Multilevel Factors in Providers’ Decisions to Utilize CPT: in Military- and Veteran-serving Treatment Settings

Abstract

Objective:

Numerous guidelines exist to inform decision making regarding psychological treatment of patients with posttraumatic stress disorder (PTSD). While strides have been made in the implementation of evidence-based psychotherapies (EBPs) for PTSD in the U.S. Department of Veterans Affairs (VA), a large population of Veterans do not receive such services. Research has been conducted on Veterans’ decisions to enroll in EBPs, however less is known about providers’ perspectives related to offering trauma-focused therapies to the military and Veteran population, particularly outside the United States.

Method:

This study utilizes baseline data from a larger investigation aimed to support the sustained implementation of Cognitive Processing Therapy (CPT) in U.S. VA and Canadian Operational Stress Injury (OSI) and Department of Defense settings. Providers who trained in CPT (N=55) participated in interviews regarding their opinions of CPT, preferred treatments for PTSD, and their process in assessing appropriate PTSD treatments for each patient.

Results:

A directed content analysis approach was used to identify themes for providers’ decision making to utilize CPT across the patient, provider, and clinic levels. Providers’ positive perceptions of CPT, including perceived effectiveness, relative advantage over other treatment options, compatibility, and fit with Veteran needs were highly influential in use.

Conclusions:

The systems surrounding and supporting EBP delivery within the U.S. VA, Canada OSI, and Canadian Forces clinics have more similarities than differences regarding barriers and facilitators to delivering CPT. Despite variability in funding and training, provider experiences across all three systems suggest similar themes. Further investigation is needed to determine whether these findings extend to community samples or sites not yet offering EBPs.

Cognitive Processing Therapy (CPT; Resick et al., 2016) is a first-line recommended evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD). Despite the national training initiatives in CPT for thousands of providers throughout the U.S. Department of Defense (DoD) and Veterans Affairs (VA; Karlin et al., 2010), adoption has been relatively low, with estimated rates being less than 20% in outpatient settings (Maguen et al., 2020; Rosen et al., 2016) but higher in residential programs (Cook et al., 2020). Implementation involves the many elements contributing to the successful and robust delivery of a treatment, such as the how much, how well, and through what processes can interventions such as CPT be trained, offered, and delivered.Several researchers have explored why the implementation of CPT and another EBP for PTSD, Prolonged Exposure (PE; Foa et al., 2019), remains low and inconsistent in VA settings at multiple levels, namely organizational-level factors (Hundt et al., 2017; Maguen et al., 2019; Rosen et al., 2019; Sayer et al., 2017), patient characteristics and concerns (Hundt et al., 2018b; Kehle-Forbes et al., 2016) and provider perspectives (Cook et al., 2014; Cook et al., 2018; Finley et al., 2020; Simiola et al., 2019). However, the vast majority of research on this topic has been conducted in VA settings solely within the U.S. with providers working in PTSD specialty settings, limiting the generalizability of the results.

At the organization level, several factors have been shown to contribute to the success of EBP implementation including strong leadership, administrators’ and providers’ positive perceptions of the treatments, and screening procedures that ensure patients who come to the clinic are interested in EBPs (Sayer et al., 2017). Policies mandating training in EBPs, such as the VA policy to ensure availability of CPT or PE at all VA medical centers (Karlin et al., 2010), have also been shown to facilitate treatment reach, with reach referring to the proportion of people with PTSD who receive CPT (Gutner et al., 2019; Hundt et al., 2017; Rosen et al., 2019). However, such policies are not sufficient to ensure the use of CPT if, for example, providers are insufficiently trained in CPT and are unable to skillfully deliver CPT, deliver CPT with fidelity to the manual, or have enough confidence in their CPT skills to initiate CPT (Gutner et al 2019; Hamblen et al 2015; Hundt et al 2018b; Maguen et al 2018; Rosen et al., 2019).

At the patient level, readiness to address their symptoms and initiate treatment, sociodemographic characteristics, type of traumatic exposure, and beliefs about PTSD and therapy have an impact on provider initiation and/or patient completion of EBPs. For instance, experiencing a military sexual trauma (MST), being married, having fewer psychiatric comorbidities, and no recent hospitalizations were predictive of treatment initiation and completion (Back, Waldrop, & Brady, 2009; Hundt et al., 2017; Hundt et al. 2018a; Maguen et al., 2019; Rosen et al., 2018; Zubkoff et al. 2016). On the other hand, service-connected disability for PTSD, being Hispanic or Latino, identifying as male, older age, and living further away from a VA were related to decreased likelihood of initiating CPT or PE (Rosen et al., 2019). In addition, patient belief in and satisfaction with treatment, as well as positivity towards the provider were all facilitators for patient engagement in EBPs for PTSD (Hundt et al., 2018a), whereas lack of buy-in or concerns about therapeutic alliance were barriers (Hundt et al., 2018a). Indeed, findings from a secondary analysis of a randomized trial of collaborative care for PTSD found that providers reported concerns that direct discussions of trauma could undermine their therapeutic alliance (Chen et al., 2020). Providers and patients alike may believe symptom exacerbation is a barrier to treatment or common reason for dropout, despite research that shows that this is often a normal and transient part of CPT (Larsen et al., 2020).

