The Veterans Health Administration (VHA) has prioritized ensuring access to Evidence-Based Psychotherapies (EBPs) for all Veterans with PTSD. In order to achieve this goal, VHA launched the Mental Health Dissemination Initiative, which to date has trained over 2700 clinicians to administer cognitive processing therapy and prolonged exposure therapy. System-level changes, including clinic restructuring and hiring of Evidence-Based Coordinators, have also been implemented. Despite these efforts, a minority of Veterans with PTSD have received EBP. Preliminary work conducted in VISN 23 suggests a lack of Veteran demand for EBP, with appointments dedicated to the delivery of EBPs for PTSD going unfilled at some sites. It has been acknowledged that the successful implementation of EBPs for PTSD will require Veteran demand for the treatments. Few Veteran-focused interventions have been developed. This project partnered with the National Center for PTSD to fill this gap by developing targeted materials for a Veteran-focused social marketing campaign to increase "pull demand" for EBPs for PTSD. Social marketing principles have long been used to effectively promote behavior change across a number of public health targets (e.g. smoking, exercise). We applied social marketing strategies to develop an intervention to increase Veteran demand for EBPs for PTSD.
The specific aims were to: 1) Develop targeted social marketing materials for three Veteran stakeholder groups (OEF/OIF era, Vietnam era, and women Veterans), and 2) Elicit feedback from members of each Veteran stakeholder group and expert members of the PTSD Coalition regarding the content, acceptability, and feasibility of implementing the social marketing campaign.
In order to achieve Aim 1, we conducted PTSD assessments with 37 Veterans at the Minneapolis VA Medical Center who had chart diagnoses of PTSD, but were not actively engaged in psychotherapy. Five Veterans did not meet criteria for PTSD and one veteran had previously received an EBP for PTSD; they were excluded from the study and did not complete the interview. Thus we completed semi-structured interviews with 31 Veterans. Participants were stratified by Veteran stakeholder population [OEF/OIF (n = 12), Vietnam (n = 12), and women (n = 7) Veterans] and location of PTSD diagnosis [primary care (n = 13) versus mental health (n = 18). Veterans were first queried about how they preferred to receive information about PTSD treatment options and their attitudes regarding PTSD recovery. They were then randomly assigned to see an educational video that described either prolonged exposure (PE) or cognitive processing therapy (CPT). Following the video, they were asked about their reactions to the video and the therapy that was presented. Following data coding and analysis, the study team met to identify the themes to be used in the marketing materials, the groups to be targeted, and the mode of delivery. To achieve Aim 2, following the creation of draft materials, 13 Veterans (3 OEF/OIF, 6 Vietnam, 4 women) attended one of three focus groups to provide feedback on the draft materials and dissemination strategies. Three members of the PTSD coalition also provided feedback (two in person; one via e-mail).
Preliminary analyses show that a majority of veterans reported that they would prefer to receive information regarding PTSD treatment options either in the mail (87%) or verbally from their mental health or primary care provider (97%). These were the preferred methods of communications by Veterans in all strata. A majority of Veterans in all three strata reported that they did not think it was possible to recover from PTSD. They felt as though the experience and the associated memories would always be with them, and as such, full recovery was not possible. However, a majority of veterans felt as though it was possible to learn to manage their symptoms. All three cohorts felt as though support from others and talking about their struggles was necessary for recovery. OEF/OIF and female Veterans also frequently mentioned internal factors (coping skills, awareness, keeping busy) that they believed were necessary. All three strata reported that recovery would involve a reduction in PTSD symptoms. Specifically, they stated they would experience a reduction in anxiety and stress. OEF/OIF and Vietnam veterans reported they would also like to have less anger; female veterans hoped they would sleep better. OEF/OIF Veterans would also like to have better relationships and function better; Vietnam Veterans would like to experience more positive emotions and engage more socially; female Veterans hoped they would function better, particularly at work.
The vast majority of Veterans had never heard of prolonged exposure (PE) or cognitive processing therapy (CPT). After viewing the PE/CPT videos, Veterans in all three strata reported that they liked the information regarding the effectiveness of the treatments. The two most common concerns about the treatments were that they seemed challenging (the time commitment and emotionally challenging) and doubts about their effectiveness. While they appreciated information regarding their effectiveness, they were left wondering if the treatments would be effective specifically for them. A majority of Veterans reported that they liked the Veteran testimonials in the videos. They could relate to the symptoms that the Veterans had struggled with and felt hopeful that they too could recover. The primary complaint about the videos was that they were too positive about recovery; participants felt the level of improvement depicted in the videos was unlikely and it made them question the authenticity of the message. Women Veterans noticed a lack of women in the videos and reported that they were more likely to respond to materials that were targeted to women.
These findings were used to create two draft pamphlets (one for men, one for women) to increase awareness of PE and CPT. Three Veteran focus groups and three members of PTSD coalition provided feedback on the materials that was used to refine the educational materials.
The long-term goal of this project is to increase the number of Veterans receiving EBP for PTSD by increasing Veteran demand for those services. Increasing the number of Veterans who receive EBPs for PTSD will result in improved well-being and functioning for Veterans and reduce the costs associated with PTSD. The project made an initial step toward that long-term goal by developing educational materials that can be used to increase Veteran awareness and demand for PE and CPT.
- Kehle-Forbes SM, Gerould H, Polusny MA, Sayer NA, Partin MR. "It leaves me very skeptical" messaging in marketing prolonged exposure and cognitive processing therapy to veterans with PTSD. Psychological trauma : theory, research, practice and policy. 2020 Jan 20.
- Kehle-Forbes SM, Meis LA, Spoont MR, Polusny MA. Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological trauma : theory, research, practice and policy. 2016 Jan 1; 8(1):107-14.
- Kehle-Forbes SM, Gerould H, Partin MR, Sayer NA, Slone L. The Development of Marketing Materials to Increase Veteran Demand for Evidence-Based Psychotherapies for PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.
- Meis LA, Spoont MR, Erbes CR, Polusny MA, Noorbaloochi S, Hagel Campbell EM, Eftekhari M, Kattar A, Rosen K, Tuerk P, Velasquez TL, Erickson E, Thompson K, Stewart K, Vang T. Because I asked you to: The role of family in Veterans' engagement in trauma-focused treatment for PTSD. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.
- Kehle-Forbes SM, Gerould HL, Polusny MA, Partin MR, Slone L, Sayer NA. Veterans’ perceptions of the role of relationships and social engagement in recovery from PTSD. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
- Kehle-Forbes SM, Partin MR, Slone L, Polusny MA, Sayer NA, Gerould HL. Veterans’ Attitudes towards Prolonged Exposure and Cognitive Processing Therapy. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
Mental, Cognitive and Behavioral Disorders