Consultation competencies in prolonged exposure therapy for posttraumatic stress disorder.

INTRODUCTION: The Emory University Prolonged Exposure (PE) Consultant Training Program seeks to develop a national network of competent PE consultants. Comprehensive training in empirically supported treatment (EST), such as PE, includes a didactic training followed by a period of experiential learning through consultation during real-world clinical practice (Karlin & Cross, 2014). Expert consultants are needed to meet demand as ESTs are disseminated. METHOD: The Emory program has developed a training model to develop 18 consultation skills within five competency domains: the consultation relationship, general psychotherapy skills, PE-specific skills, trainee barriers to delivery, and implementation. RESULTS: The current article outlines these domains and discusses their theoretical background and applied value for PE consultant training, drawing on examples from the Emory program. DISCUSSION: Just as manualizing therapy has allowed for EST dissemination, the operationalizing of consultation competencies can provide a first step in disseminating evidence-based consultation practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Consultation and professional development within the prolonged exposure initiative.

Previous studies have identified that ongoing consultation and organizational support are key factors in sustaining evidence-based implementation initiatives in community mental health. Clinician-level factors likely influence implementation but are not well delineated. This study assessed clinician-reported professional development incentives for participating in consultation in prolonged exposure (PE) therapy to guide future evidence-based practice (EBP) initiatives. Providers in the PE initiative (N = 22) completed a survey asking about their motivations to participate, the impact of consultation on the implementation of PE and their professional development goals, and the impact of organizational-level support on their goals and on organizational-level clinician turnover. Of the respondents, 10 had decided to pursue additional training to become PE consultants at their agencies. Providers (response rate = 22/35) reported joining the PE Initiative to learn an evidence-based practice in general (not PE specifically) and increase their skill in treating posttraumatic stress disorder. Providers largely found ongoing consultation helpful and reported that consultation provided the feedback and support necessary to achieve their professional goals. Providers who decided to pursue PE consultant training reported that expanding upon supervision and clinical skills were strong motivators. Providers largely attributed clinician turnover within the PE Initiative to organizational-level factors. Ongoing consultation facilitated providers' professional development goals. The survey identified several areas for further exploration, including how consultation can reduce clinician turnover, and how taking on additional responsibility within implementation initiatives can facilitate provider engagement in the EBP.

Effects of Workshop Training in the Dialectical Behavior Therapy Prolonged Exposure Protocol on Clinician Beliefs, Adoption, and Perceived Clinical Outcomes.

Although extensive efforts have been made to train clinicians in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), relatively few PTSD patients are considered appropriate for and therefore receive these treatments. The dialectical behavior therapy prolonged exposure (DBT PE) protocol was developed to expand the reach of EBPs for PTSD to suicidal patients with severe comorbidities, but methods of training clinicians to deliver this treatment have not been evaluated. We examined the impact of DBT PE workshops on clinician beliefs, adoption, and perceived patient outcomes. Clinicians (N = 266) attended 2- or 4-day workshops and completed surveys at pretraining, posttraining, and 3- and 6-month follow-ups. From pretraining to 6-month follow-up, there were significant improvements in clinician concerns regarding worsening, perceived treatment credibility, and self-efficacy that did not differ by workshop length, R2 s = .20-.45. At 6-months posttraining, 53.5% of clinicians (38.8% 2-day, 66.3% 4-day) reported using DBT PE with 241 patients. Higher posttraining ratings of self-efficacy and perceived treatment credibility predicted later DBT PE use, R2 = .28. Among adopting clinicians, 81.3% reported that, on average, their patients' PTSD improved and 66.7% reported that patients were much to very much improved on average. Most clinicians reported that their patients' comorbid problems did not worsen during DBT PE and if worsening occurred, it typically involved temporary increases in distress. Workshops may be an effective method of changing clinician beliefs and promoting the use of DBT PE in a manner that clinicians experience as effective and safe for their patients.

Training During a Pandemic: Successes, Challenges, and Practical Guidance From a Virtual Facilitated Learning Collaborative Training Program for Written Exposure Therapy.

In response to COVID-19, continued workforce training is essential to ensure that evidence-based treatments are available on the frontline to meet communities' ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID-19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence-based treatment for posttraumatic stress disorder, included virtual workshop training, phone-based clinical consultation, implementation-focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID-19-related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.

