Abstract
Community mental health providers play an essential role in delivering services to veterans who either have limited access to U.S. Department of Veterans Affairs (VA) facilities or who prefer to seek care outside of the VA. However, there are limited training opportunities in evidence-based treatments for posttraumatic stress disorder (PTSD) outside of the VA. In 2017, the STRONG STAR Training Initiative was established to develop competency-based training in two evidence-based therapies for PTSD and to provide that training for mental health providers serving veterans and their families in community settings in Texas. This article describes the program’s development and implementation, baseline characteristics of participating clinicians, and lessons learned toward the scale-up and extension of this competency-based training effort to include other interventions and locations.
Similar content being viewed by others
Notes
The term “garrison” refers to troop stationed in a particular location or military installation.
References
Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(30), 277–292. https://doi.org/10.1016/S0005-7967(03)00138-4.
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.
Bledsoe, S. E., Weissman, M. M., Mullen, E. J., Ponniah, K., Gameroff, M. J., Verdeli, H., et al. (2007). Empirically supported psychotherapy in social work training programs: Does the definition of evidence matter? Research on Social Work Practice, 17(4), 449–455. https://doi.org/10.1177/1049731506299014.
Blount, T. H., Cigrang, J. A., Foa, E. B., Ford, H. L., & Peterson, A. L. (2014). Intensive outpatient prolonged exposure for combat-related PTSD: A case study. Cognitive and Behavioral Practice, 21(1), 89–96. https://doi.org/10.1016/j.cbpra.2013.05.004.
Charney, M. E., Chow, L., Jakubovic, R. J., Federico, L. E., Goetter, E. M., Baier, A. L., et al. (2019). Training community providers in evidence-based treatment for PTSD: Outcomes of a novel consultation program. Psychological Trauma: Theory, Research, Practice, and Policy, 11(7), 793–801. https://doi.org/10.1037/tra0000427.
Chen, H., Cohen, P., & Chen, S. (2010). How big is a big odds ratio? Interpreting the magnitude of odds ratios in epidemiological studies. Communications in Statistics-Simulation and Computation, 39(4), 860–864. https://doi.org/10.1080/03610911003650383.
Cohen, J. (1990). Things I have learned (so far). American Psychologist, 45(12), 1304–1312. https://doi.org/10.1037/0003-066x.45.12.1304.
Council for Accreditation of Counseling and Related Educational Programs. (2016). 2016 CACREP standards, section 5. Alexandria, VA: Clinical Mental Health Counseling.
Department of Defense Manpower Data Center. (2019). DoD personnel, workforce reports & publications. Retrieved from https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp.
Dondanville, K. A., & Fina, B. A.; for the STRONG STAR Consortium. (2018). STRONG STAR Training Initiative working to increase veteran access to evidence-based treatments for PTSD. International Society for Traumatic Stress Studies StressPoints, 32(6). Retrieved from http://sherwood-istss.informz.net/admin31/content/template.asp?sid=62223&brandid=4463&uid=1064257099&mi=8140519&mfqid=43715967&ptid&ps=62223&fbclid=IwAR0zdTIBoD5XLzIB2sjfvDCmMXcc9ckJCguLbGaVWtRUshIH9KTE5uPfiCU.
Edmunds, J. M., Beidas, R. S., & Kendall, P. C. (2013). Dissemination and implementation of evidence-based practices: Training and consultation as implementation strategies. Clinical Psychology: Science and Practice, 20(2), 152–165. https://doi.org/10.1111/cpsp.12031.
Farmer, C. C., Mitchell, K. S., Parker-Guilbert, K., & Galovski, T. E. (2017). Fidelity to the cognitive processing therapy protocol: Evaluation of critical elements. Behavior Therapy, 48(2), 195–206. https://doi.org/10.1016/j.beth.2016.02.009.
Ferguson, C. J. (2009). An effect size primer: A guide for clinicians and researchers. Professional Psychology: Research and Practice, 40(5), 532–538. https://doi.org/10.1037/a0015808.
Fina, B., Wright, E. C., Lichner, T. K., Borah, A., Foa, E. B., & The STRONG STAR Consortium. (2014). Common challenges in conducting Prolonged Exposure Therapy with active duty service members: Case discussion and strategies. Social Work in Mental Health, 12(5–6), 482–499. https://doi.org/10.1080/15332985.2014.903885.
Fina, B. A., Lichner, T. K., Foa, E. B., & Peterson, A. L. (2016). Case study of prolonged exposure therapy for comorbid combat-related posttraumatic stress disorder and traumatic brain injury. In C. R. Martin, V. R. Preedy, & V. B. Patel (Eds.), Comprehensive guide to post-traumatic stress disorder (pp. 2237–2247). Cham, Switzerland: Springer.
Finley, E. P., Garcia, H. A., Ketchum, N. S., McGeary, D. D., McGeary, C. A., Stirman, S. W., et al. (2015). Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics. Psychological Services, 12(1), 73–82. https://doi.org/10.1037/ser0000014.
