Towards Successful Disseminationof Psychological First Aid: A Studyof Provider Training Preferences

Erin P. Hambrick, MASonia L. Rubens, MAEric M. Vernberg, PhD, ABPPAnne K. Jacobs, PhDRebecca M. Kanine, MA

Abstract

Dissemination of Psychological First Aid (PFA) is challenging considering the complex natureof disaster response and the various disaster mental health (DMH) trainings available. Tounderstand challenges to dissemination in community mental health centers (CMHCs), interviewswere conducted with nine DMH providers associated with CMHCs. Consensual qualitativeanalysis was used to analyze data. Interviews were targeted toward understanding organizationalinfrastructure, DMH training requirements, and training needs. Results clarified challenges toDMH training in CMHCs and factors that may promote buy-in for trainings. For example,resources are limited and thus allocated for state and federal training requirements. Therefore,including PFA in these requirements could promote adoption. Additionally, a variety of trainingapproaches that differ in content, style, and length would be useful. To conclude, a conceptualmodel for ways to promote buy-in for the PFA Guide is proposed.

Introduction

Research shows that disasters and crises increase the prevalence of psychological maladjust-ment,1 particularly in the absence of early intervention.2 Yet, available evidence-informed supportsfor early intervention are not widely used.3 Obstacles to dissemination of empirically based

Address correspondence to Erin P. Hambrick, MA, Clinical Child Psychology Program, University of Kansas, 1000Sunnyside Avenue, Lawrence, KS 66045, USA. Phone: +1-502-5420418; Email: erinhambrick@ku.edu.

Sonia L. Rubens, MA, Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA.Eric M. Vernberg, PhD, ABPP, Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA.Anne K. Jacobs, PhD, Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA.Rebecca M. Kanine, MA, Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA.

Journal of Behavioral Health Services & Research, 2014. 203–215. c) 2013 National Council for Behavioral Health. DOI10.1007/s11414-013-9362-y

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interventions in community settings have been well documented,4 but there are challenges uniqueto the disaster mental health (DMH) field. For example, because disasters occur infrequently, it isoften infeasible to adequately prepare local DMH providers. DMH trainings must attempt to covera wide range of topics in enough depth to be useful for DMH providers and other responders(e.g., fire departments, medical staff, government officials). Trainings must also includediscussion of how multiple agencies can coordinate efforts in a cohesive, effective manner inorder to meet survivors’ needs within a chaotic environment.5 To further complicate thematter, training opportunities are limited by time and financial resources. This makes it difficult foragencies to decide if, when, and how to offer DMH trainings amongst mental healthprofessionals’ other required trainings. Despite best intentions, DMH trainings may feel brief,piecemeal, or untimely.

The PFA guide and dissemination efforts

The Psychological First Aid Field Operations Guide, 2nd Ed.6 [Psychological First Aid (PFA)Guide] was created by collaboration between the National Child Traumatic Stress Network (NCTSN),the National Center for Posttraumatic Stress Disorder, and DMH providers. The intended purpose ofthe guide was to address the need for a common disaster mental health response method that wasdevelopmentally sensitive, evidence-informed, could be widely implemented,6 and could be used bymany types of providers.7 Specifically, the PFAGuide consists of eight Core Actions that can be used asneeded during disaster response: (a) Contact and Engagement, (b) Safety and Comfort, (c)Stabilization, (d) Information Gathering, (e) Practical Assistance, (f) Connection with Social Supports,(g) Information on Coping, and (h) Linkage with Collaborative Services. Further detail regarding thecontent of the PFA Guide is available.7–9

PFA dissemination efforts have typically been broad and low cost. The PFA Guide is availableas a free download (http://www.nctsn.org/content/psychological-first-aid), and daylong trainingsare becoming more widely available due to train-the-trainer efforts by the NCTSN. Supplementaltraining materials also exist, including a free, interactive, online training (http://learn.nctsn.org/course/category.php?id=11) and an instructional video series, Responding to Crisis in theAftermath of Disaster (http://learn.nctsn.org/login/index.php). Finally, several translations (e.g.,Spanish, Italian, Chinese) and system-specific adaptations of the PFA Guide (e.g., the MedicalReserve Corps, religious professionals, and schools) have been published. A more in-depthapproach to PFA dissemination and training is also available in the form of an NCTSN LearningCollaborative Model.10 Although avenues of potential access to PFA training have increased, theimpact of these efforts on PFA use is unknown.

