Cognitive behavioral therapy (CBT) is highly effective for treating depression and anxiety (1), and recent evidence suggests that CBT is effective for primary care patients (2–5). Unfortunately, the utilization of psychotherapeutic services is limited, and additional efforts are needed to expand access to these treatments (6, 7).
Psychotherapies such as CBT are complex, requiring intense training over a prolonged period, usually under expert supervision. Comprehensive psychotherapy training often occurs within mental health graduate and postgraduate and residency programs, and focused training in specific methods such as CBT are often optional. As a result, few practitioners, even those from mental health programs, are adequately trained to conduct focused, evidence-based psychotherapy approaches, and even fewer are able to adapt such training to fit within non-mental health specialty care settings (e.g., primary care). Focused efforts are needed to expand access to evidence-based psychotherapy trainings for treatments such as CBT (8, 9).
As a supplement and/or alternative to postgraduate training, other CBT training approaches have focused on in-person workshops that require significant resources (i.e., time, money, trainers) and are relatively inflexible for participants (i.e., limited availability, travel requirements, etc.). Recent efforts by Craske et al. (10) and Ros et al. (11) suggest that computer-aided innovations in CBT training and service delivery (e.g., provision of care by non-CBT experts) can potentially improve the treatment of anxiety in the primary care setting.
The current project sought to develop a computer-aided CBT training program using a flexible, online approach (labeled computer-aided CBT; CA-CBT) to increase training access for a broad audience of mental health providers with varying levels of psychotherapy experience. CA-CBT was envisioned to provide focused training in CBT to mental health providers, regardless of discipline and or previous training in CBT, to advance and/or establish practice-based CBT skills. The following educational resource document describes the process of constructing CA-CBT to aid others seeking to use similar computer-based teaching methods.
The explicit goal of the CA-CBT project was to create an interactive, online product that would be widely accessible and engaging for learners, while allowing for data-gathering and adaptability for future implementation efforts, by use of the following steps:
Step 1: Select Evidence-Based Intervention Material
CA-CBT used established intervention materials (Adjusting to Chronic Conditions with Education, Support and Skills [ACCESS] (12) and training methods (13) as the foundation for the development of the Internet-based CBT training program. This intervention has proven effective for a broad audience of mental health providers with varying levels of psychotherapy and/or CBT experience.
Step 2: Assemble Project Team
We assembled a multidisciplinary team with members from various learner perspectives. Team members included an expert in CBT interventions and in-person training methods (12, 13) and an expert in instructional design and information technology. Other team members included psychology interns with graduate-school training in CBT, psychiatry residents with no training in CBT, and a research coordinator with limited CBT exposure. To fully integrate the training materials into a marketable and appealing interface, a computer-graphics team created product “branding,” including logos and graphic themes for the website, PowerPoint slides, and core materials.
Step 3: Use Learning Theory and Conceptual Models to Inform Training Program
Several conceptual models were used to “ground” the CA-CBT training. Table 1 describes the theories or constructs and gives an example of how the theory informed training development.
TABLE 1.Project Theories and Constructs
| Add to My POL
|Theories and Constructs||Brief Description||Example from CA-CBT Training|
|Adult Learning (14)||Learning should capitalize on learner’s previous experience and offer choices.||Learners chose to complete concept reviews based on need.|
|Situated Learning (15)||Knowledge needs to be presented in authentic contexts.||Audio vignettes were scripted, using commonly-encountered patient situations/circumstances.|
|Social Learning (16)||Role modeling allows learners to imitate desired behaviors.||Audio vignettes modeled effective therapist–patient interaction.|
|Bloom’s Taxonomy (17)||This divides learning into cognitive, affective and motor domains, each with a hierarchy of complexity.||Learning material and post-test questions were designed to promote application of knowledge to the therapist’s practice.|
|Usability Principles (18)||Designing with good usability improves learning.||The course interface was uncluttered and consistent.|
The project team also felt it important to convey a “real-world” training approach. Thus, rather than teaching individual CBT techniques, we sought to develop methods that would facilitate the broader practice of CBT as a psychotherapy with an emphasis on the therapeutic relationship and the need to develop a patient-centered approach to care (e.g., collaborative goal-setting and patient empowerment through skill-development).
