Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 6, 547–554

In the public domain http://dx.doi.org/10.1037/tra0000059

Clinical Treatment Selection for Posttraumatic Stress Disorder: Suggestions for Researchers and Clinical Trainers Gina T. Raza and Dana R. Holohan Veterans Affairs Medical Center, Salem, Virginia and Virginia Tech-Carilion School of Medicine Posttraumatic stress disorder (PTSD) disrupts the lives of many Veterans and their families, and multiple treatment options exist. Two evidence-based psychotherapies (EBPs)— cognitive processing therapy (CPT) and prolonged exposure (PE)—are specifically identified by Veterans Affairs (VA) and Department of Defense clinical practice guidelines as first-line treatments. Despite the strong emphasis on training clinicians to provide these EBPs, several questions remain unaddressed. We sought to answer 3 main questions: What associated clinical features are clinicians considering as they select PE or CPT to treat a given patient? What exclusionary criteria are clinicians using? How helpful do clinicians find the extant literature on comorbid conditions and associated clinical features when making treatment decisions? We contacted mental health clinicians who were VA-trained in CPT and PE and requested participation in this online survey. We (a) identified several associated factors that clinicians use to help select between these treatments, (b) determined which associated factors or comorbidities clinicians identified as exclusionary criteria for CPT or PE, and (c) evaluated the perceived utility of research to practicing clinicians. We discuss factors for which clinicians reached a consensus, areas of discrepancy (e.g., substance use), and factors for which further research guidance would be beneficial (e.g., dissociation). Findings imply that VA efforts at disseminating best treatment practices and current PTSD research have been effective. Additionally, findings can help inform treatment guidelines and clinical trainings, as well as highlight gaps in research identified by clinicians. Keywords: posttraumatic stress disorder, evidence-based treatment, treatment selection, cognitive processing therapy, prolonged exposure

Ruzek, 2012) and across various trauma types (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010), such as civilian sexual assault (Resick, Nishith, Weaver, Astin, & Feuer, 2002), child abuse (McDonagh et al., 2005), combat trauma (Forbes et al., 2012), and military sexual trauma (MST; Suris, Link-Malcolm, Chard, Ahn, & North, 2013). Numerous studies also support PE and CPT as useful for Veterans across service eras, from Vietnam through Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) (Chard et al., 2010; Eftekhari et al., 2013; Forbes et al., 2012; Monson et al., 2006; Tuerk et al., 2010; Wolf, Strom, Kehle, & Eftekhari, 2012). It is important to note that treatment gains for CPT and PE have been shown to maintain for 5 or more years posttreatment (Resick, Williams, Suvak, Monson, & Gradus, 2012). Despite the large body of research supporting evidence-based psychotherapies (EBPs), a survey of mental health clinicians in 1999 and 2001 across six VAs found that EBPs were infrequently offered (Rosen et al., 2004). To increase the frequency of EBP use, the VA began roll-outs of PE and CPT in 2007. At the end of 2012, VA websites (CPT and PE Sharepoint websites) stated that over 1,300 clinicians had been trained in PE and over 5,900 VA and military clinicians were trained in CPT (http://www.ptsd.va.gov). VA supports these training efforts with EBP coordinators at each VA, online resources and manuals, patient and provider CPT and PE videos, and VA PTSD Mentoring Program calls to disseminate best practices. Results from the first three years of PE and CPT dissemination and implementation roll-outs have shown progress in the intended

Posttraumatic stress disorder (PTSD) is estimated to impact the lives of 10%–30% of veterans (Thomas et al., 2010) and is a disabling condition that is the most costly anxiety disorder to treat (Greenberg et al., 1999). Many initial PTSD treatment studies focused on civilian sexual trauma survivors, whereas more recent research documented treatment efficacy with veterans (Chard, Schumm, Owens, & Cottingham, 2010; Monson et al., 2006; Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010). Two efficacious PTSD treatments, prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (CPT; Resick, Monson, & Chard, 2010) are identified as first-line PTSD treatments by the Department of Veterans Affairs (VA) Clinical Practice Guidelines (2010). Research has found both PE and CPT effective for the treatment of PTSD from single or multiple traumas (Rauch, Eftekhari, &

This article was published Online First June 8, 2015. Gina T. Raza and Dana R. Holohan, Veterans Affairs Medical Center, Salem, Virginia and Virginia Tech-Carilion School of Medicine. This material is the result of work supported with resources and the use of facilities at the Salem VA Medical Center. The welfare of participants was protected and the IRB approved all research. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Correspondence concerning this article should be addressed to Gina T. Raza, Veterans Affairs Medical Center, Salem, 1970 Roanoke Boulevard, Psychology (116A6), Salem, VA 24153. E-mail: [email protected] 547

