Integrating Care for Chronic Pain and PTSD: A Qualitative Exploration of Staff and Patient Perspectives

Abstract

Despite the advantages of integrated care for co-occurring chronic pain and posttraumatic stress disorder (CP+PTSD), barriers impede its implementation. In this qualitative study, we examined facilitators and barriers of integrated care for CP+PTSD at a single VA medical center. We used purposive sampling and snowball recruitment to identify key stakeholders. We conducted semi-structured interviews (N=38) via video teleconferencing between January and May of 2022. We analyzed interview data employing both thematic and matrixed analysis methodologies. We interviewed VA staff (providers [n=11], clinic managers [n=5], and administrators [n=2]) and patients with CP+PTSD (n=19). There were three main findings: 1) current models disconnect care for CP+PTSD and fail in fully addressing the intricacies of this comorbidity 2) the interconnection of CP+PTSD symptoms supports the need to overcome barriers to integrated treatment 3) facility- and system-level barriers to implementation of integrated care include staffing and having an evidence-based protocol. Staff and patient stakeholders recognized growing momentum supporting the development of integrated, non-pharmacological treatments for CP+PTSD. However, interventions to address barriers are needed to increase wider adoption and implementation.

Introduction

Between 34% and 50% of individuals referred for chronic pain treatment also have significant symptoms of posttraumatic stress disorder (PTSD) or are diagnosed with PTSD (Asmundson & Katz, 2009; Benedict et al., 2020; D’Aoust et al., 2017; Otis et al., 2003). The relationship between chronic pain and PTSD is complex and is associated with harms including worsening symptoms of PTSD (Benedict et al., 2020; Hinkel et al., 2023; Shapiro et al., 2023), greater cost incurred by increased health care utilization (Outcalt et al., 2015), negative impacts on social functioning (Shor et al., 2023) and in relationships with significant others (Alschuler & Otis, 2013), and increased suicidal ideation (Shor et al., 2023).

Chronic pain and PTSD (CP+PTSD) are both characterized by avoidant behavior, catastrophic thinking, and a shared pathophysiology (Asmundson & Katz, 2009; Scioli-Salter et al., 2015; Sharp & Harvey, 2001; Vlaeyen & Linton, 2012). With chronic pain, a cycle of fear and avoidance of movement limit social and other daily activities, resulting in increased disability and diminished functioning (Outcalt et al., 2015; Vlaeyen & Linton, 2012). For PTSD, fear and avoidance of trauma reminders result in the same cycle of negative consequences (Bosco et al., 2013). Models of CP+PTSD co-occurrence based in cognitive-affective-behavioral concepts have been augmented to include the shared physiological mechanisms of CP+PTSD (e.g., neurobiological, inflammation; Scioli-Salter et al., 2015). Non-pharmacological treatment approaches like psychotherapy and complementary and integrative health modalities (CIH; e.g. yoga, mindfulness) offer unique benefits to target CP+PTSD symptoms. Figure 1 illustrates the symptoms/treatment targets of CP+PTSD and the impact of psychotherapeutic and mindfulness-based approaches. In this model, front-line treatments, such as psychotherapy, alone address some but not all symptoms of CP+PTSD.

Figure 1. Chronic Pain, PTSD, and Therapeutic Treatment Pathways.

Figure 1 shows the mutually reinforcing relationship between chronic pain and PTSD (CP+PTSD). The cognitive/affective, behavioral, and biological symptoms and sequelae of this comorbidity are demonstrated in the boxes in the middle of the figure. On the right, the mutually reinforcing relationship between psychotherapy and mindfulness is depicted, as well as how the combination of these treatment modalities impact the cognitive/affective, behavioral and biological symptoms of CP+PTSD and improve treatment engagement.

Complementary and integrative health (CIH) interventions, many of which are mindfulness-based, show promise as adjunct or alternative treatment options for CP+PTSD. Alongside front-line psychotherapeutic approaches, CIH target physiologic symptoms not directly addressed by psychotherapy (Donahue et al., 2021).

