“It Leaves Me Very Skeptical” Messaging in Marketing Prolonged Exposure and Cognitive Processing Therapy to Veterans with PTSD

Abstract

Objective:

Direct-to-consumer marketing has the potential to increase demand for specific treatments, but little is known about how to best market evidence-based psychotherapies to veterans with PTSD. The objective of this study was to gain an understanding of marketing messages that may impact veteran demand for prolonged exposure (PE) and cognitive processing therapy (CPT).

Method:

Veterans (n = 31) with full or subthreshold PTSD participated in semi-structured interviews that queried attitudes about PTSD and recovery, current knowledge of PE and CPT, and reactions to existing educational materials. A two-stage qualitative coding and analytic strategy was used to identify primary themes related to the marketing of PE and CPT.

Results:

Veterans viewed the treatments’ effectiveness as their primary selling point but questioned the credibility of improvement descriptions that didn’t fit with their experiences or beliefs about PTSD. Participants had difficulties distinguishing CPT from non-trauma-focused approaches in which they had previously participated, leading to skepticism about promised treatment effects and decreased interest. Without targeting, women veterans assumed information regarding PTSD treatment options applied only to men.

Conclusions:

Examination of the impact of a direct-to-consumer marketing campaign including these messages on PE and CPT demand is needed.

Since 2006, the U.S. Department of Veterans Affairs (VA) has been engaged in an unprecedented initiative to ensure that all veterans with posttraumatic stress disorder (PTSD) have access to prolonged exposure (PE) and cognitive processing therapy (CPT; Karlin & Cross, 2014). VA has trained over 10,000 mental health providers to deliver PE and CPT and implemented numerous system-level changes to help ensure their widespread adoption (Karlin & Cross, 2014; Rosen et al., 2016). Despite these efforts, relatively few veterans with PTSD have begun a course of PE or CPT. Only 22.8% of all Iraq and Afghanistan war veterans with PTSD seeking VA care initiated PE or CPT during a 15-year period (Maguen et al., 2019). One factor limiting the reach of these evidence-based psychotherapies (EBPs) may be a lack of veteran demand. A survey study demonstrated that few veterans were able to recognize CPT and PE as effective treatments for PTSD and a review of studies examining their implementation within VA reported that clinicians believe that patients are unwilling to participate in such trauma-focused therapies (Harik, Matteo, Hermann, & Hamblen, 2017; Rosen et al., 2016).

Direct-to-consumer marketing (e.g., “selling” directly to patients, rather than the more traditional model of marketing to healthcare providers), as has been employed by the pharmaceutical industry, is one potential strategy for building awareness and engendering positive attitudes. As such, discussion of its use to increase patient demand for EBPs for a range of mental health conditions has increased in the scientific literature over the past several years (e.g., Becker, 2015). A small number of randomized controlled trials have demonstrated that direct-to-consumer marketing can increase knowledge and intent to initiate EBPs in non-treatment seeking samples (e.g., Gallo, Comer, Barlow, Clarke, & Antony, 2015; Ponzini & Schofield, 2019). While VA has created patient-facing materials to facilitate PE and CPT initiation, information about how to best market PE and CPT and how to market EBPs to veteran populations is lacking. This manuscript presents findings from a qualitative study undertaken to better understand messaging that may build patient demand for EBPs.

Method

Participants and Procedure.

Procedures were approved by the Institutional Review Board of the Minneapolis VA Healthcare System. Veterans were identified as eligible via the electronic medical record; eligibility criteria included (a) Minneapolis VA healthcare use during the past year, (b) chart diagnosis of PTSD, with current full or subthreshold PTSD diagnosis verified during interview, (c) not engaged in psychotherapy at the time of recruitment, (d) no prior PE or CPT treatment experience, and (e) no current psychotic disorder, cognitive disorder, or suicide flag, as those may preclude PE or CPT participation. A random subset of veterans who met criteria were invited via mailed letter and subsequently by phone to participate. We stratified the sample by gender and oversampled women to have a sufficiently large sample (i.e., ≤ 8 veterans; Guest, Bunce, & Johnson, 2006) to identify high frequency themes unique to women.

The interview began with informed consent and administration of the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1998) to confirm a current DSM-IV diagnosis of PTSD or subthreshold PTSD as defined by Stein and colleagues (1997). Of the 37 veterans who consented to study participation, six veterans were excluded from the interview following the CAPS (see Supplemental Figure 1 for recruitment flow chart). A team of two interviewers (including at least one masters or PhD-level psychologist or clinical social worker) conducted the 60-minute semi-structured interviews, with one conducting the interview and the other taking field notes regarding emerging themes. The interview guide inquired about 1) how and from whom veterans preferred to receive information regarding PTSD treatment options; 2) attitudes towards PTSD recovery; 3) domains in which veterans would expect to see change following successful treatment; and 4) current knowledge of PE and CPT. Following these questions, veterans were randomly assigned to watch one of two educational videos used within VA to describe PE or CPT. After viewing the video, participants were asked about their reactions to the video and the therapy that was presented All interviews were audio-recorded and transcribed. Interview participants were later invited to participate in a 90-minute group feedback session (e.g., member check) to ensure the accuracy and validity of themes resulting from the interviews. Veterans were paid $75.00 for participating in the interview and $75 for the group session.