Furthermore, nearly 200 providers from 38 VA residential PTSD programs identified three broad categories surrounding reasons that veterans were perceived to be less suitable candidates for CPT and PE: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation (Cook et al., 2014). Similarly, complex clinical presentations, including comorbid diagnoses, such as substance abuse and pain, or recent hospitalization, were identified as barriers to initiating or delaying delivery of CPT in outpatient settings (Hundt et al., 2017; Rosen et al., 2019; Sripada et al., 2018). Many of these factors contribute to what is perceived as patient readiness for trauma processing therapies (Cook et al., 2017; Osei-Bonsu et al., 2017). Provider concerns about patient readiness have been echoed by providers across the New England region of the U.S. (Zubkoff et al., 2016) as well as a nationally representative sample of directors of VA PTSD outpatient programs (Hamblen et al., 2015). As a result, patient readiness groups have been instituted in many VA medical centers to provide patients with skills, psychoeducation, and motivation, all of which are perceived as necessary for engagement in and efficacy of CPT (Hamblen et al., 2015).

Although there is research regarding provider decisions to engage in CPT in the VA, less is known about factors that emerge across other health care systems where low but variable reach has also been identified (Wiltsey-Stirman et al., 2020; Wiltsey-Stirman et al., 2017). The aim of the current study is to better understand the reasons behind relatively low reach by examining how PTSD providers within a VA in the U.S. and Operational Stress Injury (OSI) and Department of Defense (DoD) clinics in Canada describe their reasons for selecting specific EBPs for treatment planning. Such findings can provide critical information on how to best support the implementation of EBPs, particularly CPT, in health care settings.

Method

Sampling and Data Collection

The interview transcripts used in the present research come from an ongoing large multi-site study that aims to support the sustained implementation of CPT in U.S. VA clinics, private practices and community-based clinics in the U.S. and Canada, and OSI and DoD clinics in Canada (Wiltsey Stirman et al, 2017). In the present study only interviews from the veteran and military-serving sites are included to better examine the factors influencing CPT implementation in these settings. Thomas and colleagues (under review) use a similar methodology to examine the private practices and community clinics in the U.S. and Canada. The parent study was designed to examine whether certain types of provider support and quality improvement strategies influence providers’ delivery of treatment for their PTSD patients, along with the quality in which they deliver CPT (i.e., fidelity to the manual, working alliance). Specifically, the study aimed to evaluate and compare the impact and sustained implementation of two competing strategies for sustaining high-quality EBP delivery, also called Learning Collaboratives: Continuous Quality Improvement-oriented (CQI condition) and Fidelity-oriented (FID condition). CQI focuses on mutual adaptation and quality improvement, whereas FID focuses on adherence to prescribed elements of treatment and competence/skill of delivery.

Providers were recruited from clinics across the U.S. and Canada using established contacts from a CPT-related study previously conducted by the primary investigators for the parent study. Recruitment efforts were also supported by the director of the VA CPT Implementation Program and the director of the VA PTSD Mentoring Program. These providers deliver CPT to outpatients on a regular basis and/or seek to improve their CPT delivery. All procedures were approved by the Institutional Review Boards at Stanford University and the Palo Alto VA Healthcare System.

Informed consent was obtained from providers over the phone; the purpose of the study and participation details were reviewed, and consent was obtained for use of secondary data. The semi-structured interview guide (see Appendix) was informed by the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) as well as previous literature on provider decision making and factors associated with reach, including common barriers and facilitators to effective implementation. Researchers were previously trained in CFIR and had applied the CFIR codebook to these same interviews. For research questions that were not likely to be adequately addressed by the CFIR, researchers expanded the interview guide through an extensive literature review of other phenomena that contribute to provider decision making around how to approach treatment with their PTSD patients. The codebook was reviewed by the broader research team, including co-authors, many of whom are certified CPT trainers and implementation scientists with extensive qualitative research expertise. Two of the researchers who conducted the interviews also participated in the coding of the transcripts (JL, TL). Interviews were recorded using an audio recording software and transcribed by a professional audio transcription service.