Training community providers in evidence-based treatment for PTSD: Outcomes of a novel consultation program.

OBJECTIVE: Extensive research supports the use of prolonged exposure (PE) and cognitive processing therapy (CPT), for posttraumatic stress disorder (PTSD) in veterans and service members. PE and CPT have been disseminated nationally across the Department of Veterans Affairs (VA) facilities. Many service members and veterans receive care outside the VA where access to these gold standard psychotherapies can be limited. This paper presents a novel program developed to train community providers in the use of PE and CPT and their application to veterans with PTSD through the use of a medium-touch approach to consultation. METHOD: Four 2-day trainings (2 in PE, 2 in CPT) were delivered to a total of 170 participants over an 8-month period. A subset of approximately 10 providers per training (n = 42) received 6 months of weekly, group phone consultation following the 2-day training. All providers were assessed pre- and posttraining, as well as 3 and 6 months after their training. Outcomes for the training workshop alone and the training plus 6 months of consultation were compared. RESULTS: While participant knowledge, t = -22.57, p < .001 and comfort (χ² = 74.00, p < .001) with PE and CPT significantly increased immediately following the 2-day training, those who received consultation were more likely to implement (χ² = 20.88, p < .001) and either complete or be close to completing PE or CPT with patients (χ² = 20.57, p < .001) 6 months following training. CONCLUSIONS: Despite some limitations, these preliminary data support that consultation is an important component to include in PTSD therapy training and implementation in the community. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A novel dissemination effort for prolonged exposure: Practice and dissemination curriculum.

OBJECTIVES: This study examines the effectiveness of a novel dissemination and implementation curriculum for prolonged exposure (PE). Predoctoral clinical psychology interns completed a sequential, four-part curriculum that culminated in a community-based practicum during which interns conducted a PE workshop. We hypothesized that workshop participants would report more favorable attitudes regarding PE after completing the intern-led workshop than endorsed at the outset of the workshop. METHOD: A total of 53 workshop participants attended and completed questionnaires. The majority of workshop participants had a master's-level degree or educational specialist degree (n = 28; 57.1%) and were currently a counselor or psychosocial rehabilitation worker (n = 21; 42.9%). We examined changes between pre- and posttraining time points for five self-report items related to negative attitudes toward PE and three self-report items related to intent to use PE. RESULTS: There was a significant effect of workshop training on four out of five items related to negative attitudes toward PE. The nonsignificant result of the fifth item may be due to a ceiling effect given that baseline scores for this item were very positive. There was a significant effect of workshop training on all three items related to intent to use PE. CONCLUSIONS: Results suggested that this sequential four-part curriculum may be an effective way of combining education, training, and dissemination efforts. Future research should examine if similar results can be achieved with a controlled research design and whether outcomes would generalize to actual PE delivery skills in routine clinical care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Feasibility of Training Frontline Therapists in Prolonged Exposure: A Randomized Controlled Pilot Study of Treatment of Complex Trauma in Diverse Victims of Crime and Violence.

The study aims were to determine whether prolonged exposure (PE) improved mental health and was feasible to implement by frontline clinicians in a culturally diverse sample with complex trauma. Seventy-one individuals were randomly assigned to PE or person-centered therapy (PCT). Outcome measures were administered at baseline and sessions 3, 6, 9, and 12. Mixed modeling was used to regress outcome measures on time, treatment group, and number of visits. Individuals who received PE showed significant moderate association with decline in reported posttraumatic stress disorder (PTSD) symptoms as noted by the PTSD Checklist for DSM-5 (p = 0.05) compared with PCT. Results indicated improved scores on all measures at each follow-up time point compared with baseline (p ≤ 0.01). PE was feasible, shown by positive recruitment and ability of clinicians to effectively implement and maintain treatment fidelity. Findings suggest that PE can be effective for treating complex trauma when used by clinicians in community settings.

Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training.

This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.

Targeting clinician concerns about exposure therapy: A pilot study comparing standard vs. enhanced training.

Owing to concerns about the safety and tolerability of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, which may limit its effectiveness. Although didactic training in exposure reduces clinician concerns about the treatment to a moderate extent, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an "enhanced" training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two training approaches. Relative to standard training, clinicians who received enhanced training showed: (a) significantly greater reductions in concerns about exposure from pre- to post-training, and (b) superior self-reported delivery of the treatment. Reduction in concerns during training mediated the effects of training condition on clinicians' self-reported exposure delivery. These findings underscore the importance of addressing clinician concerns about exposure therapy in training contexts.

