Bridging the gap in delivery of psychological treatments for posttraumatic stress disorder

Abstract

Scientific understanding of and treatment for posttraumatic stress disorder (PTSD) have come long way in the past few decades. Not long ago, the diagnostic features and pathophysiology of what we now know as PTSD and previously knew as shell shock or battle fatigue were poorly understood and treatment was widely considered to be futile. Advancements in our understanding of the development, onset, classification, and treatment of PTSD over the last several decades now offer great promise to Veterans with PTSD returning from the conflicts in Iraq and Afghanistan, as well as to those who returned from conflict decades ago and non-Veteran trauma survivors. As the articles in this special issue of the Journal of Rehabilitation Research and Development illustrate, the current state of the science of and treatment for PTSD provide real and unprecedented opportunities for recovery for many individuals with PTSD. Among the significant advancements in PTSD research is the development of specialized treatments for PTSD, including specific trauma-focused psychotherapies, such as prolonged exposure therapy (PE) and cognitive processing therapy (CPT). Rigorous research, including randomized controlled efficacy trials and effectiveness research, have shown that PE and CPT are quite effective in similar degree [1-5] and often yield outcomes that are enduring [6]. Much of this research has focused on non-Veteran sexual trauma survivors, though recent spate of research has demonstrated the efficacy and effectiveness of these therapies with Veteran samples [3,5,7-10]. Based on the scientific evidence, CPT and PE are recommended in the Department of Veterans Affairs (VA)/Department of Defense (DOD) VA/ DOD Clinical Practice Guideline for Management of Post-Traumatic Stress for PTSD at the highest level, indicating a strong recommendation that the intervention is always indicated and acceptable. Although the research evidence would suggest that trauma-focused psychotherapies should be considered clinical mainstay for the treatment of PTSD, the clinical reality is that these and other evidence-based psychotherapies (EBPs) have largely languished in the laboratory for years and not made their way into therapy rooms in either private or public mental health care systems [11-12]. One survey of mental health professionals conducted in 2001 assessing the extent to which mental health providers provided evidence-based care for PTSD found that fewer than 10 percent of both generalist mental health providers and specialty PTSD mental health providers reported providing manualized psychotherapy for PTSD [12]. Among the key reasons identified in the literature for this science-to-practice gap are limited systematic training of providers in these therapies and lack of organizational support and infrastructures (e.g., the availability of 60-90 minute weekly sessions as these therapies require) to implement these treatments. As an integrated healthcare system that establishes its own policies and services, the Veterans Health Administration (VHA) supports PE and CPT as first-line treatments for PTSD when clinically indicated. In fact, national VHA policy requires that all Veterans with PTSD have access to CPT or PE as designed and shown to be effective. To promote the availability of these treatments, VA has been working over the last several years to nationally disseminate and implement these therapies as part of larger initiative to transform the VA mental health care delivery system [13]. This transformation process has led to both structural and process enhancements to mental health care delivery in VHA and to the addition of more than 7,000 staff to the mental health care workforce since 2005, bringing the current total to more than 20,000 staff. As part of its efforts to nationally disseminate PE, CPT, and other EBPs, VA has established national competency-based staff training programs in these and other psychotherapies. …