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Rosen CS, Kaplan AN, Nelson DB, La Bash H, Chard KM, Eftekhari A, Kehle-Forbes S, Wiltsey Stirman S, Sayer NA. Implementation context and burnout among Department of Veterans Affairs psychotherapists prior to and during the COVID-19 pandemic. J Affect Disord 2023; 320:517-524. [PMID: 36191645 PMCID: PMC9523596 DOI: 10.1016/j.jad.2022.09.141] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The first goal of this study was to assess longitudinal changes in burnout among psychotherapists prior to (T1) and during the COVID-19 pandemic (T2). The second objective was to assess the effects of job demands, job resources (including organizational support for evidence-based psychotherapies, or EBPs) and pandemic-related stress (T2 only) on burnout. METHOD Psychotherapists providing EBPs for posttraumatic stress disorder in U.S. Department of Veterans Affairs (VA) facilities completed surveys assessing burnout, job resources, and job demands prior to (T1; n = 346) and during (T2; n = 193) the COVID-19 pandemic. RESULTS Burnout prevalence increased from 40 % at T1 to 56 % at T2 (p < .001). At T1, stronger implementation climate and implementation leadership (p < .001) and provision of only cognitive processing therapy (rather than use of prolonged exposure therapy or both treatments; p < .05) reduced burnout risk. Risk factors for burnout at T2 included T1 burnout, pandemic-related stress, less control over when and how to deliver EBPs, being female, and being a psychologist rather than social worker (p < .02). Implementation leadership did not reduce risk of burnout at T2. LIMITATIONS This study involved staff not directly involved in treating COVID-19, in a healthcare system poised to transition to telehealth delivery. CONCLUSION Organizational support for using EBPs reduced burnout risk prior to but not during the pandemic. Pandemic related stress rather than increased work demands contributed to elevated burnout during the pandemic. A comprehensive approach to reducing burnout must address the effects of both work demands and personal stressors.
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Affiliation(s)
- Craig S. Rosen
- National Center for Posttraumatic Stress Disorder Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author at: VAPAHCS (334-PTSD), 795 Willow Road, Menlo Park, CA 94025, USA
| | - Adam N. Kaplan
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B. Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Heidi La Bash
- National Center for Posttraumatic Stress Disorder Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Kathleen M. Chard
- Cincinnati VA Medical Center, Cincinnati, OH, USA,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Afsoon Eftekhari
- National Center for Posttraumatic Stress Disorder Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Shannon Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA,National Center for PTSD Women's Health Sciences Division, Boston MA, USA
| | - Shannon Wiltsey Stirman
- National Center for Posttraumatic Stress Disorder Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Nina A. Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA,Department of Medicine, University of Minnesota, Minneapolis, MN, USA,Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
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Wiltsey Stirman S, La Bash H, Nelson D, Orazem R, Klein A, Sayer NA. Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system. Front Public Health 2022; 10:984505. [PMID: 36457312 PMCID: PMC9705357 DOI: 10.3389/fpubh.2022.984505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The 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). Methods This 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). Findings Combining 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. Conclusion Healthcare 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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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States,*Correspondence: Shannon Wiltsey Stirman
| | - Heidi La Bash
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States
| | - David Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Robert Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Abigail Klein
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Nina A. Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine and Psychiatry, University of Minnesota, Minneapolis, MN, United States
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Johnson C, La Bash H, Song J, Dunlap K, Lagdamen J, Suvak M, Landy MSH, Shields N, Monson CM, Stirman SW. The role of the consultant in consultation for an evidence-based treatment for PTSD. Psychol Serv 2021; 19:760-769. [PMID: 34735197 DOI: 10.1037/ser0000592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Consultation is an important implementation strategy to improve treatment fidelity and clinical outcomes, yet research has not identified the aspects of consultation that differentially affects clinician skill development and client symptom change. Thus, the present study investigated the effect of the consultant, consultation activities, and consultants' (n = 6) perceptions of consultees (n = 60) on post-traumatic stress disorder (PTSD) treatment fidelity and client outcomes. In addition, we assessed the accuracy of consultants' evaluations of clinicians using the Perceived Enthusiasm, Skill, and Participation scale (P-ESP). Results indicated that there was a significant effect of consultant on adherence to, but not competence in, delivering Cognitive Processing Therapy (CPT). The effect of the consultant on PTSD symptom change was not significant. Consultants significantly differed in their discussion of CPT strategies and their application to individual cases, but did not differ on reviewing and providing feedback on fidelity. Consultant perceptions as assessed by the P-ESP were not associated with clinicians' current levels of adherence or competence, suggesting that consultants may not accurately assess clinician skill during consultation. Client PTSD symptom change neither predicted, nor was predicted by, consultants' perceptions of their consultees' skill. This article outlines potential reasons for consultant effects and possible biases at play that may reduce the accuracy of consultant perceptions and presents suggestions on alternative strategies to assess clinician skill during consultation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Larsen SE, Mackintosh MA, La Bash H, Evans WR, Suvak MK, Shields N, Lane JEM, Sijercic I, Monson CM, Wiltsey Stirman S. Temporary PTSD symptom increases among individuals receiving CPT in a hybrid effectiveness-implementation trial: Potential predictors and association with overall symptom change trajectory. Psychol Trauma 2020; 14:853-861. [PMID: 31971424 DOI: 10.1037/tra0000545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. METHOD We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. RESULTS Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. CONCLUSIONS The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Meyer EC, La Bash H, DeBeer BB, Kimbrel NA, Gulliver SB, Morissette SB. Psychological inflexibility predicts PTSD symptom severity in war veterans after accounting for established PTSD risk factors and personality. ACTA ACUST UNITED AC 2019; 11:383-390. [DOI: 10.1037/tra0000358] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Frankfurt SB, DeBeer BB, Morissette SB, Kimbrel NA, La Bash H, Meyer EC. Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans. Front Psychiatry 2018; 9:520. [PMID: 30450058 PMCID: PMC6225808 DOI: 10.3389/fpsyt.2018.00520] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.
