Increasing access to care for trauma‐exposed rural veterans: A mixed methods outcome evaluation of a web‐based skills training program with telehealth‐delivered coaching

Abstract

Purpose: While rural veterans with trauma exposure report high rates of posttraumatic stress disorder (PTSD), depression, and functional impairment, utilization of health services is low. This pilot study used mixed qualitative and quantitative methods to evaluate the potential benefits of a transdiagnostic web-based skills training program paired with telehealth-delivered coaching to address a range of symptoms and functional difficulties. The study directed substantial outreach efforts to women veterans who had experienced military sexual trauma given their growing representation in the Veterans Healthcare Administration (VHA) and identified need for services.Methods: Participants were 32 trauma-exposed veterans enrolled in rural-serving VHA facilities who screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed at baseline, midpoint, posttreatment, and 3-month follow-up. Veterans completed exit interviews to identify benefits and limitations of the program.Results: Intent-to-treat analyses revealed significant symptom reduction for all outcomes, with large to moderate effect sizes at 3-month follow-up. Outcomes did not differ by gender or military sexual trauma status. Veterans' rating of the therapeutic alliance was high and interview responses indicated that the presence of the coach was critical to success in the program. Conclusion: This remotely delivered transdiagnostic intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by veterans. The results indicate that further research (ie, a randomized controlled trial) is warranted. Attention to the role of the coach as a means by which to increase engagement and retention in technology-delivered interventions is warranted.

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study

“…For example, it is possible that self-guided work and the therapist sessions made unique and complementary contributions to the program outcomes and may ultimately have provided greater benefits than therapist-only or internet-only approaches [ 18 ]. Evidence for this view is supported by qualitative analyses from interviews completed in one of our earlier studies [ 21 ], which found that the self-guided work facilitated a sense of autonomy and mastery, while the therapist sessions provided emotional and practical support as well as clarity in tailoring the tools to specific problems and life experience. The potential presence of a dynamic, reciprocal relationship between these 2 treatment components deserves further investigation via assessment of cross-lagged effects and identification of underlying mechanisms of change.…”

“…The 1:1 ratio was adopted as the anchoring reference point for this investigation based on the high patient satisfaction ratings and the large effect sizes reported in the first webSTAIR study, which used this ratio [ 15 ], and because this ratio provided the maximum number of therapist sessions in a blended therapy program in which the intervention of interest was the web-based intervention. The selection of the 1:2 ratio was based on a pilot study that delivered webSTAIR with this ratio, yielding significant symptom reduction with a large effect size [ 21 ]. That study also included posttreatment interviews that identified an association between patient satisfaction and the number of therapist sessions; veterans reported in the interviews that self-guided work fostered independence and mastery.…”

Evidence of Phone vs Video-Conferencing for Mental Health Treatments: A Review of the Literature

“…Using video to conduct exposure treatments has expanded treatment possibilities in ways that neither phone nor in person modalities can: providers were able to view patients' home environments to better understand patients' symptoms and could teach patients how to do exposure treatment in their home environment [50]. Because of the unique aspects of treatments related to OCD and tic disorders, video may be preferable to phone, as it allows providers to collect collateral information from patients and tailor exposure protocols to patients' homes.…”

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study (Preprint)

“…For example, it is possible that self-guided work and the therapist sessions made unique and complementary contributions to the program outcomes and may ultimately have provided greater benefits than therapist-only or internet-only approaches [18]. Evidence for this view is supported by qualitative analyses from interviews completed in one of our earlier studies [21], which found that the self-guided work facilitated a sense of autonomy and mastery, while the therapist sessions provided emotional and practical support as well as clarity in tailoring the tools to specific problems and life experience. The potential presence of a dynamic, reciprocal relationship between these 2 treatment components deserves further investigation via assessment of cross-lagged effects and identification of underlying mechanisms of change.…”