Sequential, parallel, multimodal and integrated models of treatment are used for CP+PTSD. The most common model is sequential care (Figure 2a), where the two conditions are addressed separately in a linear fashion, often by different providers (Angelakis et al., 2020). Parallel care (Figure 2b) treats each disorder at the same time, often by different providers and without explicit collaboration or communication between them (Hobden et al., 2018). Multimodal care (Figure 2c) has been identified as the optimal treatment approach for CP+PTSD (Goldstein et al., 2019; U.S. Department of Health and Human Services, 2019). Multimodal care uses a team of treatment providers, each of whom applies their expertise to specific symptoms of CP+PTSD (Philipps et al., 2019; Stalnacke, 2010). For example, a sleep specialist addresses sleep loss, while a therapist treats distorted thinking, related to CP+PTSD. Multimodal treatment has shown effectiveness in reducing pain intensity and post-traumatic stress (Stalnacke, 2010). In multimodal care, however, the patient may not receive education on integrated treatment of the reinforcing and overlapping symptoms of CP+PTSD, leaving open the risk that the symptoms of one condition may interfere with treatment of the other, reducing treatment effectiveness. Multimodal treatment leaves patients with the responsibility of synthesizing differing perspectives, and the recommendations of multiple providers can perpetuate the burden of numerous appointments often experienced by those with CP+PTSD. Multimodal care fails to address the synergistic and mutually reinforcing symptoms of CP+PTSD (Philipps et al., 2019; Sharp & Harvey, 2001; Stalnacke, 2010).

Figure 2. Treatment Models for Comorbid Chronic Pain and PTSD.

Figure 2a shows sequential treatment of comorbid chronic pain and PTSD (CP+PTSD) where one condition, in this example, PTSD, is treated before the other condition. Figure 2b shows parallel treatment of CP+PTSD, where both conditions are treated concurrently, but by different providers or clinics. Figure 2c shows multimodal treatment of PTSD, with each specialist treating their speciality are concurrent with other providers who are each treating their specialty area. Figure 2d shows integrated treatment of CP+PTSD where the transdiagnostic symptoms are treated simultaenously by a single provider or intervention.

Integrated treatment (Figure 2d) advances multimodal care by providing treatment for both conditions simultaneously and addresses the aforementioned drawbacks to multimodal care. An integrated approach educates the patient on the overlapping and mutually reinforcing symptoms of CP+PTSD and treats both conditions in the same session or with the same intervention facilitated by the same provider(s) (Murphy et al., 2022).

Despite conceptual models illustrating the symptom overlap of CP+PTSD and the high co-prevalence of these conditions, few interventions address the two conditions simultaneously. Little is known about patient and staff perspectives on integrated care. This study aimed to qualitatively elicit staff and patient perspectives on integrated interventions for CP+PTSD and to identify facilitators and barriers to development and implementation of integrated interventions.

Methods

We used semi-structured interviews to collect the perspectives and experiences of integrated care for CP+PTSD from staff and patients of a single U.S. Veterans Health Administration health care system located in the Pacific Northwest, which includes 2 medical centers and 10 community-based outpatient clinics. This research was approved by the Oregon Health & Science University and VA Portland Health Care System joint IRB (Wendleton et al., 2019). Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative Research Checklist (Tong et al., 2007).

Sampling and Recruitment

Recruitment was initiated in January 2022, and data collection ended in May 2022. Individual interviews were conducted via Microsoft Teams and WebEx video teleconferencing platforms. We recruited staff (e.g. administrators, managers, and providers) with experience providing CP+PTSD care and patients with CP+PTSD. The study flow diagram is illustrated in Figure 3.

Figure 3. Study Flow Chart.

Figure 3 depicts the study flow chart, in four separate columns corresponding to the categories of multilevel stakeholders which comprised our sample. Each column shows the steps of recruitment, enrollment, and participation with the number of individuals that completed each step of participation in parentheses.

Staff

Administrators and managers were selected based on their role with programs that provide CP+PTSD care. Snowball sampling was employed, purposely attaining variation by position level, provider discipline, gender and clinic type. We requested managers to refer care providers (Naderifar et al., 2017). Staff (administrators, managers, and care providers) were emailed a brief introduction to the study along with a research information sheet in lieu of written consent, which was waived for this study. If agreeable, they were asked to confirm by email their consent and given an opportunity to ask questions about participation. Interviews were conducted during business hours, lunch, or approved breaks.

Patients

Patients were eligible if they were diagnosed with both chronic pain and PTSD (verified via electronic medical record review conducted by study staff [TW, AN] and confirmed in a telephone screening prior to consent) and had engaged in treatment for either or both condition(s) in the previous three years. Patients were excluded if their pain was secondary to cancer, recent injury, or surgery, or if they had a psychotic condition or active psychosis which would preclude them from being able to participate in the interview.

We asked participating providers to refer patients diagnosed with CP+PTSD who might be willing to share their perspectives about integrated care for these comorbidities. Additionally, patient alumni of an integrated pain clinic’s mindfulness group were provided a study flyer in order to self-refer into the study. Eligible and interested patients were emailed a research information sheet. A Webex video teleconference appointment was scheduled to answer their remaining questions about participation, collect verbal consent, and complete a qualitative interview. Table 1 presents participant demographic characteristics.

Table 1.