Effects of a comprehensive training program on clinician beliefs about and intention to use prolonged exposure therapy for PTSD.

OBJECTIVE: Evidence for treatment efficacy does not guarantee adoption in clinical practice. Attitudinal "buy-in" from clinicians is also important. This study examines evaluation data from a national training program in an evidence-based treatment for PTSD, Prolonged Exposure (PE) therapy, to assess changes in clinician beliefs related to the importance of specific treatment goals, PE outcome expectations, self-efficacy to deliver PE, perceived time and emotional burdens associated with delivering PE, and intentions to use PE. METHOD: Training included both an interactive workshop and posttraining telephone consultation. Participants were 943 licensed mental health clinicians who treated veterans with PTSD. They completed questionnaires before and after the workshop, and after consultation. RESULTS: Results indicated that workshop participation was associated with significant increases in perceptions of the importance of helping patients improve by employing PE, expectations that patients would benefit from PE, and self-efficacy to deliver PE, and with reduced expectations of negative patient outcomes and concerns about distressing patients. The workshop alone had little impact on expected clinician emotional burden and no impact on anticipated time burden. Participation in ongoing case consultation was associated with additional increases in expected positive patient outcomes and clinician self-efficacy and further reductions in concerns about distressing patients and negative patient outcomes. Unlike the workshop, consultation was associated with decreased expectancies that PE would take too much time and would be emotionally burdensome to provide. CONCLUSION: Overall, the results suggest that the combination of workshop and ongoing consultation can significantly improve beliefs likely to affect treatment adoption. (PsycINFO Database Record

Training in the implementation of prolonged exposure therapy: provider correlates of treatment outcome.

The authors examined the degree to which provider characteristics, such as profession, treatment orientation, prior experience in treating posttraumatic stress disorder (PTSD), prior experience with prolonged exposure (PE) therapy, and attitudes about PE, were related to the clinical outcomes of veterans receiving care from clinicians participating in the national Department of Veterans Affairs (VA) PE Training Program. Positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience treating PTSD, and prior PE training experience. With 1,105 providers and 32 predictors (13 provider variables), power was at least 90% power to detect an effect of ß = .15. Profession was the only provider characteristic significantly related to outcomes, but the mean effect (a 2 point difference on the PTSD Checklist) was too small to be clinically meaningful. The results support the intensive training model used in the VA PE training program and demonstrate that clinicians of varying backgrounds can be trained using interactive training workshops followed by case consultation to deliver PE effectively.

Exposing clinicians to exposure: a randomized controlled dissemination trial of exposure therapy for anxiety disorders.

OBJECTIVE: The present study evaluated three technology-based methods of training mental health providers in exposure therapy (ET) for anxiety disorders. Training methods were designed to address common barriers to the dissemination of ET, including limited access to training, negative clinician attitudes toward ET, and lack of support during and following training. METHOD: Clinicians naïve to ET (N=181, Mage=37.4, 71.3% female, 72.1% Caucasian) were randomly assigned to (a) an interactive, multimedia online training (OLT), (b) OLT plus a brief, computerized motivational enhancement intervention (OLT+ME), or (c) OLT+ME plus a Web-based learning community (OLT+ME+LC). Assessments were completed at baseline, posttraining, and 6 and 12weeks following training. Outcomes include satisfaction, knowledge, self-efficacy, attitudes, self-reported clinical use, and observer-rated clinical proficiency. RESULTS: All three training methods led to large and comparable improvements in self-efficacy and clinical use of ET, indicating that OLT alone was sufficient for improving these outcomes. The addition of the ME intervention did not significantly improve outcomes in comparison to OLT alone. Supplementing the OLT with both the ME intervention and the LC significantly improved attitudes and clinical proficiency in comparison to OLT alone. The OLT+ME+LC condition was superior to both other conditions in increasing knowledge of ET. CONCLUSIONS: Multicomponent trainings that address multiple potential barriers to dissemination appear to be most effective in improving clinician outcomes. Technology-based training methods offer a satisfactory, effective, and scalable way to train mental health providers in evidence-based treatments such as ET.

Factors related to clinician attitudes toward prolonged exposure therapy for PTSD.

