Original Article
A new treatment model for veterans?: Results from a program evaluation of a recovery-oriented intensive outpatient program for veterans with heterogeneous diagnostic presentations

https://doi.org/10.1016/j.jcbs.2020.12.001Get rights and content

Highlights

  • Evaluation of a transdiagnostic group intensive outpatient program for 112 veterans.

  • Decrease in depression, anxiety, and post-traumatic stress following treatment.

  • Treatment response not affected by age or number of psychiatric diagnoses.

Abstract

The purpose of this program evaluation was to investigate the effectiveness of a 10-day, group-based recovery-oriented intensive outpatient program (RIOP) offered at a VA Psychosocial Rehabilitation and Recovery Center in South Texas. The RIOP utilizes a multidisciplinary approach to treatment of veterans with acute mental health concerns, bridging cognitive-behavioral processes delivered in group format with other disciplinary approaches (e.g., recreation therapy, Chaplain services). The sample for this program evaluation consisted of 112 veterans who completed the RIOP during a twelve-month period. Ninety veterans (80.4%) had two or more recorded psychiatric diagnoses, and twenty-seven veterans had three or more recorded psychiatric diagnoses (24%). Eighty-five veterans were diagnosed with post-traumatic stress disorder (PTSD) or adjustment disorder (75.9%); seventy-two with major depressive disorder (64.3%); fifty-three (47.3%) with a borderline personality disorder and/or documented clinically significant cluster A or B personality traits; twenty-eight with an anxiety disorder (25%); twenty-one with a bipolar disorder (18.8%); and seven with a psychotic disorder (6.3%). Results indicated a statistically significant decrease in symptoms of depression, anxiety, and post-traumatic stress between pre- and post-treatment. Change in symptoms from baseline to post-treatment was not significantly correlated with age or number of psychiatric diagnoses. The results of the program evaluation suggest that a process-based cognitive-behavioral approach in combination with interventions from other recovery-oriented disciplines (delivered via group modality) can be an effective transdiagnostic treatment for veterans with complex trauma histories who meet criteria for more than one psychiatric diagnosis.

Introduction

The field of psychology continues to move away from a focus on manualized treatments for any particular disorder as identified by a biomedical or latent-disease model of psychopathology and towards a process-oriented approach in which core transdiagnostic problems, e.g., emotion dysregulation, are treated by specific evidence-based cognitive-behavioral strategies (bib_Hofmann_and_Hayes_2018Hofmann & Hayes, 2018) in a flexible and individualized manner as called for by any given case conceptualization. Barlow's (2004) seminal work on a unified treatment for emotional disorders laid out a unified approach to treatment comprised of three primary components, each targeting emotional regulation at different time points: (1) altering antecedent cognitions, (2) preventing emotional avoidance, and (3) facilitating action tendencies not associated with the disordered emotion(s).

Traditional cognitive-behavioral therapies (CBT), that is first and second wave cognitive-behavioral approaches (Beck, Rush, Shaw, & Emery, 1979; Ellis, 1962; Skinner, 1953; Wolpe, 1958) have long focused on altering antecedent cognitions and facilitating behavioral activation, and have been successfully applied to a wide range of diagnostic categories (e.g., depressive disorders, anxiety disorders, psychotic disorders, eating disorders, bipolar disorders, somatoform disorders, and personality disorders) and other clinical problems (e.g., anger and aggression, general stress, and chronic pain) (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) aims to increase psychological flexibility by undermining emotional avoidance and cognitive fusion in the service of values-consistent committed action, and Dialectical Behavior Therapy (DBT; Linehan, 1993) directly targets emotion regulation by teaching skills that facilitate acceptance of emotion and opposite action, i.e., acting opposite emotional urges. As with traditional CBT, ACT has proven effective in treating a range of diagnoses, including but not limited to anxiety disorders, depression, substance use disorders, and somatic health problems (namely chronic pain) (A-Tjak et al., 2014). Dialectical behavior therapy, initially developed as a treatment for borderline personality disorder, also shows promise as an evidence-based transdiagnostic treatment (Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014; Ritschel, Lim, & Stewart, 2015).