Matrix Domains

Domain	Description
Intersection of CP+PTSD	Observations, opinions, experiences (including treatment) with co-occurring symptoms of CP+PTSD*.
Attitudes and opinions of care models and interventions	Perspectives and attitudes of multimodal, integrated, sequential, and parallel care. Includes pharmacological, psychotherapeutic, and complementary and integrative health approaches.
Agency in treatment	Perspectives and opinions about who (patient or provider) is “in charge of care”.
Attitudes and opinions of virtual care	Descriptions of the costs and benefits of virtual care for CP+PTSD.
Barriers	Patient-, facility- and system-level barriers for integrated CP+PTSD care and its implementation.
Collaboration	Suggestions and experiences related to collaboration between providers, provider and system, and patient and provider. Includes experiences of patient-centered and tailored care.
Relationships	Descriptions of how collaboration and care integration impact relationships between providers, provider and system, and patient and provider.
Recommendations for care	Suggestions for how to develop and implement integrated care for CP+PTSD.

^*CP+PTSD- Chronic pain and PTSD

Interview Development and Data Collection

The initial draft of the semi-structured interview guide drew upon the study principal investigator’s previous research and clinical work and aimed to collect perspectives about integrated, non-pharmacological treatments for CP+PTSD. The team piloted the draft interview guide with a member of a patient engagement group at the local facility to improve the relevance of this study to those who it is intended to benefit; no changes were suggested or made to the draft interview guide (Wendleton et al., 2023).

Interviews were conducted by three female study team members: a licensed psychologist (BZ), a psychology doctoral student (AN), and a BA-level study coordinator (TW), all with previous training and experience conducting qualitative research. One interviewer (BZ) had pre-existing professional relationships with some staff participants. Prior to conducting the interviews, all participants were educated on the motivation and goals for the research. Field notes were kept during interviews. The three interviewers met weekly to discuss ongoing interviews, and mutually determined when interviews were not yielding sufficiently novel information, thereby ending data collection (Saunders et al., 2018).

Interviews concluded with self-reported demographic questions (e.g., age, race, gender). Patient participants were compensated with a $40 gift card for their participation; staff were not eligible to receive compensation.

Data Analysis

We audio recorded and transcribed interviews verbatim using a transcription service approved by the VA; transcripts were reviewed by three team members (BZ, TW, AN) for accuracy. We ultimately took two approaches to analysis. First, we employed a thematic analysis using a hybrid inductive/deductive approach and developed a draft codebook based on portions of the interview guide and team member reflections on topics identified in interviews that arose outside of the interview guide. For a random selection of three transcripts, using the codebook, each transcript was coded independently in Atlas.ti software (version 8) by at least two team members. Next, the team discussed and revised the codebook to allow for additional salient themes identified during this review. We extracted key quotes while coding. This method allowed us to organize findings by topic but did not allow for us to easily compare across participant categories. Therefore, we decided to also apply a matrixed method to compare key domains across stakeholder groups (Hamilton, 2020). Using this approach, we summarized and categorized data into a priori categories derived from our interview guide, with additional attention to facilitators and barriers associated with those modifications. To decide on domains to include in the matrix analysis, two team members (BZ, TW) consulted with a qualitative expert (SN). Over a series of three meetings, each team member read through three transcripts and discussed relevant domains, coming to a consensus on 11 domains. The study principal investigator (BZ) then reviewed the domains with consideration of the study aim, research questions, and previously completed data coding and collapsed the 11 domains into eight to reduce conceptual overlap (Table 1).

Transcripts were divided among three team members (BZ, TW, AN) and the consultant (SN) who completed a first review of a sample of three interviews while summarizing each domain for each interview for comparison. Remaining interviews were divided among three team members (BZ, TW, AN) to populate the matrix. Rows on the matrix corresponded with participants, columns reflected demographic characteristics and the domains. Once the matrix was completed, a review across domains for all participants (staff and patients) was conducted to identify patterns and themes. Interview data from the eight domains were organized into three main themes.

Results

The final sample was comprised of administrators (n=2; psychologists), clinic managers (n=5; 3 psychologists, a social worker, and a physician), clinical providers (n=11; 4 psychologists, a social workers, a psychiatrist, a chiropractor, a physical therapist, an acupuncturist, a movement therapist, and a pharmacist), and 19 patients (one patient was withdrawn following interview completion due to screen failure). Sample demographics are presented in Table 2.

Table 2.

