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Contents lists available at ScienceDirect

Journal of Anxiety Disorders

A real world dissemination and implementation of Transdiagnostic

Behavior Therapy (TBT) for veterans with affective disorders
Daniel F. Gros a,b, , Derek D. Szafranski a,b , Sarah D. Shead a
a
b

Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, United States
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States

a r t i c l e

i n f o

Article history:
Received 23 October 2015
Received in revised form 3 March 2016
Accepted 21 April 2016
Available online xxx
Keywords:
Transdiagnostic Behavior Therapy
TBT
Dissemination
Implementation
Veterans
Veterans Affairs Medical Center

a b s t r a c t
Dissemination and implementation of evidence-based psychotherapies is challenging in real world
clinical settings. Transdiagnostic Behavior Therapy (TBT) for affective disorders was developed with
dissemination and implementation in clinical settings in mind. The present study investigated a voluntary local dissemination and implementation effort, involving 28 providers participating in a four-hour
training on TBT. Providers completed immediate (n = 22) and six-month follow-up (n = 12) training assessments and were encouraged to collect data on their TBT patients (delivery delity was not investigated).
Findings demonstrated that providers endorsed learning of and interest in using TBT after the training. At
six-months, 50% of providers reported using TBT with their patients and their perceived effectiveness of
TBT to be very good to excellent. Submitted patient outcome data evidenced medium to large effect sizes.
Together, these ndings provide preliminary support for the effectiveness of a real world dissemination
and implementation of TBT.
Published by Elsevier Ltd.

1. Introduction
Transdiagnostic treatments, or those that apply the same
underlying treatment principles across mental disorders, without tailoring the protocol to specic diagnoses (McEvoy, Nathan,
& Norton, 2009; p. 21), are based on two principles, (1) some
disorder categories have common underlying symptoms and (2)
evidence-based psychotherapy (EBP) protocols designed to address
these symptoms contain overlapping components. This may be
particularly true in the affective disorders (depressive disorders,
anxiety disorders, obsessive-compulsive and related disorders, and
trauma- and stressor-related disorders). Affective disorders have
been shown to have common underlying symptoms and so their
related disorder-specic cognitive behavioral therapy (CBT) protocols contain important, but overlapping, treatment components. It
has been suggested that these components can be distilled into a
single treatment and therefore address the symptoms and comorbidities across multiple disorders at once (Norton, 2009). To date, a
small number of transdiagnostic treatment approaches have been
proposed for the affective disorders (Norton, 2009). Although still

Corresponding author: Mental Health Service 116, Ralph H. Johnson VAMC, 109
Bee Street, Charleston, SC 29401, United States.
E-mail address: grosd@musc.edu (D.F. Gros).

in development and preliminary evaluation, early outcomes suggest that transdiagnostic approaches can be delivered efcaciously
across the affective disorders, with moderate-to-high effect sizes
(Farchione et al., 2012; Gros, 2014; Norton, 2012; Schmidt et al.,
2011).
One such example of a transdiagnostic treatment is Transdiagnostic Behavior Therapy (TBT). TBT is a newly developed
transdiagnostic psychotherapy designed to treat veterans with
affective disorders, including major depressive disorder (MDD),
panic disorder (PD), social anxiety disorder (SOC), generalized
anxiety disorder (GAD), posttraumatic stress disorder (PTSD),
obsessive-compulsive disorder (OCD), and specic phobia (SP)
(Gros, 2014). TBT stands out as the only transdiagnostic psychotherapy developed and investigated in veterans and within
the Department of Veterans Affairs (DVA). In addition, TBT also
was developed specically with ease of dissemination across DVA
providers, programs, and settings in mind. The initial data on TBT
has been quite promising with large treatment effects for veterans
with various affective disorders and comorbidities (Gros, 2014).
In addition, a large randomized control trial is currently ongoing
(Gros, 2015).
The signicance of TBT with the DVA is that the DVA is among
the leaders in the efforts to disseminate and implement EBP
protocols (Ruzek, Karlin, & Zeiss, 2012). From October 2007 to
September 2010, the DVA was responsible for training over 3800

http://dx.doi.org/10.1016/j.janxdis.2016.04.010
0887-6185/Published by Elsevier Ltd.