Finley, E. P., Mader, M., Bollinger, M. J., Haro, E. K., Garcia, H. A., Huynh, A. K., et al. (2017). Characteristics associated with utilization of VA and non-VA care among Iraq and Afghanistan veterans with post-traumatic stress disorder. Military Medicine, 182(11–12), e1892–e1903. https://doi.org/10.7205/MILMED-D-17-00074.
Finley, E. P., Noel, P., Haro, E., Bernardy, N., Lee, S., & Garcia, H., et al. (2016). Education preferences among community mental health and primary care providers treating PTSD. In N. Bernardy (Chair). Innovative approaches to improving PTSD treatment: Using technology to aid public health. Dallas, TX: Symposium conducted at the annual meeting of the International Society for Traumatic Stress Studies.
Finley, E. P., Noel, P. H., Lee, S., Haro, E., Garcia, H., Rosen, C., et al. (2018). Psychotherapy practices for veterans with PTSD among community-based providers in Texas. Psychological Services, 15(4), 442–452. https://doi.org/10.1037/ser0000143.
Foa, E., Hembree, E., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide (2nd ed.). New York, NY: Oxford University Press.
Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67(2), 194–200. https://doi.org/10.1037/0022-006x.67.2.194.
Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. https://doi.org/10.1037/0022-006x.73.5.953.
Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., et al. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA: Journal of the American Medical Association, 319(4), 354–364. https://doi.org/10.1001/jama.2017.21242.
Gallo, K. P., & Barlow, D. H. (2012). Factors involved in clinician adoption and nonadoption of evidence-based interventions in mental health. Clinical Psychology Science and Practice, 19(1), 93–106. https://doi.org/10.1111/j.1468-2850.2012.01276.x.
Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968–981. https://doi.org/10.1037/a0030600.
Glisson, C., & Williams, N. J. (2015). Assessing and changing organizational social contexts for effective mental health services. Annual Review of Public Health, 36(1), 507–523. https://doi.org/10.1146/annurev-publhealth-031914-122435.
Greenhalgh, T., & Papoutsi, C. (2019). Spreading and scaling up innovation and improvement. BMJ, 365, 2068. https://doi.org/10.1136/bmj.l2068.
Hall-Clark, B. N., Wright, E. C., Fina, B. A., Blount, T. H., Evans, W. R., Carreño, P. K., et al. (2019). Military culture considerations in prolonged exposure therapy with activeduty military service members. Cognitive and Behavioral Practice, 26(2), 335–350. https://doi.org/10.1016/j.cbpra.2018.07.009.
Heisler, E. J. (2018). The mental health workforce: A primer. Washington, DC: Congressional Research Service. (CRS No. R43255) Retrieved from https://crsreports.congress.gov/product/pdf/R/R43255/15.
Hepner, K. A., Brooks Holliday, S., Sousa, J., & Tanielian, T. (n.d.). Applying the TIP Tool: A case example. Santa Monica, CA: RAND Corporation. Retrieved from https://www.rand.org/pubs/tools/TL306-1/tip/apply.html.
Hepner, K. A., Brooks Holliday, S., Sousa, J., & Tanielian, T. (2019). User guide for the Training in Pyschotherapy (TIP) Tool 2.0. Santa Monica, CA: RAND Corporation.
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., et al. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23(6), 663–673. https://doi.org/10.1002/jts.20588.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
LoSavio, S. T., Dillon, K. H., Murphy, R. A., Goetz, K., Houston, F., & Resick, P. A. (2019). Using a learning collaborative model to disseminate cognitive processing therapy to community-based agencies. Behavior Therapy, 50(1), 36–49. https://doi.org/10.1016/j.beth.2018.03.007.
Meyer, E. G., Writer, B. W., & Brim, W. (2016). The importance of military cultural competence. Current Psychiatry Reports, 18, 26. https://doi.org/10.1007/s11920-016-0662-9.
Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898–907. https://doi.org/10.1037/0022-006x.74.5.898.
Peterson, A., Foa, E., Resick, P., Hoyt, T., Straud, C. L., Moore, B., et al. (2020). A nonrandomized trial of prolonged exposure and cognitive processing therapy for combat-related posttraumatic stress disorder in a deployed setting. Behavior Therapy. https://doi.org/10.1016/j.beth.2020.01.003.
Peterson, A. L., Luethcke, C. A., Borah, E. V., Borah, A. M., & Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war veterans. Journal of Clinical Psychology in Medical Settings, 18(2), 164–175. https://doi.org/10.1007/s10880-011-9238-3.
Peterson, A. L., Straud, C. L., & Evans, W. (2019). Treating combat-related PTSD during military deployments: Importance, challenges, and special considerations. The Behavior Therapist, 42(4), 127–130.
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635–641. https://doi.org/10.1016/j.cpr.2010.04.007.
Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Publications.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867–879. https://doi.org/10.1037/0022-006x.70.4.867.
Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., et al. (2017). Effect of group vs individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2016.2729.
Resick, P. A., Wachen, J. S., Mintz, J., Young-McCaughan, S., Roache, J. D., Borah, A. M., et al. (2015). A randomized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military personnel. Journal of Consulting and Clinical Psychology, 83(6), 1058–1068. https://doi.org/10.1037/ccp0000016.