PFA guide: early research

Recent studies have shown that provider perceptions of the PFA Guide are favorable. Althoughthere is little outcome data regarding the effectiveness of PFA principles, research shows that thosewho have used the PFA Guide to respond to disasters such as Hurricanes Katrina, Gustav, and Ikefound it helpful and would recommend its use. Specifically, providers found the Core Actionsuseful5 and appropriate when responding to survivors’ immediate psychological needs. Providersreported that amidst chaos, the PFA Guide helped promote a practical, useful, cohesive responseplan.11

Using the guide in conjunction with attending a daylong workshop appeared to further increaseproviders’ confidence in using PFAwith adults and childrenwhen responding to Hurricanes Gustav andIke.11Attendance at even briefer trainings appears to lead to similar results. A version of PFA adaptedby World Vision International and the War Trauma Foundation for use in “low and middle incomecountries”12 (p. 245) was pilot-tested following the earthquakes in Haiti with 119 providers. Providers,

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who consisted of native Haitians and World Vision International volunteers, were given a 2–3-horientation to PFA and a two-page summary of key principles. Many providers indicated that despite itsbrevity, the training was “helpful, practical, and empowering”12 (p. 251) and made them morecompetent in approaching survivors. Additionally, providers indicated interest in receiving moretraining in the future.

Promising findings regarding provider perceptions of PFA and the strong evidence-informedbasis of the approach make a case for broader dissemination of PFA—particularly to entitiesalready required to have trained DMH teams. For example, community mental health centers(CMHCs) have been required by the federal government to have adequately trained and staffedDMH teams since the 9/11 attacks.13 Research has shown that including PFA or other evidence-informed approaches in state disaster training plans could increase rates of adherence to bestpractices in DMH by states that experience massive disasters.14 However, even though the NationalPreparedness Goal includes an emphasis on the use of PFA,15 the disaster plans of most states(from which CMHCs obtain their DMH training regulations) do not include requirements fortraining in PFA or other evidence-informed DMH methods.16

Despite the need for broader adoption and use of evidence-informed early interventions such as PFA,there is limited empirical evidence regarding the effectiveness of PFA dissemination efforts. There is aneed for an understanding of the effectiveness of trainings at building competence, whether trainingspromote PFA use, and whether trainings promote integration of PFA into existing preparednessefforts—or, in other words, promote “buy-in” for PFA. Results from a pilot study of outcomes of adaylong PFA training showed that 3 months following the training, only 10 of the 53 surveyrespondents reported that PFAwas their organization’s preferred DMH response method.17 The lack ofPFA adoption appeared to be related to several factors, including organizational preferences for otherDMH approaches, lack of knowledge about when PFAwould be useful, and organizational barriers toproviding ongoing trainings (e.g., financial resources, competition with other responsibilities).Although results are preliminary, the reported barriers to buy-in for PFA may indicate that one wayto increase buy-in would be to make trainings sensitive to organization-specific needs.

