As described above, we recently completed a study (Foa et al., 2002a) in which we trained community-based clinicians to use PE to treat rape survivors with PTSD. In this 6-year study we trained therapists with master's degrees in social work or counseling, using a training model in which an initial workshop was followed with ongoing supervision provided by expert PE therapists. All of the community therapists had substantial experience in working with survivors of sexual assault, but none of them had prior training in CBT, nor had they any experience with conducting research or delivering manualized interventions. Indeed, some of them expressed reservations about the ethics of doing research with rape victims and were initially reluctant to use manualized treatments with their patients. Of note, they were not opposed to using exposure therapy with rape survivors and readily accepted the idea that confronting painful memories, images, and feelings promotes healing.
In the first step of dissemination, Center for the Treatment and Study of Anxiety (CTSA) experts provided the community therapists with a 5-day intensive workshop that included an introduction to the theory and efficacy data supporting the use of PE in the treatment of PTSD as well as instruction in the administration of PE techniques. Much of the time was spent teaching and practicing how to deliver the overall rationale for the treatment, rationales for imaginal and in vivo exposure, and how to implement the two forms of exposure. Additional time was allocated to discussing ways to manage patients who present with too little or too much emotional engagement while completing imaginal exposure exercises. Training included detailed instructions of "how to do it," watching excerpts from videotapes of expert therapists demonstrating each aspect of PE, and role plays in small groups. Intensive training was devoted to cognitive restructuring (CR), conducted by Dr. David M. Clark of Oxford, England, and the CTSA experts. This training in how to implement CR was tailored to working with trauma survivors and began with a detailed theoretical presentation of the profound impact trauma has on survivors' thoughts and beliefs about the self, others, and the world.
After the initial training, each therapist then completed at least two training cases under supervision by a CTSA supervisor. Supervision consisted of weekly 3-hour meetings on the premises of the community sites. All therapists working in the study attended the supervision sessions, in which each ongoing case was discussed and videotapes of that week's therapy sessions were viewed. For the first 2 years of the study, the CTSA experts conducted 2-day booster workshops every 6 months, in which therapists from both the community clinic and the CTSA presented cases and videotapes of therapy sessions. Throughout the 6-year study, CTSA supervisors continued to provide weekly supervision to the therapists.
Participants were recruited through the CTSA and the community agency and were randomly assigned to PE, PE/CR, or waiting-list (WL) conditions at each location. Like the community therapists, CTSA therapists participated in weekly supervision meetings that included discussion about ongoing cases and the viewing of videotapes of therapy sessions. Indeed, the supervision established at the community agency was modeled after our standard supervision practices at the CTSA. As noted in the section on the efficacy of PE, the results from this study revealed that both treatments resulted in greater reductions in symptoms of PTSD, anxiety, and depression than the WL condition and that both treatments were equally effective. More importantly, no differences in treatment outcome were found between patients who were treated at the CTSA and those who were treated at the community agency. We are currently conducting additional dissemination studies to determine how well community therapists can continue to use PE as expert supervision is withdrawn.
Currently, a multisite study comparing PE to present-centered therapy (PCT) is being conducted within the Cooperative Studies Program of the Veterans Administration (Principal investigators: Paula P. Schnurr, PhD; Matthew J. Friedman, MD, PhD; and Charles C. Engel, MD, MPH) that utilizes a similar training model. Therapists were initially trained at an inten sive 5-day workshop structured like that of the Foa et al. (2002a) study. Therapists then completed an average of two training cases under weekly expert supervision before treating actual study cases, also under expert supervision. Because therapists in this study are located throughout the United States, supervision was conducted long distance rather than in person. Supervisors viewed videotapes and provided written feedback and individual telephone consultation on a weekly basis. No data are yet available on the outcome of this study, but supervisors report that most of the therapists trained to conduct PE are doing an excellent job. However, it is important to note that most of the therapists and supervisors agreed that ongoing supervision was important for the therapists to feel comfortable with the techniques.
In another application of this model, several members of the CTSA conducted a 4-day workshop to train a group of New York City therapists in the use of PE for individuals suffering significant symptoms of PTSD after the September 11 attacks on the World Trade Center. In collaboration with the Mount Sinai School of Medicine, the efficacy of a brief course of PE (four sessions) was compared to that of supportive counseling. The therapy sessions were video- or audiotaped and supervisors from the CTSA reviewed each tape and provided therapists with weekly supervision through telephone calls and frequent trips (every 2 or 3 weeks) to New York for direct group supervision, in which videotapes of therapy sessions were viewed and discussed. Although data analyses have not been completed, the supervisors indicated that therapists were able to conduct PE appropriately with trauma survivors and that both brief interventions seemed to be quite effective in alleviating PSTD and depression.
In summary, the existing evidence suggests that, for PE, a dissemination model that includes an intensive workshop over several days and ongoing supervision by experts can be quite effective. Indeed, it has been heartening to witness the natural ripple effect that our work has had in the Philadelphia rape-treatment community. Based on the study of PE versus PE/CR, PE has been adopted as one of the primary treatment interventions for survivors of rape and childhood sexual abuse at the collaborating clinic. Moreover, the therapists who were originally trained by CTSA clinicians for that study are now training other community clinicians in the use of PE. These trained therapists also took the initiative to have the PE manual translated into Spanish and then used the translated manual to train local Latino community therapists so that Spanish-speaking clients could also benefit from this treatment. Similarly, our experience training VA therapists in the ongoing study is that once therapists become familiar and comfortable with PE, they begin to use the techniques with traumatized patients who are not in the research protocol. Although it has been gratifying to see how therapists in these studies have enthusiastically adopted PE, this method of dissemination can be expensive because of the intensive, ongoing expert supervision that is involved.
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