Over the last several years there has been an increased emphasis on providing evidence-based psychotherapies (EBPs) in military and Veteran healthcare environments to treat PTSD. The Institute of Medicine (2007) produced a report indicating that the DoD and VA lacked evidence to demonstrate the effectiveness of the treatments they are providing. The report was not suggesting the treatments themselves were not effective, but simply that both the VA and DoD did not have a system in place for measuring the effectiveness of the treatment in those environments. Further inquiry in a variety of studies indicated that only a small portion of individuals diagnosed with PTSD even received EBPs.
Through two decades of treatment, the predominant focus has been on training providers and ensuring fidelity to the treatment protocol with minimal emphasis on patient characteristics and patient preparation. I have found patient characteristics and culture are particularly important in a military environment, where the cultural values are often in conflict with seeking mental health treatment. The United States can easily be described as a highly individualistic culture, where individual freedom of choice is a cherished value. I would argue that the military is much more of a collectivist culture where individual freedoms are often sacrificed in service of the mission, and this culture is essential to the success of the military. Bridging those two cultures in a manner that preserves and respects the values of both cultures is no easy task. I frequently supervise psychology interns whose predominant combat PTSD patient is an individual with 15+ years of military service and multiple combat tours who have a strong affinity for the military culture. Many of the cultural values espoused by the behavioral health culture can be perceived as a direct challenge to the principles that have guided these individuals for many years.
It takes a deliberate effort to meet the patient where they are, set appropriate expectations for treatment outcome, and get the patient to be an active and informed participant in treatment. Mott et al (2014) and DeViva et al (2016) introduce practices intended to be much more inclusive of the patient perspective in making treatment decisions. The research they have engaged in suggests providers slow the process down a little and execute the following objectives prior to treatment: provide education on PTSD and treatment options, problem identification or examination of how the patient’s symptoms impact their lives, identification of barriers to treatment, and finally collaborative treatment planning.
Mott et al (2014) adapted the concept of Shared Decision Making (SDM) as an attempt to increase treatment engagement for individuals diagnosed with PTSD. The authors’ belief is that the education and treatment planning process was already happening at some level between the therapist and patient, but there was no consistency or methodology to how this was being done. The pilot study involves individual sessions that take time (a scarce resource) to inform the patient about their diagnosis and treatment options, and allow them to take an active role in treatment decisions. The pilot study compared the effectiveness of SDM vs. Usual Care (control group) in selecting an EBP. The pilot study was small (n=27, Iraq/Afghanistan Veterans), but the results suggest that the SDM model resulted in a greater EBP selection rate by the patients. “…0% of [Usual Care] participants identified a VHA-endorsed EBP (CPT or PE) as a preferred treatment. In contrast, most SDM participants (67%) selected an EBP.” Additionally, more SDM subjects (100%) received an adequate “dose” (greater than 9 sessions) of treatment than the Usual Care subjects (9%). This pilot study did not track treatment outcomes related to PTSD.
DeViva et al (2016) expanded upon the Mott et al (2014) study by examining the effect on EBP selection of a 4-session (60-minutes/per session) group intervention that is designed to educate patients about PTSD and treatment options. The treatment involves education about PTSD, identification of current problems, identification of barriers to treatment, and finally development a treatment plan with group facilitators.
The Education and Treatment Planning Group was originally implemented as a means of managing referrals for PTSD treatment. This study was a retrospective study reviewing the records of individuals that participated in this group compared to those who did not. The most notable result is that of the individuals that participated in the Education Group (n=114), 46% selected either CPT or PE for treatment when compared to Treatment as Usual (n=68), only 15% selected either CPT or PE. The authors do note that although the Education and Treatment Planning Group appears to increase the likelihood of choosing an EBP, it does not appear to increase the likelihood that an individual will complete an EBP. However, even if the dropout rate remains the same, when more people are starting EBPs, we’re taking a step in the right direction.
Innovation is an important component of advancing our treatment for PTSD. This vein of research attempts to add structure to the process of engaging and informing our patients in the service of creating motivation to select and participate in an EBP for PTSD.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jeffrey Mann, Psy.D. is the Evidence-Based Psychotherapy (EBP) Champion-Consultant Project liaison at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
DeViva, Jason C., Bassett, Gwendolyn A., Santoro, Gia M., Fenton, Lisa. (2016) Effects of Brief Education and Treatment Planning Group on Evidence Based PTSD Treatment Utilization and Completion Among Veterens. Psychological Trauma: Theory, Research, Practice, and Policy
Mott, Juliette M., Stanley, Melinda A., Street, Richard L., Grady, Rebecca H., Tneg, Ellen J. (2014) Increasing Engagement in Evidence-Based PTSD Treatment Through Shared Decision-Making: A Pilot Study. Military Medicine, 179, 2:143
Institute of Medicine. (2007) Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC, National Academies Press