Almost 10 years ago, the U.S. Department of Veterans Affairs (VA) established national initiatives to provide training and consultation in two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD; Karlin et al., 2010): Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993).

In addition, a number of top-down supports for the implementation of PE and CPT were instituted including a mandated VA policy that all veterans with posttraumatic stress disorder (PTSD) have access to PE or CPT (Department of Veterans Affairs, 2010). A national mentoring program between treatment leaders and regional clinic managers (Bernardy, Hamblen, Friedman, Ruzek, & McFall, 2011), and the appointment of at least one staff member at each medical center to serve as EBP coordinator were also facilitated the use of EBPs.

A national longitudinal investigation examining the implementation of PE and CPT in 38 VA residential PTSD settings indicated that almost 70% had implemented CPT as a full or partial protocol and the most common level of implementation for PE was for select patients to receive the treatment (Cook, Dinnen, Thompson, Simiola, & Schnurr, 2014). Five programs however did not deliver the full protocol of either PE or CPT to any patients. Of those programs, five delivered Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), but two used ACT to define and organize their programs.

ACT is an intervention that encourages the pursuit of one’s values and goals in the presence of psychological and emotional challenges that potentially interfere with healthy behavior (Hayes, Strosahl & Wilson, 2012). Randomized clinical trials show that ACT is an EBP for a number of disorders including depression, chronic pain and obsessive-compulsive disorder (Society for Clinical Psychology, 2016; Substance Abuse and Mental Health Services Administration, 2010). ACT is also one of the treatments selected to be implemented in VA as an EBP for depression, and related program evaluation data have supported its effectiveness (Walser, Garvert, Karlin, Trockel, Ryu & Taylor, 2015; Walser, Karlin, Trockel, Mazina, Taylor, 2013; Karlin, Walser, Yesavage, Zhang, Trockel & Taylor, 2013).

Although ACT has not yet been established as an EBP for PTSD, there are a number of case studies supporting its efficacy with individuals who have experienced trauma and/or have PTSD (Batten & Hayes, 2005; Burrows, 2013; Orsillo & Batten, 2005; Twohig, 2009).

As well, there are several open trials of ACT for PTSD largely focusing on veterans (Batten et al., 2009; Ulmer, Walser, Westrup, Rogers, Gregg, & Loew, 2005; Varra, Jakupcak, & Simpson, 2009), with one open trial occurring at a non-VA integrated managed care consortium, with 80 participants who had multiple types of trauma (Wetzler, Loftus, Land, Skolnik, Christopherson, & Nelson, 2013). Each indicated significant reductions in PTSD symptoms with maintenance of recovery in two of the studies at three-month follow-up. Further, one small randomized controlled trial was conducted with Vietnam era Australian veterans with PTSD comparing a full protocol of ACT with an ACT intervention minus one of its core processes, self-as-context, removed (Williams, 2007). Significant reductions in PTSD were also found in this trial, although the group receiving the full treatment performed better.

Additionally, one small investigation using ACT with adolescents with PTSD in both community and residential settings produced significant symptom reduction post-treatment and at a three-month follow up (Woidneck, Morrison, & Twohig, 2013). Findings from a recent large randomized controlled trial of ACT in distressed veterans who served in Iraq and Afghanistan, with a host of mental health disorders including but not solely diagnosed with PTSD, found no overall difference between ACT and the active psychotherapy comparison condition (Lang, Schnurr, Jain, He, Walser, Bolton, et. al.,  2016). However, both groups improved on measures of distress and functioning.

Despite the absence of empirical data definitively establishing ACT as an EBP for PTSD, ACT was adopted as the core treatment modality instead of PE or CPT, in two VA PTSD residential treatment programs. It should be noted that ACT is often used as an adjunct intervention in many residential and outpatient treatment programs in VA, but is not the core modality. Additionally, all veterans entering these programs have access to PE and CPT in other settings at these VAs. Those entering the programs either refused these treatments, failed them, or chose to enter the program knowing it did not offer PE and CPT. Understanding the perspective of the clinicians in these programs may be useful in guiding the dissemination and implementation of EBPs. This information may then be used to inform design of training, help promote provider engagement in evidence-based innovations, assist in problem-solving with obstacles, and guide development of the implementation process.