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directions: Trained clinicians reported increased confidence in providing PE and CPT, with increased belief in positive treatment outcomes (Karlin et al., 2010). Veterans treated with PE or CPT evidenced significant reductions in PTSD symptoms. A 2009 survey of all VA medical centers found that “96% of facilities were providing CPT or PE” and “72% were providing both” (Karlin et al., 2010, p. 669). Cook et al. (2013) found that, after training, CPT and PE were implemented in some VA residential PTSD programs. Borah et al. (2013) found that the majority of military mental health providers considered the CPT or PE trainings valuable, would recommend them to colleagues, and had used CPT or PE since training. Eftekhari et al. (2013) noted that after training, relative novices with PE successfully implemented it. Thus, VA trainings appear to have been successful. Although we know PE and CPT are effective and utilized, we do not know how clinical decisions are being made by those trained in these EBPs. What clinical features do clinicians use to select treatment? What exclusionary criteria do clinicians consider for PE or CPT? Do clinicians’ decisions match the research guidance that is available? It would be beneficial to know for which variables clinicians desire more research guidance. It is astonishing that there is no research to date that examines how clinicians select between PE and CPT for any given patient. This can be partially attributed to the dearth of research comparing PE and CPT to one another, providing little data to inform clinicians’ decisions. As of 2012, there had “only been one study comparing CPT with another evidence-based treatment (PE)” (Chard, Ricksecker, Healy, Karlin, & Resick, 2012, p. 676, referring to the Resick et al., 2002 study which resulted in multiple articles). This 2002 study found PE and CPT to be similarly efficacious for reducing PTSD and depression, with improvements maintained at 9-month follow-up. The lack of studies directly comparing CPT and PE makes it difficult to determine “which patients are more appropriate for one treatment over the other” (Chard et al., 2012, p. 676). This is especially true given that complex presentations are more of a rule than exception: the National Comorbidity Survey found a lifetime history of one or more additional diagnoses in nearly 90% of men and nearly 80% of women with PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). This can make treatment selection especially challenging. Although there is little research directly comparing CPT and PE, there are many separate studies supporting the use of each treatment for certain comorbidities or clinical presentations. For instance, PE (Eftekhari et al., 2013; Foa et al., 2005; Hagenaars, van Minnen, & Hoogduin, 2010; Rauch et al., 2012; Tuerk et al., 2010; Wolf et al., 2012) and CPT (Chard et al., 2012; Liverant, Suvak, Pineles, & Resick, 2012; Resick et al., 2002) have been shown to reduce depression. Resick and colleagues (2012) found reductions in depression to be maintained at 5 to 10 year follow-up, with CPT reducing depression symptoms more than PE. Similarly, PE (Cahill, Rauch, Hembree, & Foa, 2004; Foa et al., 2005; Rauch et al., 2012) and CPT (Forbes et al., 2012; Resick & Schnicke, 1996) have been found effective for reducing anger and overall anxiety. However, one study found greater dropout for PE (vs. CPT) when strong anger was present (Rizvi, Vogt, & Resick, 2009, using data from Resick et al., 2002). A greater number of articles reported reductions in guilt or shame for CPT than for PE (Nishith, Nixon, & Resick, 2005; Resick et al., 2002), yet several case studies