Step 4: Select Information Technology Approaches
We chose the Moodle platform (www.moodle.org) to deliver the training materials. Moodle is a widely-used learning-management system. It is easy to administer, easy to learn, facilitates interaction between learners and trainers, and provides avenues for evaluations and surveys for data collection. Also, Moodle allows monitoring of learners’ progress. We used Adobe Captivate 4 (Adobe Systems, Inc., San Jose, CA) to integrate PowerPoint slides, audio vignettes, and interactive questions into each presentation.
Step 5: Convert Paper-Based Training Materials to Digital Form
Although CA-CBT was founded on previously established materials and training techniques (12, 13), notable adaptations were required to transform these methods into an effective computer-based interface. The previously-established clinician manual provided detailed information, including specific language examples for patient–therapist interactions. From these language examples, the team identified important skill-sets that required focused training. Prior face-to-face training formalized teaching methods in terms of interactive learning experiences, focused readings, modeling, and experiential exercises. CA-CBT sought to deliver this interactive content using downloadable materials, including narrated PowerPoint slides (using Captivate software) and modeling using narrated audio vignettes for discrete CBT skill-sets. We transformed the established language from the print-based materials into audio vignettes and scripted expert introductions to scaffold learning. As secondary educational components, we added experiential exercises via interactive applied questions/quizzes through the Moodle forum, which allowed participants to display their knowledge through applied questions and interface with the instructors around difficult topics. To address the heterogeneous background of our learners, we developed concept reviews (informed by Adult Learning Theory). This allowed clinicians to self-assess their training needs and complete training accordingly.
Step 6: Create Evaluation and Satisfaction Instruments
To understand the utility of the CA-CBT program, we adapted satisfaction and trainee pre–post self-evaluation surveys from our previous work (13). The satisfaction survey was constructed to be completed post-training. The pre- and post-survey instruments included an assessment of CBT use, knowledge of CBT skills, and perceived CBT abilities. Our goal was to develop outcome evaluations of trainee knowledge and potential to apply CBT techniques.
Step 7: Complete Formative Evaluations and Program Modifications
In addition to informal, internal reviews, more formal formative evaluations were completed for the explicit purpose of program refinement. We engaged external expert CBT trainers to review materials and provide constructive feedback on the quality and content of the developed product during product development and again upon project completion. We also asked psychology and psychiatry trainees from outside the project to use the materials and provide preliminary feedback about ease of use, satisfaction with the Internet interface, and general effectiveness of the program. As the program continues, additional evaluation will be conducted to “fine-tune” the approach.
On a budget of $10,000, this grant-funded project took 13 months to complete. With this level of funding, we purchased a 2-year hosting site and software programs, provided modest stipends for external reviewers, and compensated the graphics team. Funding did not include investigator or staff salary support.
The published CA-CBT program can be viewed at www.vaprojectaccess.org (see authors' contact information to obtain access to internal site and full training materials). The external site describes the ACCESS project, provides patient and clinician information and materials, and addresses how Project ACCESS has been and is currently being used. The internal site, which is password-protected, is exclusively used for clinician training.
Within the internal site, clinicians are provided with a course syllabus, pre-training survey, concept review documents, an exit/satisfaction survey, and a forum for group discussions and messages from the instructor. The primary training interface (narrated PowerPoint slides) is presented in seven “modules” or sessions, as outlined in a previously-published CBT intervention (12). Each module takes approximately 60 minutes to complete, and overall training takes approximately 8 hours. We encourage learners to complete the training sequentially over 2 to 3 weeks. Learners can receive continuing-education credits upon completion of the training.
