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

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.