reported successful use of PE when strong shame was present (Jaycox, Zoellner, & Foa, 2002; Yoder, Tuerk, & Acierno, 2010). A handful of recent studies with small samples found PE and CPT to reduce dissociation (Hagenaars et al., 2010; Resick, Suvak, Johnides, Mitchell, & Iverson, 2012), and to be effective with mild, moderate, or even severe traumatic brain injury (TBI) when combined with residential treatment (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011; Wolf et al., 2012). Similarly, patients with borderline personality disorder (BPD) or BPD characteristics who were engaged in dialectical behavior therapy (DBT) or inpatient hospitalization showed benefit from concurrent PE or CPT (Clarke, Rizvi, & Resick, 2008; Feeny, Zoellner, & Foa, 2002; Harned, Korslund, Foa, & Linehan, 2012). How aware clinicians are of these findings and whether this research impacts treatment selections is not yet addressed by the extant literature. With several thousand providers trained in CPT and PE over the last 7 years and their use burgeoning, it is not known what exclusionary criteria clinicians are using when selecting PTSD treatments and whether these are grounded in research and consistent with clinical trainings. Although research supports the use of PE and CPT in the presence of many comorbidities and associated clinical features, exclusion criteria are found in treatment manuals, research articles, and PTSD treatment guidelines. Exclusion criteria for both PE and CPT have included the following: active psychosis, current self-injury, active suicidal or homicidal intent, ongoing trauma, and substance dependence (Chard et al., 2012; Clarke et al., 2008; Foa et al., 2005, 2007; Resick et al., 2002). There are also treatment-specific rule-outs: CPT may not be beneficial for individuals with severe dementia, and mania should be stabilized prior to treatment (Chard et al., 2012). Additionally, given CPT’s emphasis on written homework, it may not be appropriate for individuals who are illiterate (Chard et al., 2012; Resick et al., 2002). Given PE’s emphasis on repeated descriptions of the traumatic event, it may not be appropriate for those with insufficient memory for their traumatic event or events (Foa et al., 2007). Recent clinical suggestions also emphasize careful assessment of psychopathy, prior perpetration or antisocial traits, context, shame, and empathy, prior to using PE for perceived acts of perpetration (Smith, Duax, & Rauch, 2013). If disgust was the primary emotion during a trauma, PE proponents suggest focusing on another emotion for habituation but do not consider disgust to be a rule-out (Engelhard, Olatunji, & de Jong, 2011). Less clarity is found for whether substance use, cognitive functioning, or subthreshold symptoms should be exclusion criteria for PE or CPT. Active substance use has not been consistently used as exclusion in the literature. Several studies have suggested PE and CPT can be effective despite active substance abuse (Chard et al., 2012; Kaysen et al., 2014) and that CPT correlated with a reduction in alcohol use (Forbes et al., 2012), although active alcohol or substance use also predicted treatment drop-out (van Minnen, Arntz, & Keijsers, 2002). Similarly, several studies indicated that cognitive functioning is not a clear exclusion: Neither low IQ nor education level was found to have an effect on PE or CPT outcomes (Rizvi et al., 2009), although lower IQ correlated with higher treatment drop-out. Other studies have excluded individuals with significant cognitive impairment (Forbes et al., 2012) or severe dementia (Chard et al., 2012). We could find no CPT or PE treatment studies specifically discussing subthreshold PTSD as an exclusion criterion. The PE therapist guide suggests using clinical

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judgment, stating “if full diagnostic criteria are not met, the client should still have significant symptoms of the disorder that are distressing and interfering” (Foa, Hembree, & Rothbaum, 2007, p. 24) for PE to be offered. Likewise, the CPT therapist guide states that “there is no reason that it [CPT] could not be implemented with someone who is subthreshold for diagnosis” (Resick, Monson, & Chard, 2010, p. 3). This study investigated whether VA clinicians’ treatment decisions match with the available literature and guidelines that exist to date.

Study Aims Clinicians currently have an incomplete set of guidelines for when CPT or PE is more likely to be beneficial for a given patient. Clinicians may make treatment selections based on their clinical training, research knowledge, clinical judgment, clinic restrictions, logistics (e.g., time, resources), and personal preferences. The present study addressed several research questions, so as to offer data to help guide future clinical trainings and treatment research. First, we examined which variables (mental health symptoms or conditions such as TBI) clinicians trained in both CPT and PE currently use to help decide between PE and CPT for a given patient. Next, we assessed which variables they considered to be exclusion criteria for PE, CPT, or both. From this, we offer recommendations for future VA trainings. Specifically, we hope future trainers could emphasize variables that research has supported as helpful in selecting between CPT and PE and variables that research or clinical guidelines/consensus suggest as rule-outs for current use of CPT or PE. Finally, we assessed the extent to which clinicians believe the current research helps them in making decisions between PE and CPT. From this, we identify (a) which variables clinicians would like to see further research on, so as to aide in clinical decisions and (b) areas of the research that are less familiar to clinicians so these could be highlighted in future trainings.

Method Participants All mental health care professionals listed on the CPT and PE SharePoint websites in 2013 as having participated in VA or DoD trainings on PE or CPT were contacted via e-mail (over 1,500 clinicians who had valid e-mail addresses/were still in the VA/ DoD system). We requested their voluntary, anonymous participation, and asked them to forward our request to colleagues and trainees who treated PTSD. Participants were informed that the study’s purpose was to determine how clinicians select between PTSD treatment options. We received 487 respondents. Twelve participants (3%) who reported that they used neither CPT nor PE were excluded. So that lack of comprehensive training would not bias treatment selection, we asked if participants had been VA trained or were in the process of completing a CPT or PE training. We removed from the sample those who learned about CPT/PE in a graduate program, non-VA training, were self-taught, or were untrained. With the inclusion criterion of being VA-trained in both CPT and PE, we ultimately had 247 participants.

