Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States

Abstract

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

Full text

Supporting the implementation of written exposure therapy for
posttraumatic stress disorder in an obstetrics-substance use
disorder clinic in the Northeastern United States
Sarah E. Valentinea,b,*, Laura B. Godfreyb, Resham Gellatlyb,c, Emilie Paulb,1, Caitlin Clarkd,
Karissa Giovanninid, Kelley A. Saiad,e, Yael I. Nillnia,f
aDepartment of Psychiatry, Boston University School of Medicine, Boston, MA, USA
bDepartment of Psychiatry, Boston Medical Center, Boston, MA, USA
cImmigrant and Refugee Health Center, Boston Medical Center, Boston, MA, USA
dDepartment of Obstetrics & Gynecology, Boston Medical Center, Boston, MA, USA
eDepartment of Obstetrics & Gynecology, Boston University School of Medicine, Boston, MA,
USA
fNational Center for PTSD, Women’s Health Sciences Division at VA Boston Healthcare System,
Boston, MA, USA
Abstract
Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder
(SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the
pregnant person and the fetus, including a host of physical and mental health consequences.
When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms
of each may exacerbate and maintain the other. Pregnancy often increases engagement in the
healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD
treatment to birthing people motivated to mitigate risks of losing custody of their children.
This paper presents implementation process outcomes of Written Exposure Therapy (WET), a
brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons
receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
*Corresponding author. 810 Massachusetts Avenue, Suite 400, Boston, MA, 02118, USA. sarah.valentine@bmc.org (S.E. Valentine).
1Present address: College of Liberal Arts and Sciences, St. John’s University, Queens, NY, USA.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to
influence the work reported in this paper.
CRediT authorship contribution statement
Sarah E. Valentine: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration,
Supervision, Writing – original draft, Writing – review & editing. Laura B. Godfrey: Data curation, Formal analysis, Project
administration, Writing – original draft, Writing – review & editing. Resham Gellatly: Formal analysis, Writing – original draft,
Writing – review & editing. Emilie Paul: Formal analysis, Investigation, Project administration, Writing – original draft, Writing –
review & editing. Caitlin Clark: Investigation, Resources, Writing – original draft, Writing – review & editing. Karissa Giovannini:
Investigation, Resources, Writing – original draft, Writing – review & editing. Kelley A. Saia: Resources, Writing – review &
editing. Yael I. Nillni: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration,
Supervision, Writing – original draft, Writing – review & editing.
HHS Public Access
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Published in final edited form as:
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Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working
(77.8%), had a high school or lower level of education (55.5%), had an annual household income
less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We
examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators
to implementation; and feedback on supporting uptake and sustainability of the intervention using
coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N
= 5]) from providers involved in trial planning and treatment delivery. Results reflected high
acceptability, appropriateness, and adoption of WET. Participants described system-, provider-,
and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not
raise concerns about core components of the intervention. Findings suggest that WET is an
appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has
the potential to positively impact pregnant persons and their children.
Keywords
Pregnancy; Trauma; Posttraumatic stress disorder (PTSD); Perinatal; Implementation
1. Introduction
Posttraumatic stress disorder (PTSD) treatment needs are high during pregnancy, particularly
in low-resource communities where pregnant people experience higher rates of trauma
exposure (Roberts et al., 2011). Up to 30% of pregnant people receiving care in low-
resource settings meet PTSD diagnostic criteria (Powers et al., 2020), compared to 3% in
high-resource settings (Seng et al., 2009). PTSD during pregnancy is linked to negative
outcomes including preterm birth, low infant birthweight, and postpartum depression (Muzik
et al., 2016; Yonkers et al., 2014). Additionally, PTSD is a risk factor for engaging in high-
risk behaviors, including using substances to cope with unresolved symptoms (Rheingold
et al., 2004). As such, PTSD and substance use disorder (SUD) commonly co-occur.
Almost half (46%) of individuals with SUD meet criteria for subthreshold or full PTSD
(Pietrzak et al., 2011), with even higher rates (63%) in pregnant people (Thompson and
Kingree, 1998). Importantly, the rate of substance use during pregnancy is increasing
(Haight, 2018) and is associated with multiple negative health outcomes (Forray, 2016;
Sanjuan et al., 2019). For persons with trauma histories, risk of return to substance use
may be elevated during pregnancy due to additional stressors that exacerbate symptoms
(Saia et al., 2016). Among individuals with comorbid SUD-PTSD, attempts to self-manage
PTSD symptoms are a commonly reported reason for substance use (Flanagan et al., 2016).
PTSD symptom reduction using exposure-based therapies has been shown to improve SUD
outcomes (Flanagan et al., 2016). Thus, PTSD treatment implementation among pregnant
people with comorbid PTSD-SUD presents a critical opportunity to interrupt the sequelae
associated with untreated PTSD and promote positive pregnancy outcomes.
Engaging pregnant people with co-morbid PTSD-SUD in PTSD treatment is a major
challenge. Birthing persons with SUD face many barriers to engaging in health care,
including lack of health insurance, poor access to childcare, and competing psychosocial
needs (Lester and Twomey, 2008; Rutman et al., 2020). Further, pregnant people with
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SUD may avoid engaging in medical care due to fear of social and legal consequences,
child welfare involvement, and criminalization associated with substance use (Saia et al.,
2016; Lester and Twomey, 2008; Rutman et al., 2020; Stone, 2015). PTSD symptoms pose
additional engagement challenges, such as avoidance of confronting the trauma memory
(Sayer et al., 2009). Despite barriers, pregnancy is marked by increased utilization of the
healthcare system, as birthing people are highly motivated to maintain custody of their child
and may be more receptive to services (Frazer et al., 2019). Pregnancy presents an opportune
window for intervention, and there is a need to test and optimize PTSD treatments during
pregnancy.
