Skip to main content
NCBI home page
VA Author Manuscripts logoLink to VA Author Manuscripts
. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Psychol Serv. 2020 Aug 27;18(4):651–662. doi: 10.1037/ser0000425

Clinical Effectiveness Study of a Treatment to Prepare for Trauma-Focused Evidence-Based Psychotherapies at a Veterans Affairs Specialty Posttraumatic Stress Disorder Clinic

Eric A Dedert 1,2,4, Stefanie T LoSavio 4, Stephanie Y Wells 1, Anne L Steel 1, Kristen Reinhardt 1, Charlene A Deming 1, Rachel A Ruffin 1, Kate L Berlin 1, Nathan A Kimbrel 1,2,3,4, Sarah M Wilson 1,3,4, Sara E Boeding 1, Carolina P Clancy 1,4
PMCID: PMC8514108  NIHMSID: NIHMS1738290  PMID: 32852996

Abstract

Posttraumatic stress disorder (PTSD) clinics in the Department of Veterans Affairs (VA) often provide psychoeducational or skill-building groups to prepare veterans for trauma-focused PTSD treatments. However, there has been limited evaluation of the effectiveness of this phase-based approach for treatment engagement and symptom reduction. Participants included 575 veterans seeking treatment for PTSD whose treatment outcomes were assessed in a VA outpatient PTSD clinic staffed by mental health professionals and trainees. Participants completed self-report measures of baseline characteristics and psychiatric symptoms as part of routine PTSD clinic treatment. We tested the association of preparatory group treatment with engagement in and treatment response to subsequent trauma-focused psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE), which are designated by VA as Evidence-Based Psychotherapies (EBP). Following participation in preparatory treatments, 94/391 (24%) of veterans engaged in a subsequent trauma-focused EBP (CPT or PE). Relative to patients who had previously completed a preparatory group, patients initiating a trauma-focused EBP without having first attended preparatory PTSD treatment had similar rates of trauma-focused EBP completion and better treatment response, as measured by decreases on the PTSD Checklist for DSM-5 (PCL-5), F(1,3009) = 10.89, p = .001, and Patient Health Questionnaire-9 measure of depressive symptoms F(1,3688) = 6.74, p = .010. Overall, veterans reported greater symptom reduction when engaging in trauma-focused EBP directly, without having previously attended a preparatory group. These data support veteran engagement in trauma-focused EBPs for PTSD without first being encouraged to complete psychoeducational or skill-building groups.

Keywords: posttraumatic stress disorder, cognitive processing therapy, prolonged exposure therapy, evidence-based psychotherapy, military veterans

Introduction

The Department of Veterans Affairs (VA) has implemented evidence-based psychotherapies (EBP) for PTSD treatments (Karlin et al., 2010), including prolonged exposure therapy (PE; Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (CPT; Resick, Monson, & Chard, 2016). However, examination of electronic health record data suggests that approximately 9% of veterans with PTSD receive eight or more sessions of an EBP for PTSD (Maguen et al., 2019). Providing military veterans with access to EBPs, such as PE and CPT, has been prioritized due in response to clinical trials evidence supporting large effects of these treatments on PTSD symptom reduction (Watts et al., 2013). While a number of clinicians have been trained in these effective treatments, veterans’ treatment initiation and completion of CPT and PE remain low (e.g., Maguen et al., 2019; Niles et al., 2017). An estimated 22% of veterans with PTSD initiate an evidence-based PTSD treatment, and 30-40% dropout of treatment prematurely (Goetter et al., 2015; Maguen et al., 2019; Sripada, Bohnert, Ganoczy, & Pfeiffer, 2018; Steenkamp, Litz, Hoge, & Marmar, 2015). Utilization of evidence-based PTSD treatments is also low within VA PTSD specialty clinics (Finley et al., 2015). For example, a study examining the use of evidence-based PTSD treatments in six New England VA specialty PTSD clinics found that only 6% of veterans received at least one session of an evidence-based treatment (Shiner et al., 2013). Moreover, veteran patients who do receive evidence-based treatment frequently do not receive a sufficient dose (Shiner et al., 2013; Spoont, Murdoch, Hodges, & Nugent, 2010). For example, Shiner and colleagues (2013) reported that veterans seen in specialty outpatient clinics typically completed an average of six sessions of PE or CPT, which is below the threshold considered to be an adequate dose of treatment (Ready, Lamp, Rauch, Astin, & Norrholm, 2018). Although some individuals may end treatment early due to being an early responder (Szafranski, Smith, Gros, & Resick, 2017), an adequate dose of treatment is associated with symptom and quality of life improvement, while dropout is associated with lower symptom improvement and increased service utilization (Myers, Haller, Angkaw, Harik, & Norman, 2018; Tuerk et al., 2013). Thus, there is a need to increase PTSD treatment utilization and completion.

There are several barriers that interfere with treatment utilization and completion, including veteran-level, agency-level, and provider-level factors. Veterans’ lack of knowledge about treatment, lack of “buy-in” to the treatment rationale, logistical issues (e.g., travel distance to the VA), stigma, not being “ready” for treatment, and trauma-related avoidance hinder veterans from seeking or remaining in care (Hoge et al., 2004; Ouimette et al., 2011; Sayer et al., 2009). Agency-level barriers such as long-wait times, restricted appointment hours, limited availability of appointments, and negative interactions with providers also impact veterans’ ability to access and utilize treatment (Ouimette et al., 2011). Lastly, clinicians’ attitudes towards trauma-focused evidence-based PTSD treatments, concerns about comorbidities, and perceptions of veterans’ readiness to engage in treatment also impact their use of evidence-based PTSD treatments (Cook, Dinnen, Simiola, Thompson, & Schnurr, 2014; Osei-Bonsu et al., 2017); however, the study conducted by Cook and colleagues (2014) was specific to VA residential treatment program providers and may not generalize to outpatient providers’ perspectives. One potential strategy adopted by many VA clinics to increase readiness, initiation, and completion of evidence-based PTSD treatments is the use of preparatory non-trauma focused group treatments, which may also address each of these aforementioned barriers to treatment.

Preparatory non-trauma focused group treatments are widely used throughout the VA; analysis of qualitative interviews with a nationally representative sample of 38 VA PTSD specialty clinic directors found that the majority of clinics offered preparatory groups prior to an evidence-based PTSD treatment (Hamblen et al., 2015). These groups may help to address the veteran, provider, and agency-level barriers that contribute to low utilization and completion of PTSD treatments. For example, veterans have reported that they have concerns about being “ready” for trauma-focused treatment (Hundt et al., 2018). Participating in a non-trauma focused preparatory group may increase veterans’ confidence to successfully engage in therapy, which may then increase their readiness for a trauma-focused PTSD treatment. If veterans are more ready for trauma-focused treatments, then they may complete treatment at greater rates, which should improve clinical outcomes. Similarly, non-trauma focused preparatory groups may alleviate providers’ concerns about veterans’ readiness for PTSD EBPs. For example, one study found that clinic directors believed that the preparatory groups help to increase readiness for evidence-based PTSD treatments, improve coping skills, assist veterans to make informed treatment decisions, and reduce no-shows to subsequent evidence-based PTSD treatment (Hamblen et al., 2015). There is also evidence from mental health provider interviews that psychiatric comorbidities such as substance use, dissociation, and personality disorders are barriers to direct initiation of EBPs (Cook et al., 2014), and these might be addressed by preparatory treatments. Non-trauma focused preparatory groups may also help overcome agency-level barriers, such as long wait-times, because providers can offer care to several veterans at once through these groups. Additionally, although many people with PTSD prefer evidence-based PTSD treatments relative to alternatives such as medications and non-trauma focused treatments (Cook et al., 2014; Simiola, Neilson, Thompson, & Cook, 2015) not all veterans ultimately engage in these treatments; therefore, non-trauma focused preparatory groups offer an additional treatment option for veterans who are unwilling to partake in trauma-focused PTSD treatments.