Data Analysis.

We employed a two-step analytic process. Immediately following each interview, the two team members present at the interview met to debrief. All debriefings were audio-recorded and transcribed. After completing all interviews, a team of two interviewers reviewed transcripts of the debriefings and created a master log summarizing themes and highlighting key insights. The themes identified through this process, revised as needed following the member check, served as the basis of the qualitative codebook to be used in the second stage of analysis. During the second phase of analysis, two coders applied the coding scheme resulting from the earlier phase to 20% (n = 7) of interview transcripts to test the coding strategy. The coders then met to discuss their codes, propose additional codes not covered by the preliminary codebook, and amend the codebook as necessary. Following codebook finalization, each transcript was coded by a primary coder and verified by a secondary coder who read the transcript and associated codes; differences were arbitrated during regular meetings between the coders. Finally, we applied the constant comparison method during analysis to determine if key themes differed for male and female veterans. Coding was conducted using NVivo 10.0.

Results

A total of 31 veterans (23 male and eight female) completed interviews. Twenty veterans were post-9/11 era veterans and eleven were Vietnam era veterans. The sample was 94% white and 6% (n = 2) black or African American; no participants identified as Hispanic or Latino. A majority (52%) of participants were service-connected for PTSD. Veterans reported a number of strengths of PE and CPT and the educational materials. Nearly all veterans found the use of first-person testimonials to be powerful and reported that they believed that PE and CPT had the potential to reduce symptoms and improve functioning. Below we present three primary themes related to better marketing PE and CPT to veterans.

Broad statements about the benefits of PE and CPT may jeopardize credibility.

Nearly all veterans viewed PE and CPT’s effectiveness as their greatest strength. It was the main factor associated with veterans’ stated willingness to engage in the treatment and instilled hope that improvement and change was possible. A female veteran stated, “Talking about how well it had worked was something that caught my eye. They were talking about how well it’s worked and how much improvement that it’s had in people who have dealt with PTSD for a long time.”

Despite the enthusiasm for the treatments’ effectiveness, approximately half of veterans (including those who saw effectiveness as a strength) were skeptical of what they saw as overly positive portrayals of improvement. In response to being asked what stood out to him in the educational video, a male veteran sarcastically responded “Just a few people that said [CPT] is the second coming of the Lord.” Similarly, a male veteran stated, “They’re making it sound like everything is going to be too good. I mean not realistic. It’s too happy, I mean it’s too positive.” Overly positive messages were perceived as depicting a lack of understanding of the experience of living with PTSD and led to mistrust of the messenger, yielding strong negative responses. One male veteran reported, “They only showed us the positive side of it, what is the negative?” A second stated, “When people promise you things like that, there’s usually a hidden agenda and it’s not you that is going to profit from that hidden agenda… It leaves me very skeptical.”

Relatedly, veterans had strong negative reactions to statistics demonstrating the percent of veterans who no longer met criteria for PTSD following a course of PE or CPT that were presented during the member check. Approximately one-half of veterans initially voiced concerns, with nearly all veterans agreeing the messaging was detrimental by the end of the discussion. Specifically, participants reported disbelief towards and strongly recommended removing a pictograph displaying the number of veterans out of 100 who lose their PTSD diagnosis following PE or CPT. A large majority of veterans believed that it is not possible (or at least is very unlikely) to lose your PTSD diagnosis; while symptoms can improve (and even remit), veterans reported they would still have PTSD. This discrepancy in belief about symptom remission and loss of PTSD diagnosis is in part due to veterans’ reported conceptualization of PTSD, which extends beyond the psychiatric symptoms. For the interviewed veterans, having a PTSD diagnosis included having been through a traumatic experience and having memories of those events (whether or not those memories were currently associated with distress or avoidance), and the lasting change to the veteran resulting from those experiences. One woman veteran stated, “It changed my life. [PTSD] is part of who I am. Part of what I’ve been through.”

Descriptions of symptom recovery perceived as overly optimistic and discussion of loss of PTSD diagnosis reduced the perceived trustworthiness and credibility of the source and the message. Such descriptions suggested to participants that the source didn’t understand veterans’ experiences, and thus would not be knowledgeable regarding their treatment. The importance of credibility of the messenger and the message was reported as being paramount throughout the interviews, and credibility was easily lost through perceived missteps such as described above.

Veterans need help understanding what makes PE and CPT unique.