Participant Demographic Characteristics

Characteristics	Value (N)
	Patients (N=19)	Staff* (N=18)	Total (N=37)
	N (%)	N (%)	N (%)
Sex
Male	15 (79%)	7 (39%)	22 (59%)
Female	3 (16%)	11 (61%)	14 (38%)
Prefer not to share	1 (5%)	-	1 (3%)
Gender
Man	14 (74%)	7 (39%)	21 (57%)
Woman	4 (21%)	10 (55.5%)	14 (38%)
Nonbinary	-	1 (5.5%)	1 (3%)
Prefer not to share	1 (5%)	-	1 (3%)
Age
30 – 39	3 (16%)	7 (39%)	10 (27%)
40 – 49	4 (21%)	5 (28%)	9 (24%)
50 – 59	5 (26%)	5 (28%)	10 (27%)
60 – 69	5 (26%)	1 (5%)	6 (16%)
70 – 79	2 (11%)	-	2 (5%)
Years of VA experience/ care
< 10	7 (37%)	7 (39%)	14 (38%)
10 – 20	7 (37%)	10 (55.5%)	17 (46%)
> 20	5 (26%)	1 (5.5%)	6 (16%)

^*administrators (n=2), managers (n=5), and care providers (n=11)

Staff interviews lasted approximately 35 minutes, and patient interviews ranged from 40–80 minutes. Table 3 presents themes, subthemes, and their brief descriptions.

Table 3.

Summary of Themes and Subthemes

Theme	Subthemes	Summary Description
Current models separate care for CP+PTSD and do not fully address the intricacies of this comorbidity		Indication of the lack of integrated care, opinions on why integrated care is not available, attitudes towards other approaches that are available
The interconnection of CP+PTSD symptoms supports the need to overcome barriers to integrated treatment and identified components of integrated care		Anecdotal descriptions on the interconnection of chronic pain and PTSD, theoretical underpinnings, transdiagnostic symptoms, interventions of integrated care
Facility- and system-level barriers to implementation of integrated care include staffing, having an evidence-based protocol	Facility-level barriers should address staffing-related issues	Which clinic or discipline should provide integrated care, treatment options beyond medication, technology
	System-level barriers need the attention and support of national leadership	Siloed care, increasing stepped models of care, volume and pace of care, productivity, technology

Current models separate care for CP+PTSD and do not fully address the intricacies of this comorbidity

We first explored the treatment in the local VA center for integrated pain care and other clinics that might integrate treatment for CP+PTSD. Despite intending to examine integrated care available at the local facility, our first finding was that integrated care (Figure 2d) was only rarely available. Yet, we found that staff and patient perspectives are largely aligned in acknowledging the interconnectedness of CP and PTSD, and that addressing both simultaneously could be advantageous. Patients and staff also outlined facilitators and barriers to integrating CP and PTSD care, both at the facility and the system level.

While most participants made statements confirming a lack of integrated care, occasionally participants would indicate integrated care was available, and in those cases, it was initiated by providers of their own volition, on a case-by-case basis, not as a function of pre-existing program structure. When asked about the main considerations and treatment needs of patients with CP+PTSD, one provider responded:

The clinics that come to mind are the PTSD Clinical Team for PTSD-focused treatment. Primary Care-Mental Health Integration for brief trauma-focused treatment. The Outpatient Mental Health Clinics for more holistic mental health treatment. And then for pain, I think of primary care as sort of the first point of contact, and then [the] Center for Integrated Pain Care as more of a specialty referral. (P6, Provider)

The term “silo” was often used by staff in reference to a treatment model that is notably absent of collaboration across subspeciality clinics. For example,

I would de-silo the care. So it would be nice to have a clinic, and I guess they’re doing this now for like substance abuse and pain where they’re getting providers with all those expertises [sic] in one clinic. Maybe sort of the same thing where there’s a pain/PTSD specialty clinic where the providers with expertise in both are located in one area, and the assessment is multidisciplinary. (P6, Provider)

Upon finding that integrated care is mostly unavailable, we adapted the interview guide to explore attitudes towards other approaches for CP+PTSD at the local VA facility, namely sequential (Figure 2a) and parallel (Figure 2b) models (Angelakis et al., 2020; Hobden et al., 2018; Murphy et al., 2022). Staff described sequential treatment for CP+PTSD:

So the first thing is: What do we have to offer on the outpatient PTSD clinic? That is one of our treatment modalities that’s going to be the first place to start. Then, after, I think let’s get them engaged with treatment for the other condition, if needed. Then I look at what are the other options that we have that can complement what we can provide in-house? (A1, Administrator)

And then there’s also the side of PTSD and trauma work and providing trauma-informed care, which has a lot of parallels to providing pain literate care as well. Understanding the relationship between the two and having a clear idea of what the target or targets are for service delivery. A lot of what I’m offering is a space for nervous system retraining to take place and creating opportunities for that to happen for the individual in the context of relating to their bodies, relating to themselves, and relating to the group and the space around them. (P1, Provider)

