In Their Own Words: Clinician Experiences and Challenges in Administering Evidence-Based Treatments for PTSD in the Veterans Health Administration

Abstract

The aim of the present study was to increase the understanding of clinician experiences with administering two evidence-based psychotherapies (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). The study assessed clinician perceptions through the use of two, one-hour focus groups and employed a rigorous data analysis approach, Consensual Qualitative Research. Clinicians who work in an outpatient PTSD clinic at a New England VA, and who routinely administer EPBs for PTSD, participated in the study. Results were categorized into seven domains by the coding team, including 1) EBP Strengths, 2) EBP Weaknesses, 3) Challenges Specific to the Veteran Population, 4) Perceived EBP Effectiveness, 5) Active Ingredients for Treating PTSD, 6) Treatment Structure and Process, and 7) Suggested Changes/Improvements to EBPs. These domains are discussed in detail, with several core ideas falling under each domain. Operational definitions and representative quotes are provided. Overall, clinicians provided a balanced perspective and identified both strengths and weaknesses of the EBPs for PTSD. They identified several challenges in applying these treatments to veteran populations, and shared their beliefs about treatment effectiveness, how they use these treatments in their clinical practice, and how they would change the treatments if given an opportunity to do so. In this way, the study offers a small but important step in attempting to address the science-practice gap related to EBP for PTSD implementation efforts in the VA.

Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration.

“…However, numerous demographic and military characteristics (e.g., gender, officer rank) were found to influence CPT/PE initiation and timing in this sample. While provider studies (Doran et al, 2019;Osei-Bonsu et al, 2017;Sayer et al, 2017) and the CPT/PE treatment manuals (Foa et al, 2007;Resick et al, 2017) have not reported that demographic and military characteristics influence decision making, this finding is consistent with some previous investigations of CPT/PE initiation (Bovin et al, 2018;Keller & Tuerk, 2016;Shiner et al, 2018;Sripada et al, 2018). Demographics (e.g., age, gender, race/ethnicity) may be associated with symptom presentation and/or severity, potentially influencing decisions to initiate CPT/PE (Koo, Hebenstreit, Madden, & Maguen, 2016;Magruder et al, 2004).…”

“…The CPT manual recommends one to three information-gathering sessions prior to initiating CPT (Resick et al, 2017), and the PE manual recommends a thorough assessment and building a solid foundation before beginning PE (Foa et al, 2007). Readiness may also refer to the need for psychotherapy prior to CPT/PE initiation, including development of coping/distress tolerance skills (Lu, Plagge, Marsiglio, & Dobscha, 2016; Osei-Bonsu et al, 2017; Sayer et al, 2017; Zubkoff, Carpenter-Song, Shiner, Ronconi, & Watts, 2016) or building a sufficient therapeutic alliance (Doran, O’Shea, & Harpaz-Rotem, 2019; Lu et al, 2016; Osei-Bonsu et al, 2017; Sayer et al, 2017). Veterans echo this rationale, reporting concern about their ability to tolerate CPT/PE and lack of familiarity with their providers as reasons to delay or never initiate CPT/PE (Hundt et al, 2018; Lu et al, 2016; Stecker, Shiner, Watts, Jones, & Conner, 2013).…”

Pretreatment stabilization increases completion of trauma-focused evidence-based psychotherapies.

“…In DSM–5 this heterogeneity has increased by a factor of eight compared with DSM–IV–TR (APA, 2000) as a result of expanded diagnostic criteria of PTSD (Galatzer-Levy & Bryant, 2013). Qualitative studies in PTSD treatment settings consistently identify concerns among providers that there are complex presentations of PTSD that may be a poor fit for the time-limited, structured nature of TF-EBPs (Doran et al, 2019; Lu et al, 2016). Heterogeneity and complexity of presentations may help to explain low engagement and high dropout from TF-EBPs, particularly in the absence of treatment to address emotional dysregulation and treatment-interfering behaviors (Landes et al, 2013).…”

Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists.

“…While not an explicit study of treatment adherence, Doran and colleagues (Doran, 2019), interviewed veterans who participated in TFTs for PTSD. Eight had dropped out of treatment and were analyzed separately.…”