Interviews were conducted at baseline, approximately three months after enrolling in the study but prior to the start of the learning collaborative, and generally took about one hour to complete. The interview included open-ended questions about providers’ experiences with EBPs, particularly CPT, perceived patient response to EBPs, and how their current workplace prioritizes EBP use. Thirty-three providers from VA sites, 15 providers from Canadian Forces (Canadian DoD sites), and seven providers from OSI clinics were interviewed and included in the present analysis (N=55). These sites all served Canadian military personnel or U.S. or Canadian veterans. Detailed information about study design, participant recruitment and procedures, such as informed consent and compensation, can be found in Wiltsey Stirman et al. (2017).

As can be seen in Table 1, providers included in the present study were mostly female (80%) and White (76.4%), with a mean age of 45.2 years. Most participants designated their primary occupation as psychologists (50.9%).

Table 1.

Provider Demographics

	VA (n=33)	CF/DoD (n=15)	OSI (n=7)	n (%) (N=55)
Age (in years)
20–29	1	0	0	1(1.8)
30–39	13	3	3	19 (34.5)
40–49	11	8	0	19 (34.5)
50–59	5	3	1	9 (16.4)
60 years or older	3	1	3	7 (12.7)
Gender
Male	4	3	4	11 (20)
Female	29	12	3	44 (80)
Ethnicity
White	22	15	5	42 (76.4)
Black	6	0	0	6 (10.9)
Asian	2	0	2	4 (7.3)
Southeast Asian	1	0	0	1 (1.8)
Mixed	2	0	0	2 (6.6)
Discipline/Degree
Psychologist (PhD/PsyD)	20	4	3	27 (49.1)
Psychiatrist (MD)	0	0	1	1 (1.8)
Social Worker(MSW)	12	7	3	22 (40)
Nurse (RN)	0	2	0	2 (3.6)
Other	1	2	0	2 (3.6)

Note. VA = Veterans Affairs; CF/DoD = Canadian Forces/Department of Defence; OSI = Operational Stress Injury. VA is in the U.S.; CF/DoD and OSI are in Canada. The last column shows aggregate data for the full sample.

Data Analysis

Interview transcripts were analyzed using Dedoose software (Dedoose Version 9.0.17). A directed content analysis approach, informed by pre-existing research and theory relevant to the topic, was used to guide qualitative analysis (Hsieh & Shannon, 2005). Directed content analysis is a deductive approach to qualitative inquiry where the analysis is informed by an existing theory or framework and data analysis results in supporting or expanding upon that framework. This approach was chosen for the present study as there is currently a solid evidence base on the implementation of EBPs.

A preliminary codebook was developed for the coding of transcripts. The initial codebook was based on both the CFIR and published findings of barriers and facilitators to the use of trauma-focused EBPs for PTSD. CFIR is an implementation framework that includes five domains: intervention characteristics, inner and outer settings, characteristics of individuals, and implementation process (Damschroder et al., 2009). Each domain consists of various constructs and sub-constructs. The overall domains and constructs were used to guide the codebook development for the present study. The codebook was iteratively revised throughout the coding process to align with emerging findings.

Five researchers (TL, JL, CM, KK, FT) were involved in coding and theme development. First, five interview transcripts were coded by each member using the initial codebook. After completion of each transcript, the team met to review the coding as well as any new codes that emerged. This process was ongoing until calibration was achieved, no new codes were added, and definitions within the codebook remained stable. Following calibration, the remaining interview transcripts were coded individually by one researcher and reviewed by a second. Where discrepancies occurred, they were discussed until resolution as a full team, preventing conceptual drift and ensuring reliability and consistency.

After coding was completed, the coded reports were divided amongst the team to synthesize emerging themes. Codes in the initial codebook that were not identified in any of the transcripts at the completion of analysis were removed. Coders discussed potential themes as well as commonalities and discrepancies across the data, resulting in the identification of overarching themes and subthemes. Coded reports corresponding with each theme were organized into the three settings (U.S. VA, Canada OSI, Canada DoD) to determine whether significant differences existed between settings. The results were presented to the full research team in order to assess bias and reflexivity in the analytic process; team feedback was integrated, and final themes were organized by CFIR domain.

Results

Provider interviews and subsequent analysis resulted in findings that aligned with and expanded upon existing CFIR theory and literature regarding how PTSD specialty care providers across VA, OSI, and DoD settings describe selecting specific EBPs for PTSD as part of treatment. Notably, the following themes occurred across all three Veteran-serving systems in which providers were based. Table 2 contains a summary of themes organized by CFIR domains.

Table 2.

