Behavioral health technician delivered written exposure therapy for posttraumatic stress disorder in the military: Design of a hybrid implementation effectiveness trial

Abstract

Posttraumatic stress disorder (PTSD) affects up to 13–17 % of active duty military personnel who deployed after 9/11 and significantly impacts military readiness. However, behavioral health providers in the Military Health System (MHS) face significant challenges in implementing evidence-based psychotherapies (EBPs) such as Written Exposure Therapy (WET). One of the main obstacles is the limited capacity to schedule and conduct weekly therapy sessions due to large patient panels and heavy workloads. This study uses a Hybrid Type 1 implementation-effectiveness design to increase access to WET by task sharing delivery with behavioral health technicians (BHTs). We will compare BHT-delivered WET plus treatment as usual (TAU) to TAU alone in a Phase II randomized clinical trial with 150 active-duty participants. The primary aims are to evaluate the clinical effectiveness of BHT-delivered WET, patient acceptability, and BHT treatment fidelity. Secondary aims include identifying barriers and facilitators to WET implementation. Participants will be randomly assigned to BHT-delivered WET or TAU alone, with WET delivered weekly over five sessions either in-person or via telehealth. Quality control will be maintained through rigorous BHT training, supervision, and fidelity assessments. Community-Based Participatory Research methods will ensure stakeholder engagement and feedback throughout the study. Data analysis involves linear mixed-effects models and rapid qualitative analysis to assess outcomes. The results will demonstrate the effectiveness of WET in routine care settings and the feasibility of BHT-delivered WET as an implementation strategy. The findings have the potential to enhance PTSD treatment accessibility and inform best practices within the MHS and similar settings.

Highlights

• •Access to evidence-based PTSD treatment is limited at military clinics.
• •Task sharing to behavioral health technicians (BHTs) may increase access to care.
• •Written exposure therapy (WET) for PTSD is well suited to BHT delivery.
• •This study tests the effectiveness of WET and the effects of task sharing with BHTs.

1. Introduction

Posttraumatic stress disorder (PTSD) is the most common psychological health condition associated with military deployments, affecting up to 13–17 % of active duty service members who deployed since 9/11 [1,2]. The impact of untreated PTSD on military readiness is considerable; PTSD is linked with high rates of psychological [3,4] and medical comorbidity [5], increased healthcare utilization [6,7], impaired functioning, and low quality of life [8,9]. Evidence-based treatments for PTSD suggested in clinical practice guidelines are individual, trauma-focused psychotherapies, such as cognitive processing therapy, eye movement desensitization and reprocessing, prolonged exposure, and written exposure therapy (WET) [10]. However, there is limited access to these EBPs at military treatment facilities (MTFs) [11].

Behavioral health providers in the military are often unable to see patients weekly due to large patient panels [12]. For example, data from a study with eight MTFs showed an average wait time between appointments of 21 days. This frequency of care is incompatible with EBP delivery because EBPs have only been tested and validated in once weekly (or more frequent) sessions. Given these challenges, it is unsurprising that researchers have estimated the rate of EBP implementation for PTSD in the Military Health System (MHS) to be low [11]. In a prior study of military behavioral health care, the strongest predictor of the proportion of military behavioral health patients who received a minimally adequate dose of care was the average wait time between follow up psychotherapy appointments [13]. Thus, long wait times between appointments preclude EBP delivery and constrain treatment dose, both of which limit therapeutic recovery from PTSD and, in turn, negatively impact military readiness.

