Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the Veterans Health Administration: A thematic analysis

Transitioning into trauma-focused evidence-based psychotherapy for posttraumatic stress disorder from other treatments: a qualitative investigation

Although trauma-focused evidence-based psychotherapy (TF-EBP) is recommended for posttraumatic stress disorder (PTSD), rates of TF-EBP initiation among veterans is very low. Service delivery research has shown that other treatments are commonly provided to veterans diagnosed with PTSD, including stabilization treatments. As little is known about how veterans experience the transition to TF-EBP, we conducted a qualitative examination of veterans' perspectives on transitions in PTSD treatment. We recruited a diverse sample of veterans (n = 30) who recently initiated TF-EBP to complete semi-structured qualitative interviews focusing on six domains (PTSD treatment options, cultural sensitivity of treatment, PTSD treatment selection, transition criteria, beliefs about stabilization treatment, treatment needs/preferences). Rapid qualitative analysis procedures were used to identify themes. Themes included: (1) wanting to learn about TF-EBP earlier; (2) perceived risks of transition; (3) relationships with non-TF-EBP providers as transition barriers; (4) high symptoms and poor interpersonal functioning as transition facilitators; (5) benefits of treatment planning and handoffs; (6) prior therapy best when aligned with TF-EBP; (7) socialization as a key benefit of prior therapy; and (8) medications supporting TF-EBP. Results highlight the importance of introducing TF-EBP early to veterans, establishing and communicating a comprehensive care plan, and anchoring stabilization treatment in TF-EBP concepts.

Veterans' experiences of somatic experiencing and prolonged exposure therapies for post-traumatic stress disorder: A qualitative analysis

PURPOSE

Despite the proliferation of research into evidence based treatment for military PTSD there is little evidence for treatment assignment criterion and military based PTSD still demonstrates low remission rates.

METHOD

Thirty participants in a randomized control trial comparing Prolonged Exposure (PE) and Somatic Experiencing (SE) were interviewed on their experiences in therapy and their responses assessed using a descriptive phenomenological analysis approach to delineate the central tenets of the two therapeutic approaches.

RESULTS

Results indicated that participants from both therapies covered themes of the experience of change, the experience of the therapeutic relationship and the therapeutic process. Within these themes, SE and PE participants reported both similar experiences, such as the predominance of physiological or bodily experiences and also described nuanced differences, specifically pertaining to therapy characteristics. SE participants described the process in terms of learning a language, applicable to alternative scenarios and PE participants described the process in terms of conquering exposures in order to achieve respite from symptoms.

CONCLUSION

The current findings have relevance in terms of presenting the key elements of the distinct trauma therapies and determining treatment appropriateness based on desired outcomes. They highlight the commonalities and differences between the patient experience in PE and SE, specifically the relevance of the bodily response, treatment expertise and therapist characteristics in both treatments. Understanding the unique elements of PE, a gold-standard PTSD treatment and SE, a novel somatic-based psychotherapy, will allow for better treatment preparation for participants and potentially aid treatment assignment.

"Pitching" posttraumatic stress disorder treatment: A qualitative study of how providers discuss evidence-based psychotherapies with patients

The two widely available evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are cognitive processing therapy and prolonged exposure. Although the U.S. Department of Veterans Affairs (VA) has invested in intensive clinical training to provide these first-line treatments, most military veterans do not receive these therapies. Prior research indicates that patient interest and motivation depend on how patients are educated, and differences in how information is presented shape their decision-making. To our knowledge, no studies have addressed how clinicians "pitch" EBPs for PTSD and examined whether certain approaches are more effective than others. We recorded and thematically analyzed 25 treatment planning sessions across 10 VA sites in the United States to better understand how providers talk to patients about treatment options. Five themes were identified: using rich description, integrating various forms of questioning to engage the patient, sharing prior patient success stories, using inviting and direct language, and tailoring therapy talk to fit patient needs. Providers learning to offer EBPs can use these strategies to serve as a "menu" of options that will allow them to present EBPs in a way that appeals to a particular patient.

Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings.

Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care

Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.