Buy-in is a term that has been used to describe the result of successful dissemination efforts atthe organizational level that recognize the importance of meeting site-specific needs (Twemlow andSacco).18 For buy-in to occur, there must be a “group of concerned and engaged individuals whoconsider the program essential and necessary to follow”18 (p. 311) within the organization.Additionally, the program must gain “institutional support” through being “compatible with theinstitution’s mission and culture”18 (p. 311). Thus, it is likely that if PFA trainings are not relevantto and workable within the organization, adoption is unlikely.19

Study aims

Many organization- and DMH-specific challenges to dissemination of the PFA Guide exist, anda flexible, multifaceted approach to dissemination and training is likely needed to promote buy-in.To clarify nuanced organizational, personal, and DMH-specific issues that could affect buy-in forthe PFA Guide within CMHCs, semi-structured interviews of providers serving on CMHC DMHteams were obtained. Qualitative analysis of themes present in the interviews was used to identifyrecommendations for future trainings. CMHC DMH team members were selected as participantsfor several reasons. First, national mandates require that all CMHCs have a DMH team. Second,CMHCs exist nationwide, and some challenges to PFA adoption may generalize across CMHCs.Third, it was important to use only one type of organization given the small sample size.

Two research aims shaped the questions posed to CMHC staff. The first was to identify trainingneeds and preferences of CMHCs in DMH because creation of effective trainings that are workablewithin a system’s infrastructure theoretically promotes buy-in. The second was to solicit challengesand facilitators of conducting ongoing DMH trainings in CMHCs, such as resources and

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characteristics of DMH teams. Although the ultimate goal was to understand how to bestdisseminate PFA, interview questions were targeted toward understanding barriers to DMH trainingin general. Many CMHCs offer trainings in more than one psychological response method,16 andgaining an understanding of an organization’s broad DMH training needs and goals would providea clearer picture of how PFA could become integrated.

Method

Participants

Participants for this study included nine clinicians (five female and four male) affiliated with fourdifferent CMHCs across a Midwestern state. Eight to 15 participants are recommended for thequalitative methodology employed in this study to allow for adequate depth and breadth in thedata.20 Three clinicians were members of their center’s DMH team and expressed interest insupporting PFA trainings at their center. All four CMHCs had a disaster response team, and onlyone of the CMHCs had responded to a large-scale disaster within the past decade. Eight of theparticipants were master’s-level mental health clinicians employed by a CMHC, and one was amaster’s-level school psychologist who worked closely with a CMHC DMH team. All participantshad attended at least one daylong PFA training or completed the 6-h online training.

Procedures

Graduate research assistants led four semi-structured interviews. Two interviews contained twoparticipants, one interview four participants, and one interview one participant. Participantsprovided written informed consent. Interviews were conducted at the CMHCs and included open-ended questions about their organization and their organization’s DMH training needs. Questionswere developed by the research team (Table 1), and were partly derived from a pilot study of tenphone interviews with potential PFA providers regarding barriers to conducting continued DMHtrainings in their organizations.17 Interviewers asked questions in an open-ended, non-leadingmanner.21 Interviews were audio recorded and lasted 60 to 90 min.

Analysis

Audio recordings were transcribed verbatim and checked for accuracy. Consensual qualitativeresearch (CQR) procedures were used to analyze the transcripts.20,22 CQR is a method that wasdeveloped through influences of other qualitative analysis strategies, including grounded theory,comprehensive process analysis, and phenomenological approach.20,22 CQR was chosen because itallows for themes within the data to be identified and analyzed.

Three research team members coded the transcripts using the software NVIVO version 9, and afourth research team member acted as an independent auditor. The four coders all had varyinglevels of familiarity with PFA to decrease coder bias. The coding process proceeded as follows:First, the three primary coders independently reviewed the transcripts and developed a list ofdomains to group the data into salient topics. Once domains were chosen, each coder placedrelevant quotes into the domains. The final determination of a quote’s placement in a domain wasreached by consensus. Next, core ideas, or abstracts, were developed to describe the domains.Then, the auditor reviewed the domains and core ideas, and the auditor’s feedback was used tomake changes. The final step was to create categories to clarify themes within the domains.Categories separate important subgroups of the domain to further organize the results. Followingcategorization, results were audited once more. The Human Subject Committee at the University ofKansas provided Institutional Review Board approval for the present study.