Access to PTSD treatment is limited in usual prenatal and SUD care settings. Despite
high prevalence, PTSD screening and treatment during pregnancy is not common practice,
resulting in a lack of data on PTSD treatment in the perinatal period (Nillni et al.,
2018). Similarly, despite the common co-occurrence of PTSD and SUD, PTSD treatment
is often not prioritized within the context of SUD treatment (Gielen et al., 2014), and
most individuals engaged in SUD treatment never receive PTSD treatment (Brown et al.,
1998). Offering PTSD treatment within integrated behavioral health (IBH) settings may
promote engagement and maximize uptake. IBH models in obstetrics are growing to meet
the complex behavioral health needs of pregnant people by providing comprehensive social
supports, prenatal services, mental health, and substance use care in the same setting. This
approach has been shown to be effective in promoting patient engagement (Lester and
Twomey, 2008), improving perinatal outcomes (Brown et al., 1998), and is highly acceptable
to birthing people with SUD (Goodman, 2015). Thus, incorporating PTSD treatment within
an IBH model in obstetrics is ideal.
Lack of access to PTSD treatment where pregnant people with SUD receive medical
or behavioral health treatment necessitates novel delivery strategies to minimize existing
barriers and implementation science research to inform uptake and sustainability in usual
care. Qualitative research from provider perspectives is particularly important in offering
nuanced insight on factors that affect implementation processes (Patton, 2014). The present
study fills gaps in research of PTSD treatment during pregnancy as the first to test
delivery of a brief, scalable, and sustainable evidence-based treatment (EBT) for PTSD
among people with comorbid PTSD-SUD in an integrated obstetrical-addiction recovery
program. We used a hybrid 1 effectiveness-implementation design to test intervention
effectiveness while gathering data on implementation (Curran et al., 2012). Main clinical
effectiveness findings of this pilot open trial (N = 18) are reported elsewhere (Nillni et
al., 2023). In this manuscript, we present implementation process and outcome findings,
guided by Proctor’s Taxonomy of Outcomes (Proctor et al., 2011), primarily from qualitative
analysis of provider interviews and supported by consultation field notes. We used provider
perspectives to (1) report on feasibility, acceptability, appropriateness, adoption, and fidelity,
(2) specify implementation determinants, and (3) gather feedback on how to support uptake
and sustainability.
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2. Methods
2.1. Setting
This study took place at Project Recovery, Empowerment, Social services, Prenatal care,
Education, Community and Treatment (RESPECT), an integrated obstetrical-addiction
recovery program at Boston Medical Center, the largest safety net hospital in New England.
Project RESPECT serves approximately 211 patients annually and utilizes an IBH model
to provide comprehensive obstetric and SUD treatment for pregnant people and their
newborns from an interdisciplinary team of co-located clinicians. See Fig. 1 for a diagram of
Project RESPECT’s collaborative care model. The clinical team (N = 9) includes obstetric
providers, a psychiatrist, nurse case managers, and clinical social workers, and patients have
access to their entire care team during medical visits. Clinical social workers are responsible
for case management, crisis response, and brief support; yet the provision of therapy was not
central to their role during the pilot study.
Written Exposure Therapy (WET) is a five-session exposure-based PTSD intervention
(Sloan and Marx, 2019) selected for the trial due to its demonstrated effectiveness and
brevity compared to other evidence-based PTSD treatments (LoSavio et al., 2021; Sloan et
al., 2022). WET includes treatment rationale, PTSD psychoeducation, and directed writing
assignments each session where patients write in detail for 30 min about their traumatic
experience followed by approximately 10 min checking in with a therapist on reactions to
writing. Therapists collect and review writings between sessions and provide feedback on
how well writing instructions were followed to guide the next writing assignment. Although
WET does not include assignments between sessions, patients are encouraged to allow
themselves to have thoughts and feelings related to the trauma (rather than avoid).
Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), with Non-Hispanic
Black (22.2%), Hispanic Black (5.6%), Hispanic White (5.6%), and Other (5.6%) ethnicities
less represented. The majority of participants were not currently working (77.8%), had a
high school or lower level of education (55.5%), an annual household income less than
$35,000 (94.4%), and were living in a substance use residential program (55.6%). The
sample was medically complex, with 50% experiencing an obstetrical medical condition
such as hypertension. Main outcomes are reported elsewhere (Nillni et al., 2023).
2.2. Participants and procedures
Provider participants were hospital employees in Project RESPECT, including clinical
leadership and behavioral health providers. Providers were first recruited via email to
support trial planning, and clinical social workers were offered participation as study
therapists. Participation was voluntary and none declined. Self-reported information on
demographics, previous mental health training, and previous experience with PTSD
treatment was collected. Participating providers did not have prior experience delivering
PTSD or exposure-based treatments. Study therapists completed a 5-h pre-recorded training
presented by the co-developer of WET and a 2-h in-person training led by two study authors
(S.E.V., Y.I.N.), which focused on study procedures. Study therapists received ongoing
weekly group consultation and individualized written feedback based on audio review
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of sessions. Consultation included case presentation and troubleshooting implementation
barriers, and field notes were collected from October 2019–June 2021 (total word count:
10,769) by the research assistant (RA) to capture real-time implementation barriers and
responses. Study therapists completed a brief investigator-adapted three-item survey for each
patient at the end of treatment to gauge the appropriateness, usefulness, and adoption of
WET. Post-trial, providers completed a 30–45 min semi-structured interview conducted by
two doctoral-level clinical psychologists (S.E. V., Y.I.N.). The interview guide (Table 1)
was adapted from other trials implementing PTSD EBTs in the setting (Godfrey et al.,
2023). Interviews were audio-recorded and transcribed verbatim. Identifiable information
was removed from transcripts. Participants were remunerated $25. The study received an
exempt determination from the Institutional Review Board.