Summary of Themes

CFIR domain	Outer setting	Inner setting	Characteristics of individuals	Intervention characteristics
Theme(s)	Disconnect from policy/leadership	Available resources Leadership support Compatibility	Theoretical orientation and training	Perceived strength of evidence ComplexityRelative advantage

Outer Setting

Disconnect from Policy and Leadership

Within the CFIR framework, outer setting refers to factors within the external system in which the providers were located. Two subthemes emerged within this system level. First, across systems, providers noted a disconnect between policy, leadership, and front-line staff delivering CPT. When asked about clinic- or system-wide policies that support the implementation of EBPs, most providers stated that they were not aware of any, although some were aware that it was important to their leadership. Further, providers expressed frustration that leadership at the system level did not understand their day-to-day clinical work (e.g., time demands, complexity of patient symptom presentations and difficulties). A common sentiment from participants was that leadership does not clearly communicate their expectations and priorities. One provider described how administrative demands disrupted EBP implementation:

I would say for [administrators], it is numbers, like getting the population served… I know it’s going to sound bad, but I wouldn’t even say the [patient] outcome is that important to the administration level. (Canadian Forces provider)

There is a metric that looks at, “Are you delivering five psychotherapy sessions within 10 weeks of PTSD [diagnosis]?” …that really puts the pressure on admins to prioritize EBPs. So, I love that. Then we have another metric that looks at clinical reach. “How many PTSD patients in your system are you actually seeing?” That one is trying to get as many [patients served] as possible. Without, necessarily, providing good quality care. (U.S. VA provider)

This VA [system] is very big on the checkboxes. I’m not saying they’re not focused on patient care, but… they’re very focused on numbers, RVUs [relative value units], not so much on what we are doing programmatically. (U.S. VA provider)

Inner Setting

Available Resources

Providers recognized that EBP implementation was important to their clinic leadership, but they did not always find the type of support in the form of training, time, and resources that would make delivering EBPs more feasible. Some providers noted the disconnect between their clinic’s requirement to offer EBPs and the lack of time and training available to execute that requirement:

They [administrators] definitely want us all to be offering these evidence-based treatments, but I don’t think they fully get what’s needed in terms of investment via either training or allowing for adequate time in a schedule. (Canadian Forces provider)

We have CBOCs [community-based outpatient clinics] where there might be only one provider who is trying to do [CPT]. We’ve asked to have a consultation team so that we could regularly… connect, so they don’t feel so isolated… We don’t have anyone who is a master trainer, but it would be helpful if we had a master trainer. To be able to have consultations locally, and I think that would make a difference towards more people using it. (U.S. VA provider)

Leadership Support

Providers expressed the importance of stakeholders across all levels of the organization (e.g., administration, leadership, providers, etc.) receiving EBP/CPT education so that providers and patients can be better supported, receive better/more referrals, and help motivate their patients. One provider described the lack of system-level advocacy for EBPs:

The reason we got training for both PE and CPT was, I was fed up. I haven’t been trained, and sometimes managers focus more on budgets and getting the bottom line done and aren’t necessarily really highly involved in the clinical aspects of the clinic. So, I went to the manager and said, “This is becoming a problem. I’ve been here for two and a half years. I haven’t officially been trained in CPT; this needs to happen. How can we make it happen?” And was on his case until it happened. So, it’s not an issue of funding… it just isn’t on his radar and a priority. (Canada OSI provider)

A related subtheme at the inner setting level was the need for flexibility and support for providers to implement CPT. Key suggestions included providing support for time off to attend training and consultation; creating flexible appointment schedules to allow for the weekly, 60-min sessions for 12 weeks that are required to complete CPT; and time in between patients to allow for session preparation. For example, some VA providers specifically noted the burden of weekly sessions because of barriers from their clinic’s policies and structure:

So if people aren’t regularly doing EBPs they are seeing a lot more people infrequently, maybe once every two weeks, so they’re less likely to do [CPT]. I think if they wanted to, even if they felt like they had the perfect case or they wanted to, they’re less likely to because they can’t get their client to come in, their schedule is so booked up at three months. I think if they wanted it, they could get it… but there’s only a couple people that really, really do it enough that they have the greater flexibility to make it happen. (U.S. VA provider)

I think that policies need to change. So, if a patient is referred, they need to be seen within X amount of days, 30 days… So, if people are getting a lot of new referrals, they need to see them within a month. Again, that might get in the way of somebody feeling able to schedule out 12 sessions of CPT with multiple clients. (U.S. VA provider)

I think for other providers, what could potentially be helpful is… if [CPT] could be provided every other week, other clinics might be able to have the time to do more treatment, if it wasn’t necessarily a weekly treatment, or if there was some kind of flexibility in how it can be delivered. (U.S. VA provider)

Participants also noted the value of administrative and resource support that can make session preparation less burdensome (e.g., prepared worksheets and handouts) as a facilitator for initiating manualized psychotherapies like CPT. One provider reflected on the administrative and resource support in a clinic with a culture that supported EBPs:

