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Newsletter | Winter 2020 | South Central MIRECC

Research to Practice | Adapting CALM for CBOCs: An Iterative Approach

Summary by Sonora Hudson, MA and Darius B. Dawson, PhD

An article by SC MIRECC and VHA researchers, among others, in the Journal of Medical Internet Research Mental Health describes the process used by a group attempting to redesign the Coordinated Anxiety Learning Management (CALM) program for use by mental health providers in rural VHA community-based outpatient clinics (CBOCs).

CALM, originally evaluated in a National Institute of Mental Health-funded study for use in non-VHA outpatient clinics, relies on a computer-delivered program that Veterans and providers use simultaneously in CBOCs to facilitate delivery of cognitive behavioral therapy (CBT) for treating anxiety disorders, including panic disorder, generalized anxiety disorder and social anxiety disorder, posttraumatic stress disorder, and depression.

The study aimed to modify CALM to make it more useful for rural Veterans, because they are much less likely to receive psychotherapy than their urban counterparts, and training of providers has not boosted translation of new treatments into routine clinical practice. This study relied on three waves of focus-group discussion involving four groups of key stakeholders:

  • Veterans who had received recent mental health care for anxiety disorders/depression in a CBOC
  • CBOC mental health providers
  • VHA clinicians with expertise in cognitive behavioral therapy
  • Cognitive dysfunction
  • VA Central Office leaders experienced in implementing evidence-based practices within the VHA

Following each focus-group discussion, rapid analytic techniques were used to develop recommendations for program modifications. Three broad domains were analyzed: recommendations from groups, evaluative observations or initial reactions or concerns, and questions. The two analysts summarized the content individually and then discussed analytic findings and resolved differences in interpretation. After analyses were finalized for all focus-group discussions, findings were compiled and summarized, before review by a panel of experts and submission to the design and development team. The summary template was then reduced to actionable recommendations for modification.

Suggested modifications to the program were mainly “look and feel” changes affecting images and illustrations in the modules. For example, photos and illustrations were made more Veteran-centric to reinforce Veteran participation and reflect Veterans’ service experience; and existing video of Veterans discussing their experiences were added. Links to web-based psychoeducation materials developed for Veterans were also added. Importantly, visuals were cleaned up to be less wordy and content heavy to make screens more appealing and easily assimilable.

The changes were then evaluated during a second wave of focus-group discussions; and feedback was evaluated, with the expert panel again reviewing a summary of recommendations and prioritized actionable modifications. The modifications were submitted to the design team, and a prototype of the modified CALM program was developed. Wave 3 involved validation of the modifications during a teleconferenced focus-group discussion with CBOC mental health providers, expert CBT clinicians and VHA leaders in clinical operations and implementation. Veteran stakeholders reviewed modifications at an in-person meeting with the principal investigator.

Overall recommendations from the researchers include:

  • Judicious use of text in computer- and web-based programs
  • Use of up-to-date images and illustrations
  • Tailoring/individualizing information to the target audience, with adaptations based on feedback from key stakeholders and program modifications presented to and reviewed by participating stakeholders.

The authors suggest that the next step is to determine whether the modified version of CALM improves providers’ fidelity to the CBT model and Veterans’ mental health outcomes.

Visit to read the free article.

*MIRECC affiliates in bold

Citation: Abraham TH, Marchant-Miros K, McCarther MB, Craske MG, Curran GM, Kearney LK, Greene C, Lindsay JA, Cucciare MA (2018). Adapting coordinated anxiety learning and management for Veterans Affairs community-based outpatient clinics: Iterative approach. Journal of Medical Internet Research Mental Health, 5, e10277.

Last updated: October 29, 2020