Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 6, 539 –546
In the public domain http://dx.doi.org/10.1037/tra0000035
Veterans’ Perspectives on Initiating Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Natalie E. Hundt
Juliette M. Mott
Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine
Veterans Affairs National Center for PTSD–Executive Division, White River Junction, Vermont
Shannon R. Miles
Jennifer Arney
Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine
University of Houston Clear Lake and Baylor College of Medicine
Jeffrey A. Cully and Melinda A. Stanley Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine Evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) are effective at reducing symptoms and improving quality of life. Despite their effectiveness, few veterans receive EBP. To examine veterans’ experiences initiating EBP for PTSD, we conducted qualitative interviews with those who completed at least 8 sessions of prolonged exposure (PE) or cognitive processing therapy (CPT). Veterans reported learning about EBP from therapists, psychiatrists, and other veterans. Ambivalence and delaying EBP initiation were common. Barriers included fears that EBP would increase symptoms, beliefs that avoidance was helpful, disbelief of the therapy rationale, particularly for PE, and less commonly, lack of knowledge about EBP. Facilitators included feeling a “need to talk about it,” prior treatment that increased confidence in the ability to handle EBP, prior knowledge of the EBP therapist, provider behaviors that facilitated buy-in, encouragement from other veterans, and desperation for symptom relief. There were few differences in barriers and facilitators between PE and CPT, although veterans in PE were more likely to express skepticism of the therapy rationale. These results highlight the importance of “word of mouth” about EBP among the veteran community and identifying provider behaviors that may promote EBP initiation. Keywords: PTSD, evidence-based psychotherapy, qualitative, patient perspectives, barriers and facilitators
Clinical practice guidelines identify trauma-focused cognitive– behavioral therapies as the most effective treatments for posttraumatic stress disorder (PTSD; APA, 2004; VA/DoD, 2010). Prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007),
cognitive processing therapy (CPT; Resick, Monson, & Chard, 2008), and eye movement desensitization reprocessing therapy (EMDR; Shapiro, 1989) have amassed considerable evidence for their effectiveness in reducing PTSD symptoms in both civilians
This article was published Online First April 27, 2015. Natalie E. Hundt, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Juliette M. Mott, Veterans Affairs National Center for PTSD–Executive Division, White River Junction, Vermont; Shannon R. Miles, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Jennifer Arney, Department of Sociology, University of Houston Clear Lake, and Department of Medicine, Section on Health Services Research, Baylor College of Medicine; Jeffrey A. Cully and Melinda A. Stanley, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine.
This research was supported by a pilot grant from the United States Department of Veterans Affairs (VA) South Central Mental Illness Research Education and Clinical Center (MIRECC) and partially supported by the Office of Academic Affiliations, VA Advanced Fellowship Program in Mental Illness Research and Treatment and the VA\Health Services Research & Development, Houston Center for Innovations in Quality, Effectiveness and Safety Grant CIN 13-413; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The views expressed reflect those of the authors and not necessarily the policy or position of the VA, the U.S. government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Correspondence concerning this article should be addressed to Natalie E. Hundt, Veterans Affairs Health Services Research & Development, Houston Center of Innovation (MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX 77030. E-mail: [email protected] 539
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and military veterans (Steenkamp & Litz, 2013; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010) and are considered evidencebased psychotherapies (EBP) for PTSD. PE and CPT have been the focus of national dissemination mandates across the U.S. Department of Veterans Affairs (VA) health-care system and current VA policy mandates that CPT or PE must be available to all veterans with a primary diagnosis of PTSD (VHA, 2012). Despite these dissemination efforts, few VA patients receive these interventions. Estimates of the number of veterans receiving EBP in specialized VA PTSD clinics range from 6% to 13% (Lu, Plagge, Marsiglio, & Dobscha, 2013; Mott, Mondragon et al., 2014; Shiner et al., 2013). Reasons for this low utilization are likely complex and multifaceted, including patient, provider, and system-level factors (Cook et al., 2015; Watts et al., 2014). Though not focused on EBP specifically, several studies have examined veterans’ perceptions of barriers and facilitators to PTSD treatment initiation in general. In qualitative interviews with veterans, barriers to treatment included lack of knowledge about PTSD, limited access to care, an invalidating posttrauma environment, and beliefs that discourage treatment seeking (Sayer et al., 2009). This is largely consistent with a prior qualitative study that identified emotional readiness, concerns about treatment (e.g., fear of being prescribed medication), stigma, and logistical issues as primary barriers to PTSD treatment (Stecker, Shiner, Watts, Jones, & Conner, 2013). Many of these same general barriers to PTSD treatment may also be relevant to EBP. However, given that the structure and content of these evidence-based protocols differ in many ways from nontrauma-focused PTSD treatments, EBP may also be associated with unique barriers and facilitators. Indeed, VA Veterans’ Health Administration (VHA) utilization data suggest that the majority of veterans receive non-EBP treatments (e.g., Shiner et al., 2013), suggesting that even veterans who are willing to engage in PTSD treatment may face a second layer of barriers that inhibit participation in EBP. Several studies have examined patient preferences for EBP using nontreatment seeking participants who selected among hypothetical treatment options. Among trauma-exposed women in the community, feeling “a need to talk about” trauma predicted selecting PE over psychotropic medications (Angelo, Miller, Zoellner, & Feeny, 2008). Similarly, among Iraq war veterans, credibility of the therapy rationale and beliefs about therapy efficacy predicted selection of PE over antidepressant medications (Kehl-Forbes, Polusny, Erbes, & Gerould, 2014). However, little research has examined what influences initiation of PE among veterans in real-world settings, and no research has examined reasons for initiation of CPT or EMDR. Given that prior studies have examined veterans who refused to engage in PTSD therapy at all, the present study aims to enhance knowledge of facilitators to EBP initiation by examining veterans’ real-world experiences initiating EBP for PTSD and how they overcame barriers to EBP in their own life. We examine patients’ experiences initiating EBP, including ambivalence about treatment and coming to the decision to engage in treatment. One advantage of this exploratory, qualitative approach is that it allows for the identification of a broad range of themes not specified a priori (Glaser & Strauss, 1967). A thorough understanding of the relevant facilitators to EBP initiation from the patient perspective is necessary to inform future efforts to increase initiation of these effective treatments.
Method Participants We used principles of purposive sampling (Glaser & Strauss, 1967) to recruit veterans who completed at least eight sessions of EBP in a VA PTSD clinic. Given that this clinic does not offer EMDR, we only sampled patients who completed PE or CPT. Eight sessions is the minimum number of sessions for PE (Foa et al., 2007) and represents completion of 75% of the standard 12-session CPT course (Resick et al., 2008). We stratified sampling by therapist, completion of PE versus CPT, and patient ethnicity. Because women represent the minority of VA patients (approximately 10%; United States Department of Veterans Affairs, Office of the Actuary, 2011), and Operation Iraqi Freedom/ Operation Enduring Freedom (OEF/OIF) veterans are less likely to initiate and complete EBP (Mott, Mondragon et al., 2014), we overrecruited these patients. Given that qualitative guidelines suggest a minimum of five– eight participants per subgroup is necessary to capture the perspectives of each subgroup (Kuzel, 1999), we attempted to recruit at least five women, five military sexual trauma (MST) patients, and five OEF/OIF veterans. We also sampled to match the ethnic and racial distribution of veterans in our geographic region. Consented participants included 23 veterans treated by nine different therapists.