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Participant demographic data is provided for the sample (N ⫽ 247). Respondents were primarily female (74%; 182). For those who provided their age (n ⫽ 233), ages ranged from 25 to 75 (M ⫽ 44.7, SD ⫽ 10.3). The majority of the sample self-identified as Caucasian (88%; 217), with 3% (8) African American, 4% (10) Latino/a, 1% (1) Asian American (e.g., Indian, Filipino, Japanese), less than 1% (1) American Indian, and 3% (8) biracial or multiracial. Clinicians reported their degrees as PhD (47%; 116), MA/MS/ MSW (38%; 93), PsyD (14%; 34), or MD (1%; 3). Reported disciplines were psychology (61%; 149), social work (35%; 87), psychiatry (2%; 4), counseling (1%; 3), and other (1%; 3). Theoretical orientations were reported as follows: 70% (171) cognitive– behavioral, 10% (24) eclectic, 7% (17) integrative, 5% (12) behavioral, 3% (7) psychodynamic, and 5% (12) other. The majority (65%; 160) reported currently or typically supervising trainees. Of the clinicians, 50% (122) reported no personal trauma exposure, 39% (95) reported trauma exposure, and 11% (28) declined to respond.

Procedure An online survey link was sent via email, requesting participation from identified VA mental health clinicians who had participated in VA trainings on PE or CPT. Potential participants were sent one e-mail reminder 3 weeks after the study began, and the online survey was active for 1 month. Participants were not compensated for their participation.

Measures Survey items. Participants were informed of our focus on which co-occurring factors helped them choose between CPT and PE for PTSD. Participants were presented with a list of factors: current depression, strong anger, strong guilt, strong shame, general anxiety, disgust, dissociation history, current substance dependence, unmedicated bipolar, active psychotic symptoms, active suicidal intent, current self-injury, current panic attacks, borderline personality disorder (BPD) or characteristics, subthreshold PTSD, low literacy, mild traumatic brain injury (TBI), moderate to severe TBI, low cognitive functioning, acts of perpetration, ongoing trauma, patient preference for CPT or PE, single trauma, multiple traumas, combat trauma, noncombat trauma, military sexual trauma (MST), Vietnam or Korean era, OEF/OIF/OND era. Participants were asked three main questions: (a) When treating a patient for trauma, which treatment (PE, CPT, either, or neither) are you more likely to use for an individual with each of these additional variables? (b) Please indicate whether you consider any of these factors to be exclusion criteria for using PE and/or CPT. (c) To what extent has research helped you make decisions about which treatment to offer to patients with trauma (PE or CPT or neither) with these additional symptoms or variables (not at all, slightly, somewhat, a lot, very strongly)? We also requested write-in responses for any additional variables participants used (a) to decide whether to use PE or CPT and (b) as exclusionary criteria for either or both treatments. This online survey took approximately 10 min to complete. Demographics. Participants were asked to specify CPT and PE training-levels, if they regularly used CPT or PE, personal

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preference for CPT or PE or no preference, if they supervised trainees, and treatment options offered at their VA (PE or CPT individually or in group, inpatient PE or CPT-based programs, etc.). Age, gender, race, highest degree, mental health specialty, theoretical orientation, and personal trauma exposure were also collected.

Results Analyses were conducted using SPSS 17.0. Among our final sample (N ⫽ 247), 46% (n ⫽ 114) reported a personal preference for PE, 41% (n ⫽ 101) had no preference for PE or CPT, and 13% (n ⫽ 32) had a preference for CPT. This preference for PE was unexpected. Using chi-square tests, we assessed whether participant demographics influenced these preferences. We found no significant differences for treatment preference across clinician racial identification, sex, mental health discipline, theoretical orientation, level of education, or personal trauma experience. Clinicians indicated that their VAs offered many PTSD treatment options: individual CPT at 98% (n ⫽ 243) of clinicians’ VAs, individual PE at 99% (n ⫽ 246), group CPT at 77% (n ⫽ 190), and outpatient group exposures (in vivo or imaginal) at 21% (n ⫽ 52). Further, PE- or CPT-based inpatient programs (17%; n ⫽ 43), other inpatient PTSD programs (21%; n ⫽ 50), and additional PTSD treatments (19%; n ⫽ 48; e.g., psycho-education, Seeking Safety (Najavits, 2007), Eye-Movement Desensitization and Reprocessing (Shapiro, 1989), DBT (Linehan, 1993) were offered. Selecting PE or CPT. We asked clinicians whether they would use PE, CPT, either, or neither treatment when certain variables co-occurred with PTSD. We found that, for the majority of variables, most clinicians would use either treatment (see Table 1 for factors that varied). Of particular interest are the variables