Task sharing the role of the mental health therapist to a less expert professional is an approach to increasing the availability of care at a relatively low cost [14]. Numerous studies have found that task sharing can be used effectively to deliver skills-based, time-limited mental health interventions, including trauma-focused psychotherapy. For example, one study found that prolonged exposure therapy was efficacious in reducing PTSD symptoms when delivered by trained non-specialist health workers [15]. Another study found that an online version of WET was effective when delivered by peer coaches, who demonstrated good fidelity to the WET protocol [16]. Within the Department of Defense (DoD), behavioral health technicians (BHTs) are enlisted service members and civilians who support behavioral health providers in the MHS. BHTs are required to complete 14–17 weeks of course work and practicum training that includes an introduction to counseling [17]. They are trained and expected to serve as “provider extenders” within the MHS, supporting providers in delivering care to service members and their families [17]. They are trained to perform various clinical tasks including triaging patients, conducting intake assessments, clinical administrative duties, and delivering therapeutic interventions under the supervision of a provider [18]. BHTs have greater capacity to deliver clinical care on a weekly basis than behavioral health providers because they do not normally have clinical appointments booked within a clinic's system. However, research suggests that BHTs are underused as provider extenders [12,17]. The current underuse of BHTs as provider extenders represents an opportunity to expand the capacity for delivering EBPs for PTSD in the MHS. No previous studies have used BHTs to deliver PTSD treatment.

Certain EBPs may be particularly well suited for BHTs to deliver under provider supervision. WET [19] is an evidence-based, brief, exposure therapy derived from Pennebaker and Beall's[20] expressive writing procedure that was developed and found to be effective for individuals who have experienced trauma and have PTSD. WET typically consists of five sessions that are 40–60 min each, during which the patient writes for 30 min followed by briefly discussing the experience with the provider. WET has been found to be superior to waitlist among motor vehicle accident survivors [21] and non-inferior to other more well-established first line PTSD treatments. Specifically, WET was non-inferior to 8–15 sessions of prolonged exposure therapy among Veterans [22] and to 12 sessions of cognitive processing therapy among Veterans [23] and active duty personnel [24]. In addition to being efficacious, WET may be well suited for BHT delivery because the treatment rationale is straightforward and the therapeutic tasks are well-defined [16,19]. However, no prior study has tested WET in this context.

The goal of this study is to increase access to effective care by task sharing WET delivery with BHTs. We will test BHT-delivered WET for PTSD in active duty military personnel to determine the clinical effectiveness and feasibility of this implementation strategy.

2. Design and Methods

2.1. Study methods overview and study design

This study will use a Hybrid Type 1 implementation-effectiveness design to test the effects of a clinical intervention (WET) while simultaneously collecting information on the implementation strategy (task sharing to BHTs). We will test the effects of WET via a Phase II randomized clinical trial (RCT). We will compare BHT-delivered WET plus treatment as usual (TAU; including standard appointments with providers, as available) to TAU alone. Comparing TAU with and without WET will provide a real-world test of the proposed implementation strategy in the context of routine behavioral health care, and increases the feasibility of patient-participant recruitment. See Fig. 1 for an overview of the RCT.

Fig. 1.

Overview of study design.

2.2. Study aims and hypotheses

Aim 1: Determine the clinical effectiveness of behavioral health technician (BHT)-delivered written exposure therapy (WET). We hypothesize that participants who receive BHT-delivered WET + TAU will experience greater reductions in a) interviewer-assessed and self-reported PTSD symptoms, b) self-reported symptoms of depression, anxiety, and insomnia, and c) self-reported functioning, compared to those who receive TAU alone.

Aim 2: Determine the acceptability of BHT-delivered WET among patients. We hypothesize that participants who receive BHT-delivered WET + TAU will a) complete more psychotherapy appointments and b) experience greater self-reported satisfaction with their behavioral health care, compared to those who receive TAU alone.

Aim 3: Examine the fidelity of BHT-delivered WET. We hypothesize that BHTs will demonstrate acceptable adherence and competence in their delivery of WET.

Aim 4: Explore staff members' and patients’ perceptions and experiences with WET and use of task sharing to deliver care. We will explore barriers and facilitators to maintenance of a) WET, and b) task sharing among staff who were involved in BHT-delivered WET and potential spread (increased adoption and expanded reach) among staff who were previously uninvolved with the study.