Over the past decade, frameworks have been used to guide and study EBP dissemination and implementation (McHugo et al., 2007). One comprehensive theoretical framework comes from a systematic review of evidence from 13 distinct research traditions (Greenhalgh, Glenn, Bate, Macfarlane, & Kyriakidou, 2005; Rogers, 1962, 2003).

It defines adoption as a complex process influenced by five broad constructs:

(a) perceived characteristics of innovation,
(b) potential adopter characteristics,
(c) communication and influence,
(d) inner organizational context (e.g., system readiness to change), and
(e) outer organizational context.

In brief, providers’ perceptions of psychotherapy (e.g., is it seen as having more advantages than other treatments?), their characteristics (e.g., needs, interests, willingness to adopt new treatments), and social networks can impact their adoption of new practices. In addition, contextual factors such as a program’s leadership and vision or an organization’s incentives and mandates, can also play a role in the uptake of a new treatment. Table 1 provides articulation of some of the sub-constructs and their definitions (readers interested in the full model are referred to Cook, et al., 2012).

Qualitative case study methodology can be a helpful tool in conducting implementation research particularly when causal processes are multifaceted, complicated and poorly captured in survey or experimental methodologies (Flyvberg, 2006; Platt, 1992; Yin, 2003). Case studies provide an opportunity for program evaluation through multiple lenses, revealing detailed information to assist in understanding treatment adoption phenomena (Powell et al 2014). The current investigation evaluated the implementation of ACT in two VA PTSD residential treatment settings using a case study methodology and a theoretical implementation science framework. More specifically, in person semi-structured interviews were conducted with mental health providers in two VA PTSD treatment settings concerning a set of variables shown to influence adoption of innovations.

Method

Data presented in this paper are part of a longitudinal investigation funded through two consecutive National Institute of Mental Health grants (RC1 MH088454 and R01MH096810) on the dissemination, implementation and sustainability of PE and CPT for PTSD in VA residential PTSD treatment programs across the U.S.

During past waves of data collection, it was found that five programs did not deliver the full PE or CPT protocol to any patients. ACT was identified as the core modality of programming in two programs (Cook et al., 2014). In order to explore the decision-making regarding adoption of ACT within these two programs, the investigative team contacted program managers at each site to obtain permission for an in-person site visit by two team members. During the site visit each provider on the residential team met first independently with one investigative team member to complete a semi-structured qualitative interview followed by an end of the day group interview. The interview guide was adapted from previously used semi-structured measures of the dissemination and implementation of EBPs (Cook, Biyanova, & Coyne, 2009; Cook et al., 2015). Providers were asked questions to measure the five broad constructs of implementation. See Table 1 for examples of questions.

Participants and programs

Participants included mental health providers from two VA residential PTSD treatment programs. The first was located in a rural area, had 6 providers and served a total of 12 patients per cohort.  The second program was located in a suburban area, had 13 beds and 6 providers. The primary treatment modality in both programs was group format. Interviews were open-ended to allow participants to share their opinions and recollection of events in the least restrictive way.

Each interview lasted between 30 minutes to 1 hour. In total, 12 mental health clinicians (6 females and 6 males) participated in the ACT interview, six at each site.

Of them, nine (75%) were White, and one (8.3%) each were African-American, American Indian, and Pacific Islander. The mean age was 46.67years (SD = 11.9) ranging from 31 to 64 years. The majority were doctoral level (n = 7; 58.3%) psychologists followed by social workers (n = 4; 33.3%) and one (8.3%) recreational therapist. Nearly all (n = 11; 91.8%) primarily provided clinical services to veterans and one provided some clinical work but was primarily administrative. Participants at the two sites did not differ in age, gender, or profession.

Procedure

This study was exempted for review by the Yale Human Research Protection Program due to perceived low risk to human subjects and was approved by the VA Connecticut Health Care System Institutional Review Board. Providers provided consent to participate in the study and be audio-recorded. Interview questions were open-ended and follow-up probative questions were asked to elucidate further detail. To facilitate analysis, the codebook previously developed for the longitudinal investigation with 32 sub-constructs across the five main constructs (e.g., perceived innovation characteristics: relative advantage, compatibility, etc.) was utilized (Cook et al., 2015).