Despite the widespread use of preparatory groups throughout VA PTSD specialty clinics, there are few studies examining the effectiveness of these groups and their impact on subsequent engagement in trauma-focused EBPs. One previous study examined the association between engagement in preparatory treatment (specifically, group treatment) and trauma-focused treatment completion and outcomes (Wiedeman, Hannan, Maieritsch, Robinson, & Bartoszek, 2018). Engagement in preparatory group treatment did not have a significant effect on rates of trauma-focused EBP treatment completion or changes in PTSD and depression symptoms. These findings suggest that preparatory treatment may not be fulfilling its intended functions of facilitating the transition to trauma-focused treatment and enhancing its outcomes. The present study aims to replicate findings from the previous work (Wiedeman et al., 2018) in another PTSD specialty clinic with a different sociodemographic make-up. The study by Weideman and colleagues (2018) was conducted in the Midwestern United States, and over half of the participants identified as non-Hispanic White. The present study was conducted in the Southeastern United States with a more diverse sample including approximately two-thirds of participants who identified as African American. There is conflicting evidence on the association of sociodemographic characteristics on response to EBPs for PTSD (Holliday, Holder, Williamson, & Suris, 2017; Lester, Resick, Young-Xu, & Artz, 2010), which underscores the value of replicating clinical effectiveness studies in multiple settings. The current study also provides data that were collected at each session, rather than at three time points during the course of treatment, which was the assessment schedule in the previous study (Wiedeman et al., 2018).

The objective of the present study was to further evaluate the effectiveness of preparatory treatments for (1) engaging veterans in a subsequent course of trauma-focused EBP for PTSD and (2) enhancing trauma-focused EBP treatment outcomes (i.e., reductions in PTSD and depression symptoms). We did not make specific hypotheses about the effectiveness of preparatory treatments because there are existing few studies in this area to inform our hypotheses. Therefore, we have examined these aims for exploratory purposes to better understand the role of these widely used preparatory groups.

Method

Participants.

Study participants included 872 veterans of the United States military who participated in outpatient treatment at the Durham VA Health Care System (VAHCS) PTSD Clinic between 2007 and 2018. All participants had a presumed diagnosis of PTSD according to DSM-IV or DSM-5 criteria. All veterans were eligible for PTSD clinic services based on having either 1) a history of military-related trauma, or 2) received VA service-connected disability payments for PTSD. Patient sociodemographic and psychiatric diagnosis information are listed in Table 1.

Table 1.

Baseline Sociodemographic and Clinical Variables.

Sociodemographic Variable Preparatory Treatments (n=391) EBP Following Preparatory Treatment (n=94) EBP Without Previous Preparatory Treatment (n=481)
Frequency (%) Frequency (%) Frequency (%)
Race
 African American 259 (66%) 65 (69%) 231 (48%)
 Caucasian 121 (31%) 29 (31%) 230 (48%)
 Multi-Racial 8 (2%) 0 (0%) 7 (1%)
 Other 3 (1%) 0 (0%) 13 (3%)
Hispanic Ethnicity 6 (2%) 1 (1%) 17 (4%)
Gender (% Women) 18 (5%) 2 (2%) 41 (9%)
Currently Married 252 (64%) 53 (56%) 297 (62%)
Index Trauma 337 (86%) 83 (88%) 397 (83%)
 Military Sexual Trauma 8 (2%) 1 (1%) 19 (4%)
 Other Sexual Trauma 1 (<1%) 0 (0%) 6 (1%)
 Combat 324 (83%) 72 (77%) 398 (83%)
 Childhood Trauma 7 (2%) 2 (2%) 9 (2%)
 Other Adult Trauma 51 (13%) 10 (20%) 49 (10%)
Service-Connected for PTSD 276 (71%) 73 (78%) 337 (70%)
Major Depressive Disorder 140 (36%) 28 (30%) 185 (38%)
Personality Disorder 30 (8%) 7 (7%) 25 (5%)
Alcohol Use Disorder 70 (18%) 23 (24%) 104 (22%)
Nicotine Dependence 82 (21%) 28 (30%) 105 (22%)
Open in a new tab

Note: Because some patients initiated more than one EBP treatment episode, the numbers of patients listed in this table differ from numbers of patients in results analyzing all treatment episodes. “Other” race included veterans identifying as American Indian/Native American, Asian, or Native Hawaiian/Pacific Islander.

Procedures.

Procedures for this clinic program evaluation project were approved by the Durham VAHCS Institutional Review Board. Data were drawn from routine outcome monitoring conducted at the Durham VAHCS PTSD Clinic. Clinicians determined whether patients had a PTSD diagnosis through the veteran’s electronic medical record (e.g., by reviewing recent mental health treatment notes) or a diagnostic evaluation for PTSD, which included the Clinician Administered PTSD Scale for DSM-IV (CAPS-IV; (Blake et al., 1995) or the Clinician Administered PTSD Scale for CAPS-5 (Weathers et al., 2018). If a PTSD diagnosis could not be established through the electronic medical record, then the veteran was scheduled for a diagnostic evaluation in the PTSD clinic, which includes a clinician-administered PTSD diagnostic interview, self-report measures, and a clinical interview assessing psychosocial, occupational, and military history, as well as current functional impairment and mental health treatment history.

Veterans eligible for services at the PTSD Clinic met individually with clinic providers for a treatment planning session. Treatment options included preparatory treatments that were focused on psychoeducation and building coping skills (i.e., preparatory treatment), medication management, recommended evidence-based psychotherapies for PTSD recommended by the VA/DOD Clinical Practice Guidelines, and problem-specific group treatments (e.g., Seeking Safety; Dialectical Behavioral Therapy Skills; Coping with Grief and Loss; Anger Management) that were not presented as preparatory treatments. Because this clinical effectiveness study was carried out on data collected in the course of clinical work, there was likely variability between clinicians in how treatment options were presented than there would be in a clinical trial. However, standard procedures for clinicians presenting treatment options included 1) recommending PE and CPT as first-line treatment options that had the most evidence in support of their effectiveness for reducing PTSD and depressive symptoms, 2) suggesting that patients who had reservations about going into EBPs first enroll in a preparatory treatment that was designed to provide basic coping skills and transition into EBPs, and 3) providing alternative treatment options that had less evidence for reducing PTSD and depressive symptoms, but were designed to help with specific problems or symptoms that were commonly associated with PTSD. This distinction between treatments designed to prepare patients for EBPs and alternative stand-alone treatments that are not necessarily designed to transition patients into EBPs was described by a number of VA PTSD clinic directors in previous qualitative studies with VA PTSD clinic directors (Hamblen et al., 2015) and clinicians doing treatment planning sessions (Barnett et al., 2014).