2.3. Participants

Study participants will include both patients and staff. Patient participants will be 150 active-duty service members, ≥18 years old, with clinically significant symptoms of PTSD (i.e. a CAPS-5 score ≥25). Exclusion criteria are: 1) current suicide or homicide risk meriting crisis intervention (e.g., escort to the emergency room), 2) serious mental health symptoms such as mania, psychosis, or alcohol or substance use disorders warranting immediate clinical attention, 3) inability to comprehend the baseline screening questionnaires, and 4) definite plans to leave the military within 10 weeks. Concomitant therapy and medications will not be exclusionary. Criteria #1 and #2 will be assessed as part of the clinics’ routine patient triaging and intake assessment procedures. During study screening procedures, team members will informally assess criterion #3 and inquire about #4.

Staff participants will include approximately 40–59 BHTs, clinic providers, and clinic leaders working at the participating behavioral health clinics.

2.4. Treatment conditions

WET [19] is a 5-session, trauma-focused intervention. After the therapist provides psychoeducation about PTSD and a treatment rationale, individuals write about their traumatic experience following scripted instructions. In this study, WET will be delivered by trained BHTs under provider supervision. WET will be delivered once or twice weekly [25] either in person or via video teleconferencing [22], depending on clinic guidelines and patient preference. Each WET session involves providing specific instructions to write a narrative of their index trauma for 30 min, which is the trauma event that causes the patient the most distress. For Sessions 2–5, BHTs will also provide individual feedback based on their review of the trauma narrative that the patient wrote during the previous session. During the trauma writing time, BHTs will remain in the room or video teleconferencing meeting with the patient and can engage in quiet work activities. At the end of the 30 min, the BHT will briefly check-in with the patient to discuss the experience of the writing exercise. There are no formal between-session assignments. Instead, patients are simply asked not to avoid any thoughts, images, feelings, and reactions related to the trauma that arise between sessions.

Treatment as usual (TAU) will consist of routine provider-delivered behavioral health care, either at the MTF clinic or through the DoD-funded care network. When MTF clinics have insufficient capacity, patients can be referred to a network of community providers in the local area who are reimbursed by DoD. TAU will be delivered at whatever frequency of care the assigned provider determines and will be comprised of whatever therapeutic approach (psychotherapy and/or medication) the provider selects. Regardless of whether they are working in the study site MTF or in the nearby community, all TAU providers will be licensed providers who routinely provide behavioral health care to service members.

2.5. Study procedures

This study has been reviewed and approved by the Institutional Review Boards of Stanford University, as well as the San Antonio IRB on behalf of the two study performance sites: Brooke Army Medical Center (BAMC) and Navay Hospital Camp Pendelton (NHCP).

Potential patient participants will be identified from the BAMC Outpatient Behavioral Health and Campus Behavioral Health Clinics and the NHCP Mental Health Clinics. Potential participants who are deemed pre-eligible based on a brief phone screen will be scheduled for a consent visit followed by a baseline assessment comprised of a clinical interview and surveys. During the clinical interview, independent evaluators (IEs) will collect information about the worst traumatic event (i.e., “index trauma”) and the immediate beginning and end points of the event (i.e., “bookends”), to be shared with the assigned BHT as needed. Eligible patient participants will be randomly assigned using an online random number generator to either BHT-delivered WET + TAU or TAU alone, using a 1:1 parallel group design using permuted block randomization with randomly varying block sizes of 2, 4, and 6 participants, with a 1:1 allocation ratio within each block.

WET sessions will be scheduled once or twice weekly with the BHT. BHTs will meet regularly for supervision with a clinic provider who is a member of the study team to review their WET cases. To accommodate disruptions in care (e.g., mandatory trainings, holidays), participants in both study conditions will have up to eight weeks to complete treatment. TAU will occur at whatever frequency the provider usually schedules appointments. Participants will complete a posttreatment assessment approximately one month after the treatment window ends (i.e., Week 12), which will include a clinical interview and surveys. Follow-up assessments will include surveys only and will be completed at 3- and 6-months posttreatment. See Fig. 2 for a depiction of participant flow through the study.