Procedure This study was approved by the local internal review board and the VA Research and Development Committee. We obtained a list of patients referred for individual PE and group or individual CPT in the PTSD clinic between May, 2012 and September, 2013. A research assistant and the first author each completed chart reviews to determine whether patients had completed at least eight sessions of EBP. A letter was sent to selected patients, according to our purposeful sampling strategy, describing the study and providing a phone number to opt out of participation. Five to seven days after sending the letter, a research assistant called patients. Of the 40 letters sent, 23 patients (57%) agreed to participate, 13 (33%) declined participation, and four (10%) could not be contacted. Patients were provided the option to participate in person or via telephone. Veterans who were interviewed face to face (n ⫽ 15) completed written consent and consent to audio-record at the beginning of their interviews. Those who participated via telephone (n ⫽ 8) signed and returned consent forms via mail before their interviews. All interviews were audio-recorded and audio files were password protected and saved on a HIPAA-compliant (U.S. Health Insurance Portability and Accountability Act) server. Interviews lasted approximately an hour (M ⫽ 59 min; range ⫽ 42– 85 min) and were conducted from October, 2013 to March, 2014. Interviews were conducted by the first and second authors. The fourth author is a medical sociologist trained in qualitative methods who provided guidance in study design and conduct. The research team developed a qualitative interview guide that queried participants’ experiences initiating and participating in EBP and assessing opinions about new VA services/programs. In this paper we present only those data regarding EBP initiation. As is common in qualitative studies, we refined the interview guide over the
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initial interviews to elicit information about new ideas brought up by patients. For example, we recognized that some patients who were identified as completing one EBP during the study period had also previously completed the other EBP, and we added questions regarding a potential relationship between PE and CPT initiation. We ended recruitment when we reached data saturation, defined a priori as the point when coders agreed that three consecutive transcripts within a given interview category rendered no new thematic concepts (Morse, 1995; Aita & McIlvain, 1999).
Data Analysis Audio-recorded interviews were transcribed by a professional service. The first author and a research assistant trained in qualitative methods reviewed transcripts to determine initial codes using grounded theory analysis, which facilitates the development of coding categories to generate theory that best fits the data and to preclude the use of theories that may inadequately portray the data (Glaser & Strauss, 1967). This is a popular analytical approach that has been recommended for use in qualitative psychology research (Ponterotto, 2005). A codebook with definitions of codes and example quotations was derived from consensus and used to guide final coding. Each transcript was then coded by both coders, and discrepancies were resolved through discussion. We linked quotations to multiple codes as appropriate and used Atlas.ti V6.0, a qualitative data-management software package, for coding and analysis.
Results Our grounded theory analysis identified veterans’ descriptions of pathways into EBP, barriers to engaging in EBP, and factors that facilitated entry into treatment. Veteran demographic characteristics are presented in Table 1.
Pathways Into EBP Veterans reported hearing about EBP from therapists (i.e., psychologists or social workers delivering psychotherapy), psychiatrists, and fellow veterans (see Table 2); these sources did not appear to differ by era or gender. Therapists were the most common source of information about EBP, with approximately half of the sample first hearing of EBP from a therapist or during an intake assessment. Nearly one third of veterans reported initially receiving information about EBP from a psychiatrist. My psychiatrist, she said that she thought it could be helpful. It was a new program, and she thought that I needed it or it would be beneficial for me . . . she explained it well enough to know what I was getting in for . . . (male Vietnam veteran in PE).
A smaller group of veterans reported first hearing of EBP from other veterans who were personal friends, family members, or more commonly, acquaintances from non-EBP treatment programs at the VA. This pathway also appeared to serve as a facilitator for treatment engagement (see Facilitator section below). I actually heard about it from other Vets. They recommend the program highly. They said that it really done them well and it was a little bit more intense . . . (male Vietnam veteran in group CPT)
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Table 1 Veterans’ Demographic Characteristics and Treatments Received Demographic
No. of participants (N ⫽ 23)
%
6 17
26.1 73.9
8 10 2 1 2 53.74 (SD ⫽ 12.23)
34.8 43.5 8.7 4.3 8.7
Gender Female Male Race/Ethnicity Non-Hispanic White African American Hispanic Native American Asian Mean age Service era OEF/OIF Vietnam Persian Gulf Noncombat era Treatment type PE only CPT individual only CPT group only Both PE and CPT
9 9 3 2
39.1 39.1 13.0 8.7
11 3 6 3
47.8 13.0 26.1 13.0
Note. OEF/OIF ⫽ Operation Enduring Freedom (Afghanistan)/Operation Iraqi Freedom (Iraq); PE ⫽ prolonged exposure; CPT ⫽ cognitiveprocessing therapy.
The pathway into treatment and eventually into EBP was marked with ambivalence. Some veterans expressed delaying EBP entry for up to a year after first learning about it; others mentioned dropping out of EBP after the first few sessions, only to later complete a course of EBP. She made us aware it would go into maybe some painful areas. And I’m thinking, “No I’m not ready for that” . . . I was able to go back to (therapist’s name) a year later and say, “Hey is that course still available? I’d like to take it” (female veteran with MST in CPT).
Consistent with significant delays entering EBP, nearly all patients engaged in other mental health treatment before EBP, including medication management (87%), group psychotherapy (65%), and individual psychotherapy (39%). The most common types of prior psychotherapy included PTSD psychoeducation, skills-based treatments, process or support groups, and EBPs for comorbid disorders.
EBP-Specific Barriers Patients experienced a variety of EBP-specific barriers, including anxiety, avoidance, skepticism regarding the treatment rationale, and lack of knowledge about EBP.
Anxiety About Engaging in EBP Anxiety about engaging in an intense trauma-focused treatment was the most commonly cited barrier, endorsed by approximately two thirds of patients. Veterans were concerned that discussing the trauma would worsen symptoms or overwhelm their coping abilities, and this occurred for both PE and CPT patients. “I remember
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Table 2 Summary of Common Themes Theme First source of information about EBP Psychotherapy provider Psychiatrist Other veteran Significant ambivalence about starting EBP Barriers to EBP engagement Anxiety Avoidance Skepticism of therapy rationale Lack of knowledge of EBP Facilitators of EBP engagement Buy in to treatment rationale/Need to talk about it Prior treatment provided readiness for EBP Prior knowledge of EBP therapist Provider behaviors facilitated EBP engagement Choice in treatment Encouragement without pushing Thorough explanation of treatment Information about research support Provider testimonials about patient success Encouragement from other veterans Desperation for relief from symptoms/hit rock bottom Duty to family Hope for life worth living
Frequency of theme
% of Veterans endorsing theme
Common Common Common Common
52% 30% 17% 74%
Common Common Less common Rare
65% 30% 22% 13%
Common Less common Common
30% 17% 30%
Rare Less common Less common Rare Rare Common Common
9% 17% 17% 9% 9% 30% 30%
Common Less common
43% 17%
Note. EBP ⫽ evidence-based psychotherapies. Common themes were expressed by 30 – 65% veterans; less common by 17–26%; and rare by 9 –13%.
thinking ‘That may break me and I don’t want to be broken so I can’t’” (female veteran with MST in CPT). Other veterans were afraid that discussing the trauma would confirm their guilt and responsibility for the trauma. If you bring up bad thoughts for me, now I’m worse off than when I came in the door . . . Like if you said something to the effect of “You might have had time to (save friend’s name),” oh man, what did you just do? You just compound the guilt, you know (male Vietnam veteran in PE).
This appeared to be a particular concern of patients engaging in PE. CPT patients appeared to fully accept the rationale for treatment, despite their anxiety. Some PE patients, on the other hand, expressed that the treatment differed from their expectations for what therapy should be like. It was just weird to me more than anything. The whole closing my eyes part you know, tape recording myself and listening to myself, I mean I just didn’t understand like what kind of treatment that was (male OEF/OIF veteran in PE).
Avoidance-Related Beliefs The second most commonly expressed barrier was the belief that avoidance was helpful. Leave it alone. “Don’t trouble trouble, trouble won’t trouble you.” One of my mother’s greatest sayings. And I thought that (PE) was troubling trouble but it was good for me in the long run (male Vietnam veteran in PE).