that helped to differentiate between PE and CPT: Clinicians were most likely to select PE over CPT when low literacy (84%; n ⫽ 207), low cognitive functioning (70%; n ⫽ 172), or moderate-tosevere TBI (43%; n ⫽ 106) was present. Although most clinicians stated that they would use either treatment in instances of a single trauma (64%; n ⫽ 158), mild TBI (62%; n ⫽ 153), or current panic attacks (57%; n ⫽ 140), for those who selected between PE and CPT, the majority chose PE (33%; n ⫽ 82) for single trauma, 30% (n ⫽ 74) chose PE for mild TBI, and 28% (n ⫽ 70) chose PE for panic over CPT. Clinicians were most likely to select CPT over PE when a patient has strong guilt (49%; n ⫽ 120) or strong shame (45%; n ⫽ 110), although a significant number of clinicians felt that guilt or shame could be addressed by either treatment (37%; n ⫽ 91 and 39%; n ⫽ 96, respectively). Although most clinicians (44%; n ⫽ 107) stated that they would use either treatment for subthreshold PTSD, for those who selected, the majority chose CPT (29%; n ⫽ 71) over PE (9%; n ⫽ 21). For both PE (91%; n ⫽ 225) and CPT (92%; n ⫽ 227), clinicians were highly likely to select treatment on the basis of patient preference. Dissociation history, current substance dependence, and acts of perpetration were the factors with the least clinician consensus. For dissociation, 40% (n ⫽ 98) would select CPT, and 39% (n ⫽ 95) would use either treatment. For current substance dependence, clinicians were divided as to whether they would use either (41%; n ⫽ 101) or neither treatment (44%; n ⫽ 109). For acts of perpetration, 35% (n ⫽ 86) would select CPT, 24% (n ⫽ 59) would use either treatment, and 35% (n ⫽ 85) would use neither treatment. Exclusion. We asked clinicians whether they considered specific factors to be exclusion criteria for PE, CPT, or both. The vast majority suggested very few exclusion criteria for PE and CPT

Table 1 Percent of Clinicians Selecting Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Either, or Neither for Each Listed Factor Co-occurring variable

PE (%, n)

CPT (%, n)

Either (%, n)

Neither (%, n)

Low literacy Low cognitive functioning Moderate/severe TBI Mild TBI Subthreshold PTSD Strong guilt Strong shame Acts of perpetration Dissociation history Current substance dependence Single trauma Current panic attacks

84 (207) 70 (172) 43 (106) 30 (74) 9 (21) 13 (31) 15 (37) 5 (13) 11 (27) 7 (18) 33 (82) 29 (70)

1 (3) 2 (4) 4 (10) 5 (13) 29 (71) 49 (120) 45 (110) 35 (86) 40 (98) 7 (18) 3 (7) 11 (28)

11 (27) 16 (40) 19 (47) 62 (153) 44 (107) 37 (91) 39 (96) 24 (59) 39 (95) 41 (101) 64 (158) 57 (140)

4 (9) 13 (31) 33 (81) 3 (7) 19 (46) 2 (4) 2 (4) 35 (85) 10 (25) 44 (109) 0 (0) 3 (8)

Note. Ns ⫽ 243–247. Exact sample sizes listed parenthetically after each percentage. Modal responses bolded. Response options: I am more likely to use PE; I am more likely to use CPT; I am equally likely to use PE or CPT; I would NOT use PE or CPT. Dissociation history and substance dependence are nearly bimodal; acts of perpetration is bimodal. The majority (63%– 81%) would use either treatment when these were present: single (n ⫽ 158) or multiple (n ⫽ 155) traumas, combat (n ⫽ 193), or noncombat (n ⫽ 199) trauma, depression (n ⫽ 166), anger (n ⫽ 145), MST (n ⫽ 177), disgust (n ⫽ 154), general anxiety (n ⫽ 168), Vietnam or Korean era (n ⫽ 194), or OEF/OIF/OND era (n ⫽ 192). The majority (66%– 88%) would use neither treatment when these were concurrent: psychotic symptoms (n ⫽ 216), suicidal intent (n ⫽ 213), self-injury (n ⫽ 163), ongoing trauma (n ⫽ 188), or unmedicated bipolar (n ⫽ 189). TBI ⫽ traumatic brain injury; PTSD ⫽ posttraumatic stress disorder; MST ⫽ military sexual trauma; OEF/OIF/OND ⫽ Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn.