The number of patients choosing each of the problem-specific treatments were as follows: Anger Management (n = 86), Emotion Coping (n = 88), PTSD & Relationships (n = 39), Sleep Disturbance (n = 47), Acceptance and Commitment Therapy (n = 7), Couples Coping with PTSD (n = 25), Seeking Safety (n = 49), and Pain & PTSD (n = 29). Seventy veterans transitioned from the preparatory treatments to the problem-specific treatments. Twenty Veterans engaged with EBP treatment that had been preceded by both preparatory and problem-specific treatments. The Sleep Disturbance, Acceptance and Commitment Therapy and Seeking Safety treatments were not offered for the entire time period for which data were reported for this paper.

The treatment planning sessions included an overview of each of the treatment options and a shared decision-making approach that facilitated collaborative discussion of treatment options followed by a treatment decision by the patient. During this discussion, veterans were typically provided with copies of written materials describing the treatments and the National Center for PTSD website that had videos introducing PE and CPT. This treatment planning session also included a brief review of psychosocial, military, occupational, and treatment history, as well as current functional impairment, followed by a description of the treatment and scheduling logistics. Clinicians met weekly to review cases and treatment planning procedures to promote standardization of care. At the end of treatment, clinicians completed case disposition forms that indicated whether the patient was a treatment completer; veterans were coded as treatment completers when patients completed the intended number of sessions (i.e., 10 sessions of the preparatory group, 9-12 sessions of PE, and 12 sessions of group or individual CPT until 2018; after 2018, veterans could complete earlier than 12 sessions of CPT if they demonstrated satisfactory early treatment response) or terminated therapy early due to satisfactory early treatment response; however, there were no specific symptom reduction criteria for permitting early termination.

Preparatory treatments.

From 2007-2014, veterans who selected a preparatory treatment received a group-based psychoeducational treatment called “Symptom Coping.” Facilitators of the Symptom Coping group provided psychoeducation about PTSD symptoms and related problems (e.g., difficulty sleeping), taught coping skills (e.g., deep breathing, progressive muscle relaxation, guided imagery, grounding), provided recommendations for improving sleep, encouraged lifestyle changes to reduce PTSD symptoms and improve quality of life, and discussed treatment options for PTSD. In 2014, the group was re-named “Introduction to Trauma Recovery” and revised to include additional coping skills and psychoeducation about CPT and PE and since the most recent VA/Department of Defense Clinical Practice Guidelines, Eye Movement Desensitization and Reprocessing (EMDR). These additional skills include cognitive restructuring, behavioral strategies for reducing PTSD symptoms (e.g., increasing positive behaviors), and skills for managing anger and communicating effectively. Veterans who opted to participate in a preparatory group were scheduled at the treatment planning session. The group ranged in size from 8 to 12 veterans and consisted of 10 weekly 60 minute sessions. Preparatory groups were facilitated by 1-2 of the same PTSD Clinic staff or trainees who facilitated the trauma-focused EBPs.

Trauma-focused evidence-based psychotherapies.

Evidence-based psychotherapies offered up until 2017 included PE and CPT. In 2017, our clinic began offering EMDR. PE in this clinic is offered in an individual therapy format. Veterans who chose to participate in CPT were offered group or individual therapy, as well as the option of writing a trauma account. In the sample for this study, 282 (49%) patients received trauma-focused EBPs in a group format, and 293 (51%) received trauma-focused EBPs in an individual format. Group treatments were scheduled at the treatment planning session, while veterans selecting individual PE or CPT were assigned to the next available therapist. CPT groups consisted of an initial orientation session to review the treatment structure and rationale, followed by 12 weekly 90 minutes sessions of CPT. Groups ranged in size from 8 to 12 veterans. The typical clinic policy required that veterans who miss more than two sessions of group therapy leave the group and restart treatment at a later date. However, some participants in the present sample may have continued in the group after missing more than two sessions at the discretion of group leaders. Patients who missed a session of group CPT were invited to meet individually with clinicians to make up the session and then resume group CPT. During the course of treatment reported here, CPT was provided in some groups that included the written trauma account (n = 352) and groups that did not included the written trauma account (n = 49).

Individual CPT also typically consisted of 12 60-minute sessions while individual PE ranges from 8 to 15 90-minute sessions. Sessions were held weekly, although some participants adopted alternate schedules as needed (e.g., meeting twice weekly or twice monthly), and therapists sometimes provided additional sessions to address remaining symptoms. Within the present sample, a minority of participants who were enrolled in an EBP completed more than 12 sessions (n = 73, 11%, maximum number of sessions = 24).

Both individual and group treatment were conducted by PTSD Clinic staff. Clinicians providing EBPs received training through the applicable VA EBP training and consultation program for each relevant treatment. Clinicians included licensed psychologists and social workers, as well as psychology trainees (postdoctoral fellows, interns, and practicum students). Clinicians typically completed EBP consultation requirements, and trainees were in the process of completing consultation requirements while providing treatment in the clinic. Groups had 2-3 facilitators, which allowed one therapist to lead the group discussion while the other therapist examined specific patients’ home practice worksheets and marked comments on the worksheets to provide feedback and guidance on the work that patients had done between sessions. In addition, if a patient missed a group session, one of the therapists attempted to meet with the veteran for an individual therapy appointment to discuss missed material with the patient before the next group session to keep that patient up to date.

Veterans enrolled in individual or group treatment completed self-report measures of PTSD and depressive symptoms at every treatment session. Patients sometimes returned for multiple episodes of EBPs, therefore the number of total EBP treatment episodes exceeds the number of patients initiating any EBP.

Comorbid diagnoses.

To code psychiatric diagnosis for comorbidities, a provider in the PTSD clinic viewed the list of diagnoses and other health problems in 1) the patient’s electronic health record problem list, 2) the patient’s most recent note from a mental health provider, and 3) the patient’s most recent note from a primary care provider. If there were conflicts between the three different diagnostic sources, the clinician coding comorbid diagnosis would defer to the most recent mental health note. Comorbid diagnoses are provided in this report to characterize the sample. Note that medical records and problem lists can often have out of date diagnoses, so there are limitations to the validity of comorbid diagnoses listed in this sample.

Measures

PTSD symptoms.

