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Lee, A.J.; Lafreniere, L.S. Psychotherapy for PTSD of Veterans Affairs. Encyclopedia. Available online: https://encyclopedia.pub/entry/52645 (accessed on 20 July 2024).
Lee AJ, Lafreniere LS. Psychotherapy for PTSD of Veterans Affairs. Encyclopedia. Available at: https://encyclopedia.pub/entry/52645. Accessed July 20, 2024.
Lee, Alexander J., Lucas S. Lafreniere. "Psychotherapy for PTSD of Veterans Affairs" Encyclopedia, https://encyclopedia.pub/entry/52645 (accessed July 20, 2024).
Lee, A.J., & Lafreniere, L.S. (2023, December 13). Psychotherapy for PTSD of Veterans Affairs. In Encyclopedia. https://encyclopedia.pub/entry/52645
Lee, Alexander J. and Lucas S. Lafreniere. "Psychotherapy for PTSD of Veterans Affairs." Encyclopedia. Web. 13 December, 2023.
Psychotherapy for PTSD of Veterans Affairs
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This entry is adapted from the peer-reviewed paper 10.3390/traumacare3040024

The United States Department of Veterans Affairs (VA) uses a systematized approach for disseminating evidence-based, trauma-focused psychotherapies for post-traumatic stress disorder (PTSD). Within this approach, veterans with PTSD must often choose between Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), each delivered in their standard protocols. Many veterans have been greatly helped by this approach. Yet limiting trauma-focused therapy to these two options leaves the VA unable to fully address the needs of a variety of veterans. 

post-traumatic stress disorder attrition veterans affairs military trauma-focused psychotherapy trauma

1. PTSD in Veterans of Military Service

Post-traumatic stress disorder (PTSD) is a psychological syndrome that may develop after exposure to an event involving the perceived danger of death or sexual violence (i.e., a trauma). Such situations include near-death experiences, sexual assault, or witnessing the death of a beloved person, among others. A diagnosis of PTSD requires a specific set of enduring and interfering symptoms resulting from a trauma, including mental intrusions, avoidance, arousal or reactivity, and negative mood changes (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision [DSM-5-TR]) [1]. Unfortunately, veterans are particularly at risk of experiencing trauma both during and outside of their military service. In a survey of 3157 veterans, 87% reported experiencing at least one potentially traumatic event in their lifetime [2]. Results showed a mean of 3.4 traumatic events per veteran (SD = 2.8). Such events include military combat, the sudden death of a close friend or family member, witnessing death and injury, and military and non-military sexual trauma [3].
Although veterans may experience trauma of all kinds, participating in combat bears a particularly high likelihood of traumatic events. The duration and intensity of traumas experienced in combat are often associated with elevated levels of PTSD symptoms [4][5][6]. Those who have had extensive combat exposure are also thought to be around 25–35% more likely to develop PTSD [2]. Furthermore, the uniqueness of combat can result in symptoms specific to the battlefield [7]. Thus, combat-related PTSD differs from PTSD seen in other populations [5]. However, despite differences in individual symptoms and their severity, combat-related PTSD and non-combat PTSD are usually addressed with the same treatments [8][9][10].

2. Current Trauma-Focused Psychotherapies Offered by the Department of Veterans Affairs

Currently, the Veterans Affairs (VA) offers several specific psychotherapies to treat PTSD [9][11]. Broadly, VA psychotherapies can be categorized as trauma-focused or non-trauma-focused therapies. Trauma-focused therapies concentrate on processing traumatic events. They involve patients willingly engaging with trauma-related memories, beliefs, and cues/triggers in some way. This engagement can be performed through any combination of behavioral, cognitive-behavioral, or emotion-focused strategies [9]. On the other hand, non-trauma-focused psychotherapies do not engage with the traumatic event itself. Instead, they focus on veterans garnering support and empathy, understanding/insight, and adaptive response patterns in ways that are not directly related to trauma stimuli [12] Current non-trauma-focused therapies offered by the VA include Stress Inoculation Therapy (SIT), Present-Centered Therapy (PCT), and Interpersonal Psychotherapy (ITP). The VA also offers Cognitive Behavioral Conjoint Therapy (CBCT) for couples, helping partners understand and manage the impact of PTSD on their relationship. Some of these psychotherapies tend to be used if patients are unwilling to engage with their trauma directly. A sequential combination of any of these therapies may be used, as veterans can generally receive treatment for as long as they need. Although trauma and non-trauma-focused therapies can both achieve beneficial results, trauma-focused therapies have been demonstrated to be significantly more efficacious [13][14][15]. 