So, I can offer [CPT] and I do have protected time in my clinic so that I can offer it weekly and have people consistently attend and get through it… We are very much supported as well to offer it virtually. We have access to fillable PDFs even, to be able to make it easier to get the worksheets to patients, that they can just fill them out, and then even securely message them back to us. (U.S. VA provider)

Conversely, the provider below commented on the clinic culture only recently shifting towards support for EBPs:

Some people refuse to offer [EBPs]. They may have been trained in and don’t like a time-limited model. We definitely have a handful of people like that. Other people though are very willing to make referrals when it seems appropriate. We have more people now who are trained in them, so I think it is definitely becoming more of a positive in this clinic, but I think that culture is only kind of recently changing. (U.S. VA provider)

Compatibility

Providers noted the importance of CPT compatibility with the needs of their patient populations. Providers described feeling that CPT was most likely to be successful with patients perceived to be “ready” for CPT; for example, one participant described:

If they’ve had multiple med changes, maybe a new provider. Medications going off… going on. They’re not stable, their support system is not strong. If they’re dual-diagnosed… If they have been suicidal and that’s not stabilized. Those are some things that I would say, “not yet,” for starting trauma therapy. (U.S. VA provider)

This sense that CPT was not appropriate for a less stable subset of patients was reported as an important barrier to initiating CPT, although not necessarily a permanent one. Providers expressed intent to revisit CPT later, once other perceived higher priority goals and complex symptom presentations were addressed, and the patient was observed to be able to fully participate in and benefit from CPT.

There was little agreement among participants regarding CPT’s perceived appropriateness for patient characteristics. For every characteristic for which CPT was considered an appropriate treatment, another provider offered a counter example. For example, one provider remarked, “I found it to be very effective with military sexual trauma or sexual abuse… but a little bit more difficult when it’s specifically a combat trauma.” In contrast, another provider reflected, “CPT’s a little bit too cerebral for people who’ve had sexual trauma”. Consequently, there was little to no consensus on what makes a patient a good or bad fit for CPT.

As a final note on CPT’s appropriateness for diverse patients, some providers suggested it that CPT may be problematic for patients who face discrimination and might experience the challenging of their thoughts as invalidating. For example, regarding minoritized populations, one provider said:

I would just say when people are cultural minorities or traditionally marginalized groups that you need to be really careful when the providers say, “Are your thoughts really realistic?” It can be seen as invalidating by anybody but particularly when there’s a cultural difference between the provider and the client. (U.S. VA provider)

The provider noted the importance of building trust with such patients, due to distrust with military and veteran systems and mental health services. Although this aspect of CPT’s potential appropriateness was not raised frequently in this sample, it signals an important issue worthy of further exploration.

Characteristics of Individuals

Theoretical Orientation and Training

Providers described how their theoretical orientation and training impacted their openness to, and adoption of, CPT with patients. Most commonly, providers remarked that their background, personal style, and prior training experiences set them up well to grasp CPT quickly (e.g., previous experience with cognitive-behavioral therapies). For example, a provider explained, “My theoretical framework is cognitive behavioral, so CPT really fits in, in terms of my own theoretical conceptualization.” In cases in which prior training did not overlap with CPT, providers described an initial hurdle in learning the treatment but ultimately being able to implement it successfully. One provider noted:

I was new to manualized treatments, as well as new to [cognitive therapy] so, it was a big learning curve for me. But the training was well done and helpful. It really shaped a lot of my clinical style and the way I practice today. (U.S. VA provider)

Intervention Characteristics

Within CFIR, perceived characteristics of the intervention refer to factors of the treatment, including perceived strength of its effectiveness, complexity of use, relative advantage over other treatment options, and appropriateness for the needs of patients. Across all systems, providers discussed that the unique structure and characteristics of CPT served as both motivations and deterrents for its use with patients.

Perceived Strength of Evidence

On the positive side, providers described their views of CPT as an effective treatment, based on both research evidence and clinical experience. The overwhelming majority of providers indicated that they believe in (and have clinical experience with) the effectiveness of CPT. One provider noted:

I’ve seen [CPT] work really well for lots of individuals. I definitely advocate for EBPs for PTSD… but CPT is definitely one that I have enjoyed and seems quite effective. (U.S. VA provider)

This finding may be expected from this sample of providers who have consented to be part of a CPT implementation research study. Nonetheless, providers’ perceptions of CPT as an effective treatment were an important facilitator of its use.

