B.A. and M.S.W. providers on the clinical intervention team were asked to implement the CBT readiness assessment during the baseline evaluation of patients randomized to the treatment arm (Zataick et al., 2010). The baseline evalua- tion occurred between hospital discharge and the one-month post-injury time point, and it cluded an assessment of patient preference for multi-session CBT treatment, as rated on 0 (less willing to enter CBT) t0 10 (more willing to enter CBT) Likert scale (Dwight- Johnson, Sherbourne, Liao, & Wells, 2000), Providers were asked to evaluate the CBT readiness tool’s face validity as well as fea- sibility of implementation, including time re- quited to administer the assessment. Finally, to determine interrater reliabil- ity, a separate clinical team of mental health ‘case managers used the final assessment tool to independently rate 20 intervention patient cases by reviewing the clinician logs (JL). Intraclass correlations were calculated and compared against a “gold standard” rater (scr), Associations Between Readiness Assess- ment and Clinical and Demographic Char- acteristics. Prior investigations suggest that some clinical and demogeaphic characteris- tics would be associated with PTSD-related clinical engagement, while others would not (Brewin, Andrews, & Valentine, 2000; Ghes- quiere, Wagner, Russo, & Zatzick, 2004; Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007). To better understand these convergent au and discriminant aspects of the CBT readi- ness tool, we examined associations between assessment domains (independent variables) and clinical characteristics, including prior trauma and PTSD (dependent variables). We used analysis of variance (ANOVA) with a Bonferroni adjustment for pairwise tests for the continuous outcomes and a chi-square analysis for categorical outcomes. Using the same statistical approach, we also explored associations between assessment domains (dependent variables) and demogeaphics, in- cluding gender, age, race, and injury sever- ity (independent variables). Prior cumula- tive trauma burden was assessed with CIDI trauma history module (Kessler et al., 2005; World Health Organization, 1997), and PTSD. symptom levels were assessed with the PTSD Checklist Civilian Version (PCL- ) (Ruggiero, Del Ben, Scotti, & Rabalais, 2003; Weathers, Huska, & Keane, 1991) We used an algorithm for the PCL-C where patients needed a score of three or greater fon one intrusive, three avoidant, and two arousal symptoms to meet diagnostic criteria consistent with the Diagnostic and Statisti- cal Manual of Mental Disorders (4'ed., text revision; DSM-IV-TR) (American. Psychiat- ric Association, 2000). Data analyses were conducted using SAS 9.2 (SAS Institute Inc., Cary, North Carolina) and STATA 10 (STA- TA Corporation LP, College 335 Station, Texas} software. RESULTS. ‘The demographic and clinical charac- teristics of patients recruited into the inter- vention arms of Study I and Study II did not substantially differ from the characteristics of all other patients admitted to the Harbor- view Level I trauma center during the time period of the two studies. In Study I, there ally or statistically significant differences in gender, intentional injury, oF blood alcohol concentration between inter-212 vention patients and all other patients admie- ted. Literature Review and Content Analysis of Factors Impeding CBT Treatment Delivery. We identified five domains in the literature review that encompassed all individual fac- tors impacting CBT treatment delivery: en- gagement, barriers, preferences, remission, and stigma (defined in Table 1). Sub-domains included: clinical, logistical, crisis, and pro- vider and setting barriers. The content analy- sis revealed that engagement, clinical, and logistical barriers impeded CBT entry for over 47 (80%) of the acute care population of trauma survivors (Figure 1). In Study I, all intervention patients (1 = 59, 100%) had one ‘or more factors impeding entry to CBT treat- ‘ment (x = 152, Mean, 2.6; SD, 1.4). Forty- three (72.8%) patients had more than one factor that prevented them from progressing through treatment to CBT (Range, 2-7), Engagement was the domain with the highest relative proportion of primary factors impeding progeession to CBT; 