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, providing specialty mental health care to more than 1.7 million veterans in fiscal year 2018 (https://www.va.gov/health/). Treatment delivery to such a large population is further influenced by external political and regulatory forces that have contributed to an important shift in veterans’ healthcare in which access to certain evidence-based psychotherapies is now mandated (Rosen et al., 2016). As a result, VHA has been at the forefront of recent efforts for widespread implementation of evidenced-based psychotherapy (EBP) since its release of the Comprehensive Mental Health Strategic Plan 15 years ago (Department of Veterans Affairs, 2004). The VHA has enacted systematic roll-outs of 16 EBPs across its system, including interventions for post-traumatic stress disorder (PTSD), depression, serious mental illness, relationship distress, insomnia, chronic pain, motivation and adherence, and substance use (Karlin & Cross, 2014). Given the prevalence of posttraumatic stress disorder in the veteran population, much of the initial focus was on increasing the availability of two manualized trauma-focused protocols for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) (Chard, Ricksecker, Healy, Karlin, & Resick, 2012; Karlin et al., 2010).

Despite this shift, the training of VHA clinicians in CPT and PE has not consistently translated into the implementation of those EBPs into clinicians' daily usage with patients (Rosen et al., 2016). One explanation for the gap between training in EBPs and their implementation is clinicians’ view that EBPs are not uniformly appropriate for all patients (Rosen et al., 2016). Clinicians may feel that EBPs are too “mechanistic” and rigid to meet the needs of their patients (Karlin & Cross, 2014). With respect to the implementation of CPT and PE, Cook, Dinnen, Simiola, Thomspon, and Schnurr (2014) divided provider concerns into three categories: psychiatric comorbidity, cognitive capacity, and motivation. VA clinicians have expressed the belief that certain co-morbid psychiatric diagnoses and other clnical problems (e.g., bipolar disorder, personality disorders, substance use disorders, self-injurious behavior, dissociation, or problems with anger management) be treated and/or stabilized prior to engagement in trauma-focused treatment (Cook et al., 2014; Lu, Duckart, O’Malley, & Dobscha, 2011; Osei-Bonsu et al., 2017).

There has also been widespread concern and report of difficulties with treatment initiation, retention, and dropout (Rosen et al., 2016) for both CPT and PE. Hundt and colleagues (2015) investigated reasons for declining CPT or PE and found that the most frequently endorsed barrier was VA-system-related barriers (e.g., difficulty navigating the VA system, inefficiencies and delays), with most veterans reporting multiple barriers, including emotional and therapy-related barriers, such as concerns about emotional readiness for exposure, a lack of trust in the therapist, hopelessness about the success of treatment, and preference for alternative treatments (e.g., yoga, art therapy, or ongoing supportive therapy). An earlier retrospective chart review found that Iraq and Afghanistan veterans were less likely to initiate CPT or PE than veterans from other eras of service (Mott et al., 2014); these same veterans were also less likely to complete a course of CPT or PE, as were veterans with histories of psychiatric hospitalization.

Another retrospective chart review (Kehle-Forbes, Meis, Spoont, & Polusny, 2016) revealed that approximately 18% of veterans who were offered PE or CPT failed to initiate treatment. Of those who began treatment, approximately one-third dropped out before completion with one-quarter of those leaving before the third session. Additional predictors of dropout were age (younger), service era (OEF/OIF/OND), and therapy type (PE).

In terms of treatment effectiveness, a review of randomized clinical trials (Steenkamp, Litz, Hoge, & Marmar, 2015) revealed that mean scores post-treatment (CPT or PE) remained at or above the clinical cut-off for PTSD, and between 60 and 72% of participants receiving either therapy retained their PTSD diagnosis after treatment. The same review revealed that when CPT and PE were compared to non-trauma focused psychotherapies (as opposed to waitlist or treatment as usual), similar levels of symptom improvement were found. For example, in one trial comparing CPT to present-centered therapy (PCT; Suris, Link-Malcom, Chard, Ahn, & North, 2013), CPT was not superior to PCT on primary outcomes measures, and in other trials (Forbes et al., 2012; Schnurr, Friedman, & Engel, 2007), neither CPT nor PE demonstrated superior gains at follow-up intervals. Similar results have been found for interpersonal psychotherapy (Markowitz et al., 2015).

Finally, another major barrier to implementation of EBPs within VHA has been fit with institutional structure (Rosen et al., 2016), i.e., CPT and PE have specified session lengths and treatment durations that may conflict with the competing demand of access to mental health services and/or the structure of residential treatment programs or intensive-outpatient programming, which rely heavily on the group modality. Thus, although CPT and PE remain gold standard treatments for PTSD, there remain veterans for whom these treatments are not appropriate and who may benefit from other interventions either alone, prior to engaging in PE or CPT, or adjunctively.