Fig. 2.

Overview of participant flow through the study.

Staff participants will be recruited during regular staff meetings or by email and invited to complete a brief semi-structured qualitative phone interview at the end of the patient participant treatment phase. Working with our military collaborators to identify potential participants, we will aim to interview 10–15 BHTs, 8–10 clinic providers, and 2–4 clinic leaders. We will also interview a subset of 10–15 patient participants purposively sampled based on high and low scores on the patient satisfaction survey. At the end of the treatment follow up phase (∼6 months after the end of the treatment phase) we will conduct a second round of staff interviews with a subset of 10–15 clinic staff who were interviewed previously to assess maintenance of the implementation effort among BHT, providers, and clinic leaders who were involved in supporting WET implementation. In the second round of interviews that occur ∼6-months later, we will again interview staff who were involved in supporting WET implementation as well as an additional 10–15 clinic staff who were not involved in supporting WET implementation during the treatment phase and not previously interviewed. This latter group will be presented with a summary of local data and staff feedback from the first round of interviews to assess potential spread of the implementation strategy. Interviews will be digitally audio-recorded with participant consent and transcribed to facilitate data analysis.

2.6. Quality control

BHTs will complete training in WET facilitated by an expert WET trainer and consultant. Training will consist of a 2-day didactic and experiential workshop followed by weekly group clinical case consultation during which time BHTs will deliver WET to two training cases. During the trial, BHTs will receive weekly supervision by a licensed clinic provider trained in WET.

To assess fidelity to the WET protocol, BHTs will audio record treatment sessions and submit a copy of the written trauma narratives. A random subset of 20 % of the WET sessions will be reviewed and rated for fidelity by a WET expert who is not involved in treatment oversight during data collection. Sessions will be rated using the WET Therapist Adherence and Competence Protocol. Raters will indicate (yes/no) whether each session task was completed (e.g., “BHT presented the treatment rationale for writing about traumatic event”) and also how well each task was delivered (1 = poor to 7 = excellent). An overall competence score is also provided for each session.

2.7. Community-based participatory research method

This study uses a Community-Based Participatory Research (CBPR) approach through regular meeting with a community advisory board (CAB). The CAB includes individuals with lived experience of PTSD and individuals who have worked or currently work in military behavioral health clinics as BHTs or behavioral health providers. The CAB will meet quarterly during Year 1 and biannually thereafter. CAB members will review and provide feedback on all aspects of the clinical trial, including the recruitment plan, patient recruitment materials, and assessment schedule and materials to ensure that the materials are clear and understandable. The CAB will also assist with developing procedures for the implementation effort, including BHT training materials, provider education and staff briefing materials, and the implementation outcomes assessment plan to help ensure feasibility and acceptability. The CAB will review a summary of the data collected during the treatment phase and initial staff interviews. They will also help develop and package the local evidence that will be shared with clinic staff who have not engaged with the trial to collect their input. CAB members will act as members of the study team and will also be involved in interpreting the study findings and collaborating on dissemination of the findings (e.g., manuscript co-authorship) as appropriate.

3. Assessment

3.1. Clinical outcomes

To assess clinical outcomes (Aim 1), trained IEs who are masked to study condition will assess PTSD symptom severity using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) [26] at baseline and again at posttreatment. The CAPS-5 [26] is a 30-item structured interview that can be used to determine a diagnosis of PTSD and also yields a symptom severity score. This is the primary outcome. IEs will have a bachelor's degree or higher and will have completed the Veteran Affairs online training in the CAPS and two mock interviews reviewed by expert assessors. During data collection, they will demonstrate reliability in co-ratings of interviews during monthly fidelity meetings. Interviews will be recorded, and 10 % will be co-rated for fidelity by a CAPS-5 expert who is otherwise not involved in the study. Prior to completing the CAPS-5, the IE will use the Life Events Checklist for DSM-5 (LEC-5) [27], which assess 16 different potentially traumatic life events that are commonly associated with PTSD symptoms in order to facilitate the identification of an index event. Additional self-report assessments of PTSD, associated psychopathology, and functioning will be collected at baseline through 6 months posttreatment. These are secondary clinical outcomes. See Table 1.

