The overarching goal of our program of research is to determine how to facilitate the high quality delivery of evidence-based psychosocial interventions (EBPs) in public sector mental health settings. Areas of emphasis include training and consultation, treatment fidelity and adaptation, and the identification of strategies that promote sustained implementation of EBPs. Dr. Wiltsey Stirman's early work examined the degree to which the randomized controlled trial (RCT) literature included individuals with characteristics like those seen in routine care settings. This work highlighted some gaps in the literature, but largely demonstrated that the RCT literature may be more applicable to typical clients in routine care settings than previously assumed.

This early work also led Dr. Wiltsey-Stirman to become interested in developing and studying strategies to promote the implementation and sustained use of EBPs in public sector settings. Her systematic review of research on sustainability suggested that EBPs are often fully or partially discontinued a short time after they are introduced into routine care settings. Identification of factors associated with sustained implementation is therefore an important step in promoting the long-term success of implementation efforts. Dr. Wiltsey-Stirman's K99/R00 award used qualitative and quantitative methods to examine system, organizational, clinician, and patient-level influences on the long-term trajectory of clinicians’ use of cognitive therapy.

The degree of fidelity (adherence to the protocol and skill of delivery) with which EBPs are delivered, and adaptations to EBPs made in routine care, are key implementation outcomes. Without time- and cost-intensive direct observation, these outcomes are difficult to assess. An R21 funded the development of a strategy for assessing EBP fidelity that uses materials generated during routine sessions. Our lab is now following up this research with the imAPP study, which compares strategies to assess CBT fidelity. The overarching goal is to reduce the burden associated with fidelity assessment and support in both clinical trials and in implementation initiatives.

As a first step toward understanding the implications of different types of adaptations to EBPs, Dr. Wiltsey Stirman and colleagues and also developed a framework for identifying and classifying adaptations that are made to EBPs in routine care. This framework makes it possible to determine whether specific types of adaptations lead to different clinical or implementation outcomes. Using the framework, we have identified evidence that clinicians do make changes to EBPs in their own practice, and that certain clinician characteristics predict the use of adaptations that are inconsistent with the protocol.

While the work described above is based on observation of implementation efforts and has laid important groundwork for future research, our larger goal is to develop and test strategies to facilitate high-quality implementation of EBPs in routine care settings. Beyond the growing recognition that workshops, web-based trainings, and manuals alone are insufficient, little is known about strategies to train and prepare clinicians to deliver EBPs with fidelity in public sector mental health settings. We recently completed data collection for a fully-powered hybrid implementation/effectiveness RCT that compares consultation alone, consultation combined with observation, and a fidelity-monitoring alone strategy for training clinicians to deliver Cognitive Processing Therapy (CPT) for PTSD. The next step is to find ways to sustain the use of EBPs after initial training and implementation In one of the first studies of strategies to promote sustainment of EBPs, we are following up with a study that compares a fidelity-oriented learning collaborative strategy to a continuous quality improvement-oriented learning collaborative to support the ongoing use of an EBP in three large mental health systems.