Psychological Trauma: Theory, Research, Practice, and Policy
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Psychological Trauma: Theory, Research, Practice, and Policy “It Leaves Me Very Skeptical” Messaging in Marketing Prolonged Exposure and Cognitive Processing Therapy to Veterans With PTSD Shannon M. Kehle-Forbes, Heather Gerould, Melissa A. Polusny, Nina A. Sayer, and Melissa R. Partin Online First Publication, January 20, 2020. http://dx.doi.org/10.1037/tra0000550 CITATION Kehle-Forbes, S. M., Gerould, H., Polusny, M. A., Sayer, N. A., & Partin, M. R. (2020, January 20). “It Leaves Me Very Skeptical” Messaging in Marketing Prolonged Exposure and Cognitive Processing Therapy to Veterans With PTSD. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000550
Psychological Trauma:
Theory, Research, Practice, and Policy
In the public domain 2020, Vol. 1, No. 999, 000
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000550
BRIEF REPORT
“It Leaves Me Very Skeptical” Messaging in Marketing Prolonged
Exposure and Cognitive Processing Therapy to Veterans With PTSD
Shannon M. Kehle-Forbes Heather Gerould
Minneapolis VA Health Care System, Minneapolis, Minnesota, and Minneapolis VA Health Care System, Minneapolis, Minnesota
National Center for PTSD Women’s Health Sciences Division at
VA Boston Health Care System, Boston, Massachusetts
Melissa A. Polusny and Nina A. Sayer Melissa R. Partin
Minneapolis VA Health Care System, Minneapolis, Minnesota, University of Minnesota, Minneapolis
and University of Minnesota, Minneapolis
Objective: Direct-to-consumer marketing has the potential to increase demand for specific treatments, but
little is known about how to best market evidence-based psychotherapies to veterans with posttraumatic
stress disorder (PTSD). The objective of this study was to gain an understanding of marketing messages
that may impact veteran demand for prolonged exposure (PE) and cognitive processing therapy (CPT).
Method: Veterans (n ⫽ 31) with full or subthreshold PTSD participated in semistructured interviews that
queried attitudes about PTSD and recovery, current knowledge of PE and CPT, and reactions to existing
educational materials. A 2-stage qualitative coding and analytic strategy was used to identify primary
themes related to the marketing of PE and CPT. Results: Veterans viewed the treatments’ effectiveness
as their primary selling point but questioned the credibility of improvement descriptions that didn’t fit
with their experiences or beliefs about PTSD. Participants had difficulties distinguishing CPT from
non-trauma-focused approaches in which they had previously participated, leading to skepticism about
promised treatment effects and decreased interest. Without targeting, women veterans assumed infor-
mation regarding PTSD treatment options applied only to men. Conclusions: Examination of the impact
of a direct-to-consumer marketing campaign including these messages on PE and CPT demand is needed.
Clinical Impact Statement
Veterans may lack information about the availability of effective treatments for posttraumatic stress
disorder. This study sought to better understand how to market prolonged exposure (PE) and
cognitive processing therapy (CPT) to veterans. Describing specific symptom improvements that
other veterans have experienced with the treatments, clearly stating how PE and CPT differ from
present-centered therapies, and creating materials specifically for women may be important for
successful marketing of PE and CPT to veterans.
Keywords: social marketing, PTSD, evidence-based psychotherapy, veterans, implementation
Supplemental materials: http://dx.doi.org/10.1037/tra0000550.supp
This material is based upon work supported by U.S. Department of
X Shannon M. Kehle-Forbes, Center for Care Delivery and Out- Veterans Affairs, Quality Enhancement Research Initiative, Grant RRP12-
comes Research, Minneapolis VA Health Care System, Minneapolis, 512. Shannon M. Kehle-Forbes was supported by VA Health Services
Minnesota, and National Center for PTSD Women’s Health Sciences Research & Development Career Development Award CDA09-020.
