Introduction
Training has an important role to play in the dissemination of evidence-based psychological therapies such as cognitive behavioural therapy (CBT). Whilst the development of effective treatments has advanced quickly over recent years, a ‘research–practice gap’ (McHugh and Barlow, Reference McHugh and Barlow2010) runs the risk of leaving many clinicians insufficiently trained or supervised to deliver optimally effective treatments, at a time when the demand for psychological therapies is rapidly increasing (White, Reference White2008).
The Improving Access to Psychological Therapies (IAPT) programme has trained thousands of therapists across the UK to deliver evidence-based psychological therapies for common mental health problems. Outcome data from pilot sites showed clinical outcomes similar to those demonstrated in research studies (50–60% recovery) and increased patient employment (Clark et al., Reference Clark, Layard, Smithies, Richards, Suckling and Wright2009). However, outcomes differ across services and disorders. Recent figures for post-traumatic stress disorder (PTSD) suggest an average recovery rate of 37.8% (Health and Social Care Information Centre, 2016), but dropping as low as 15–20% for some services, making it one of the disorders with lowest recovery in IAPT.
One reason for poorer outcomes may be that clinicians treating PTSD often feel under-confident in applying some of the most effective techniques, such as imaginal reliving. Becker et al. (Reference Becker, Zayfert and Anderson2004) found that only 17% of clinicians used imaginal exposure in treatment, with both lack of training and concerns about risks associated with the treatment cited as barriers. Gray et al. (Reference Gray, Elhai and Schmidt2007) found positive attitudes towards evidence-based treatments for PTSD in their survey of trauma therapists, but these attitudes did not always correspond with behaviours; again barriers such as lack of time and access to training were cited as factors inhibiting practice of evidence-based therapies.
Furthermore, in an economic climate where NHS services are under increasing pressure, many IAPT services are treating increasingly complex cases, such as clients with PTSD to multiple events, prolonged and early life trauma, and additional complicating features such as co-morbid difficulties. IAPT services were originally intended for the treatment of mild to moderate psychological problems, and diploma-level CBT training courses may not cover interventions for more complex presentations. Although IAPT therapists have varying professional backgrounds and may have extensive experience of CBT, others have only undergone a year-long course, involving training and supervised practice in the treatment of all anxiety disorders and depression (see https://www.england.nhs.uk/mental-health/adults/iapt/workforce/).
Studies have indicated that PTSD treatments are disseminable. Foa et al. (Reference Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin2005) trained therapists in both an academic treatment centre and a community clinic to high levels of competence in prolonged exposure and cognitive restructuring for PTSD, and clients showed significant improvements compared with a waitlist sample. Gillespie et al. (Reference Gillespie, Duffy, Hackmann and Clark2002) reported an effective dissemination study whereby therapists treating survivors of the Omagh bombing were trained in cognitive therapy for PTSD and achieved excellent recovery rates, comparable to those in the research clinic samples of the same treatment (Ehlers et al., Reference Ehlers, Clark, Hackmann, McManus, Fennell, Herbert and Mayou2003, Reference Ehlers, Clark, Hackmann, McManus and Fennell2005). Several large-scale PTSD dissemination projects are ongoing. For example, the Veterans Health Administration in the USA is training thousands of clinicians in cognitive-processing therapy (Resick and Schnicke, Reference Resick and Schnicke1992) and prolonged exposure (Foa et al., Reference Foa, Hembree and Rothbaum2007), via workshops and consultation calls. Preliminary results suggest that the training has been widely accessed, and client outcomes have improved for both treatments (Karlin et al., Reference Karlin, Ruzek, Chard, Eftekhari, Monson and Hembree2010).
The training package evaluated in this report aimed to pilot a novel model for IAPT services: the training of ‘trauma experts’ across a region to provide expertise and supervisory capacity within their teams, and to disseminate knowledge. Such a model draws on ‘cascade’ or ‘train the trainer’ concepts, which have been recommended to encourage efficient dissemination (Becker and Stirman, Reference Becker and Stirman2011; Nakamura et al., Reference Nakamura, Selbo-Bruns, Okamura, Chang, Slavin and Shimabukuro2014).