100% of the time a patient was not engaged (rating of 0), they did not enter CBT. Clinical and logistical barriers, including crisis, were ranked second in the assessment. Barriers stopped progres- sion to CBT for 56% of patients; 32% of the time a barrier emerged, the patient could not ultimately progress to CBT. Patient prefer- ence rarely emerged as a primary factor im- peding CBT entry; only $% of patients did not progress to CBT due to preference alone. Although they did not emerge as primary factors, remission and stigma did influence CBT progression if other primary factors were resolved. OF note, for patients with di- agnosis of alcohol abuse or dependence up to fone year prior to the CBT readiness assess- ‘ment (1 = 21) (determined by CIDI alcohol screen with DSM-IV-TR criteria for abuse and dependence; APA, 2000; World Health Organization, 1997), past diagnosis of alco- hol abuse or dependence did not emerge as a clinical barrier if they remained sober for six ‘months of longer (n= 10). Assessing CBT Barriers and Readiness Review of clinical notes revealed 59 (100%) of intervention patients received case management, were considered for and offered CBT if possible. Five of the ten pa- tients who did not have significant barriers and were offered CBT were able to sched- ule and subsequently attend the first session; these five patients completed a range of 5-12 sessions (Mean, 4.8). Barriers reemerged for the five patients who did not attend the first session. In comparison to CBT, 100% of pa- tients requiring treatment for substance use or risk behaviors received a motivational interviewing (Ml) intervention. Case notes revealed that flexible delivery outside of of- fice-based sessions (e.g., at bedside, over the phone, waiting in primary care clinics) and brevity of intervention (Range, 5-30 minutes) appeared to be responsible for the enhanced reach of ML Implementation of the Readiness Assessment in Second Stepped-Care PTSD Trial. The final CBT readiness assessment tool (Table 2) was implemented in a second stepped-care PTSD prevention trial (Study Il) with intervention patients (7 = 104) who were all encouraged to receive a CBT intervention. Over 95% (99/104) of patients had at least one factor impeding entry to CBT treatment (M, 2.26; SD, 1.24), and 73% (76/104) of patients had ‘more than one factor (Median, 2; Range, 2-6) (Table 1). Despite these multiple factors impeding entry, patients expressed high lev- els of CBT willingness (Mean, 7.8; SD, 2.6). Study Il interventionists. reported that the assessment demonstrated face va~ lidity and ease of usage. The tool was feasi- bly administered to all intervention patients at the baseline assessment. On average, the assessment required one minute and 36 sec- onds (SD, 7.9 seconds) to complete; this in- cluded time for the team to review and file the assessment in the appropriate electronic study chart. B.A. and M,S.W-level clinicians reported that the assessment fit with the stepped-care procedures in that it facilitated comprehensive documentation of factors im- peding CBT progression, and it aided under-213 (sei9e se wr % ‘one a (esi99 cy eo) zo0 ov gg 8b» on ESE usise ot ford (oot) vor loottes ee em ee a omep imag "Taye mosegiwanay —siomeg er, naps ‘eda aps 1s dane rung sey oupAeL Geiss Truse etal "HUD WORTDATIO| Uap er WONTON Suipedu Toney PUP STEAIOG THUY SUPE LGD 1 TTAVLAssessing CBT Barriers and Readiness 24 pas: no 489 30 po sno Hon oud serosa | 1 Pa BOE HM Hf TE HZ) 1 owe 0 save imo imo we ot wae uo tea yo se, np 54 9 jsesaesn] oneness you oop poe 3ey, sons 20 anetpalamareaegn une fo 952 aun fossioneas ssyo sods ageuxpylesssouBepBaage Bupa vussu0s olde Ne ins stun nase 9p 9 84 Sou a0 sovdop pur as yo usu cs ows 28 yucca ou us emonutand ed usa Hy ro oan ym ig a, vom ro 0 0 Uo # dey pon pus ood eng. sare ‘og Buty gy oom es BaeGeiss Truse etal 2s 2514 External population for sampling 1177 Target population for PTSD prevention a ‘589 (100%) Randomized to intervention Send, [> Beene 10168 (1775) CBT ely {5169 (8.5%) CBT completion etl 20%; feelin Pai 208 Hi standing of treatment planning especially for patients facing multiple barriers to care. The interrater reliability was excellent (Intraclass correlation range, .89-.96}, indicating near perfect agreement