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Results

The first aim of the study was to clarify training needs and preferences of CMHCs in DMH. Thesecond aim was to identify challenges and facilitators to conducting ongoing DMH trainings inCMHCs—with the ultimate goal of learning how to best tailor PFA dissemination efforts. Sevendomains relevant to the research questions were identified. Domains, core ideas, and categories areprovided in Table 2. Below is a description of each domain with quotes from selected categories tohighlight important points.

Domain 1: Disaster response and preparedness

Federal mandates require that all CMHCs have a disaster response plan and a DMH team that isprepared to respond to disasters and crises. Teams must also meet the often-burdensome federal,state, and agency training requirements.

Training Requirements Category: We have so many [trainings] that are required…for a lot of our case managementstaff, they have to do the case management training through the [local university], and then the annual trainings, andthen since we’re managed care, we have to do every year a whole slew of trainings for [local CMHC].

Additionally, collaboration and communication prior to disasters amongst agencies facilitatespreparedness, although collaboration can also result in barriers to DMH provision.

Table 1Semi-structured interview questions

Question Follow-up probes

Tell us about your organization’s role indisaster mental health

How many people are involved?How do people join the response team?Is there a difference in your crisis response vs.DMH team?What is the team turnover rate?What types of disasters/crises do you respond to?Have you encountered any setbacks inresponding?

Tell us about the training the response teamreceives in DMH

Are there any areas in which you want moretraining?

What are the training priorities for your group?What are some barriers/challenges within yourorganization to further training?

What would the ideal DMH training include? Curriculum?Style (role play, etc.)?Time constraints/time line?How many people would you like to be trained?How would you track the progress of trainees?Who would lead the trainings/develop the trainingoutline?

How can this type of training becomesustainable in your organization?

No probes

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Table 2Domains, core ideas, and categories

Domain Core idea Categories

Disaster Responseand Preparedness

Federal mandates require that all CMHCs have aDMH team and a disaster response plan. Teamsmust be prepared to respond to various disastersand crises—federal, state, or local. These teamsalso must meet federal, state, and agency trainingrequirements. Part of this training is geared towardincreasing knowledge of how the DMH teamoperates amongst a larger system of responders.Collaboration and communication prior to disastersbetween different agencies that respond facilitatespreparedness. Collaboration includes informingagencies of the importance of including DMH inresponse plans.

Collaboration/Connection

Response toDisaster

Role of GovernmentTrainingRequirements

Disaster MentalHealth Team

Team composition refers to the following aspects ofDMH teams: turnover, recruitment, educational ortraining backgrounds of team members, leadershipand hierarchy of the team, and the make-up of theteam (e.g., volunteers).

Characteristics of team members include qualitiessuch as commitment to DMH, propensity towardthrill seeking, flexibility, various levels ofexpertise, and various special abilities.

Team CompositionCharacteristics ofTeam

MembersLevel of Education

Resources DMH team members are volunteers who haveresponsibilities other than disaster response.Additionally, CMHCs must maintain clinicoperations, which makes attending DMH trainingsand responding to disasters difficult. If trainingsare not required, the priority often goes to regularjob responsibilities. Scheduling of trainings shouldbe sensitive to responders’ regular jobs. Onlinetraining gives more opportunity and flexibility,plus is less expensive. Even if agencies desireDMH training, there is often a lack of resourcessuch as time and money to provide trainings.

Agency SupportTime and MoneyRegular JobResponsibilities

Training Nuts andBolts

Providers desire a mixture of approaches (e.g.,online, face-to-face, interactive, role play,discussion of real-world applications). They alsowant a manual or other materials for personalreview (e.g., in the field, between trainings).

