Provider Decisions to Use Evidence-Based Psychotherapy for PTSD Among Veterans: Assessments of Overidentification With the Sick Role and Comorbid Personality Disorders

Despite being recommended as first-line treatments for posttraumatic stress disorder (PTSD) by the Veterans Health Administration (VHA), the two evidence-based psychotherapies (EBPs), cognitive processing therapy (CPT) and prolonged exposure (PE), remain underutilized. Provider perceptions of certain clinical characteristics may pose barriers to EBP utilization. VHA providers (N = 227) in PTSD clinical teams across the United States rated their levels of preference for CPT, PE, and other psychotherapy with each of the six clinical characteristics (high severity, sexual assault, combat, guilt, overidentification with the sick role, and comorbid personality disorders) and reported whether they had received training in CPT and PE. We conducted repeated measures ANOVA and multivariate multiple regression analyses to evaluate providers’ patterns of treatment utilization by clinical characteristics and the effects of training on treatment preference. We found that providers preferred to engage in the two EBPs over others forms of psychotherapy when their patients’ PTSD is characterized by high severity, sexual assault, combat, or guilt. Providers preferred to engage in CPT with patients who overidentify with the sick role but did not prefer to engage in either of the EBPs over other psychotherapy with patients who exhibit comorbid personality disorders. Additionally, prior trainings in CPT and PE were associated with increased preference for the respective EBPs. Given that patients’ clinical characteristics may constitute legitimate clinical concerns, patientlevel factors will require special attention to discern actual contraindications from perceived clinical barriers without empirical support. More research is also needed to differentiate the underlying reasons for overidentification with the sick role.