The training was evaluated at each level of Kirkpatrick's (Reference Kirkpatrick, Craig and Bittel1967, Reference Kirkpatrick1975) hierarchy of training evaluation: reactions, learning or knowledge acquisition, behaviour change and results, as well as penetration (whether trainees had successfully disseminated information and skills back to their services), and sustainability (Proctor et al., Reference Proctor, Silmere, Raghavan, Hovmand, Aarons and Bunker2011).
Method
The training course
The training was delivered by the author, an experienced PTSD therapist, supervisor and trainer, and took place over a 6-month period between September 2013 and March 2014. It comprised 4 days of workshops, four half-day webinars, designed for the course, which were accessed remotely via an online videoconferencing system, and monthly consultation telephone calls (lasting an hour, in pairs) aimed at helping participants apply learning from the course to their current clients. The focus of the workshops was on learning and practising skills for assessing and treating PTSD using the Ehlers and Clark (Reference Ehlers and Clark2000) model of cognitive therapy. All participants were aware of the model from their CBT training, but had varied experience in its use. The initial workshop therefore focused on refreshing basic skills, such as imaginal reliving, working with hotspots and stimulus discrimination; later workshops focused on working with more complex issues, such as co-morbidity and multiple trauma. The webinars focused on modifications of the treatment for particular groups, including traumatic bereavement, military veterans, domestic abuse and childhood sexual abuse survivors. The training methods emphasized active learning using role-plays, therapy videos and experiential exercises. Overall, participants who attended all training events and consultation calls received 38 hours of training.
An online network was set up on the NHS Networks website (https://www.networks.nhs.uk/) to support the training. The network was used to promote communication between the trainer and trainees and to share resources such as papers, training slides and handouts. Message boards allowed the trainees to ask the trainer questions, or to communicate with each other.
Context and participants
The training was commissioned by a managed clinical network which supported the development of IAPT services across the East of England, a large region encompassing five NHS Trusts and ten IAPT services. Clinical leads for each IAPT service selected two ‘step 3’ therapists to participate in the training. Step 3 therapists have undergone CBT training, and see the more complex clients referred to IAPT. PTSD clients in IAPT are automatically seen at ‘step 3’, and should receive individual trauma-focused psychological therapy in line with NICE guidance (NICE, 2005).
The participants in the training course were therefore 20 CBT therapists working within IAPT. They had a range of professional backgrounds including clinical or counselling psychology, psychiatric nursing and social work, and had all completed additional CBT training. The course was predominantly female (19 females, 1 male).
Twenty therapists started the training course. One failed to complete the training, due to illness. The remainder completed the training, defined as missing no more than one training event. Six therapists were lost to follow-up. Of these, two were known to be off sick, and the others did not respond to attempts to contact.
Evaluation and measures
The training package was evaluated on a range of outcomes: acceptability, PTSD knowledge, self-rated competence, supervisor-rated competence and client outcomes. The time points for data collection are illustrated in Fig. 1.
Figure 1. Data collection time points
Training acceptability
At the end of each training event, participants were asked to complete an anonymous feedback form. Free text items asked for comments on aspects of the event that trainees liked, and areas for improvement. Participants were asked to rate the event on variables using Likert scales, including whether the content of the workshop was at an appropriate level, relevant to their practice, well-structured and of a high quality.
PTSD knowledge
Participants completed a ‘PTSD quiz’ at the start and end of the training course, and a year later. The quizzes were different at each time point and were developed specifically for the training evaluation as no existing measure could be found. Potential quiz items were generated by a group of clinical psychologists specializing in PTSD and randomly assigned to pre-training, post-training or follow-up. The quiz items were chosen to measure basic knowledge about PTSD, such as prevalence, risk factors and diagnostic criteria.
Self-rated competence
Trainees completed a PTSD competence checklist at the start and end of the training programme and at 1-year follow-up. The checklist was adapted from Roth and Pilling's (Reference Roth and Pilling2008) list of 68 knowledge, assessment and treatment competences for PTSD (Ehlers and Clark model) which was developed as part of a project by the Centre for Outcomes, Research and Effectiveness (CORE). The competence framework is available as a self-assessment tool on the CORE website (http://www.ucl.ac.uk/clinical-psychology/CORE/competence_frameworks.htm), where participants rate themselves using a traffic light system, as ‘I do not have this competence’ (red); ‘I have developed part of this competence’ (amber); or ‘I have fully developed this competence’ (green). The competence list was adapted to a self-assessment form for the purpose of this study. This form has not been subject to any empirical validation.