3. Dissemination of Evidence-Based Psychotherapies

Within the category of trauma-focused therapies, the VA system offers Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Written Exposure Therapy (WET), and Eye Movement Desensitization and Reprocessing Therapy (EMDR). However, substantial evidence demonstrates that not all treatments have been equally disseminated. Although different therapies may be disseminated to differing degrees at different VA sites, PE and CPT markedly predominate. VA efforts to disseminate evidence-based psychotherapies (EBPs) began in 2005. These efforts were guided by the Veteran Health Association’s (VHA) plans to reform its mental healthcare system broadly. Based on the evidence at that time, only two psychotherapies were recommended for the treatment of PTSD: PE and CPT [16]. Following development and testing, initiatives to disseminate CPT began in 2006, followed by PE in 2007. An exceptional amount of support from the VA in the speed and degree of training resulted in 96% of VA facilities providing either PE or CPT within two to three years [17]. Access to both therapies appears to continue to the present day. They are the only two PTSD-specific therapies that VA clinics have been required to offer per VHA guidelines [16][18][19]. To the VA’s credit, the provision of these psychotherapies has helped a great many veterans recover from PTSD and other concerns. The efficacy of PE and CPT for reducing PTSD symptoms is clearly supported by meta-analyses examining many trials (e.g., Asmundson et al.; Powers et al.) [13][20][21]. PE and CPT also reduce suicide risk among veterans by reducing suicidal ideation [22]. Yet the focused, widespread dissemination of mostly PE and CPT leaves many patients with a limited choice of trauma-focused treatments.

3.1. Prolonged Exposure (PE)

Prolonged Exposure is a type of cognitive-behavioral therapy (CBT) derived from the Emotional Processing Theory (EPT). EPT posits that trauma-related stimuli activate emotional and cognitive networks that contain information about the meanings of various stimuli and responses. These networks predominantly rely on the processes of classical conditioning. Within the networks are various associations between aversive or threatening unconditioned stimuli (US) and associated, previously neutral conditioned stimuli (CS). According to EPT, danger associations remain in the fear network until fear-inconsistent safety evidence becomes available. Engagement with objectively safe trauma-related stimuli—exposure—provides this evidence. When this happens, new associations and safety meanings can be formed that inhibit the prior ones. However, this loss of fear can only occur if the underlying emotional networks are activated and the new information is inconsistent with previous beliefs (“disconfirming evidence”) [23]. Note that EPT was updated in 2006 [24], although many scholars incorrectly refer to the 1986 theory [25]. The updated EPT includes (1) the formation of new memories inhibiting older memories in the fear structure, as well as (2) the importance of engaging with disconfirming evidence [24].
Thus, PE aims to provide patients with new learning opportunities to create more accurate associations. This is achieved through four treatment components: psychoeducation, imaginal exposure (i.e., vividly recalling the trauma events), in vivo exposure (i.e., approaching feared-yet-safe stimuli associated with the trauma), and breathing retraining [8][26]. Throughout the treatment, a strong emphasis is placed on reducing the avoidance of trauma stimuli and stopping the suppression of related psycho-emotional content. For patients, treatment involves directly remembering and discussing their trauma in sessions, often with emotional intensity. Outside of sessions, they also listen to their trauma narratives at home, engage in in vivo exposures, and complete other between-session assignments. The treatment itself is manualized and follows a step-by-step protocol which—in its current, traditional form—takes eight to fifteen one-on-one sessions, each lasting around 90 min.