Division at VA Boston Health Care System, Boston, Massachusetts; The views expressed in this article are those of the authors and do not
X Heather Gerould, Center for Care Delivery and Outcomes Research, necessarily reflect the position or policy of the Department of Veterans
Minneapolis VA Health Care System; Melissa A. Polusny, Center for Affairs or the U.S. government. Marketing materials resulting from
Care Delivery and Outcomes Research, Minneapolis VA Health Care the reported study are available at https://www.ccdor.research.va.gov/
System, and Department of Psychiatry, University of Minnesota; Nina CCDORRESEARCH/Resources.asp.
A. Sayer, Center for Care Delivery and Outcomes Research, Minneap- Correspondence concerning this article should be addressed to Shan-
olis VA Health Care System, and Departments of Medicine and Psy- non M. Kehle-Forbes, Center for Care Delivery and Outcomes Re-
chiatry, University of Minnesota; Melissa R. Partin, Department of search, Minneapolis VA Health Care System, One Veterans Drive
Medicine, University of Minnesota. (152/Building 9), Minneapolis, MN 55417. E-mail: shannon.kehle-
Heather Gerould is now at the Santa Teresa, Costa Rica. forbes@va.gov
12 KEHLE-FORBES, GEROULD, POLUSNY, SAYER, AND PARTIN
Since 2006, the U.S. Department of Veterans Affairs (VA) has Mental Disorders (4th ed.; DSM–IV; American Psychiatric Asso-
been engaged in an unprecedented initiative to ensure that all ciation, 1994) diagnosis of PTSD or subthreshold PTSD as defined
veterans with posttraumatic stress disorder (PTSD) have access to by Stein, Walker, Hazen, and Forde (1997). Of the 37 veterans
prolonged exposure (PE) and cognitive processing therapy (CPT; who consented to study participation, six veterans were excluded
Karlin & Cross, 2014). VA has trained over 10,000 mental health from the interview following the CAPS (see Supplemental Figure
providers to deliver PE and CPT and implemented numerous 1 in the online supplemental materials for a recruitment flowchart).
system-level changes to help ensure their widespread adoption A team of two interviewers (including at least one master’s- or
(Karlin & Cross, 2014; Rosen et al., 2016). Despite these efforts, PhD-level psychologist or clinical social worker) conducted the
relatively few veterans with PTSD have begun a course of PE or 60-min semistructured interviews, with one conducting the inter-
CPT. Only 22.8% of all Iraq and Afghanistan war veterans with view and the other taking field notes regarding emerging themes.
PTSD seeking VA care initiated PE or CPT during a 15-year The interview guide inquired about (a) how and from whom veterans
period (Maguen et al., 2019). One factor limiting the reach of these preferred to receive information regarding PTSD treatment op-
evidence-based psychotherapies (EBPs) may be a lack of veteran tions, (b) attitudes toward PTSD recovery, (c) domains in which
demand. A survey study demonstrated that few veterans were able veterans would expect to see change following successful treat-
to recognize CPT and PE as effective treatments for PTSD (Harik, ment, and (d) current knowledge of PE and CPT. Following these
Matteo, Hermann, & Hamblen, 2017), and a review of studies questions, veterans were randomly assigned to watch one of two
examining their implementation within the VA reported that cli- educational videos used within the VA to describe PE or CPT.
nicians believe that patients are unwilling to participate in such After viewing the video, participants were asked about their reac-
trauma-focused therapies (Rosen et al., 2016). tions to the video and the therapy that was presented. All inter-
Direct-to-consumer marketing (e.g., “selling” directly to pa- views were audio-recorded and transcribed. Interview participants
tients, rather than the more traditional model of marketing to health were later invited to participate in a 90-min group feedback session
care providers), as has been employed by the pharmaceutical (e.g., member check) to ensure the accuracy and validity of themes
industry, is one potential strategy for building awareness and resulting from the interviews. Veterans were paid $75.00 for partici-
engendering positive attitudes. As such, discussion of its use to pating in the interview and $75 for the group session.