2.3. Data analysis
We utilized a team-based approach (Patton, 2014) in developing the qualitative codebook for
interview data. The coding team included two doctoral-level psychologists, one postdoctoral
fellow, one doctoral student, and one bachelor’s level RA, all of whom had previous
experience in qualitative coding and analysis. Team psychologists and fellows had led
content analysis of provider interviews on over 10 projects and provided direct training
and supervision to junior team members, including a standardized training on qualitative
methods (content analysis, rapid coding, and implementation-focused research questions)
and frequent team meetings. Junior members of the team were coders in the analysis of
similar data from another PTSD treatment implementation study conducted by the same
principal investigator (PI) (Godfrey et al., 2023). A rapid coding procedure was first applied
to consultation field notes to quickly capture core themes and identify evaluation foci of
qualitative data (Neal et al., 2015). Two members of the coding team (the RA and a PI)
reviewed consultation field notes and identified salient themes pertaining to implementation
outcomes, which formed the preliminary codebook. Following directed content analysis
(Hsieh and Shannon, 2005), the coding team met weekly to expand, refine, and finalize
the codebook by applying codes to interview transcripts until no new codes emerged
(see Table 2). All interview transcripts were coded collaboratively through live consensus
coding (LoSavio et al., 2021) during weekly meetings using NVivo 12 software (QSR
International).
3. Findings
Our evaluation of implementation process and outcomes was guided by Proctor’s Taxonomy
of Outcomes (Proctor et al., 2011), which outline indicators of implementation success.
We used semi-structured interviews (N = 5) to assess provider perspectives of acceptability
(satisfaction with various aspects of the intervention), adoption (uptake, ongoing intention to
use), appropriateness (perceived fit of the intervention for patients), feasibility (sustainability
for everyday use), and sustainability of the intervention (recommended modification to
ensure sustainability in the practice), and consultation field notes (N = 47) to support
findings. We present interview findings by theme with exemplar quotes in-text and a
summary of recommendations for enhancing implementation in Table 3.
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3.1. Appropriateness
3.1.1. Patient outcomes—Respondents described WET as highly appropriate for
patient needs, evidenced by
“Not just reductions in their PTSD symptoms based on the
scaling that we used, but more forward thinking, goal-oriented, safe choices that people are
making that they may not have made prior to engagement in this treatment.”
Respondents
noted the profound impact of WET in supporting SUD recovery, and the potential long-term
positive impact of offering WET to this population, stating
“It could be paramount in
helping sustained recovery and remission from their substance use disorder
.
And also,
I think what I’ve observed is it really just builds internal coping and increases distress
tolerance
.
A lot of these women are already resilient, but [WET] helps them realize that. …
it brings it forward – ‘hey, yeah, I have survived a lot and I can move forward’ so, I think the
long-term impact is huge. And I would be worried if this is something that we stop doing.”
3.1.2. Pregnancy window—Providers perceived pregnancy as an ideal window to
implement WET. As one respondent described,
“This is such an opportune time to capture
women in care. There’s often high motivation, you know? I think that’s why we try to
capture women in substance use disorder treatment during pregnancy, but I think we really
want to try to get women into treatment when they’re motivated
.
And then if they [also] get
PTSD treatment, then the goal is to minimize symptoms and substance use and really enable
them to be present with their family.”
Another perceived benefit of offering WET during pregnancy was the potential for treatment
to facilitate recovery prior to giving birth. One respondent stated, “
I thought it was really
a good time to be using it. Especially trying to get in before they give birth, trying to get
in earlier in the pregnancy to help them with the healing process of some of their past
traumas.”
However, WET may be a better fit for some patients after delivery:
“For some
women I feel like prenatal made sense and they could do it, and then some women I feel like
have a different stage of change postpartum and things drastically adjust and they’d be better
candidates
[then] …
I wish we could do it for everyone.”
3.1.3. Need to support patient engagement given complex needs—Notably,
no respondents endorsed concerns about appropriateness of intervention components.
Rather, challenges were attributed to complex needs and competing stressors (e.g., ongoing
domestic violence; social needs [housing]), which interfered with the ability to fully engage
in WET:
“The multiple stressors that are ongoing with our patients, it’s just, their level of
vulnerability is astounding. Even if we’ve tried to set forth some sort of stable ground
for them, there is just a lot of assistance with resources. Sometimes these things are
unpredictable and just … sitting with a patient while they lose housing, or the program
kicks them out … the vulnerability level just keeps going up.”
Providers underscored that potential benefits of WET outweigh the risk of patients dropping
out of care:
“One thing I’ve learned from this treatment too is not to really ‘fragilize’ the
patients, and ultimately, regardless of the intervention, [dropping out of treatment] could
happen for any reason and that’s a choice that people can make … It’s sad but, I think
that the risk-benefit analysis of having it easier to access for people … outweighs the risk
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of patients maybe not returning.”
Supporting patient engagement should be a focus moving
forward, more so than adapting intervention components.
3.1.4. Quantitative assessment of appropriateness—Therapists’ ratings of
appropriateness via self-report surveys supported qualitative interview findings. The extent
to which WET was viewed as appropriate and the perceived usefulness of WET for
the patient were high: M = 97.5 (SD = 7.0) and M = 81.8 (SD = 20.4) out of 100,
respectively. This suggests that while WET was appropriate based on patient needs, it may
not be useful for all patients due to challenges with engagement. For example, survey
open-text boxes noted other stressors (e.g., custody loss, dissatisfaction with SUD residential
treatment program) and in-session avoidance in accessing emotions as individual barriers to
engagement/full benefit of WET.
3.2. Acceptability
Respondents expressed high satisfaction with WET and reflected on key treatment
components. One respondent described emotion identification (labeling) and expression as
a core component in promoting distress tolerance:
“I think just learning that your feelings
and emotions and what happened to you is in the past and you can survive it right now …
sitting with the intense emotions and learning that you will get back to a homeostatic place.”