Patients also experienced a lack of integrated care. Some patients identified different clinicians for CP or PTSD treatment, suggesting lack of integrated care, while others explicitly stated they do not receive integrated care for CP+PTSD. One patient mentioned they had previously received a CBT-based psychotherapy that addressed CP+PTSD, despite the therapy not being advertised as such, and other participants mentioned care outside of the VA that addressed both conditions simultaneously, “I had therapy in the past… It was a combination. It was really nice. It was like a combination of CBT and different pain techniques” (V3, Patient). In response to being asked “Can you speak about any VA treatments that address pain and PTSD together at the same time?”, one patient responded “No” (V2, Patient) another said “I wouldn’t say together” (V4, Patient). In other circumstances, when questions about CP+PTSD care were posed, participants separated their responses about care for CP from that of PTSD, suggesting a lack of integration. For example, when asked about the last time they received care for pain and PTSD, one patient responded “Pain part, just a couple weeks ago. PTSD would be through behavioral health care and that was about three weeks ago” (V2, Patient) another stated “PTSD is therapy and medication. And the pain is physical therapy” (V8, Patient).

The interconnection of CP+PTSD symptoms supports the need to overcome barriers to integrated treatment and identified components of integrated care

Notably, administrators, managers, providers, and patients all agreed that the symptoms of CP and PTSD are intimately interconnected and there is a need to address that in care:

They are connected and it’s important to identify the patient’s understanding of their symptoms and the meaning of them. Disentangling them is hard. (P6, Provider)

When I’m experiencing an increase in the pain that I experience day-to-day, it seems like I’m less resilient to some of the PTSD symptoms. (V19, Patient)

Further, the staff we interviewed noted “I think chronic pain and PTSD are probably the two most common presenting mental health issues that we face in our clinic” (M1, Manager) and “Chronic pain and PTSD are related, and one can exacerbate the other…these are two complicated problems. And a third variable (e.g. depression, substance use) can affect both of them as well, so they’re all affected” (A2, Administrator). Providers and patients expressed the belief that interventions designed to address one condition have the potential to address both conditions.

Often, guarding or sensitization comes along with chronic pain, and pain patients will notice that when their mental health is in a difficult place, the pain flares and vice versa. Being a holistic provider, I’m looking for those links trying to down regulate the sympathetic nervous system to help with that guarding, get the body to start to relax, go into a more parasympathetic state where it can do better repair and healing. We have to work on those things simultaneously. (P7, Provider)

I’d say the chronic pain puts me in a constant state of anxiety, which is a known effect of PTSD, and just by reducing the pain, it naturally takes that extra layer of anxiety off that isn’t necessary and makes PTSD much worse. I think a person with those issues, if you could really reduce the chronic pain, I think it influences the PTSD. And, on the other hand, if you could find ways to mitigate effects of PTSD, then maybe your pain wouldn’t be as bad.” (V2, Patient)

Providers and patients identified critical components and main considerations for integrated treatment of CP+PTSD. Providers felt integrated care should include pain neuroscience education and should convey to patients how the relationship between the two conditions exists. Patients commented on the need for options and tailoring care to address the unique needs of each person. Managing emotions, and learning about suffering were interventions cited by patients as beneficial and effective:

I don’t think the chronic pain class impacted my pain, but it impacted my suffering. I learned things. I learned that I was overdoing it. I was trying to do everything and then I would just be in pain for days and not be able to do anything and I would just be depressed. But it also decreased my suffering which decreased my mental pain which decreased my susceptibility to PTSD symptoms. (V15, Patient)

Complementary and integrative health (CIH) interventions (e.g., yoga, acupuncture) were mentioned by providers and patients who found potential opportunities in those modalities for integrated care based on their previous experiences with them:

I think there’s such a need for integrated treatment, because we’re treating the whole person, and chronic pain and PTSD really do intersect. They really are so intimately related and affect each other so much, that if you’re not attending to one’s physical well-being while you’re trying to attend to their psychological well-being, the treatment benefits are limited. And I’ve just seen CIH really work well for patients. (M2, Manager)

Specific CIH interventions or protocols (e.g., mindfulness, acupuncture) were mentioned as opportunities for integrated care:

I work in the pain clinic. We offer a pain class. It’s pain psychology with a pain physical therapist where they teach skills about pain neuroscience and how to manage chronic pain. I know there’s several mindfulness classes geared towards our pain patients, but a lot of other patients utilize mindfulness for things like PTSD, depression, and anxiety. We also have hypnosis, biofeedback, tai chi, yoga. Interventions that can help down regulate the central nervous system, get you more into that parasympathetic state. Which would help with, you know, PTSD and pain. Acupuncture is another great one that overlaps with, you know, PTSD and pain. (P9, Provider)