Lack of EBP Knowledge A less commonly mentioned barrier was lack of knowledge about the existence of EBP. See, that’s the problem. I didn’t find out ‘til, you know, I’m walking with some guy that said, “Man, you know, that thing work. It work.” I said “What work?” He said “prolonged exposure, you need to try it” (male Vietnam veteran in PE).
Skepticism of the Therapy Rationale Beliefs about the helpfulness of avoidance led some veterans to be skeptical of the therapy rationale and to distrust the explanation of treatment mechanisms. And he said, “Then you’re going to look at the same thing so many times that you’ll be so familiar with it; it’ll be just like it happened yesterday but it won’t bother you anymore.” When he said that I thought it was BS. I thought, “You’re crazy” (male Vietnam veteran in PE).
EBP-Specific Facilitators Veterans also reported a variety of motivations and supports for engaging in EBP, including buying into the rationale, believing that prior treatment gave them the skills to handle EBP, prior knowledge of the EBP therapist, specific therapist behaviors that encouraged EBP, seeing treatment success in other veterans, and desperation for relief from symptoms.
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Buy-In to Treatment Rationale Although PE patients were more likely to endorse initial concerns about the therapy rationale than CPT patients, nearly half of PE patients reported strong credibility of the treatment rationale. Many felt a need to discuss the trauma due to beliefs that talking about it would relieve emotional pain. It’s always been something that I wanted to do. You know, get some things off my chest . . . the one thing that’s eating you up the most. You’ve got to talk about it (male OEF/OIF veteran in PE).
Some veterans reported frustration that other nontraumafocused PTSD treatments they had received previously discouraged discussion of trauma. I basically called the group out because I’m sitting there being open and everybody’s talking about, “You know I’m so scared to go to Walmart” and “I can’t go out and I have nightmares.” And I’m like, dude, that’s normal. We got PTSD. Are we going to sit here and talk about this (expletive) every time we come here? We need to talk about trauma (male OEF/OIF veteran in PE).
Veterans with MST often experienced their disclosure of MST to be a step forward in recovery. Thus, discussing the trauma, whether in PE or in CPT, was anticipated to be therapeutic in and of itself, lending credibility to the therapy rationale. Some veterans reported that buy-in arose gradually during a few initial pre-EBP therapy sessions with their providers. Initially I was totally against it . . . but the more I talked to the doctor about it and he started explaining things so then I start understanding that the only way through this is to go back through this again” (male Persian Gulf veteran in PE).
Prior Treatment Provided Skills to Handle EBP Veterans also reported that engaging in other treatments prior to EBP helped them feel confident they had the tools to handle EBP. The other courses we talked about deep breathing and when someone else would . . . touch on something that would trigger something and . . . then rather than me getting up and running out because I felt overwhelmed I could work on the deep breathing. So those courses definitely helped me to be able to stay in the room some days (female veteran with MST in group CPT).
Three veterans completed Group CPT followed by individual PE. All three reported that having CPT first was helpful, not only because it provided them with cognitive coping skills, but also because it built self-efficacy about engaging in trauma-focused treatment. (CPT) got me to the point where I could do the individual prolonged exposure. And have confidence in the therapy Number 1. And confidence in myself Number 2 . . . I have to tell you that I don’t believe I could’ve gotten the results that I got if I hadn’t had the other therapy before it (male Vietnam veteran).
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helped some veterans overcome their skepticism of the therapy rationale. In fact, some veterans were only willing to engage in EBP with a known provider and were willing to wait for that person to become available rather than initiate with an available but unfamiliar therapist. I’ve known Dr. (name) for quite a while based on my time here walking into other groups, coming here to the Medical Center so, you know, I trust his methods (male Vietnam veteran in group CPT). I’ve had experiences with her since I came here in (year) . . . my experience with her has proven that she wouldn’t deliberately have me to go through the motions of suffering through the pain if there wasn’t some benefit on me. So I trusted her (female veteran with MST in group CPT).
Provider Behaviors Facilitating EBP Some veterans describe specific therapist behaviors that encouraged them to initiate EBP. For instance, several veterans appreciated the opportunity to make choices about which treatment to initiate. One male Persian Gulf veteran in PE described his route into EBP. They kind of explained it to me . . . gave us more detail about what was going on and it was a choice of group or one on one . . . they had a list that had the different options. And I decided to start (PE) first.
This suggests that providing options can be an effective way to offer veterans autonomy and increase buy-in to the therapy chosen. Other participants noted that providers who provided gentle encouragement and expressed confidence in the patient’s ability to handle EBP which helped them feel empowered to try EBP without feeling coerced. She said, “Do you want to try it?” And I said, “Yeah, I’m willing to try anything at this point.” I was a little anxious. Thinking, “Oh man I don’t know if I can do that you know.” And she told me, “Just try” . . . She said, “If you can’t do it, you can’t do it.” She said, “But I think you probably would be able to (female veteran with MST in PE).
Several patients mentioned that therapists who provided a thorough orientation to treatment procedures and methods before beginning EBP helped allay their fears and increase buy-in. These patients wanted to know exactly “what they were getting in for” before they agreed to participate. She even said that before, that it would be different from the other group . . . there’s going to be a certain structure, like programmed . . . certain things that needed to be discussed and needed to be done each session (female OEF/OIF veteran in group CPT).
Therapists also increased buy-in by providing two sources of evidence for the success of these treatments: statistics from treatment outcome research and testimonials about a clinician’s own experiences with patient success in EBP.
Prior Knowledge of EBP Therapist
Talking about research . . . I think the reason why I feel so positive too is because I understand the concept of research in the medical field (female patient with MST in PE).
Previous exposure to other treatments also provided veterans with another key ingredient: familiarity with their EBP therapist. Knowing that the therapist was a competent, caring individual
She made it very apparent that there was going to be light at the end of the tunnel . . . she would tell me, “Look, I’ve had guys that were— had done this for years. And they wouldn’t even hardly go
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outside of the house and now they’re riding the bus . . . almost every day” (male Vietnam veteran in PE).
Encouragement From Other Veterans Other veterans also provided encouragement to engage in EBP. Some veterans appeared to make active efforts to convince fellow veterans to do EBP; their observable improvement provided evidence of the success of EBP. They said, “It’s hell, but it’s worth it in the end.” And there was one guy in there that convinced me that I ought to do it. And I knew how he had struggled because I’d watched it . . . I saw it work in him and I guess I learned to believe in him. And I could see the difference. He was happier. And he was calmer (male Vietnam veteran in PE).
Desperation for Relief From Symptoms Other veterans retained some skepticism of the therapy rationale but were driven to try EBP because of desperation from years of suffering and feeling like they had exhausted other coping and treatment options. I done tried everything and that (expletive) don’t work. Drugs definitely don’t work . . . I know what’s next after this. What’s next is the penitentiary or the graveyard for me. It’s like this is the last boat to come through for me to save myself. If I don’t get on this (expletive) I’m (expletive). I was determined to do whatever (male Persian Gulf veteran in PE).
This desperation was often accompanied by the feeling that the veteran had hit their own personal “rock bottom” and had nothing left to lose by trying EBP. It was like hallucinations and I mean it was horrible; it was scary. And somehow I drove 30 miles on the highway and I mean I don’t even know how I got there or what; I don’t know . . . that was like the lowest point (male OEF/OIF veteran in individual CPT).
Many veterans reported that spouses and children were a key reason they were motivated to engage in EBP. For some, marital tension had reached the point that the possibility of divorce had arisen. Others felt a need to “make it up to” their family for enduring years of deployments or the ways in which symptoms like nightmares, irritability, and avoidance had interfered with family life. If it wasn’t for (my family) I wouldn’t have done any of this because to be perfectly honest with you I’m very happy being miserable. I’m just alone and I don’t have any pain; you know I’m happy with that. But my family isn’t. So I have to do what I can so that my son can have a normal 5-year-old childhood (male OEF/OIF veteran in PE).