between raters Analyses of convergent and discrimi- nant properties of the tool revealed no sig- nificant associations between any domain (ie., barriers, engagement) and demograph- s, including gender, age, race, and injury severity. Exploratory quantitative analyses of characteristics associated with decreased likelihood to complete CBT revealed greater prior trauma was significantly associated with decreased engagement (as measured from not engaged, 0, to extremely engaged, 3) (F (3, 100) = 2.98; p <.04). Similarly, we observed a trend such that symptoms consis- tent with a diagnosis of PTSD were associ- ated with lower treatment engagement (723) = 6.55 p< 0.09), No significant association was observed between greater prior trauma and increased CBT barriers (F (6, 97) = 1.29; p< .29), oF between PTSD diagnosis and in- URE 1. Patient Flow in a Stepped Collaborative Care Intervention (Study 1° creased barriers ((6) = 7.41; p < 0.28) at baseline. DISCUSSION ‘This investigation identified primary factors impeding progression to CBT entry for the acute care patient population in two stepped collaborative care, early PTSD pre- vention studies. Across the trials examined, lack of engagement between the provider and the patient was most frequently respon- sible for impeding patient progression to CBT entry, followed by clinical and logisti- cal barriers. Within one month post-trauma, over 95% of patients demonstrated one oF more CBT barriers, with an average of two to three barriers that needed to be resolved before they could attend multiple sessions of office-based CBT treatment. It was only for the small proportion of patients (ap- proximately one-fifth) who advanced to theAssessing CBT Barriers and Readiness 216 “199 ub pessrppe svos09 yun uen20 ogojdus209 uonojdusayso2a44 aia aR we -=woll 1929051607 (pobs6uy Aouras7 £ elem epee rediaes RET BRP RONTSTA oR RATT TOA STRATGeiss Truse etal stage of CBT entry that patient preferences, stigma, and symptom remission emerged as key factors influencing CBT progression Unfortunately, the patients who were inter- ested and willing to enter CBT treatment but demonstrated high rates of past traumatiza- tion or diagnosis of PTSD were also the least likely to engage in any PTSD treatment one month post-discharge and could not enter trauma-focused CBT. Of these patients, all whom were abusing substances received mo- tivational interviewing (MI) treatment, per- hhaps because it required less readiness and ‘could be more flexibly delivered. To assist providers in the assessment of factors influencing CBT entry, we devel- oped a CBT readiness assessment tool. The tool demonstrated adequate face validity, convergent and discriminant properties, and interrater reliability. We found that it could be feasibly and productively implemented as part of a stepped PTSD early intervention in the acute care medical setting. The CBT readiness assessment allowed interyention- ists t0 comprehensively document domains that impeded progression to trauma-focused CBT, and it assisted in treatment planning to address barriers. For instance, if a patient demonstrated ambivalence around CBT en- try and had inconsistent access to transport, providers used MI to target entry ambiva- lence and also offered care management (e.g., bus passes) to ensure that the patient could attend sessions. Acute care providers, operat- ing under multiple competing demands, were able to assess trauma survivors on average in less than two minutes. ‘The investigation has a number of limitations. We could not test the predictive validity of the readiness assessment for CBT entry and retention because the outcomes of the implementation trial are not complete Based on the quantitative associations and content analysis, itis likely that patients who are not engaged (0-1), have unresolved crisis and clinical barriers, and/or are in pre-con- templation, will indeed be unable to enter or 217 complete CBT. Predictive validity is an area for future psychometric development, as is the assessment of the tool’s test-retest reliabil- ity. Another imitation of the study is that we hhad no independent measures to determine whether the tool increased recruitment into the intervention and completion of CBT oth- er than reports from the clinical team