Supervisor-rated competence
Trainees were asked to submit therapy tapes (audio or video-recorded) to their supervisors prior to the start of training (for a therapy session in the preceding 3 months), at the end of training, and a year later. The only instructions for tape selection were that it should show a CBT treatment session with a PTSD client, who had consented to recording.
Supervisors assessed the tapes using the CTS-PTSD; a version of the cognitive therapy scale (CTS; Young and Beck, Reference Young and Beck1980,Reference Young and Beck1988) adapted to measure PTSD-specific competencies. The CTS-PTSD consists of 16 items, including standard items from the CTS measuring general CBT competences, with seven additional items relating to PTSD-specific skills. Competence on each item, and overall competence, is rated on a scale of 0 (poor) to 6 (excellent). Scores over 3 are generally considered ‘competent’, over 4 ‘proficient’ and over 5 ‘expert’. Supervisors received no extra training in the use of the CTS-PTSD; however, they were familiar with the CTS, on which the measure is based, and were asked to contact the trainer if they had any difficulty with its administration.
Although the original CTS, and its revised version (Blackburn et al., Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001), have been widely used in research and clinical training, and have demonstrable levels of reliability and validity (e.g. Blackburn et al., Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001; Dimidjian et al., Reference Dimidjian, Hollon, Dobson, Schmaling, Kohlenberg and Addis2006), they measure general CBT skills, rather than the disorder-specific techniques that are often central to many treatments (Fairburn and Cooper, Reference Fairburn and Cooper2011). The CTS-PTSD was chosen for this study for increased sensitivity in assessing PTSD-specific skills. It is yet to be published or validated (A. Ehlers and S. Liness, unpublished observations, 2008).
Client outcomes
Clinical outcome data were collected for PTSD clients treated by participating therapists in the year before, and the year after, the training course. In IAPT services, clients routinely complete standardized measures, including the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., Reference Kroenke, Spitzer and Williams2001), a 9-item measure of depression, and the Generalised Anxiety Disorder-7 (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006), a 7-item measure of anxiety. Most services now also use disorder-specific measures, including the Impact of Events Scale- Revised (IES-R; Weiss and Marmar, Reference Weiss and Marmar1997) for PTSD. Data on these measures were extracted from IAPT databases by participants and anonymized before analysis.
Barriers to change
At 1-year post-training, participants completed the ‘Barriers to Change Questionnaire’ (BARQ; Corrigan et al., Reference Corrigan, Kwartarini and Pramana1992). This measure asks users to rate whether certain factors had impaired their capacity to apply training in the workplace on a scale of 0 (not a barrier at all) to 5 (insurmountable barrier). Sixteen potential barriers are rated, which are subcategorized into ‘institutional constraints’, ‘support from colleagues’, ‘philosophical opposition’, ‘client dissatisfaction’ and ‘interference’.
The BARQ has a significant test–retest reliability (r = 0. 41–0.92, P < 0.01; Corrigan et al., Reference Corrigan, Kwartarini and Pramana1992) and has been used in other training evaluation studies to measure factors affecting training uptake (e.g. Myles and Milne, Reference Myles and Milne2004; Kennedy-Merrick et al., Reference Kennedy-Merrick, Haarhoff, Stenhouse, Merrick and Kazantzis2008).
Dissemination
An idiosyncratic measure was developed for this study to assess attempts by participants to disseminate the training. Participants were asked whether they had changed their own practice as a result of the training, were providing supervision differently, or had provided training events or other resources to their team. Trainees were also asked to report any major changes to their team or role, for example if they had changed jobs.
Analysis
The primary analyses were conducted using multi-level modelling (MLM) software (MLwiN v2.32; Rasbash et al., Reference Rasbash, Charlton, Browne, Healy and Cameron2009). This strategy was selected in order to account for within-participant correlation of responses recorded at a succession of time points. Models were developed for each evaluation outcome. Where responses were a proportion (e.g. a quiz score out of 10), a binomial logit model was applied. This was estimated initially using marginal quasi-likelihood (MQL), then refined using predictive quasi-likelihood (PQL) methods in order to limit downwards estimates caused by the small sample size, while minimizing convergence risk. Model fit was assessed using diagnostic plots supplemented by the Shapiro–Wilk normality test, in accordance with Collett (Reference Collett2003).