From October, 2007 to May, 2014, symptoms of PTSD were assessed at each therapy session using the PTSD Checklist – Military Version for DSM-IV (PCL-IV; Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-IV is a 17-item self-report measure of PTSD symptoms associated with “stressful military experiences” that is based on DSM-IV diagnostic criteria. The PCL-IV exhibits high internal consistency and test-retest reliability as well as good discriminant validity among veterans (Owens, Chard, & Cox, 2008; Weathers et al., 1993). In this sample, Cronbach’s alpha ranged from 0.83-0.91 for the subscales of the PCL-IV. The established reliable change threshold for the PCL-IV is a decrease of five or more points (Monson, Schnurr, Stevens, & Guthrie, 2004).

Beginning in June, 2014, the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) was utilized. The PCL-5 is a 20-item self-report measure of PTSD symptoms that demonstrates good internal consistency, test-retest reliability, and convergent and discriminant validity among veterans (Bovin et al., 2016). In this sample, Cronbach’s alpha ranged from 0.84-0.90 for the subscales of the PCL-5. In contrast to the established reliable change threshold for the PCL-IV, there is no established reliable change for the PCL-5.

Depressive symptoms.

From October, 2007 to May, 2014, depressive symptoms were measured using the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), administered at every session. The BDI-II is a 21-item self-report measure that assesses depressive symptoms within the past two weeks. It has demonstrated high internal consistency, convergent validity, and test-retest reliability in clinical and community samples (Beck et al., 1996). In this sample, Cronbach’s alpha was 0.95 for the BDI. Beginning in June, 2014, the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) was utilized to assess depressive symptoms. The PHQ-9 is a 10-item self-report measure of depressive symptoms within the past two weeks that exhibits strong internal consistency, high test-retest reliability, and high convergent validity among treatment-seeking adults (Kroenke, Spitzer, & Williams, 2001). In this sample, Cronbach’s alpha was 0.87 for the PHQ-9. Data from studies that administered both questionnaires (i.e., the BDI-II and the PHQ-9) have been used to develop a conversion equation that uses BDI-II scores to predict PHQ-9 scores. This study found that PHQ-9 scores generated by the conversion equation differed from observed PHQ-9 scores by an average of 0.95 points on the PHQ-9 (Hawley et al., 2013). We converted all participant BDI-II scores to PHQ-9 scores using this conversion, which allowed us to conduct analyses on all data using the same scale.

Data Analysis Plan

We first coded the sequence of treatments within patients to determine whether trauma-focused EBPs were preceded by preparatory treatments. We then calculated descriptive statistics by treatment type. Outcome variables were plotted using histograms to evaluate their distributions. We used independent sample t-tests to evaluate differences between groups (EBP first vs. Preparatory treatment first) in PTSD and depressive symptoms at the first EBP treatment session. Among veterans initiating an EBP, we used a chi-square test to evaluate whether baseline sociodemographic and clinical variables were associated with statistically significant differences in the proportion of veterans who selected preparatory treatment before an EBP. We calculated within-treatment effect sizes by using the following formula: Cohen’s d = (MPOST-TREATMENT – MPRE-TREATMENT)/(SDPOOLED). To evaluate differences between treatments over time, we used mixed models that modeled treatment type as the between-subjects variable and time as the within-subjects variable. The outcome variable intercept was modeled as a random effect. Missing data were estimated using the restricted maximum likelihood method. We modeled outcome scores as a function of session for within-treatment estimates of effect and tested the association of previous preparatory treatment attendance on response to EBP by modeling the interaction of previous preparatory treatment with time. All analyses were conducted with SAS version 9.4 software.

Results

A total of 391 veterans (64%; Mage = 57.5, SD = 10.3) initiated a preparatory treatment. Because veterans sometimes completed preparatory treatment multiple times, these 391 veterans initiated a total of 419 episodes of preparatory treatment, with 311/419 (74%) being coded by their clinicians as treatment completers and 108/419 (26%) coded as dropouts. Of the 391 veterans attending preparatory treatment, 94/391 (24%) subsequently initiated EBPs. Because veterans sometimes completed EBPs multiple times, the 94 veterans who subsequently initiated EBPs initiated a total of 115 episodes of EBPs.

A total of 575 veterans (Mage = 52.8, SD = 13.7) initiated EBPs, and those veterans initiated a total of 645 episodes of EBP treatment, with 398/645 (62%) being coded by their clinicians as treatment completers and 247/645 (38%) coded as dropouts. There were 530 EBP treatment episodes that were initiated without having previously received treatment in a preparatory group, and 326/530 (62%) of those veterans completed treatment. Veterans who had previously attended preparatory treatment initiated a total of 115 EBP treatment episodes, and 72/115 (63%) of those veterans were coded as having completed treatment. There was not a statistically significant difference in EBP treatment completion by the presence/absence of a previous preparatory treatment, χ2(1) = 0.09, p = .765. EBPs were more likely to be selected first (i.e., without first participating in a preparatory treatment) by veterans who identified as White, χ2(1) = 9.14, p = .003, and by veterans who were women, χ2(1) = 4.65, p = .031. However, sensitivity analyses including race and gender as covariates in models of the interaction of previous preparatory treatment with response to EBP over time did not impact the pattern of results. There were no differences in the proportion selecting a preparatory treatment before an EBP as a function of ethnicity; marital status; history of combat exposure; presence of service-connected disability for PTSD; or presence of comorbid major depressive disorder, personality disorder, substance use disorder, alcohol use disorder, or nicotine dependence.

To test for pre-treatment differences in symptoms at the outset of an episode of an EBP, we used independent sample t-tests comparing symptoms at session 1 of EBPs by presence/absence of a previous preparatory treatment. Tests found no session 1 difference by presence/absence of a previous preparatory treatment in PTSD symptoms measured by the PCL-IV, t(217) = 0.41, p = 0.68, in PTSD symptoms measured by the PCL-5, t(387) = 0.47, p = 0.64, or in depressive symptoms, t(567) = 1.24, p = 0.214. Independent sample t-tests comparing symptom levels at session 1 of an EBP (EBP first vs. EBP after a preparatory treatment) also found no statistically significant between-group differences in the levels of session 1 PTSD symptom clusters.

Within-group symptom reductions over time

Pre- and post-treatment descriptive statistics and effect sizes are listed in Table 2. The preparatory treatments resulted in small within-group changes in PTSD symptoms on the PCL-5, F(1,148) = 12.08, p < .001, and PCL-IV, F(1,445) = 53.52, p < .001, and in depressive symptoms, F(1,598) = 19.14, p < .001. When an EBP followed a preparatory treatment, the EBP resulted in small decreases in PTSD symptoms as measured by the PCL-5, F(1,539) = 17.53, p < .001, and the PCL-IV, F(1,342) = 8.36, p = .004, as well as decreases in depressive symptoms, F(1,729) = 21.14, p < .001.When an EBP was initiated first, without following a preparatory treatment, the EBP resulted in moderate to large decreases in PTSD symptoms as measured by the PCL-5, F(1,2529) = 480.73, p < .001, and the PCL-IV, F(1,1089) = 202.94, p < .001, as well as decreases in depressive symptoms, F(1,3093) = 254.16, p < .001.

Table 2.

Baseline and Post-treatment PTSD and Depressive Symptoms.

