Mental Health Providers’ Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD
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- Osei-Bonsu, P.E., Bolton, R.E., Wiltsey Stirman, S. et al. J Behav Health Serv Res (2017) 44: 213. doi:10.1007/s11414-015-9489-0
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It is estimated that <15% of veterans with posttraumatic stress disorder (PTSD) have engaged in two evidence-based psychotherapies highly recommended by VA—cognitive processing therapy (CPT) and prolonged exposure (PE). CPT and PE guidelines specify which patients are appropriate, but research suggests that providers may be more selective than the guidelines. In addition, PTSD clinical guidelines encourage “shared decision-making,” but there is little research on what processes providers use to make decisions about CPT/PE. Sixteen licensed psychologists and social workers from two VA medical centers working with ≥1 patient with PTSD were interviewed about patient factors considered and decision-making processes for CPT/PE use. Qualitative analyses revealed that patient readiness and comorbid conditions influenced decisions to use or refer patients with PTSD for CPT/PE. Providers reported mentally derived and instances of patient-involved decision-making around CPT/PE use. Continued efforts to assist providers in making informed and collaborative decisions about CPT/PE use are discussed.
The Department of Veterans Affairs (VA) is one of the first health care systems to implement evidence-based treatments for psychiatric disorders. For posttraumatic stress disorder (PTSD), these include cognitive processing therapy (CPT)1 and prolonged exposure (PE).2 Other treatments for PTSD exist (e.g., eye movement desensitization and reprocessing and stress inoculation); however, CPT and PE have the strongest evidence base for effectively treating PTSD,3, 4, 5, 6, 7 and as a result, the VA/Department of Defense (DoD) Clinical Practice Guidelines for PTSD specify that CPT and PE should be offered as first-line treatments.8 The VA has invested significant resources including training, staffing, and materials to make CPT and PE available in its medical centers and community-based outpatient clinics. Over 95% of VA medical centers report the availability of either treatment.9 However, it is estimated that less than 15% of veterans with PTSD are receiving CPT or PE.10,11 This is a significant concern since there is a substantial number of veterans enrolled in VA who have been diagnosed with PTSD,12,13 and untreated PTSD is associated with depression, suicidality, substance abuse/addiction, chronic pain, and psychosocial problems such as relationship issues and unemployment.14, 15, 16, 17, 18
A variety of factors may contribute to low CPT and PE utilization. These can include perceived stigma and negative perceptions of mental health care on the part of the patient, system-level challenges such as balancing providers’ competing demands, and providers’ low adherence to clinical practice guidelines.9, 10, 11,19, 20, 21, 22, 23 The latter is particularly important since both CPT and PE are provider-delivered treatments—as opposed to self-help interventions. However, there is a dearth of research on provider decision-making around CPT and PE use, namely, patient factors considered and processes used to make decisions.
According to the CPT and PE developers, mental health providers should consider certain patient factors before initiating these treatments.2,24 Imminent danger to self or others and current high risk of domestic violence are contraindications for both treatments. Additional contraindications include severe dissociation, severe panic attacks, and unstabilized substance dependence for CPT, and serious self-injurious behavior, active psychosis, and insufficient memory of the traumatic event for PE. Each manual also specifies factors that do not exclude patients from the therapy but can be considered with respect to using other interventions prior to beginning or concurrently with CPT or PE. These include poor emotion regulation for CPT and substance dependence for PE. Only a handful of studies have examined what patient factors providers consider when making decisions about using CPT and PE. They suggest that providers may make decisions that are inconsistent with the current guidelines, including eliminating CPT and PE as treatment options when patients have low motivation or comorbid depression.10,25,26 However, these studies were limited to exposure therapy only or to PTSD-focused programs (as opposed to other mental health programs where patients can also receive CPT and/or PE).