Significance testing was applied using one-sided tests, as it was not anticipated that the training would lead to a decrease in outcomes. In all cases the null hypothesis was of no change to scores.
Results
Trainee satisfaction
Overall, training events received high satisfaction ratings on the feedback measures, with an overall mean of 4.8/5 (SD 0.25), indicating that the training was acceptable. A one-way ANOVA showed no significant differences in overall satisfaction ratings across individual training events (F = 1.92; P = 0.08).
A multi-level model was constructed to compare webinar and workshop ratings and revealed no significant differences (z = –0.52; P = 0.70), suggesting that participants found these formats equally acceptable.
Responses from the free text items on feedback questionnaires were categorized as positive or negative, and then subcategorized into comment type. The majority of comments were positive (91.43%) and related primarily to training content and the style of delivery.
Attendance at training events and for consultation calls was consistently very high, and there were indications of high engagement with the course. For example, the content of consultation calls indicated that clients were applying techniques learnt in the workshops to clients on their caseload. Although not systematically recorded, the web-based elements of the course were less well attended, with fewer participants accessing the webinars compared with the workshops, and the online forum appeared to be used only sporadically.
Knowledge of PTSD
Mean scores for the PTSD quiz are illustrated in Table 1. The change in scores from pre- to post-training equates to an effect size of r = 0.60, meeting Cohen's criterion of a large effect.
Table 1. Multi-level estimates for participant outcomes
*P < 0.05; **P < 0.01; Exp./OR, exponential/odds ratio.
A multi-level model was built with participants as level 2 variables. Table 1 summarizes the estimates from fitting the logit model. There were significant improvements on quiz scores after the training, which were maintained at follow-up. Improvements from post-training to follow-up were non-significant.
Self-rated competence
An overall self-rated competence score was calculated for each participant. Mean scores are summarized in Table 1. The change in scores from pre- to post-training equates to an effect size of r = 0.60, meeting Cohen's criterion of a large effect.
A visual comparison for scores at the different time points is illustrated in Fig. 2.
Figure 2. Self-competence ratings across time points
A multi-level model was built with participants as level 2 variables. Table 1 summarizes the estimates from fitting the logit model. There were significant improvements on self-rated competence after the training, which were maintained at follow-up. Improvements from post-training to follow-up were non-significant.
Supervisor-rated competence
Mean scores at each time point are summarized in Table 1. As well as the overall supervisor rating (out of six), a mean of scores on the generic CBT items (the nine items from the standard CTS) and the seven PTSD-specific items on the CTS-PTSD were calculated. Pre-training scores were in the ‘proficient’ range for generic CBT and ‘competent’ for PTSD skills. The training improved the PTSD-specific skills to the proficient level. The effect size for the improvement on PTSD-specific skills on the CTS-PTSD was high according to Cohen's classifications (r = 0.75).
Only five participants returned tapes at follow-up. No differences were found on quiz scores (z = 0.55; P = 0.29), self-rated competence (z = 0.44; P = 0.33) or CTS-PTSD ratings (z = –0.67; P = 0.75) at post-treatment between those who did or did not submit tapes.
A multi-level random effects model was built for each outcome, with participants at level 2. The results are summarized in Table 1.
Supervisors rated participants as significantly more competent on the CTS-PTSD overall following training, although this was not maintained at follow-up. When analysed by section, participants’ scores on general CBT skills did not improve following training, but PTSD-specific skills significantly improved, and were maintained at follow-up.
Client outcomes
Scores on the PHQ-9 and GAD-7 at both pre- and post-treatment were available for 57 cases, and for 21 cases on the IES-R. A 3-level multi-level model was built, with clients at level 2 and participants at level 3. Training time point (pre- or post-training) and treatment time point (pre- or post-treatment) were entered as predictor variables, with the key outcome relating to an interaction between the two. The outcome data models showed a poor diagnostic fit for a binomial model, probably due to correlation between the measured items, so a normal linear model was fitted. A folded log transformation was necessary to obtain acceptable normality and homoscedasticity.