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Affiliation(s)
- Sheila B. Frankfurt
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
| | - Bryann B. DeBeer
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
| | | | - Nathan A. Kimbrel
- Durham VA Medical Center, Durham, NC, United States
- Mental Illness Research, Education and Clinical Centers MIRECC (VA), Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Heidi La Bash
- National Center for PTSD, VA Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Eric C. Meyer
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
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Meyer EC, Walser R, Hermann B, La Bash H, DeBeer BB, Morissette SB, Kimbrel NA, Kwok OM, Batten SV, Schnurr PP. Acceptance and Commitment Therapy for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veterans: Pilot Treatment Outcomes. J Trauma Stress 2018; 31:781-789. [PMID: 30338561 DOI: 10.1002/jts.22322] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022]
Abstract
Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD-AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness- and acceptance-based form of behavior therapy, has potential as a treatment option for PTSD-AUD. In this uncontrolled pilot study, we examined ACT for PTSD-AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ≥ 10 of 12 sessions). Clinician-assessed and self-reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self-reported symptoms of PTSD remained lower at 3-month follow-up, d = 0.88. There were reductions on all alcohol-related outcomes (clinician-assessed and self-reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3-month follow-up, dmean = 0.91 (d range: 0.65-1.30). Quality of life increased at posttreatment and follow-up, ds = 0.55-0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow-up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow-up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow-up. Consistent with the ACT theoretical model, these improvements were associated with more between-session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD-AUD include assigning frequent between-session mindfulness practice and initiating values clarification work and values-based behavior assignments early in treatment.
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Affiliation(s)
- Eric C Meyer
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | - Robyn Walser
- National Center for PTSD Training and Dissemination Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Department of Psychology, University of California, Berkeley, California, USA
| | | | - Heidi La Bash
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | - Bryann B DeBeer
- U.S. Department of Veterans Affairs Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Healthcare System, Waco, Texas, USA.,Texas A&M University Health Science Center, College of Medicine, College Station, Texas, USA
| | | | - Nathan A Kimbrel
- Durham VA Medical Center, Durham, North Carolina, USA.,VA Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA.,School of Medicine, Duke University Health System, Durham, North Carolina, USA
| | - Oi-Man Kwok
- Texas A&M University, College Station, Texas, USA
| | - Sonja V Batten
- Mental Health Services, Department of Veterans Affairs, Washington, D.C., USA.,Booz Allen Hamilton, Washington, D.C., USA
| | - Paula P Schnurr
- National Center for PTSD, Executive Division, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Wiltsey Stirman S, Marques L, Creed TA, Gutner CA, DeRubeis R, Barnett PG, Kuhn E, Suvak M, Owen J, Vogt D, Jo B, Schoenwald S, Johnson C, Mallard K, Beristianos M, La Bash H. Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study. Implement Sci 2018; 13:69. [PMID: 29789017 PMCID: PMC5964900 DOI: 10.1186/s13012-018-0756-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/19/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions. METHODS To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity. DISCUSSION Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Luana Marques
- Harvard Medical School and Massachusetts General Hospital, 70 Everett Ave., Chelsea, MA 02150 USA
| | - Torrey A. Creed
- University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 3038, Philadelphia, PA 19104 USA
| | - Cassidy A. Gutner
- National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave., Boston, MA 02130 USA
| | - Robert DeRubeis
- School of Arts and Sciences, University of Pennsylvania, 425 S. University Ave., Philadelphia, PA 19104 USA
| | - Paul G. Barnett
- Palo Alto Veterans Institute for Research, 3801 Miranda Ave., Palo Alto, CA 94304 USA
| | - Eric Kuhn
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Michael Suvak
- Suffolk University, 73 Tremont Street, Boston, MA 02108 USA
| | - Jason Owen
- National Center for PTSD, VA Palo Alto HCS and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave., Boston, MA 02130 USA
| | - Booil Jo
- Stanford University, 401 Quarry Rd, Stanford, CA 94305 USA
| | | | - Clara Johnson
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Kera Mallard
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
| | | | - Heidi La Bash
- National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025 USA
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