Understanding how providers come to these decisions is also lacking in the literature. The VA/DoD Clinical Practice Guidelines for PTSD specifically recommends that providers engage patients in a “shared decision-making process” to select treatment and form “a supportive and collaborative treatment relationship or therapeutic alliance” as they progress through treatment.8 Shared decision-making is a unique process defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider option to achieve informed preferences.”27 One study outlined decision points to guide providers in selecting a PTSD treatment (e.g., CPT, PE, and stress inoculation) for their patient at various points in treatment.28 Such a guide can help clinicians systematically determine what intervention is appropriate for specific patient factors. However, it did not discuss what processes providers can or should use to make these decisions. Little is known about whether providers are engaging patients with PTSD in decision-making and/or using other processes to make decisions about using CPT and PE. Thus, the current study explored patient factors considered as well as decision-making processes used by VA mental health providers to decide whether to use CPT or PE with their patients with PTSD. Concordance between providers’ decision-making and treatment guidelines was also examined.
Participants and recruitment
Mental health providers from two VA medical centers in the northeast USA and their affiliated community-based outpatient clinics were eligible to participate in this study if they were a licensed psychologist or licensed social worker and had at least one veteran on their caseload with a diagnosis of PTSD. One of the two medical centers had specialty PTSD outpatient clinics; the other had a general mental clinic that provided services for a wide range of mental health conditions including PTSD. Recruitment took place between February and October 2013. Eligible providers at each site were sent a recruitment letter via VA email. Providers were asked to respond within 1 week. Those who were interested were screened to assess if they had been trained in CPT or PE and their level of use (number of patients in the previous 12 months). Untrained providers were included since they can make decisions about referring veterans for CPT or PE. Interested providers were contacted to schedule a face-to-face interview. Written informed consent was obtained after all procedures were fully explained. All procedures were approved by the institutional review boards at the participating VA medical centers.
Data collection involved 30- to 60-min semi-structured interviews exploring providers’ decision-making around CPT and PE for their patients with PTSD. Due to the limited research in this area at the time of this study, the interview guide was also informed by the clinical expertise of the co-authors of this paper and recommendations from national VA PTSD leaders. Interviews queried providers about indicators of CPT/PE candidacy, considerations for CPT and PE, and referrals. Example interview questions included “Who is a candidate for CPT/PE?” “What factors do you consider before you make a treatment plan for your patients with PTSD?” “How do you define ‘ready’?” and “How do you make the determination to refer for CPT or PE?” Demographic information (age, gender, discipline, and years in discipline) and training status (CPT, PE, or both) were also obtained. Interviews were audio-recorded and transcribed verbatim. Interviews were conducted until thematic saturation was reached.29
Qualitative analyses were conducted by the first two authors. NVivo 1030 was used to organize data for coding and analysis. Content analysis, a qualitative research method that involves a systematic process of coding and identifying themes in text data,31 was used to develop the codebook. First, a priori codes (e.g., factors influencing offering CPT/PE, candidacy for CPT/PE, and decision-making process) were identified based on the interview guide. Transcripts were then coded line-by-line using these codes, and subcodes as well as new codes were generated when additional domains emerged from the transcripts. The first three transcripts were coded jointly by both authors to create an initial codebook. This codebook was then used to code two more transcripts independently and the codebook was refined. The 11 remaining interviews were then coded independently by one of the two authors, who met weekly to discuss questions about coding and worked iteratively to further refine the codebook. A constant comparison process32 was used to group codes into broader themes that captured provider decision-making about CPT and PE use.
Years in discipline
Up to 5 years
CPT and PE
Used CPT/PE in last 12 months
Number of patients for which CPT/PE was used in the last 12 months
Patient factors considered and resulting decisions about CPT and PE
Patient factors considered
Summary of reported provider decisions
Is the patient “ready?”
Willing to engage
Yes > began or referred for CPT/PE
No > began another treatment and/or revisited CPT/PE at a later time
Has adequate coping skills
Yes > began CPT/PE
No > began or referred to another treatment first (e.g., DBT)
Yes > began CPT/PE
No > began CPT/PE anyway, modified CPT/PE, or waited until patient was stable
The patient has comorbid conditions.
Yes, substance use disorder > did not use CPT/PE or monitored substance use during CPT/PE
Yes, personality disorder/paranoia > did not use CPT/PE
Yes, other (e.g., anxiety) > began another treatment first (e.g., ACT)
The patient is “ready”
Whether a patient is ready for CPT or PE was the most frequently discussed factor. When asked to define the term, providers offered three definitions and discussed how it impacted their treatment decisions.