3.2. Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy (CPT) is a type of cognitive therapy grounded in both the information-processing theory and the social-cognitive theory of PTSD [27]. The information-processing theory posits that PTSD develops from cognitive fear networks that lead to avoidant behaviors. This first theory undergirds an optional trauma narrative exposure component of CPT (yet in vivo exposure is not part of CPT’s protocol). The social-cognitive theory of PTSD focuses on how trauma is processed and coped with by an individual attempting to recover. Thus, it is concerned with (1) the content of trauma-related cognitions, such as beliefs about the trauma, other people, or the world, and (2) the effects of these thoughts on emotional, physiological, and behavioral responses. According to the theory, affective components in trauma memories are changed by forming new beliefs and emotional responses that alter prior maladaptive responses. In CPT, patients work towards forming more accurate, comprehensive, and adaptive trauma-related memories and beliefs. When such trauma-related content is changed, their consequent trauma-related emotions (such as fear) and other cue responses are expected to lessen [27].
Accordingly, CPT utilizes psychoeducation, written accounts of beliefs resulting from the trauma, and cognitive techniques to recognize and challenge beliefs [28]. Treatment involves weeks of in-session discussion of their trauma and trauma beliefs, as well as near-daily trauma-related practices and assignments outside of sessions. Like PE, CPT is a manualized treatment completed over approximately 12 individual weekly sessions. Each session lasts from 60 to 90 min. Similar to PE, it was selected by the VA for widespread dissemination due to its high efficacy in research trials [8][13][20].

4. Attrition from Trauma-Focused PTSD Treatments at the VA

Both PE and CPT have been shown to be highly successful at reducing PTSD symptoms under controlled laboratory conditions [29][30][31]. However, these high-effort therapies suffer from high attrition rates, with large numbers of veterans routinely dropping out from treatment. Studies examining treatment attrition in trauma-focused therapies such as PE and CPT have found attrition rates upwards of 60% [32][33]. Although treatment attrition is a risk to all treatments, it is a significant issue when veterans’ primary available treatment options consistently yield high rates [34]. Thus, if veterans want to directly address their PTSD through therapy, they are faced with participating in treatments that a significant portion of them will not complete or—for many—even initiate.

4.1. Factors Influencing Treatment Attrition

Numerous studies have examined why veterans choose to terminate treatment prematurely. Many of these factors are related to the therapeutic process and relationship, such as poor therapeutic alliance, patients’ perception that treatment oversimplifies their distress, and a general disconnect between therapists and clients [35]. Though such factors can lead to dropout, they are not unique to trauma-focused PTSD treatments [36]. Furthermore, because they are not necessarily caused by the VA’s dissemination model, they cannot be addressed by individualizing or increasing the number of treatments available [11][37]. However, the VA’s limited trauma-focused treatment options are specifically related to other treatment barriers [34][38]. By reducing such treatment barriers, the VA may reduce veteran attrition.

4.2. Practical Barriers to VA PTSD Treatment

Practical barriers to trauma-focused therapies have to do with stressors that increase the difficulty of presenting to treatment and/or fully engaging in its procedures. These stressors include traveling to and attending therapy sessions as well as the time and resources for therapy homework tasks. Many do not have the luxury of living near a VA outpatient clinic or having flexible work hours. A study examining why veterans might decline treatment found that, among other reasons, many simply could not take time off from work and had issues traveling to and from treatment [39].
When faced with having to choose between having their PTSD treated or being able to providing for themselves and their loved ones, many veterans will ultimately choose the latter option. For some veterans, these issues may not present a significant problem. However, not all veterans suffer from similar traumatic experiences nor have the same symptom severity and coping skills [2][5][37]. Studies examining the differences between veterans who were able to complete treatment and those who dropped out concluded that, among other factors, treatment completers coped better with stress. Veterans who dropped out were overwhelmed with more minor stressors and chose to prioritize daily obligations over treatment [34]. Thus, when veterans are under high stress, even lower-level stressors can be overwhelming, resulting in attrition from treatment.

4.3. Psychological Barriers to VA PTSD Treatment

In addition to practical factors, stress and emotions stemming from treatment itself can also cause veterans to discontinue therapy. Given that PE and CPT are trauma-focused treatments, they tend to create short-term distress and discomfort by design. The experience and processing of negative—and often intense—emotions is a key element of successful trauma-focused work [23]. Although these aversive states eventually lessen, leading to longer-term benefits, it takes time. Repeatedly subjecting oneself to painful,  traumatic memories and stimuli can cause veterans to drop out of treatment before achieving hard-earned gains [39][40].