Please cite this article in press as: Gros, D. F., et al. A real world dissemination and implementation of Transdiagnostic Behavior Therapy
(TBT) for veterans with affective disorders. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.04.010

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DVA providers and over 800 Department of Defense personnel

(Ruzek et al., 2012). The treatments that were most disseminated
include Cognitive Processing Therapy for PTSD, Prolonged Exposure
for PTSD, Cognitive Behavioral Therapy for MDD, and a few others
(e.g., Problem Solving Therapy). The goal of this effort is to make
these treatments available to all veterans in need. A second goal
is to educate DVA providers on how to deliver EBPs for a variety
of disorders. However, there are obvious gaps in these efforts. For
example, PD, SOC, GAD, and OCD have a high prevalence within
the DVA (Gros, Frueh, & Magruder, 2011; Gros, Magruder, & Frueh,
2013; Kashdan, Frueh, Knapp, Hebert, & Magruder, 2006; Milanak,
Gros, Magruder, Brawman-Mintzer, & Frueh, 2013), and yet, no
EBP trainings have been made available for them. Second, DVA
providers who treat a variety of affective disorders are required to
learn and implement a large number of EBPs for specic disorders,
resulting in substantial allocated time for training, huge funding
required from the DVA, and increased provider burden (e.g., travel)
(Ruzek et al., 2012). Transdiagnostic psychotherapies, such as TBT,
attempt to address these concerns by increasing veteran access to
EBPs and reducing training requirements for providers and related
costs for the DVA, with the primary goal of delivering better coverage across affective disorders as a whole and for their comorbidities.
Unfortunately, no published dissemination efforts of transdiagnostic psychotherapy exist, leaving a substantial gap in the
literature.
The goal of the present study is to investigate a dissemination
effort of TBT to providers at a large Southeastern DVA Medical
Center (VAMC). In contrary to the larger dissemination efforts for
disorder-specic EBP protocols (e.g., Prolonged Exposure for PTSD),
that involve travel, three days of training, and six months of continued supervision, the present study involved a four hour in-person
training at the local site with no required supervision for and
continuing education on TBT. The investigation included: (1) TBT
learning acquired by provider participants during the training session and the provider participants likelihood of using TBT with
various diagnoses in their clinical practice, (2) a 6-month follow-up
evaluation of provider participants use and perceived effectiveness
of TBT with various diagnoses, and (3) the basic effectiveness of
TBT as delivered and collected by the participating providers (no
delity data collected). Despite the short training period and lack
of formal requirements or nancial compensation, we hypothesize
that a portion of providers will elect to use TBT in lieu of disorderspecic EBP protocols when treating a variety of affective disorders,
and for those that did and collected data on said patients, the treatment would demonstrate basic effective in treating veterans with
affective disorders.