The purpose of this program evaluation was to investigate the effectiveness of a 10-day group-based recovery-oriented intensive outpatient program (RIOP) offered at a VA Psychosocial Rehabilitation and Recovery Center in South Texas. The RIOP was developed in 2009 in response to the need for a level of care that was less intensive than psychiatric hospitalization but more intensive than what was available via existing outpatient services, i.e., it was developed for veterans with diverse and complex diagnostic presentations who were experiencing acute mental health symptoms. As such, the RIOP does not adhere to any particular manualized, diagnosis-driven protocol but instead utilizes of a variety of core cognitive-behavioral processes augmented by recreation therapy, peer support, psychiatry, and Chaplain services. Prior research suggests that a more modular approach to cognitive-behavioral therapies improves therapists’ attitudes towards using evidence-based treatment (Borntrager, Chorpita, Higa-McMillan, & Weisz, 2009). The most common processes utilized by RIOP psychologists and social workers align with the core processes laid forth by Hofmann and Hayes (2018) and include arousal reduction, coping and emotion regulation, problem-solving, exposure strategies, behavioral activation, interpersonal skills, cognitive restructuring and modification of core beliefs, cognitive defusion, the cultivation of acceptance, values choice and clarification, and mindfulness practice. Thus, the interventions used within the RIOP were evidence-based components of cognitive-behavioral treatment packages (i.e., CBT, ACT, DBT) that, broadly speaking, are behavioral evidence-based components. These components were chosen for their proven effectiveness in treating transdiagnostic problems commonly seen among veterans admitted to the program, including but not limited to emotion dysregulation, chronic suicidal ideation, and interpersonal skills deficits. A modular, or flexible approach to these cognitive-behavioral interventions was determined to be the best fit due to the diagnostic heterogeneity of the veterans admitted to RIOP as well as to the logistics of the group setting (e.g., constantly changing group composition due to the need for open enrollment so as to maximize treatment access). As different veterans cycled into and out of the group, the treatment team determined which of the evidence-based cognitive-behavioral intervention components would best meet the current needs of the group enrolled in the RIOP.

Under the guidance of the VHA measurement-based care initiative, in February 2018 RIOP providers began administering self-report measures to veterans at both intake and discharge. Understanding whether this program has been effective at decreasing psychological symptoms in veterans will both inform the refinement of the services offered by this particular program as well as add to the extant knowledge of the effectiveness of process-based transdiagnostic programs implemented in intensive outpatient settings within the VA system.

Section snippets

Material and methods

The electronic medical records of 112 veterans who were enrolled in a transdiagnostic recovery-oriented intensive outpatient program (RIOP) between February 2018 and February 2019 were reviewed for this program evaluation. The third author conducted the initial review of the electronic medical records. Data was then checked by the first and second authors for accuracy and corrected as needed. The following information was gathered from participants’ medical records: demographic variables (e.g.,

Participant demographics and clinical characteristics

Table 2 summarizes participant demographics for the 112 veterans ranging in age from 25 to 70 (M = 44.97, SD = 10.78, range 25–70) who were enrolled in the RIOP during the one-year period. The majority of veterans in the sample completed the two-week program (81.25%; n = 91). There were no significant differences in pre-treatment scores on the three outcome measures between those who did not complete treatment and those who did complete treatment (PHQ-9: t (109) = 0.60, p = .28; GAD-7: t

Discussion

The results of the program evaluation suggest that veterans who complete the RIOP experience a clinically significant reduction in reported symptoms over the course of treatment, providing tentative support for current practices. That is, a process-based cognitive-behavioral approach that bridges approaches from other recovery-oriented disciplines such as recreation therapy and chaplain services (delivered via group modality) may be an effective transdiagnostic treatment for veterans who have

Conclusions

Despite its limitations, this program evaluation represents a demonstration of the importance of the VHA's ongoing mission for the implementation of evidence-based care. The RIOP was developed in 2009 in response to a need for appropriate treatment for veterans who were at-risk for psychiatric hospitalization or re-hospitalization. These veterans had complex needs that required more than the general outpatient mental health clinic could provide and, as is evident from this program evaluation,

Declaration of competing interest

The authors have no conflicts of interest to disclose.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System. Karen M. O'Brien, Mary E. Dozier, and Julia Lopez were employed by the South Texas Veterans Health Care System during the data collection phase of the evaluation. This manuscript does not represent the views of the U.S. Department of

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