Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

Kehle‐Forbes, Shannon M.; Spoont, Michele; Meis, Laura; Orazem, Robert J.; Lyon, Alexandra; Valenstein-Mah, Helen; Schnurr, Paula P.; Zickmund, Susan; Foa, Edna B.; Chard, Kathleen M.; Alpert, Elizabeth; Polusny, Melissa A.

doi:10.1016/j.brat.2022.104123

Cited by 21 publications

(56 citation statements)

References 43 publications

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“…A few providers noted that substance misuse and emotion dysregulation were barriers to improvement. In the domain of social and contextual resources, patients and providers emphasized the importance of social support, normalization, and shared learning experiences, echoing the findings of other interview studies (Hundt et al, 2017;Kehle-Forbes et al, 2022;St Cyr et al, 2022). Providers noted that the transition to outpatient care was a weak point of their programming.…”

Section: Discussionmentioning

confidence: 72%

“…Hypothesized Themes. Previous qualitative studies have identified factors associated with psychotherapy treatment engagement and response, including therapeutic alliance factors (Hundt et al, 2020;Kehle-Forbes et al, 2022;McLaughlin et al, 2014;Nilsson et al, 2007), distress tolerance/avoidance of negative emotion (Crowe & Luty, 2005), or lack of social support (Price et al, 2013). Previous quantitative investigations suggest that RRTP providers perceive the use of EBPs and the cohesion of the residential milieu to be important contributors to RRTP treatment effectiveness (Cook et al, 2014).…”

Section: Subgroup Analysismentioning

confidence: 99%

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“I wish people could come together like we have,” patient and provider perspectives on VA residential PTSD treatment.

Sripada¹,

Walters²

2023

Psychological Services

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Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. Impact StatementWhen queried about factors that contribute to treatment response in veterans affairs (VA) residential rehabilitation treatment programs for posttraumatic stress disorder, patients and providers agreed that first-line evidence-based treatments, social support from Veterans and providers, and patient openness and willingness to change were all critical components to success. Policy makers and program administrators could consider ways to enhance these elements in residential programs.

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Section: Discussionmentioning

confidence: 72%

Section: Subgroup Analysismentioning

confidence: 99%

“I wish people could come together like we have,” patient and provider perspectives on VA residential PTSD treatment.

Sripada¹,

Walters²

2023

Psychological Services

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“…We found that a substantial proportion of variance for some modifications was accounted for by patients (e.g., tailoring the protocol, integration of other treatments), while others appeared to be more driven by therapists. In fact, the magnitude of therapist contribution for many modifications is relatively large compared with previous studies of therapist effects on outcomes such as dropout and symptom change ( 15 – 17 ).…”

Section: Discussionmentioning

confidence: 89%

“…While this study did not assess outcomes in relation to modifications, prior research indicated that modifications that were consistent with the protocol were associated with increased symptom change ( 9 ). A recent qualitative study further suggested that rigid protocol adherence was associated with treatment dropout, whereas more flexible and patient-centered application of EBPs for PTSD were associated with treatment completion ( 17 ). Thus, training on how to maintain flexibility while still ensuring that patients experience essential treatment components may be particularly helpful.…”

Section: Discussionmentioning

confidence: 99%

“…However, refinements like those suggested above, as well as the use of other approaches, such as training providers to clearly document their modifications in the free text sections of their notes, could advance efforts to understand how EBPs are modified in routine care settings. Research suggests that there is substantial room for improvement in terms of engagement of underrepresented populations ( 19 , 20 ) and veterans in specialty care programs ( 17 ) and for optimizing CPT and PE patient outcomes ( 21 – 26 ) in large healthcare systems. With refinement, methods to understand modifications and fidelity to EBPs through medical record documentation can contribute to efforts to understand how to optimize EBPs for PTSD, and how to train and support providers as they use these interventions to treat their patients.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system

Stirman

Bash

Nelson

et al. 2022

Front. Public Health

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BackgroundThe US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD).MethodsThis study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30–45-min semi-structured interviews with a purposive subsample of these therapists (n = 32).FindingsCombining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review.ConclusionHealthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care.

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Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder

Campbell

Wallace

2023

Journal of Traumatic Stress

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Clinical practice guidelines for managing posttraumatic stress disorder (PTSD) encourage incorporating loved ones into treatment, and supportive relationships can increase engagement in mental health care for veterans with PTSD. This study describes the iterative refinement, feasibility/acceptability testing, and national dissemination of a brief support and psychoeducation intervention for loved ones of veterans with PTSD. Loved ones (n = 181; range:1–11 per group) attended and qualitatively rated “PTSD 101 for Family and Friends: A Support and Education Workshop.” Open‐ended questions were used to gather data on suggestions for improvement and descriptions of helpful content, and the workshop was refined following participant and operational partner feedback using a quality improvement framework. Rating quantitative items on a 1–5 scale, participants found the overall quality (M = 4.76) and relevance (M = 4.82) to be excellent, noting they learned substantial new information (M = 4.45). Sense of support (M = 4.95), intentions to use the material (M = 4.87), PTSD self‐efficacy (M = 4.41), and understanding of PTSD (M = 4.76) were rated favorably. Common themes among helpful elements were a sense of shared experience and optimism and increased knowledge of treatments/resources. Suggestions for improvement referenced logistics. Following continual stakeholder feedback and refinement, the workshop represents a novel method for providing loved ones with empirically supported psychoeducation, coping skills, and community. It is being disseminated by the Family Services Section of the Veterans Health Administration Office of Mental Health and Suicide Prevention.

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Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

Cited by 21 publications

References 43 publications

“I wish people could come together like we have,” patient and provider perspectives on VA residential PTSD treatment.

“I wish people could come together like we have,” patient and provider perspectives on VA residential PTSD treatment.

Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system

Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder

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