Willing to engage
Some providers defined “readiness” as a patient’s “willingness” to engage in a treatment like CPT or PE where they would discuss their traumatic experience(s). As one trained provider stated, “Trauma survivors have their own sense of what they’re ready for and what they’re not and what they’re willing to approach in this moment with me.” Providers who believed their patients were willing to discuss their trauma reported offering CPT and/or PE. Another provider who is not trained in either treatment but refers patients for these treatments indicated that patients’ readiness is apparent when they report that they “want” or “need” to talk about their trauma. Providers who were not trained in CPT or PE reported discussing the treatments and/or placing referrals for CPT and PE for willing patients.
Has coping skills
Providers reported that patients’ ability to adequately cope with the emotional experience of engaging in CPT and PE was also a sign of readiness and factored into their decision to offer CPT and/or PE. Coping skills were defined as a “basic level” or “tool bag” of skills to manage intense emotions and using one’s social support. These providers reported using other treatment interventions (e.g., dialectical behavior therapy) before using CPT or PE for patients lacking these coping skills. Another provider shared that some patients who have problems managing their emotions can still engage in CPT: “…if someone's really emotionally dysregulated to begin with, but I think CPT would be really helpful for them, I may not have them do a trauma account. I may do the cognitive version [of CPT].” Notably, this provider also reported that she has a preference for having her patients learn “grounding skills and [have an] ability to self-soothe” prior to beginning CPT or PE.
Safety and stability
…almost everybody I work with has some kind of history of suicidality. I think the complicating piece is what’s the function of suicidality—is this person like truly at risk? Is it functioning as avoidance? I’m a bigger fan of going ahead and targeting trauma. If folks are engaging in behavior that has high risk …I certainly would back off, but suicide ideation doesn’t necessarily bother me as much… If I can get a commitment, then I’m usually good to go.
Thus, for this provider, if a patient is not in imminent danger, the patient’s willingness or “commitment” to engage in the treatment will determine if they begin CPT or PE.
Other providers described safety and stability in terms of a patient’s home environment and lifestyle. For example, one provider explained that while it is “really important they’re in a safe environment to be able to do the work,” CPT and PE could be used with patients who have experienced violence in the home by making protocol modifications (e.g., completing homework assignments in the clinic before session). However, another provider shared that if a patient is homeless, unemployed, “and stressed out about how are they gonna get by week to week, that may be a harder time for them to focus on that kind of therapy.” For this type of patient, the provider reported making referrals to various clinics and services for a “holistic” approach to the patient’s care.
Presence of comorbid conditions
The presence of comorbid conditions was also considered by providers. Several providers discussed the impact of comorbid substance abuse. Some expressed hesitation or ruled out using CPT or PE for patients with a substance use issue. For example, one provider strongly articulated the following, “I don’t feel that it’s appropriate to do CPT or PE with anyone who has an active substance use, even if they say ‘I'm doing better. I'm cutting down.’” Other providers did not view substance use issues as an automatic rule-out of CPT or PE. For instance, one provider shared that if a patient is “able to set limits,” they can begin CPT or PE and monitor the patient’s substance use throughout the course of treatment. Providers also mentioned that other conditions like paranoia and personality disorders may reduce their likelihood of using CPT and PE. For example, one provider explained that one patient’s personality disorder made it difficult for the patient to stay focused, and if they began PE, it would be “ineffective.”
Providers discussed the process through which they consider individual patient factors and make decisions about CPT/PE use described above. These processes fell into two themes—mentally derived decisions and patient-involved decision-making.
As I’m starting off with somebody, I’m getting a sense of what their goals are, what’s really bringing them in and how motivated they are to work. I have almost a decision tree in my mind …are these people that want [a] Band-Aid and just figure out enough coping skills that they can get by without doing trauma-focused work and people that really just have absolutely no interest [in trauma-focused work]…or are these folks that have at least ambivalence and…they’re not certain that the Band-Aid approach…is going to be enough for them.