Discussion Although prior studies have examined barriers and facilitators to treatment seeking among veterans, to the authors’ knowledge, this is the first study to examine veterans’ real-world experiences initiating PTSD EBP. Our analysis revealed routes into EBP and the facilitators that helped these veterans overcome barriers to initiating EBP. These findings suggest that mental health providers remain the most frequent source of knowledge about EBP. However, veter-
ans’ pathways into EBP were diverse and indicate the importance of obtaining buy-in from all potential disseminators of information about EBP, including psychiatrists and providers outside of PTSD clinics, which may increase referral rates to these clinics. We also found that some veterans purposefully shared information about EBP with other veterans, and that witnessing treatment success in other veterans can provide the final “push” to initiate EBP. Given that veterans often trust fellow veterans more than mental health professionals (Chinman, Young, Hassell, & Davidson, 2006), peer-to-peer promotion of EBP represents one promising avenue to increasing EBP initiation. Therapists might consider specifically asking patients to tell other veterans about positive experiences in EBP. In addition, the recent increase in VA peer-support providers (United States Department of Veterans Affairs, the Veterans Health Administration, 2011) may provide an opportunity for EBP completers to share their recovery stories with treatment-naïve veterans. Despite recent efforts to promote EBP through the Internet, no veteran mentioned using any electronic or paper resource regarding EBP, suggesting that more work to promote these resources is needed. Previous research that has examined barriers and facilitators to non-EBP-specific treatment seeking for PTSD found that barriers included lack of knowledge about PTSD and access to care, beliefs that discourage treatment seeking, and stigma (Sayer et al., 2009; Stecker, Shiner, Watts, Jones, & Conner, 2013). This study found that barriers and facilitators to engagement in EBP for PTSD largely differ from those relevant to non-EBP. In the current study, ambivalence about participating in EBP was a consistent theme, with the majority of veterans expressing fears that EBP might be too anxiety provoking or beliefs that avoidance was helpful. Overall, this suggests that future researchers should examine the utility of interventions to increase initiation of EBP, such as motivational interviewing. Although originally developed with substance-use disorders, motivational interviewing is beginning to be used in anxiety treatment (Westra, Arkowitz, & Dozois, 2009) and may help veterans recognize how EBP fits with values such as the importance of family. Another barrier for a minority of patients included skepticism of the therapy rationale. Exposure-based treatments have suffered a credibility problem, both among providers and patients (Feeny, Hembree, & Zellner, 2003), despite their strong research support. Although provider concerns about initial worsening of symptoms have historically been associated primarily with PE, many patients preparing to engage in CPT have similar concerns. This may be because CPT typically involves repeatedly writing and reading a trauma narrative, and even veterans who complete a form of CPT without this narrative (CPT-C; Resick et al., 2008) may complete trauma-related cognitive restructuring worksheets, which are sufficient to provoke substantial anxiety. These barriers were balanced with motivations to pursue treatment. Although some veterans reported engaging in EBP to improve quality of life and meet personal goals, the most commonly cited motivations included improving family functioning, sometimes due to fear of family dissolution, and desperation for relief from symptoms that were extremely disruptive to everyday functioning. Other EBP facilitators included the credibility of the therapy rational and feeling a “need” to talk about the trauma. Veterans reported that engaging in prior skills-based treatments provided them with the self-efficacy to believe they could engage
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in EBP. Although few researchers have examined whether nontrauma-focused treatments increase the initiation or effectiveness of EBP, our data suggest that some veterans prefer this approach. Finally, familiarity with the EBP therapist sometimes provided assurance that the therapist was a competent, caring individual and increased the credibility of EBP. This highlights the importance of continuity of care, particularly in training hospitals with providers who rotate through various clinics. Veterans also cited a variety of therapist behaviors that increased their willingness to participate in EBP. Some of these techniques, such as providing gentle encouragement and expressing confidence in the patient’s ability to get better, are standard therapeutic practice, but this study confirms their importance from the perspective of veterans. These findings also provide support for a less commonly used therapeutic practice, informed decision making interventions (Mott, Stanley, Street, Grady, & Teng, 2014) that provide PTSD patients comparative information about different treatment options and support in choosing the best treatment for them.
Limitations As this study only examined EBP completers in a VA PTSD clinic, we cannot comment upon factors that may be barriers for other patients. For example, although lack of knowledge of EBP was rarely cited as a barrier in this study, it may be the case that other veterans, particularly those not enrolled in specialty VA PTSD clinics, are unaware of EBPs. Because all patients in this sample did participate in EBP, although some did so after extensive delay, we could not provide information through this study regarding the ambivalence or barriers of those who have not participated in EBP.
Conclusion These results provide insight into veterans’ experiences initiating EBP. Given that many of the barriers and facilitators identified are unique from those previously identified to PTSD treatment in general, attention to these EBP-specific factors will be important in ongoing and future efforts to implement EBP within the VHA system.
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Policy in Mental Health and Mental Health Services Research, 42, 147–156. http://dx.doi.org/10.1007/s10488-014-0555-3 Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2003). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice, 10, 85–90. http://dx.doi.org/10.1016/S1077-7229(03)80011-1 Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine. Kehle-Forbes, S. M., Polusny, M. A., Erbes, C. R., & Gerould, H. (2014). Acceptability of prolonged exposure therapy among U.S. Iraq war veterans with PTSD symptomology. Journal of Traumatic Stress, 27, 483– 487. http://dx.doi.org/10.1002/jts.21935 Kuzel, A. (1999). Sampling in qualitative inquiry. In B. F. Crabtree & W. F. Miller (Eds.), Doing qualitative research (pp. 33– 46). Thousand Oaks, CA: Sage. Lu, M. W., Plagge, J. M., Marsiglio, M. C., & Dobscha, S. K. (2013). Clinician documentation of receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. Journal of Behavioral Health Services & Research. Retrieved from http://link.springer.com/article/ 10.1007%2Fs11414-013-9372-9 Morse, J. (1995). The significance of saturation. Qualitative Health Research, 5, 147–149. http://dx.doi.org/10.1177/104973239500500201 Mott, J. M., Mondragon, S., Hundt, N. E., Beason-Smith, M., Grady, R. H., & Teng, E. J. (2014). Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. Journal of Traumatic Stress, 27, 265–273. http://dx.doi.org/10.1002/jts.21927 Mott, J. M., Stanley, M. A., Street, R. L., Jr., Grady, R. H., & Teng, E. J. (2014). Increasing engagement in evidence-based PTSD treatment through shared decision-making: A pilot study. Military Medicine, 179, 143–149. http://dx.doi.org/10.7205/MILMED-D-13-00363 Ponterotto, J. G. (2005). Qualitative research in counseling psychology: A primer on research paradigms and philosophy of science. Journal of Counseling Psychology, 52, 126 –136. Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635– 641. http://dx.doi.org/10.1016/j.cpr.2010.04.007 Resick, P. A., Monson, C. M., & Chard, K. M. (2008). Cognitive processing therapy: Veteran/military version. Washington, DC: United States Department of Veterans Affairs. Retrieved from http://depts.washington .edu/hcsats/PDF/research/Cognitive%20Processing%20Therapy%20 Manual%208.08.pdf Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., & Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry: Interpersonal and Biological Processes, 72, 238 –255. http://dx.doi.org/ 10.1521/psyc.2009.72.3.238 Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199 –223. http://dx.doi.org/10.1002/jts.2490020207 Shiner, B., D’Avolio, L. W., Nguyen, T. M., Zayed, M. H., Young-Xu, Y., Desai, R. A., . . . Watts, B. V. (2013). Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Administration and Policy in Mental Health and Mental Health Services Research, 40, 311–318. http://dx.doi.org/10.1007/s10488-012-0421-0 Stecker, T., Shiner, B., Watts, B. V., Jones, M., & Conner, K. R. (2013). Treatment-seeking barriers for veterans of the Iraq and Afghanistan conflicts who screen positive for PTSD. Psychiatric Services, 64, 280 – 283. http://dx.doi.org/10.1176/appi.ps.001372012 Steenkamp, M. M., & Litz, B. T. (2013). Psychotherapy for militaryrelated posttraumatic stress disorder: Review of the evidence. Clinical