Complexity

At the same time, participants across all systems noted that CPT requires 12 weekly, 60-minute sessions, making it difficult to schedule, initiate, and deliver. This barrier was categorized at the inner setting level within the subtheme of “need for flexibility and support.” Conversely, the clear structure and timeline of CPT was often described as aligning well with the learning style of patients who served in the military. Participants believed that Veterans could relate to and feel comfortable with the structured and predictable nature of the manualized therapy. As one provider explained:

I think patients are very appreciative of the fact that CPT is structured… they know what to expect, it’s 12 sessions. It’s not like with a lot of other types of therapies where there’s no end in sight, sometimes that can be really daunting and scary. (U.S. VA provider)

Relative Advantage

In efforts to facilitate improved assessment of treatment options, the practice assignment component of CPT was addressed by most providers as a factor impacting a patient’s likely treatment choice. Patients unwilling to complete practice assignments (a core feature of CPT) were often encouraged to choose a different therapy, and providers reported having low confidence in CPT’s success among patients not willing to complete the between-session practice. A representative quotation is presented below:

CPT does have quite an emphasis on doing the homework, so if you can’t get compliance around that, I guess CPT wouldn’t be the way to go. I would consider maybe doing another therapy that doesn’t have that requirement. (Canadian Forces provider)

Ultimately, while some providers elected to use other treatments for patients not likely to complete practice assignments, others perceived CPT to be superior for its generalizability to a diverse clientele and adaptability of delivery (e.g., individual or group; with or without trauma account; telehealth).

Discussion

The present study involved a qualitative examination of the factors that affect provider decision making regarding implementation of CPT for PTSD in several clinics that serve military and Veteran populations in the U.S. and Canada. Most of the existing research focused on providers in the U.S. VA PTSD specialty programs (e.g., Cook et al., 2020; Rosen et al., 2016). This sample is unique, however, in including providers who worked in VA settings that offered CPT through PTSD, addiction, and general mental health programs, as well as in government settings that serve military and Veteran patients in Canada. Thus, this was a more diverse sample of providers who work with military personnel and Veterans with PTSD. The current study results supported and deepened understanding of previously published findings, and suggested more similarities than differences across the three mental health systems.

The three systems from which providers were included were analyzed both in aggregate and separately in an effort to identify system-level differences in provider experiences of barriers and facilitators to delivering CPT. While these three systems have differences in their policies, funding, and training sources, these differences did not appear to manifest at the provider level. Specifically, OSI and CF/DoD were trained through a grant-funded study through a partnership between the systems, but this difference in training source was not observed in analyses. Only one clear difference was identified, such that only U.S. VA providers made specific remarks about the policies impeding their ability to do CPT due to its weekly, 60-minute format. At the agency level our sample sizes were too small to accurately assess differences.

Use of the CFIR framework provided additional depth and context for findings. Themes in the present study were found to be consistent with the domains of CFIR, including the inner and outer setting, intervention characteristics, and the characteristics of individuals (Damschroder et al., 2009). Consistent with previous research (Cook et al., 2015; Sayer et al., 2017), organizational and leadership support were central to providers’ perceptions of how feasible it was to provide EBPs.

In the current study, across systems, these inner setting factors included leadership support, organizational readiness, dedicated time, resources, flexibility for scheduling sessions, administrative support to caseload reorganization and reduction, and ensuring that there was an effective strategy for referrals to CPT-trained providers. The “culture within a clinic” was also found to influence the relative priority of EBPs, evidenced at both the leadership and provider level. Clinic culture was found to influence whether facilitators were in place to encourage the use of EBPs as well as whether providers endorsed their importance.

Although providers had a general understanding that they were required to use EBPs as part of a larger official policy and mandate, they did not indicate awareness of specific policies or procedures intended to promote EBPs within their systems, such as the VA Uniform Mental Health Services Handbook, VA/DoD PTSD treatment guidelines (VA/Department of Defense, 2017), national performance metrics, or requirements to document use through EBP templates (Crowe et al., 2020; Rosen et al., 2016). In the Canadian systems, there were fewer policies in place to support EBPs, although newly hired therapists are told that use of EBPs is expected and encouraged. It may be that such policies are at least a decade old, and more salient for clinic leads who are tasked with carrying out policies. Since providers may only be aware of local expectations and clinic processes that support or hinder the implementation of such policies (e.g., scheduling, caseloads, referral systems, support for training), messages and supportive actions from leadership is especially important. Whether greater awareness of policy at the provider or patient level would reinforce the reach of EBPs remains to be explored. However, research on organizational climate suggests the importance of conveying a clear rationale, securing buy-in, setting clear standards and plans for implementation, and providing ongoing support, and agency cultures are influenced by factors such as policy and consistent leadership support and reinforcement (Aarons et al., 2015).

Despite evidence that some providers were practicing in programs with relatively strong organizational and leadership support for CPT, providers did not report any external incentives, such as recognition or accolades for providing this EBP. While top down, organizational, and leadership support are central to the successful implementation of CPT, these findings also indicate that both top-down and bottom-up processes contribute to reach. Individual provider perceptions and experiences also appear to play a key role in decisions to offer and provide EBPs. However, in some programs, structures and processes are not in place to support EBP use despite providers’ intentions and favorable views of CPT, or structures and processes are intended to support EBP use, but actually end up creating barriers to a full course of CPT. The way in which already-established structures created a rigidity that impeded CPT delivery was most notably addressed by the U.S. VA providers.