Similarly, one participant described how WET enabled patients to confront avoidance and
process their trauma, explaining,
“I think their coping skills have been to avoid for a very
long time and internalize, and I don’t think that they’ve ever really been given the space to
process some of this stuff.”
Another respondent perceived the exposure component of WET
as critical to helping patients regain a sense of control over the memory and their affective
responses, describing
“This person had to go through that experience
[sexual assault]
by
herself and there was such a loss of control, and then as she was narrating the experience I
was able to sit with her … sort of re-experiencing with somebody you trust and regaining a
sense of control that way.”
3.3. Adoption
Intent to continue using WET was high, with an average of 98.6 (SD = 5.3) out of 100
for the likelihood to use WET with future patients. One respondent described being “
Super
excited to use it anywhere I go and everywhere I go now that I feel confident in using it,”
while also expressing the need for ongoing consultation to support providers:
“I think the
consultation is really important. So, I feel like it would be hard to do it in isolation, at least
right now. But I think that I’m super excited about it … I would want to continue doing it
here.”
3.4. Feasibility: barriers/facilitators to implementation
3.4.1. Patient-level
Ongoing trauma.: Providers noted that ongoing violence interfered with patients’ ability
to focus on distal events. One respondent described the challenge of addressing the trauma
when patients were still involved with the perpetrator:
“I think something I found both
surprising and challenging was that for both of my patients their traumas were linked
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to a person … they were still very involved with
.
”
Another respondent described how
contextual factors interfered with patients’ ability to distance themselves from the trauma
and implement change outside of session:
“Unfortunately with my first patient she was
legally tied [to her abuser] in a lot of ways too because he had custody of her children,
which I think made it so much more difficult. And I know a lot of our … work was about
those boundaries, and then also trying to navigate how she still sees her kids.”
Importantly,
therapists still perceived WET to be suitable for 86% of patients who were experiencing
ongoing violence during treatment.
Difficulty selecting index trauma event.: Patients reported lifetime exposure to M = 7 (SD
= 1.8) types of potentially traumatic events. Respondents described how extensive trauma
histories made it difficult for patients to identify a single index event, stating,
“Women that
have gone through this study have just such high levels of acuity and such complex trauma,
and it’s typically not just … one incident …. This is … lifelong trauma, starting … at
[their own] birth.”
As clinically appropriate, index events often switched during the course
of therapy, thereby extending the number of sessions:
“… [treatment] can be [complicated]
when we are working on a single incident and then the other traumas come up as well.”
Avoidance of shame-based trauma experiences also interfered with selecting the accurate
index event. One respondent described,
“With picking the index event … I know for [one
particular] patient I was just talking about, who started and then didn’t finish, there is totally
a different index event that [should] have been picked. And I think especially in cases of
incest, right? We know how high that is in our patient population and I think there’s a lot of
shame in putting words to that, and so, how can you help normalize the spectrum of what an
index event could be
[beyond]
the checkbox screening tools. Because people might not be
as authentic on those.”
There may need to be increased assessment of initial selection of the
index event, particularly for shame-based traumas.
Motivational factors.: Avoidance of confronting the trauma memory was a barrier to
engagement despite initial high motivation to complete WET. One provider described that
patients were “
Super excited in the beginning, and then I would talk to them maybe a day
after their session and they’d be like ‘I hate it, I’m never doing that again!’ but a lot of
that is just the treatment itself, right? It’s the distressing feelings they’ve never sat with,
so it was a lot of psychoeducation and just validation and reinforcing – ‘this is what we’re
looking for.’”
To minimize dropout, providers suggested repeated orientation to the rationale
for exposure and trajectory of WET, including setting the expectation of initial heightened
distress, and increased support for patients throughout treatment. Patients’ conceptualization
of PTSD as part of SUD recovery was cited as supporting engagement: “
I heard one person
say to me ‘I know I have to do this, because if I don’t do this … I’m never gonna get to the
bottom of my substance use disorder.’”
Increased psychoeducation around the link between
PTSD and SUD may bolster motivation.
3.4.2. Provider-level
Misconceptions.: Respondents described initial misconceptions of trauma-focused
treatments (e.g., may lead to relapse for patients with SUD), which were debunked through
training and observed outcomes delivering WET:
“I think when I first was reading about
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it and watching those videos I was really skeptical because I don’t have a background in
exposure therapies. I had been concerned that it would be really triggering and lead to
relapse, and we’re finding that doesn’t happen … The connection [between PTSD treatment
and SUD relapse] isn’t there …. If anything, it decreases the likelihood of relapse if the
patient is engaged and motivated to continue
[WET].” Provider perceptions about trauma-
focused treatments may be a barrier to uptake of WET without addressing misperceptions
through consultation.
Provider discomfort.: Some providers described challenges tolerating their own distress
during WET, underscoring the need for ongoing support to minimize provider burnout and
secondary traumatization. One provider noted the importance of bolstering both patient and
provider distress tolerance during WET:
“I think a big part of it is developing comfort with
the discomfort. Not just with patients, but with myself.”
3.4.3. System-level
Inter-system care coordination.: Respondents suggested that inconsistent messaging
across the patient’s extended interdisciplinary care team (RESPECT vs. outside providers)
impacted engagement. Outside providers were reported to possibly discourage patients from
engaging in PTSD treatment, perhaps due to misconceptions of harm. One respondent
suggested
“the reason why we saw such high level of activation in a lot of the participants is
that they’ve never really done this before, and the direction of every other treatment provider
has been like, ‘you need to not think about this right now.’”
Similarly, respondents stated
that PTSD treatment is not prioritized in SUD treatment programs, which may encourage
avoidance of trauma reminders (also substance use cues) rather than addressing them.