the TBT protocol was taught session-by-session with availability for

questions and answers throughout. As detailed elsewhere (Gros,
2014), TBT is designed as a 12 session transdiagnostic exposure
therapy that includes primary components of psychoeducation
on symptoms, avoidance (targeted transdiagnostic symptom), and
exposure, exposure practices and their renement, and relapse prevention strategies. Several case examples were provided using TBT
to more fully explain its implementation.
At the conclusion of the training session, provider participants were asked to complete a voluntary immediate post-training
assessment on their learning and likelihood use of TBT (e.g., assessments passed out at end of session and turned in by willing
provider participants). Twenty-two immediate assessments were
completed. Provider participants also were asked to collect data
on their TBT patients and provided with an assessment packet
described below. The immediate post-training assessment and collection of patient data were not required, nor was any nancial
incentive offered or provided to complete them.
At a six-month mark following the training, a voluntary
six-month post-training assessment was emailed to provider participants in June 2015 and then again in July 2015 as a reminder.
The assessment focused on provider participants use and perceived
effectiveness of TBT. Twelve six-month assessments were returned.
There was no requirement for provider participants to use TBT
after the training, nor any nancial incentive to use TBT, collect
patient outcome data, and/or return the six-month assessment or
collected patient data. All treatment and related patient data collection procedures were approved by the local DVA Research and
Development Committee as well as the afliated medical universitys Institutional Review Board.
2.2. Participating providers
The training was attended by 28 provider participants from a
large Southeastern VAMC and afliated Department of Psychiatry from a neighboring medical school. Of this group of providers,
13 were Ph.D. level psychologists (61.5% licensed), 7 MSWs (85.7%
licensed), 7 clinical psychology interns (0% licensed), and 1 MAlevel licensed profession counselor intern (0% licensed). In addition,
70% of these provider participants were in direct patient care positions spanning across a variety of DVA programs including, primary
care mental health integration, cognitive behavioral treatment
clinic, telehealth psychotherapy, and PTSD clinic. No demographics were collected on this sample of providers beyond their degree,
licensure status, and direct patient care status.
2.3. Provider assessment tools

2. Method
2.1. Training and assessment procedures
A service wide email was sent to providers at the VAMC and
afliated medical university in October 2014, soliciting interest and
availability in training in TBT. Forty-one staff and trainees replied
with interest. The training was set in December 2014 to allow time
to gain supervisor approval and block treatment clinics. The training also was tailored and set for a 4-h block based on staff/trainee
availability and permissions. On the day of the training, 28 provider
participants attended the entire training. There was no requirement
or compensation for providers to attend the training.
The training involved several sections. The rst section began
with training on the background on the transdiagnostic perspective as well as review of available transdiagnostic psychotherapies
and their support in published research. The second section covered the development and related evidence supporting TBT. Next,

2.3.1. Immediate post-assessment

The immediate post-assessment measure is made up for three
primary sections. The rst section assesses the quality of the training session on a 5-point scale, including the course content, slides,
TBT manual and its presentation, and training activities. The second section assesses provider participants experience and comfort
with EBPs, exposure to transdiagnostic practices in general, understanding of TBT, and their likelihood of using TBT with affective
disorders and their comorbidities. Each question was rated on a
5-point scale and was assessed for before training and after training. The third section contains open-ended questions on how to
improve the training experience. This measure was created for the
TBT training. For the purposes of this study, only the questions in
the second section will be presented.
2.3.2. Six-month post-assessment
The Six-Month Post-Assessment measure contains ve sets of
questions. Questions 1 and 2 ask in what percentage of patients

Please cite this article in press as: Gros, D. F., et al. A real world dissemination and implementation of Transdiagnostic Behavior Therapy
(TBT) for veterans with affective disorders. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.04.010

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Table 1
Pre- to post-training provider learning in TBT initial training.
Scale

Pre

Post

Effect Size

Past experience with EBPs for ADs

Comfort using EBPs with patients with ADs
Exposure to transdiagnostic treatment
Understanding transdiagnostic treatment need
Understanding TBT
Condence in using TBT
Likelihood of using TBT with ADs single disorder
Likelihood of using TBT with ADs comorbidity
Likelihood of using TBT with PTSD

3.6 (1.0)
3.8 (0.9)
1.7 (1.1)
2.2 (1.1)
2.0 (1.2)
1.9 (1.2)
2.0 (1.2)
1.9 (1.2)
1.8 (1.0)

3.4 (1.0)
4.0 (0.8)
3.9 (0.8)
3.8 (0.9)
3.9 (0.8)
3.8 (0.9)
3.2 (1.0)

8.2*
8.9*
9.7*
8.8*
9.6*
9.2*
6.6*

1.62
1.87
1.86
1.79
1.86
1.79
1.4

Note: EBPs = Evidence-based psychotherapies. ADs = affective disorders. Pre and post values are presented as means (standard deviations). All scales are scored on a 5 point
scale ranging from 1 to 5. Cohens ds used for effect sizes.
*
p < 0.001.