Despite variations in perceptions of leadership and support for EBPs, many providers in this sample indicated positive perceptions of CPT, including perceived effectiveness and relative advantage over other treatment options, compatibility, and fit with their patients’ needs (Aarons & Sawitzky, 2006). This is consistent with findings from a national investigation in VA residential PTSD programs indicating that influential factors for CPT implementation included compatibility of CPT with providers’ existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network (Cook et al., 2015). However, since the interviews here occurred in the context of a larger study aimed at supporting ongoing use of CPT, the participants were likely to have more positive attitudes. Despite the sampling bias within the parent study to only include providers seeking to improve their CPT skills, the prevalence of barriers identified speaks to how strongly ingrained those barriers are.

While previous work on provider perceptions of suitable patient characteristics including readiness have been reported (e.g., Cook et al., 2014, Finley et al., 2020; Zubkoff et al., 2016), new insights emerged. First, across systems and consistent with previous studies in the VA (e.g., Cook et al., 2014; Osei-Bonsu et al., 2017), some providers considered factors like psychiatric comorbidity (e.g., suicidality, self-injurious behaviors, substance dependence) or life stressors (e.g., homelessness) to mean that patients were not a good fit for CPT. However, in this sample, though some providers expressed concern about patient willingness to engage in and efficacy of CPT for some patients, this was something they planned to monitor and thus reconsider use in the future. While providers expressed a willingness to re-assess, other literature suggests that providers may not know how to re-assess readiness or facilitate patient motivation (Zubkoff et. al., 2016).

In addition, the VA has disseminated resources on shared decision making (Mott et al., 2014) and collaborative treatment planning through measurement-based care that may serve to facilitate provider comfort in revisiting treatment options. Such efforts may impact how providers make decisions about when and for whom EBPs are offered. At the same time, a minority of providers indicated that they have colleagues who do not offer CPT or other EBPs to their patients at all, indicating that shared decision making may not in fact occur in some settings. They suggested that it is important to ensure that all patients and their families are aware of EBPs, as well their evidence and availability. This suggestion is consistent with a key recommendation of a recent national workgroup that focused on improving EBP reach and fidelity within the VA (Crowe et al., 2020).

This study involved a rigorous approach to qualitative analysis, in which directed content analysis facilitated the identification of a number of factors that extend beyond the existing CFIR domains. For example, this investigation explored what factors influence provider decisions for PTSD treatment options when they or their patient elect not to use CPT. This query provided novel information about what determinants providers consider when they do not choose to implement an EBPs (e.g., social determinants of health, complex clinical presentations), and consistent with previous work, highlights the importance of integrating more nuanced aspects of patient factors and experiences into the CFIR and other implementation frameworks (Gutner et al., 2019; Rosen et al., 2016).

Limitations, Implications, and Future Directions

Despite several study strengths, there are some limitations that should be noted. First, this study included providers who consented to participate in research designed to support the sustained implementation of CPT, so the recurring positive attitudes towards EBPs and CPT in particular may be expected and may therefore limit the generalizability of findings. Second, while this study included providers from several veteran and military treatment programs in the U.S. and Canada, it did not include providers working with civilians. It is likely that veteran- and military-serving programs are uniquely resourced and somewhat standardized across locations as compared to non-governmental settings. In fact, while there is some consistency between government and community providers, some barriers and facilitators, including policy, reimbursement, and the degree of fragmentation within the system of care, appear to be unique to the systems within which they work (Thomas et al., submitted; Loskot et al., 2021). Future research on system-level differences may include providers from organizations not yet using CPT or other PTSD EBPs to yield additional information about how these barriers may impact disparities in patients being offered these treatments. Regarding the lack of differences identified between systems as portrayed by providers when asked about policies, it is important to note that while our interview guide asked about system-level issues such as policies, provider responses were often terse, especially compared to the sometimes lengthy and detailed responses given to other elements of the interview. Further investigation is needed to understand whether providers genuinely have limited awareness of policies in place to support the use of EBPs, or if instead these findings represent the true absence of policies reaching providers, a disconnect between policies and provider perceptions, a failed implementation of policies, or some other potential explanation. Finally, although interviews were voluntary and confidential, it is possible that providers may have been reluctant to report a lack of implementation or negative aspects of their administration, leaders, or program.

