A multistep mediation model examining how consultation in prolonged exposure therapy affects PTSD treatment outcomes

Abstract

Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or patient outcomes. The present study addressed these gaps by examining associations between consultation, provider self-efficacy, use of PE, and patient outcomes using a multistep mediation model. This study used data from Foa et al. (2020), a two-armed randomized implementation trial comparing two PE training models: standard training (workshop only) and extended training (workshop + 6-8 months of postworkshop expert consultation) at three U.S. Army sites. Participants were patients with PTSD (N = 242) receiving care from the participating providers (N = 103). Providers who received extended training reported greater PE self-efficacy compared to standard training providers, but self-efficacy was unrelated to their use of PE components or to patient outcomes. Extended training providers used more PE components and had superior patient outcomes than standard training providers, and patient outcomes were mediated by the use of PE components. To our knowledge, this is the first study to demonstrate that EBP consultation leads to improved clinical outcomes for patients through increased use of the EBP. PE adoption (i.e., use of PE components in therapy) was not explained by increases in self-efficacy among providers who received extended training. Therefore, future research should assess how other factors may influence provider behavior in implementing EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Figure 1.

Moderated mediation model for the relationships between Provider Treatment Group and patient PTSD symptoms, via Provider Self-Efficacy and PE use. Note: *** designates path coefficients that are p ≤ .001; * designates path coefficient that are p < .05. Path coefficients without asterisks are not significant. EOT designates End of Treatment. Bold arrows indicate significant paths. Three paths are moderated by treatment session (Baseline vs. EOT): the direct effect of Treatment Group on patient PTSD symptoms, the effect of Self-Efficacy on patient PTSD symptoms, and the effect of Use of PE Components on patient PTSD symptoms. Path coefficients above those three moderated paths are the coefficients at EOT, are indicated by the superscript “EOT”, and are in bold. Path coefficients below the three moderated paths are the coefficients for the relation between that predictor and patient PTSD symptoms at baseline, have a superscript “b”, and are not bolded.