Table 1.

Schedule of clinical outcomes assessment (aim 1).

	Visit
	Baseline	Session 1	Mid	Post	3-Month	6-Month
1. Demographics	X
2. Life Events Checklist [27]	X
3. Clinician Administered PTSD Scale [26]	X			X
4. PTSD Checklist - 5[28]	X		X	X	X	X
5. Patient Health Questionnaire-9 [29]	X		X	X	X	X
6. Generalized Anxiety Disorder - 7[30]	X		X	X	X	X
7. Depression Symptom Index-Suicidality Subscale [31]	X		X	X	X	X
8. Insomnia Severity Index [32]	X		X	X	X	X
9. History of Head Injuries [33]	X
10. Brief Inventory of Psychosocial [34] Functioning	X			X		X
11. Credibility and Expectancy Questionnaire [35]		X		X

3.2. Implementation outcomes

Implementation outcomes include treatment acceptability, WET fidelity, and perceptions and experiences with WET provision and use of task sharing. This study will use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework [36], a widely used framework for evaluating the implementation of evidence-based practices in health care. RE-AIM includes evaluation across multiple levels of stakeholders, including intervention recipients (e.g., active duty military personnel with PTSD) and intervention providers (e.g., BHTs and providers), and leaders (e.g., MTF clinic leaders). To assess treatment acceptability (Aim 2), we will examine the number of psychotherapy sessions that patients complete. Data on the number and type of TAU appointments will be collected from the electronic medical record by the supervising providers, supplemented by patient via self-report to capture any private-pay behavioral health care they received. We will also examine patients’ perceptions and experiences of their care via a) a survey assessing satisfaction with treatment and willingness to recommend treatment among all patient participants at posttreatment, and b) brief semi-structured qualitative phone interviews with a subset of patient participants at posttreatment.

To assess fidelity to the WET protocol (Aim 3), a random subset of 20 % of the audio-recordings of WET sessions and copies of the written trauma narratives will be reviewed and rated for fidelity to the WET protocol. Acceptable fidelity will be operationalized as ≥80 % adherence and a mean rating of 4 (“satisfactory”) or higher for competence in the delivery of WET. To assess barriers and facilitators to WET implementation using task sharing (Aim 4), we will track the proportion of available BHTs who opt into the WET training and deliver WET to study participants, and we will conduct brief semi-structured qualitative phone interviews with patient participants, BHTs, providers, and clinic leaders on two occasions as described in 2.4 Study Procedures. See Table 2.

Table 2.

Schedule of implementation outcomes assessment (aims 2–4).

	Visit
	During Active Treatment	Posttreatment for Each Patient	End of Posttreatment Data Collection	End of Follow-Up Data Collection
1. WET Adoptiona	X
2. Treatment Engagementa	X
3. Treatment Experiences Interviewa		X
4. Patient Satisfaction Surveya		X
5. WET Fidelityb	X
6. Staff Feedback Interviewc			X
7. Implementation Maintenance Interviewc				X

Note. WET = written exposure therapy.

^aAim 2 (acceptability of BHT-delivered WET).

^bAim 3 (fidelity of BHT-delivered WET).

^cAim 4 (perceptions and experiences with provision of WET and use of task sharing to deliver care).