increase patient demand for EBPs for a range of mental health
conditions has increased in the scientific literature over the past
Data Analysis
several years (e.g., Becker, 2015). A small number of randomized
controlled trials have demonstrated that direct-to-consumer mar- We employed a two-step analytic process. Immediately follow-
keting can increase knowledge and intent to initiate EBPs in non- ing each interview, the two team members present at the interview
treatment-seeking samples (e.g., Gallo, Comer, Barlow, Clarke, & met to debrief. All debriefings were audio-recorded and tran-
Antony, 2015; Ponzini & Schofield, 2019). Although the VA has scribed. After completing all interviews, a team of two interview-
created patient-facing materials to facilitate PE and CPT initiation, ers reviewed transcripts of the debriefings and created a master log
information about how to best market PE and CPT and how to market summarizing themes and highlighting key insights. The themes
EBPs to veteran populations is lacking. This article presents findings identified through this process, revised as needed following the
from a qualitative study undertaken to better understand messaging member check, served as the basis of the qualitative codebook to
that may build patient demand for EBPs. be used in Stage 2 of analysis. During the second phase of analysis,
two coders applied the coding scheme resulting from the earlier
Method phase to 20% (n ⫽ 7) of interview transcripts to test the coding
strategy. The coders then met to discuss their codes, propose
Participants and Procedure additional codes not covered by the preliminary codebook, and
amend the codebook as necessary. Following codebook finaliza-
Procedures were approved by the Institutional Review Board of tion, each transcript was coded by a primary coder and verified by
the Minneapolis VA Health Care System. Veterans were identified a secondary coder, who read the transcript and associated codes;
as eligible via the electronic medical record; eligibility criteria differences were arbitrated during regular meetings between the
included (a) Minneapolis VA health care use during the past year; coders. Finally, we applied the constant comparison method during
(b) chart diagnosis of PTSD, with current full or subthreshold analysis to determine whether key themes differed for male and
PTSD diagnosis verified during the interview; (c) not engaged in female veterans. Coding was conducted using NVivo 10.0.
psychotherapy at the time of recruitment; (d) no prior PE or CPT
treatment experience; and (e) no current psychotic disorder, cog-
Results
nitive disorder, or suicide flag, because those may preclude PE or
CPT participation. A random subset of veterans who met criteria A total of 31 veterans (23 male) completed interviews. Twenty
were invited via mailed letter and subsequently by phone to partici- veterans were post-9/11-era veterans and 11 were Vietnam-era
pate. We stratified the sample by gender and oversampled women to veterans. The sample was 94% White and 6% (n ⫽ 2) Black or
have a sufficiently large sample (i.e., eight or more veterans; Guest, African American; no participants identified as Hispanic or Latino.
Bunce, & Johnson, 2006) to identify high-frequency themes unique to A majority (52%) of participants were service-connected for PTSD.
women. Veterans reported a number of strengths of PE and CPT and the
The interview began with informed consent and administration educational materials. Nearly all veterans found the use of first-person
of the Clinician-Administered PTSD Scale (CAPS; Blake et al., testimonials to be powerful and reported that they believed that PE
1998) to confirm a current Diagnostic and Statistical Manual of and CPT had the potential to reduce symptoms and improve func-MARKETING EVIDENCE-BASED PTSD THERAPY TO VETERANS 3
tioning. Below we present three primary themes related to better messenger and the message was reported as being paramount
marketing PE and CPT to veterans. throughout the interviews, and credibility was easily lost through
perceived missteps such as described above.