Both in-house vs. outside trainers are desired. Shortyet ongoing trainings are preferred. Using existingtraining venues and prescheduled training times tohold DMH trainings is most feasible (e.g.,conferences, agency meetings, in-service days).Completion of training requirements in a timely

Scheduling/Availability

“Just in Time”Training

TrainerFrequencyLengthMaterialsStyleVenueParticipants

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Collaboration/Connection Category: I mentioned Red Cross earlier, and they have…basically it’s disastercounseling…but I have never seen it offered around here. So, which was part of the dilemma when I was talkingabout the shelter thing here after Katrina…they were ‘gonna tell us that we couldn’t do crisis counseling, but theydon’t offer training.

Finally, collaboration includes informing agencies of the importance of including DMH inresponse plans.

Table 2(continued)

Domain Core idea Categories

manner decreases the frustration with quick,insufficient “just-in-time” trainings. Getting arange of employees trained at different levels ofexpertise in DMH is preferred (including someexposure for all employees).

Desired TrainingFocus

Providers desire a range of topics to be covered atDMH trainings. These include understanding thebasics of how to respond to disasters, how to applythese techniques to special populations, techniquesof crisis counseling, response debriefings, and site-specific scenarios.

Specific desired trainings included required trainingsfor ARC and KABH, PFA, and CISM, along withchild-focused trainings.

Desired trainings are preferably evidence based andallow providers to have more tools in their tool belt.

Basic TrainingEvidence-basedSite-specific trainingSpecial populationsSpecific DesiredTrainings

ResponseDebriefing

TrainingSustainability

Several factors would help make DMH trainingsustainable (e.g., evaluations, certifications, andhaving internal trainers). Making trainings requiredand making trainings site-specific could generatecontinued interest. Training local trainers in DMHapproaches allows for local provision of trainings(thus making them more affordable).

Tracking TrainingTraining EvaluationTrain-the-TrainerCredentials

Buy-In Buy-in for training in DMH will increase ifproviders understand that attending DMH trainingsdoesn’t mean they are required to be part of theDMH team. Time spent in training does not seemuseful due to the infrequency of disasters. Lack ofunderstanding of the applicability and usefulnessof this training beyond the disaster response resultsin decreased training attendance.

Certain incentives could increase trainingattendance, such as free trainings, decreasedresponsibility for billable hours, and CE credits).Personal interest in DMH also promotes buy-in.

Practicality/Applicability (ofTraining)

Training Incentives

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Domain 2: Disaster mental health team

The DMH team domain has two main categories: team composition and characteristics of teammembers. Important considerations for team composition include turnover, recruitment, educationaltraining or backgrounds of people on the team, and the fact that the team is made up of volunteers.

Team Composition Category: [Our team has] concentric kind of circles…there isn’t a general requirement right nowfor [our] employees [to be on the DMH team], if they’re part of the [crisis response] team, then they’ve had the CISMtraining, and then possibly some, many of them participated in Psychological First Aid training, and if they’re partof the disaster response team, they [also] had to have FEMA training. We try to incorporate some diversity of age,and we have some who are fluent in Spanish and…we’ve got a nice, I think, mix of…expertise.

The “characteristics of team members” category refers to qualities often found among DMHteam members, such as commitment to DMH, propensity for thrill-seeking, flexibility, variouslevels of expertise, and various special abilities.

Characteristics of Team Members Category: I wouldn’t really call them thrill-seekers or adrenaline junkies, but that’skinda what it is! So it’s a real different, uh, constitution if you will…to do this kind of stuff and do it successfully.

Domain 3: Resources

DMH team members in CMHCs are volunteers who have competing time commitments thataffect their ability to participate in DMH training.

Time and Money Category: If [name] who is an outpatient therapist wants to attend a training, she’s gotta think inadvance, I’ve got clients that day, how do I rearrange it? We wouldn’t say you have to take vacation. But, she doesn’tget a pass for the productivity for that day…she’s gotta figure that out in some fashion.

Relatedly, CMHCs must maintain clinic operations, which makes attending DMH trainingsdifficult. Scheduling of trainings should be sensitive to responders’ regular jobs.