4.3.1. Avoidance

PE and CPT aim to help patients habituate to trauma-related stimuli and learn new safety information about them [23][27]. Yet, this can only be achieved by confronting the traumatic memories and stimuli directly. A common human response is to do the opposite, avoiding any stimuli associated with perceived danger or distress. This natural avoidance motivation is a major barrier to exposure. Many veterans will choose not to participate in PE and CPT because of the exposure elements required. In interviews with veterans who have turned down treatment, researchers found that many feared what would happen if they re-experienced the trauma [39].
Avoidance is certainly not limited to refusing to attend therapy. Avoidance across life can be behavioral (e.g., declining social invitations) or psycho-emotional (e.g., suppressing unwanted thoughts and feelings). When a person has experienced trauma, the most common course of behavior is to gradually process the event, coming to terms with it over time. For example, some may seek support from their loved ones, discuss the event, and pursue insight about what happened. Yet others may adopt maladaptive coping strategies, such as becoming dependent on alcohol and substances, numbing their emotions, or developing dissociative tendencies to cope with the trauma [37][41][42]. Such strategies will only treatment efficacy and may lead to dropout [23].

4.3.2. Perceived Lack of Treatment Efficacy

Because PE and CPT require active and deliberate participation from patients, avoidance can delay treatment gains. Even when progressing by their intended timeframes, PE and CPT last upwards of eight and twelve weeks, respectively [8][27]. Significant improvements are typically not seen before the fourth or fifth sessions—over a month into treatment [43]. Thus, veterans dutifully taking the time and effort to complete distressing homework assignments may become discouraged by a lack of results.

4.3.3. Treatment-Related Secondary Effects

The exposure components of PE and CPT are known to cause a temporary escalation in symptoms for some patients [23][27][34]. Even if trauma is only directly addressed during therapy tasks, this work can lead to negative emotions, intrusive thoughts, lessened concentration, physiological arousal, and other secondary effects at later times. As a result, many veterans worry about how their symptoms may impact them outside of treatment, both psychologically and practically. Reflecting on their therapy’s intensity, some veterans have stated that they feared becoming depressed, harming themselves or their loved ones in some way, or relapsing with substance use [34].

5. The Need for Treatment

After acknowledging the obstacles veterans must overcome to recover from PTSD, one may wonder whether it is worth presenting to therapy. Unfortunately, PTSD is unlikely to remit sufficiently on its own, making it imperative that veterans receive treatment [44][45].

However, getting treatment from the VA that matches a veteran’s particular needs and barriers can be difficult. As stated above, the VA has devoted unprecedented amounts of effort and resources to widely disseminate standard PE and CPT [16][46]. This priority has left many veterans having to choose exclusively between PE and CPT for PTSD treatment or wait extensively on the limited availability of other options [11]. In their standard format, both treatments can only address the needs of a limited number of veterans [32][33]. A combination of a lack of individual tailoring in treatment options and delivery, as well as the barriers previously addressed, can result in many veterans being unable to access effective and individualized treatment [34][39][40].

6. Addressing Practical Barriers

6.1. Shortening the Duration of Sessions and Protocols

Given the practical barrier of veteran’s limited time, it is appropriate to question the necessity of the standard duration of PE and CPT. Currently, standard treatments last around eight to fifteen sessions for PE and 12 sessions for CPT, each once per week [8]. To complete these standard protocols, veterans must manage practical inconveniences such as taking time off from work, managing familial obligations, and relying on partners or coworkers for up to 15 weeks or more [8][34]. Given that the duration of PE and CPT protocols are described by their procedures (i.e., the number of sessions and their content) and not their length of time, both treatments could theoretically be shortened.
This can be done by either shortening the duration of individual sessions or the duration of the entire treatment protocol. The latter is known as intensive protocols and can be as simple as traveling to a VA outpatient clinic multiple times a week or enrolling in an intensive outpatient program (IOP) for integrative care. Although such protocols have much shorter treatment duration, they appear to be at least as efficacious as their standard counterparts. Intensive PE and CPT only vary in the frequency of doses and maintain the essential manualized nature and tasks of standard protocols [47][48]. Studies examining the efficacy of intensive PE and CPT protocols have found that they achieved the same results as standard treatments, yet with the added benefit of lower attrition rates [47][48][49].
Even so, it is yet unclear to what degree these intensive formats specifically address veterans’ practical barriers, particularly in the case of IOPs. One qualitative study found that some veterans could not afford to commit three weeks of their time to treatment, even though the overall time was much shorter. Even so, veteran enrollment in this format appears to be enough to warrant the adoption of IOPs [49][50][51][52][53].