Patients also expressed attitudes that CIH treatments like acupuncture and mindfulness had potential to address the interconnected symptoms of CP+PTSD, “it’s all about how do you control the mind, and how do you control all of those feelings” (V12, Patient). Some staff noted that the personal agency required for self-managed CIH approaches may not be a good fit for some patients with CP+PTSD. Some patients mentioned a preference for CIH due to its “portability” and having options that appealed to “not wanting to talk about [trauma and pain]” (V8, Patient) such as one does with psychotherapeutic approaches. In contrast, another patient noted that yoga and psychotherapy have different benefits for pain:

I would say some of the yoga helped me out. I’m trying to get rid of the pain, and the pain is just kind of always there, so there was the physical stretching and working it out, but then there, honestly, the talk therapy because I can sit there and discuss the pains that I’m having. (V5, Patient)

Overall, staff and patients expressed preferences for, and positive experiences with, CIH for CP+PTSD. One provider conveyed that a patient noted they had “never been treated this well” when referencing CIH modalities they received.

Facility- and system-level barriers to implementation of integrated care include staffing, having an evidence-based protocol

Exploration of barriers generally fell into two subthemes – facility-level barriers unique to the staff and patient experiences at the local hospital where they are employed or receive care, and system-level barriers that may be present at the facility as well as the larger, national health care system of which the local facility is a part. There was some overlap between these subthemes.

Facility-level barriers should address staffing-related issues

An implementation barrier mentioned by staff is the question of “who” (e.g., which discipline or clinic) would be responsible for integrated treatment given that, historically, pain has been managed as a medical issue, treated in primary care by medical practitioners, and PTSD is treated in mental health service lines. One administrator noted:

PTSD is always thought of as mental health and pain as physical and the two haven’t been blended much historically, but psychology is getting better at treating pain. (A2, Administrator)

Suggestions as to which clinics and programs where integrated treatment might be housed included Whole Health (a holistic health program and approach to care that starts with identifying values in the patient’s life), the integrated pain clinic, and outpatient mental health clinics.

Other barriers to implementing integrated care included recent and ongoing staffing issues (e.g., inadequate staff, inadequate experience of staff, staff turnover), limited knowledge about available resources (e.g., lack of centralized location for current information of available treatment options), and scheduling issues (e.g., a need for options occurring outside of workday hours). Related to this, inconsistency of available care was mentioned. This was described as a program or treatment being available at a given facility for a period of time and then unavailable once the facilitating staff member vacated their employment.

Managers of rural outpatient clinics noted that community-based outpatient clinics were in particular need of treatment options beyond medication, and the barriers to implementing it could be addressed by the use of telehealth and virtually delivered care. Across groups, participants expressed optimistic and positive attitudes towards the use of virtual care and telehealth, citing notable benefits and some drawbacks specific to treatment of CP+PTSD. Benefits of virtual care that were named included: 1) the ability for virtual care to provide a comfortable space (one’s home); 2) eliminating commute burdens (which can exacerbate PTSD hypervigilance symptoms and chronic pain); and 3) delivering care to patients who are located in a familiar and safe surrounding has the potential to increase engagement. One patient commented:

It is a mental and a physical struggle to get out of my house, to get in the car, go through the traffic, find a parking space, traipse into the building, sit in a waiting room, and wait for somebody. Virtual care takes the messiness out of it. (V2, Patient)

Providing tablets and technology support of those devices was mentioned as a facilitator for patients in rural areas without access to adequate and reliable bandwidth and elderly patients who may benefit from easy to operate devices and technology support.

System-level barriers need the attention and support of national leadership

The lack of integrated care was a source of frustration with terms like “lagging” and “siloed care” used by managers and providers to describe the system-level barriers. Increasing “stepped approaches”, where a patient progresses through iteratively more intense treatment over time, as indicated, was suggested as a solution to the lack of integrated care.

Volume and pace of care set by national level leadership has impacts at the facility level of care delivery. For example, providers do not have time to help patients with technology during care appointments, a barrier which indicates the need for technology support and preparation for virtual care.

Staff demonstrated positive opinions of, and optimistic attitudes towards, integrated care, particularly non-psychotherapeutic modalities for integrated CP+PTSD care . However, system-level barriers prevent the scale up of these interventions. For example, staff mentioned inadequate funding for hiring specialists like acupuncturists, massage therapists, and other CIH clinicians impeding implementation of CIH. Inadequate staffing creates long-waitlists and delays in care or having to refer patients into community care. Support from the “top-down” is desired by providers to increase interdisciplinary and multidisciplinary care; options adjacent to multimodal care which rely on collaboration between professionals of different disciplines. Existing measures of productivity also impede the success of CIH care implementation. For example, providers expressed that the measurement of volume of services provided does not capture outcomes like wellness and job satisfaction. Despite these barriers, several staff mentioned that institutional support is improving and increasing:

The leadership support is growing, 10 years ago it was less. We’re learning more as we go, and we’re open to complementary and integrative health offerings as a treatment approach. In our department in particular, we have yoga and the tai chi, so in that sense, the department supports it. My particular supervisor and service chief supported me in getting trained in CBT for chronic pain, mindfulness, hypnosis. So I think as a department, there’s a lot of support. I think as a facility, we’re moving in that direction. (P5, Provider)

Patients also mentioned limits to care. For example, the “episode of care” model which limits the number of individual therapy sessions a patient may receive in a calendar year was described as problematic and creating a barrier.