Broad Statements About the Benefits of PE and CPT
May Jeopardize Credibility Veterans Need Help Understanding What Makes PE
Nearly all veterans viewed PE’s and CPT’s effectiveness as and CPT Unique
their greatest strength. It was the main factor associated with
More than one half of participants believed that they had pre-
veterans’ stated willingness to engage in the treatment and instilled
hope that improvement and change was possible. One female viously participated in PE or CPT, even though the medical record
veteran stated, “Talking about how well it had worked was some- and detailed queries during the interview suggested they had not.
thing that caught my eye. They were talking about how well it’s This was due to difficulty differentiating PE and CPT from other
worked and how much improvement that it’s had in people who mental health treatments in which they had previously participated,
have dealt with PTSD for a long time.” even after viewing the educational videos. This was particularly
Despite the enthusiasm for the treatments’ effectiveness, ap- problematic for the CPT video; nearly all veterans perceived CPT
proximately half of veterans (including those who saw effective- as being a present-centered, skills-based treatment, rather than a
ness as a strength) were skeptical of what they saw as overly trauma-focused treatment. Only one veteran who viewed the CPT
positive portrayals of improvement. In response to being asked video accurately understood the treatment’s focus and rationale.
what stood out to him in the educational video, a male veteran Veterans’ beliefs that they had previously participated in PE or
sarcastically responded, “Just a few people that said [CPT] is the CPT (or a very similar treatment), lessened their interest in partic-
second coming of the Lord.” Similarly, a male veteran stated, ipating in one of those treatments in the future. One male veteran
“They’re making it sound like everything is going to be too good. reported,
I mean, not realistic. It’s too happy. I mean it’s too positive.”
Overly positive messages were perceived as depicting a lack of I think that’s what [case manager] is doing with me—making me
understanding of the experience of living with PTSD and led to write the list of things that happened, how I handled it before, and how
mistrust of the messenger, yielding strong negative responses. One I want to handle it. I feel like I am [already] doing that stuff.
male veteran reported, “They only showed us the positive side of
A second male veteran stated, “I’ve been through a treatment
it. What is the negative?” A second stated, “When people promise
program that seems very similar. I think that it’s very similar to
you things like that, there’s usually a hidden agenda, and it’s not
one I’ve been through, and I haven’t seen results.” This mismatch
you that is going to profit from that hidden agenda . . . It leaves me
very skeptical.” between veterans’ perceived experience with the same or a very
In a related vein, veterans had strong negative reactions to similar treatment and the promised results yielded a loss of cred-
statistics demonstrating the percentage of veterans who no longer ibility and interest in the treatments.
met criteria for PTSD following a course of PE or CPT that were
presented during the member check. Approximately one half of
In the Absence of Gender-Specific Material, Women
veterans initially voiced concerns, and nearly all veterans agreed
the messaging was detrimental by the end of the discussion.
Believed That PE and CPT Were for Men
Specifically, participants reported disbelief toward and strongly Most women veterans who participated in the study stated a
recommended removing a pictograph displaying the number of preference for materials that were specifically tailored to women
veterans out of 100 who lose their PTSD diagnosis following PE veterans and found the lack of women veterans in the educational
or CPT. A large majority of veterans believed that it is not possible videos shown during the interviews to be problematic. One woman
(or at least is very unlikely) to lose one’s PTSD diagnosis; al- veteran stated, “I saw a couple females, but none of them talk-
though symptoms can improve (and even remit), veterans reported ed—it was mostly males that talked . . . If it was geared specifi-
they would still have PTSD. This discrepancy in belief about
cally towards women, you know, it would definitely grab my
symptom remission and loss of PTSD diagnosis is in part due to
