Stepped-Care Approaches to Posttraumatic Stress Disorder: Sharpening Tools for the Clinician

Abstract

Austern (2017) presents three composite Veteran case studies using Written Exposure Therapy (WET; Sloan, Lee, Litwack, Sawyer, & Marx, 2013) as a first-level intervention in a larger stepped-care model for PTSD. The relatively minimalist WET intervention may be appealing to Veterans with PTSD who have opted not to seek out more time and therapist-intensive treatments. In addition, writing has been used effectively in other protocols as a method of achieving exposure to memories of traumatic experiences. Austern's three cases demonstrate a range of success in using WET to engage Veterans in evidence-based treatment and reduce suffering associated with PTSD. We comment on the current status of the research literature on stepped-care models for PTSD, the potential value of incorporating Motivational Interviewing principles and specific homework tasks into these efforts, and the promise that abbreviated interventions and stepped-care approaches may hold for helping clinicians manage their clinical caseloads and avoid burnout.

Beyond Binary Thinking: Providing Best Practice Treatment to Veterans with PTSD

“…I am also honored to receive the feedback of Drs. Cigrang and Peterson (2017), who have made highly significant contributions to the PTSD treatment literature as well. Their commentary likewise offers a unique perspective on treatment development, as they discuss how they created a brief, flexible adaptation of Prolonged Exposure (PE) for active duty military service members deployed to Iraq.…”

“…In their commentary, Cigrang and Peterson (2017) call attention to the issue of provider burnout. Burnout may occur when providers experience exhaustion, cynicism, and inefficacy in the face of chronic emotional and interpersonal stressors at work (Maslach, Schaufeli & Leiter, 2001).…”

“…Garcia and colleagues (2014) social costs to these clinicians burning out and thus recommend supporting VHA infrastructure to guard against burnout. Cigrang and Peterson (2017) suggest that WET in particular and stepped-care models in general can "lighten the load" and thus serve this purpose. If a provider is using WET with at least some proportion of their caseload, they may experience less exhaustion than if they are expected to deliver PE or CPT with their entire caseload; and this may be an important topic to explore in future research.…”

“…Another interesting suggestion by Cigrang and Peterson (2017) involves the role that Motivational Interviewing (MI) principles and techniques may play in the early stages of treatment planning with veterans suffering from PTSD. As they note, there is a dearth of published studies examining how MI principles can be used in this fashion.…”

“…While conventional wisdom argues for a required stabilization phase prior to initiating first-line, trauma-focused treatments like PE and CPT with complex PTSD, De Jongh et al argue that this is not necessary due to lack of supporting data and that providers should thus initiate EBP immediately. Cigrang and Peterson (2017) advocate weaving MI principles into the patient education and treatment phase, which sounds more akin to current recommendations than having a standalone MI intervention up front. Another option is the use of a "Shared Decision Making" intervention during treatment planning, which has been found to increase patient motivation in discussing treatment options with providers (Mott, Stanley, Street, Grady, & Teng, 2014 that Mott and colleagues found this intervention increased the likelihood of EBP selection, it may be an important component for providers to employ during treatment planning.…”