Heidi La Bash | University of Nevada, Reno (original) (raw)

Papers by Heidi La Bash

Frontiers in Public Health

BackgroundThe US Department of Veterans Affairs (VA) has over 15 years of experience in delivery ... more BackgroundThe US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD).MethodsThis study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we cond...

Journal of Affective Disorders

Practical Implementation Science, 2022

The dominant theory of PTSD and, subsequently, current gold standard PTSD treatments are based on... more The dominant theory of PTSD and, subsequently, current gold standard PTSD treatments are based on a model of dysregulated fear. However, a growing body of research suggests that other emotional responses, like shame, are important contributors to PTSD symptom maintenance. The current study sought to forward the trauma literature by using an experimental paradigm to test if trauma survivors, especially those distressed by an interpersonal (vs. non-interpersonal) trauma, experience shame in response to day-today experiences of fear. This experimental study used a pre-post between group design in which participants (N = 178) were randomized to receive either a fear or neutral emotion prime with postmanipulation state shame serving as the outcome measure. As predicted, the fear emotion prime interacted with PTSD symptom level to significantly predict postmanipulation state shame. Among participants who reported an interpersonal index trauma and received the fear emotion prime, those with high PTSD symptom levels reported significantly more postmanipulation shame than those with low symptom levels. Interestingly, among participants who reported a non-interpersonal index and received the fear emotion prime, those with high PTSD symptom levels reported significantly less postmanipulation shame than those with low symptom levels. Exploratory analyses did not implicate emotion regulation skill deficits in this relationship. This study contributes to the literature by demonstrating the relationship of shame to daily experiences of fear in the maintenance of PTSD symptoms, but further exploration into the dynamics of fear, shame, and PTSD represents a priority for the field of traumatology. This is, in part, because shame may impede the treatment and emotional processing of traumas in current gold standard exposure-based treatments. ii Dedication I dedicate this project to the female and male veterans I have had the privilege to work with, particularly in the Women's Trauma and STARR Programs at the Albuquerque VA. They are the reason I transitioned into psychology and remain passionate as I stand at the crest of my journey into life as a psychologist. iii Acknowledgments and Gratitude Goodbye 30's, Hello PhD! If education were a sport, a PhD would be an ultramarathon. In my case, one that took the bulk of my 30's. Obtaining a PhD is a test of endurance and tenacity. The challenge is to keep moving forward when your body and brain ache and are screaming for rest, until you get the endorphin rush at the finish line. Like any successful überathlete (or über-nerd, in this case), I could not have reached the finish line without the help and support of many others along the way. First and foremost, my advisor Tony Papa was essential in challenging me and keeping me on course. Like many who complete a PhD, I am a different person now than when I began the program. I credit much of this to my experiences with Tony, and I am proud of the growth and change that has occurred under his guidance. He played a vital role in shaping me into a clinical scientist. Thank you, Tony! I also appreciate the mentorship and support of other faculty. In particular, I appreciate Bill Follette, who was consistent with his support and sound advice during some of the harder moments. Additionally, I appreciate that he was always available for a quick question, particularly when we night owls worked at MSS. I remember fondly the early grad school years when we shared a wall and had dueling stereos. I also appreciate fellow night owl Markus Kemmelmeier, who let me share my excitement and professional successes, ask stats questions, and just generally pick his brain. Victoria Follette also served as a mentor, particularly as I first began my journey in iv Reno. The mentorship and support of the following individuals was also important to me during my journey: Amy Street, Jillian Shipherd, Dan and Lynda King, and Dawne Vogt. Thank you to each of you! Fundamental to my professional growth was the clinical training I received not only from Tony, but also from Steven Hayes, as a member of the ACT treatment team, and Victoria Follette, as a member of the trauma treatment team. I also appreciate the clinical supervision I received from Cindy Marczynski at the UNR Counseling Center, Do Trauma Survivors Experience Shame after Fear? An Experimental Examination of a Basic Assumption in the Trauma Literature While the experience of overwhelming fear is linked to the maintenance of posttraumatic stress disorder (PTSD), recent research suggests that other emotions, particularly shame, may also play a role in the maintenance of PTSD (Hathaway, Boals, & Banks, 2009; Leskela, Dieperink, & Thuras, 2002). This research is consistent with a basic assumption in the trauma literature that trauma survivors can experience shame around a number of trauma-related factors, including feeling ashamed of their dysregulated fear responses, which perpetuates PTSD avoidance and hyperarousal symptoms (e.g., Frankl, 1962; Herman, 1992). The primary goal of the current study is to experimentally test the assumption that trauma survivors are ashamed of their dysregulated fear responses by assessing if trauma survivors with high levels of PTSD symptoms experience shame after experiencing experimentally induced fear. Emotional Responses to Trauma The dominant theory of PTSD hypothesizes that PTSD is a result of dysregulated fear responding in reaction to exposure to events involving death, the threat of death, or physical harm. In this theory, the experience of the trauma is hypothesized to cause hypersensitivity to trauma-related cues and hyperactivation of fear-related memories (Foa & Kozak, 1986; Keane, Fairbank, Caddell, Zimering, & Bender, 1985). Over time these responses generalize to other stimuli, leading to hypersensitivity to a broad range of threat cues, physiological hyperarousal, and avoidance of stimuli associated with the trauma, which negates the opportunity for new learning (Foa & Riggs, 1993). Thus, fear responding is hypothesized to both cause and maintain PTSD (Foa & Rothbaum, 1998). A growing body of research, however, suggests that other emotional responses to trauma exposure, like shame, are important contributors to PTSD symptom profiles (Friedman, Resick,

