A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments

Laura A. Meis, Siamak Noorbaloochi, Emily M. Hagel Campbell, Emily P.G. Erickson, Tina L. Velasquez, David M. Leverty, Katie Thompson, Christopher Erbes

Research output: Contribution to journalArticlepeer-review


Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs =.19–.38; treatment completion, rs =.21–.25; practical treatment barriers, rs = −.19 to −.24; and therapeutic alliance, rs =.39–.57.

Original languageEnglish (US)
Pages (from-to)440-453
Number of pages14
JournalJournal of Traumatic Stress
Issue number2
StatePublished - Apr 2021

Bibliographical note

Funding Information:
Cognitive behavioral, trauma-focused therapies for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE) and Cognitive Processing Therapy (CPT), result in significant symptom improvement for many patients and are recommended as first-line therapies for veterans with PTSD (U.S. Department of Veterans Affairs and Department of Defense [VA/DoD], 2017). The VA has widely disseminated both therapies, improving the availability of effective treatments for veterans with PTSD. However, among individuals who initiate these interventions, a large proportion fail to complete enough sessions to ensure benefit. Recently, Hale and colleagues (Hale et?al., 2019) found that in a national sample, only 31% of individuals who initiated PE or CPT received an ?adequate dose? of treatment, defined as at least eight sessions. Although dropout is a well-documented problem for cognitive behavioral therapy across multiple conditions (Fernandez et?al., 2015), it may be especially problematic in VA facilities among patients with PTSD.

Publisher Copyright:
© 2020 International Society for Traumatic Stress Studies

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