in the implementation trial. Future studies could focus on whether the assessment increases reach of the CBT intervention. Finally, the patient perspectives on CBT barriers were not comprehensively assessed and could be the focus of future investigations. ‘As reflected in patient progression and flow to the CBT intervention, patients in the first effectiveness trial reveived targeted MI and were offered CBT, however only 8.4% were able to attend theie frst CBT session. In contrast, 100% of patients received MI. Pa- tients are not receiving maltisession CBT pri- marily because it requires that both the pro- vider and patient have the time and stability as well as the mental and finaneial resources; even with these elements, the patient must be ready to commit to and attend multi-session trauma-focused treatment. The literature re- view also revealed specific clinical exclusions in CBT efficacy trials, such as lack of distress tolerance skills and anxiety sensitivity, which ndicate that the patients must have a base of psychological support and skills in order to begin treatment (Cloitre, Koenen, Cohen, &¢ Han, 2002; Jaycox & Foa, 1996). The cur- rent investigation suggests that patients who may have the greatest need and preference for CBT are the least likely to become en- ‘gaged in treatment and complete CBT. It is unclear from the present inves- tigation what factors accounted for lack of engagement in treatment. In both trials, at- tempts were made to increase engagement (e.g, case management, community visits, telehealth, and weekend/evening visits), but this still emerged as the primary factor in preventing CBT delivery. We found there was no racial, gendered, or age variable that21s accounted for trends in lack of engagement. ‘We found that symptom remission (a clinical barrier) did not account for low engagement, as was suggested by previous trials (Monson et al., 2006). Instead, we found that lower engagement was associated with high prior traumas and PTSD diagnosis. One hypoth- esis could be that lower engagement is ac- tually an expression of avoidance symptoms around discussing the trauma. Alternatively, high prior traumas could result in such sig- nificant life chaos that providers were not able to contact the patient after initial admit and thus were unable to assess the existence Of possible barriers. Exploring therapist and patient factors that lead to both increased and decreased engagement in the relation- ship should be a subject of future inquiry. ‘The investigative findings relating to the limited number of patients who are able to receive CBT have important implications for policy recommendations guiding the de- sign and implementation of PTSD prevention trials. A review of recent published accounts of CBT trials targeting PTSD in veterans re- veals high rates of lifetime substance abuse and dependence but extremely low rates of active substance abuse among patients re- eruited into the randomized control trials (Hoge et al., 2004; Monson et al., 2006; Schnure et al., 2007). Our investigation also revealed high levels of alcohol abuse/depen- dence in the acute care population, and that patients who were able to remain sober for six months after recruitment into the trial were able to enter CBT. Reflecting on the difference between the effectiveness and ef- ficacy tials, volunteer sampling procedures may actually serve as stepped-care substi- tutes whereby patients who have previously been stabilized in substance abuse treatment, ‘with medications and/or case management, are recruited into the trials. Future clinical trials that define target populations for PTSD Assessing CBT Barriers and Readiness prevention and meticulously track flow into CBT treatment may be warranted. A key criterion for the progression of knowledge with regard to PTSD prevention is consistency of observations across exposed populations (Rothman & Greenland, 1998; Zatzick et al., 2010). Though the CBT readi- ness assessment tool was designed for use in acute care settings, the assessment frame- ‘work could be applied in resource-limited or disaster settings to assist in common early intervention triage scenarios where patient populations have multiple barriers to access- ing treatment, have multiple comorbidities, andlor where