“First,
they’re always siloed … the mental health and the addiction piece, and I think that’s a huge
systemic problem in general, but when we think about the substance use piece, a lot of it
is, ‘what are your triggers? Let’s talk about how to avoid them,’ rather than ‘let’s talk about
how to manage them.’”
Cohesive messaging and disseminating of information to outside
providers is an important consideration in supporting patient engagement.
Delivery setting.: There were clear benefits to the integration of WET within obstetrics and
scheduling therapy alongside prenatal visits. For some,
“It may have been easier for people
who have to go into the hospital anyway for their prenatal care to just do it all in person
while they’re there and try to schedule it that way.”
One potential con of this integrated
model was that patients may be too exhausted to engage in intense therapy following
lengthy prenatal visits:
“When the patients come in for an appointment, they’re here for 5
h already, and sometimes the last thing they want to do is more meetings, and especially
one that is going to be challenging.”
Space and privacy constraints in the hospital setting
were challenges. One provider expressed difficulty with using an obstetric exam room for
therapy, explaining, “
I think the exam room is hard, and even the room I would use that
was near the ultrasound had a giant window. People are walking by, people are talking
in the hall. It’s just pretty distracting,”
and described benefits in shifting to telehealth due
to COVID-19:
“eliminating the barrier of having to come here [by offering telehealth] is
great.”
However, remote delivery introduced new barriers, including difficulty responding
to in-session avoidance, obtaining writings, technology access and literacy challenges, and
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preference for in-person visits. Although providers acknowledged that “
Some liked the
Zoom. Some did,”
they also described that
“I think for the patients I got assigned, most were
like, ‘I feel like the Zoom is awkward’ and they really wanted to come in person. And so
having them have to sit with … the challenge of toggling space [for privacy] and … figuring
all of that [out was] tricky.”
There seems to be advantages to offering a hybrid approach that
works best for the individual patient.
Therapist burden.: Therapist burden is a major barrier to sustainability of WET in
Project RESPECT. Due to the severity of competing social, medical,
and
behavioral needs,
providers describe “
so much uncertainty with the volume of patients.”
Therapy provision is
not central to the role of study therapists, and other urgent stressors may take precedence
over WET sessions. One provider described how frequent WET sessions are not feasible
in their current caseload, resulting in
“not seeing as many Project RESPECT patients, and
I think that has to do with my availability to offer appointments more frequently. My
capacity right now is once every 4 to 6 weeks, which is really not ideal for patients seeking
therapy.”
Another provider suggested that therapist capacity challenges speak
“to the fact
that our clinic really needs a higher drive of psychosocial support. But the medical providers
outnumber the psychosocial providers and until we even out that balance it just makes it a
little bit harder because psychosocially, when we do interventions, they take double the time
of providers, and then the documentation is triple what providers write.”
3.4.4. Sustainability—Respondents made several recommendations to address
determinants of WET implementation, including bolstering support for providers, increasing
collaboration of with external care teams to support patient engagement, and allowing
for flexible frequency of delivery. No adaptations to intervention components were
recommended. See Table 3 for a comprehensive list of recommendations with exemplar
quotes.
4. Discussion
Pregnant people with comorbid PTSD-SUD are at high risk for adverse obstetric and mental
health outcomes (Muzik et al., 2016; Yonkers et al., 2014), yet have historically been
excluded from mental health treatment (Myers et al., 2015). Pregnancy presents a crucial
opportunity to dually address PTSD and SUD, as pregnant people are more engaged with
health care. There is little research on PTSD treatment embedded within obstetrics, and
no studies we could find conducted in an obstetrics-SUD program. The purpose of this
evaluation was to understand provider perceptions of using a brief PTSD treatment (WET)
with pregnant people with comorbid SUD. We present key implementation outcomes and
provide recommendations to promote sustainability and improve access and engagement
among this high-risk population. Findings suggest high acceptability, appropriateness, and
intended adoption of WET. Providers were highly satisfied with WET, observed reductions
in PTSD symptoms and functional improvements, and were optimistic that participation
in WET would promote long-term SUD recovery. Respondents affirmed that pregnancy
was an ideal window to engage patients in treatment due to high motivation, especially
when patients understood the link between PTSD and SUD recovery, and noted that the
immediate postpartum period may also be suitable for some patients given risks for mental
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health and relapse during this period. Although intent to continue using WET was high,
respondents described system-, provider-, and patient-level barriers to implementation and
offered suggestions to enhance uptake in the setting. Importantly, recommendations did not
include revision of core components of the intervention, but, rather, ways to support delivery
and patient engagement.
Most implementation barriers occurred at the system-level, as shown in Table 3. Lack of
access to training and therapist capacity challenges have been cited as main barriers to EBT
implementation (Foa et al., 2013). Prior to training in WET, many therapists were new to
manualized and PTSD treatments, yet high provider satisfaction and adoption highlighted
that clinicians in this setting were eager to provide EBTs. Thus, there is a need to prioritize
access to trainings in EBTs, particularly in low-resource settings where training is less
accessible (Sauer-Zavala et al., 2019). Capacity was particularly challenging in Project
RESPECT, as therapy provision was not central to the role of therapists, and competing
responsibilities interfered with their ability to deliver WET consistently. Respondents
emphasized the need for protected time to deliver WET and additional behavioral health
staffing to meet high patient behavioral health needs. This pilot study coincided with
redefining the roles of embedded social workers, and one outcome of this partnership was
sustaining integrated behavioral health services. The clinic has since increased the size of the
integrated practice and clinicians have reported continued use of WET post-trial.