that provider participants used TBT and how much they liked TBT,
respectively. Question 3 assesses how frequently provider participants used TBT with patients with various diagnoses (e.g., MDD,
PD, PTSD, SOC, GAD, and OCD), as well as in patients with a single
diagnosis and in patients with diagnostic comorbidity. Question 4
assesses provider participants perceived effectiveness of TBT with
each disorder and presentation. Question 5 asks why provider participants did not use TBT with some or all of their patients.
2.4. Patient assessment tools
2.4.1. Depression anxiety stress scales 21-item version (DASS)
The DASS (Lovibond & Lovibond, 1995) is a 21-item measure
with three subscales designed to assess dysphoric mood (depression subscale), symptoms of fear and autonomic arousal (anxiety
subscale), and symptoms of tension and agitation (stress subscale).
Items are rated on a 4-point Likert scale, ranging from 0 to 3, and
summed to compute the three subscales. Support for the factor
structure, convergent and discriminant validity, and internal consistency of the DASS has been found (Lovibond & Lovibond, 1995).
Additional support for the internal consistency of the scales was
found in the present studies (s 0.85).

with a score of 38 or greater indicating that participant likely has

PTSD (Weathers et al., 2013). Previous versions of the PCL have
been shown to have excellent internal consistency (s > 0.94) and
excellent test-retest reliability in veterans (r = 0.96; Orsillo, Batten,
& Hammond, 2001).

2.4.5. State-Trait inventory for cognitive and somatic anxiety

trait version (STICSA-T)
The STICSA-T (Gros, Antony, Simms, & McCabe, 2007; Ree,
French, MacLeod, & Locke, 2008) is a 21-item measure designed
to assess trait cognitive and somatic anxiety. The cognitive and
somatic subscales have been supported by factor analysis and
both subscales have been found to have high internal consistency
(alphas > 0.87; Gros et al., 2007, 2010). In addition, the STICSA-T
scale was found to remain stable over repeated administrations
during several stress manipulations (rs > 0.65; Ree et al., 2008).

3. Results
3.1. Provider assessments

2.4.2. Illness intrusiveness ratings scale (IIRS)

The IIRS (Devins et al., 1983) is a 13-item questionnaire that
assesses the extent to which a disease interferes with important
domains of life, including health, diet, work, and several others.
Each item is rated on a 7-point Likert scale, ranging from 1 to
7. The total summed scale score was used in the present study,
rather than the three subscales, due in part to the sample size and
planned analyses (Devins, 2010). The IIRS has been shown to have
strong psychometric properties in the previous literature in participants with physical and/or emotional health concerns (Devins et al.,
2001; Devins, 2010). Additional support for the internal consistency
of the scale was found in the present studies (s > 0.74).

3.1.1. Initial training

Twenty-two provider participants completed the immediate
post-training assessment at the completion of the training. The
ndings are presented in Table 1. In general, provider participants
reported having existing experience with EBPs and in delivering
them to patients with affective disorders (Ms > 3.5). Through the
course of the training, provider participants demonstrated significant learning on all measures, including understand the need for
transdiagnostic treatments, understanding TBT, condence in using
TBT, and the likelihood of using TBT in various conditions (ts > 6.5;
ps < 0.001).

2.4.3. Mini international neuropsychiatric interview 7.0 (MINI)

The MINI is a structured diagnostic interview designed to provide a brief, but accurate, assessment of a wide range of DSM-5
psychiatric disorders (American Psychiatric Association, 2014),
including the mood disorders, anxiety disorders, and substance use
disorders. Previous versions of the MINI have demonstrated adequate inter-rater and test-retest reliability across most disorders,
and have shown good inter-rater reliability with SCID diagnosis
( = 0.7) (Sheehan et al., 1998). For the purposes of the present
study, only the affective disorders were assessed.