there are few providers trained to deliver CBT. The tool may be especially useful when applied in conjunction with a stepped-care intervention, such that repeated assessment informs decisions to step up care to more intensive therapy or targeted inter- ventions (e.g., use MI to target alcohol abuse before beginning trauma-focused CBT). The assessment may also. prevent potentially harmful consequences of unsuccessful treat- ‘ment delivery, such as an increase in symp- toms or distress that might occur after pre- ‘mature attrition from trauma-focused CBT treatment after one or two sessions (Bisson, Jenkins, Alexander, & Bannister, 1997; May- ‘ou, Ehlers, & Hobbs, 2000; Van Emmerik, Kamphuis, Hulsbosch, 8 Emmelkamp, 2002). Offering CBT in the context of re- peated readiness assessments may allow for appropriate treatment planning and realis- tic allocation of limited early posttraumatic treatment resources. Alternative delivery strategies that dismantle traditional office- based multi-session CBT into stepped, deliv- erable components may also be necessary to enhance the reach and population impact of early trauma-focused CBT in acute care set- tings, and other non-specialty settings such as combat and post-disaster contexts.Geiss Truse etal 219 REFERENCES Aday, L. A., & Andersen, R. (1974). A frame: work for the study of access to medical care, Health Services Research, 9(3), 208-220, American Psychiatrie Association. (2000). Di- agnostic and statistical manual of mental dis- orders (4 ed., text revision). Washington DC Author, Bisson J., & Andrew M. (2007). Psychologi ‘eal treatment of post-traumatic stress di der (PTSD). Cochrane Database of System- atic Reviews, 1(3). dois 10.1002/14651858. (CD003388.pub3, Bisson, J. L; Jenkins, P. L., Alexander, J., 8 Bannister, C. (1997). Randomised controlled tial of paychological debriefing for vietims of acute burn trauma. British Journal of Psychia- try, 171(1), 78-81. dois10.1192/bjp. 1711.78 Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta analysis of psychotherapy for PTSD. Ameri can Journal of Psychiatry, 162(2), 214-227. dois10.1176lappiajp.162.2.214 Brewin, C., Andrews, B, & Valentine, J. (2000), Meta-analysis of risk factors for posttraumatic stress disorder in trauma-esposed adults. Jour- nalof Consultingand Clinical Psychology, 68(5), 748-766. doi: 10.1037/0022-006X.68.5.748 Brogan, M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and con’ tinuation status in psychotherapy using the transtheoretical model. Psychotherapy, 36(2), 105-113. doi:10.1037/h0087773 Bryant, R., Creamer, M., O’Donnell, M., Si love, D., & MeFarlane, A. (2009). A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder. Biological Psychiatry, 65(5), 438-440. doi:10.1016)-biopsych.2008.10.032 Bryant, R.A, & Harvey, A. G. (1998). Re. lationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Peyebiatry, 155(5}, 625-629. Beymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J, & Steinberg, A. (2006). Psychologi- cal first aid: Field operations guide (2nd ed.) Washington DC: National Center for Child Traumatic Stress and National Center for PISD. Cloitre, M., Koenen, K., Cohen, L., & Han, Hi. (2002). Skills training in affective and in terpersonal regulation followed by exposured: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067-1074. ddois10.1037/0022-006X.70.5.1067 Creswell, J. (1998). Qualitative inquiry and re- search design: Choosing among five traditions. Thousand Oaks, CA: Sage. Department of Veterans Affairs. (2003). Man agement of post-traumatic stress. Retrieved April 17, 2005, from hetp/iwww.ogp.med, va.govlepg/PTSDIPTSD_Base htm, Dwight-Johnson, M., Sherbourne, C. D., Liao, D., 8 Wells, K.B. (2000). Treatment preferences among depressed primary care patients. Journal of General Internal Medicine, 15|8), 527-534. dois10.1046/).1525-1497.2000,08035.x Ehai, J., North, T., & Frueh, B. (2005). Health service use predictors among trauma survivors A critical review. Psychological Services, 2(1), 3-19, dois10.1037/1541-1559.2.1.3 Foa, E., Keane, TT, Friedman, M., & Cohen, J. (2009). Effective treatments for PTSD: Prac- tice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford. Ghesquiere, A., Wagner, A., Russo, J., & Za wick, D. (2004). Predicting injured’ trauma survivors’ engagement in case management Paper presented at the 20th annual meeting of the International Society for Traumatic Stress Studies, New Orleans, LA. Glasgow, R. E., Lichtenstein, E., & Marcus, A.C. (2003). Why don’t we see more transla tion of health promotion research to practice? Rethinking the efficacy to effectiveness transi20 tion, American Journal of Public Health, 93(8), 1261-1267. doi:10.2105/AJPH.93.8.1261 Gray, M. J., & Acierno, R. (2003). Reviewing the literature and evaluating existing data. In J C. Thomas & M. Hersen (Eds.), Understand ing research in clinical and counseling psychol- ogy (pp. 295-318). Mahwah, NJ: Erlbaum. Greenhalgh, , Robert, G.., Macfarlane, B, Bate, P., & Kyriakidou, O. (2004). Diffusion (of innovations in service organizations: tematic review and recommendations. Milbank Quarterly, $2(4), $81-629.doi:10.1111/.0887- 378X.2004.00325.x Grote, N. K., Zuckoff, A., Swartz, H., Bledsoe, S.E,, & Geibel, S. (2007). Engaging women ‘who are depressed and economically disadvai taged in mental health treatment. Social Work, 52(4), 295-308. Hobjoll, S. E., Watson, P, Bell, C. C., Bryant, R.A., Beymer, M. J., Friedman, M. J. (2007). Five essential elements of immediate and mid- term mass trauma intervention: Empirical e dence. Psychiatry, 70(4), 283-369. dois10.1521/ psye.2007.70.4.283 Hoge, C. W., Castro, C. A., Messer, S.C, McGurk, D., Cotting, D-L, & Koffman, R. L (2004). Combat duty in Iraq and Afghanistan, ‘mental health problems, and barriers to care New England Journal ‘of Medicine, 351(1), 13-22, dois10.1056/NEJMoa040603 Institute of Medicine (JOM). (2007). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: National ‘Academies Press. Jaycox, L. H., Cohen, J. A., Mannarino, A. P, Walker, D. W., Langley, A. K., & Gege hheimer, K. L. (2010). Children’s mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Trauma Stress, 23(2), 223-231. dois10.1002/ jts.20518 Jaycox, L. H., & Foa, E. B. (1996). Obstacles in implementing exposure therapy for PTSD: Case discussions and practical solutions. Clinical Psychology and Psychotherapy, 3(3), 176-184, Assessing CBT Barriers and Readiness Kerner, J., Rimer, B., & Emmons, K. (2005) Dissemination research and research dissemi nation: How can we close the gap? [Introduc- tion to the special section on dissemination Health Psychology, 2415), 443-446, Knight, K. M., MeGowan, L., Dickens, C,, & Bundy, C. (2006). A’ systematic re view of motivational interviewing in phy cal health care settings. British Journal of Health Psychology, 11(2}, 319-332. doi: 10,1348/135910705X52516 Koepsell, T, Zatzick, D., & Rivara, F (xxx) Using evidence from randomized trials of pre- ventive interventions to estimate potential pop- ulation impact. American Journal of Preventive ‘Medicine, 40(2), 191-198. doi:10.1016/y.ame~ ppre.2010.10.022 Liang, B., Goodman, L., Tummala-Narra, P, & Weintraub, S."(2005). A. theoretical framework for understanding help-seeking processes among survivors of intimate part ner violence. American Journal of Commu nity Psychology, 36(1-2), 71-84. dois10.1007/ s10464.005-6233-6 Lovell, K., & Richards, D. (2000). Multiple cess points and levels of entry (MAPLE): En- suring choice, accessibility and equity for CBT serviees. Behavioural and Cognitive Psycho- therapy 28(4), 379-391. ‘Mancebo, M. C., Pinto, A., Rasmussen, 5. A. & Eisen, J-L. (2008). Development ofthe Treat- ‘ment Adherence Survey-Patient version (TAS-P) for OCD. Journal of Anxiety Disorders, 22(1), 32-43. doi:10.1016),janxdis.2007.01.009 Mayou, R.A. Ehlers, A., & Hobbs, M. {2000}. Psychological debriefing for road traf- fic accident victims: Three-year follow-up of a randomised controlled trial. British Journal of Psychiatry, 176(6), 589-593. dois10.1192/ jp.176.6.589 MeKay, M., Nudelman, R., & MeCadam, K. (1996). Involving inner-city families in-m tal healeh services: First interview engagement skills. Research on Social Work Practice, 6, 462-472,Geiss Truse etal MeKay, M. M., & Bannon, W. M., Jr (2004), Engaging families in child mental health servic. cs. Child and Adolescent Psychiatrie Clinics of North America, 13(4), 905-921. doi:10.1016), ‘che.2004.04.001 Medley, A. R., & Powell, T. (2010). Motiva tional interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review. Neuropsychology Rehabilitation, 20(4), 1-28. doi:10.1080/09602010903529610 Miles, M. B., 8& Huberman, M. (1994). Quali- tative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage. Monson, C. M., Schnurr, P. P, Resick, PL A., Friedman, M. J., Young-Xu, Y., & Stephens, 5 P. (2006). Cognitive processing therapy for vet ‘erans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psycbology, 74(5), 898-907. doi:10.1037/0022. (006X.74.5.898 National Collaborating Centre for Mental Health. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. London: National Institute for Clinical Excel lence National Institute of Mental Health. (2002), Mental health and mass violence: Evidence based early psychological intervention for vic- tims/survivors of mass violence. A workshop to reach consensus on best practices. Washington, DC: Author Prochaska, J. O., & DiClemente, C. C. (1986), Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive bebaviors: Processes of change (pp. 3.27). New York: Plenum, Prochaska, J. O., Velicer, W-F, Fava, J.L., Ros: si,J.S., & Tsob, J. ¥. (2001). Evaluating a popu lation: based recruitment approach and a stage: based expert system intervention for smoking cessation. Addictive Behaviors, 26(4), 583-602. doi: 10.1016/80306-4603(00)00151-9 Raphael, B. (2007). The human touch and mass catastrophe. Psychiatry, 70(4), 329-336, 221 Roberts N. P, Kitchiner N. J., Kenardy J., & Bisson J. 1. (20092). Multiple session early chological interventions for the preven: tion of posttraumatic stress disorder, Co- chrane Database of Systematic Reviews 13) doiz10.1002/14651858.CD006869.pub2 Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. . (2009b). Systematic review and meta-analysis of multiplesession early inter: ventions following traumatic events. Ameri- can Journal of Psychiatry, 166(3), 293-301 dois10.1176lappi.ajp.2008.08040590 Rose, G.. (1992). The strategy of preventive medicine. London: Oxford University Press Rothman, K. J., & Greenland, S. (1998). Mod- ern epidemiology (2nd ed,). Philadelphia: Lip pincort, Williams & Wilkins. Ruggiero, K. J, Del Ben, K., Scott, J. R, & Rabalais, A. E. (2003). Psychometric proper ties of the PTSD checklis-civilian version Journal of Traumatic Stress, 16(5), 495-502. loi: 10.102:/8:1025714729117 Schnurr, P. P, Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M.'T., 8 Chow, B. K. (2007) Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized con trolled trial. Journal of the American Medical Association, 297(8), 820-830. dois10.1001 jama,297.8.820 Simon, G. ., Ludman, E. J, Tatty, 8., Oper skalski,B., & Von Korff, M. (2004). Telephone psychotherapy and telephone care management for primary care patients starting antidepres sant treatment: A randomized controlled trial Journal of the American Medical Association, 202(8), 935-942. Street, L. L., Niederehe, G., & Lebowitz, B. D. (2000). Toward greater public health relevance for psychotherapeutic intervention research: An NIMH workshop report. Clinical Psy chology: Science and Practice, 7(2), 127-137. dois10.1093/elipsy/7.2.127 Tuma, (2007). Mass trauma intervention: A case for integrating principles of behavioral health with intervention to restore physical2 order, and infrastructure. Psychiatry, 7014), 356-360, Ussano, R. Jy Bell, C. Eth, S. Friedman, ML, Norwood, A. 8 Plfferbaum, B. et al. (2004) Practice guidline forthe treatment of patients with acute stress disorder and posttraumatic steess disorder American Journal of Psychiatr, 161(Sappl.2), 331. Van Emmerik, A, Kamphuis, JH. Hulsbo ALM,, 8 Emmeliamp, P2002). Single session debriefing after paychotogical trauma A meta- analysis, Lancet, 36019335), 766-771 van Ommeren, M., Saxena, S., & Saraceno, B. (2005). Mental and social health during and after acute emergencies: Emerging consensus? Bulletin of the World Health Organization, $3(1), 71-76. Wagner, A. W. (2003). Cognitive-behavioral therapy for PTSD: Applications to injured trau- ima survivors. Seminars in Clinical Neuropsy- chiatry, 8(3), 175-187. ‘Wagner, A. W., Zatzick, D., Ghesquiere, A., & Jurkovieh, G. J. (2007). Behavioral activation ‘as an early intervention for posttraumatic stress disorder and depression among physically i jured trauma survivors. Cognitive and Behav ioral Practice, 14(4), 341-349. doi:10.1016). cebpea.2006.05.002 