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Received September 25, 2014 Revision received December 18, 2014 Accepted January 29, 2015 䡲
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In the public domain http://dx.doi.org/10.1037/tra0000035
Veterans’ Perspectives on Initiating Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Natalie E. Hundt
Juliette M. Mott
Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine
Veterans Affairs National Center for PTSD–Executive Division, White River Junction, Vermont
Shannon R. Miles
Jennifer Arney
Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine
University of Houston Clear Lake and Baylor College of Medicine
Jeffrey A. Cully and Melinda A. Stanley Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Baylor College of Medicine Evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) are effective at reducing symptoms and improving quality of life. Despite their effectiveness, few veterans receive EBP. To examine veterans’ experiences initiating EBP for PTSD, we conducted qualitative interviews with those who completed at least 8 sessions of prolonged exposure (PE) or cognitive processing therapy (CPT). Veterans reported learning about EBP from therapists, psychiatrists, and other veterans. Ambivalence and delaying EBP initiation were common. Barriers included fears that EBP would increase symptoms, beliefs that avoidance was helpful, disbelief of the therapy rationale, particularly for PE, and less commonly, lack of knowledge about EBP. Facilitators included feeling a “need to talk about it,” prior treatment that increased confidence in the ability to handle EBP, prior knowledge of the EBP therapist, provider behaviors that facilitated buy-in, encouragement from other veterans, and desperation for symptom relief. There were few differences in barriers and facilitators between PE and CPT, although veterans in PE were more likely to express skepticism of the therapy rationale. These results highlight the importance of “word of mouth” about EBP among the veteran community and identifying provider behaviors that may promote EBP initiation. Keywords: PTSD, evidence-based psychotherapy, qualitative, patient perspectives, barriers and facilitators
Clinical practice guidelines identify trauma-focused cognitive– behavioral therapies as the most effective treatments for posttraumatic stress disorder (PTSD; APA, 2004; VA/DoD, 2010). Prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007),
cognitive processing therapy (CPT; Resick, Monson, & Chard, 2008), and eye movement desensitization reprocessing therapy (EMDR; Shapiro, 1989) have amassed considerable evidence for their effectiveness in reducing PTSD symptoms in both civilians
This article was published Online First April 27, 2015. Natalie E. Hundt, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Juliette M. Mott, Veterans Affairs National Center for PTSD–Executive Division, White River Junction, Vermont; Shannon R. Miles, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Jennifer Arney, Department of Sociology, University of Houston Clear Lake, and Department of Medicine, Section on Health Services Research, Baylor College of Medicine; Jeffrey A. Cully and Melinda A. Stanley, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine.
This research was supported by a pilot grant from the United States Department of Veterans Affairs (VA) South Central Mental Illness Research Education and Clinical Center (MIRECC) and partially supported by the Office of Academic Affiliations, VA Advanced Fellowship Program in Mental Illness Research and Treatment and the VA\Health Services Research & Development, Houston Center for Innovations in Quality, Effectiveness and Safety Grant CIN 13-413; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The views expressed reflect those of the authors and not necessarily the policy or position of the VA, the U.S. government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Correspondence concerning this article should be addressed to Natalie E. Hundt, Veterans Affairs Health Services Research & Development, Houston Center of Innovation (MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX 77030. E-mail: [email protected] 539
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and military veterans (Steenkamp & Litz, 2013; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010) and are considered evidencebased psychotherapies (EBP) for PTSD. PE and CPT have been the focus of national dissemination mandates across the U.S. Department of Veterans Affairs (VA) health-care system and current VA policy mandates that CPT or PE must be available to all veterans with a primary diagnosis of PTSD (VHA, 2012). Despite these dissemination efforts, few VA patients receive these interventions. Estimates of the number of veterans receiving EBP in specialized VA PTSD clinics range from 6% to 13% (Lu, Plagge, Marsiglio, & Dobscha, 2013; Mott, Mondragon et al., 2014; Shiner et al., 2013). Reasons for this low utilization are likely complex and multifaceted, including patient, provider, and system-level factors (Cook et al., 2015; Watts et al., 2014). Though not focused on EBP specifically, several studies have examined veterans’ perceptions of barriers and facilitators to PTSD treatment initiation in general. In qualitative interviews with veterans, barriers to treatment included lack of knowledge about PTSD, limited access to care, an invalidating posttrauma environment, and beliefs that discourage treatment seeking (Sayer et al., 2009). This is largely consistent with a prior qualitative study that identified emotional readiness, concerns about treatment (e.g., fear of being prescribed medication), stigma, and logistical issues as primary barriers to PTSD treatment (Stecker, Shiner, Watts, Jones, & Conner, 2013). Many of these same general barriers to PTSD treatment may also be relevant to EBP. However, given that the structure and content of these evidence-based protocols differ in many ways from nontrauma-focused PTSD treatments, EBP may also be associated with unique barriers and facilitators. Indeed, VA Veterans’ Health Administration (VHA) utilization data suggest that the majority of veterans receive non-EBP treatments (e.g., Shiner et al., 2013), suggesting that even veterans who are willing to engage in PTSD treatment may face a second layer of barriers that inhibit participation in EBP. Several studies have examined patient preferences for EBP using nontreatment seeking participants who selected among hypothetical treatment options. Among trauma-exposed women in the community, feeling “a need to talk about” trauma predicted selecting PE over psychotropic medications (Angelo, Miller, Zoellner, & Feeny, 2008). Similarly, among Iraq war veterans, credibility of the therapy rationale and beliefs about therapy efficacy predicted selection of PE over antidepressant medications (Kehl-Forbes, Polusny, Erbes, & Gerould, 2014). However, little research has examined what influences initiation of PE among veterans in real-world settings, and no research has examined reasons for initiation of CPT or EMDR. Given that prior studies have examined veterans who refused to engage in PTSD therapy at all, the present study aims to enhance knowledge of facilitators to EBP initiation by examining veterans’ real-world experiences initiating EBP for PTSD and how they overcame barriers to EBP in their own life. We examine patients’ experiences initiating EBP, including ambivalence about treatment and coming to the decision to engage in treatment. One advantage of this exploratory, qualitative approach is that it allows for the identification of a broad range of themes not specified a priori (Glaser & Strauss, 1967). A thorough understanding of the relevant facilitators to EBP initiation from the patient perspective is necessary to inform future efforts to increase initiation of these effective treatments.
Method Participants We used principles of purposive sampling (Glaser & Strauss, 1967) to recruit veterans who completed at least eight sessions of EBP in a VA PTSD clinic. Given that this clinic does not offer EMDR, we only sampled patients who completed PE or CPT. Eight sessions is the minimum number of sessions for PE (Foa et al., 2007) and represents completion of 75% of the standard 12-session CPT course (Resick et al., 2008). We stratified sampling by therapist, completion of PE versus CPT, and patient ethnicity. Because women represent the minority of VA patients (approximately 10%; United States Department of Veterans Affairs, Office of the Actuary, 2011), and Operation Iraqi Freedom/ Operation Enduring Freedom (OEF/OIF) veterans are less likely to initiate and complete EBP (Mott, Mondragon et al., 2014), we overrecruited these patients. Given that qualitative guidelines suggest a minimum of five– eight participants per subgroup is necessary to capture the perspectives of each subgroup (Kuzel, 1999), we attempted to recruit at least five women, five military sexual trauma (MST) patients, and five OEF/OIF veterans. We also sampled to match the ethnic and racial distribution of veterans in our geographic region. Consented participants included 23 veterans treated by nine different therapists.
