Approximately 40% of Veterans live in rural areas, and while the prevalence of trauma-related mental health difficulties, including PTSD, are equivalent to other Veteran groups, their rates of service use are among the lowest. In response, VA has made several remote care options available as alternatives to in-person mental healthcare through its Office of Connected Care. Remote care helps solve logistical barriers, such as distance, transportation, and travel costs, as well as barriers such as taking time off work or school, arranging child or elder care, and physical limitations, all of which limit Veterans’ ability to engage in in-person mental healthcare. Remote care also helps resolve clinical barriers, such as stigma around seeking mental healthcare.
Led by Marylene Cloitre, PhD – a core investigator with HSR&D’s Center for Innovation to Implementation: Fostering High-Value Care – this pilot study sought to evaluate the potential benefits of an internet-based self-guided approach (webSTAIR) combined with biweekly video-delivered coaching sessions (with clinical psychologists) to address a range of symptoms and functional difficulties. This analysis included 32 Veterans (59% were women) who had been exposed to trauma and screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed by an independent evaluator via telephone at baseline, midpoint, post-treatment, and at three-month follow-up. In addition, Veterans completed exit interviews to identify the benefits and limitations of the program (see Veterans’ feedback below).
Led by Susan Frayne, MD, MPH, and located in Palo Alto, CA, HSR&D’s Center for Innovation to Implementation (Ci2i
) fosters high-value healthcare for Veterans by identifying opportunities to improve value, and by testing the implementation of innovations that respond to those opportunities
The webSTAIR program is a manualized intervention that consists of 10 web-based modules, adapted from STAIR. The first half of the program (5 modules) provides skills to improve emotional awareness and emotion management, and the second half (5 modules) reviews relationship patterns and focuses on changing behaviors related to difficulties with effective assertiveness, interpersonal flexibility, and compassion for self and others. Coaches met with Veterans for 50-minute sessions via video teleconferencing after the initial module, and again after each two skill modules Veterans completed. Three clinical psychologists who held positions in the outpatient mental health clinics of their respective VHA facilities served as webSTAIR coaches. All coaches were female.
The study team was committed to enrolling underserved Veterans, particularly women Veterans with Military Sexual Trauma (MST) who may experience multiple barriers to care. Veterans were recruited from three rural-serving VA medical centers in California, Texas, and Illinois, and the majority of Veterans lived in rural or highly rural areas (78%). Participants reported experiencing an average of 8.25 traumatic events within their lifetimes, with 53% (all women) endorsing a history of MST.
The webSTAIR intervention – a blended model of an Internet-based self-guided approach combined with biweekly video-delivered coaching sessions – was found to be well-liked and to provide reductions in PTSD, depression, emotion management, and interpersonal problems. In addition:
- This remotely delivered intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by Veterans.
- Of the 26 participants, 50% who met a probable diagnosis of PTSD symptoms at baseline were below the clinical cutoff at post-treatment, and of the 28 Veterans with a probable diagnosis of depression at baseline, 46% were below the clinical cutoff at post-treatment.
- Veterans’ interview responses (see below) indicated that a coach was critical to success.
- Outcomes did not differ by gender or MST status.
On using the web
When asked about their experiences completing the Internet-based modules independently, 9 Veterans reported that they liked being able to go through the modules at their convenience and/or that they appreciated the opportunity to reflect on the content before meeting with their coach.
I liked it because I was able to work at my own pace. I was able to work it around my schedule instead of working my schedule around it. I liked doing the modules beforehand because we were able to talk about them better when I’d done them first. —47-year-old female Veteran
On coaching sessions
Ten of the 12 Veterans reported that the five coaching sessions they received was the right amount of contact. Only two Veterans said they would have preferred more sessions with their coach, with one 30-year-old White female Veteran commenting, “A lot of the stuff I've never seen before. With more sessions I could understand it more. I would have gotten more out of it if I could have discussed each module with her weekly.”
Veterans also reported feeling comfortable talking with their coach over video telehealth.
I think it was important that we establish rapport. I didn’t think that would be possible over video, but it was the first thing that she did before we started talking about the modules. I was apprehensive to reveal things to her at first, but I became very comfortable over the course of the first few weeks. —43-year-old male Veteran
Six Veterans noted that the coach helped increase their understanding of the skills.
Having the coach actually drive the facts home had a big impact. Without the positive relationship it wouldn't be as successful. —31-year-old female Veteran
This information will contribute to the development of personalized blended treatments tailored to the individual to enhance engagement, retention, and outcome. Results also indicate that further research (i.e., a randomized controlled trial) is warranted, especially regarding attention to the role of a coach as a means by which to increase engagement and retention.
Next steps will include a randomized controlled trial assessing webSTAIR versus waitlist among Veterans in the community, thereby determining whether coaching with Veteran peers will provide benefits.
For more information about webSTAIR, please contact Dr. Cloitre at: Marylene.firstname.lastname@example.org.
*This study was funded by VA’s Office of Rural Health.
Fletcher T, Amspoker A, Wassef M, et al., and Cloitre M. 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. Journal of Rural Health. October 14, 2021; online ahead of print.