3.3. Statistical analysis plan and power analysis

3.3.1. Statistical power

Sample size estimates for the RCT were based on identifying the minimal sample size required to detect clinically significant differences in change scores on interviewer-assessed PTSD severity using the CAPS-5 with a repeated measures model using PASS software [37]. Statistical parameter estimates were derived from previous studies of WET [[22], [23], [24]]. CAPS-5 will be assessed at baseline and posttreatment in both groups, and we varied the difference in change between groups from 5 to 10 points. We inflated the variance estimates by 40 % from baseline to post-intervention to mirror findings from previous studies. Although the primary evaluation of the treatment effects will be based on an intent-to-treat (ITT) approach (models including imputed outcomes) [38], we based the power on a per-protocol analysis (models including only measured data) to ensure a sufficient sample size for all models of interest. Thus, the power models represent a conservative estimate of sample size requirements. We will be able to detect a 5-point difference in CAPS-5 scores between groups at 0.90 power with a sample size of approximately 150 (75 per arm of the trial), assuming an overall attrition rate of 20 % for a per-protocol model.

3.3.2. Data analysis plan

Statistical modeling will be conducted using both R 4.3.1 and Python 3.11.5 (or latest versions). Analyses will include univariate, bivariate and multivariate techniques. Prior to developing statistical models, exploratory data analysis will be conducted. All variable distributions will be examined with the use of frequency distributions, scatter plots, and histograms. Statistics such as means or proportions, standard errors, ranges, and estimates of skewness and kurtosis will be computed and used as guidelines in the application of both bivariate and multivariate analyses. Data transformation procedures may be applied to quantitative variables with considerable departure from normality.

To examine changes in PTSD symptoms (Hypothesis 1a, PTSD), both per-protocol and ITT linear mixed-effects (LME) repeated measures model will be developed for the CAPS and PCL-5. The models will include a fixed effect for time and an indicator variable for intervention arm and the interaction between time and intervention arm. More computationally complex models also will be considered that include a separate intercept and slope for each subject which allows for the accommodation of individual variability in both baseline (intercept) change over time (slope) for PTSD symptoms. For ITT models, multiple imputation using the R package “Multivariate Imputation By Chained Equations”, will be used to derive 100 imputed datasets [39]. The LME model will be repeated on the imputed datasets and the pooled results compared to the original LME outcomes. While we hypothesize that an autoregressive of order 1 (AR1) covariance structure will provide the best model fit, we will test that assumption by comparing the fit of other covariance structures using the R package glmmTMB [40]. Secondary outcomes (Hypotheses 1b, associated psychopathology, and 1c, functioning) will be examined using methods similar to those for 1a. Session spacing (average days between sessions and total days from first to last session) will be examined as a covariate. All therapy and medication changes will be monitored and sensitivity analyses will be conducted to determine possible therapy or medication effects on outcome.

For Hypothesis 2a (engagement in care), we will compare the average number of sessions received by participants randomized to the WET + TAU condition compared to the TAU condition during the intervention period of the trial using a two-sample t-test. The equal variance assumption will be evaluated using Levene's Test. Based on prior research, we assume that participants in the TAU only condition will receive only 2–3 sessions during the 8-week treatment window. We will have substantial statistical power for this test (power >0.8 for ≥2 session difference between groups). Therefore, we will also examine the distribution of session dose with visualizations in each condition and evaluate the clinical significance of those differences. To examine Hypothesis 2b (patient satisfaction), statistical methods similar to Hypothesis 2a will be used for the Patient Satisfaction Survey. Hypothesis 2b also includes qualitative analysis of the Treatment Experiences Interview data collected by patient participants at posttreatment. The analytic approach for these qualitative data are the same as those used for the Aim 4 and are described below.

