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Should We Keep Training Therapists in a Pandemic? An Example of a Virtual Facilitated Learning Collaborative for Written Exposure Therapy

Courtney Worley, Ph.D., Syed Aajmain, Stefanie T. LoSavio, Ph.D.

October 5, 2020

Should We Keep Training Therapists in a Pandemic?  

The COVID-19 pandemic has significantly impacted daily life, including the need to socially distance. Thus, now may not seem like the ideal time to embark on training, which typically involves convening people in-person. However, the need is greater than ever to deliver evidence-based treatments, pointing to an urgent need to build workforce capacity. Fortunately, our experience with a training that began before and continued during COVID-19 has shown it is possible to successfully train in evidence-based treatment during challenging transitions. We highlight elements of our program that proved durable as an example of how teams may continue to provide training during this unprecedented time.

The Written Exposure Therapy Virtual Facilitated Learning Collaborative

Before the COVID-19 pandemic, we embarked on a multisite training and implementation pilot to disseminate Written Exposure Therapy (WET; Sloan & Marx, 2019) in a complex healthcare system.  Being faced with a challenge that impacted sites, clinicians, and patients in different ways presented us an opportunity to reflect on aspects of our training program that were conducive to ongoing training. 

In designing our virtual, facilitated learning collaborative, we considered organizational factors, intervention characteristics, and clinician factors (Beidas et al., 2010; Stirman et al., 2010) to address implementation barriers and leverage strengths (e.g., Karlin & Cross, 2014; McHugh & Barlow, 2010).  In our model, we included:
  1. a fully virtual workshop training with phone-based clinical consultation;
  2. team-based training with program leadership, including implementation-focused video calls;
  3. program evaluation.
Fortunately, this virtual format proved sufficiently flexible to enable successful continuation of training during the COVID-19 pandemic. 

The COVID-19 pandemic was a specific challenge that we encountered, but training programs often face challenges, especially in complex, healthcare delivery systems or in multisite initiatives. We considered the impact of delaying or pausing the training program much like the clinical considerations we used for patients during this time. Would delaying be colluding with avoidance? What are the risks and benefits in continuing to offer evidence-based workforce training?  In what ways could our program continue as is and what aspects needed adaptation? Implementation models such as the ACCESS Model for training and consultation (Stirman et al., 2010) can provide guidance for facilitating implementation when faced with challenges.  

For example, one of our largest challenges was the conversion to telehealth delivery of the intervention, which was addressed at each level of our training program. We distributed didactic training materials to address telehealth delivery of WET. We used the components of our learning collaborative to facilitate the dissemination of these updated materials. Our training staff served as external facilitators working with program leads, who served as internal facilitators for their respective sites. Ongoing program leadership calls provided an opportunity to update implementation plans and problem-solve barriers as challenges arose. Group consultation was also used as a forum to discuss recruitment, transitions, adaptations, and content while supporting clinicians facing their own challenges. Several clinicians commented that having the continuity of the consultation calls provided structure and stability in a time that was both professionally and personally challenging. Consultation may have also helped clinicians remain adherent to an evidence-based treatment when faced with new challenges to delivery. The virtual nature of the program meant that there was no interruption to training delivery and strategies were in place for sharing training materials and program evaluation data.

Feedback from program leaders and clinicians reflected overall positive attitudes about participation in training during COVID-19.  We were able to retain the majority of our clinician trainees (87.8% completed all requirements). The team-based approach may have made it possible for clinicians to continue in consultation as they received support from the organization (i.e., local program leads who were internal facilitators). Moreover, our patient dropout rate was only about 7% higher than in our previous cohorts unimpacted by COVID-19, and remained below the 30% typically seen in patients receiving trauma-focused therapies in this healthcare system (Hale et al., 2019).

In this unprecedented time, ongoing training is essential to ensure adequate availability of evidence-based treatments. Those facilitating training are encouraged to consider elements such as those in this virtual facilitated learning collaborative to maximize flexibility. If interested in more information, please see the reference article, in which we describe our approach and outcomes continuing  evidence-based training and highlight our adaptations in a table for the reader. Challenges, successes, and practical guidance are discussed to inform the field on training strategies likely to be durable in an uncertain, dynamic healthcare landscape. 

References

Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence‐based practice: A critical review of studies from a systems‐contextual perspective. Clinical Psychology: Science and Practice, 17(1), 1-30. https://doi.org/10.1111/j.1468-2850.2009.01187.x

Hale, A. C., Bohnert, K. M., Ganoczy, D., & Sripada, R. K. (2019). Predictors of treatment adequacy during evidence-based psychotherapy for PTSD. Psychiatric Services, 70(5), 367–373. https://doi.org/10.1176/appi.ps.201800361

Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. American Psychologist, 69(1), 19-33. https://doi.org/10.1037/a0033888

 McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. American Psychologist, 65(2), 73-84. https://doi.org/10.1037/a0018121
 
Sloan, D. M., & Marx, B. P. (2019). Written exposure therapy for PTSD: A brief treatment approach for mental health professionals. American Psychological Association.

Stirman, S.W., Bhar, S.S., Spokas, M., Brown, G.K., Creed, T.A., Perivoliotis, D., Farabaugh, D.T., Grant, P.M. and Beck, A.T. (2010). Training and consultation in evidence-based psychosocial treatments in public mental health settings: The ACCESS model. Professional Psychology: Research and Practice, 41(1), 48-56. https://doi.org/10.1037/a0018099

Reference Article

Worley, C.B., LoSavio, S.T., Aajmain, S., Rosen, C., Stirman, S.W. and Sloan, D.M. (2020), Training During a Pandemic: Successes, Challenges, and Practical Guidance From a Virtual Facilitated Learning Collaborative Training Program for Written Exposure Therapy. Journal of Traumatic Stress. doi:10.1002/jts.22589

Questions for Discussion

  1. What are your thoughts about continuing to offer EBP trainings when sites or clinicians are impacted by adverse events (e.g. pandemics, natural disasters)?
  2. How can training programs be designed for durability across a changing healthcare landscape?
  3. How do learning collaboratives support clinicians and programs in adapting to new innovations

About the Authors

Courtney Worley, Ph.D., ABPP, M.P.H. is a board certified clinical psychologist in the Department of Veterans Affairs where she specialized in the delivery of Evidence-Based Psychotherapies (EBPs) for PTSD. She has served for the last two years on this implementation project through a special detail assignment to the National Center for PTSD, Dissemination and Training Division. She also serves as a trainer and consultant for several VHA EBP training programs. Her research interests include dissemination and implementation of evidence based practices for PTSD, public health approaches to mental health service delivery, and behavioral sleep medicine.  She is also an affiliate of the Alabama Research Institute on Aging.
 
Syed Aajmain is a research assistant in the F.A.S.T lab at the National Center for PTSD, Dissemination and Training Division. His research interests include PTSD and shared symptoms across different forms of psychopathology as well as treatment effectiveness and measurement-based care.
 
Stefanie T. LoSavio, Ph.D., ABPP is a licensed psychologist specializing in cognitive behavior therapy for PTSD. She conducts research at Duke University Medical Center and the Department of Veterans Affairs trains mental health providers in evidence-based, trauma-focused treatments. In her research, Dr. LoSavio studies the role of cognitive and emotional processing in recovery from stressful and traumatic events, mechanisms of trauma-focused treatments, and adaptations to treatments and training methods to increase the reach of evidence-based treatments.
 
Author Note: The views expressed here are those of the authors and do not necessarily reflect the position or policy of the VA, the United States government, or any of the institutions with which the authors are affiliated.