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Virtually Endless Possibilities in Trauma-Related Mental Health Care: A New NYC-DOHMH Training Initiative

We are at a turning point in the way we teach and learn medicine. In this information age, virtual technology-based training methods are becoming powerful learning tools for medical professionals, allowing them to learn and practice new skills, anytime, anywhere: from their homes, offices or from remote locations, as their schedules permit. These trainings are designed to capture interest, enhance learning, and encourage retention of information through active participation.

Embracing these new computer-based technologies and responding to the changing training needs of health care professionals, the New York City DOHMH in collaboration with Kognito Interactive (www.kognito.com) is developing two online interactive trainings (Winter 2012) designed to promote behavioral changes and thereby increase providers’ ability to manage the acute and long term mental health conditions most commonly associated with trauma exposure.

The trainings will utilize Kognito’s proprietary and award-winning simulation platform (previously tested with emergency room physicians and returning military veterans and their families) to create virtual role-play conversations with avatars who are intelligent, fully animated, and emotionally responsive. Key information and practical strategies will be presented through the use of narrative “case-examples,” role-play situations and high levels of interactivity. By embracing this new method of training and professional learning, the DOHMH hopes to better accommodate health care professionals’ needs, training preferences and busy schedules, offering a custom training program.

The first training is focused on providing integrated disaster and other trauma related care in primary care settings, and the second on exposure therapy for PTSD (both trainings are further described below). Each training is approximately 90 minutes long and broken into modules of 20 minutes or less to allow providers to take the course all at once or module-by-module, as time permits.

In addition to adopting an emerging new technology with the key advantages of allowing learners to practice and master new skills in a safe, simulated environment and revisit cases as needed; these two trainings also aim to address a critical need for enhancing the healthcare system’s capability to better address the mental health needs of populations exposed to trauma. While the majority of people exposed to disasters and other traumatic events will recover, others will find coping with what they experienced or witnessed more difficult, and without help they may develop trauma-related mental health disorders. As many who would benefit from getting professional support are reluctant to seek help and those who do seek support often find the system-of-care challenging to navigate, these trainings are designed to improve the identification and management of trauma related mental health needs and thus, foster recovery and better outcomes. Primary Care Providers:

Often the First Point of Contact for Mental Health Care

Primary care settings are often the first point of contact for individuals seeking medical care, including those with mental health conditions. Yet, according to the SAMHSA Mental Health 2010 Study, a significant proportion of adults (62.1% or an estimated 27.9 million people) with mental illness go untreated.

Patients who experienced a traumatic event, such as a terrorist attack or violence or sexual assault, may seek treatment for their physical ailments from their primary care provider (PCP). At that time, they may also present with symptoms, or seek treatment for, trauma-related mental health conditions such as PTSD, depression, alcohol or substance abuse, and GAD. Primary care providers are in a key position to recognize symptoms and risk factors for trauma related mental health disorders, identify at-risk patients, and discuss treatment options with patients whose symptoms might otherwise go unnoticed and untreated.

By developing this training, DOHMH aims to supports PCPs in this key role. The training will support the provision of more effective and integrated mental health care by increasing PCPs’ awareness of and knowledge about managing trauma related mental health disorders in their settings.

The training recognizes and provides strategies to overcome the main obstacles PCPs face when providing trauma related mental health care. Many PCPs view physical and mental health as separate and parallel tracks in healthcare provision and the majority have limited formal training about risk factors, symptoms and treatment options for mental health disorders. This lack of knowledge can impact the PCPs’ ability to identify, treat or refer patients who may be at risk for, or already suffer from, trauma related mental health conditions.

Those PCPs who do provide treatment often turn to pharmacotherapy, overlooking evidence-based psychotherapeutic approaches; PCPs prescribe over 75% of all anti-depressants. (Wintersteen and West: Hylan et al, 1998). Consequently, the training aims to increase PCPs’ knowledge about the symptoms, risk factors and treatment options for PTSD, depression, alcohol and substance abuse, and GAD, so that they can better recognize and identify these mental health issues in their patients. Through interaction with virtual patient avatars, PCPs will learn to navigate patient questions, concerns and potential resistance, thereby building skills for conversing with patients about potentially sensitive issues in a non-threatening, efficient and professional manner.