Outcomes Session 1 End of Treatment Test of Within-Group Change Within-Group Effect Size (Cohen’s d)
PCL-IV
Preparatory Treatments (n = 290) 66.20 (10.46) 62.51 (11.99) F(1,445) = 53.52, p < .001 d = 0.33
Evidence-Based Psychotherapies
 Following Preparatory Treatment (n = 46) 65.20 (9.86) 62.98 (10.98) F(1,342) = 8.36, p = .004 d = 0.21
 Without Preparatory Treatment (n = 172) 64.44 (11.74) 53.74 (16.10) F(1,1089) = 202.94, p < .001 d = 0.76
PCL-5
Preparatory Treatments (n = 96) 57.69 (12.93) 55.47 (14.05) F(1,148) = 12.08, p < .001 d = 0.16
Evidence-Based Psychotherapies
 Following Preparatory Treatment (n = 63) 53.23 (14.60) 48.19 (14.84) F(1,539) = 17.53, p < .001 d = 0.34
 Without Preparatory Treatment (n = 326) 52.30 (14.35) 39.75 (17.97) F(1,2529) = 480.73, p < .001 d = 0.77
PHQ-9
Preparatory Treatments (n = 385) 15.88 (5.02) 14.74 (5.18) F(1,598) = 19.14, p < .001. d = 0.22
Evidence-Based Psychotherapies
 Following Preparatory Treatment (n = 105) 16.14 (5.24) 14.74 (5.54) F(1,729) = 21.14, p < .001 d = 0.27
 Without Preparatory Treatment (n = 463) 15.40 (5.59) 12.18 (5.79) F(1,3093) = 254.16, p < .001 d = 0.57
Open in a new tab

PCL = Posttraumatic Stress Disorder Checklist.

PHQ = Patient Health Questionnaire.

End of Treatment was session 10 for the Preparatory Treatments. Though some patients terminated EBPs earlier or later than session 12, the 12th session is listed as the end-point in this table to provide information on an end-point that is consistent across patients. End of Treatment was session 12 for Evidence-Based Psychotherapies.

Symptom reductions in EBP by presence of previous preparatory treatment

In models of the interaction of the presence of a previous preparatory treatment with change over the course of EBP treatment sessions on the PCL-5, there was a statistically significant main effect of time, F(1,3009) = 167.32, p < .001, and no main effect of previous preparatory treatment, F(1,372) = 1.45, p = .2294. Relative to EBPs that followed a preparatory treatment, EBPs initiated without previous preparatory treatment resulted in greater decreases in PTSD symptoms as measured by the PCL-5, as indicated by the statistically significant interaction between previous preparatory treatment and time, F(1,3009) = 29.20, p < .001.

When this same analysis was focused on the association of previous participation in the Introduction to Trauma group specifically (i.e., the Symptom Coping group was deleted from the data set), a similar pattern of findings was observed. Relative to EBPs that followed an Introduction to Trauma Recovery group, EBPs initiated without Introduction to Trauma Recovery group treatment resulted in greater decreases in PTSD symptoms as measured by the PCL-5, as indicated by the statistically significant interaction between previous Introduction to Trauma Recovery treatment and time, F(1,3009) = 10.89, p = .001.

In models of the interaction of the presence of a previous preparatory treatment with change over the course of EBP treatment sessions on the PCL-IV, there was a statistically significant main effect of time, F(1,1391) = 24.95, p < .001, no significant main effect of previous preparatory treatment, F(1,213) = 0.00, p = .956. Relative to EBPs that followed a preparatory treatment, EBPs initiated without previous preparatory treatment resulted in greater decreases in PTSD symptoms as measured by the PCL-IV, as indicated by the statistically significant interaction between previous preparatory treatment and time, F(1,1391) = 6.87, p = .009. The PCL-IV had stopped being administered by the time the Introduction to Trauma Recovery group treatment began being used in this clinic, so no follow-up analysis by type of preparatory treatment was conducted.

In models of the interaction of the presence of a previous preparatory treatment with change over the course of EBP treatment sessions on the PHQ-9, there was a statistically significant main effect of time, F(1,3688) = 120.64, p < .001, but no statistically significant main effect of previous preparatory treatment, F(1,558) = 1.31, p = .254. Relative to EBPs that followed a preparatory treatment, EBPs initiated without previous preparatory treatment resulted in greater decreases in depressive symptoms as measured by the PHQ-9, as indicated by the statistically significant interaction between previous preparatory treatment and time, F(1,3688) = 6.74, p = .010. Differences in response to EBP in depressive symptoms as a function of previous preparatory treatment are illustrated in Figure 2.

Figure 2.

Figure 2.

Open in a new tab

Differences in Response to EBP on the PHQ-9 as a Function of Previous Preparatory Treatment.

When this same analysis was focused on the association of previous participation in the Introduction to Trauma Recovery group specifically (i.e., the Symptom Coping group was deleted from the data set), there was no association of previous Introduction to Trauma Recovery group treatment to change over time in depressive symptoms, F(1,3687) = 0.06, p = .812.

Discussion

We examined whether participation in preparatory treatment was associated with greater treatment completion and better symptom outcome in subsequent evidence-based, trauma-focused treatment. Contrary to the intended role of preparatory treatments, results indicated that participation in preparatory treatment was not associated with EBP treatment completion, and, in fact, prior participation in preparatory treatment was associated with worse treatment response during trauma-focused treatment. In other words, veterans who went directly into an EBP had a better treatment response for PTSD and depressive symptoms compared to those who participated in a preparatory group first.

Specifically, results indicated that less than a quarter of veterans who participated in preparatory treatment subsequently engaged in a trauma-focused EBP. Subsequently, those veterans who received preparatory treatment first were no more likely to complete a trauma-focused EBP than those who went into a trauma-focused EBP directly. These results are consistent with findings from Wiedeman and colleagues (2018), who found that preparatory group participation did not predict subsequent completion of trauma-focused treatment. Additionally, the proportion of veterans who transitioned from preparatory to trauma-focused treatment in the previous study was similar to that from the present study (Wiedeman et al., 2018), reflecting a low rate of transfer from preparatory to trauma-focused treatment. Thus, although a major goal of preparatory treatment is to increase engagement in trauma-focused treatment (Hamblen et al., 2015), data do not demonstrate that preparatory treatment results in high rates of subsequent engagement with trauma-focused EBP treatment.

Results also indicated that those veterans who went into a trauma-focused EBP directly exhibited greater decreases in PTSD and depressive symptoms relative to veterans who engaged in preparatory treatment first. This finding is in contrast to findings from Wiedeman and colleagues (2018), who found no effect of preparatory treatment on treatment outcome. One potentially relevant difference in methodology between studies is that the previously reported study assessed symptoms only at treatment selection and pre- and post-EBP, whereas the current study included weekly assessment of symptoms across treatment. More frequent measurement enables better sensitivity to smaller effects at the group level, which could explain why this effect was detected in the current report. Again, this finding is in contrast to the putative purpose of preparatory treatment, demonstrating that preparatory treatment was actually associated with worse response to trauma-focused EBP.