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(see Table 2 for factors that varied). However, clinicians did not show a strong consensus for the following: moderate to severe TBI, low cognitive functioning, acts of perpetration, current substance dependence, and current self-injury. For these factors, 30% to 59% (see Table 2 for exact sample sizes) of clinicians ruled out one or both treatments, whereas another 35% to 58% did not consider them to be exclusion criteria. Clinicians also lacked consensus on several safety-related factors. As seen in Table 2, though the majority (71% to 83%) considered active suicidal intent, active psychotic symptoms, unmedicated bipolar, and ongoing trauma to be exclusion criteria, some clinicians did not (13% to 24%). Analyses showed that participants who did not consider active self-injury or ongoing trauma to be rule-outs did not differ from the rest of the sample by mental health discipline, degree, theoretical orientation, or sex. Last, although the majority (75%) did not consider dissociation history to be an exclusion criterion, 14% considered it an exclusion criterion for PE but only 1% for CPT. Open-ended responses. Approximately half of participants completed the write-in items (n ⫽ 146, 59% for PE, and n ⫽ 139, 56% for CPT). Of these, the most frequent reiterated our study variables: the primacy of veteran preference in treatment selection; selecting PE for a single trauma, low literacy, or low education level; selecting CPT for multiple traumas or prominent guilt/ shame; and choosing neither for acts of perpetration. A minority of participants listed alternative responses. The following themes emerged as reasons for selecting PE (listed in order of response frequency): patient dislikes written work or therapist expects low homework adherence, prominent avoidance or reexperiencing symptoms, fear as the primary emotion, therapist wants to focus on emotions and believes CPT may aid in avoidance via intellectualizing, therapist expects in vivo exposures will reduce fear and reintegrate patient into community, therapist believes PE is simpler to implement or is faster, past successes with PE, past incomplete success of patient with CPT, patient expressed desire to process event verbally. The following themes emerged as reasons for

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selecting CPT: patient expressed willingness to complete written homework, clear stuck points expressed during intake, fewer avoidance symptoms, mild or subthreshold symptoms, patient’s previous positive experiences with journaling or with CBT, patient or clinic preference for group therapy, resource limitations (CPT requires no recorder; 60- vs. 90-min sessions), trouble with memory for trauma. Research. We asked clinicians to rate the extent to which the current research helped them to select between PE and CPT. The majority reported research was somewhat to very strongly helpful for making treatment decisions for all presented variables. Participants as a whole reported relatively lower confidence in research regarding PTSD with disgust (57%; n ⫽ 137 stated it was somewhat to very strongly helpful) or acts of perpetration (58%; n ⫽ 142), and relatively stronger confidence in research on PTSD with guilt (80%; n ⫽ 197), shame (77%; n ⫽ 191), depression (79%; n ⫽ 195), single (77%; n ⫽ 189) or multiple (76%; n ⫽ 188) traumas, combat (84%; n ⫽ 208) versus noncombat (83%; n ⫽ 205) trauma, MST (84%; n ⫽ 208), and active suicidal intent (77%; n ⫽ 190).

Discussion Our foremost finding is that clinicians are making decisions as to when to use CPT and/or PE that are highly consistent with each other and with the research. Consistent with the research, clinicians believed that either PE or CPT could be used for the majority of factors under consideration and did not consider most factors to be exclusion criteria. Likewise, selection between PE and CPT was generally in agreement with the research. For example, clinicians were more likely to select PE when low literacy was present, and more likely to select CPT when strong guilt/shame was present. Clinicians also took patient treatment preference into account, in line with VA and DoD clinical guidelines (Management of Posttraumatic Stress Working Group, 2010) which emphasize that

Table 2 Percentage of Clinicians Rating Each Factor As an Exclusion Criterion for Prolonged Exposure (PE) and/or Cognitive Processing Theory (CPT) Co-occurring variable

Rule out PE (%, n)

Rule out CPT (%, n)

Rule out both (%, n)

Not an exclusion (%, n)