Psychological Services, 2021

Consultation is an important implementation strategy to improve treatment fidelity and clinical o... more Consultation is an important implementation strategy to improve treatment fidelity and clinical outcomes, yet research has not identified the aspects of consultation that differentially affects clinician skill development and client symptom change. Thus, the present study investigated the effect of the consultant, consultation activities, and consultants' (n = 6) perceptions of consultees (n = 60) on post-traumatic stress disorder (PTSD) treatment fidelity and client outcomes. In addition, we assessed the accuracy of consultants' evaluations of clinicians using the Perceived Enthusiasm, Skill, and Participation scale (P-ESP). Results indicated that there was a significant effect of consultant on adherence to, but not competence in, delivering Cognitive Processing Therapy (CPT). The effect of the consultant on PTSD symptom change was not significant. Consultants significantly differed in their discussion of CPT strategies and their application to individual cases, but did not differ on reviewing and providing feedback on fidelity. Consultant perceptions as assessed by the P-ESP were not associated with clinicians' current levels of adherence or competence, suggesting that consultants may not accurately assess clinician skill during consultation. Client PTSD symptom change neither predicted, nor was predicted by, consultants' perceptions of their consultees' skill. This article outlines potential reasons for consultant effects and possible biases at play that may reduce the accuracy of consultant perceptions and presents suggestions on alternative strategies to assess clinician skill during consultation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychological Trauma: Theory, Research, Practice, and Policy, 2020

OBJECTIVE Concern about symptom worsening with trauma-focused treatment may be one factor hinderi... more OBJECTIVE Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. METHOD We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. RESULTS Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. CONCLUSIONS The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Current Treatment Options in Psychiatry, 2019

Purpose of review Extensive resources have been devoted to implementing evidence-based psychother... more Purpose of review Extensive resources have been devoted to implementing evidence-based psychotherapies (EBPs) to facilitate the best available treatments to clients. Yet, when treatment settings or client characteristics do not align with the contexts in which an EBP was developed and tested, adaptations may be indicated. The purpose of this article is to provide a summary of the adaptation literature and highlight key issues, using Cognitive Processing Therapy as an example throughout the paper. Recent findings Informed by the literature to date, we use Stirman and colleagues' Framework for Reporting Adaptations and Modifications (FRAME) to organize current thinking and provide a guide for conceptualizing different types of adaptations. Broadly, we discuss (1) why adapt, (2) goals of the adaptation, (3) who is involved in the adaptation process, (4) when to adapt, (5) forms of adaptation, and (6) measurement and evaluation. Summary As effective interventions for PTSD are developed and identified, implementation in routine care settings will increase access for underserved populations, who may not have been well-represented in the research that originally established efficacy or effectiveness of the EBP. However, a careful process of EBP adaptation, informed by theory, research, and program-level evaluation, can result in successful implementation. Stakeholder-informed, carefully-evaluated adaptation can allow more individuals to benefit from treatment.

Implementation science : IS, May 22, 2018

Identifying scalable strategies for assessing fidelity is a key challenge in implementation scien... more Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new ap...

Psychological Trauma: Theory, Research, Practice, and Policy, 2018

Objective and method: Numerous risk factors for posttraumatic stress disorder (PTSD) have been id... more Objective and method: Numerous risk factors for posttraumatic stress disorder (PTSD) have been identified; however, many do not inform treatment. Psychological inflexibility is a modifiable factor that can be targeted in psychological treatment. This study examined whether higher levels of psychological inflexibility predicted unique variance in PTSD symptom severity at 1-year follow-up in 236 U.S. veterans of the wars in Iraq in Afghanistan after accounting for the strongest known risk factors for PTSD. PTSD symptom severity was assessed using the Clinician Administered PTSD Scale. Results: In hierarchical regression analyses, higher baseline psychological inflexibility predicted unique variance in 1-year PTSD symptom severity (p < .001, medium effect) after accounting for the strongest predictors, including: serving in the Army, rank, trauma severity, perceived threat, peritraumatic dissociation, recent life stress, and social support. Psychological inflexibility remained a significant predictor of unique variance in 1-year PTSD symptom severity after accounting for all other predictors and personality factors (neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness; p < .001, small effect) and after accounting for all other predictors, personality factors, and baseline PTSD avoidance symptoms (p < .001; small effect). Conclusions: Findings indicate a key unique association between psychological inflexibility and PTSD symptom severity over time that is not attributable to overlap with personality or PTSD avoidance symptoms. Additional research on psychological inflexibility in the development and maintenance of PTSD is warranted, as well as whether increasing psychological flexibility leads to reductions in PTSD symptoms and improved psychosocial functioning.