Procedure This study was approved by the local internal review board and the VA Research and Development Committee. We obtained a list of patients referred for individual PE and group or individual CPT in the PTSD clinic between May, 2012 and September, 2013. A research assistant and the first author each completed chart reviews to determine whether patients had completed at least eight sessions of EBP. A letter was sent to selected patients, according to our purposeful sampling strategy, describing the study and providing a phone number to opt out of participation. Five to seven days after sending the letter, a research assistant called patients. Of the 40 letters sent, 23 patients (57%) agreed to participate, 13 (33%) declined participation, and four (10%) could not be contacted. Patients were provided the option to participate in person or via telephone. Veterans who were interviewed face to face (n ⫽ 15) completed written consent and consent to audio-record at the beginning of their interviews. Those who participated via telephone (n ⫽ 8) signed and returned consent forms via mail before their interviews. All interviews were audio-recorded and audio files were password protected and saved on a HIPAA-compliant (U.S. Health Insurance Portability and Accountability Act) server. Interviews lasted approximately an hour (M ⫽ 59 min; range ⫽ 42– 85 min) and were conducted from October, 2013 to March, 2014. Interviews were conducted by the first and second authors. The fourth author is a medical sociologist trained in qualitative methods who provided guidance in study design and conduct. The research team developed a qualitative interview guide that queried participants’ experiences initiating and participating in EBP and assessing opinions about new VA services/programs. In this paper we present only those data regarding EBP initiation. As is common in qualitative studies, we refined the interview guide over the
VETERAN PERSPECTIVES ON INITIATING PTSD TREATMENT
initial interviews to elicit information about new ideas brought up by patients. For example, we recognized that some patients who were identified as completing one EBP during the study period had also previously completed the other EBP, and we added questions regarding a potential relationship between PE and CPT initiation. We ended recruitment when we reached data saturation, defined a priori as the point when coders agreed that three consecutive transcripts within a given interview category rendered no new thematic concepts (Morse, 1995; Aita & McIlvain, 1999).
Data Analysis Audio-recorded interviews were transcribed by a professional service. The first author and a research assistant trained in qualitative methods reviewed transcripts to determine initial codes using grounded theory analysis, which facilitates the development of coding categories to generate theory that best fits the data and to preclude the use of theories that may inadequately portray the data (Glaser & Strauss, 1967). This is a popular analytical approach that has been recommended for use in qualitative psychology research (Ponterotto, 2005). A codebook with definitions of codes and example quotations was derived from consensus and used to guide final coding. Each transcript was then coded by both coders, and discrepancies were resolved through discussion. We linked quotations to multiple codes as appropriate and used Atlas.ti V6.0, a qualitative data-management software package, for coding and analysis.
Results Our grounded theory analysis identified veterans’ descriptions of pathways into EBP, barriers to engaging in EBP, and factors that facilitated entry into treatment. Veteran demographic characteristics are presented in Table 1.
Pathways Into EBP Veterans reported hearing about EBP from therapists (i.e., psychologists or social workers delivering psychotherapy), psychiatrists, and fellow veterans (see Table 2); these sources did not appear to differ by era or gender. Therapists were the most common source of information about EBP, with approximately half of the sample first hearing of EBP from a therapist or during an intake assessment. Nearly one third of veterans reported initially receiving information about EBP from a psychiatrist. My psychiatrist, she said that she thought it could be helpful. It was a new program, and she thought that I needed it or it would be beneficial for me . . . she explained it well enough to know what I was getting in for . . . (male Vietnam veteran in PE).
A smaller group of veterans reported first hearing of EBP from other veterans who were personal friends, family members, or more commonly, acquaintances from non-EBP treatment programs at the VA. This pathway also appeared to serve as a facilitator for treatment engagement (see Facilitator section below). I actually heard about it from other Vets. They recommend the program highly. They said that it really done them well and it was a little bit more intense . . . (male Vietnam veteran in group CPT)
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Table 1 Veterans’ Demographic Characteristics and Treatments Received Demographic
No. of participants (N ⫽ 23)
%
6 17
26.1 73.9
8 10 2 1 2 53.74 (SD ⫽ 12.23)
34.8 43.5 8.7 4.3 8.7
Gender Female Male Race/Ethnicity Non-Hispanic White African American Hispanic Native American Asian Mean age Service era OEF/OIF Vietnam Persian Gulf Noncombat era Treatment type PE only CPT individual only CPT group only Both PE and CPT
9 9 3 2
39.1 39.1 13.0 8.7
11 3 6 3
47.8 13.0 26.1 13.0
Note. OEF/OIF ⫽ Operation Enduring Freedom (Afghanistan)/Operation Iraqi Freedom (Iraq); PE ⫽ prolonged exposure; CPT ⫽ cognitiveprocessing therapy.
The pathway into treatment and eventually into EBP was marked with ambivalence. Some veterans expressed delaying EBP entry for up to a year after first learning about it; others mentioned dropping out of EBP after the first few sessions, only to later complete a course of EBP. She made us aware it would go into maybe some painful areas. And I’m thinking, “No I’m not ready for that” . . . I was able to go back to (therapist’s name) a year later and say, “Hey is that course still available? I’d like to take it” (female veteran with MST in CPT).
Consistent with significant delays entering EBP, nearly all patients engaged in other mental health treatment before EBP, including medication management (87%), group psychotherapy (65%), and individual psychotherapy (39%). The most common types of prior psychotherapy included PTSD psychoeducation, skills-based treatments, process or support groups, and EBPs for comorbid disorders.
EBP-Specific Barriers Patients experienced a variety of EBP-specific barriers, including anxiety, avoidance, skepticism regarding the treatment rationale, and lack of knowledge about EBP.
Anxiety About Engaging in EBP Anxiety about engaging in an intense trauma-focused treatment was the most commonly cited barrier, endorsed by approximately two thirds of patients. Veterans were concerned that discussing the trauma would worsen symptoms or overwhelm their coping abilities, and this occurred for both PE and CPT patients. “I remember
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Table 2 Summary of Common Themes Theme First source of information about EBP Psychotherapy provider Psychiatrist Other veteran Significant ambivalence about starting EBP Barriers to EBP engagement Anxiety Avoidance Skepticism of therapy rationale Lack of knowledge of EBP Facilitators of EBP engagement Buy in to treatment rationale/Need to talk about it Prior treatment provided readiness for EBP Prior knowledge of EBP therapist Provider behaviors facilitated EBP engagement Choice in treatment Encouragement without pushing Thorough explanation of treatment Information about research support Provider testimonials about patient success Encouragement from other veterans Desperation for relief from symptoms/hit rock bottom Duty to family Hope for life worth living
Frequency of theme
% of Veterans endorsing theme
Common Common Common Common
52% 30% 17% 74%
Common Common Less common Rare
65% 30% 22% 13%
Common Less common Common
30% 17% 30%
Rare Less common Less common Rare Rare Common Common
9% 17% 17% 9% 9% 30% 30%
Common Less common
43% 17%
Note. EBP ⫽ evidence-based psychotherapies. Common themes were expressed by 30 – 65% veterans; less common by 17–26%; and rare by 9 –13%.
thinking ‘That may break me and I don’t want to be broken so I can’t’” (female veteran with MST in CPT). Other veterans were afraid that discussing the trauma would confirm their guilt and responsibility for the trauma. If you bring up bad thoughts for me, now I’m worse off than when I came in the door . . . Like if you said something to the effect of “You might have had time to (save friend’s name),” oh man, what did you just do? You just compound the guilt, you know (male Vietnam veteran in PE).