Regular Job Responsibilities Category: It’s kinda like herdin’ cats…you know…they’re busy, doin their other stuff,so…it’s not a priority for them.

Finally, some participants noted that online training gives them more opportunity and flexibility.

Domain 4: Training nuts and bolts

Providers desire a mixture of approaches (e.g., online, face-to-face, interactive, role play, real-world applications).

Training Style Category: People hate to do role plays…and it’s just hard to get…nobody wants to do smallgroups….It’s probably more palatable than role playing, but even though literature says that adult education needsto be interactive and, uh, changing up what you’re doing all the time…our professionals don’t want to participate inan adult learning strategy. So…and lecture is boring…and people complain about that…and they don’t want toparticipate. So I’m not sure.

Participants also indicate wanting a manual or other materials for personal review (e.g., in thefield, between trainings). Both in-house and outside trainers are desired, and short yet ongoingtrainings are preferred.

Materials Category: The online [PFA] training was good…the only downside is the length of it….I’m not suggesting that yourevamp your…training, but…if you could get something that’s an overview…that takes an hour,maybe two to complete… soyou either could have people do the whole thing, online or live, or you have them do the orientation overview either live oronline…and then you do the little face-to-face things to start talking about the nuts and bolts of how to do it.

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Using existing training venues and prescheduled times to hold DMH trainings tends to be mostfeasible, such as conferences and agency meetings. Completion of trainings in a timely mannerdecreases the need for “just-in-time” trainings (trainings that are scheduled after a disaster hasoccurred). Finally, getting a range of employees trained at different levels of expertise is preferred,including some exposure for all trainees.

Domain 5: Desired training focus

Providers desire a range of topics to be covered at DMH trainings. These include understandingthe basics of how to respond to disasters.

Basic Training Category: We were talking about the [PFA] principles…I think an annual get-together, causeit has to be brief, cause…these are all people that have jobs…just a quick review of that….just kind of thatreminder…..I love the idea of having, in the back of my mind, the principles. That just helps ground you…in an emotionally-charged situation. That’s how I keep myself together is I think about “all I have to do isthese things.”

Also, providers would like training regarding how to apply these techniques to special populationssuch as children and those who are seriously and persistently mentally ill.

Special Population Category: As psychologists we’re great at admiring the problem…but I think that we needalso to, to place an emphasis on interventions. What are proven, uh, interventions for children…that haveexperienced different kinds of crises….and if we could make sure that that’s part of the training, it would bemore meaningful.

Desired training topics included crisis counseling, disaster response debriefings, and site-specificscenarios. Trainings are preferably evidence-based. Specific desired trainings mentioned wereARC, PFA, and CISM.

Domain 6: Training sustainability

Several factors would help make DMH training sustainable, such as training evaluations andcertifications that indicate competence in DMH response.

Credentials Category: I would like all of [the disaster responders] to have some experience with…how to help peoplesurvive disasters and trauma….we may need to be doing crisis counseling sometime…and I don’t want it to be sucha specialized thing that ‘you can’t do it because you haven’t had this. Only I can do that. I want to have peopletrained sufficiently so…anybody could potentially be able to do it on some level.

Additionally, there was a preference for having internal trainers.

Trainers Category: I would think you would want to get more trainers out there that can either do it…one at eachagency, I don’t know if [the] focus is just CMHCs or, or if it’s gonna be broader in the communities…I think you’d,you’d probably want key people at your CMHCs since they’re statewide.

Finally, participants suggested that making trainings required and site-specific might promotecontinued interest in DMH training. Moreover, training local trainers in DMH approaches wouldallow for more affordable trainings.

Domain 7: Buy-in

Many factors appear to affect buy-in for DMH training. For example, providers mentioned thattraining does not seem useful due to the infrequency of disasters.

Practicality/Applicability Category: It needs to be a type of topic that they’re actually gonna feel like…if they learn it theycan use it. And sometimes with the disaster stuff we hear… “I’ve taken trainings on this in the past and never used it.”

