Complementary and Alternative Medicine in VA Specialized PTSD Treatment Programs

Program coordinators from eight VA PTSD treatment programs that were known to offer CAM treatments were interviewed to help generate a list of CAM treatments for the survey. The list of treatments was intended to be comprehensive and was derived from those described by the program coordinators and by NCCAM (1). The final survey created for this exploratory, cross-sectional study consisted of 81 mixed-format questions covering 32 CAM treatments (and an “other” response option). Study procedures, including a waiver of informed consent, were approved by the Human Studies Subcommittee of the VA Connecticut Healthcare System.

The VA’s Northeast Program Evaluation Center (NEPEC) directory of specialized PTSD programs (12) was used to identify program coordinators from each of the 170 specialized PTSD programs listed in the directory. NEPEC is responsible for conducting evaluations of VA specialized PTSD treatment programs nationwide. Although PTSD treatment is offered in VA mental health services outside of these programs, the designation of “specialized PTSD program” is used for programs staffed by experts who have concentrated their clinical work in PTSD treatment and who meet specific staffing and reporting requirements (12).

The program coordinators identified were asked to complete the survey and return it in a postage-paid envelope provided. Two follow-up e-mails were sent in the event of nonresponse, followed by an attempt to make telephone contact.

Of the 170 surveys sent, 125 were completed between September 2010 and March 2011 (16% by telephone), representing a 74% response rate. Table 1 presents data on 24 types of CAM offered in VA specialized PTSD programs by program type. (Eight CAM treatments were not offered by any program: applied kinesiology, ayurvedic medicine, aromatherapy, chelation therapy, homeopathy, naturopathic medicine, somatic experiencing, and traditional Chinese medicine.) Ninety-six percent of the programs reported offering at least one CAM treatment. However, when guided imagery, progressive muscle relaxation, and stress management–relaxation therapy, which are commonly part of conventional PTSD treatments, were excluded, the percentage was 88%. The most popular forms of CAM offered were mindfulness, stress management–relaxation therapy, progressive muscle relaxation techniques, and guided imagery; each was offered by more than 50% of treatment programs. Several programs reported offering “other” CAM treatments: two programs offered equine-assisted therapy, two programs offered therapeutic riding, and one program offered aikido.

This study found that CAM is widely offered in VA specialized PTSD treatment programs. Only 4% of programs responding to the survey indicated that CAM was not offered. For the CAM treatments most commonly offered, there is an evidence base indicating effectiveness for the development of autonomic regulation (13), an important skill for individuals with PTSD. In fact, many of these treatments, although categorized as CAM, are often offered as part of conventional psychotherapeutic treatment of PTSD (for example, stress management–relaxation therapy).

The study had several limitations. Only 74% of programs returned the survey. The availability of CAM treatments may be overestimated if programs that did not offer CAM were less likely to return the survey. In addition, the survey did not gather information on the number of veterans using these treatments, the frequency with which the treatments are offered, or their effectiveness. In addition, some CAM practices can be accurately categorized under several headings, leading to ambiguity in responses. For example, yoga often includes meditation and guided imagery, and a program offering yoga may have reported that it offered yoga, meditation, and guided imagery or only yoga.

Although the VA has invested resources in disseminating evidence-based treatments for PTSD, research has shown that many veterans do not complete these treatments and that many who complete them continue to have symptoms (14). Furthermore, the efficacy of these treatments among veterans with comorbid disorders and prolonged, complex trauma histories has not been established. Future studies should examine whether participation in CAM therapies that have been shown to help with autonomic regulation (such as yoga and meditation) increases retention rates in evidence-based practices and improves outcomes by giving participants additional skills in self-regulation and affect management.

Many CAM treatments are not standardized or manualized. Those that are manualized, such as mindfulness-based stress reduction, may be improved by making them “trauma sensitive” (15). For example, yoga therapy for veterans with PTSD may be more effective if tailored specifically to emphasize autonomic regulation, mindfulness, and acceptance. In addition, yoga therapy for veterans with PTSD can be customized to reinforce therapeutic concepts used in other evidence-based practices for PTSD. Similarly, meditation may be more effective for the treatment of PTSD when it incorporates psychoeducation about effectively managing symptoms of reexperiencing that may arise during meditation. These are empirical questions that deserve research attention.

Use of CAM in VA PTSD treatment is widespread. Researchers, therefore, have an excellent opportunity to determine whether offering CAM treatments has an impact on treatment engagement and outcomes. Future research should assess the efficacy of CAM treatments, both as an alternative and as an adjunct to conventional PTSD treatment, and develop methods to tailor these treatments to veterans with PTSD.

This project was supported by the Advanced Fellowship Program in Mental Illness Research and Treatment of the VA’s Office of Academic Affiliations and by the National Center for PTSD.

The authors report no competing interests.