6.2. Expanding Telehealth and Smartphone Technology Support

Even with the addition of intensive protocols, there will still be a population of veterans who cannot receive treatment due to travel and timing issues. Telehealth is one possible solution for this state of affairs. Telehealth uses electronic communication and information to support remote clinical services with technology [54]. A common example of telehealth is conducting a psychotherapy session over a secure videoconferencing platform. Fortunately, the VA does offer a broad variety of telehealth options [55].
By bringing therapy into the home, telehealth does not require veterans to leave their homes for treatment. This advantage addresses any barriers stemming from the inconveniences of travel. A study examining the effects of telehealth on practical barriers found that veterans attending in-person PE reported twice as many issues as those attending at-home PE [46].
Due to the often-stressful nature of PE and CPT, one concern about telehealth is that veterans may feel more comfortable attending in-person therapy. Certain veterans may also be uncomfortable using unfamiliar technology. However, most of the evidence suggests that in-person therapy and videoconferencing have been equally acceptable to veterans [56]. Furthermore, studies examining the efficacy of at-home PE found similarly large effect sizes to that of in-person therapy [57]. 
Lastly, the VA has also bridged gaps in care by developing over 20 interventional smartphone apps in partnership with the National Center for PTSD (e.g., PTSD Coach) [58][59][60]. While these apps do not provide PE or CPT protocols themselves, they do provide psychoeducation, symptom tracking, and coping tools for PTSD and other related mental health concerns, free of cost. VA mental health apps have been shown to be sufficiently feasible for veteran use and acceptable to veterans, with preliminary evidence of efficacy and effectiveness (particularly for PTSD Coach) [58]. Yet, increasing awareness and access to these apps is still an essential task for the VA. Reger et al. [61] found that only 20.4% of veterans in VA mental health care had used any of the apps, with only 42.5% reporting that they had even heard of them. Fortunately, there have been some preliminary efforts by research teams to train VA staff to promote and use the apps across medical and psychotherapeutic domains (e.g., nurses, chaplains, social workers, etc.) [62].

6.3. Offering Intensive Protocols Using Telehealth and Smartphone Technology

As previously addressed, intensive in-person PE and CPT protocols do not fit every veteran’s schedule or lifestyle: They are still subject to the constraints of travel time, transportation, and mobility. However, it may be possible to deliver these intensive protocols through telehealth. Recent research has explored this option. One of the few studies that have tested this modality discovered that it may be efficacious and effective [63]. Gathering 24 civilians with a history of sexual trauma, Held and colleagues [63] administered two sessions of CPT per day via telehealth for a total of five days. They reported significant effects for PTSD symptom reduction, with 15 out of 20 participants no longer meeting the diagnostic criteria at the end of treatment.

7. Addressing Psychological Barriers

7.1. Intensive Protocols to Address Psychological Barriers

7.1.1. Avoidance and Procrastination

In addition to countering practical concerns, intensive protocols may also address psychological barriers to PE and CPT. As previously noted, patient avoidance and procrastination toward therapy tasks are issues that can routinely arise during standard PE and CPT. Accordingly, the amount of time between therapy sessions has been significantly associated with higher attrition rates [64]. The exact reasons for this effect have yet to be uncovered. However, it is quite plausible that a weeklong break provides opportunities for veterans to procrastinate and avoid their difficult assignments and treatment sessions, given their aversive nature. It is also possible that veterans can simply become distracted or overburdened by other competing activities and obligations.
The rapid pace of intensive protocols may lessen opportunities for veterans to avoid or procrastinate on homework and exposure. The ability of intensive protocols to address avoidance is supported by a number of studies which found that the pace of treatment forced veterans to prioritize treatment and significantly reduced opportunities for avoidance [47][65]. Intensive protocols may also instill a mindset of driven commitment to “get it over with,” much like “ripping off a band-aid.”

