Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation

Briana S Last; Christina Johnson; Natalie Dallard; Sara Fernandez-Marcote; Arturo Zinny; Kamilah Jackson; Lauren Cliggitt; Brittany N Rudd; Chynna Mills; Rinad S Beidas

doi:10.1177/26334895231199467

Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation

Implement Res Pract. 2023 Sep 11:4:26334895231199467. doi: 10.1177/26334895231199467. eCollection 2023 Jan-Dec.

Authors

Briana S Last^{1

2}, Christina Johnson^{3

4}, Natalie Dallard⁵, Sara Fernandez-Marcote⁵, Arturo Zinny^{5

6}, Kamilah Jackson^{5

7}, Lauren Cliggitt⁸, Brittany N Rudd⁹, Chynna Mills^{3

4}, Rinad S Beidas^{3

4}

Affiliations

¹ Department of Psychology, Stony Brook University, Stony Brook, NY, USA.
² Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA.
³ Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁴ Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
⁵ Community Behavioral Health, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA.
⁶ Center for Nonviolence and Social Justice, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA.
⁷ Talawa International Consultants, Philadelphia, PA, USA.
⁸ Hall-Mercer Community Mental Health Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁹ Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA.

Abstract

Background: In 2012, Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) developed an initiative to implement an evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health system. This report evaluates the initiative's 10-year implementation and effectiveness outcomes. Method: The Exploration, Preparation, Implementation, and Sustainment framework guided our implementation evaluation. The implementation outcomes include adoption, reach, and sustainment; these were obtained during regular evaluation data collection from publicly funded behavioral health agencies participating in the TF-CBT initiative. We analyze effectiveness outcomes (i.e., changes in PTSD symptoms) from a subset of patients receiving TF-CBT, which were collected in 6-month intervals by our research team between 2013 and 2021. Results: From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for potentially traumatic events and PTSD symptoms, and 7,550 youths received TF-CBT. Through the TF-CBT initiative, the city expanded the network of TF-CBT providers from 3 to 20 agencies. DBHIDS sustained this network by maintaining the participation of 16 behavioral health agencies over the course of a decade. The subset of 202 youths who were evaluated to assess TF-CBT effectiveness was drawn from 94 therapists and 20 agencies across Philadelphia. All participating youths completed a baseline assessment, and 151 (75%) completed at least one follow-up assessment. Linear mixed-effects models accounting for observations nested within participants and nested within clinicians found that treatment significantly reduced PTSD symptoms. Conclusion: Between 2012 and 2021, DBHIDS successfully implemented and sustained TF-CBT across the city's behavioral health system. Adoption, reach, and sustainment of TF-CBT were high. Despite the considerable adverse experiences faced by youths seeking treatment in Philadelphia's behavioral health system, TF-CBT was effective. Future directions to improve TF-CBT implementation in the next iteration of the initiative are described.

Keywords: Trauma-focused cognitive behavioral therapy; community partnerships; implementation research; practice-based evidence.

Plain language summary

This practical implementation report describes a 10-year effort by the city of Philadelphia to develop a trauma-informed behavioral health system, making this report one of the longest evaluations of an implementation initiative in a large metropolitan area in the United States. In particular, the report describes the implementation and effectiveness outcomes of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS)'s implementation of the evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health agencies. From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for posttraumatic stress symptoms, and 7,550 youths received TF-CBT. A subset of 202 youths receiving TF-CBT from 94 therapists across 20 Philadelphia agencies were evaluated to assess the initiative's effectiveness. Linear mixed-effects models revealed that youths receiving TF-CBT from DBHIDS-trained clinicians saw their PTSD symptoms significantly reduce. The initiative's success in adoption, reach, sustainment, and effectiveness reveals the promise of sustained, multipronged, community-partnered implementation initiatives. In the future, researchers and policymakers must account for and address the structural and financial barriers that hinder these community-partnered implementation efforts from realizing their full potential in improving population health.