3.1.2. Six month follow-up

Twelve (50%) provider participants completed the six month
follow-up training assessment. Of the responders, six (50%)
provider participants reported using TBT post-training; however,
all respondents reported liking TBT and described TBT as a useful
treatment (M = 4.3; SD = 0.7) on a 5-point scale. The ndings for use
and perceived effectiveness of TBT with various conditions are presented in Table 2. In general, provider participants that endorsed
using TBT reported using it roughly equally across conditions, but
reported some variation in its perceived effectiveness across conditions, with GAD receiving the least perceived effectiveness and
with OCD receiving the most perceived effectiveness. Provider participants rated their likelihood to use and perceived effectiveness
equally in patients with a single diagnosis and in patients with
diagnostic comorbidity.

2.4.4. PTSD checklist 5 (PCL-5)

The PCL-5 is a 20-item self-report measure that assesses DSM-5
criteria PTSD symptoms experienced in the last month. Items assess
symptoms on a 04 Likert scale. Total scores range from 0 to 80,

Please cite this article in press as: Gros, D. F., et al. A real world dissemination and implementation of Transdiagnostic Behavior Therapy
(TBT) for veterans with affective disorders. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.04.010

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Table 2
Reported use and success of TBT by trained providers at 6-month after training.
Disorder

Frequency of Use

Perceived
Effectiveness

Major Depressive Disorder

Panic Disorder
Posttraumatic Stress Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Patients with a Single Diagnosis
Patients with Diagnostic Comorbidity

2.4 (1.3)
2.7 (1.9)
2.7 (1.6)
2.4 (1.5)
2.1 (1.6)
2.8 (2.0)
2.4 (1.3)
2.4 (1.3)

3.8 (1.0)
4.3 (1.0)
4.0 (0.8)
4.0 (0.8)
3.5 (1.3)
4.7 (0.6)
3.8 (1.0)
3.8 (1.0)

Note: Values are presented as means (standard deviations). All scales are scored on
a 5 point scale ranging from 1 to 5.

3.2. Patient assessments

3.2.1. Demographics
Data from 16 complete patients were submitted by providers
with the six month follow-up assessment. Unfortunately, data on
the patients that discontinued treatment was not available, because
most providers only forwarded completers data. And so, only treatment completers were investigated. The average patient was 47.4
years old (SD = 15.0), male (87.5%), White (81.3%; Black: 18.8%),
employed (56.3%), served in a combat zone (50.0%), and was receiving disability services through the DVA (62.5%). The average patient
was diagnosed with 1.8 affective disorders, with 56.3% endorsing
at least one comorbid affective disorder. The most common principal diagnosis was PTSD (37.5%), followed by MDD (25.0%) and
SOC (18.8%). MDD (18.8%) and SOC (18.8%) were the most common
additional diagnoses.
3.2.2. Treatment outcome
Patients attended an average of 11.6 (SD = 4.3) treatment sessions. Paired-samples t-tests were conducted to examine the preto post-treatment symptom improvement in treatment completers
on the DASS subscales, PCL-5, STICSA-T, and IIRS. As presented in
Table 3, patients demonstrated signicant improvements across
all assessed symptoms (ts > 2.3; ps < 0.04), including symptoms of
depression, general anxiety, stress, PTSD, cognitive anxiety, somatic
anxiety, and general impairment. Medium-to-large effects were
demonstrated for each of these symptom improvements (ds > 0.65),
with over 70% of them large with ds > 1.0.
4. Discussion
The present study investigated the effectiveness of a real world
dissemination and implementation effort of TBT, a transdiagnostic psychotherapy developed in part with ease of dissemination
and implementation in mind (Gros, 2014). After attending a voluntary four hour training, provider participants completed immediate
feedback, six-month feedback, and provided patient outcome data,
if collected. There were no requirements and no compensation
for provider participants complete any of the assessments and
data collections, use TBT in clinical practice, or collect symptom
related outcome data. Despite the voluntary nature of the training and related assessments, sufcient data was collected to test
our hypothesis that providers would elect to use TBT and that TBT
would be effective in patients that were treated by said providers
with TBT. In general, TBT was well liked by provider participants
after the training, used by half of the responders in many of their
patients by the six month follow-up assessment, and was effective
in treating transdiagnostic symptoms across patients.
The true novelty of the study design was its use of a real world
clinical setting. The study was completed in a VAMC with VAMC
staff and trainees working in a variety of VAMC clinical programs,