Patients simultaneously receiving care in external SUD programs faced additional
engagement barriers. Some residential treatment programs imposed transportation and
childcare restrictions and limited phone access/privacy, which interfered with patients’
ability to attend in-person and telehealth sessions. One potential solution is to implement
WET within SUD residential programs by disseminating training to providers in these
settings. Future research is needed to identify the optimal setting to engage patients. Despite
evidence that exposure-based therapy is safe, effective, and may promote long-term recovery
among patients with comorbid SUD-PTSD (Flanagan et al., 2016), previous qualitative
research among providers in SUD care settings has suggested that misconceptions around
trauma-focused treatments are a main barrier for integration of PTSD treatment in SUD care
(Gielen et al., 2014), which was consistent with our findings. External providers in SUD
treatment settings actively discouraged patients from engaging in PTSD treatment due to the
erroneous belief that confronting the trauma would promote cravings or relapse. Inconsistent
messaging is particularly harmful in the context of PTSD treatment, as it promotes patient
avoidance, maintaining PTSD symptoms and interfering with engagement. Dissemination
efforts on education surrounding PTSD treatment, the mechanisms underlying WET
specifically, and the link between PTSD-SUD are needed to bolster provider support for
trauma-focused treatments in SUD treatment settings. Increased collaboration to ensure
consistent messaging across patients’ entire care teams would be paramount in promoting
patient engagement.
Providers were eager to implement WET in Project RESPECT, and few provider-level
barriers existed. Despite initial misconceptions about the harm of exposure-based treatments
for SUD recovery, once providers began using WET these concerns were quickly assuaged.
Managing personal discomfort and vicarious trauma that arose during the therapy process
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was a challenge. Providers described consultation as a crucial space to process session
content and receive additional support in WET delivery. Indeed, ongoing consultation
has been identified as an effective implementation strategy in adoption, uptake, and
sustainability of EBTs (Edmunds et al., 2013; Nadeem et al., 2013), and may prevent
secondary traumatization and burnout.
Patient-level engagement barriers included competing hierarchical needs, ongoing trauma,
and motivational challenges. New stressors (e. g., housing instability, child welfare
involvement) would arise, taking precedence over engagement in therapy. Importantly,
respondents affirmed that despite complex needs, and even in cases of ongoing trauma,
WET was still an appropriate treatment for most patients. In addition to greater psychosocial
needs, individuals in low-resource settings experience higher rates of trauma exposure
(Hatch and Dohrenwend, 2007), which challenged treatment trajectory. Patients had
difficulty identifying a single index trauma and switched during WET, which extended
treatment. Manualized treatments may require flexibility in the number and frequency of
sessions to accommodate these challenges. Consistent with literature on PTSD treatment
engagement across all populations (Sayer et al., 2009; Forbes et al., 2019), and WET
specifically (Andrews et al., 2022), combating avoidance was a challenge. Difficulty
tolerating distress when confronting trauma is a significant contributor to dropout,
particularly in exposure-based interventions (Najavits, 2015). Incorporating WET within
Project RESPECT and scheduling sessions alongside prenatal visits was described as
effective in bolstering engagement and minimizing avoidance. Respondents highlighted
how patients were highly motivated by their desire to maintain custody of their children
and more willing to engage in WET despite initial distress. Incentives (e.g., certificates of
completion) were also useful as indicators of progress that patients could present in cases of
child welfare involvement. Taken together, findings suggest that pregnancy may be an ideal
opportunity to minimize patient-level barriers and provide PTSD treatment to an otherwise
difficult-to-engage population.
While the trial was designed to implement WET alongside in-person prenatal visits to
maximize patient engagement, the COVID-19 pandemic shifted all visits to telemedicine,
yielding additional barriers and facilitators. Remote delivery of WET introduced challenges
in responding to in-session avoidance and obtaining writings, and research suggests that
the shift to telemedicine may exacerbate disparities due to technology access and literacy
challenges in low-resource communities (Ortega et al., 2020). Ultimately, respondents
supported hybrid delivery of WET. For patients who were already in clinic for prenatal
care, in-person sessions were effective in promoting engagement, while for others, remote
improved accessibility by removing transportation and childcare barriers.
4.1. Limitations
This study may be limited in its generalizability to other obstetrics settings. This exploratory,
single-site, hybrid 1 open pilot reflects input from five providers. Replication of these
findings in a larger sample and a less integrated care setting will lend additional support to
the conclusions drawn from this study.
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Project RESPECT provides specialized obstetrics care to pregnant persons with SUD—and
is one of few such specialty clinics in Massachusetts. This clinic employs embedded clinical
social workers to address behavioral health needs of patients—thus, there was an existing
workforce to deliver WET. We positioned our selected intervention in this context, and
exclusively focused on PTSD symptom targets. Further research is needed to understand
the feasibility, acceptability, and implementation strategies for providing WET in a more
typical obstetrics setting, or within SUD programming focused on pregnant people. That
said, we believe that our success in implementing WET in this integrated care practice, with
a highly complex patient population, signals that WET may be feasible in settings where
pregnant people access medical or behavioral health treatment. Implementation of WET in
a non-integrated obstetrics setting may have additional challenges with therapy provision—
as there may not be a clinical team member with skills to dually address obstetrics and
behavioral health concerns. Our study clinicians were highly skilled, competent therapists,
although their job roles did not accommodate therapy visits.
The level of consultation provided to therapists was higher than would be feasible in
typical settings. At least one PI reviewed every audio-recorded therapy session and provided
written and verbal feedback in weekly consultation meetings. Therapists expressed high
satisfaction with this level of support, but voiced concerns about scale-up and sustainability.
Future research should focus on more sustainable training and consultation approaches
to supporting fidelity, and preventing drift or drop in voltage that can happen in usual
care post-training. Project RESPECT has a strong record of hiring exceptionally qualified
clinical social workers, which should be considered in determining the resources necessary
to support fidelity.