For Hypothesis 3 (fidelity), acceptable WET fidelity is operationalized as ≥80 % adherence and a mean rating of 4 (“satisfactory”) or higher (on a scale from 1 to 6) for competence in the delivery of WET. For the exploratory aim (Aim 4) we will use Rapid Qualitative Analysis (RQA) [[41], [42], [43], [44]] strategies to ensure timely analysis of the data. RQA will be used to examine qualitative data captured through the Treatment Experiences Interview (completed by patient participants at posttreatment [Hypothesis 2b]), the Staff Feedback Interview (completed by clinic staff who were early adopters of BHT-delivered WET at the end of the treatment phase), and the Implementation Maintenance Interview (completed with a subset of early adopters and clinic staff who were previously uninvolved with BHT-delivered WET). RQA will be conducted following the PARRQA framework [45]. Structured templated summaries of interviews will be generated and content from each template will be entered into a matrix organized by domains based on the RE-AIM framework and interview guides. Matrix analyses will use directed content analysis, combining deductive and inductive approaches. A subset of transcripts will be analyzed by more than one team member to ensure consensus and reliability in content analysis, interpretation, and derivation of themes. Procedures such as maximization of validity (attention to deviant cases) and constant comparison within the data and within a case, and a reflexive approach to analysis will be used to enhance the rigor and credibility of our qualitative findings.

4. Discussion

PTSD is a major public health problem in the military, and there is an urgent need to mitigate this burden by effectively treating the large number of military personnel with PTSD. The goal of this study is to evaluate a potential solution for increasing access to effective treatment. By comparing the effects of BHT-delivered WET + TAU to TAU alone and assessing clinical and implementation outcomes, this trial will determine the effectiveness of WET and the feasibility of task shifting to BHTs as an implementation strategy.

This study will yield two critical knowledge products: 1) data on the efficacy of WET in the context of treatment as usual in the MHS, and 2) data on whether task-sharing with BHTs to deliver WET is an acceptable implementation strategy to increasing access to EBPs for PTSD in the military. Numerous prior studies have documented the efficacy of WET, including among veterans and active duty service members [22,24]. In addition, a recent study found that WET was effective when delivered to veterans with PTSD by trained peer coaches [16]. However, this will be the first study to examine the effectiveness of WET delivered by BHTs. This will also be the first study to evaluate the implementation strategy of training BHTs to deliver WET under provider supervision. The study will yield data that are critical for the DoD to determine whether this approach to increasing access to EBPs for PTSD is feasible, acceptable (to patients, BHTs, providers, and clinic leaders), and effective.

In the long term, this study has the potential to shape best practices for PTSD care delivery in the MHS and can inform broader efforts to integrate BHTs into clinical care. If successful, training BHTs to deliver brief manualized EBPs for highly prevalent behavioral health conditions may offer a scalable, cost-effective model for delivering care, which is critical for sustainability of service delivery in the MHS and other systems, such as VA.

CRediT authorship contribution statement

Carmen P. McLean: Writing – original draft, Project administration, Methodology, Funding acquisition, Conceptualization. Meghan M. Bell: Writing – original draft, Project administration, Investigation. Christopher K. Haddock: Writing – review & editing, Methodology, Funding acquisition. Stefanie T. LoSavio: Writing – review & editing, Methodology, Investigation, Funding acquisition, Conceptualization. Jeffrey Mann: Writing – review & editing, Project administration, Investigation. Shannon McCaslin: Writing – review & editing, Methodology, Investigation. Nazia Rahman: Writing – review & editing, Resources, Investigation. Lauren Rodden: Writing – review & editing, Project administration. Timothy Rogers: Writing – review & editing, Project administration, Methodology, Investigation, Conceptualization. Craig S. Rosen: Writing – review & editing, Methodology, Funding acquisition, Conceptualization. Craig Woodworth: Writing – review & editing, Funding acquisition, Conceptualization. Jeffrey Cook: Writing – review & editing, Investigation, Funding acquisition, Conceptualization.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Carmen McLean reports administrative support and equipment, drugs, or supplies were provided by Palo Alto Veterans Institute for Research. Carmen McLean reports financial support was provided by US Office of Congressionally Directed Medical Research Programs. Carmen McLean serves on the editorial board of Contemporary Clinical Trials. She had no involvement in the peer review of this article and had no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to another journal editor. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

No data was used for the research described in the article.