The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: A randomized implementation trial

Foa, E. B., McLean, C. P., Brown, L. A., Zang, Y., Rosenfield, D., Zandberg, L. J., Ealy, W., Hanson, B. S., Hunter, L. R., Lillard, I. J., Patterson, T. J., Rosado, J., Scott, V., Weber, C., Wise, J. E., Zamora, C. D., Mintz, J., Young-McCaughan, S., & Peterson, A. L., for the STRONG STAR Consortium.

Abstract:

Background

Prolonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to determine the incremental utility of post-workshop consultation.

Methods

This study used a hybrid type III randomized implementation trial at 3 US Army installations. Providers were randomized to receive a 4-day prolonged exposure workshop (Standard training condition, n = 60), or the prolonged exposure workshop followed by 6–8?months of post-workshop expert case consultation (Extended training condition, n = 43). The effects training condition were examined on provider attitudes (self-efficacy in delivering PE, expectations for patient improvement, and beliefs about PE), use of PE and PE components, and clinical outcomes of patients with PTSD (using the Clinician-Administered PTSD Scale [CAPS-5]).

Results

Extended condition providers reported greater improvements in self-efficacy, b = .83, 95% CI [.38, 1.27], t(79) = 3.71, p = .001, and d = .63. A greater proportion of patients in the Extended condition (44%) than in the Standard condition (27%) received at least 1 PE session, b = .76, t(233) = 2.53, p = .012, and OR = 2.13. Extended condition providers used more PE components (M = .9/session) than did Standard condition providers (M = .5/session), b = .54, 95% CI [.15, .93], t(68) = 2.70, p = .007, and d = .68. Finally, decrease in patients’ PTSD symptoms was faster for patients of Extended condition providers than for patients of Standard condition providers, b = -1.81, 95% CI [-3.57, -.04], t(263) = -2.02, p = .045, and d = .66, and their symptoms were lower at the second assessment, b = -5.47, 95% CI [-9.30, -1.63], t(210) = -2.81, p = .005, and d = .66.

Conclusions

Post-workshop consultation improved self-efficacy for delivering PE, greater use of PE, faster PTSD reduction, and lower PTSD severity at the second assessment. To our knowledge, this is the first demonstration that post-workshop case consultation for PE improves patient outcomes.