Limitations and Future Directions

While the present findings are informative, they must be interpreted in light of the study’s limitations. First, this study did not involve random assignment to preparatory versus trauma-focused treatment. Therefore, it is likely that a selection effect occurred, whereby certain veterans were more likely to select preparatory treatment than others. As a result, differences in outcomes may be due to third variables; for example, it may be that veterans who were more avoidant were less likely to initially select trauma-focused EBP treatment and also less likely to meaningfully engage and benefit from trauma-focused treatment.

Likewise, it is not possible to know how many veterans would have ultimately pursued an EBP if they had not received preparatory treatment first (e.g., if preparatory treatment were not offered), nor is it possible to know how many veterans would have completed a trauma-focused EBP treatment had they not engaged in preparatory treatment. With this in mind, there is no way to determine the course of treatment and symptom response for veterans in a clinic without preparatory treatments. Future research will be needed to disentangle these possibilities and determine the effects of preparatory treatment with a more controlled design. Nonetheless, the present study provides valuable information about the outcomes associated with patients’ real-world treatment selections.

Future research may also examine the outcomes of specific patient populations with and without preparatory treatment. For example, many providers are concerned about initiating trauma-focused treatment with patients with comorbidities, such as borderline personality disorder, or other “complex” presentations (LoSavio, Dillon, Murphy, & Resick, 2019). While some researchers and clinicians advocate for phase-based treatment (e.g., Landes, 2013), others have shown that trauma-focused EBP work just as well for these populations (e.g., Holder, Holliday, Pai, & Suris, 2017; van Minnen, Harned, Zoellner, & Mills, 2012). However, as noted earlier, clinical trials are needed to overcome some of the threats to validity present in clinical effectiveness studies to conclusively evaluate the effectiveness of PTSD treatment using a phase-based approach.

Another potential limitation is that we examined treatment engagement and outcomes based on the treatment services available at one PTSD specialty clinic. The associations of the preparatory treatments used in this clinic with subsequent EBP effectiveness do not generalize to the different types of preparatory treatments used in other clinics. In addition, since diagnostic assessments were not completed on all veterans at the treatment planning session, it is possible that some of the veterans in this study were sub-threshold for PTSD at the time of treatment initiation. Regarding EBPs, the treatment completion rates in our sample were on par with or higher than those observed in other naturalistic PTSD treatment studies (e.g., Garcia, Kelley, Rentz, & Lee, 2011; Kehle-Forbes, Meis, Spoont, & Polusny, 2016; Mott, Stanley, Street, Grady, & Teng, 2014; Niles et al., 2017). With regard to treatment effectiveness, symptom reduction observed in this study, particularly for veterans who went directly into trauma-focused EBP (most of the EBP recipients), was consistent with effect sizes reported in other effectiveness studies (e.g., 0.63-0.77; Lamp, Avallone, Maieritsch, Buchholz, & Rauch, 2018)), although, overall, our effect sizes were somewhat smaller than others in the literature (e.g., 0.96-2.0; Goodson, Lefkowitz, Helstrom, & Gawrysiak, 2013; Jeffreys et al., 2014; Lamp et al., 2018; Tuerk et al., 2011).

Additionally, clinics vary greatly with respect to treatment offerings and procedures. The use of similarly designed preparatory and EBP treatment tracks is common in Veterans Health Administration PTSD specialty clinics (Hamblen et al., 2015). Nonetheless, further examination of the present research questions should be completed in other clinics with different treatment options and clinic flow processes. For example, different preparatory treatments may have better or worse effects on subsequent EBP engagement and outcomes. Additionally, EBPs in the current study were heterogeneous with respect to treatment modality, format, and provider. However, while some studies have revealed better outcomes from individual versus group EBPs (Lamp et al., 2018; Resick et al., 2017), veterans received individual and group treatment in both the preparatory treatment and no preparatory treatment comparison groups, and including treatment format as a covariate did not change the pattern of results.

Finally, this study relied on self-reported symptom outcomes, which are commonly used in this type of effectiveness research. However, the lack of a post-treatment diagnostic interview limits our ability to determine the percentage of veterans who no longer met criteria for PTSD following treatment.

Clinical Implications

Many clinicians and clinical administrators have doubts and concerns about delivering evidence-based, trauma-focused treatments like PE and CPT, such as concerns about patient readiness or dropout (Hamblen et al., 2015; LoSavio et al., 2019; Ruzek et al., 2016), contributing to high rates of preparatory treatment (Hamblen et al., 2015) and low rates of gold-standard PTSD treatments, even in PTSD specialty care settings (e.g., Lu, Plagge, Marsiglio, & Dobscha, 2016; Shiner et al., 2013). However, this practice is in contrast to a lack of data supporting a required amount of “readiness” to benefit from treatment and data suggesting more clinical worsening during waitlist than trauma-focused treatment (Jayawickreme et al., 2014). While preparatory treatments may commonly be employed in an attempt to overcome patient-, provider-, and/or agency-level barriers, the results of the present study build on previous research and suggests that preparatory treatment may not have the intended effect of improving readiness or engagement and may simply delay receipt of effective treatment. Given the lack of evidence that preparatory treatments improve outcomes relative to immediate provision of EBPs, clinicians and patients could benefit from prioritizing engagement in trauma-focused EBPs early in the course of PTSD treatment. PTSD treatment programs utilizing preparatory groups should consider encouraging patients to engage in EBPs directly. The current report was drawn from a naturalistic VA PTSD specialty clinic setting, which is informative for VA clinics that have similar treatment options. We believe this is a strength of the study that contributes to decisions about the structure and sequencing of treatments in similar VA PTSD specialty clinics.

Conclusions

The present research found that veterans who received trauma-focused EBPs without first receiving preparatory treatment had similar levels of engagement and superior symptom improvement relative to veterans who first received preparatory treatment. Thus, our findings provide no evidence of benefit from preparatory treatment prior to engagement in trauma-focused EBPs and provide support for encouraging veterans to engage with EBPs directly within the context of shared decision making treatment planning.

Figure 1. Differences in Response to EBP on the PCL-5 as a Function of Previous Preparatory Treatment.

Figure 1.

Open in a new tab

PCL-5 = Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual, Version 5. PTSD = Posttraumatic Stress Disorder. EBP = Evidence-Based Psychotherapies.

Impact Statements.

  • Preparatory skills-based treatments used to prepare veterans for trauma-focused, evidence-based psychotherapies (EBPs) for PTSD were ineffective in promoting subsequent initiation of trauma-focused treatment.

  • Contrary to the common clinical belief that preparatory treatments are needed prior to PTSD EBPs, Veterans receiving preparatory treatments prior to an EBP did not report as much PTSD symptom reduction in subsequent EBPs compared Veterans who went straight into an EBP.

  • Clinicians engaged in shared decision making with Veterans might consider encouraging Veterans who are interested in trauma-focused EBPs to engage in EBPs directly, without preparatory skills-based treatments.