Walker, D. D., Roffman, R. A., Picciano, J. B, & Stephens, RS. (2007). The check-up: hi person, computerized, and telephone adapta tions of motivational enhancement treatment to elicit voluntary participation by the conter plator. Substance Abuse Treatment, Prevention, and Policy, 2(2). dois 10.1186/1747-597X-2-2 Walles,R., & Gilbody, S. (2009), Barriers to the uptake of computerized cognitive behavioural therapy: A systematic review of the quantitative and qualitative evidence. Psychological Medi- cine, 39(5), 705-712. doi: $0033291708004224 {pi) 10.1017/S0033291708004224 ‘Weathers, FW., Huska, J. A., & Keane, T. M. (1991). The PTSD checklist-civilian version. Boston: National Center for PTSD, Boston VA Medical Center. Assessing CBT Barriers and Readiness ‘Weisaeth, L., Dyb, G., & Heir, T. (2007). Di- saster medicine and mental health: Who, how, when for international and national disasters Psychiatry, 70(4), 337-344. Wierzbicki, M., & Bekarik, G. (1993). A meta~ analysis of psychotherapy drop out. Profes- sional Psychology, 24(2), 190-195, ‘Wong, E. C., & Marshall, G.. N. (2010). Bar- tiers to the collaborative care of patients with ‘orofacial injury. Oral & Maxillofacial Surgery Clinics of North America, 22(2), 247-250. dois10.1016/.coms.2010.01.001 Wong, E.C., Schell, TL, Marshall, G.N.,Jay- cox, [. HL, Hambarsoomians, K., & Belzberg, H. (2009). Mental health service utilization af ter physical trauma: The importance of physi- cian referral. Medical Care, 47(10), 1077-1083. doi: $1042-3699(10)00002-6 [pil] 10.10165 coms.2010.01.001 World Health Organization, (1997). Compos- ite International Diagnostic Interview (CIDI) (Version 2.1). Geneva, Switzerland: Author. Zatzick, D. (2003). Posttraumatic stress, func tional impairment, and service utilization after injury: A public health approach. Seminars in Clinical Neuropsychiatry, 8(3), 149-157. ddoiz10.1016/S1084-3612(03)00017-0 Zatzick, D., & Galea, 8. (2007). An epidemio- logic approach to the development of early trauma-focused intervention. Journal of Traw- matic Stress, 20(4), 401-412. dois10.1002/ jts.20256 Zatzick, D., Kang, $. M., Hinton, W. L., Kelly, RH, Hilly, D.M., & Franz, C. E. (2001) Posttraumatic concerns: A patient-centered ap- proach to outcome assessment after traumatic physical injury: Medical Care, 39(4), 327-339. Zawick, D., Koepsell, T., & Rivara, FP. (2003). Using target population specification, effect size, and reach to estimate and compare the population impact of two PTSD preventive interventions. Psychiatry: Interpersonal & Bio- logical Processes, 72(4), 346-359. dois10.1521/ psye.2009.72.4.346 Zatick, D., Rivara, F, Jurkovich, G., Hoge, C., Wang, J, Fan, M., Russo, J, Geiss Trusz,S.,Geiss Truse etal Nathens, A., & Mackenzie, E. (2010). A multi site investigation of traumatic brain injuries, posttraumatic stress disorder, and self-reported health and cognitive impairments. Archives of General Psychiatry, 67(12), 1291-1300. Zatzick, D., Rivara, F, Jurkovich, G., Russo, Js Geiss Teusz, S., Wang, |., Wagner, A., Ste phens, K., Dunn, C., Uehara, E., Engle, C. Davydow, D., & Katon, W. (2011). Enhane ing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related co- morbidities after acute trauma. General Hos. pital Psychiatry, 33(2), 123-134. doi: 10.1016/ igenhosppsych.2011.01 Zatzick, D., Roy-Byrne, P,, Russo, J. Rivara, Ey Droesch, R-, & Wagner, A. (2004). A random ized effectiveness trial of stepped collaborative ‘care for acutely injured trauma survivors. Ar- chives of General Psychiatry, 61(5), 498-506. doi:10.100 Varchpsye.61.5.498 23 Zatzick, D., Roy-Byrne, P., Russo, J., Rivara, EP, Koike, A, & Jurkovich, G. J. (2001), Collaborative or physically injured trauma survivors: A pilot random ized effectiveness trial. General Hospital Psycbiatry, 23(3), 114-123. dois10.1016/ $0163-8343(01)00140-2 Zayfert, C., & Black Becker, C. (2000). Imple- mentation of empirically supported treatment for PTSD: Obstacles and innovations. Behavior Therapist, 23(8), 161-168. Zoellner, L.A, Feeny, N. C., & Bittinger, JN. (2009). What you believe is what you Want: Modeling PTSD-related treatment pref erences for sertraline or prolonged exposure. Journal of Bebavior Therapy and Experimen- tal Psychiatry, 40(3), 455-467. doi:10.1016), ibtep.2009.06.001