Low literacy Low cognitive functioning Moderate/severe TBI Acts of perpetration Dissociation history Current substance dependence Unmedicated bipolar Current self-injury Ongoing trauma Active psychotic symptoms Active suicidal intent

0 (1) 1 (2) 2 (4) 11 (27) 14 (34) 4 (10) 4 (10) 5 (13) 5 (13) 4 (9) 3 (7)

36 (88) 34 (83) 22 (53) 1 (2) 1 (2) 1 (3) 0 (1) 0 (0) 0 (1) 0 (0) 0 (0)

2 (5) 7 (18) 30 (73) 33 (81) 9 (22) 51 (125) 71 (176) 59 (145) 71 (175) 83 (205) 83 (204)

61 (150) 58 (142) 46 (114) 53 (132) 75 (186) 44 (108) 24 (59) 35 (87) 22 (55) 13 (13) 14 (34)

Note. Ns ⫽ 242–246. Exact sample sizes listed parenthetically after each percentage. Modal responses bolded. Answer options: I would NOT use PE; I would NOT use CPT; I would NOT use PE or CPT; I do not consider this an exclusion criterion. The following variables were NOT considered to be exclusion criteria by the majority (78%–99%): current depression (n ⫽ 243), strong anger (n ⫽ 234), strong guilt (n ⫽ 242), strong shame (n ⫽ 243), mild TBI (n ⫽ 237), general anxiety (n ⫽ 242), disgust (n ⫽ 238), single (n ⫽ 245) or multiple (n ⫽ 242) traumas, combat (244) or noncombat (244) trauma, MST (n ⫽ 242), current panic attacks (n ⫽ 238), Vietnam or Korean era (n ⫽ 245), OEF/OIF/OND era (n ⫽ 242), BPD/characteristics (n ⫽ 207), patient prefers PE (n ⫽ 192) or CPT (n ⫽ 192), and subthreshold PTSD (193). TBI ⫽ traumatic brain injury; PTSD ⫽ posttraumatic stress disorder; MST ⫽ military sexual trauma; OEF/OIF/OND ⫽ Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn.

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“patient preferences along with provider recommendations should drive the selection of treatment” (p. 30). Particular factors led clinicians to discriminate between PE and CPT. Clinicians more often selected PE over CPT for low cognitive functioning, moderate-to-severe TBI, single trauma, mild TBI, or current panic attacks. These decisions may have been influenced by PE’s behavioral exposures, relatively less cognitive nature, and its typical focus on one trauma, although there is no available research suggesting that PE is more effective than CPT in these circumstances. Similarly, clinicians more often selected CPT over PE for subthreshold PTSD. This preference may relate to the fact that addressing cognitive distortions is relevant across many treatments. However, there is no research indicating PE would not be equally efficacious. Dissociation history, current substance dependence, and acts of perpetration resulted in the least clinician consensus, which likely reflects the relative lack of guidance on these factors. The majority chose CPT for dissociation, nearly tied with those who would use either treatment. Limited research on dissociation (e.g., Hagenaars et al., 2010; Resick et al., 2012) suggests either treatment may be used. For current substance dependence, clinicians were split between using either (41%) or neither (44%) treatment. Recent guidelines and research suggest CPT or PE may be used with concurrent substance use, on a case-by-case basis (e.g., Chard et al., 2012; Forbes et al., 2012), though our data suggest clarifying this further in trainings and future studies would be helpful. Our results are also likely an incomplete picture of clinical decisions regarding PTSD and substance use, as there is a growing literature on treatment options beyond CPT and PE that may impact clinical decision making. For example, Seeking Safety (Najavits, 2007; Ouimette, Brown, & Najavits, 1998) specifically targets comorbid PTSD and substance use, and Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; Mills et al., 2012) is a treatment being developed which adapts PE for use with concurrent substance use. Clinicians may select one of these rather than PE or CPT for patients with comorbid substance use, and we did not assess this in our study. Regarding acts of perpetration, clinical trainings and treatment guidelines could highlight the nuances to consider when determining if CPT or PE is appropriate. Clinicians were split between using CPT, using CPT or PE, or considering such acts as exclusion criteria for both, reflecting a lack of research or guidance. Until very recently, there was no published guidance on this topic. Smith, Duax, and Rauch (2013) offer guidance on using PE in cases of perpetration. They suggest assessing psychopathy, shame, empathy, prior perpetration, and context. If PE is used, they suggest using clinical judgment to tailor psychoeducation and imaginal exposures, and incorporating amends into in vivo exposures, as appropriate. These authors note that “for patients who have a longer-standing history and pattern of antisocial acts, absence of guilt, overconcern for negative consequences of disclosure, PTSD is not likely a primary diagnosis and treatment via PE is not appropriate” (Smith et al., 2013, p. 9). The CPT manual offers similar advice, stating to first “determine if a patient’s self blame is a form of assimilation” and then if the act was “intended and unprovoked harm against an innocent person,” further assess whether this is a behavioral pattern or something that only occurred in the context of war (Resick, Monson, & Chard, 2014, p.