Acknowledgements

This work was primarily supported by Merit Review Award Number I01 CX001757-01 from the United States (U.S.) Department of Veterans Affairs Clinical Sciences R&D (CSRD) Service. This work was also supported by award number IK2HX002398 to Dr. Wilson from the HSR&D Service of the VA Office of Research and Development. This work was also supported by the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), and the Health Services Research Core of the Durham VA Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the United States government or any of the institutions with which the authors are affiliated.

References

  1. Barnett ER, Bernardy NC, Jenkyn AB, Parker LE, Lund BC, Alexander B, & Friedman MJ (2014). Prescribing clinicians’ perspectives on evidence-based psychotherapy for posttraumatic stress disorder. Behavioral Sciences, 4, 410–422. doi: 10.3390/bs4040410 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Beck AT, Steer RA, & Brown G (1996). Beck Depression Inventory-II. San Antonio, TX: The Psychological Corporation. [Google Scholar]
  3. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, & Keane TM (1995). The development of a clinician-administered posttraumatic stress disorder scale. Journal of Traumatic Stress, 8, 75–80. doi:0894-9867/95/0100--U075507,50/1 [DOI] [PubMed] [Google Scholar]
  4. Bovin MJ, Marx BP, Weathers FW, Gallagher MW, Rodriguez P, Schnurr PP, & Keane TM (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. doi: 10.1037/pas0000254 [DOI] [PubMed] [Google Scholar]
  5. Cook JM, Dinnen S, Simiola V, Thompson R, & Schnurr PP (2014). VA residential provider perceptions of dissuading factors to the use of two evidence-based PTSD treatments. Professional Psychology: Research and Practice, 45(2), 136–142. doi: 10.1037/a0036183 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Finley EP, Garcia HA, Ketchum NS, McGeary CA, Stirman SW, & Peterson AL (2015). Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics. Psychological Services, 12, 73–82. doi: 10.1037/ser0000014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Foa EB, Hembree EA, & Rothbaum BO (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, therapist guide. New York, NY: Oxford University Press. [Google Scholar]
  8. Garcia HA, Kelley LP, Rentz TO, & Lee S (2011). Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war veterans. Psychological Services, 8(1), 1–11. doi: 10.1037/a0022705 [DOI] [Google Scholar]
  9. Goetter EM, Bui E, Ojserkis RA, Zakarian RJ, Brendel RW, & Simon NM (2015). A systematic review of dropout from psychotherapy for posttraumatic stress disorder among Iraq and Afghanistan combat Veterans. Journal of Traumatic Stress, 28(5), 401–409. doi: 10.1002/jts.22038 [DOI] [PubMed] [Google Scholar]
  10. Goodson JT, Lefkowitz CM, Helstrom AW, & Gawrysiak MJ (2013). Outcomes of prolonged exposure therapy for veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 26, 419–425. doi: 10.1002/jts.21830 [DOI] [PubMed] [Google Scholar]
  11. Hamblen JL, Bernardy NC, Sherrieb K, Norris FH, Cook JM, Louis CA, & Schnurr PP (2015). VA PTSD clinic director perspectives: How perceptions of readiness influence delivery of evidence-based PTSD treatment. Professional Psychology: Research and Practice, 46(2), 90–96. [Google Scholar]
  12. Hawley CJ, Gale TM, Smith PSJ, Jain S, Farag A, Kondan R, … Graham J (2013). Equations for converting scores between depression scales (MADRS, SRS, PHQ-9, and BDI-II): good statistical, but weak idiographic, validity. Human Psychopharmacology, 28, 544–551. [DOI] [PubMed] [Google Scholar]
  13. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, & Koffman RL (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. doi: 10.1056/NEJMoa040603 [DOI] [PubMed] [Google Scholar]
  14. Holder N, Holliday R, Pai A, & Suris A (2017). Role of borderline personality disorder in the treatment of military sexual trauma-related posttraumatic stress disorder with cognitive processing therapy. Behavioral Medicine, 43(3), 184–190. doi: 10.1080/08964289.2016.1276430 [DOI] [PubMed] [Google Scholar]
  15. Holliday RP, Holder ND, Williamson ML, & Suris A (2017). Therapeutic response to Cognitive Processing Therapy in White and Black female veterans with military sexual trauma-related PTSD. Cognitive Behaviour Therapy, 46, 432–446. doi: 10.1080/16506073.2017.1312511 [DOI] [PubMed] [Google Scholar]
  16. Hundt NE, Helm A, Smith TL, Lamkin J, Cully JA, & Stanley MA (2018). Failure to engage: A qualitative study of veterans who decline evidence-based psychotherapies for PTSD. Psychological Services, 15(4), 536–542. doi: 10.1037/ser0000212 [DOI] [PubMed] [Google Scholar]
  17. Jayawickreme N, Cahill SP, Riggs DS, Rauch SAM, Resick PA, Rothbaum BO, & Foa EB (2014). Primum non nocere (first do no harm): Symptom worsening and improvement in female assault victims after prolonged exposure for PTSD. Depression & Anxiety, 31, 412–419. doi: 10.1002/da.22225 [DOI] [PubMed] [Google Scholar]
  18. Jeffreys MD, Reinfeld C, Nair PV, Garcia H, Mata-Galan E, & Rentz TO (2014). Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic. Journal of Anxiety Disorders, 28(1), 108–114. doi: 10.1016/j.janxdis.2013.04.010 [DOI] [PubMed] [Google Scholar]
  19. Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, … Foa EB (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23(6), 663–673. doi: 10.1002/jts.20588 [DOI] [PubMed] [Google Scholar]
  20. Kehle-Forbes SM, Meis LA, Spoont MR, & Polusny MA (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychol Trauma, 8(1), 107–114. doi: 10.1037/tra0000065 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Kroenke K, Spitzer RL, & Williams JB (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Lamp KE, Avallone KM, Maieritsch KP, Buchholz KR, & Rauch SAM (2018). Individual and group cognitive processing therapy: Effectiveness across two veterans affairs posttraumatic stress disorder treatment clinics. Psychological Trauma: Theory, Research, Practice, and Policy. doi: 10.1037/tra0000370 [DOI] [PubMed] [Google Scholar]
  23. Landes SJ, Garovoy ND, Burkman KM (2013). Treating complex trauma among veterans: Three stage-based treatment models. Journal of Clinical Psychology, 69(5), 523–533. doi: 10.1002/jclp.21988 [DOI] [PubMed] [Google Scholar]
  24. Lester K, Resick PA, Young-Xu Y, & Artz C (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting & Clinical Psychology, 78, 480–489. [DOI] [PubMed] [Google Scholar]
  25. LoSavio ST, Dillon KH, Murphy RA, & Resick PA (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes. Professional Psychology: Research and Practice, Online first publication. doi:10.1037%2Fpro0000224 [Google Scholar]