Discussion

In this qualitative study, hospital administrators, managers, providers, and patients provided perspectives and opinions on integrated treatment for CP+PTSD. Data from semi-structured interviews conducted with stakeholders were organized into eight domains and supported three main themes.

According to the experiences of our participants, integrated care for CP+PTSD at the local VA facility is not widely available, and instead care for multiple or co-occurring conditions, such as CP+PTSD, is delivered in sequential or parallel models. Both of these models are widely available in large hospital systems. While patients may eventually receive care that addresses all of their concerns, they incur a significant burden of organizing, traveling, and attending their multiple appointments, an added stress that may compound their existing health concerns. While this study reflects the experiences of individuals within one facility of the larger VA health Care system, care integration is a dimension of quality improvement efforts that is of importance within health care at large. A policy from Substance Abuse and Mental Health Services Administration (SAMHSA) called the “No Wrong Door Policy” is one example of increasing integrated services for comorbid substance use and mental health conditions (The Case for Screening and Treatment of Co-Occurring Disorders, 2019). Frameworks seeking to measure quality of care for common comorbidities have been proposed indicating the direction of improving care across treatment “silos” is of empirical importance (Kilbourne et al., 2010). Within the VA Health Care System, state-of-the-art care coordination has been the topic for policy and research directions for Veterans with multiple chronic conditions and specialty care needs, like CP+PTSD (Cordasco et al., 2019). Future research should examine examples of successful care integration such as integrated treatments for other common comorbidities (e.g., PTSD and substance use disorder) which are advancing integrated care models and may offer guidance on implementation of non-pharmacological integrated care for CP+PTSD (Back et al., n.d.; Hien et al., 2024; Roberts et al., 2022).

While the information gathered from staff participants revealed a lack of integrated care at the local VHA site, those participants also named sites and providers that they know of who are providing integrated care. The study PI (BZ) sought additional funding to replicate this study with a nationwide sample of participants in order to describe what models of integrated care exist in the VA and discuss implementation of those models in a forthcoming publication.

Staff and patients spoke about the interconnection between symptoms of CP+PTSD, which corroborates existing literature and comorbidity models (Philipps et al., 2019; Sharp & Harvey, 2001; Stalnacke, 2010). Participants noted that treating either chronic pain or PTSD with psychotherapy and pharmacology may indirectly influence symptoms of the other condition; however, without explicit discussion of the comorbidity, it is the burden of the patient to develop and apply that understanding. Psychotherapy protocols including Acceptance and Commitment Therapy, Behavioral Activation, and Pain and Trauma Intensive Outpatient Treatment Program have been tested for CP+PTSD (Åkerblom et al., 2024; Otis et al., 2009; Plagge et al., 2013). Meta-analytic findings of 10 RCTs that used single modality psychological interventions and multimodal interventions found moderate effects for reducing PTSD and nonsignificant effects for pain intensity and pain interference (Goldstein et al., 2019). Trauma informed approaches to pain care may address facets of the comorbidity, however, explicit education was identified as beneficial by staff and patients in this study. Increasing understanding of the relationship between CP+PTSD, the impact of emotions and avoidance, and testing transdiagnostic interventions and treatment protocols that target underlying mechanisms and processes that are present in both conditions (i.e. using graded exposure interventions to address fear and avoidance) are directions for future research (Murphy et al., 2022). Epidemiological studies show that complex presentations of comorbid mental health conditions are more common than single diagnosis presentations which supports the need for developing and implementing integrated and transdiagnostic treatment protocols (Kessler et al., 2005). The VA healthcare system offers robust training programs of evidence based protocols that target single diagnoses, which could be expanded to include transdiagnostic protocols that integrate treatments for common comorbidities. These trainings are offered to behavioral health care providers (e.g. social workers, psychologists, and psychiatrists) who are trained as generalists with a knowledge base of the diagnostic features and presentations of the mental health conditions in the diagnostic manual. They are well suited for advanced education in the facilitation of transdiagnostic protocols. This would essentially embed specialists within various clinics. Health psychologists have received additional training in comorbid behavioral and clinical health conditions, as such this type of subspeciality provider may be an appropriate avenue for implementation of transdiagnostic treatments and integrated care. Psychotherapy is the standard of care for both chronic pain and PTSD, however, CIH approaches and mindfulness-based interventions address the “we don’t want to talk about it” sentiment that some participants expressed. All stakeholder groups expressed support for CIH approaches as opportunities for integrated CP+PTSD care. Many of these approaches are rooted in mindfulness (e.g., yoga, tai chi). A meta-analysis of integrated treatments conducted subgroup analyses and found that of exposure-based, cognitive-behavioral, and mindfulness-based therapies exposure and cognitive-behavioral psychotherapies had large effects for reducing PTSD, but not pain (Goldstein et al., 2019). Conversely, mindfulness-based therapies evidenced medium-size effects for both PTSD and pain (Goldstein et al., 2019). Yoga is one mindfulness-based approach that has been trialed for CP+PTSD, and showed trend-level reductions in PTSD symptoms and pain related outcomes (e.g., social activities; Chopin et al., 2020). Notably, CIH approaches have shown desirability particularly among patients with CP+PTSD compared to those with just pain (Reed et al., 2022). Participation in CIH approaches also increases the odds of engaging with evidence based psychotherapies (Etingen et al., 2024).