Our study may be subject to biases that may have occurred during qualitative interviewing
and analysis. The interview guide did not contextualize WET within the larger context of
clinic demands, services, and priorities, which may have resulted in providers’ overstating
the importance of WET within their array of services. We attempted to reduce biases in
analysis through consensus coding, however, data were coded by three women psychologists
with expertise in trauma-specific therapies, and two women RAs receiving mentorship
from study PIs. Familiarity with the psychological training and EBTs for PTSD may have
influenced how interview data were coded (e.g., PIs may have been more attuned to provider
training gaps).
Finally, this study focuses on the perceptions of behavioral health providers in Project
RESPECT and does not include programmatic or system stakeholders whose perspective
may be essential when considering uptake, sustainability, and future scale of WET in
obstetrics. Patient perspectives are also not reported here, yet are published elsewhere (Nillni
et al., 2023). Future implementation studies ought to aim for a wider, more diverse set
of stakeholders, including in the broader OB practice, across the hospital, and community-
based SUD programs. Policy stakeholders may also be key in addressing implementation
challenges related to inter-system care coordination, yet were not included in the current
study.
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5. Conclusion
Although pregnant people with PTSD and SUD face numerous barriers to treatment, based
on these preliminary findings, WET appears to be an acceptable and appropriate intervention
for this population, offering hope that these complex and comorbid problems can be
simultaneously addressed in the context of routine obstetrics care. PTSD treatment during
the prenatal period may lead to positive clinical and psychosocial outcomes for pregnant
people and their children. While respondents described barriers to implementation, they
were optimistic about the potential for uptake and sustained use of WET. Scaling up delivery
of WET has the potential to improve the lives of high-risk pregnant people with PTSD and
SUD.
Acknowledgements
The authors would like to thank Denise Sloan, PhD for her substantial contributions and guidance during project
planning and throughout the trial. This study was funded by the Grayken Center for Addiction (PIs: Sarah E.
Valentine and Yael I. Nillni). Sarah E. Valentine’s time on the project was additionally supported by the National
Institute of Mental Health (K23MH117221).
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Fig. 1.
Project RESPECT collaborative care model.
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Table 1
Interview guide.
Please tell me how you have been involved in the WET treatment and/or its evaluation.
What do you think of WET and its use in Project RESPECT?
What were the best/worst
things
about using WET?
What did you find surprising unexpected, or challenging when implementing or evaluating WET? How did you address it?
How feasible was it for patients to participate in WET?
In what ways did the treatment fit or not fit the needs of
Project
RESPECT Patients?
How satisfied do you think patients have been with WET?
Overall, what impact do you think providing
this
type of treatment has had on the clinic?
How can we make WET more effective at reducing symptoms and improving functioning?
How can we make WET more
useable
and sustainable in the clinic?
What do you think about
treating
PTSD within an obstetrics clinic?
How likely are you to want to continue to participate in efforts to provide PTSD treatment in Project RESPECT?
What
would make you
more/less likely to participate?
Is there anything else that we should know about what it was like to deliver this treatment in Project RESPECT?
WET, written exposure therapy; PTSD, posttraumatic stress disorder.
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Table 2
Overview of coding scheme.
Appropriateness
Perceived fit for patients’ needs
PTSD symptom reduction
Functional improvement
Patient complexity (poor fit)
Patient
Therapy Process
Difficulty selecting an index trauma/switching during WET
Recent trauma (ongoing violence/risk) interferes with accessing distal events
Initial selection of Non-Criterion A (grief, custody loss)
Unable to label emotions
Written exposure fails to activate patient distress
Misconceptions of WET
Concerns that exposure therapy will be harmful to baby
Concerns that exposure therapy will lead to substance use relapse
Engagement barriers/facilitators
Transportation
Childcare
Motivational Factors
Provider
Acceptability (satisfaction)
Adoption (future plan to continue use)
Provider discomfort with exposure-based methods
Perception of treatment mechanism
Therapy Process
Evaluation of loss experiences for Criterion A
Application of exposure for shame-based (v. fear-based) traumas
Training Gaps
Prior experience with manualized treatments [style]
Maintaining directive style
Adherence to session length/number of sessions
Prior experience with treating PTSD [content]
Additional evidence-based techniques (e.g., Socratic questioning)
Additional metaphors for treatment rationale and concepts
Misconceptions of WET
Concerns that exposure therapy may lead to substance use relapse
System
Care coordination and communication
Outside providers may actively discourage engagement
Education to other providers on the care team
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Residential programs and shelters pose challenges to engagement
Historically poor access to PTSD treatment; women get siloed into SUD treatment
Covid-19-related challenges
Therapist burden, capacity, and turnover
Therapy provision is not central to job roles/responsibilities
Time
Obstetrics Context
PTSD, posttraumatic stress disorder; SUD, substance use disorder; WET, written exposure therapy.
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Table 3
Recommendations for enhancing WET and improving sustainability.
Level Problem Recommendation Exemplar Quote
Patient Difficulty selecting
index event;
switching during
WET
Additional sessions to account
for switching events and ensure
habituation
Engage patient in conversation
and aim to link event to most
prominent PTSD symptoms
(selecting “worst”)
“Maybe leaving more of the wiggle room for 5 [sessions]. Maybe more
sessions too just to think about trying to get that Criterion A event
down. Picking the right one can take a session, or two, or maybe even
three. So ... kind of making the time frame looser I think would be
beneficial.”
Motivational
challenges Use of MI to support
engagement
Enhance collaboration across
care team to ensure consistent
positive messaging and
treatment support
Use psychoeducational
materials to enhance PTSD
literacy (e.g., address beliefs
about nonrecovery, treatment
expectations)
Incentives to engage (e.g.,
certificate of completion)
“I wish all of our patients could have the opportunity to engage in
WET therapy or that we could do the motivational interviewing to get
all of our patients to engage.”