Following this assessment of patient factors, this provider indicated that she presents different treatment options that may include CPT and PE and other treatments to build coping skills to her patients and solicit their thoughts and reactions about these options. For other providers, there seemed to be a pre-treatment decision to offer CPT and PE to nearly every patient. As one provider shared, “I think any veteran with PTSD is a potential candidate for PE or CPT. And so I have that in my head as an option for everybody. I don't think there's any veteran with PTSD who I would say, ‘No, I would never offer these therapies to.’”
There were instances when certain patient factors led providers to make a mental decision to not discuss or begin CPT or PE. One provider shared that although a patient’s inconsistent attendance was driving a decision to not begin CPT or PE, the importance of consistent attendance was not discussed with the patient due to the provider’s “fear that I'd be telling them very explicitly how to avoid having a discussion about [CPT and PE].” This provider shared that the patient needed to demonstrate consistent attendance before CPT or PE was offered. Another provider shared how a patient’s poor mental status led to her decision not to begin CPT: “[One patient] was very suspicious of everything. He’s also having a lot of [legal] issues so referred him to a lawyer… and he came in the next session and felt like I had referred him to her to set him up.” This provider explained that although the patient was referred for CPT, she did not believe he was “a great candidate for CPT” based on her “clinical judgment,” and did not begin CPT.
A few providers reported instances when the decision to use CPT and/or PE was a product of a collaborative effort between the provider and the patient. For example, one provider shared that following her assessment, “I am really transparent…I really [want] the decision to be in the hands of the veteran, whether they're choosing to move forward with an EBP (evidence-based psychotherapy) or not.” Thus, she reported that she has an open dialogue with her patients with PTSD about the option CPT and/or PE. Another provider reported that particularly when the patient’s safety at home is a concern, a “joint decision” is made about whether to proceed with CPT or PE. Other providers reported that when they introduced CPT or PE, they involved their patient by soliciting the patient’s feedback and discussing patient preferences. For example, one provider shared that one patient was concerned about engaging in PE, stating “‘You want me to tell my story over and over again?’ ‘You wanna record me? I'm not gonna listen to…the recordings of that. That makes me feel uncomfortable.’” As a result, they decided to use CPT.
Patient readiness was frequently considered by providers when determining if CPT or PE is appropriate for their patients with PTSD. While the CPT and PE manuals do not directly discuss readiness, they do highlight the components of readiness reported by providers in this study. For example, prior to beginning CPT, providers are supposed to have patients sign a treatment contract as a form of informed consent. PE manual also provides guidance on how providers can address willingness or motivation before starting the treatment (i.e., spending one to two sessions discussing the benefits of treatment). This suggests that a patient’s willingness can be a significant driver of CPT/PE initiation and providers are encouraged to help boost patients’ motivation for these treatments. Other definitions of readiness reported in this study (e.g., level of coping, and safety) are also described in the manuals as pre-treatment patient factors.
Providers in this study also reported that a patient’s comorbidities were considered prior to beginning CPT or PE. The results suggest that providers may tend to exclude patients with substance use issues, paranoia, and personality disorders from CPT and PE. Since PTSD is highly comorbid with other mental health and substance use conditions,33 comorbidities do not necessarily exclude patients from CPT or PE. Although more naturalistic studies are needed, there is evidence that CPT and PE can be effective in patients with comorbid conditions like substance abuse.4,34,35
In terms of decision-making processes, the VA/DoD Clinical Practice Guidelines specify that a collaborative effort between the provider and the patient should be used to select a treatment for PTSD and that EBPs for PTSD should be offered as first-line treatments. In this study, providers reported using their clinical judgment or some other mental process to make treatment decisions which is not surprising since clinical judgment is an important component of psychotherapy delivery. Some use of collaborative decision-making was reported; however, there appeared to be instances when providers may have prejudged a patient’s readiness or appropriateness for CPT/PE and did not engage the patient in the decision-making process and/or did not offer CPT and PE. This has the potential to be problematic if providers make overly conservative judgments about a patient’s appropriateness for CPT or PE as this could lead to the exclusion of patients who could benefit from these treatments. CPT and PE developers encourage providers to start these treatments as soon as possible as to not collude with the avoidance that is symptomatic of PTSD. It was not entirely clear from this study if CPT and PE were discussed with patients who were engaged in other treatments to prepare for CPT and PE (e.g., learn grounding skills, and stabilize alcohol use). Due to the association between PTSD and avoidance, waiting until the patient is deemed ready to discuss these treatment options could lead to unnecessary delays in or lack of CPT and PE use for appropriate patients. A recent study showed that PTSD clinics can spend a significant amount of time getting patients ready for CPT and PE by delivering preparatory group therapy that can range from 1 to 12 sessions.36 Some of these preparatory groups can be lengthy and/or provide information that is redundant with PTSD EBPs (e.g., psychoeducation about common reactions to trauma which is covered at the start of PE). Instead, patient time and clinic resources may be better served by educating providers about the tenets of shared decision-making so that patients can make an informed decision within the context of individual therapy and reduce the need to make a determination about readiness.
