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Starting in 2006, the U.S. Department of Veterans Affairs (VA) invested significant resources to provide their mental health workforce with training, supervision, staffing and implementation support for two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD): Prolonged Exposure (PE; Foa et al., 2019) and Cognitive Processing Therapy (CPT; Resick et al., 2016). As part of a theory-driven, mixed-method longitudinal investigation, our research group interviewed 526 mental health providers from 39 VA residential programs throughout the US across five timepoints spanning a seven-year period concerning use of PE and CPT. This paper presents the adoption patterns that emerged for PE and CPT across the study period. We highlight potential factors that may have influenced adoption and how data gathered from this study can be used to support and reinforce programs delivering treatment to individuals with PTSD. 

Results of this investigation demonstrate a meaningful increase in evidence-based treatment adoption over a prolonged period. More specifically, for CPT, five patterns of adoption were observed. Continued rates of low or no adoption throughout the seven-year period were least common. One fourth of programs had low adoption at the beginning and moderate increases in adoption over time while another group began with low adoption and reached high adoption by the end of the study. Nearly one-third of programs that had moderate or greater adoption at the start of the study sustained this use over time. Finally, seven programs adopted CPT as the core of their program throughout the study period. For clinic leaders and policymakers, these results suggest perseverance of implementation efforts are worthwhile and can lead to increased adoption, even if there is no or slow uptake initially.

Implementation of PE was not as strong as CPT, with three distinct patterns of adoption emerging. One in six programs reported no use of PE during the majority of timepoints. Of those who implemented PE early, it was typically done with few patients except for one-quarter of programs who started at moderate levels and increased their use over time. Barriers to PE implementation have been discussed in a previous publication from this longitudinal investigation. The most cited barrier to implementing PE in VA residential programs was insufficient time and dedicated resources (Cook et al., 2015). More specifically, numerous providers indicated that their program lacked adequate resources (e.g., audio recorders, trained providers), while others felt they did not have the flexibility in their schedule to block 90-minute individual sessions at least weekly, if not more. At sites that utilize group programming as their primary or sole method of treatment delivery, providers indicated that the lack of an efficacious VA-approved group PE protocol also inhibited their ability to offer PE. In turn, this may have influenced programs that primarily use group-based treatments to adopt CPT, rather than undertaking more robust changes to implement PE.

Although many programs had consistently high or increasing adoption of CPT and PE, a minority of programs tended to be consistently lower adopters of CPT and PE. In fact, seven of the VA residential PTSD treatment programs, including five identified in the initial evaluation, were not regularly using PE or CPT. All these programs instead prioritized other treatments, namely Eye Movement Desensitization and Reprocessing (Shapiro, 2001), Acceptance and Commitment Therapy (Hayes et al., 1999) or war-zone focused trauma groups (Foy et al., 1997).

Findings from this study are encouraging given that these treatments are among the most efficacious for reducing PTSD symptoms and that substantial time and resources have been devoted to their dissemination. The results may help to guide strategies needed to improve and sustain high quality of care for PTSD survivors within and outside of VA. For example, certain organizational factors, such as prioritization of EBPs may contribute to program sustainability. This kind of information can help policymakers, administrators, and practitioners to support and reinforce program continuation.


Cook, J.M., Dinnen, S., Thompson, R., Ruzek, J., Coyne, J., & Schnurr, P.P. (2015). A quantitative test of an implementation framework in 38 VA residential PTSD programs. Administration and Policy in Mental Health and Mental Health Services Research, 42, 462-473.  doi:10.1007/s10488-014-0590-0

Foa, E., Hembree, E., Rothbaum, B. O., & Rauch, S. (2019). Prolonged Exposure Therapy for
PTSD: Emotional processing of traumatic experiences therapist guide. New York, NY: Oxford University Press.

Foy, D. W., Ruzek, J. I., Glynn, S. M., Riney, S. J., & Gusman, F. D. (1997). Trauma focus group therapy for combat-related PTSD. In Session: Psychotherapy in Practice: Psychotherapy in Practice3(4), 59-73.

Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (1999). Acceptance and Commitment Therapy.
New York, NY: Guilford.

Resick, P. A., Monson, M. C., & Chard, C. M. (2016). Cognitive Processing Therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, basic principles, protocols and procedures. (2nd ed.). New York, NY: Guilford.

Reference Article

Cook, J.M., Simiola, V., Thompson, R., Mackintosh, M.‐A., Rosen, C., Sayer, N. and Schnurr, P.P. (2020), Implementation Patterns of Two Evidence‐Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five‐Point Longitudinal National Investigation. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22557

Questions for Discussion

  • What are the most common patterns of PE and CPT adoption across in U.S. Department of Veterans Affairs residential PTSD treatment programs?
  • What accounts for the differences between PE and CPT adoption patterns?

About the Authors

Joan Cook, Ph.D., is an Associate Professor in the Yale Department of Psychiatry. She has served as the principal investigator on seven federally-funded grants and has disseminated research on trauma to the public by writing over 90 op-eds in places like CNN, TIME Ideas, Newsweek and The Hill.

Vanessa Simiola, Psy.D., is a Research Associate and licensed clinical psychologist at Kaiser Permanente's Center for Integrated Health Care Research. Much of her research to date has focused on dissemination, implementation, and sustainability of evidence-based treatments for PTSD.