“I think obviously if our only coping skill is avoiding I think there’s
gotta be, yeah, just some sort of middle. But I think if the patient is sort
of enveloped in care, um, with providers who sort of get that, then I
think that it increases their chance of staying in [the therapy].”
“I feel like PTSD treatment in theory could be a motivation, but I think
once you start doing it that could be more challenging. So it’s ... I
think that’s also kind of the benefit of really keeping things integrated.
Because, you know, things like ultrasounds are often very reinforcing,
and medications, and showing up.”
“I think they have the knowledge of PTSD as like a concept that like
people just throw out there, right, like the words ‘PTSD.’ But I don’t
think many of the women had insight into how trauma can impact like,
neurobiology, and how trauma can impact their mental health beyond
just the depression, anxiety. And so I think that deeper understanding
of PTSD ... they had the word, but not really what that meant for
them.”
“I find our women respond pretty well to psychoeducation, so I think
some sort of visual aid or psychoeducation piece when we’re trying
to enroll them in the therapy versus just the telephone call. I found
when [the RA] came to the clinic to meet the patients it was a little bit
more successful. But I also think like, beefing up some sort of visual
psychoeducation piece to get buy-in.”
“Even if we’re not doing specific gift cards for them but like, ‘okay
if you complete this you’ll get a pack of diapers.’ Something to
incentivize them to come in might be helpful. It’s also like a form of
contingency management, which we know works for substance use.”
“I do think that offering a certificate of completion would be another
incentive to continue to do it. Because the biggest –the first two
questions t always get asked are ‘is my baby going to be safe?’ and ‘is
DCF going to take my kid?’ So I think that having a certification of
completion and a latter explaining that we will give it to you and if you
lose it we’ll give you another one would be really helpful. Because,
you know, it’s something they can present at delivery, it’s something
they can give to a court, you know, that can help.”
Difficulty labeling
emotions Visual aid Obtained from consultation field notes
Transportation
Barriers Hybrid delivery of WET
Consistent schedule for WET
“I also see the appeal of doing it remote for women who are not
leaving as much and who can then fit it into their schedules more
easily if it’s just hopping on a phone call for 30 min, or for an hour.”
“I think in terms of [scheduling therapy sessions], having the
consistent schedule.
Not saying that patients might be able to make that schedule, but for us
to be able to offer that to the patients with consistency. That’s part of
the stability we can create.”
Provider Evaluation for
Criterion A Training on PTSD assessment
tools Obtained from consultation field notes
Training gaps (new
to manualized and
PTSD treatments)
Use consultation/supervision
to address training gaps
(e.g. training in emotional
and cognitive processing,
metaphors for treatment
rationale, orientation to natural
recovery, identifying and
“One barrier could be access to the training and then trying to schedule
time for that and keep up with the consultation. I think that one thing
that was really helpful too was the consultation and having you listen
to my sessions and giving me feedback.”
SSM Ment Health
. Author manuscript; available in PMC 2024 April 19.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Valentine et al. Page 22
Level Problem Recommendation Exemplar Quote
responding to avoidance,
shame vs. fear based traumas)
Managing discomfort
and vicarious trauma Use consultation/supervision to
process responses to WET (e.g.
reading accounts of rape or
incest, sitting with distressed
patients)
“Maybe peer support [from other clinicians] or more supervision
around the vicarious trauma. I think the pandemic makes us a little
bit more vulnerable to everything.”
System Outside providers
may discourage
engagement due to
misconceptions that
exposure therapy
may be harmful
Education/collaboration with
external providers to
ensure that care team is
knowledgeable about WET and
supportive
“I think it would be beneficial to do a better job of explaining what the
treatment is to other people that are on their teams. We have the flyer,
but even just sending that out universally to all the treatment programs
that women are in, even the outpatient ones. All these different referral
bases that we use all the time just to kind of explain what [WET] is,
about what the research is and what the function of it is, so that way
there can be this continuity of what the message is behind it. Because
we saw that some patients would get a message of ‘you can absolutely
not do this, like, this isn’t a good time for you,’ and then they would
disappear. So, that would be something that might make it easier to get
buy-in from people.”
Residential programs
pose challenges to
engagement
Embed WET in residential
SUD treatment programs
“I know there was a conversation about even doing [WET] in a
residential treatment setting. Taking this to [residential SUD treatment
program name]. I think that would be good because you’re going to
them – you don’t have to rely on them to show up to you.”
PTSD treatment not
prioritized (SUD
focus)
Conceptualize PTSD as part of
SUD recovery
“While trauma is a commonly used word, I don’t know that programs
isolated that piece of mental health outside of the substance use.
And ... with the WET therapy approach, it’s like, ‘you had this really
hard thing happen, and one way to cope with the hard thing that
happened is to numb out with substances.’”
Therapist burden
(therapy provision is
not central to job
roles)
Protected time for WET
delivery
“It’s easier for me to know what I’m doing at the same time every
week. Whoever’s in my role it’s easier to know ‘okay, well I have this
standing time that I need to block’.”
Telehealth
(responding to
insession avoidance,
adequate privacy,
obtaining writings)
Schedule WET alongside
prenatal visits Technology
advancements to obtain
writings
“What I’ve observed is that people try to get out of [engaging with the
trauma memory] whether they’re making a bowl of cereal, or talking
on the phone, it does take a lot of redirection. I think being in the
room ... makes it easier to redirect someone back to the task.”
“I think it would be helpful to use technology in some way where
they’re writing it and you can see it at the same time.”
Women arrive late
to prenatal care,
have complicated
pregnancies, and
deliver early
Need to study optimal
treatment window Obtained from consultation field notes
WET, written exposure therapy; PTSD, posttraumatic stress disorder; MI, motivational interviewing; SUD, substance use disorder.
SSM Ment Health
. Author manuscript; available in PMC 2024 April 19.