Abstract
Background: Posttraumatic Stress Disorder (PTSD) is a serious mental health condition with substantial costs to individuals and society. Among military veterans, the lifetime prevalence of PTSD has been estimated to be as high as 20%. Numerous research studies have demonstrated that short-term cognitive-behavioral psychotherapies, such as Cognitive Processing Therapy (CPT), lead to substantial and sustained improvements in PTSD symptoms. Despite known benefits, only a minority of clinicians provide these therapies. Transferring this research knowledge into clinical settings remains one of the largest hurdles to improving the health of veterans with PTSD. Attending a workshop alone is insufficient to promote adequate knowledge transfer and sustained skill; however, relatively little research has been conducted to identify effective post-training support strategies. Methods: The current study investigates whether clinicians receiving post-workshop support (six-month duration) will deliver CPT with greater fidelity (i.e., psychotherapy adherence and competence) and have improved patient outcomes compared with clinicians receiving no formal post-workshop support. The study conditions are: technology-enhanced group tele-consultation; standard group tele-consultation; and fidelity assessment with no consultation. The primary outcome is independent assessment (via audio-recordings) of the clinicians’ adherence and competence in delivering CPT. The secondary outcome is observed changes in patient symptoms during and following treatment as a function of clinician fidelity. Post-consultation interviews with clinicians will help identify facilitators and barriers to psychotherapy skill acquisition. The study results will inform how best to implement and transfer evidence-based psychotherapy (e.g., CPT) to clinical settings to attain comparable outcomes to those observed in research settings. Discussion: Findings will deepen our understanding of how much and what type of support is needed following a workshop to help clinicians become proficient in delivering a new protocol. Several influences on clinician learning and patient outcomes will be discussed. An evidence-based model of clinical consultation will be developed, with the ultimate goal of informing policy and influencing best practice in clinical consultation. Trial registration: ClinicalTrials.gov: NCT01861769
Highlights
Posttraumatic Stress Disorder (PTSD) is a serious mental health condition with substantial costs to individuals and society
Cognitive Processing Therapy (CPT) is a 12-session, traumafocused cognitive therapy that targets symptoms of PTSD and its comorbidities [19] that results in sustained, significant reductions in symptoms and increases in quality of life for diverse populations [20-34]
To adequately prepare clinicians to deliver Evidence based psychotherapy (EBP) with fidelity, training packages that include post-workshop consultation and feedback have emerged as best practices, but little is understood about the relative benefits of different consultation strategies [41,42]
Summary
This randomized controlled dismantling trial has independent fidelity rating as the primary outcome and patient outcomes as the secondary outcomes. Participation in the study requires that all clinicians consent at least two clients to have all of their CPT sessions audio-recorded for use in consultation and/or fidelity rating. Provider status will be awarded to clinicians who demonstrate an acceptable level of fidelity to CPT based on session recordings randomly selected from the last two weeks of the six-month post-workshop period. Fidelity is a key implementation outcome in the model by Proctor and colleagues [73] and in this study, fidelity to EBPs has not been adequately assessed by independent evaluators in prior implementation research It has either not been assessed at all, or has been assessed through self-report, standardized patient protocols [74], or a single session selected by providers (c.f., [52,75]). Using transcripts from consultation sessions, members of our research team will develop and test a theory of evidence-based consultation
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