While some providers in this study reported collaborating with their patients to make PTSD treatment decisions, shared decision-making is not widely adopted and the most effective strategy to increase this practice among providers is unknown.37 There are patient-focused efforts underway in VA that may boost shared decision-making for PTSD treatment. Researchers have developed patient-targeted decision support aids such as online tools and print materials to increase demand for CPT and PE. The goal is to empower patients with knowledge of these treatment options so that they can initiate a discussion with their provider, thereby potentially increasing shared decision-making around CPT and PE use. Early research shows that patient decision aids can increase initiation and retention in EBPs for PTSD, underscoring the potential impact of shared decision-making on the rate of CPT and PE use.38,39 In the VA, the teams responsible for the dissemination and implementation of CPT and PE across the VA should consider developing and standardizing a provider-targeted decision-making tool or rubric to help providers navigate the decision-making process, including how to engage patients in shared decision-making.
CPT and PE consultation calls are an existing resource available to trained providers to help them to use CPT and PE with patients who are ambivalent about trauma-focused treatment and complex patients such as those with comorbid conditions like substance use problems. These calls may also serve as a mechanism to train providers to incorporate shared decision-making into treatment planning for PTSD. Though beneficial, providers tend to have limited time for professional development activities such as consultation calls. Incentivizing participation may encourage busy providers to participate in these calls. For instance, leaders at VA medical centers should consider giving clinical credit or provide protected time. In addition, future studies should explore other methods and strategies (e.g., academic detailing) that can facilitate additional consultation/training to providers.
This study is not without limitations. First, providers were sampled from only two sites within the same region. It is possible that the results are unique to this region. However, providers interviewed in this study provided a range of responses and some are likely to overlap with experiences in other regions. Second, providers were asked general questions about their decision-making around CPT and PE use. Although they were also asked to give specific case examples when relevant, more details about their decision-making processes may have emerged from using vignettes and asking providers about specific decision points (e.g., offer CPT/PE vs. offer another treatment vs. discuss CPT/PE with a plan to begin after some period of time). Lastly, while this investigation focused primarily on patient factors, other factors (e.g., provider comfort/clinical experience, and organizational factors) may also impact CPT/PE use but were beyond the scope of this paper. Despite these limitations, this study adds to the body of literature by examining the alignment between CPT and PE guidelines, VA/DoD guidelines, and provider practices, and illuminates provider conceptualizations of readiness and processes used to make decisions about CPT and PE use.
Implications for Behavioral Health
While providers’ descriptions of readiness factors are generally aligned with treatment guidelines, providers may be more selective in using CPT and PE with patients with comorbid conditions. In addition, how providers make judgments about patient factors may limit CPT and PE use. When delivering psychotherapy, there is a tension between considering patient factors and preferences and working therapeutically to address the patient’s issues. This tension can be stronger when treating PTSD since avoidance is both a symptom of PTSD and a coping method for many with the condition. More active efforts are needed to assist providers in making decisions that will not exclude patients based solely on any one factor, but instead engage patients in the decision-making process to discuss the best treatment options in light of these factors. Engaging patients in the discussion and decisions about PTSD treatment options not only is concordant with guidelines but may also lead to increased use of EBPs for PTSD.
This study was funded by VA HSR&D/QUERI (Grant #: RRP 12–239). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Compliance with Ethical Standards
Conflict of interest