but without any expectations, requirements, or incentives associated with the training. In fact, the participation in the training
and use of TBT afterwards without extrinsic incentive to do so
demonstrate the true effectiveness of the training. More specically, provider participants learned TBT and used TBT with their
patients because they simply wanted to learn it and believed that
TBT could work (better) with their patients. As such, these ndings
have excellent external validity, mirroring what could be possible
in similar settings. In contrast, DVA dissemination efforts only promoted disorder-specic EBPs for a small set of disorders, took a
full week between travel and the three day trainings as well as six
months of supervision to complete, and typically are required by
local EBP coordinators. Although outcomes are very promising in
the specic conditions/treatments under investigation (e.g., EBPs
for PTSD) (Ruzek et al., 2012), the approach in the present study
may be an easier, less expensive, and more welcoming (voluntary)
approach to train providers in EBPs pending replication and comparison studies. Moreover, in order to effectively treat the many
disorders common in psychotherapy clinics (e.g., affective disorders), training in transdiagnostic treatments allow providers to
learn only one protocol in one training, instead of a multitude of
diagnosis specic protocols across multiple trainings.
Even more surprising than the learning from and acceptance of
the training was the use of TBT by providers following the training. Without any requirement, half of the responding providers
endorsed using TBT with some of their patients across all disorders
assessed. This is particularly impressive as several of the responders
that denied using TBT, noted that their treatment setting would
not permit its use (e.g., disorder-specic EBP clinics that require
a specic treatment or non-treatment setting). And on top of that
nding, patients that received TBT demonstrated signicant treatment gains. In fact, moderate-to-large effects were seen across all
measures of psychopathology despite not all patients having the
symptoms or disorder that was assessed. For example, a large effect
was found on the DASS-Depression with only 43.8% of patients with
MDD diagnoses. The effect sizes for TBT were smaller than those in
the initial TBT study (Gros, 2014); this could be a result of the differences in exposure to and supervision of TBT between the studies
and lack of delity data in the present study. However despite the
lack of delity data, patients reported to receive TBT still demonstrated large effects compared to expected effects for the typical
treatment-as-usual for many of these conditions in the DVA (e.g.,
eclectic/support therapies).
Although the mechanisms for successful implementation are
yet unknown (Greenhalgh, Mcfarlane, Bate, & Kyriakidou, 2004),
this TBT dissemination and implementation efforts appears to have
been effective. The success in these efforts may be explained by how
the study addressed several of the common challenges in dissemination and implementation research as outlined by Weisz, Ng, and
Bearman (2014). First for the implementation cliff, TBT was developed in a DVA clinical research setting with the training of DVA
providers in mind, rather than in an academic department. Second
for the (ir)relevance of research to practice, the focus on transdiagnostic practice and goal to reduce EBPs to learn was shown to be
appealing to providers. Third for the timeline mismatch, the TBT
dissemination effort was completed prior to the completion of the
currently in-progress randomized clinical trial (Gros, 2015) to maximize its relevance to providers, versus waiting another three years
for study completion and dissemination of the ndings. And forth
for the goal tensions and the implementation limbo, this project
was an unfunded pilot/demonstration in a real world clinical setting without any nancial or time pressures, which prevented these
challenges from inuencing the dissemination and implementation
effort. Due to the success of this implementation, similar (voluntary and brief) efforts for treatments in similar settings and stages
should be considered.

