Background

Many children and adults are exposed to potentially traumatic events during their lifetime. Some of these are at risk of developing post-traumatic stress disorder (PTSD). According to international guidelines, there are several evidence-based treatment methods for PTSD. For children, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is the most recommended. For adults, Eye Movement Desensitization & Reprocessing (EMDR) and Cognitive Therapy for PTSD (CT-PTSD) are recommended.

The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) are commissioned by the Ministry of Health to implement evidence-based treatment for PTSD in the specialist health services. Since 2012, the TF-CBT project at NKVTS has implemented TF-CBT in the child and adolescent psychiatric centers (BUP) nationwide, while the ITV project (implementation of trauma treatment for adults) has implemented EMDR and CT-PTSD in the district psychiatric centers (DPS) since 2018. Implementation of evidence based treatment methods in the health services has proved to be quite demanding. Many obstacles make it difficult for the services to arrange for the treatment methods to be used and maintained over time. Among several things, surveys show that employees in mental health services lack knowledge about the type of treatment that has an effect, and that they do not have enough time to update themselves professionally. Leaders lack training in leadership, and do not ensure that the services are working systematically to improve quality. The use of evidence-based treatment methods is also not specifically mentioned in the Specialist Health Services Act, and the lack of such can consequently contribute to making their implementation more demanding.

In the period 2018–2020, the ITV and TF-CBT projects joined forces to use and test an implementation strategy to meet the obstacles. The Leadership and Organizational Change for Implementation (LOCI) strategy was chosen. LOCI seeks to promote first-line leaders’ general and implementation leadership, as well as to strengthen other employees in their work to develop a good organizational climate for the implementation of evidence-based treatment methods. The implementation project was shaped so that it was possible to investigate the effect of LOCI on the implementation at the participating clinics. The main objective of the study was to investigate whether LOCI contribute to employees in BUP and DPS experiences of better facilitation and support from the leaders to provide evidence-based practice for PTSD.

Method

A cluster randomized cohort design was used. This means that the therapists from all the clinics received training in screening for trauma and PTSD and the evidence-based treatment methods at the same time point. The clinics were then randomly divided into three cohorts that participated in the LOCI strategy at three different time points. Through LOCI, clinic leaders were followed up for 12 months with regular meetings, telephone guidance and 360° feedback.

Twenty-one DPS and 22 BUP from all over the country were invited to participate. A total of 790 therapists, 24 executive leaders and 47 first-level leaders (so called «LOCI leaders») from DPS and BUP responded to the questionnaire every 4th month, a total of six times. In the reporting of the employee results, the total figures for DPS and BUP are stated. Clinic affiliation is controlled for in the analyses and reported where there are significant differences. The employees were asked about background, workload, first-level leaders’ general and implementation leadership and implementation climate. In addition, they were asked whether the screening tools and treatment methods were perceived as acceptable, appropriate and feasible. Fidelity to the treatment methods and replacement of therapists in the clinics were also registered. A selection of therapists and leaders also participated in qualitative interviews after completing the LOCI.

A total of 452 patients responded to the surveys in connection with the treatment sessions. Patients were asked, among other things, about their trauma experiences and symptoms of PTSD, alliance with their therapist, their satisfaction with the treatment and some background information.

Results

The majority of patients that received treatment in the project were girls (64.8%) and women (68.9%). The child and the adult patients who received the trauma treatment had experienced an average of four and five different types of trauma events, respectively. The most common forms of experiences among children were serious accidents, illness and sexual abuse, while among adults there was psychological violence in close relationships and sexual abuse. Both children and adults reported high levels of symptoms of PTSD. The children scored an average of 30.7 (SD = 10.1) on the PTSD screening, where it is recommended to offer trauma treatment with a score around 15. The adults scored an average of 52.4 (SD = 10.1), where it is recommended to offer trauma treatment with a score around 33. Most children (g = 1.59, CI 1.25–1.93) and adults (g = 1.52, CI 1.2–1.85) who completed the treatment experienced a significant decrease in symptoms of post-traumatic stress.

Most children and adults reported having a good relationship with their therapist. The patients themselves or the children’s parents were quite satisfied with the help they received in the service.

There was a large turnover of therapists in the participating clinics. During the two years of implementation, approximately 40% of the therapists left or went on leave. Most therapists and leaders reported that they experienced high job demands. At the same time, the therapists reported that they felt in control of their work and that they experienced mastery. The therapists felt that they only occasionally received feedback from the leaders on the quality of work with the patients, but still reported that they could occasionally or fairly often decide whether they had done good or bad work.

The results showed that LOCI had a positive impact on implementation leadership, transformational leadership and implementation climate. This means that when the leaders started up in LOCI, the therapists scored their leaders significantly higher on implementation leadership and transformational leadership, and implementation climate. This remained stable throughout the implementation period. Findings also indicated that implementation leadership had an impact on therapists’ assessment of the screening tools’ and treatment methods’ acceptability, appropriateness and feasibility in the clinics. Implementation leadership, transformational leadership and implementation climate were positively related to the therapists’ experiences of the screening tools and treatment methods as acceptable, appropriate and feasible. It might be that implementation climate is a possible mechanism through which implementation leadership works, and this should be tested in future research.

Summary and further recommendations

The findings presented in this report shows that the evidence-based treatment methods for PTSD could be implemented in Norwegian DPS and BUP. However, some challenges emerged. Among other things, there were many patients who did not complete the last questionnaire at the end of treatment, and who we can therefore not say with certainty whether dropped out or completed the treatment. More research should be done on patients who do not complete treatment, what kind of other treatment they might receive, and how they are doing over time.

Systematic screening and collection of treatment data is a prerequisite for increasing quality improvement in health services. It is therefore a paradox that most of the therapists in the sample reported that they only occasionally received information about the quality of the work they performed. Services are recommended to put in place systems that can register data on the use of treatment methods (fidelity), patient outcomes and patient satisfaction.

When evidence-based treatment methods are to be implemented in the services, active efforts must be made to reduce obstacles at various levels, such as political, bureaucratic, health trust, service and employee levels. Among other things, a pronounced lack of resources is a current obstacle at the clinic level. This was expressed in the project in that therapists reported high job demands and high turnover rates. This indicates that obstacles to implementation of evidence-based treatment methods at the political or bureaucratic level can have consequences for the patient treatment provided in the individual clinic.

Achieving successful implementation is not just about reducing obstacles, but also about using effective implementation strategies. LOCI seem to be a promising strategy for implementing evidence-based treatment methods for PTSD in Norwegian health services. However, there is a lack of research showing that LOCI have a direct effect on the use of treatment; the lack of data on use of the treatment methods and patient outcomes in the clinics makes it difficult to evaluate whether the implementation strategies such as LOCI are related to successful implementation (actual use). There is a need for research on mechanisms and whether LOCI can increase reach and patient outcomes.

Key points

• Evidence-based treatment methods for PTSD can be implemented in Norwegian specialist health services.

• Most patients who received treatment in the project experienced significant symptom improvements.

• The patients reported a positive relationship with their therapist, and they were very pleased with the help they received in the services.

• The services that participated experienced challenges that could have a negative effect on implementation over time, including high job demands and high turnover rates.

• LOCI seem to be a promising strategy for implementing evidence-based treatment methods for PTSD in Norwegian health services. However, more research is needed to understand the mechanisms of the strategy, that is, what in the strategy has an impact on successful implementation