Faculty Bibliography

Posttraumatic stress disorder (PTSD) is a costly mental health issue in the United States and throughout the world. Effective treatments are available; however, most people with PTSD never access these treatments. Prolonged exposure (PE) therapy has emerged as an effective, first-line treatment for PTSD and is provided in specialty mental health in eight to 15 sessions, each lasting 90 minutes. Most people with PTSD do not enter specialty mental health to access this service. Over the past 15 years, provision of mental health care in primary care has increased due to patient preference for care in this setting and the ability to overcome many access barriers (stigma, longer sessions, insurance coverage, etc.). While medications for PTSD are available in primary care, effective brief psychotherapeutic PTSD treatment options have only recently been established. PE-PC (prolonged exposure for primary care) is a brief version of PE therapy for PTSD with efficacy in a primary care (PC) setting in reducing PTSD, depression, and related mental disorder symptoms. PE-PC has four 30-minute sessions and focuses on imaginal exposure to the trauma memory, in vivo exposure to trauma-related avoidance, and emotional processing of the memory. Dissemination efforts are currently underway to expand availability.

The purpose of this study is to explore the effects of a stepped-care model of treatment on Posttraumatic Stress Disorder (PTSD) symptomatology and sequelae in United States' Veterans. The study provides a literature review of the burden of PTSD, describes current best treatment practices, and illustrates key processes in the service-delivery of these treatments. Treatment considerations are demonstrated via three hybrid case examples, which serve as vivid portrayals of Veteran clients who struggle with research-consistent PTSD symptomatology and difficulties engaging in psychotherapy. In addition to being informed by clinical examples in relevant psychological literature, these composite cases, "Alex," "Bruno," and "Charles," contain disguised aspects drawn from psychotherapy clients who have been in my caseload in a PTSD clinic. Demonstrating these clients' courses of treatment provides an avenue for describing key clinical issues related to Veteran engagement in evidence-based PTSD therapy. By adopting a qualitative, disciplined inquiry approach, treatment is tailored to the client's unique psychological struggles within the context of historical, contextual, and cultural factors. Using a pragmatic case study research format (Fishman, 2013), case material is analyzed both qualitatively and quantitatively. The cases illustrate how a stepped-care model of treatment, beginning with Written Exposure Therapy (WET; Sloan, Lee, Litwack, Sawyer, & Marx, 2013) and culminating in Prolonged Exposure Therapy (PE; Foa, Hembree, & Rothbaum, 2007), has the potential to be distinctively helpful in the treatment of Veterans suffering from PTSD. These case studies are designed to be a resource for therapists who seek to gain additional understanding of how to provide efficient and effective treatment to Veterans.

In "Written Exposure Therapy as Step One in Reducing the Burden of PTSD: The Composite Cases of 'Alex,' 'Bruno,' and 'Charles'" (Austern, 2017), I presented three composite case study examples of how veterans suffering from PTSD may benefit from written exposure to their trauma memories. For one case (Bruno), Written Exposure Therapy (WET) was the initial treatment in a stepped-care approach that culminated in Prolonged Exposure therapy. However, for the two others, WET became a standalone treatment. In two commentaries on the cases, Cigrang and Peterson (2017) and Sloan and Marx (2017) discuss the development and efficacy of WET, WET implementation strategies, and practice implications of WET (e.g., the potential to reduce clinician burnout). In my response to these commentaries, I aim to contribute to the bourgeoning discussion of how mental health providers can best incorporate this promising writing-based treatment (WET) into their existing approaches to working with veterans suffering from Post-Traumatic Stress Disorder (PTSD). My response will address themes raised by my composite case studies and by the commentaries, including how stepped-care service delivery models may have the potential to make PTSD care more efficient.

Compared to their White counterparts, Black and Hispanic Vietnam-era, male, combat veterans in the United States have experienced discrimination and increased trauma exposure during deployment and exhibited higher rates of postdeployment mental health disorders. The present study examined differences in deployment experiences and postdeployment mental health among male and female Black, Hispanic, and White veterans deployed in support of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq. Data were drawn from a national survey of veterans (N = 924) who had returned from deployment within the last 2 years. Ethnoracial minority veterans were compared to White veterans of the same gender on deployment experiences and postdeployment mental health. The majority of comparisons did not show significant differences; however, several small group differences did emerge (.02 < eta(2) < .04). Ethnoracial minority veterans reported greater perceived threat in the warzone and more family-related concerns and stressors during deployment than White veterans of the same gender. Minority female veterans reported higher levels of postdeployment symptoms of anxiety than their White counterparts, which were accounted for by differences in deployment experience. These differences call for ongoing monitoring.

Exposure and response prevention (ERP) is considered the gold standard treatment for obsessive-compulsive disorder (OCD). However, when comorbidity or other clinically relevant issues arise, the standard ERP protocol may require modification. Golden and Holaway's (2013) case of "Mr. H" and Pontes and Pereira's (2013) case of "Angela" offer excellent examples of clients presenting with these clinical challenges. Our commentary addresses some of the concerns raised by these authors by bringing in the emerging field of Distress Tolerance (DT) research. Using examples from the authors' cases, along with relevant research, we suggest that clinicians who wish to modify ERP consider the proposed alterations carefully by simultaneously thinking more broadly and more specifically about the psychopathology present. In addition, we stress the necessity of various forms of continual outcome monitoring