WASHINGTON, DC—It can take upwards of 15 or 20 years to develop an evidence-based therapy, clinically prove its effectiveness, and then disseminate pertinent information across the population of patients that need it. When that population involves the Department of Veterans Affairs health care system, which serves four million veterans throughout hundreds of facilities, it might be expected that dissemination of information could take much longer. However, in the two years since VA researchers proved the clinical effectiveness of cognitive behavioral therapies for post-traumatic stress disorder—cognitive processing therapy and prolonged exposure therapy—hundreds of VA health care professionals have been trained in the treatments and VA asserts that both are available throughout their entire system.

Cognitive Behavioral Therapy

Both cognitive process therapy and prolonged exposure therapy involve exposing the veteran to memories, dialogue, and introspection about the traumatic event that triggered their PTSD in a safe, clinical setting.

Prolonged exposure therapy utilizes techniques to promote confrontation with feared objects, situations, memories, and images. It involves use of psycho education, breathing retraining, prolonged exposure to the memory of the trauma through imaginary reliving, and repeated exposure to safe situations the patient is avoiding because of traumatic fear. Cognitive process therapy involves psychoeducation; written exposure in which patients write about the impact of trauma on themselves and others, and interpret traumatic events. This approach challenges the patient’s interpretations of traumatic events and provides an opportunity for cognitive restructuring of their beliefs that have been disrupted by traumatic events.

Research into both treatment techniques for PTSD was led by VA physician-researchers. Dr Patricia Resick, head of the Women’s Division of the National Center for PTSD in Boston, helped develop cognitive process therapy. The leading researcher in prolonged exposure therapy was Dr Edna Foa, who helps train VA mental health professionals.

Both therapies fall under the category of cognitive-behavioral therapy, which has been tested and proven successful for years in civilian PTSD populations, reducing symptoms by 60% to 80%. The degree of success drops somewhat in veterans with chronic, combat-related PTSD, but the evidence of treatment effects is greater with CBT than any other treatment. Other treatments being tested include various forms of pharmacotherapy, group therapy, marital and family therapy, social rehabilitative therapy, and various creative therapies. In 2007, the Institute of Medicine combed through the medical literature and evaluated 90 studies on PTSD treatment techniques. A report released near the end of that year found that exposure-based therapies were the only treatments solidly backed by evidence.

Amassing Human Resources

Also in 2007, VA began training its physicians in cognitive process therapy. The following year, they developed a similar training program for prolonged exposure therapy, with the goal being that all veterans who could benefit from the treatment have access to trained providers. Doctor Antoinette Zeiss, VA’s Deputy Chief of Mental Health Services, has helped oversee that effort and reports unmitigated success. “Both of those trainings are built around a similar model. Start with a very intensive weekend didactic—a workshop that combines experiential and didactic training,” Dr Zeiss told U.S. Medicine last month. “What is special about this is that people are also linked to consultants. So that when they go back to their VA facility, they pick up cases and they’re guided in a consultative manner through the delivery of this new approach.”

New trainees are required to work with these consultants on at least two cases before they are considered able to provide the treatment independently. More than two cases are recommended for those who are struggling with how to effectively deliver the therapy. “We started with that model—sort of a bootstrap model in some ways—and as more and more people around the country get trained, we can have trainers who have been trained and are spread out around the country,” explained Dr Zeiss. VA currently has around 2,900 staff trained in one or the other therapies. While they do not certify therapists, they do keep a roster of who has been trained and has reached the criterion to be able to administer the treatments effectively.

Changing the System, Culture

Recently VA has placed a local, evidence-based psychotherapy coordinator in every VA health care facility that offers CBT treatment. The role of the coordinator is to work with therapists that have gone through the training to ensure that any necessary resources are available to providers on a local level. “They also work with management to make sure clinical schedules are set up appropriately, that management understands why it’s so important these therapies be delivered and that there is support at the local level for the therapies,” Dr Zeiss explained.

Once the staff is trained, VA’s next priority is whether each facility is set up to properly deliver the treatment. CBT therapies are time consuming, both for the provider and for the patient. They involve weekly appointments of up to 90 minutes for however many weeks it takes to deliver a full course of therapy. “How do you make sure the treatment rooms are available; that people’s schedules are set up so that this can be done; and that they don’t get pulled to meet other clinical needs?” Dr Zeiss asked. “At this point, all facilities should have sufficient resources.”

However, the barrier is not always a lack of physical resources. The culture of a facility may be an obstacle if it has become used to providing a different form of therapy. “For instance, a facility that might have gotten into a model of doing all group psychotherapy, to rethinking to ensure that they plan how they use their resources differently, so they can support the required delivery of the individual evidence-based psychotherapy,” Dr Zeiss said. Part of the job of the local coordinator is to help facilities go through that culture shift.

Coordinators also act as part of VA’s overall evaluation effort, speaking regularly with VA’s Central Office and collecting information on treatment success. While no formal data on treatment effectiveness has been collected, some sites have amassed significant samples. Doctor Zeiss is optimistic about this preliminary data, saying, “people really are doing a good job of delivering this care once they’ve been fully trained and these are treatments that potentially could be quite helpful to veterans.”

Therapy for All Who Need It

VA has made it mandatory that these evidence-based therapies be available to all veterans who might benefit from them—those that have a diagnosis of PTSD and are interested in participating. Doctor Zeiss stressed that VA would never force the therapy on any patient, and that psychotherapy does not work unless the patient is fully invested. “Sometimes people need to have some supportive therapy. They need to develop trust, and to know that VA really is going to take care of them. And they need to develop other skills before they’re ready to fully participate in these evidence-based psychotherapies,” she explained. The intense and sensitive nature of the treatment requires trained and confident providers to help guide the patient. There is a fine line between therapeutic exposure and re-traumatizing a patient.

According to Dr Zeiss, VA only has around a 10% vacancy rate in its mental health positions—a number not inconsistent with a large health care provider—and that trouble the department had filling mental health slots several years ago is now in the past. Rural areas, however, remain a difficult area for specialized care—a problem not limited to VA facilities.

For those patients who live far away from a VAmedical facility that offers the treatment, VAcan provide the therapies through telehealth services. That is, patients videoconferencing with providers in another facility. Doctor Zeiss admits that evidence-based research on the effectiveness of providing the therapies using telehealth techniques does not yet exist, “but we’ve tried it out and it’s been working nicely.” In cases where telehealth services are provided, a member of the local staff needs to be available for the patient. This person is, “not necessarily someone trained in the therapy, but if it’s a difficult session, the person needs to be able to sit with someone and have some support before they head out to face the day,” Dr Zeiss explained.

Future Research

The success of the two therapies in question does not mean that evaluation has ceased on other therapies. Doctor Zeiss noted that more research is definitely needed in the field of pharmacological therapy. In 2007, VA researchers proved prazosin was effective in alleviating the nightmares of PTSD patients. Further studies are examining the drug’s effectiveness on overall PTSD symptoms.

Comorbidity of PTSD with traumatic brain injury and other cognitive impairments is another example of an area where more research is needed. “We’ve adapted psychotherapies to older adults with some cognitive impairment [they] are quite effective,” Dr Zeiss explained. The adaptive versions accommodate memory impairments, changes in information processing, attention and other aspects of cognitive impairment. VA could use this data to develop a CBT model for treating older veterans suffering from similar comorbidities. “We’ve love to see research in using these adaptations in veterans with both TBI and PTSD,” Dr Zeiss declared. “It’s a logical clinical place to start and would be a great research topic.”

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