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Another quote from this category indicates that there is a lack of understanding of theapplicability and usefulness of this training beyond the disaster response:

Because many of our people…we’d be able to say, “You do this stuff already, you know, here’s just sort of a formatfor you to think about it when you’re talking to this group or with this person.”

Low applicability results in decreased attendance and enthusiasm for training. Additionally, thereare certain incentives that could increase the likelihood of attending the trainings (e.g., freetrainings, decreased responsibility for billable hours, and CE credits). Finally, personal interest inDMH is an internal incentive that promotes buy-in.

Training Incentives Category: If you don’t have a personal, vested interest like I do…it’s not a priority so you justdon’t stay on top of it. So, if you all can figure out the magic wand to keep people interested….I’m open to ideas,believe me.

Discussion

The field of DMH needs a unified response method to improve quality of post-disaster care. Toaccomplish this, providers must be effectively trained in evidence-informed approaches. PFA, asoutlined in the PFA Guide, is an evidence-informed approach that clinicians are confidentimplementing11,17 and that shows preliminary empirical support.12 However, challenges todisseminating PFA must be identified and addressed.

Aim 1

The first aim of this study was to gain a better understanding of training needs and preferences ofCMHCs in DMH. Generally, it appeared as if clinicians are interested in obtaining PFA training, atleast as a component of the DMH team’s training, and that they desire to learn practical approachesthat can be easily implemented in diverse situations. Participants also identified trainingpreferences that could increase buy-in for evidence-informed DMH trainings. They reported apreference for brief, frequent trainings as opposed to daylong trainings and a preference for mixedtraining styles. For example, some participants noted dreading role plays, yet others mentionedgaining little from didactic theoretical explanations—making variation key. Having trainingsavailable in multiple styles would be ideal so that organizational preferences could beaccommodated.

Preferences for different types of DMH training approaches are likely a product of the range ofdisasters and crises to which teams typically respond. Additionally, the emotions that accompanydisaster response, past experiences with disaster response, and populations with which providershave worked play a role, as do national, state, local, and organization-specific trainingrequirements. Despite myriad influences and discrepancies amongst study participants, someconsensus was reached. Providers appeared to prefer trainings that are evidence-based, site-specific, focus on special populations, and fulfill training requirements. For example, severalparticipants desired trainings that reviewed scenarios relevant to their geographic area (e.g.,tornadoes or hurricanes). PFA trainers should work to promote inclusion of PFA into governmentaland site-specific training requirements and also find ways to highlight the applicability of PFAprinciples to multiple scenarios.

Providing incentives for attending trainings (including certification for trainees) and clarifyingthe perceived practicality/applicability of trainings also appeared important. This could be done byemphasizing the relevance of PFA principles in contexts other than disasters. If providers areinformed that DMH trainings offer skills that apply to many situations, then they may be morewilling to attend trainings.

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Aim 2

The second aim was to identify challenges and facilitators to conducting ongoing DMH trainingsin CMHCs. In general, results indicated that training agendas should be tailored to the limitedresources and competing demands faced by DMH teams at CMHCs. Because of the unpredictableand chaotic nature of disasters, challenges to dissemination of evidence-informed DMH responsesexist at multiple levels. During disaster response, various providers and organizations must worktoward shared goals. Yet, most providers, including mental health providers, have diverse trainingbackgrounds that can interfere with effective collaboration. To further complicate matters, DMHteams at CMHCs are often volunteers. Requiring volunteers to attend several in-depth trainingsmay be infeasible no matter their degree of personal investment.

Because it is likely that all mental health professionals at CMHCs will be involved in a large-scale response to some extent, offering multiple levels of training could be helpful. For example,providers who would like to become PFA trainers could complete a rigorous track of training,including NCTSN train-the-trainer programs and available online courses. Members of the coreDMH teams could participate in daylong workshops (or the 6-h online workshop), as well as brieffollow-up trainings throughout the year. Other staff at CMHCs could be encouraged to attend briefPFA overviews when possible, or simply participate in one daylong workshop.