Richards, L. K., Bui, E., Charney, M., Hayes, K. C., Baier, A. L., Rauch, P. K., et al. (2017). Treating veterans and military families: Evidence-based practices and training needs among community clinicians. Community Mental Health Journal, 53(2), 215–223. https://doi.org/10.1007/s10597-016-0013-7.
Rosen, R. C., Mattieu, M. M., Wiltsey Stirman, S., Cook, J. M., Landes, S., Bernardy, N. C., et al. (2016). A review of studies on the system-wide implementation of evidence-based psychotherapies for posttraumatic stress disorder in the Veterans Health Administration. Administration and Policy in Mental Health and Mental Health Services Research, 43, 957–977. https://doi.org/10.1007/s10488-016-07550.
Rosen, R. C., Ruzek, J. I., & Karlin, B. E. (2017). Evidence-based training in the era of evidence-based practice: Challenges and opportunities for training of PTSD providers. Behaviour Research and Therapy, 88, 37–48. https://doi.org/10.1016/j.brat.2016.07.009.
Rosen, A. K., Wagner, T. H., Pettey, W. B., Shwartz, M., Chen, Q., Lo, J., et al. (2018). Differences in risk scores of veterans receiving community care purchased by the Veterans Health Administration. Health Services Research, 53(S3), 5438–5454. https://doi.org/10.1111/1475-6773.13051.
Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616. https://doi.org/10.1002/jts.20069.
Salsberg, E., Quigley, L., Mehfound, N., Acquaviva, K., Wyche, K., Sliwa, S., et al. (2017). Profile of the social work workforce: A report to the Council on Social Work Education and National Workforce Initiative Steering Committee. Washington, DC: The George Washington University Health Workforce Institute.
Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA: Journal of the American Medical Association, 297(8), 820–830. https://doi.org/10.1001/jama.297.8.820.
Stirman, S. W., Buchhofer, R., McLaulin, J. B., Evans, A. C., & Beck, A. T. (2009). Public-academic partnerships: The Beck Initiative: A partnership to implement cognitive therapy in a community behavioral health system. Psychiatric Service, 60(10), 1302–1304. https://doi.org/10.1176/ps.2009.60.10.1302.
Sullivan, G. M., & Feinn, R. (2012). Understanding effect size-or why the p value is not enough. Journal of Graduate Medical Education, 4(3), 279–282. https://doi.org/10.4300/jgme-d-12-00156.1.
Tanielian, T., Farris, C., Epley, C., Farmer, C. M., Robinson, E., Engel, C. C., et al. (2014). Ready to serve. Community-based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. Santa Monica, CA: RAND Corporation.
Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.
Texas Comptroller of Public Accounts. (2017). Texas' military installations economic impact, 2017. Austin, TX: Texas Comptroller of Public Accounts.
U.S. Department of Veterans Affairs. (2015). Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 1st Qtr FY 2015. Washington, DC: U.S. Department of Veterans Affairs.
U.S. Department of Veterans Affairs. (2017). Veteran population projections 2017–2037. (Website; Graph illustration to visualize data of the Veteran Population Projection Model 2016). Retrieved from https://www.va.gov/vetdata/docs/Demographics/New_Vetpop_Model/Vetpop_Infographic_Final31.pdf.
Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Molino, A., Carson, C. S., Blankenship, A. E., et al. (2016). Implementing cognitive processing therapy for posttraumatic stress disorder with active duty US military personnel: Special considerations and case examples. Cognitive and Behavioral Practice, 23(2), 133–147. https://doi.org/10.1016/j.cbpra.2015.08.007.
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013a). The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov.
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013b). The PTSD Checklist for DSM-5 (PCL-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov.
Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., et al. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925–934. https://doi.org/10.1001/archpsyc.63.8.925.
Acknowledgements
We would like to thank the Texas mental health providers and their organizations for their enthusiastic engagement in this project and the important care they provide every day to veteran and non-veteran trauma survivors. We would like to thank our regional Learning Community partner organizations which include: University of Texas at San Antonio, University of North Texas, Texas A&M Corpus Christi, Baylor University, Texas State University, Innovative Alternatives, and University of Texas at Austin. The authors thank Julie Collins and Joel Williams, who provided editorial support for this manuscript and Jeremy Karp and Arthur Marsden, who provided project management support.
Funding
Funding for this project was made possible by the Texas Health and Human Services Texas Veterans + Family Alliance Grant program and the Bob Woodruff Foundation.
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Ethical Approval
The UT Health San Antonio Institutional Review Board reviewed the project and determined it to be nonresearch and exempt from further oversight.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Dondanville, K.A., Fina, B.A., Straud, C.L. et al. Launching a Competency-Based Training Program in Evidence-Based Treatments for PTSD: Supporting Veteran-Serving Mental Health Providers in Texas. Community Ment Health J 57, 910–919 (2021). https://doi.org/10.1007/s10597-020-00676-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10597-020-00676-7