78). If the incident only occurred during war, the manual advises to help the patient evaluate who s/he is, consider contextual factors, discuss values and self-forgiveness, and make amends as possible. No strong consensus was found for moderate to severe TBI or low cognitive functioning. Although approximately one third to one half of clinicians ruled out one or both treatments, another one half did not consider these to be exclusion criteria. This may reflect the very limited research available on TBI and cognitive functioning, and the need for additional guidance. Another area of interest relates to patient safety. Although the majority considered active suicidal intent, active psychotic symptoms, unmedicated bipolar, and ongoing trauma to be exclusion criteria, as many as one fourth of the sample did not. One third of our sample did not consider current self-injury a rule-out for treatment. Currently, clinical researchers suggest stabilizing bipolar, suicidal intent, psychotic symptoms, or ongoing trauma prior to the use of trauma-focused treatment. Given the substantial minority of participants who did not consider these factors to be rule-outs for trauma-focused treatment, future trainings should highlight the stabilization of these factors prior to PE or CPT. Clinicians reported that, overall, research on co-occurring factors was strongly helpful. They also demonstrated an awareness of areas where research does not offer much guidance, such as with feelings of disgust or acts of perpetration. These encouraging results may reflect the VA’s efforts to help clinicians stay up-todate on PTSD research (e.g., emailing quarterly PTSD research summaries, offering a database on PTSD literature, training programs).

Limitations A notable strength of the study is a large sample of diverse clinicians who routinely diagnose and treat comorbid PTSD. Despite this, a relative minority of all VA clinicians trained in CPT and PE participated in the study. Furthermore, our sample showed a preference for PE. We are unaware of differences that may exist between this sample and those who did not participate, and whether there was a selection bias that resulted in certain providers participating. We are also unaware of how frequently each clinician uses each modality and their level of comfort with each treatment; this would be useful information. The need for brevity also resulted in several limitations: We did not assess common, complex presentations (e.g., TBI, current alcohol use, and multiple traumas) and did not include options to select treatments other than PE or CPT that address PTSD (e.g., Seeking Safety). These are important questions for future research as it would allow for consideration of sequential or concurrent treatment. We also did not assess clinicians’ use of PTSD symptom cluster intensity when selecting treatment (e.g., patients with prominent avoidance, arousal, cognitive, or reexperiencing symptoms). To decrease social desirability responding, we asked participants whether they found the research helpful. However, it is unclear whether participants who indicated that research was not helpful had knowledge of the research and found it to be unhelpful or did not have knowledge of the available research. We also did not assess abuse versus dependence or consider clinicians’ views on varying substances (e.g., alcohol vs. cocaine).

CLINICIAN TREATMENT SELECTION

Conclusion We found that the majority of clinicians reported selections of PE and CPT that were in agreement with the research. Several factors stood out as those with less clinician consensus or as safety-related factors which not all clinicians considered to be priorities ahead of trauma-focused treatment. Researchers could provide clinicians with a great service by bolstering research on these factors. Then, informed by this research, clinical guidelines and trainers could offer further guidance on factors such as moderate-to-severe TBI, comorbid substance use, acts of perpetration, dissociation, low cognitive functioning, panic attacks, disgust, and subthreshold PTSD. Similarly, these findings serve as a reminder that clinical guidelines and trainings should continue to highlight the need to stabilize current safety concerns (e.g., active suicidal intent, active self-injury) prior to initiating trauma-focused treatment. These findings call for additional research examining whether specific patient populations respond better or worse to each treatment (CPT/PE). We recommend that all studies include specifics about those who respond well and poorly to each treatment. Similarly, with the changes to the fifth edition of the Diagnostic and Statistical Manual of mental disorders (DSM–5; American Psychiatric Association, 2013), there was a re-categorization of problematic substance use. Researchers could aide clinicians by clarifying their exclusion criteria and whether differences in results were found across individuals with varying levels of substance use.

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Received January 30, 2014 Revision received April 22, 2015 Accepted April 26, 2015 䡲