  26. Lu MW, Plagge JM, Marsiglio MC, & Dobscha SK (2016). Clinician documentation on receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. The Journal of Behavioral Health Services and Research, 43(1), 71–87. doi: 10.1007/s11414-013-9372-9 [DOI] [PubMed] [Google Scholar]
  27. Maguen S, Li Y, Madden E, Seal KH, Neylan TC, Patterson OV, … Shiner B (2019). Factors associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system. Psychiatry Research, 274, 112–128. doi: 10.1016/j.psychres.2019.02.027 [DOI] [PubMed] [Google Scholar]
  28. Mott JM, Stanley MA, Street RL, Grady RH, & Teng EJ (2014). Increasing engagement in evidence-based PTSD treatment through shared decision-making: A pilot study. Military Medicine, 179(2), 143–149. doi: 10.7205/MILMED-D-13-00363 [DOI] [PubMed] [Google Scholar]
  29. Myers US, Haller M, Angkaw AC, Harik JM, & Norman SB (2018). Evidence-based psychotherapy completion and symptom improvement among returning combat veterans with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, Advance online publication. doi: 10.1037/tra0000360 [DOI] [PubMed] [Google Scholar]
  30. Niles BL, Polizzi CP, Voelkel E, Weinstein ES, Smidt K, & Fisher L (2017). Initiation, dropout, and outcome from evidence-based psychotherapies in a VA PTSD outpatient clinic. Psychological Services, 15(4), 496–502. doi: 10.1037/ser0000175 [DOI] [PubMed] [Google Scholar]
  31. Osei-Bonsu PE, Bolton RE, Wiltsey-Stirman S, Eisen SV, Herz L, & Pellowe ME (2017). Mental health providers’ decision-making around the implementation of evidence-based treatment for PTSD. Journal of Behavioral Health Services & Research, 44, 213–223. doi: 10.1007/s11414-015-9489-0 [DOI] [PubMed] [Google Scholar]
  32. Ouimette P, Vogt D, Wade M, Tirone V, Greenbaum MA, Kimerling R, … Rosen C (2011). Perceived barriers to care among veterans health administration patients with posttraumatic stress disorder. Psychological Services, 8(3), 212–223. doi: 10.1037/a0024360 [DOI] [Google Scholar]
  33. Owens GP, Chard KM, & Cox TA (2008). The relationship between maladaptive cognitions, anger expression, and posttraumatic stress disorder among veterans in residential treatment. Journal of Aggression, Maltreatment and Trauma, 17(8), 439–452. doi: 10.1080/10926770802473908 [DOI] [Google Scholar]
  34. Ready DJ, Lamp K, Rauch SAM, Astin MC, & Norrholm SD (2018). Extending prolonged exposure for veterans with posttraumatic stress disorder: When is enough really enough? . Psychological Services, Advance online publication. doi:doi: 10.1037/ser0000309 [DOI] [PubMed] [Google Scholar]
  35. Resick P, Monson C, & Chard K (2016). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. New York, NY: Guilford Press. [Google Scholar]
  36. Resick PA, Wachen JS, Dondanville KA, Pruiksma KE, Yarvis JS, Peterson AL, … CONSORTIUM, S. S. (2017). Effect of group vs. individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74(1), 28–36. [DOI] [PubMed] [Google Scholar]
  37. Ruzek JI, Eftekhari A, Rosen CS, Crowley JJ, Kuhn E, Foa EB, … Karlin BE (2016). Effects of a comprehensive training program on clinician beliefs about and intention to use prolonged exposure therapy for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 348–355. doi: 10.1037/tra0000004 [DOI] [PubMed] [Google Scholar]
  38. Sayer NA, Friedemann-Sanchez G, Spoont M, Murdoch M, Parker LE, Chiros C, & Rosenheck R (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry: Interpersonal and Biological Processes, 72(3), 238–255. [DOI] [PubMed] [Google Scholar]
  39. Shiner B, D’Avolio LW, Nguyen TM, Zayed MH, Young X,Y, Desai RA, … Watts BV (2013). Measuring use of evidence based psychotherapy for posttraumatic stress disorder. Adm Policy Ment Health, 40, 311–318. doi: 10.1007/s10488-012-0421-0 [DOI] [PubMed] [Google Scholar]
  40. Simiola V, Neilson EC, Thompson R, & Cook JM (2015). Preferences for trauma treatment: A systematic review of the empirical literature. Psychological Trauma: Theory, Research, Practice, and Policy, 7(6), 516. [DOI] [PubMed] [Google Scholar]
  41. Spoont MR, Murdoch M, Hodges J, & Nugent S (2010). Treatment receipt by Veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric Services, 61(1), 58–63. doi: 10.1176/ps.2010.61.1.58 [DOI] [PubMed] [Google Scholar]
  42. Sripada RK, Bohnert KM, Ganoczy D, & Pfeiffer PN (2018). Documentation of evidence-based psychotherapy and care quality for PTSD in the Department of Veterans Affairs. Administration and Policy in Mental Health and Mental Health Services Research, 45, 353–361. doi: 10.1007/s10488-017-0828-8 [DOI] [PubMed] [Google Scholar]
  43. Steenkamp MM, Litz BT, Hoge CW, & Marmar CR (2015). Psychotherapy for Military-Related PTSD: A Review of Randomized Clinical Trials. Journal of American Medical Association, 314(5), 489–500. doi: 10.1001/jama.2015.8370 [DOI] [PubMed] [Google Scholar]
  44. Szafranski DD, Smith BN, Gros DF, & Resick PA (2017). High rates of PTSD treatment dropout: A possible red herring? Journal of Anxiety Disorders, 47, 91–98. doi: 10.1016/j.janxdis.2017.01.002 [DOI] [PubMed] [Google Scholar]
  45. Tuerk PW, Wangelin B, Rauch SA, Dismuke CE, Yoder M, & Myrick H (2013). Health service utilization before and after evidence-based treatment for PTSD. Psychological Services, 10(4), 401–409. doi: 10.1037/a0030549 [DOI] [PubMed] [Google Scholar]
  46. Tuerk PW, Yoder M, Grubaugh A, Myrick H, Hamner M, & Acierno R (2011). Prolonged exposure therapy for combat-related posttraumatic stress disorder: An examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq. Journal of Anxiety Disorders, 25(3), 397–403. doi: 10.1016/j.janxdis.2010.11.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. van Minnen A, Harned MS, Zoellner L, & Mills K (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3(1), 1–14. doi: 10.3402/ejpt.v3i0.18805 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Watts BV, Schnurr PP, Mayo L, Yinong Y, Weeks WB, & Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541–e550. doi: 10.4088/JCP.12r0822 [DOI] [PubMed] [Google Scholar]
  49. Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, … Marx BP (2018). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Pscyhological Assessment, 30(3): 383-395. Psychological Assessment, 30(3): 383–395. doi: 10.1037/pas0000486 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Weathers FW, Litz BT, Herman DS, Huska JA, & Keane TM (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the International Society for Traumatic Stress Studies Annual Meeting, San Antonio, TX. [Google Scholar]
  51. Wiedeman LD, Hannan SM, Maieritsch KP, Robinson C, & Bartoszek G (2018). Treatment choice among veterans with PTSD symptoms and substance-related problems: Examining the role of preparatory treatments in trauma-focused therapy. Psychological Services, Advance online publication. doi: 10.1037/ser0000313.supp [DOI] [PubMed] [Google Scholar]

RESOURCES