Frontiers in Psychiatry, 2018

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate d... more Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 − 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 − 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 − 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

Journal of Nervous & Mental Disease, 2017

The objective of this study was to test the hypothesis that sleep quality mediates the associatio... more The objective of this study was to test the hypothesis that sleep quality mediates the association between traumatic brain injury (TBI) history and current suicidal ideation. Measures of TBI history, sleep quality, and suicidal ideation were administered to 130 Iraq/Afghanistan veterans. As expected, sleep quality mediated the effect of TBI history on current suicidal ideation (indirect effect = .0082, 95% CI: 0.0019-0.0196), such that history of TBI was associated with worse sleep quality, which was, in turn, associated with increased suicidal ideation. These findings highlight the importance of assessing TBI history and sleep quality during suicide risk assessments for veterans. Keywords sleep; suicide; traumatic brain injury; veterans Veterans are at increased risk for suicide attempts and death by suicide (e.g.

Journal of Contextual Behavioral Science, 2016

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are a... more Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD-AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness-and acceptance-based form of behavior therapy, has potential as a treatment option for PTSD-AUD. In this uncontrolled pilot study, we examined ACT for PTSD-AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ࣙ 10 of 12 sessions). Clinician-assessed and self-reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self-reported symptoms of PTSD remained lower at 3-month follow-up, d = 0.88. There were reductions on all alcohol-related outcomes (clinician-assessed and self-reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3-month follow-up, d mean = 0.91 (d range: 0.65-1.30). Quality of life increased at posttreatment and follow-up, ds = 0.55-0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow-up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow-up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow-up. Consistent with the ACT theoretical model, these improvements were associated with more between-session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD-AUD include assigning frequent between-session mindfulness practice and initiating values clarification work and values-based behavior assignments early in treatment.

Psychological Trauma: Theory, Research, Practice, and Policy, 2014

Although current theories emphasize the role of fear in the etiology of posttraumatic stress diso... more Although current theories emphasize the role of fear in the etiology of posttraumatic stress disorder (PTSD), recent research suggests that shame may also play a role in the development of PTSD symptoms. This study tested if the experience of peritraumatic shame mediates the relationship between 2 conceptually linked PTSD risk factors (i.e., experiencing an interpersonal vs. impersonal reference trauma and number of previous potentially traumatic events [PTEs]) and current levels of PTSD symptoms. Path analysis was used to test a series of nested models assessing the indirect effects of these risk factors on PTSD via peritraumatic shame, while controlling for the potential indirect effect of these risk factors via peritraumatic fear. The final structural model found that the number of previous PTEs had a direct effect on current levels of PTSD, no association with fear, and a marginally significant indirect effect on PTSD symptoms via shame. The effects of reference trauma type on PTSD symptom levels was mediated by levels of both peritraumatic shame and fear, suggesting that shame, in addition to fear, may contribute to the development of PTSD symptoms in survivors of interpersonal traumas. The results underscore the need for further, more fine-grained research in this area and contribute to the nascent literature suggesting that other emotions, beyond fear, are important to our theoretical understanding of PTSD.

Handbook of Forensic Psychology, 2004

Publisher Summary This chapter outlines the aim and the purpose of accurate assessment of Post-Tr... more Publisher Summary This chapter outlines the aim and the purpose of accurate assessment of Post-Traumatic Stress Disorder (PTSD). The chapter discusses methods of assessment and reviews the measures with established psychometric data to support their use. Several common problems in assessment of PTSD and related concerns are considered. One of the major aims of assessment is to determine the extent of PTSD symptoms to evaluate whether a diagnosis of PTSD is warranted. Common problems associated with trauma, such as depression, ritualized behaviors, and substance use, must also be evaluated. Another purpose of assessment is to provide an accurate baseline of functioning. The severity of the person's presenting problems are ascertained and measured in an objective fashion to be used as a comparison against which gains in treatment can be compared. Self-monitoring, clinical interviews, and standardized measures are the multiple methods of assessment available. In using self-monitoring with a patient, the clinician must explain the rationale, identify specific target behaviors, and emphasize accuracy. A sensitive clinical interview is also a valuable method of assessing PTSD and related symptoms. A standardized measure involves specific questions that are objectively asked and can be psychometrically evaluated.

The Cambridge Handbook of Forensic Psychology, 2010

Journal of Trauma & Dissociation, 2013