7.1.2. Perceived Lack of Improvement and Motivation

Another psychological barrier that veterans may face is a perceived lack of improvement or slower-than-desired progress in PE or CPT. For some, it may take an extended time to see significant reductions in symptomology, which can be discouraging [66]. They may be especially demoralized by slow gains if they have low treatment expectancy, feel they are undertaking notable distress and working hard, or must make practical sacrifices to attend treatment [35][39].
With condensed intensive PE and CPT protocols, improvements in symptom reduction tend to happen quickly—often as quickly as one to two weeks [48][63]. As a striking example, the intensive treatment administered by Held and colleagues [63] yielded a five-point reduction in scores per day on a self-reported PTSD measure. This eventually resulted in 15 out of 20 participants no longer meeting the diagnostic criteria for PTSD, further demonstrating the ability of intensive protocols to produce rapid improvements [63]. This quick change may have a beneficial effect on veterans’ motivation: They experience the fruits of their labor, receiving both positive and negative reinforcement for approach behavior. As a result, they may be more willing to fully participate in exposure-based activities, as well as to do so longer and practice them more frequently [65].

7.2. Motivational Interviewing Prior to Trauma-Focused Treatments

Many veterans may refuse trauma-focused treatments due to ambivalence—holding multiple motivations that oppose one another (“mixed feelings”). On one hand, they may acknowledge the likely recovery benefits of PE and CPT. Yet, on the other, they may fear that engaging with their trauma will be too burdensome in distress, life interference, or other costs. Research has found that veterans often report ambivalent, mixed positive and negative feelings about engaging in trauma-focused therapy [67]. Such ambivalence toward treatment predicts limited engagement in psychotherapy, lower efficacy of action-oriented therapies like behavioral and cognitive interventions, and patients completing fewer of their therapy homework tasks (i.e., noncompliance [68]; see Engle and Arkowitz [69] and Westra and Norouzian [70] for reviews). A portion of VA sites do offer preparatory classes prior to PE or CPT [18]. Yet these courses (1) vary widely in what they offer, ranging from basic psychoeducation to teaching skills for symptom management, (2) do not routinely include strategies for resolving ambivalence toward PE or CPT, and (3) mainly reduce attrition by preventing the initiation of PE or CPT when providers believe, a priori, that certain veterans could not tolerate trauma-focused treatment [18].
Motivational interviewing (MI) is a treatment technique that helps patients resolve ambivalence toward committing to a course of action or life change [71]. MI uses open conversation to gently guide clients toward realizing their own personal reasons to change. It then helps them gather the motivation to commit to action. Although it can serve as a standalone treatment, it has also been effectively integrated with other treatments to support their aims (see the review and meta-analysis by Marker and Norton [72]). The VA may help veterans overcome psychological barriers to trauma work by preceding that work with MI or similar motivational enhancement therapies. In fact, adding sessions of MI that target therapy ambivalence to the beginning of therapy protocols has outperformed therapy alone in several clinical trials [72].

7.3. Acceptance and Commitment Therapy as an Alternative Treatment

Veterans with PTSD may also be well-served by greater access to evidence-based treatment alternatives such as Acceptance and Commitment Therapy (ACT). ACT is a mindfulness-based CBT that encourages accepting unwanted internal experiences in order to pursue valued actions [73]. The main goal of ACT is to increase patients’ psychological flexibility: the ability to freely carry out any valued behavior regardless of one’s psycho-emotional state. It is often achieved by decreasing patients’ experiential avoidance, which occurs when an individual is unwilling to engage in an activity due to the associated feelings or thoughts. Experiential avoidance often hinders the pursuit of one’s personal goals and values, such as the beneficial activities or relationships that may trigger veterans’ PTSD symptoms [74]. Avoidance can also render exposure exercises ineffective [41][42]. To help patients increase their psychological flexibility and decrease experiential avoidance, ACT trains patients in six skill processes: contacting the present moment (i.e., the attentional components of mindfulness), defusion (i.e., disobeying and distancing from one’s automatic thoughts and motivations), self-as-context (flexible identity), identifying one’s values, committed action to engage with those values, and acceptance [75][76]. Such skills may actually aid the mechanisms of PE and CPT by promoting better investment in the exposure-based components of PE and CPT later on [76].
Accordingly, ACT has shown benefits specifically in veterans with PTSD, with studies reporting large effect sizes for symptom reduction on clinician and self-reported measures for PTSD, as well as increases in quality of life [73][77]. The ability of ACT alone to address veterans’ psychological treatment barriers has yet to be extensively examined. However, preliminary evidence suggests that using ACT to treat PTSD may yield attrition rates lower than those of PE and CPT, with one study reporting that every veteran who began treatment was able to complete it [77]. However, while a limited number of VA facilities do provide general ACT treatments that are independent of targeted PTSD, the VA still does not consider ACT a suitable treatment for PTSD [9].