Please cite this article in press as: Gros, D. F., et al. A real world dissemination and implementation of Transdiagnostic Behavior Therapy
(TBT) for veterans with affective disorders. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.04.010

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Table 3
Efcacy of providers use of TBT with DVA patients.
Scale

Pre

Post

t (p)

Effect Size

IIRS-Impairment
PCL-5-PTSD
STICSA-T-Cognitive
STICSA-T-Somatic
DASS-Depression
DASS-Anxiety
DASS-Stress

58.1 (12.7)
48.8 (19.6)
28.1 (5.0)
23.0 (5.9)
10.9 (4.6)
9.6 (5.3)
12.9 (5.4)

42.6 (17.5)
27.0 (18.3)
20.3 (6.2)
18.9 (6.5)
4.9 (3.9)
6.0 (4.6)
7.6 (4.4)

4.3 (0.001)
3.4 (0.004)
4.3 (0.001)
2.4 (0.031)
4.9 (<0.001)
3.3 (0.005)
4.3 (0.001)

1.01
1.15
1.39
0.66
1.08
0.73
1.08

Note: Sum scores reported as means (standard deviations). Cohens ds used for effect sizes.

The implications for these ndings are numerous given the

challenges in current dissemination and implementation efforts
(Fairburn & Wilson, 2013; Ruzek et al., 2012; Weisz et al., 2014).
The present study demonstrated a real world dissemination and
implementation effort with reasonable success as demonstrated
by 50% of responders and 21.4% of the total sample of providers
reported using TBT six-months after the four hour training and
without unnecessary burden on provider volunteers (e.g., no ongoing supervision and delity recordings). These ndings suggest that
shorter trainings may be possible in order to engage providers. In
addition, no additional resources, beyond administrative support to
block clinics, were needed due largely to the short duration, local
presentation of the training, and its voluntary nature. In addition,
the freshness of TBT (still under investigation) seemed to engage
providers, with some even attending despite no availability to use
the treatment in their own clinical settings (e.g., providers from
solely research settings). And nally, the simplicity of and attention to dissemination and implementation of TBT may contribute
to the success of its dissemination. More complicated EBP protocols
may consider lighter/more straightforward versions to potentially
improve their dissemination and implementation efforts.
The study contained a number of limitations, especially with its
demonstration nature in real world clinical setting. The response
rate to the two provider assessments and patient data was small.
The voluntary nature of the procedures may explain the provider
component and the clinical setting in which most clinicians do
not keep self-report data on their patients beyond the session
itself. No demographic or clinical experience data were collected
on the providers to determine factors associated with use and
success with TBT. No information on delity of the delivery of
TBT was collected to determine the consistency of the delivery of
TBT with the TBT protocol. Finally, no provider control group was
investigated to determine and compare TBT patient outcomes with
standard patient outcomes without TBT, nor was there a comparison group for another EBP to investigate the use and effectiveness of
the dissemination and implementation of an alternative treatment
delivered in this manner.
The present study investigated a real world dissemination and
implementation effort of TBT. The treatment was well received
and used by 50% of respondents six months after the training, and
patients that received TBT from said providers demonstrated large
treatment effects. This small successful dissemination and implementation effort with a voluntary, short, local training may have
implications for larger efforts that have been less successful and/or
more costly (Fairburn & Wilson, 2013; Ruzek et al., 2012; Weisz
et al., 2014). In addition, the dissemination and implementation
effort was consistent in addressing each of the common challenges
in this area of research (Weisz et al., 2014), which likely aided in
its success. Together, these preliminary ndings support the effectiveness of local and voluntary dissemination and implementation
methods as well as providing continued support for TBT in the
treatment of the affective disorders.

Acknowledgments
This study is supported by Department of Veteran Affairs Clinical
Sciences Research and Development Career Development Award
CX000845 (PI: Gros). The views expressed in this article are those
of the authors and do not necessarily reect the position or policy
of the Department of Veterans Affairs or the United States government. There are no conicts of interest to disclose. I would like to
thank the providers within the Ralph H. Johnson Veterans Affairs
Medical Center for their participation in this project.

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Please cite this article in press as: Gros, D. F., et al. A real world dissemination and implementation of Transdiagnostic Behavior Therapy
(TBT) for veterans with affective disorders. Journal of Anxiety Disorders (2016), http://dx.doi.org/10.1016/j.janxdis.2016.04.010