Although a number of evidenced-based psychotherapies, including CBT, are known to be clinically effective, many do not have access to them in part because widespread dissemination and implementation of these practices has been challenging. The goal of our work was to develop and evaluate a system for training primary care staff to deliver evidenced-based treatment for anxiety disorders. Such a system would provide an important mechanism for dissemination of evidence-based care for anxiety disorders. An additional aspect of the CALM study is that training occurred at four geographic sites covering a wide and diverse swatch of the US. Practitioners were located at 13 primary care clinics among these sites and the training and evaluation of the training was managed out of the UCLA (Los Angeles) site. Therefore, this training or a substantial part of it can be done at a distance. Based on study psychologists' ratings of the training cases, our training resulted in ACS who were competent at delivering CBT skills and adherent to the computer-assisted CBT program.
The training was generally viewed very positively and as being very useful, with the more active components of training (i.e., role-plays, and ongoing supervision) rated as most helpful. ACS's previous clinical experience was negatively associated with how well they performed on their training cases as rated by study psychologists. Perhaps ACS with greater clinical experience were more set in their ways and took a bit longer to adapt to the structure of the computer-assisted CBT intervention. It should be noted that despite the significant inverse relationship between prior clinical experience and proficiency ratings, all ACS were rated proficient on their training cases with the average proficiency rating being greater than 6 out of 7 points.
] reported, training in evidenced-based interventions in psychology, psychiatry, and social work programs is lacking. Behavioral health professionals need access to training that is practical and applicable to real-world settings. The CALM training program addressed that void in evidenced-based training and successfully trained clinicians in the principles of CBT, not just in the use of a manual. Additionally, outcome data for the 503 subjects randomized to the CALM intervention shows that they did significantly better than those randomized to TAU (N=501). Furthermore 91% of those in the CALM intervention received CBT [3
]. This suggests that our training led to effective outcomes.
There are some limitations to the data presented here. Bias may have been introduced because the ACS may have not felt fully comfortable to rate the training negatively given their close interactions with the study psychologists. While the study psychologists who rated ACS performance on role-plays and training cases specialized in CBT treatment for anxiety disorders, an inter-rater reliability check was not conducted. Although the CALM study aimed to address issues of increasing dissemination and transportability of the intervention, there are no data yet to support whether it will accomplish that.
The ACS survey suggests areas for further refinement of the CALM training program. Based on ACS feedback, the training could have been streamlined in terms of duration and content. While the training model presented here was effective even with novice CBT clinicians, the hours of training provided in the study might be impractical in actual primary care settings. Future studies should empirically evaluate how much and what kind of training is essential to adequately train novice clinicians in CBT for use in real-world settings such as primary care. Another possible direction for dissemination of training in evidence-based interventions would be to create an autonomous version of self-guided CBT training available via the Internet.
In summary, clinicians without prior experience in CBT can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders in primary care settings. A diverse training program blending didactic presentations, role-playing, video demonstrations of CBT skills, and closely monitored training cases was very acceptable to the clinicians-in-training and led to high levels of proficiency in their intervention delivery. An important future direction involves streamlining the CALM training program with the aim of decreasing overall training hours and thereby reducing the time and financial costs of training to trainees, supervisors, and health care settings.