The outcomes are summarized in Table 2. Overall, clients significantly improved on measures of PTSD, depression and anxiety following treatment. The improvement on the PTSD measure was significantly increased by the training intervention, i.e. scores on the IES dropped to a greater degree when therapists had undergone training. Scores for treatment completers were an extra 10 points lower on the IES when their therapist had completed the training. This effect was not found on measures of depression and anxiety.
Table 2. Multi-level estimates for client outcomes
*P < 0.05; **P < 0.01; Exp./OR, exponential/odds ratio.
Dissemination
Twelve participants reported their dissemination attempts at 1-year follow-up. No differences were found on quiz scores (z = 0.83; P = 0.20), self-rated competence (z = 0.32; P = 0.37) or CTS-PTSD scores (z = –0.09; P = 0.53) between those who did or did not return questionnaires.
Participants were asked whether the training had changed their practice. On a scale of 0 (not at all) to 10 (completely), responses ranged from 7 to 10, with a mean of 8.33 (SD 0.98). Therapists were asked which areas of their work had changed as a result of the training. All reported having made changes to their own practice and all had made attempts to disseminate the training to their teams. These attempts included sharing new knowledge (93.20%), sharing resources such as handouts (84.60%), facilitating training events (23.10%), changes to supervision (69.20%), and taking on additional supervisory responsibilities (14.40%).
On questions relating to significant changes to work environments since the course, two participants (16.67%) were no longer working for the same service; one had left the NHS and another had moved to a different IAPT service. Four (20%) of the participating services had changed provider, and two (10%) therapists had changed role within their service.
Barriers to change
On the ‘Barriers to Change Questionnaire’, completed at follow-up, participants rated ‘institutional constraints’ as the greatest barriers to implementing the training in their work place. Ratings of the barriers, ranked greatest to least, are displayed in Table 3.
Table 3. Barriers to change, ranked
Discussion
A training course in PTSD was found to be highly acceptable and to significantly improve the knowledge, self-rated competence and supervisor-rated competence (on PTSD skills) of a group of IAPT therapists. These improvements were maintained a year later. Outcomes of PTSD clients treated by the participating therapists were better following the training on a measure of PTSD, but not depression or anxiety. These findings suggest that a relatively brief training course in a disorder-specific treatment can significantly improve therapists’ skills and outcomes.
Prior to the training intervention, therapists showed moderate levels of skill and confidence in treating PTSD. Generic CBT skills were scored as ‘proficient’ by supervisors but, prior to training, PTSD-specific skills were scored lower, although still in the ‘competent’ range. An expectation that therapists are proficient at treating the full range of psychological disorders seen in IAPT following a year-long CBT diploma course may be unreasonable. Therapists regularly encounter complicated cases in routine clinical practice and, unless changes are made to IAPT service inclusion criteria, disorder-specific training courses may be required to continue professional development post-qualification.
Changes to client outcomes are rarely investigated in training evaluations. In this study, improvements were found on a PTSD outcome measure after the training intervention, but not on measures of depression or anxiety. Although PTSD was the main target of the training intervention, given the high rates of co-morbidity associated with the disorder, it is unclear why a change in depression and anxiety symptoms was not also found. Such changes may have become evident in a larger sample, or with longer follow-up of outcomes. It is also possible that, as participants were already competent CBT therapists, and were achieving good outcomes across all measures before the training, the additive factor of the training was finesse in delivering the trauma-specific elements of therapy which targeted PTSD symptoms in particular.
Effect sizes across the different outcome variables were broadly similar, although the different measurement methods used makes it difficult to draw conclusions about how the training impacted different outcomes. For example, a large change was seen in participants’ self-assessed competency, indicating that they felt more confident in trauma-specific treatment competencies after the training. It cannot be established from the data whether the improved PTSD outcomes were related to participants’ willingness to use trauma-focused techniques after training, or their improved competence in using elements of treatment which they were already delivering.
