Staff Perspective: Assessing Patient Readiness for Evidence-Based Psychotherapy
Participants at our evidence-based psychotherapy (EBPs) workshops frequently ask how to determine patients’ readiness for treatment. Although providers are often eager to implement the new skills and techniques they learn in our workshops, they also want some guidance on how to prepare patients for EBPs. A recently published article (VA PTSD Clinic Director Perspectives: How Perceptions of Readiness Influence Delivery of Evidence-Based PTSD Treatment) suggests that these are common concerns among treatment providers.
The article reported findings from a study in which the authors interviewed a nationally-representative sample of 38 directors of specialized Post-Traumatic Stress Disorder (PTSD) outpatient treatment clinics within the VA. Directors were asked if and how their programs delivered two gold-standard treatments for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). In what I consider to be excellent news, every director reported that their clinic provided CPT and/or PE and that their staff are encouraged to utilize these treatments when appropriate.
However, the study also revealed obstacles that are sometimes encountered in the delivery of EBPs. Despite Herculean efforts to disseminate CPT and PE within the VA since 2007, and despite the mandate that all Veterans with PTSD be offered an EBP when clinically appropriate, it is estimated that only 6-11% of veterans with PTSD actually begin either treatment. What barriers get in the way? Several trends were noted:
- Veterans of the recent conflicts in Afghanistan (OEF) and Iraq (OIF) were more likely than other Veterans to be offered these treatments
- Structural challenges made it difficult for providers to offer 90-minute sessions (required for PE) or weekly appointments (required for both EBPs)
- Resource challenges of not having enough trained providers to meet the demand
- Veterans’ practical challenges, such as obtaining transportation or taking time off from work to attend sessions
- Providers’ assumptions about patient readiness and the safety of EBPs
Although it is important to consider and address all of these trends, I will focus on this last issue of patient readiness, which seems common across settings. Our faculty encounter similar concerns raised by our civilian and DoD colleagues at CDP-led workshops. Our participants seem genuinely invested in providing the best available treatment to patients, but want to thoughtfully consider the issue of patient readiness.
In this study, 90% of programs offered or required “preparatory” treatments to Veterans prior to beginning PE or CPT. The treatment length varied from “1-2 sessions” to a 20-week protocol. The stated rationale for these preparatory treatments is that they improve patient readiness for EBP by:
- Educating Veterans so that they can make informed decisions about their treatment
- Increasing commitment to treatment and decreasing rates of missed appointments and treatment dropout
- Increasing coping skills and symptom management
- Ensuring patient safety and ability to tolerate EBP
On first glance, these are compelling goals. However, when I read that eligible Veterans may wait up to 20 weeks for an EBP, I become concerned about the potential negative consequences of that delay. In my clinical experience, many clients are ready and eager to begin EBPs following their initial appointments. If we delay EBPs for these patients, we ironically run the risk of having them prematurely drop out of treatment because they’ve lost confidence in their provider and have received the message that treatment is ineffective. In the spirit of Goldilocks and the Three Bears, when it comes to providing EBPs, we want to prepare patients in a way that is not too little or too much, but “just right”.
So how do we ensure patient readiness? In my opinion, there are only a few hard and fast rules:
- Assessing the patient’s safety is paramount; that is, is there imminent risk of the patient harming him/herself, harming someone else, or being harmed (i.e., ongoing domestic violence, etc.)? If so, getting the patient into a safe environment is the primary goal.
- Assess the patient’s substance use history. For patients with severe physical dependence, they may need medical detox prior to starting an EBP. However, EBPs can be started as soon as they are medically stable. Patients with comorbid PTSD and substance use disorders have the best treatment outcomes when both concerns are treated concurrently and providers on the treatment team work collaboratively.
- Standard exclusionary criteria for trauma-focused therapies, such as PE and CPT, include uncontrolled bipolar and psychotic disorders. While recent studies are beginning to challenge these assumptions, most of us will prefer to wait until such patients’ non-PTSD symptoms are stabilized. If the cautions above do not apply to your patient with PTSD, he or she may be ready for an EBP. To help you make that determination, you might discuss the following points with your patient:
- What are their goals and motivations for treatment? If they are eager to improve their symptoms or related psychosocial stressors (work performance, relationship issues, etc.), EBPs may be a good fit. If they describe wanting only to maintain their current functioning, EBPs may not be a good choice. You may want to help them weigh the pros and cons of maintaining their symptoms as you discuss treatment options.
- Do they understand the theories underlying the treatment and the possible risks and benefits? In my experience, patients can cope with a potential increase in anxiety or discomfort during EBP if they are helped to understand why it is occurring and the anticipated benefits and course of treatment.