More than one-half of participants believed that they had previously participated in PE or CPT, even though the medical record and detailed queries during the interview suggested they had not. This was due to difficulty differentiating PE and CPT from other mental health treatments in which they had previously participated, even after viewing the educational videos. This was particularly problematic for the CPT video; nearly all veterans perceived CPT as being a present-centered, skills-based treatment, rather than a trauma-focused treatment. Only one veteran who viewed the CPT video accurately understood the treatment’s focus and rationale. Veterans’ beliefs that they had previously participated in PE or CPT (or a very similar treatment), lessened their interest in participating in one of those treatments in the future. One male veteran reported, “I think that’s what [case manager] is doing with me. Making me write the list of things that happened, how I handled it before, and how I want to handle it. I feel like I am [already] doing that stuff.” A second male veteran stated, “I’ve been through a treatment program that seems very similar. I think that it’s very similar to one I’ve been through and I haven’t seen results.” This mismatch between veterans’ perceived experience with the same or a very similar treatment and the promised results yielded a loss of credibility and interest in the treatments.

In the absence of gender-specific material, women believed that PE and CPT were for men.

Most women veterans who participated in the study stated a preference for materials that were specifically tailored to women veterans and found the lack of women veterans in the educational videos shown during the interviews to be problematic. One woman veteran stated, “I saw a couple females, but none of them talked – it was mostly males that talked… if it was geared specifically towards women, you know, it would definitely grab my attention more.” Further, about one-half of women stated that if VA materials regarding PTSD treatment weren’t specifically targeted to women, they assumed the information did not apply to them. This was particularly notable in women veterans’ concerns that PE and CPT would not address PTSD resulting from sexual assault due to the lack of discussion regarding sexual trauma and the reliance on combat images in the educational videos. One woman veteran stated, “There weren’t any women… If they don’t understand what we face, will they understand how to help? Nothing addressed sexual assault.” A second woman veteran shared a similar sentiment, “[I want to know] if it works for sexual trauma, something more directly related [to my experience]. It might be great for people that have seen blown up bodies, but what about other types of PTSD?”

Discussion

Findings from this qualitative analysis suggest that PE and CPT marketing materials directed at veterans may be most effective in creating demand if they highlight treatment effectiveness, include veteran testimonials, avoid global descriptions of symptom improvement in favor of specific impacts on symptoms and functioning, and clearly delineate how EBPs differ from other psychotherapies. There is limited prior work regarding how to best market PE and CPT to patients, however, the treatment preferences literature provides insight into factors patients take into account when forming treatment opinions. Similar to this study’s findings, Iraq and Afghanistan war veterans reported that treatments’ perceived effectiveness was one of the most salient factors in selecting treatments (Kehle-Forbes, Polusny, Erbes, & Gerould, 2014). Treatment rationale has been the focus of a majority of treatment preferences research, with prior studies showing that the presence of a rationale – although not necessarily the specific rationale itself – impacts perceived credibility and preferences (e.g., Chen, Keller, Zoellner, & Feeny, 2013). With the exception of the role it might play in differentiating PE and CPT from other psychotherapies, treatment rationale did not emerge as an important theme. Kehle-Forbes et al. (2014) and Chen et al. (2013) found that treatment rationale and perceived effectiveness were closely tied to treatment preferences; future research should experimentally examine whether providing a rationale is necessary to convey effectiveness when marketing EBPs to veterans.

One of the strongest themes that emerged was participants’ negative reactions to broad statements of great improvement, particularly the use of “loss of diagnosis.” Loss of PTSD diagnosis has been associated with the achievement of good end state in nearly all domains of functioning following treatment, increasing interest in it as a patient-centered outcome (Schnurr & Lunney, 2016). Our findings suggest that while it may be useful treatment target and research outcome, caution may be warranted in using that or similar language in patient-facing materials. It is unclear if the impact of such language on credibility is relevant for non-veteran populations; trauma event centrality or the receipt of PTSD-related disability benefits may contribute to variability across populations. Comparing our findings to the small literature on marketing PTSD treatment to patients suggests important differences may exist between veteran and civilian samples. For example, the majority of our sample had a history of prior mental health treatment and found patient testimonials to be compelling in conveying effectiveness, while prior research has found that testimonials are only impactful among treatment naïve trauma-exposed individuals (Pruitt, Zoellner, Feeny, Caldwell, & Hanson, 2012). Further, the inclusion of only veterans from one medical center is an important study limitation; future research is needed to verify the generalizability of findings to geographically and racially / ethnically diverse veterans. Despite these important limitations, this study provides the first exploration of themes important in marketing PE and CPT in veterans. Examination of the impact of a direct-to-consumer marketing campaign including these messages on PE and CPT demand is needed.

Clinical Impact Statement:

Veterans may lack information about the availability of effective treatments for PTSD. This study sought to better understand how to market prolonged exposure (PE) and cognitive processing therapy (CPT) to veterans. Describing specific symptom improvements that other veterans have experienced with the treatments, clearly stating how PE and CPT differ from present-centered therapies, and creating materials specifically for women may be important successful marketing of PE and CPT to veterans.