This appeared to be a particular concern of patients engaging in PE. CPT patients appeared to fully accept the rationale for treatment, despite their anxiety. Some PE patients, on the other hand, expressed that the treatment differed from their expectations for what therapy should be like. It was just weird to me more than anything. The whole closing my eyes part you know, tape recording myself and listening to myself, I mean I just didn’t understand like what kind of treatment that was (male OEF/OIF veteran in PE).
Avoidance-Related Beliefs The second most commonly expressed barrier was the belief that avoidance was helpful. Leave it alone. “Don’t trouble trouble, trouble won’t trouble you.” One of my mother’s greatest sayings. And I thought that (PE) was troubling trouble but it was good for me in the long run (male Vietnam veteran in PE).
Lack of EBP Knowledge A less commonly mentioned barrier was lack of knowledge about the existence of EBP. See, that’s the problem. I didn’t find out ‘til, you know, I’m walking with some guy that said, “Man, you know, that thing work. It work.” I said “What work?” He said “prolonged exposure, you need to try it” (male Vietnam veteran in PE).
Skepticism of the Therapy Rationale Beliefs about the helpfulness of avoidance led some veterans to be skeptical of the therapy rationale and to distrust the explanation of treatment mechanisms. And he said, “Then you’re going to look at the same thing so many times that you’ll be so familiar with it; it’ll be just like it happened yesterday but it won’t bother you anymore.” When he said that I thought it was BS. I thought, “You’re crazy” (male Vietnam veteran in PE).
EBP-Specific Facilitators Veterans also reported a variety of motivations and supports for engaging in EBP, including buying into the rationale, believing that prior treatment gave them the skills to handle EBP, prior knowledge of the EBP therapist, specific therapist behaviors that encouraged EBP, seeing treatment success in other veterans, and desperation for relief from symptoms.
VETERAN PERSPECTIVES ON INITIATING PTSD TREATMENT
Buy-In to Treatment Rationale Although PE patients were more likely to endorse initial concerns about the therapy rationale than CPT patients, nearly half of PE patients reported strong credibility of the treatment rationale. Many felt a need to discuss the trauma due to beliefs that talking about it would relieve emotional pain. It’s always been something that I wanted to do. You know, get some things off my chest . . . the one thing that’s eating you up the most. You’ve got to talk about it (male OEF/OIF veteran in PE).
Some veterans reported frustration that other nontraumafocused PTSD treatments they had received previously discouraged discussion of trauma. I basically called the group out because I’m sitting there being open and everybody’s talking about, “You know I’m so scared to go to Walmart” and “I can’t go out and I have nightmares.” And I’m like, dude, that’s normal. We got PTSD. Are we going to sit here and talk about this (expletive) every time we come here? We need to talk about trauma (male OEF/OIF veteran in PE).
Veterans with MST often experienced their disclosure of MST to be a step forward in recovery. Thus, discussing the trauma, whether in PE or in CPT, was anticipated to be therapeutic in and of itself, lending credibility to the therapy rationale. Some veterans reported that buy-in arose gradually during a few initial pre-EBP therapy sessions with their providers. Initially I was totally against it . . . but the more I talked to the doctor about it and he started explaining things so then I start understanding that the only way through this is to go back through this again” (male Persian Gulf veteran in PE).
Prior Treatment Provided Skills to Handle EBP Veterans also reported that engaging in other treatments prior to EBP helped them feel confident they had the tools to handle EBP. The other courses we talked about deep breathing and when someone else would . . . touch on something that would trigger something and . . . then rather than me getting up and running out because I felt overwhelmed I could work on the deep breathing. So those courses definitely helped me to be able to stay in the room some days (female veteran with MST in group CPT).
Three veterans completed Group CPT followed by individual PE. All three reported that having CPT first was helpful, not only because it provided them with cognitive coping skills, but also because it built self-efficacy about engaging in trauma-focused treatment. (CPT) got me to the point where I could do the individual prolonged exposure. And have confidence in the therapy Number 1. And confidence in myself Number 2 . . . I have to tell you that I don’t believe I could’ve gotten the results that I got if I hadn’t had the other therapy before it (male Vietnam veteran).
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helped some veterans overcome their skepticism of the therapy rationale. In fact, some veterans were only willing to engage in EBP with a known provider and were willing to wait for that person to become available rather than initiate with an available but unfamiliar therapist. I’ve known Dr. (name) for quite a while based on my time here walking into other groups, coming here to the Medical Center so, you know, I trust his methods (male Vietnam veteran in group CPT). I’ve had experiences with her since I came here in (year) . . . my experience with her has proven that she wouldn’t deliberately have me to go through the motions of suffering through the pain if there wasn’t some benefit on me. So I trusted her (female veteran with MST in group CPT).
Provider Behaviors Facilitating EBP Some veterans describe specific therapist behaviors that encouraged them to initiate EBP. For instance, several veterans appreciated the opportunity to make choices about which treatment to initiate. One male Persian Gulf veteran in PE described his route into EBP. They kind of explained it to me . . . gave us more detail about what was going on and it was a choice of group or one on one . . . they had a list that had the different options. And I decided to start (PE) first.
This suggests that providing options can be an effective way to offer veterans autonomy and increase buy-in to the therapy chosen. Other participants noted that providers who provided gentle encouragement and expressed confidence in the patient’s ability to handle EBP which helped them feel empowered to try EBP without feeling coerced. She said, “Do you want to try it?” And I said, “Yeah, I’m willing to try anything at this point.” I was a little anxious. Thinking, “Oh man I don’t know if I can do that you know.” And she told me, “Just try” . . . She said, “If you can’t do it, you can’t do it.” She said, “But I think you probably would be able to (female veteran with MST in PE).
Several patients mentioned that therapists who provided a thorough orientation to treatment procedures and methods before beginning EBP helped allay their fears and increase buy-in. These patients wanted to know exactly “what they were getting in for” before they agreed to participate. She even said that before, that it would be different from the other group . . . there’s going to be a certain structure, like programmed . . . certain things that needed to be discussed and needed to be done each session (female OEF/OIF veteran in group CPT).
Therapists also increased buy-in by providing two sources of evidence for the success of these treatments: statistics from treatment outcome research and testimonials about a clinician’s own experiences with patient success in EBP.
Prior Knowledge of EBP Therapist
Talking about research . . . I think the reason why I feel so positive too is because I understand the concept of research in the medical field (female patient with MST in PE).
Previous exposure to other treatments also provided veterans with another key ingredient: familiarity with their EBP therapist. Knowing that the therapist was a competent, caring individual
She made it very apparent that there was going to be light at the end of the tunnel . . . she would tell me, “Look, I’ve had guys that were— had done this for years. And they wouldn’t even hardly go
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outside of the house and now they’re riding the bus . . . almost every day” (male Vietnam veteran in PE).
Encouragement From Other Veterans Other veterans also provided encouragement to engage in EBP. Some veterans appeared to make active efforts to convince fellow veterans to do EBP; their observable improvement provided evidence of the success of EBP. They said, “It’s hell, but it’s worth it in the end.” And there was one guy in there that convinced me that I ought to do it. And I knew how he had struggled because I’d watched it . . . I saw it work in him and I guess I learned to believe in him. And I could see the difference. He was happier. And he was calmer (male Vietnam veteran in PE).
