About 1 in 8 veterans using VA primary care clinics meets criteria for PTSD. This underscores the importance of having VA providers who are highly skilled in the implementation of the best PTSD treatments available. Prolonged exposure (PE), a treatment protocol developed by Dr. Edna Foa (a key investigator on this project), was recently identified as a "best practice" approach by the Institute of Medicine. A national initiative is ongoing to train VA providers in this approach, funded by the Office of Mental Health Services in the VHA Central Office. The availability of high-quality, low-cost training tools for VA providers is therefore of high significance. To this end, this application describes a plan to develop PE-Web, an innovative, 8-10 hour Web-based training protocol for VA providers that has the capacity to strengthen providers'preparation to deliver PE to veterans with PTSD with a high level of fidelity. Our investigative team is well positioned to develop and evaluate PE- Web, having been highly successful in development of other Web-based clinician-training protocols relating to traumatic stress populations (TF-CBTWeb, CTGWeb). TF-CBTWeb, launched in October 2005, has already logged over 29,000 registered learners representing all 50 states and 88 countries. The proposed project, in addition to supporting the development of PE-Web, will support efforts to preliminarily evaluate it with 100 VA providers who had previously received initial training in PE. We will evaluate PE-Web using randomized controlled methods. If findings are supportive of PE-Web as a valuable VA provider-training tool, numerous avenues for disseminating this low-cost resource to VA providers will be explored.
Anticipated Impacts on Veterans Health Care: This project will develop and conduct a randomized controlled trial to evaluate a sophisticated, interactive, Internet-based VA provider-training protocol in prolonged exposure (PE): PE-Web. Exposure-based treatment was recently identified as an efficacious treatment for posttraumatic stress disorder (PTSD) by an Institute of Medicine committee charged by the Department of Veterans Affairs to evaluate the state of the evidence in treatment of PTSD. The committee concluded that evidence was insufficient to support all other psychotherapy, group-treatment, and pharmacotherapy approaches. These conclusions underscore the critical importance of disseminating exposure-based treatment to VA providers. Currently, a national Prolonged Exposure dissemination initiative is funded by the Office of Mental Health Services in the VHA Central Office. Implementation of this project will provide VHA with permanent capacity to train and supervise mental health practitioners in the delivery of PE. The goal of this project is to strengthen the capacity to train VA providers rapidly via the cost-efficient use of asynchronous e-learning methods that can augment current dissemination and training initiatives in several ways. Project Background: Posttraumatic stress disorder (PTSD) is highly prevalent in veteran populations, and the availability to veterans of effective treatment for PTSD is a national health care priority. About 1 in 8 veterans using VA primary care clinics meets diagnostic criteria for PTSD. Exposure-based treatment, such as prolonged exposure (PE), was recently identified as an efficacious treatment for PTSD. Several randomized controlled trials have supported the efficacy of PE. This has led to the emergence of a PE dissemination initiative that aims to provide training in PE to mental health providers in VA settings across the nation. New communication technologies have greatly expanded our ability to increase the effectiveness of training experiences, allowing learners to have repeated access to high-value information (e.g., video demonstrations, training scripts, solutions to challenging clinical issues). Our investigative team has been highly successful in the development of an Internet-based, asynchronous distance education course in exposure-based treatment for youth: TF-CBTWeb: this protocol, launched in October of 2005, had already logged over 29,000 registered learners through July 2008 representing all 50 states and 88 countries. Project Objectives: The primary purposes of the proposed project are to (a) develop an innovative, Internet-based training protocol for VA providers that has the capacity to strengthen providers'preparation to deliver PE to veterans with PTSD with a high level of fidelity;(b) develop video illustrations, sample scripts, clinical-challenge scenarios, and cultural-considerations components to include within the Web-training protocol;and (c) conduct a randomized controlled trial to evaluate PE-Web with 100 VA providers who have previously participated in a 4-day workshop training via the PE dissemination initiative. Whereas this study will evaluate PE-Web as a refresher course, this protocol will have the potential for use in a variety of PE-training contexts. We will test the hypotheses that VA providers in the PE-Web refresher condition, vs. providers in the no-refresher condition, will demonstrate greater PE fidelity-change and knowledge-change improvements. Project Methods: Following development of PE-Web (months 1-12) in collaboration with the developer of prolonged exposure (Dr. Foa, Co-I) and leaders of the PE initiative (Dr. Ruzek, Co-I), the Website will be alpha- and beta-bested in preparation for RCT evaluation (month 18). During years 2-3, we will randomly assign 100 VA providers into PE-Web refresher training vs. a no-refresher condition. Baseline and post-training assessments will consist of (a) role-plays with standardized patients, (b) knowledge change measures addressing key components and principles relating to PE, and (c) structured interview questions to assess provider characteristics (e.g., theoretical orientation, years of experience, attitudes toward manualized and evidence-based treatment). Providers assigned to the no-refresher condition will be given access to PE-Web following the second assessment. Primary dependent variables will be provider fidelity to the PE model (assessed via role plays and coded by trained fidelity raters) and provider knowledge levels relating to PE.