Another obstacle that PCPs face is time management related to the high volume of patients they see and the time required to thoroughly assess patients who may be at risk for developing trauma related mental health disorders. The training is designed to help PCPs to recognize that investing time initially with their patients can reduce the number of return visits, and can increase the chance of a better long-term treatment outcomes.

The training will also focus on the importance of providing adequate follow-up care for patients recognized as at risk for PTSD, depression, alcohol or substance abuse, and GAD. It will offer exercises for effectively encouraging patient treatment adherence to help PCPs build skills that will support compliance with essential follow-up care. Finally, the training will address PCPs’ concerns about their legal responsibilities when it comes to mental health treatment by emphasizing the importance of forming mutually beneficial partnerships with their mental health colleagues for consultation, and, if appropriate, referral of patients seeking care for trauma-related issues.

Embracing Exposure Therapy

According to the American Psychological Association (2008) traumatic events are those that threaten injury or death, while also causing shock, and feelings of terror or helplessness. With over two thirds of the general population experiencing a significant traumatic event at some point in their lives, and up to one fifth of the US population in any given year; traumatic experiences are relatively common. Post-traumatic stress disorder (PTSD) is one of the most common, and most widely studied mental health disorders, linked to trauma exposure. (Galea,2005). Almost 8 % of adult Americans experience PTSD at some point in their lives (C. Kessler ,National Comorbidity Survey Report, 2005).

Most individuals who develop PTSD find it very difficult to process their experience and cope with the memory of the trauma. As a result, even many years after the event, situations, objects, sounds, even smells can serve as “triggers” evoking bad memories, and causing the person to “re-live” their traumatic experience. Fearing these highly distressing memories, survivors with PTSD try to avoid such environmental “triggers” and may withdraw from activities they once enjoyed and distance themselves from friends and family.

Exposure therapy has a demonstrable effect in treating PTSD and other anxiety disorders. It is a form of cognitive behavioral therapy (CBT) which encourages individuals to confront their memories of the traumatizing events. In a meta-analytic journal article that included 13 studies, Foa et al. (2007) found that, “prolonged exposure therapy is highly effective in treating PTSD, and results in substantial treatment gains that are maintained over time.” The core of prolonged exposure therapy is the repeated description of the memory in vivid detail in a safe environment; through this, the patient learns that the memory itself is not dangerous, which then enables them to cope with the attendant memory and resultant anxiety.”

Many clinicians are nonetheless reluctant to employ exposure-based interventions in their practices because they lack the comfort level and skills that adequate training provides. It is our aim in developing this training, to overcome this obstacle and to increase the number of mental health specialists capable of providing exposure-based intervention for patients with PTSD.

By presenting the theoretical cognitive-behavioral principles of exposure therapy and the evidence-based data supporting its use in the treatment of PTSD and other anxiety disorders, we expect that those taking the training will gain a better understanding of what prolonged exposure therapy is and why it is an effective treatment option for patients with PTSD. Because exposure therapy makes unique psychological demands on the patients, the training also help learners develop a strong therapeutic alliance with their patients and gain the skill, knowledge and self-confidence necessary to effectively present the rationale for the therapy to those they treat, to explain to them what exposure therapy is and how it works, as well as what can be expected from the treatment, both in the short- and the long-term.

The majority of the training is a blend of didactic and interactive/experiential learning, and aims to help clinicians develop a better understanding of how to conduct prolonged exposure therapy in their practice. This part of the training explains: the structure of prolonged exposure therapy, how to start patients on prolonged exposure therapy conduct imaginal exposure, build an in vivo hierarchy, recognize when the client is under or over-engaged, manage anxiety levels so the patient remains within an effective range of engagement, and know when it’s appropriate to terminate therapy. We hope that learners will come away from the course feeling confident in their abilities to conduct prolonged exposure therapy and motivated to learn more about it.

The Common Goal

By offering these two CME trainings to an unlimited number of primary care and mental health professionals in New York City the DOHMH hopes to increase the number of trained professionals capable of providing the needed care to those psychologically impacted by disasters and other traumatic events. Integrating mental health services into primary care and increasing the number of trained mental health professionals capable of providing evidence-based exposure therapy will help mitigate the consequences of undetected or inadequately treated trauma related disorders. We encourage primary care practitioners and mental health professionals in New York City interested in receiving additional information about these free trainings to forward your contact information to DOHMH by e-mailing tsmith9@health.nyc.gov.

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