Multilevel factors in providers’ decisions to utilize CPT in military- and veteran-serving treatment settings.

Abstract

Numerous guidelines exist to inform decision-making regarding psychological treatment of patients with posttraumatic stress disorder (PTSD). While strides have been made in the implementation of evidence-based psychotherapies (EBPs) for PTSD in the United States. Department of Veterans Affairs (VA), a large population of veterans does not receive such services. Research has been conducted on veterans’ decisions to enroll in EBPs; however, less is known about providers’ perspectives related to offering trauma-focused therapies to the military and veteran population, particularly outside the United States. This study utilizes baseline data from a larger investigation aimed to support the sustained implementation of cognitive processing therapy (CPT) in U.S. VA and Canadian Operational Stress Injury (OSI) and Department of Defense settings. Providers who trained in CPT (N = 55) participated in interviews regarding their opinions of CPT, preferred treatments for PTSD, and their process in assessing appropriate PTSD treatments for each patient. A directed content analysis approach was used to identify themes for providers’ decision-making to utilize CPT within the context of four Consolidated Framework for Implementation Research (CFIR) domains. In the outer setting domain, providers reported disconnect from policy and leadership as a barrier, and in the inner setting CFIR domain, providers reported multiple facilitators: available resources, leadership support, and compatibility with CPT. The CFIR domain for characteristics of the individuals aligned with a theme of theoretical orientation and training as a facilitator. The intervention characteristics domain aligned with facilitators and barriers; complexity of CPT was a barrier, but relative advantage and perceived strength of evidence were facilitators toward implementation. The systems surrounding and supporting EBP delivery within the U.S. VA, Canada OSI, and Canadian Forces clinics have more similarities than differences regarding barriers and facilitators to delivering CPT. Despite variability in funding and training, provider experiences across all three systems suggest similar themes. Further investigation is needed to determine whether these findings extend to community samples or sites not yet offering EBPs.

Rates and reasons for veteran mental health service utilization following completion of evidence-based trauma-focused treatment for PTSD.

“…Future research should also consider the potential role that therapists have in influencing post TFT service use. Research suggests providers have concerns about patient readiness for trauma-focused therapy (Hamblen et al, 2015; Osei-Bonsu et al, 2017) that impact clinical decisions to provide evidence-based interventions (Loskot et al, 2022); providers may have similar beliefs about veterans’ readiness to step down from an episode of treatment, and such beliefs may impact clinical decisions post TFT. We are not aware of any research examining providers’ perceptions of whether PE/CPT meets the full range of patient needs; however, it is likely therapists play a pivotal role in MHSU by setting expectations for patients about the need and duration of their mental health care.…”

Examining the Veterans Health Administration whole health model of care within the context of posttraumatic stress disorder.

“…However, recent literature suggests that only 9% of veterans receive and complete the “gold standard” nonpharmacologic VA PTSD treatments of prolonged exposure therapy or cognitive processing therapy (Maguen et al, 2019). There are a number of factors that support the completion of evidence-based psychotherapies for PTSD, including system-level factors (e.g., clinician training, use of telehealth and other available resources, and leadership support; Loskot et al, 2023; Sripada et al, 2018) and individual patient factors (e.g., fewer deployments; Maguen et al, 2019). Moreover, patients may find the treatments themselves difficult to manage emotionally, thus leading to dropout (Hundt et al, 2020).…”