One aim of the training initiative was to trial a model whereby two ‘trauma experts’ were trained to provide a resource for the whole service. Although responses indicated that individuals did make attempts to pass on their learning to others in the team, there were several reasons for caution in concluding whether the model was successful. Within a year of the training, two therapists had left their service, three were off sick, and four services had new providers. Clearly, the model can only be sustainable if trained individuals remain embedded within teams and have sufficient resources and support to continue the specialist work.
In keeping with this, participants rated ‘institutional constraints’ such as high caseloads and too few staff as the main barriers to implementing the training. Even in the ‘institutional constraints’ category, ratings were generally in the mid-range, suggesting that such barriers were important, but not insurmountable. Very low ratings were found for most other perceived barriers. Both Myles and Milne (Reference Myles and Milne2004) and Kennedy-Merrick et al. (Reference Kennedy-Merrick, Haarhoff, Stenhouse, Merrick and Kazantzis2008) also found institutional constraints to be the primary barriers in their studies of CBT training courses, and other studies have reported problems with the sustainability and penetration of training initiatives due to institutional problems (e.g. Schmidt and Taylor, Reference Schmidt and Taylor2002; Ebert et al., Reference Ebert, Amaya-Jackson, Markiewicz, Fairbank, McHugh and Barlow2012).
Limitations
This evaluation was a naturalistic cohort study, and lacked randomization, control groups and blind assessment, which would be features of a controlled trial. While these are common limitations of training studies (Rakovshik and McManus, Reference Rakovshik and McManus2010), they reduce the generalizability of findings and conclusions. Without a control group, other unmeasured factors, such as access to other training and supervision, or service changes, may have contributed to improvements. However, the lack of improvement during the follow-up period, and on general CBT skills on the CTS-PTSD, appears contrary to this conclusion, and suggests that the programme succeeded in its aim of training PTSD-specific treatment skills. A further design limitation was the difficulty in dismantling the active components of the training. Workshops and webinars were equally popular, but the individual impact on learning was not measured, nor was the role of the consultation sessions [found to be integral in training transfer and durability in studies by Miller et al. (Reference Miller, Yahne, Moyers, Martinez and Pirritano2004), Sholomskas et al. (Reference Sholomskas, Syracuse-Siewert, Rounsaville, Ball, Nuro and Carroll2005) and Mannix et al. (Reference Mannix, Blackburn, Garland, Gracie, Moorey and Reid2006)]. Although not measured, it was observable that the workshops and consultation calls were better attended than the web-based elements of the course. It may be that the online training led to a lower sense of accountability, a finding noted by McMillen et al. (Reference McMillen, Hawley and Proctor2015) in their training study. Due to the absence of published measures, many of the outcomes in the study were measured using unvalidated tools. In particular, the knowledge quizzes were designed for the purpose of the study, and not psychometrically tested. Although randomization of items was used to promote equivalence of difficulty at each timepoint, this has not been confirmed. The sample size was small, and there was considerable missing data, particularly for supervisor-rated tapes at follow-up, which limits conclusions that can be drawn, and may have led to a reporting bias. However, no evidence was found of important differences between those who completed data and those who did not. Finally, the evaluation of dissemination was limited to self-reported attempts to disseminate, rather than an objective measure of these attempts.
Conclusions
Overall, the results seem to indicate that the trauma training package appeared to improve knowledge, skills and PTSD client outcomes for IAPT clinicians. The improvements were maintained a year later, and some evidence of attempts to disseminate learning back to teams.
This study could be extended in various ways. With respect to the limitations described, a randomized, controlled trial of the training package would allow firmer conclusions about its effectiveness to be drawn. Careful dismantling of the different elements of the training would allow for a better understanding of the effective ingredients. Longer-term and more intensive follow-up would allow the sustainability and penetration of the intervention to be fully assessed. Extending the evaluation of the dissemination of the programme, for example assessing broader benefits to teams, would be essential to evaluate the model.
Nevertheless, the results provide promising indications that relatively brief and cost-effective training interventions can lead to service improvements, and may assist with closing the gap between research outcomes and routine clinical practice.
Acknowledgements
The author thanks Sarah Rakovshik, Sharif El-Leithy and Jo Billings for their valuable advice; Ruth Cocksedge for making the training possible; Glorianne Said for being a fantastic assistant; Dan Lunn for statistical support; and all the participating services and therapists.
Financial support: This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest: None.
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