Despite the promise of integrated care, facility- and system-level barriers limit implementation. In this study, barriers included: administrative uncertainty regarding how integrated care may be managed within the hospital clinics given the presence of parallel or sequential models of care, having staff adequately trained in treatment of both conditions such that they could provide integrated care, managing staff burnout and turnover, a lack of a central hub of current and updated information on available treatment options, logistical issues including scheduling, space, and limited access for individuals in rural areas. It has been suggested that exploration of how to leverage treatment settings that offer care for one or the other condition, for example a subspecialty clinic for PTSD or chronic pain care, might offer integrated care is a potential next step (Murphy et al., 2022).

Virtual delivery has been a viable option for healthcare, which increased dramatically following the COVID-19 global pandemic (Anderson et al., 2022). Within the context of CP+PTSD, virtually delivered care can increase the safety in which one receives care and reduce commute burden, potentially reducing hypervigilance and pain symptoms. However, virtually delivered care may collude with avoidance symptoms identified in comorbidity models of CP+PTSD (Foa & Kozak, 1985; Norton & Asmundson, 2003; Reed et al., 2023; Vlaeyen & Linton, 2012). Additional equipment is needed for some CIH interventions (e.g., yoga mats) and appropriate space to engage in such care may act as barriers.

Institutional barriers limit the implementation and feasibility of integrated care for CP+PTSD. The high volume and pace of care expected at the local facility is limited to the amount of available, trained, and supported staff. Another burden impacting staff is the limited knowledge of the availability of treatments offered. When staff are uncertain of integrated treatment options currently available, opportunities for improved patient care are lost. This can be improved by increasing efforts to educate both providers and patients of care options with a centralized care list for both in-person and virtual settings.

Limitations, Strengths, Conclusions

These findings are limited to the VA setting where this study was conducted. Different hospital systems function differently than the VA, and VA facility practices vary between facilities. Therefore, these findings may not reflect VA practices as a whole or non-VA care settings.

Despite these limitations, this work is an important exploration into implementation considerations related to integrated treatment for CP+PTSD. Strengths of this study include sampling multiple groups including patients, providers, managers, and administrators across clinics and disciplines. Findings from this study emphasize the need to expand and improve care options and accessibility of treatments for CP+PTSD. Expanding access to care, including increasing access to virtually delivered care, and integrating treatments for CP+PTSD, may have positive effects on treatment engagement, outcomes, patient satisfaction, and reduced cost of care.

Conclusions

The high prevalence and interconnection of symptoms of comorbid CP+PTSD have consequences that interfere with and limit the success of current interventions for these conditions. Integrated treatments, particularly non-pharmacological, mindfulness-based approaches are promising and desired. The development of integrated, non-pharmacological approaches is in early stages, and is offered in rare circumstances. Staff and patients agree that there is a momentum supporting the development of integrated, non-pharmacological treatments for CP+PTSD and there is a need to address barriers in order to expand access and improve implementation.

Public Significance Statement:

Despite the interconnection of symptoms and similar treatment approaches, co-occurring chronic pain and PTSD (CP+PTSD) have historically been treated separately. Our study revealed that among those with CP+PTSD, the providers who treat them, and managers and administrators who make decisions influencing that treatment, there is a desire for, yet barriers to, integrating CP+PTSD care. We outline suggested directions for increasing the availability to implementation of integrated treatment for CP+PTSD and subsequently improve care.