Use of evidence-based treatment for posttraumatic stress disorder in Army behavioral healthcare

Early Successful Eye Movement Desensitization and Reprocessing (EMDR) Therapy for Verbal Memory Impairment in an Adjustment Disorder: A Case Report in a Newly-Diagnosed Multiple Sclerosis Patient

Multiple sclerosis (MS) is a chronic inflammatory disease of the immune system affecting the central nervous system. Several phenotypes are possible, and cases usually present with a relapsing-remitting (RR) course with disease onset at a young age. MS diagnosis can represent a traumatic event for the patient, possibly evolving into adjustment disorder (AD). AD is defined by the presence of emotional or behavioral symptoms in response to identifiable stress occurring within the prior three months and similarly to post-traumatic stress disorder (PTSD) can significantly affect quality of life. Usually, neuropsychological disorders are not associated with AD. Several treatments are available for AD, and among them, eye movement desensitization and reprocessing (EMDR) is one of the most effective in relieving depression and anxiety. However, little is known about AD and PTSD in the MS population and no data are available on the effectiveness of EMDR for cognitive impairment associated with AD. We describe a 25-year-old patient with RR MS developing an AD with a verbal memory deficit after being diagnosed. Both the psychological and cognitive deficits were diagnosed using an extensive neuropsychological battery. Considering the high impact of the verbal memory deficit, on the patient’s quality of life, an EMDR intervention was planned. After a six-month EMDR intervention performed by two trained neuropsychologists, the patient was retested. There was an improvement in verbal memory tests and depression anxiety scales and the Dissociative Experiences Scale. It is recognized that emotional changes and psychiatric disorders, frequently affect MS patients at diagnosis. It is imperative to recognize this and promptly set a neuropsychological treatment. Moreover, we suggest checking cognition along with depression and anxiety. Finally, to our knowledge, this is the first report of AD with an isolated neuropsychological deficit (verbal memory) developed after the MS diagnosis and treated beneficially with e EMDR. More studies are needed to confirm the efficacy of EMDR in treating cognitive impairment associated with AD in MS patients.

Posttraumatic stress disorder intervention for people with severe mental illness in a low-income country primary care setting: a randomized feasibility trial protocol

Background

In this protocol, we outline a mixed-methods randomized feasibility trial of Brief Relaxation, Education and Trauma Healing (BREATHE) Ethiopia. BREATHE Ethiopia is a culturally and contextually adapted intervention for PTSD in participants with severe mental illness. BREATHE Ethiopia maps onto the World Health Organization’s guidelines for posttraumatic stress disorder (PTSD) treatment in low- and middle-income country primary care settings.

Methods

Specifically, this study includes a non-randomized pre-pilot (n = 5) and a randomized feasibility trial comparing BREATHE Ethiopia to Treatment as Usual (n = 40) to assess trial procedures, acceptability, and feasibility of intervention delivery, and investigate potential effectiveness and implementation. In a process evaluation, we will collect data that will be critical for a future fully randomized controlled trial, including the numbers of participants who are eligible, who consent, who engage in treatment, and who complete the assessments, as well as the feasibility and acceptability of assessments and the intervention. Qualitative data on facilitators and barriers to intervention delivery and quantitative data on provider fidelity to the intervention and participant and provider satisfaction will also be collected. Quantitative assessments at baseline, post-treatment, 1-month follow-up, and 3-month follow-up will assess change in mental health symptoms and functional impairment and hypothesized intervention mechanisms, including knowledge about PTSD, stigma, trauma-related cognitions, and physiological arousal.

Discussion

Findings from this study will inform a future fully-powered randomized controlled trial, and if found to be effective, the intervention has the potential to be integrated into mental healthcare scale-up efforts in other low-resource settings.

Trial registration

Registered with ClinicalTrials.gov (NCT04385498) first posted May 13^th, 2020; https://www.clinicaltrials.gov/ct2/show/NCT04385498?term=ethiopia&cond=PTSD&draw=2&rank=1.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00883-3.

Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial

Adaptive Disclosure (AD) is a new emotion-focused psychotherapy for combat-related PTSD. As a second step in the evaluation process, we conducted a non-inferiority (NI) trial of AD, relative to Cognitive Processing Therapy - Cognitive Therapy version (CPT-C), an established first-line psychotherapy. Participants were 122 U.S. Marines and Sailors. The primary endpoint was PTSD symptom severity change from pre- to posttreatment, using the Clinician Administered PTSD Scale for DSM-IV. Secondary endpoints were depression (Patient Health Questionnaire-9; PHQ-9) and functioning (Veterans Rand Health Survey-12; VR-12). For cases with complete data, the mean difference in CAPS-IV change scores was 0.33 and the confidence interval (CI) did not include the predefined NI margin (95% CI =-10.10, 9.44). The mean difference in PHQ-9 change scores was -1.01 and the CI did not include the predefined margin (95% CI = -3.31, 1.28), as was the case for the VR-12 Physical Component and VR-12 Mental Component subscale scores (0.27; 95% CI = -4.50, 3.95, and -2.10; 95% CI = -7.03, 2.83, respectively). A series of intent-to-treat sensitivity analyses confirmed these results. The differential effect size for CAPS-IV was d = 0.01 (nonsignificant). As predicted, Adaptive Disclosure was found to be no less effective than a first-line psychotherapy.

Risk of Secondary Traumatic Stress in Treating Traumatized Military Populations: Results from the PTSD Clinicians Exchange

INTRODUCTION

This study examined risk factors for secondary traumatic stress (STS) in behavioral health clinicians and whether access to the Post-Traumatic Stress Disorder (PTSD) Clinicians Exchange website mitigated STS risk.

METHODS

A diverse sample of clinicians (N = 605) treating traumatized military populations in Department of Veterans Affairs (VA), Department of Defense, and community practice settings were randomized to a newsletter-only control group or the exchange group. The exchange website included resources for treating PTSD and promoting clinician well-being. Online surveys were administered at 0-, 6-, and 12-months postrandomization. Regression analyses were used to examine the link among risk factors, exchange access, and STS.

RESULTS

Baseline clinician demographics, experience, total caseload, appeal of evidence-based practices (EBPs), and likelihood of adopting EBPs if required were not linked with STS at the 12-month assessment period. Providing care at the VA, more burnout, less compassion satisfaction, greater trauma caseload, less openness to new EBPs, and greater divergence from EBP procedures were linked with greater STS. Only burnout and divergence were associated with STS after accounting for other significant STS risk factors. Exchange and control group clinicians reported similar STS levels after accounting for burnout and divergence.

CONCLUSIONS

Given that burnout was linked with STS, future intervention may use techniques targeting burnout and STS (eg, emotion regulation strategies). Research exploring the link between divergence from EBPs and STS may inform EBP dissemination efforts and STS interventions. Finally, results highlight the need for research optimizing STS intervention efficacy among clinicians treating military populations.

Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study

BACKGROUND

Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone.

METHODS

The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS.

DISCUSSION

TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03663452.

Study design comparing written exposure therapy to cognitive processing therapy for PTSD among military service members: A noninferiority trial

Although there are a number of effective treatments for posttraumatic stress disorder (PTSD), there is a need to develop more efficient evidence-based PTSD treatments to address barriers to seeking and receiving treatment. Written exposure therapy (WET) is a potential alternative that is a 5-session treatment without any between-session assignments. WET has demonstrated efficacy, and low treatment dropout rates. However, prior studies with WET have primarily focused on civilian samples. Identifying efficient PTSD treatments for military service members is critical given the high prevalence of PTSD in this population. The current ongoing randomized clinical trial builds upon the existing literature by investigating whether WET is equally efficacious as Cognitive Processing Therapy (CPT) in a sample of 150 active duty military service members diagnosed with PTSD who are randomly assigned to either WET (n = 75) or CPT (n = 75). Participants are assessed at baseline and 10, 20, and 30 weeks after the first treatment session. The primary outcome measure is PTSD symptom severity assessed with the Clinician Administered PTSD Scale for DSM-5. Given the prevalence of PTSD and the aforementioned limitations of currently available first-line PTSD treatments, the identification of a brief, efficacious treatment that is associated with reduced patient dropout would represent a significant public health development.

Fidelity to Best Practices of Psychiatric Assessments in Army Behavioral Health Settings

While civilian and military psychiatric clinical practice guidelines (CPGs) exist for psychiatric assessments, data are lacking on providers' adherence to these criteria. This study evaluated the use of psychiatric CPGs' assessment criteria by Army behavioral health providers (BHPs). In a weighted cross-sectional survey, 348 BHPs were evaluated on their assessment of a systematically selected patient on 15 total domains recommended by the Departments of Veterans Affairs and Defense CPGs for substance use disorders, posttraumatic stress disorder, and major depressive disorder. The proportion of BHPs providing high-quality assessment and the association between high-quality assessment and BHP and patient characteristics were examined. Using the weighted sample, 80% of BHPs provided a high-quality assessment. BHPs who saw ≥20 patients per week were significantly more likely to provide high-quality assessments compared with BHPs who saw <20 patients per week [odds ratio (OR)=1.72, 95% confidence interval (CI)=1.01-2.92]. Patients diagnosed with generalized anxiety disorder [adjusted OR (AOR)=0.42, 95% CI=0.18-0.96] or whose BHPs did not assess patients' current overall physical health (AOR=0.26, 95% CI=0.07-0.97) or lifetime duration of treatment for mental health (AOR=0.03, 95% CI=0.01-0.20) were less likely to receive high-quality assessments. A majority of Army BHPs are conducting high-quality assessments for the 3 most common mental disorders in military populations. If recommendations to increase fidelity to assessment could be implemented, more patients could receive optimized care.

VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components

OBJECTIVE

Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT).

METHOD

Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT.

RESULTS

Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment.

CONCLUSIONS

These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record

A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial

Importance

Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT).

Objective

To determine if WET is noninferior to CPT in patients with PTSD.

Design, Setting, and Participants

In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis.

Interventions

Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered individually in 60-minute weekly sessions. The first WET session requires 60 minutes while the remaining 4 sessions require 40 minutes.

Main Outcomes and Measures

The primary outcome was the total score on the Clinician-Administered PTSD Scale for DSM-5; noninferiority was defined by a score of 10 points. Blinded evaluations were conducted at baseline and 6, 12, 24, and 36 weeks after the first treatment session. Treatment dropout was also examined.

Results

For the 126 participants (66 men and 60 women; mean [SD] age, 43.9 [14.6] years), improvements in PTSD symptoms in the WET condition were noninferior to improvements in the CPT condition at each of the assessment periods. The largest difference between treatments was observed at the 24-week assessment (mean difference, 4.31 points; 95% CI, -1.37 to 9.99). There were significantly fewer dropouts in the WET vs CPT condition (4 [6.4%] vs 25 [39.7%]; χ21 = 12.84, Cramer V = 0.40).

Conclusions and Relevance

Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD. The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers.

Trial Registration

clinicaltrials.gov Identifier: NCT01800773.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Patterns of practice in community mental health treatment of adult depression

OBJECTIVE

Community mental health therapists often endorse an eclectic orientation, but few studies reveal how therapists utilize elements of evidence-based psychotherapies. This study aimed to characterize treatment as usual patterns of practice among therapists treating depressed adults in community mental health settings.

METHOD

Therapists (N = 165) from the USA's largest not-for-profit provider of community-based mental health services completed surveys assessing their demographics and practice element use with depressed adult clients. Specifically, therapists indicated whether they utilized each of 45 unique practice elements from the following evidence-based psychotherapies: Acceptance and Commitment Therapy, Behavioral Activation, Brief Psychodynamic Therapy, Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Mindfulness-Based CBT, Problem-Solving Therapy, and Self-Control Therapy. Principal component analysis was employed to identify practice patterns.

RESULTS

The principal component analysis included 31 practice elements and revealed a three-factor model with distinct patterns of practice that did not align with traditional evidence-based practice approaches, including: (i) Planning, Practice, and Monitoring; (ii) Cognitive, Didactic, and Interpersonal; and (iii) Between Session Activities.

CONCLUSIONS

Therapist-reported practice patterns confirmed an eclectic approach that brought together elements from theoretically distinct evidence-based psychotherapies. Future research is needed to explore how these patterns of practice relate to client outcomes to inform focused training and/or de-implementation efforts.

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

BACKGROUND

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.

METHODS

To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.

DISCUSSION

It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.

TRIAL REGISTRATION

NCT02449421 . Registered 02/09/2015.

The Effectiveness of Emotional Freedom Techniques in the Treatment of Posttraumatic Stress Disorder: A Meta-Analysis

BACKGROUND

Over the past two decades, growing numbers of clinicians have been utilizing emotional freedom techniques (EFT) in the treatment of posttraumatic stress disorder (PTSD), anxiety, and depression. Randomized controlled trials (RCTs) have shown encouraging outcomes for all three conditions.

OBJECTIVE

To assess the efficacy of EFT in treating PTSD by conducting a meta-analysis of existing RCTs.

METHODS

A systematic review of databases was undertaken to identify RCTs investigating EFT in the treatment of PTSD. The RCTs were evaluated for quality using evidence-based standards published by the American Psychological Association Division 12 Task Force on Empirically Validated Therapies. Those meeting the criteria were assessed using a meta-analysis that synthesized the data to determine effect sizes. While uncontrolled outcome studies were excluded, they were examined for clinical implications of treatment that can extend knowledge of this condition.