7.4. Combining Components of Other Therapies

7.4.1. Mindfulness-Based Techniques

One option is adding or pre-empting PE and CPT with mindfulness-based techniques. Broadly defined, mindfulness is a state in which one purposefully attends to their present situation while adopting a nonjudgmental, accepting mindset [78]. Though there are a number of mindfulness-based treatments (mindfulness-based stress reduction, mindfulness-based cognitive therapy, etc.), all include the practice of acceptance. Acceptance occurs in mindfulness when one willingly allows the presence of unwanted internal experiences noticed in the present moment, forgoing urges to resist or change them [79]. Mindfulness-based treatments can comprise several components and delivery methods, such as meditations, yoga, or group discussions [80][81]. As such, mindfulness practices may be a logical treatment to pre-empt or combine with trauma-intensive treatments like PE and CPT. Like ACT, the emphasis that mindfulness practices place on acceptance makes it ideal for veterans who may struggle to cope with or avoid treatment.

7.4.2. Components of Dialectal Behavioral Therapy

DBT is a cognitive-behavioral treatment that mixes behavioral and crisis intervention theories with Eastern meditative practices and philosophies. Like ACT, it is partly based on mindfulness and has the facilitation of acceptance among its aims. Though most often used to treat borderline personality disorder (BPD), there are elements of DBT that may be appropriate for treating PTSD. The acceptance of unwanted internal experiences (like negative emotions, sensations, and cognitions) is certainly an important one. DBT also promotes and trains the acceptance of the external world as it is in the present moment, even if one aims to make changes. Additionally, DBT includes tools which teach patients to manage the external and internal experiences of life, including interpersonal relationships, emotion regulation, and the tolerance of distress. Due to the overlap of those symptoms, learning such skills would be highly beneficial for veterans with PTSD [1][4][37][82][83].

7.4.3. Components of Family and Couples Therapies

Lastly, veterans may be assisted in overcoming psychological barriers such as avoidance by incorporating family members or significant others into their trauma-focused therapy process [35]. Individuals close to the veteran may provide encouragement and support throughout the veteran’s trauma processing or exposure therapy. They may motivate patients to complete difficult exercises, both during sessions and in the veteran’s familiar environment. Significant others and family may also remind the veterans of their values and reasons for pursuing recovery. Including close others in treatment may also change family behaviors that interfere with treatment success, such as unwittingly reinforcing PTSD symptoms by enabling and fostering veterans’ avoidance.
Preliminary studies on involving loved ones in trauma-focused veteran treatments are promising. For example, Thompson-Hollands (2021) found that adding a two-session adjunctive intervention with family members to the beginning of PE or CPT led to 20% less attrition than standard PE or CPT without family sessions [84]. Currently, Meis et al. [85] are running a randomized controlled trial to test whether Family-Supported Prolonged Exposure reduces symptoms and attrition relative to standard, individual PE.

8. Conclusions

Many veterans experience traumatic events both in and out of service, including combat trauma, accidents, natural disasters, sexual trauma, or other misfortunes. Given that untreated PTSD is not likely to remit, treatment is often necessary. A significant portion of American veterans seek trauma-focused treatment for their PTSD from the VA. To its credit, the VA has made powerfully efficacious treatments like PE and CPT widely available, helping a great number of veterans in need. Yet the VA’s dissemination approach (often called “one-size-fits-all”) may not serve all veterans optimally. Due to the small number of psychotherapies broadly available and the wide variety of veteran needs, treatment attrition rates with PE and CPT remain relatively high. Many veterans drop out of treatment prematurely due to practical and psychological reasons that are all related to the often-high burdens of undertaking standard PE and CPT. However, treatment barriers can be lessened by increasing the variety and emphasis of available psychotherapies, as well as their delivery modalities, in ways that match veteran needs.

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