Two raters (VS, JC) independently reviewed and coded each interview to identify comments that fit with provider perceptions of factors influencing ACT implementation. Quotations were assigned codes according to a priori themes (i.e., operationalization of the implementation model sub-constructs). Each interview was coded by these two raters two times, once for ACT predictors, and once each for ACT deterrents. Raters met with RW to review the few differences in coding that arose and to discuss consensus. Several strategies were used to increase reliability and validity of data including standardization of the interview, audio-taping and professional transcription, development of a standardized coding scheme with the aid of computer programs, searching for deviant cases and the use of the transcription techniques of conversation analysis (Popay, Rogers, & Williams, 1998).

Results

Several themes mapping onto the theoretical model emerged as especially relevant to decision making regarding the use of ACT as the core modality of programming by the providers in the two VA residential PTSD programs. The three main influences on the adoption of ACT were all under the broad umbrella of perceived characteristics of the treatment. Namely, the perception of ACT’s compatibility with providers’ previous practices and programs’ treatment philosophies, its relative advantage over other treatments, and its positive observable effects on patients’ outcomes were seen as the most powerful predictors of use. Each of these is described in more detail below.

Compatibility

All of the providers in both programs explained that they viewed ACT as “fitting very, very nicely with who we are” as programs and as providers. Indeed, providers suggested that they adopted the ACT model, in part, because it fit with the treatments they historically implemented in the program. One provider said, “When we found ACT, it was just the natural fit of who we were already. It just gave us labels to put it in a context that made sense in our clinical minds.” Providers within these programs indicated that the principles of ACT, specifically the values-based approach, fit with the underlying doctrine of their programs. One provided stated, “I’m certified in PE and I’ve done CPT and I love the richness that the values work  ….it’s like living it in my life, that’s something I think to me is about this team is that we keep each other in check about practicing what we preach.”

Additionally, providers within these programs overwhelmingly expressed that ACT not only fit with their program philosophy but also fit who they are as clinicians and people compared to other modalities. One provider said, “It [ACT] just seems to be aligned with my kind of views on how things are, so it feels very natural for me, where some other interventions feel a little bit forced.”

Another elaborated stating, “I really value flexibility in my clinical approach and so I love having those ACT tools in my toolbox because they’re such a fit with some patients or with some scenarios that they’re experiencing.” Another added, “It feels right in my gut. This is just not an authoritarian program. It’s not a top down program and that’s why ACT fits so beautifully with who we are.” Others made comments like, “I come from Eastern philosophy, so does a lot of things in ACT, so naturally I gravitate towards it because of my background” and “This really is client-led with you sort of helping to facilitate, just resonated with me naturally as a therapist, so yeah, it just gave me a better context to do what I’m most comfortable doing.”

Providers explained that ACT offered a foundation for what they see as crucial ingredients for effective reduction of PTSD and improvement in life functioning. One provider explained, “The language of being in a process and being with something [emotional experience] rather than trying to push it away to me is where real change happens. And so for me that – there’s no question for me in that this is what I know how to do and want to do and want to teach people to do.” One provider said, “Our program fits with our philosophy of ‘you figure out what it is you value and then how are you going to move your feet and your hands and walk towards it.’  What are you actually going to do?” Another said, “I don’t need to like change or talk patients out of thinking a certain way. I can help them figure out what’s important to them and try to move in that direction. So that makes sense to me.”

In considering the clinical fit and foundations of ACT, the overarching reason for implementation appeared to be related to offering clients post trauma life enhancement through values-based work in treatment and personal choice.

Many providers commented on the nature of the values-based work done in ACT. One provider stated, “Folks are putting it into action in all kinds of rich ways, which is really what life is like right?  It’s very rich, it’s very multifaceted” One noted, “ACT seems to work better because it’s a way of getting, kind of your arms around your life.

A third stated, “The values piece is critical to me with PTSD…[as]…a trauma survivor, if you can’t give me a reason to change, don’t ask me to change. And that’s what it’s all about for them.  You’ve got to give them a reason to change; otherwise they are going to stay the same. … And so part of the reason that I love ACT is it’s none of us telling them a reason to change …. You know they change it in this area and then they look around and they go, oh my gosh I’m capable of so much more.”

Finally, one provider summed up the apparent sentiment with the following, “We don’t just do therapy, we do lifestyle change.”

Relative advantage

The majority of providers viewed ACT as a more comprehensive and advantageous treatment as compared with other trauma-focused EBPs. In particular, the providers within these programs expressed a belief that trauma-processing is necessary, but not sufficient in resolving traumatic experiences. Providers noted that working towards improvement in multiple areas of life, not solely or primarily PTSD was important.