No matter the training plan, limited resources may pose challenges. Having trainings availableduring local mental health conferences or during times the CMHC has already set aside for trainingcould help, as could an increased variety of online trainings. Participants in this study who werefamiliar with the current PFA Online training found it useful and recommended coming up with aversion that is a brief overview and other versions that are 60–90-min seminars on special topicswithin PFA, such as lifespan-related issues.

Buy-in

The concept of buy-in could be used an overarching concept to help organize results and clarifysteps for future research. Although Buy-In emerged as a distinct domain, during data analysis, thecoders regularly noted that the other six domains also contained quotes that referred to ways to

Figure 1Proposed conceptual model of training-related factors that may promote buy-in for PFA

Buy-In for PFA Adoption

Institutional Support:

Nature of Desired

Trainings

Challenges related to Disaster

Response and Preparedness

Characteristics of Disaster

Mental Health Team

Resources of Training Site

Engaging Clinicians: Training

Preferences of DMH Providers

Training Logistics/Traini

ng Nuts & Bolts

Desired Training Focus

Training Sustainability

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increase attendance at DMH trainings and to increase use of principles presented at trainings.Further, it appeared that the other six domains could be logically placed into two groups: (a)Logistical training preferences of DMH providers, or clinician engagement: Training Nuts andBolts, Desired Training Focus, and Training Sustainability, and (b) Factors affecting the nature ofdesired trainings, or promotion of institutional support: Disaster Response and Preparedness,Disaster Mental Health Team, and Resources. Clustering or hierarchically ordering domains is nota part of the CQR process, but might help guide future research. Figure 1 contains a model that ispresented as a possible way to measure or predict buy-in for PFA.

Study limitations and future directions

Several limitations should be noted. First, clinicians from four CMHCs within one stateparticipated in this study. Second, these CMHCs indicated interest to the research team inproviding PFA trainings at their site. Therefore, some of the findings may not represent challengesfor DMH training or preferred training styles at CMHCs in other states or regions. Third, manyDMH teams include team members from various disciplines and training backgrounds. The currentstudy only included masters’-level clinicians; future research may wish to interview DMH teammembers from other disciplines, such as medical providers, religious professionals, and AmericanRed Cross staff.

Finally, the interviews were conducted by members of a research team who also providedtrainings in PFA. This may have resulted in a positive bias towards PFA. Some concerns with PFAtraining experiences, however, such as length and applicability, were expressed throughout theinterviews. This suggests that at least some participants were comfortable providing accounts ofpositive and negative experiences with PFA trainings. Future research should evaluate the extent towhich ideas about dissemination efforts provided by participants promote PFA adoption, and thusthe extent to which current findings can generalize to CMHCs in other regions. The proposedconceptual model could be used to guide future data collection efforts, and could be modified byintegrating ongoing research.

Implications for behavioral health

The ideal amount of training providers should receive and the possible amount of training theycan receive will likely differ given factors highlighted in this study. However, even small doses ofPFA awareness could facilitate confidence in providing PFA and impart meaningful basicinformation that could be used in the disaster setting.12 Ongoing, in-depth trainings may producethe greatest benefit, but briefer PFA overviews have the potential to increase awareness and interestin PFA and promote participation in more in-depth trainings. Moreover, brief trainings that addressspecific topics within PFA at a deeper level may facilitate ongoing interest and responseproficiency. In sum, a diversity of training approaches may best promote PFA dissemination andultimately increase use of this evidence-informed approach.

Acknowledgments

This research was supported in part by grants from the Substance Abuse and Mental HealthServices Administration through the University of Oklahoma Terrorism and Disaster Center.

Conflict of Interest The authors have no conflicts of interest to report.

214 The Journal of Behavioral Health Services & Research 41:2 April 2014

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