Desperation for Relief From Symptoms Other veterans retained some skepticism of the therapy rationale but were driven to try EBP because of desperation from years of suffering and feeling like they had exhausted other coping and treatment options. I done tried everything and that (expletive) don’t work. Drugs definitely don’t work . . . I know what’s next after this. What’s next is the penitentiary or the graveyard for me. It’s like this is the last boat to come through for me to save myself. If I don’t get on this (expletive) I’m (expletive). I was determined to do whatever (male Persian Gulf veteran in PE).
This desperation was often accompanied by the feeling that the veteran had hit their own personal “rock bottom” and had nothing left to lose by trying EBP. It was like hallucinations and I mean it was horrible; it was scary. And somehow I drove 30 miles on the highway and I mean I don’t even know how I got there or what; I don’t know . . . that was like the lowest point (male OEF/OIF veteran in individual CPT).
Many veterans reported that spouses and children were a key reason they were motivated to engage in EBP. For some, marital tension had reached the point that the possibility of divorce had arisen. Others felt a need to “make it up to” their family for enduring years of deployments or the ways in which symptoms like nightmares, irritability, and avoidance had interfered with family life. If it wasn’t for (my family) I wouldn’t have done any of this because to be perfectly honest with you I’m very happy being miserable. I’m just alone and I don’t have any pain; you know I’m happy with that. But my family isn’t. So I have to do what I can so that my son can have a normal 5-year-old childhood (male OEF/OIF veteran in PE).
Discussion Although prior studies have examined barriers and facilitators to treatment seeking among veterans, to the authors’ knowledge, this is the first study to examine veterans’ real-world experiences initiating PTSD EBP. Our analysis revealed routes into EBP and the facilitators that helped these veterans overcome barriers to initiating EBP. These findings suggest that mental health providers remain the most frequent source of knowledge about EBP. However, veter-
ans’ pathways into EBP were diverse and indicate the importance of obtaining buy-in from all potential disseminators of information about EBP, including psychiatrists and providers outside of PTSD clinics, which may increase referral rates to these clinics. We also found that some veterans purposefully shared information about EBP with other veterans, and that witnessing treatment success in other veterans can provide the final “push” to initiate EBP. Given that veterans often trust fellow veterans more than mental health professionals (Chinman, Young, Hassell, & Davidson, 2006), peer-to-peer promotion of EBP represents one promising avenue to increasing EBP initiation. Therapists might consider specifically asking patients to tell other veterans about positive experiences in EBP. In addition, the recent increase in VA peer-support providers (United States Department of Veterans Affairs, the Veterans Health Administration, 2011) may provide an opportunity for EBP completers to share their recovery stories with treatment-naïve veterans. Despite recent efforts to promote EBP through the Internet, no veteran mentioned using any electronic or paper resource regarding EBP, suggesting that more work to promote these resources is needed. Previous research that has examined barriers and facilitators to non-EBP-specific treatment seeking for PTSD found that barriers included lack of knowledge about PTSD and access to care, beliefs that discourage treatment seeking, and stigma (Sayer et al., 2009; Stecker, Shiner, Watts, Jones, & Conner, 2013). This study found that barriers and facilitators to engagement in EBP for PTSD largely differ from those relevant to non-EBP. In the current study, ambivalence about participating in EBP was a consistent theme, with the majority of veterans expressing fears that EBP might be too anxiety provoking or beliefs that avoidance was helpful. Overall, this suggests that future researchers should examine the utility of interventions to increase initiation of EBP, such as motivational interviewing. Although originally developed with substance-use disorders, motivational interviewing is beginning to be used in anxiety treatment (Westra, Arkowitz, & Dozois, 2009) and may help veterans recognize how EBP fits with values such as the importance of family. Another barrier for a minority of patients included skepticism of the therapy rationale. Exposure-based treatments have suffered a credibility problem, both among providers and patients (Feeny, Hembree, & Zellner, 2003), despite their strong research support. Although provider concerns about initial worsening of symptoms have historically been associated primarily with PE, many patients preparing to engage in CPT have similar concerns. This may be because CPT typically involves repeatedly writing and reading a trauma narrative, and even veterans who complete a form of CPT without this narrative (CPT-C; Resick et al., 2008) may complete trauma-related cognitive restructuring worksheets, which are sufficient to provoke substantial anxiety. These barriers were balanced with motivations to pursue treatment. Although some veterans reported engaging in EBP to improve quality of life and meet personal goals, the most commonly cited motivations included improving family functioning, sometimes due to fear of family dissolution, and desperation for relief from symptoms that were extremely disruptive to everyday functioning. Other EBP facilitators included the credibility of the therapy rational and feeling a “need” to talk about the trauma. Veterans reported that engaging in prior skills-based treatments provided them with the self-efficacy to believe they could engage
VETERAN PERSPECTIVES ON INITIATING PTSD TREATMENT
in EBP. Although few researchers have examined whether nontrauma-focused treatments increase the initiation or effectiveness of EBP, our data suggest that some veterans prefer this approach. Finally, familiarity with the EBP therapist sometimes provided assurance that the therapist was a competent, caring individual and increased the credibility of EBP. This highlights the importance of continuity of care, particularly in training hospitals with providers who rotate through various clinics. Veterans also cited a variety of therapist behaviors that increased their willingness to participate in EBP. Some of these techniques, such as providing gentle encouragement and expressing confidence in the patient’s ability to get better, are standard therapeutic practice, but this study confirms their importance from the perspective of veterans. These findings also provide support for a less commonly used therapeutic practice, informed decision making interventions (Mott, Stanley, Street, Grady, & Teng, 2014) that provide PTSD patients comparative information about different treatment options and support in choosing the best treatment for them.
Limitations As this study only examined EBP completers in a VA PTSD clinic, we cannot comment upon factors that may be barriers for other patients. For example, although lack of knowledge of EBP was rarely cited as a barrier in this study, it may be the case that other veterans, particularly those not enrolled in specialty VA PTSD clinics, are unaware of EBPs. Because all patients in this sample did participate in EBP, although some did so after extensive delay, we could not provide information through this study regarding the ambivalence or barriers of those who have not participated in EBP.
Conclusion These results provide insight into veterans’ experiences initiating EBP. Given that many of the barriers and facilitators identified are unique from those previously identified to PTSD treatment in general, attention to these EBP-specific factors will be important in ongoing and future efforts to implement EBP within the VHA system.
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Received September 25, 2014 Revision received December 18, 2014 Accepted January 29, 2015 䡲
New Editors Appointed The Publications and Communications Board of the American Psychological Association announces the appointment of 6 new editors. As of January 1, 2016, manuscripts should be directed as follows: ●
American Psychologist (www.apa.org/pubs/journals/amp/) Anne E. Kazak, PhD, ABPP, Nemours Children’s Health Network, A.I. du Pont Hospital for Children
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Developmental Psychology (http://www.apa.org/pubs/journals/dev/) Eric F. Dubow, PhD, Bowling Green State University
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International Perspectives in Psychology: Research Practice, Consultation (www.apa.org/ pubs/journals/ipp/) Stuart Carr, PhD, Massey University
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Journal of Consulting and Clinical Psychology (www.apa.org/pubs/journals/ccp/) Joanne Davila, PhD, Stony Brook University
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School Psychology Quarterly (www.apa.org/pubs/journals/spq/) Richard Gilman, PhD, Cincinnati Children’s Hospital Medical Center
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Sport, Exercise and Performance Psychology (www.apa.org/pubs/journals/spy/) Maria Kavussanu, PhD, University of Birmingham, UK
Electronic manuscript submission: As of January 1, 2016, manuscripts should be submitted electronically to the new editors via the journal’s Manuscript Submission Portal (see the website listed above with each journal title). Current editors Norman Anderson, PhD, Jacquelynne Eccles, PhD, Judith Gibbons, PhD, Arthur M. Nezu, PhD, Shane R. Jimerson, PhD, and Jeffrey J. Martin, PhD will receive and consider new manuscripts through December 31, 2015.