Providers shared ways that they believe ACT uses an approach, beyond trauma-processing, by incorporating individual “meaningfulness of life,” and “broader values systems” through more experiential processes. As one provider stated, “I think good trauma treatment addresses the trauma, of course, but then also addresses the whole person. And I think PE and CPT are excellent, and in many cases they can do the job, and sometimes it doesn’t do the complete job and it doesn’t treat the whole person and at the same time.” Other providers noted perceived limitations of other EBPs that ACT seems to address. For example, “[CPT] was not addressing the moral injury. And for me ACT addresses the moral injury and it was just evident more and more.”

Another reported advantage was related to veterans’ perceived choice for therapy. It was noted that ACT provided choice to veteran’s who did not want to do or who had dropped out of trauma-focused EBPs.

One provider noted that veterans “point out…in their opinion, there should be ‘a place for a program where folks have done CPT or PE, you know what?  It hasn’t worked or you know what, I’m not willing to do it at this point.’ I think that’s where our program is wonderful … because we have those veterans who said I dropped out of PE and then they come in here and they do some trauma work that might even look a little bit like PE, not to the same extent, not the same repetition, but in some ways, that’s why I believe in what we do, and I believe in flexibility because those people who like learn about PE started out like I’m not going to do it, do come here and do some really good trauma work and [implement] changes in their lives.”

Another stated, “It’s all in diversity of treatment and choices. Choices for people … Some of these [PE and CPT] have worked really well for almost everybody, but they don’t work for everybody. We need another choice on our menu.”

Prior to implementing ACT as the primary modality, these programs reported using some traditional cognitive-behavioral approaches and noted associated challenges. For example, one provider said, “The client and I can agree on what the therapeutic targets are. So we’re not fighting with them. And a lot of CBT, so originally CBT stuff, you’re fighting with.” Another added, “They used to have homework battles over whether the homework got done or not. Well now, 100% of all of our homework is done.”

Several providers spoke to ways that practicing ACT resulted in their increased enthusiasm for work. For example, one provider spoke to how attending the ACT training and then utilizing the treatment helped increase job satisfaction, “I was kind of approaching this place of burn out and it was rejuvenating and just kind of ‘yeah,’ just re-inspiring meaningful therapy.” Another echoed a similar sentiment, “The thing that I like about ACT is its creativity and flexibility. I’ve been doing it for years now and I don’t feel tired of it.”

Providers also expressed how ACT left them feeling “empowered” and how “it just takes away part of the burden of doing therapy.” Another said, “I enjoy ACT the most, where I feel personal, I guess joy, in using it. I think it’s a nice solution to get people out of being stuck.” Other providers said it was an easier therapy to deliver than PE or CPT. One provider mentioned practical aspects related to job functioning that assisted in the adoption of ACT. This included the belief that ACT entailed less paperwork, “I am CPT trained and have an affinity for CBT … there’s just a lot of like worksheets, just a lot more of that stuff that I think can be labor intensive, but I think it might be more of an experiencing for me.”

Observability

The majority of providers in the two programs explained since implementing ACT they were observing symptom reduction as measured by patient self-report of PTSD symptoms but also by observation of a broad range of other improved outcomes. These experiences of patient change have reportedly greatly impacted their implementation and sustained use of ACT within these programs. As one provider stated, “I can see the changes … and I can document that, the PCLs (PTSD Checklist) prove it.” Another provider noted, “The list of pre-post PCLs, which is good, like it’s somewhere around 13. So for the last – since implementing the ACT model, there has been 15 or 16-point drop [on the PCL].” In addition, providers spoke to the outcomes that were not captured in symptom inventories. For example, one provider explained, “The evidence is in what you see in that room … how people do change their lives”.

Socio-political climate

Despite believing that this treatment approach was best for their program, providers at both sites identified being “scrutinized” as one challenge to using ACT. Namely they explained that there are some providers within the VA system who do not agree with the implementation of therapies other than PE and CPT for the treatment of PTSD. One person stated, “You can’t say we’re doing the gold standard treatment that the VA wants us to do, so I think… it’s been a fight to kind of protect the program and stay in ACT.”