attention more.” Further, about one half of women stated that if
veterans’ reported conceptualization of PTSD, which extends be-
VA materials regarding PTSD treatment weren’t specifically tar-
yond the psychiatric symptoms. For the interviewed veterans, having
geted to women, they assumed the information did not apply to
a PTSD diagnosis included having been through a traumatic experi-
them. This was particularly notable in women veterans’ concerns
ence and having memories of those events (whether or not those
memories were currently associated with distress or avoidance) and that PE and CPT would not address PTSD resulting from sexual
the lasting change to the veteran resulting from those experiences. assault due to the lack of discussion regarding sexual trauma and
One woman veteran stated, “It changed my life. [PTSD] is part of who the reliance on combat images in the educational videos. One
I am, part of what I’ve been through.” woman veteran stated, “There weren’t any women . . . If they don’t
Descriptions of symptom recovery perceived as overly optimis- understand what we face, will they understand how to help? Nothing
tic and discussion of loss of PTSD diagnosis reduced the perceived addressed sexual assault.” A second woman veteran shared a similar
trustworthiness and credibility of the source and the message. Such sentiment, “[I want to know] if it works for sexual trauma, something
descriptions suggested to participants that the source didn’t under- more directly related [to my experience]. It might be great for people
stand veterans’ experiences and thus would not be knowledgeable that have seen blown-up bodies, but what about other types of
regarding their treatment. The importance of credibility of the PTSD?”4 KEHLE-FORBES, GEROULD, POLUSNY, SAYER, AND PARTIN
Discussion Becker, S. J. (2015). Direct-to-consumer marketing: A complementary
approach to traditional dissemination and implementation efforts for
Findings from this qualitative analysis suggest that PE and CPT mental health and substance abuse interventions. Clinical Psychology:
marketing materials directed at veterans may be most effective in Science and Practice, 22, 85–100. http://dx.doi.org/10.1111/cpsp.12086
creating demand if they highlight treatment effectiveness, include Blake, D., Weathers, F. W., Nagy, L., Kaloupek, D., Charney, D., &
veteran testimonials, avoid global descriptions of symptom im- Keane, T. M. (1998). Clinician-Administered PTSD Scale for DSM–IV.
provement in favor of specific impacts on symptoms and function- Available at https://www.ptsd.va.gov/
ing, and clearly delineate how EBPs differ from other psychother- Chen, J. A., Keller, S. M., Zoellner, L. A., & Feeny, N. C. (2013). “How
apies. There is limited prior work regarding how to best market PE will it help me?”: Reasons underlying treatment preferences between
sertraline and prolonged exposure in posttraumatic stress disorder. Jour-
and CPT to patients; however, the treatment preferences literature
nal of Nervous and Mental Disease, 201, 691– 697. http://dx.doi.org/10
provides insight into factors patients take into account when form-
.1097/NMD.0b013e31829c50a9
ing treatment opinions. Similar to the case in this study’s findings, Gallo, K. P., Comer, J. S., Barlow, D. H., Clarke, R. N., & Antony, M. M.
Iraq and Afghanistan war veterans reported that treatments’ per- (2015). Direct-to-consumer marketing of psychological treatments: A
ceived effectiveness was one of the most salient factors in select- randomized controlled trial. Journal of Consulting and Clinical Psychol-
ing treatments (Kehle-Forbes, Polusny, Erbes, & Gerould, 2014). ogy, 83, 994 –998. http://dx.doi.org/10.1037/a0039470
Treatment rationale has been the focus of a majority of treatment Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are
preferences research, with prior studies showing that the presence enough? Field Methods, 18, 59 – 82. http://dx.doi.org/10.1177/1525822
of a rationale—although not necessarily the specific rationale X05279903
itself—impacts perceived credibility and preferences (e.g., Chen, Harik, J. M., Matteo, R. A., Hermann, B. A., & Hamblen, J. L. (2017).
Keller, Zoellner, & Feeny, 2013). With the exception of the role it What people with PTSD symptoms do (and do not) know about PTSD:
might play in differentiating PE and CPT from other psychother- A national survey. Depression and Anxiety, 34, 374 –382. http://dx.doi
.org/10.1002/da.22558
apies, treatment rationale did not emerge as an important theme.
Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room:
Kehle-Forbes et al. (2014) and Chen et al. (2013) found that
National dissemination and implementation of evidence-based psychother-
treatment rationale and perceived effectiveness were closely tied to apies in the U.S. Department of Veterans Affairs Health Care System.
treatment preferences; future research should experimentally ex- American Psychologist, 69, 19 –33. http://dx.doi.org/10.1037/a0033888
amine whether providing a rationale is necessary to convey effec- Kehle-Forbes, S. M., Polusny, M. A., Erbes, C. R., & Gerould, H. (2014).
tiveness when marketing EBPs to veterans. Acceptability of prolonged exposure therapy among U.S. Iraq war
One of the strongest themes that emerged was participants’ veterans with PTSD symptomology. Journal of Traumatic Stress, 27,
negative reactions to broad statements of great improvement, par- 483– 487. http://dx.doi.org/10.1002/jts.21935
ticularly the use of “loss of diagnosis.” Loss of PTSD diagnosis Maguen, S., Li, Y., Madden, E., Seal, K. H., Neylan, T. C., Patterson,
has been associated with the achievement of good end state in O. V., . . . Shiner, B. (2019). Factors associated with completing
nearly all domains of functioning following treatment, increasing evidence-based psychotherapy for PTSD among veterans in a national
interest in it as a patient-centered outcome (Schnurr & Lunney, healthcare system. Psychiatry Research, 274, 112–128. http://dx.doi.org/
10.1016/j.psychres.2019.02.027
2016). Our findings suggest that although it may be a useful
NVivo Qualitative Data Analysis Software (Version 10) [Computer soft-
treatment target and research outcome, caution may be warranted ware]. Melbourne, Australia: QSR International.
in using that or similar language in patient-facing materials. It is Ponzini, G. T., & Schofield, C. A. (2019). Randomized controlled trials
unclear whether the impact of such language on credibility is evaluating the effectiveness of a direct-to-consumer marketing campaign
relevant for nonveteran populations; trauma event centrality or the for social anxiety disorder. Stigma and Health, 4, 450 – 461. http://dx
receipt of PTSD-related disability benefits may contribute to vari- .doi.org/10.1037/sah0000163
ability across populations. Comparing our findings to the small Pruitt, L. D., Zoellner, L. A., Feeny, N. C., Caldwell, D., & Hanson, R.
literature on marketing PTSD treatment to patients suggests im- (2012). The effects of positive patient testimonials on PTSD treatment
portant differences may exist between veteran and civilian sam- choice. Behaviour Research and Therapy, 50, 805– 813. http://dx.doi
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mental health treatment and found patient testimonials to be com- Rosen, C. S., Matthieu, M. M., Wiltsey Stirman, S., Cook, J. M., Landes,
S., Bernardy, N. C., . . . Watts, B. V. (2016). A review of studies on the
pelling in conveying effectiveness, whereas prior research has
system-wide implementation of evidence-based psychotherapies for
found that testimonials are impactful among only treatment-naïve
posttraumatic stress disorder in the Veterans Health Administration.
trauma-exposed individuals (Pruitt, Zoellner, Feeny, Caldwell, & Administration and Policy in Mental Health and Mental Health Services
Hanson, 2012). Further, the inclusion of veterans from only one Research, 43, 957–977. http://dx.doi.org/10.1007/s10488-016-0755-0
medical center is an important study limitation; future research is Schnurr, P. P., & Lunney, C. A. (2016). Symptom benchmarks of improved
needed to verify the generalizability of findings to geographically quality of life in PTSD. Depression and Anxiety, 33, 247–255. http://dx
and racially or ethnically diverse veterans. Despite these important .doi.org/10.1002/da.22477
limitations, this study provides the first exploration of themes Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and
important in marketing PE and CPT in veterans. Examination of partial posttraumatic stress disorder: Findings from a community survey.
the impact of a direct-to-consumer marketing campaign including American Journal of Psychiatry, 154, 1114 –1119. http://dx.doi.org/10
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