There are several potential resolutions to address real and perceived barriers across the organizational, provider, and patient levels. Alignment across the outer and inner context of systems and strong leadership support are necessary for consistent and sustained CPT reach and fidelity (Crowe et al., 2019). At the provider level, increased education on EBPs and promotion of CPT buy-in appears to be a strong facilitator and should be a focus during training and consultation. Trainers and consultants may consider spending more time on how providers can introduce CPT to their patients in a way that includes broader justification for EBPs and examples of their evidence base. Additionally, rather than starting CPT training at session 1, trainers may take more time to advise on how to describe and build motivation for CPT with their patients. At the patient level, more in-depth education from the provider and organization would promote greater awareness and buy-in. As one provider stated, providers can function as an advocate or a cheerleader for CPT during the intake and treatment decision phase.

By understanding patterns that are present across systems and settings, as well as those that are unique, researchers can identify strategies to better support decision making around EBPs and sustainment of CPT. One area for future research is empirically measuring patient readiness and formally assessing veterans’ perceptions of and willingness to participate in these EBPs.

Future research is also needed to examine the role of provider experiences of discrimination in their decisions to offer EBPs. While the interview guide did not explicitly address this important consideration, and while our sample was majority White, some of the participating minority providers brought up issues of discrimination during their interview. Relationships between race and attitudes toward mental health treatment can be mediated by internalized stigma, suggesting negative attitudes about mental health treatment, specifically with African Americans (Conner et al., 2009). For example, one Black provider reported feeling isolated in her workplace due to a lack of support from her leadership in response to Black Lives Matter movements across the globe. If providers do not feel safe and included in their workplace, expecting them to feel supported enough to deliver evidence-based interventions with fidelity becomes a less realistic request.

Conclusion

Widespread dissemination and implementation efforts regarding EBPs for PTSD in U.S. and Canadian VA and DoD settings are outstanding examples of how to introduce and support best practices. Although the dissemination and implementation efforts are substantial, multiple barriers exist in providers’ decisions to initiate CPT. At the provider level, EBP training and dissemination should focus on clarifying providers’ understanding of who can benefit from EBPs, because providers so thoroughly diverged on their beliefs about the types of patients and co-occurring problems for which CPT is appropriate. This is a key provider-level barrier, as many of the beliefs held by providers are not based on the existing research or recommendations (Resick et al., 2016). At the system and clinic level, EBPs can be further supported through adequate time, training, and clear expectations from leadership. Importantly, providers reported that CPT’s structure and time-limited nature makes it a natural fit for military veterans. Such insights, especially when they are obtained from broader samples of providers and settings, can provide important guidance to treatment developers, organizations, and providers in settings that serve individuals with PTSD.

Clinical Impact Statement.

The current study indicates several factors that influence how military-/Veteran-serving mental health providers make decisions regarding use of CPT. Training alone is insufficient; understanding organizational, therapist, and patient level determinants can inform efforts to ensure sustained implementation of CPT.

Appendix A

Questions from Interview Guide Most Relevant to the Present Study

How do you assess whether a client needs psychotherapy or whether a client is qualified or in need of trauma-focused therapy?

Do you foresee any barriers delivering CPT in your clinic?

How easy or challenging is it to use CPT?

Do you anticipate making any changes to:

…CPT so that you, as a clinician, will be more comfortable using it?

…CPT to address client-level needs, preferences, or constraints?

…CPT to accommodate clinic or system-level needs or requirements?

Given the experience you’ve had with CPT, would you change any of its components?

What are your thoughts on how CPT fits with your clientele?

What characteristics of the clients you see make it less of a good fit?

…More of a good fit?

How do your clients respond to the idea of doing trauma focused treatments? [if they say no, what reasons do they give?]

When someone isn’t appropriate for CPT/Trauma focused therapy or refuses them, what do you do with them/how do you work with them?

Do you ever revisit the idea of trauma focused treatment with them? When/Under what circumstances?

What is the most important thing that would need to change about CPT itself in order to make it possible to do more CPT?

How do your clients feel about the idea of offering treatments like CPT, PE, CBT, and other evidence-based treatments?

What are the biggest priorities for administrators?

In general, how do people at your workplace feel about the idea of offering treatments like CPT, PE, CBT, and other EBTs?

Is anything done:

…To support their delivery?

…That makes you think it’s not a big priority?

Does local leadership do anything to support CPT implementation at your clinic?

…Have you received any other support in your efforts to use CPT?

Up until now, are you aware of any changes that have been made to support CPT?

Does your clinic do anything to examine how well CPT, or treatment in general seems to be working? Or to examine client outcomes?

What is the most important thing that would need to change about your clinic in order to make it possible to provide CPT to more clients with PTSD where you work? (e.g., procedures, leadership attitudes, policies, the way the clinic is set up)

What is the most important thing that would need to change in the provincial or local healthcare system in order to make it possible to provide CPT to more individuals with PTSD where you work?

Are there any local or national policies that either interfere with or help the use of EBPs?