This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.

Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation.

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs' residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.

Implementation outcomes of military provider training in cognitive processing therapy and prolonged exposure therapy for post-traumatic stress disorder.

Between 2006 and 2012, the Department of Defense trained thousands of military mental health providers in the use of evidence-based treatments for post-traumatic stress disorder. Most providers were trained in multiday workshops that focused on the use of Cognitive Processing Therapy and Prolonged Exposure. This study is a follow-up evaluation of the implementation practices of 103 Air Force mental health providers. A survey was administered online to workshop participants; 34.2% of participants responded. Findings on treatment implementation with the providers indicated that a majority of respondents found the trainings valuable and were interested in using the treatments, yet they reported a lack of time in their clinic appointment structure to support their use. Insufficient supervision was also cited as a barrier to treatment use. Results suggest the need to improve strategies for implementing evidence-based practices with providers to enhance clinical outcomes in military settings.

Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care.

IMPORTANCE: Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. OBJECTIVE: To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. DESIGN, SETTING, AND PARTICIPANTS: This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. MAIN OUTCOMES AND MEASURES: Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. RESULTS: Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d = 0.87) and depression (pre-post d = 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklist decreased from 87.6% to 46.2%. CONCLUSIONS: Clinically significant reductions in PTSD symptoms were achieved among male and female veterans of all war eras and veterans with combat-related and non-combat-related PTSD. Results also indicate that PE is effective in reducing depression symptoms, even though depression is not a direct target of the treatment.

Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation.

Despite its effectiveness, exposure therapy is underutilized and frequently implemented in suboptimal fashion. Research has shown negative beliefs about exposure are related to its underutilization, and these beliefs are held by exposure therapists and may play a causal role in its suboptimal delivery. This study examined the effect of negative beliefs about exposure on treatment delivery. Participants (n=53) received training in basic exposure implementation and were given additional information intended to elicit either positive or negative beliefs about the treatment's safety, tolerability, and ethicality prior to conducting an exposure session with a confederate client. Results indicated that participants with experimentally induced negative beliefs about exposure delivered the treatment more cautiously (e.g. creation of a less ambitious exposure hierarchy, selection of a less anxiety-provoking exposure task, attempts to minimize client anxiety during exposure) compared to participants with positive beliefs who pursued more ambitious delivery of exposure (e.g. encouraging clients' use of oppositional actions). The present findings suggest that therapist reservations about exposure cause suboptimal delivery and may adversely affect client outcomes.

Predicting adoption of exposure therapy in a randomized controlled dissemination trial.

The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) after training. Therapists naïve to ET (N=181) were randomized to: (1) online training (OLT), (2) OLT plus motivational enhancement (ME), or (3) OLT+ME plus a learning community. Twelve weeks after training, self-reported use of ET in clinical practice was high (87.5%) and therapists demonstrated moderate clinical proficiency. Use of ET was predicted by therapist degree, self-efficacy, and knowledge. Clinical proficiency was predicted by therapist anxiety sensitivity, attitudes, and knowledge, as well as organizational and client barriers. Several of these effects were moderated by training condition, indicating that therapists who received more comprehensive training were less impacted by barriers and showed enhanced adoption in the presence of facilitating factors. Overall, these results suggest that the primary barriers to the adoption of ET are therapist, not organizational or client, factors.

A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs.

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced-based treatments (EBTs). Face-to-face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.

Overcoming barriers to disseminating exposure therapies for anxiety disorders: a pilot randomized controlled trial of training methods.

The present study evaluated methods for training mental health providers (N=46) in exposure therapies (ETs) for anxiety disorders. A pilot randomized controlled trial compared: (1) an interactive, multimedia online training (ET OLT), (2) the ET OLT plus a brief Motivational Interviewing-based intervention (ET OLT+MI), and (3) a placebo control OLT. Assessments were completed at baseline, post-training, and one-week following training. Both ET OLT and ET OLT+MI received high satisfaction ratings and were comparably effective at increasing knowledge of ETs as well as clinicians' overt efforts to learn and use the treatment. ET OLT+MI was the most effective method for improving clinicians' attitudes toward ETs. Results indicate that OLT is effective for disseminating knowledge about ETs to clinicians, and suggest that supplementing OLT with a brief MI-based intervention may be a promising direction to address potential attitudinal barriers to adopting these highly efficacious treatments.