RESULTS

Seven randomized controlled trials were found to meet the criteria and were included in the meta-analysis. A large treatment effect was found, with a weighted Cohen׳s d = 2.96 (95% CI: 1.96-3.97, P < .001) for the studies that compared EFT to usual care or a waitlist. No treatment effect differences were found in studies comparing EFT to other evidence-based therapies such as eye movement desensitization and reprocessing (EMDR; 1 study) and cognitive behavior therapy (CBT; 1 study).

CONCLUSIONS

The analysis of existing studies showed that a series of 4-10 EFT sessions is an efficacious treatment for PTSD with a variety of populations. The studies examined reported no adverse effects from EFT interventions and showed that it can be used both on a self-help basis and as a primary evidence-based treatment for PTSD.

Brief treatment for PTSD: A non-inferiority trial

Prior studies have identified several psychosocial treatment approaches as effective for posttraumatic stress disorder (PTSD). Unfortunately, a substantial minority of individuals who receive these treatments drop out prematurely. Moreover, a considerable number of individuals in need of PTSD treatment do not present for treatment due to time constraints and other barriers to care. Thus, there is a need to develop alternative evidence-based PTSD treatments that have lower treatment dropout rates and address current barriers to receiving care. One recently developed PTSD treatment that has demonstrated efficacy and potentially meets these criteria is Written Exposure Therapy (WET), a 5-session treatment protocol that promotes recovery through writing about the trauma event as well as one's thoughts and feelings about it without any assigned homework. In an ongoing randomized controlled trial (RCT) we are investigating whether WET is equally efficacious as Cognitive Processing Therapy (CPT), a treatment that typically requires more therapist training and more therapy sessions. The study sample consists of 126 adults diagnosed with PTSD who are randomly assigned to either WET (n=63) or CPT (n=63). Participants are assessed prior to treatment and 6-, 12-, 24-, 36-, and 60-weeks after the first treatment session. The primary outcome measure is PTSD symptom severity assessed with the Clinician Administered PTSD Scale for DSM-5. Given the prevalence of PTSD and the aforementioned limitations of currently available first-line PTSD treatments, the identification of a brief, efficacious treatment that is associated with reduced patient dropout would represent a significant public health development.

Cognitive-behavioral group treatment for veterans diagnosed with PTSD: Design of a hybrid efficacy-effectiveness clinical trial

Despite significant advances in individual treatment approaches for PTSD, knowledge of group approaches has lagged behind. Much of the reason knowledge about group treatment for PTSD has been limited is due to the complexity of conducting randomized controlled trials in the group treatment context. This limited empirical knowledge is unfortunate given the frequency with which group treatment for PTSD is used in clinical settings, including the Department of Veteran Affairs. The goal of this study is to examine the efficacy of a group cognitive-behavioral treatment (GCBT) for PTSD relative to group supportive counseling approach (i.e. group present centered treatment; GPCT). The sample consists of 196 veterans diagnosed with PTSD who are randomly assigned to either GCBT (n=98) or GPCT (n=98). Both treatments are administered by two therapists over the course of 14 sessions. Assessments take place at baseline, mid-treatment, post-treatment and 3-, 6-, and 12-month follow-up. The primary outcome measure is the PTSD symptom severity assessed with a semi-structured diagnostic instrument. Given the substantial rise of veterans presenting for PTSD treatment services, identifying an efficacious group treatment approach is invaluable.

System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network

OBJECTIVE

The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system.

METHODS

Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach.

RESULTS

Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge.

CONCLUSIONS

Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.

Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics

In response to the growing numbers of veterans with posttraumatic stress disorder (PTSD), the Department of Veterans Affairs (VA) has sought to make evidence-based psychotherapies for PTSD available at every VA facility. We conducted a national survey of providers within VA PTSD clinical teams (PCTs) to describe utilization of prolonged exposure (PE) and cognitive processing therapy (CPT) and to identify individual and organizational factors associated with treatment uptake and adherence. Participants (N = 128) completed an electronic survey assessing reported utilization of PE and CPT treatments, adherence to treatment manuals, and characteristics of the provider and workplace environment. Participants reported conducting a weekly mean of 4.5 hours of PE, 3.9 hours of CPT (individual format), 1.3 hours of CPT (group format), and 13.4 hours of supportive care. Perceived effectiveness of PE and CPT were significantly associated with utilization of and adherence to those treatments. Reported number of hours conducting supportive care was positively associated with feeling the clinic was not sufficiently staffed (p = .05). Adherence to the PE treatment manual was positively associated with receiving emotional support from coworkers (p < .01). Provider attitudes and organizational factors such as staffing and work relationships may have an important impact on treatment selection and the quality of PTSD care provided in VA PCTs.