Initial qualitative feedback from the formative evaluation process (external reviewers: two CBT experts and two mental health trainees) suggests that clinicians found the overall training to be appropriate and effective for both advanced and novice clinicians. Feedback suggested that the flexibility of the module-based training program was a strong advantage for practitioners who have limited protected time for training. One reviewer suggested that video-based content would add to the interactive “feel” of the program.
The completed CA-CBT Program is targeted to expand CBT training outreach beyond local and regional clinicians. CA-CBT is learner-directed and allows teacher-to-learner and learner-to-learner interactions, thereby retaining aspects of face-to-face training. Notably, the CA-CBT program reduces time, resource, and geographic barriers, thereby increasing access for providers unable to obtain similar training (e.g., rural mental health practitioners).
Other advantages of this computer-aided approach include 1) the ability of the instructor to easily embed data-collection avenues for following learner needs, satisfaction, and outcome; 2) the standardization of training delivery, which increases internal control over knowledge dissemination; 3) the ability to monitor and track training progress, as well as assess knowledge of concept and application via post-training quizzes; and 4) the reuse of training materials. The ability to monitor provides the instructor with unique data to identify and address learner difficulties.
A potential disadvantage of the current computer-aided approach is the self-directed nature of training. Clinicians are asked to engage in self-directed learning that is different from in-person, face-to-face training, which is structured by the educator and more passively received by the learner. Therefore, the implementation of computer-aided training approaches must attend to the learner’s motivation to acquire these new skills, and consideration should be given to adding external incentives and/or structured training timelines to increase training compliance.
Recommendations for Developing a Computer-Aided Training Approach
1. Begin With the End in Mind
Envisioning a final product and quickly working toward developing methods to meet this goal helped the design team remain on task and avoid instructional “luxury items” (e.g., time and resource-intensive video examples) that could have distracted from project goals.
Developing an initial timeline and product-delivery date was important. We evaluated teaching options and methods with an eye on opportunity costs. In whatever direction the team decided to move, there were costs in terms of areas not explored or pursued.
3. Know Your Budgetary Limitations
Some technologies, such as video, are more expensive and time-consuming than others. Trade-offs between training fidelity and affordability are required. Given our limited time and budget, teaching of CBT skills was restricted to audio vignettes, thereby limiting our modeling of nonverbal skills.
4. Use the Multidisciplinary Team Wisely
With any multidisciplinary team, there exists an opportunity to build something greater than the sum of the respective parts. To fully realize this opportunity, a team culture of respect, openness, and willingness to learn is important. This is particularly important when disparate disciplines come together for a common cause. In this project, the mental health experts were exposed to a wide variety of previously unknown educational and information technology approaches that greatly enhanced delivery of the educational content. Weekly meetings allowed for discussion, experimentation, and problem-solving.
5. Take Advantage of the Medium
Narrated lectures had to be educationally effective and engaging. This required careful considerations and proved time-consuming. Audio vignettes were scripted and practiced by study personnel to ensure appropriate modeling and delivery. Learners were able to access the materials as often as necessary to learn the material.
6. Evaluate Early and Often
We recommend that outside evaluators begin reviewing the product at an early stage. Initial formative evaluations directed the project team to salient or unrecognized issues, which led to refocused project goals. Delaying evaluation may result in the project moving away from established goals and/or missing essential components. To be fully effective, program developers should conduct iterative formative evaluation and revision throughout the project.
We thank Cynthia Phelps and Phelps Designs for their graphic artist work and Maria Armento, Ph.D., Michael Kauth, Ph.D., and Melinda Stanley, Ph.D., for their thoughtful feedback and contributions to the project.
This work was supported by grant funding from the South Central MIRECC and VA HSR&D IIR (#09-088) to the first author and partly supported by the VA HSR&D Houston Center of Excellence (HFP90-020). The views expressed are those of the authors and do not necessarily reflect those of the Department of Veterans Affair/Baylor College of Medicine.