- Do they have time and resources to complete the treatment? Even the most motivated patient will find it difficult or impossible to complete treatment if they are simultaneously working full-time, going to school full-time, and raising three children, for example. We want to empower our patients to succeed in treatment, not set them up for failure. So talk openly with them about time commitments and help them to problem-solve around foreseeable obstacles. In this example, this fictional patient may have better odds of successful treatment if he waits until the summer semester break and engages in twice-weekly EBP sessions.
So how long does it take to get a patient ready for EBP? This varies from patient to patient. Some of my patients only considered EBPs after they had engaged in years’ worth of supportive therapy and found that it was not giving them the benefits that they wanted. While it’s true that some patients never become interested in EBPs, the majority of my patients have been ready to engage (successfully!) in CPT or PE within a few weeks or months of starting treatment. Often patients require just a couple of sessions to become educated about PTSD and their treatment options, as well as to feel comfortable with their therapist.
In summary, I recommend that you introduce your patients to EBP as soon as it is clinically indicated. Assess your patient’s current symptoms, comorbid conditions, motivation, and availability for treatment. Look at each patient’s individualized needs, rather than using a standardized process that is likely not based on research and may needlessly delay treatment for patients. Remember that delaying treatment goes against our ethical responsibilities and can have the unintended effect of reducing patients’ confidence in treatment and the provider. Take the time to address patients’ questions and concerns. If you’re still unsure, consult with a trusted colleague. Remember that CDP offers free consultation for providers who have attended our EBP workshops and that our consultants enjoy discussing these issues!
Carin M. Lefkowitz, Psy.D., is a clinical psychologist and Cognitive Behavioral Therapy Trainer at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Lefkowitz earned her M.A. and Psy.D. in clinical psychology at Widener University, with a concentration in cognitive-behavioral therapy.
Reference: Hamblen, J. L., Bernardy, N. C., Sherrieb, K., Norris, F. H., Cook, J. M., Louis, C. A., & Schnurr, P. P. “VA PTSD Clinic Director Perspectives: How Perceptions of Readiness Influence Delivery of Evidence-Based PTSD Treatment.” Professional Psychology: Research and Practice. 46.2 (2015): 90-96. DOI: 10.1037/a0038535
Participants at our evidence-based psychotherapy (EBPs) workshops frequently ask how to determine patients’ readiness for treatment. Although providers are often eager to implement the new skills and techniques they learn in our workshops, they also want some guidance on how to prepare patients for EBPs. A recently published article (VA PTSD Clinic Director Perspectives: How Perceptions of Readiness Influence Delivery of Evidence-Based PTSD Treatment) suggests that these are common concerns among treatment providers.
The article reported findings from a study in which the authors interviewed a nationally-representative sample of 38 directors of specialized Post-Traumatic Stress Disorder (PTSD) outpatient treatment clinics within the VA. Directors were asked if and how their programs delivered two gold-standard treatments for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). In what I consider to be excellent news, every director reported that their clinic provided CPT and/or PE and that their staff are encouraged to utilize these treatments when appropriate.
However, the study also revealed obstacles that are sometimes encountered in the delivery of EBPs. Despite Herculean efforts to disseminate CPT and PE within the VA since 2007, and despite the mandate that all Veterans with PTSD be offered an EBP when clinically appropriate, it is estimated that only 6-11% of veterans with PTSD actually begin either treatment. What barriers get in the way? Several trends were noted:
- Veterans of the recent conflicts in Afghanistan (OEF) and Iraq (OIF) were more likely than other Veterans to be offered these treatments
- Structural challenges made it difficult for providers to offer 90-minute sessions (required for PE) or weekly appointments (required for both EBPs)
- Resource challenges of not having enough trained providers to meet the demand
- Veterans’ practical challenges, such as obtaining transportation or taking time off from work to attend sessions
- Providers’ assumptions about patient readiness and the safety of EBPs
Although it is important to consider and address all of these trends, I will focus on this last issue of patient readiness, which seems common across settings. Our faculty encounter similar concerns raised by our civilian and DoD colleagues at CDP-led workshops. Our participants seem genuinely invested in providing the best available treatment to patients, but want to thoughtfully consider the issue of patient readiness.