This was echoed by other providers who explained that on local and national levels their programs’ “credibility” has been questioned. In an effort to dispel doubts regarding their programming, providers in these two treatment programs explained that they have been tracking patient outcomes and sharing their purported encouraging results with higher level administrators.

Discussion

Although VA national training initiatives and top down supports have promoted the use of PE and CPT for PTSD, this case study of two VA PTSD residential treatment programs illustrates providers decision-making regarding the implementation of ACT as the core treatment modality. Compatibility, relative advantage, and observability were the three most commonly perceived characteristics of the treatment that impacted adoption and sustained use of this intervention. According to the providers in these two settings, ACT created the opportunity and framework from which to treat veterans with PTSD from a more holistic and flexible approach. It offered them the opportunity to address more than the symptoms of PTSD, particularly it supported improving quality of life. This emphasis was compatible with the values of the program and providers, specifically promoting recovery through values-based living. The providers explained that ACT is not only a treatment that they believe in for their patients, but that it is something they apply to their own lives.

Our findings are consistent with national dissemination endeavors of ACT for depression in and outside of VA. ACT has experienced a “grass-roots” growth in VA outside of the official training initiative, with requests for training and supervision starting as early as 2001. Much of this grass-roots request for training appeared to be due to ACT’s focus on values-based living, with the intervention giving more attention to improving quality of life through mindfulness and acceptance processes as well as commitment and behavior change processes, than symptom reduction – a large focus of other therapies. Specifically, the ACT processes are focused on helping clients to be mindfully aware of their internal experience while continuing to engage in personally meaningful life goals.

These findings are both overlapping and distinct from the results obtained in the longitudinal investigation of the implementation of PE and CPT in VA residential settings. Supportive context (dedicated time and resources and incentives and mandates) was the most powerful predictor of implementation of PE and CPT (Cook et al., 2015b). If providers believed there was adequate time, adequate numbers of trained providers, and availability of consultation to implement these treatments, they were more likely to be implemented, or if providers were expected to use the EBP as part of their job, then they were more likely to use it. In this study, the VA’s sociopolitical climate and incentives and mandates were viewed as deterrent to delivering ACT and providers’ preferences and perceptions were more influential in their adoption of a treatment.

Trauma and its aftermath can present serious challenges for those suffering with PTSD. Many individuals suffering with post-trauma difficulties often cease the pursuit of personal values as they seek to reduce symptoms. Unfortunately, the very efforts to eliminate the experience of the trauma, often sustains the symptoms. Avoidance of reminders, sensations, memories, and other internal experiences disrupts normal functioning, meaning in life can be lost to the fear and memories that follow a traumatic event.

ACT serves to encourage recovery and restoration of functioning by supporting reengagement in values-based living. Whereas cognitive behavioral therapy focuses on changing the content or structure of problematic thoughts (e.g., questioning how likely a predicted outcome might be in order to create a more realistic appraisal), ACT focuses on changing the function of the thought or the context in which thoughts occur (e.g., a thought can be observed as an momentary experience that rises and falls in the ongoing process of thinking; Fletcher & Hayes, 2005).

There are several limitations to this study. First, the results come from only two VA residential PTSD programs out of a larger sample of 38. Residential PTSD programs within VA vary in their structure, resources and programming. Results presented may not be generalizable to other programs, particularly outpatient programs.

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Robyn Walser, Ph.D.

Robyn D. Walser, Ph.D. is Director of TL Consultation Services, staff at the National Center for PTSD and is Associate Clinical Professor at University of California, Berkeley. As a licensed clinical psychologist, she maintains an international training, consulting and therapy practice. Dr. Walser is an expert in Acceptance and Commitment Therapy (ACT) and has co-authored 4 books on ACT including Learning ACT, The Mindful Couple, Acceptance and Commitment Therapy for the Treatment of Posttramatic Stress disorder and ACT for Clergy and Pastoral Counselors: Using Acceptance and Commitment Therapy to Bridge Psychological and Spiritual Care. She also has expertise in traumatic stress and substance abuse and has authored a number of articles, chapters and books on these topics. She has been doing ACT workshops since 1998; training in multiple formats and for multiple client problems. Dr. Walser is invested in developing innovative ways to translate science-into-practice and continues to do research and education on dissemination of ACT and other therapies. She has had a number of leadership roles in international and national organizations and she served as Member At Large and President for the Association for Contextual and Behavioral Science, the main association that houses ACT.