In this study, 90% of programs offered or required “preparatory” treatments to Veterans prior to beginning PE or CPT. The treatment length varied from “1-2 sessions” to a 20-week protocol. The stated rationale for these preparatory treatments is that they improve patient readiness for EBP by:
- Educating Veterans so that they can make informed decisions about their treatment
- Increasing commitment to treatment and decreasing rates of missed appointments and treatment dropout
- Increasing coping skills and symptom management
- Ensuring patient safety and ability to tolerate EBP
On first glance, these are compelling goals. However, when I read that eligible Veterans may wait up to 20 weeks for an EBP, I become concerned about the potential negative consequences of that delay. In my clinical experience, many clients are ready and eager to begin EBPs following their initial appointments. If we delay EBPs for these patients, we ironically run the risk of having them prematurely drop out of treatment because they’ve lost confidence in their provider and have received the message that treatment is ineffective. In the spirit of Goldilocks and the Three Bears, when it comes to providing EBPs, we want to prepare patients in a way that is not too little or too much, but “just right”.
So how do we ensure patient readiness? In my opinion, there are only a few hard and fast rules:
- Assessing the patient’s safety is paramount; that is, is there imminent risk of the patient harming him/herself, harming someone else, or being harmed (i.e., ongoing domestic violence, etc.)? If so, getting the patient into a safe environment is the primary goal.
- Assess the patient’s substance use history. For patients with severe physical dependence, they may need medical detox prior to starting an EBP. However, EBPs can be started as soon as they are medically stable. Patients with comorbid PTSD and substance use disorders have the best treatment outcomes when both concerns are treated concurrently and providers on the treatment team work collaboratively.
- Standard exclusionary criteria for trauma-focused therapies, such as PE and CPT, include uncontrolled bipolar and psychotic disorders. While recent studies are beginning to challenge these assumptions, most of us will prefer to wait until such patients’ non-PTSD symptoms are stabilized. If the cautions above do not apply to your patient with PTSD, he or she may be ready for an EBP. To help you make that determination, you might discuss the following points with your patient:
- What are their goals and motivations for treatment? If they are eager to improve their symptoms or related psychosocial stressors (work performance, relationship issues, etc.), EBPs may be a good fit. If they describe wanting only to maintain their current functioning, EBPs may not be a good choice. You may want to help them weigh the pros and cons of maintaining their symptoms as you discuss treatment options.
- Do they understand the theories underlying the treatment and the possible risks and benefits? In my experience, patients can cope with a potential increase in anxiety or discomfort during EBP if they are helped to understand why it is occurring and the anticipated benefits and course of treatment.
- Do they have time and resources to complete the treatment? Even the most motivated patient will find it difficult or impossible to complete treatment if they are simultaneously working full-time, going to school full-time, and raising three children, for example. We want to empower our patients to succeed in treatment, not set them up for failure. So talk openly with them about time commitments and help them to problem-solve around foreseeable obstacles. In this example, this fictional patient may have better odds of successful treatment if he waits until the summer semester break and engages in twice-weekly EBP sessions.
So how long does it take to get a patient ready for EBP? This varies from patient to patient. Some of my patients only considered EBPs after they had engaged in years’ worth of supportive therapy and found that it was not giving them the benefits that they wanted. While it’s true that some patients never become interested in EBPs, the majority of my patients have been ready to engage (successfully!) in CPT or PE within a few weeks or months of starting treatment. Often patients require just a couple of sessions to become educated about PTSD and their treatment options, as well as to feel comfortable with their therapist.
In summary, I recommend that you introduce your patients to EBP as soon as it is clinically indicated. Assess your patient’s current symptoms, comorbid conditions, motivation, and availability for treatment. Look at each patient’s individualized needs, rather than using a standardized process that is likely not based on research and may needlessly delay treatment for patients. Remember that delaying treatment goes against our ethical responsibilities and can have the unintended effect of reducing patients’ confidence in treatment and the provider. Take the time to address patients’ questions and concerns. If you’re still unsure, consult with a trusted colleague. Remember that CDP offers free consultation for providers who have attended our EBP workshops and that our consultants enjoy discussing these issues!
Carin M. Lefkowitz, Psy.D., is a clinical psychologist and Cognitive Behavioral Therapy Trainer at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Lefkowitz earned her M.A. and Psy.D. in clinical psychology at Widener University, with a concentration in cognitive-behavioral therapy.
Reference: Hamblen, J. L., Bernardy, N. C., Sherrieb, K., Norris, F. H., Cook, J. M., Louis, C. A., & Schnurr, P. P. “VA PTSD Clinic Director Perspectives: How Perceptions of Readiness Influence Delivery of Evidence-Based PTSD Treatment.” Professional Psychology: Research and Practice. 46.2 (2015): 90-96. DOI: 10.1037/a0038535