Exploring the Facilitation of Successfully Completing Treatment within a Residential Setting with Veterans Diagnosed with PTSD

Symptoms of Post-Traumatic Stress Disorder (PTSD) in military veterans have been linked with a high level of impairment in psychological, functional, and social exclusion measures (Iversen et al., 2011). In addition, treatment for veterans with PTSD has been found to be less effective than in non-military populations (Kitchiner et al., 2012). As well as being less effective, drop-out rates, and non-response to treatment rates are high in this group (Schottenbauer et al., 2008). This has been seen to have a high financial impact (Currier et al., 2014), thus research into understanding effective treatment for this population would be advantageous. Research has suggested that offering intensive treatment programmes (for example, 18 sessions of therapy are offered over a six-week period rather than an 18-week period), could improve the efficacy and engagement with PTSD treatment (Schnyder et al., 2015). In addition to intensity of treatment, the inclusion of a group aspect has been found to be beneficial. In the United Kingdom (UK), United States (US), Canada, and Australia, treatment programmes for veterans with PTSD that consist of trauma-focused therapy combined with group therapy have reported significant improvements in symptoms, and these gains are maintained at follow-up (Murphy et al., 2015; Chard et al., 2010; Richardson et al., 2014; Forbes et al., 2008). It has been found that during treatment, group cohesion significantly predicted outcomes for military personnel receiving inpatient group PTSD treatment (Ellis et al., 2014). Research has reported that this may be associated with the social aspects of group therapy, such as being around others with similar experiences, enhanced RESEARCH

empathy, and camaraderie (Crowe & Grenyer, 2008). As previously mentioned, veterans with PTSD struggle with impairments in social functioning and isolation (Iversen et al., 2011), thus it is hypothesised that treatment within a group allows an opportunity to reduce emotional isolation by the development of cohesion between cohort members (Freedberg, 2008). This is moderated by the veteran's willingness to engage in the group setting (Crowe & Grenyer, 2008). However, to date, little research has focused on exploring the impact of receiving support for PTSD whilst part of a cohort of other treatment-seeking veterans; thus, the current study aims to explore this aspect of treatment.
Evidence has previously been reported on treatment response in UK veterans with PTSD attending Combat Stress (CS). CS is a national charity in the UK that provides mental health services to veterans. CS provides an intensive residential treatment programme for PTSD which has been described in previous publication (Murphy et al., 2015). The programme consists of a combination of individual trauma-focussed cognitive behavioural therapy (TF-CBT) and psycho-educational group sessions. Murphy et al. (2016) found that following completion of this programme, veterans had a significant reduction in PTSD symptom severity a year after treatment, alongside reductions in secondary outcomes.
Factors influencing outcome from this programme have been hypothesised (Murphy et al., 2015;Murphy et al., 2016). However, qualitative analysis would offer a richer understanding of the influence of intense residential treatment within a group on treatment outcomes. This is needed to inform future clinical practice and provide further insight into the mechanisms and influences involved during this type of treatment.
The current study aims to qualitatively investigate the impact and experiences of being part of a cohort within an intensive treatment programme for UK veterans diagnosed with PTSD.

Method Setting and Design
Participants for this study were recruited from a population of individuals who had previously contacted CS. All partici-pants had completed a six-week residential treatment programme for PTSD symptoms that consisted of a mixture of psycho-educational groups and individual TF-CBT sessions. A fuller description of the programme has been published elsewhere (Murphy et al., 2015). The study adopted a qualitative approach to gain a more in-depth understanding of the experience of veterans who had been part of a cohort undergoing intensive residential treatment. The study was approved by the CS research ethics committee.

Participants
The inclusion criteria for this study were: a) UK veterans that had successfully completed intensive residential treatment for PTSD between November 2017 and May 2018; b) participants with completed psychometric measures at admission, discharge, and six-month follow up; and c) participants demonstrated a clinically significant change in symptoms of PTSD between admission and six-month follow up. It is reported that treatment gains maintain over time (Creamer et al., 2002), and previous research on this treatment programme has found a similar effect size at six-month and 12-month follow up (Murphy et al., 2016). Symptoms of PTSD were measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5; Weathers et al., 2013) using cut-off score of 34 , and clinically significant change was defined as a reduction by 10 points. These participants were used for the current study as they had maintained clinically significant treatment gains at six-month follow-up.
Overall, 75 veterans met these criteria. Participants were randomly selected and contacted via the telephone and given the opportunity to participate. The final sample consisted of eight veterans, at which point saturation in data themes had emerged (Pope & Mays, 2009). Participant numbers were used in replacement of participant names in order to protect anonymity.
Demographic data was collected from each of the participants and is described in Table 1. The sample consisted of all male participants, and the majority were married (6/8) and had served in the British Army (6/8). A large proportion of the sample had served in combat roles (7/8). The participants age ranged from 32 to 65 years old (Mean (M) = 50.50 years, Standard Deviation (SD) = 10.97). Duration within the military ranged from four years to 25 years (M = 14.88 years, SD = 6.66). The participants came from six different treatment cohorts, with participants three, five, and six having been on the same cohort.

Materials
A semi-structured interview schedule was used during telephone-based interviews. The interview included the following qualitative questions: a) Whilst you were here on the programme you were part of a cohort. What do you think the positives are of being part of a cohort/group whilst having treatment? d) On the other hand, do you think there are any negatives of being part of a cohort or group whilst having treatment? c) What do you think are the benefits of receiving therapy within a residential setting, such as the sixweek programme, as compared to if you had received therapy as a weekly outpatient?

Procedure
Outcome data was collected from Combat Stress' two treatment centres, and eligible participants were approached sequentially. 10 participants were contacted and eight consented to participate. The lead researcher (AM) conducted all interviews following an interview schedule over the telephone, each lasting between 30 and 60 minutes. Interviews were recorded digitally, and the recordings were transcribed in verbatim. Participants' demographics were obtained from their previous clinical record.

Data Analysis
The analysis of the transcripts was conducted using thematic analysis (TA). TA methodology involves identifying and analysing any emerging patterns or themes within the data, with the aim of describing and interpreting the research topic (Boyatzis, 1998). This methodology is a useful research tool as it allows for both flexibility and a complex account of data (Braun & Clarke, 2006). Initially, the lead researcher (AM) researchers familiarized themselves with the dataset by reading through transcriptions and checking against the audio recordings. The process of data analysis involved familiarization and immersion in the dataset; this was done by the researcher reading over and noting on the transcript several times, searching for patterns or trends. Following this, interpretative statements and developing emerging themes were collated. The most common themes were then grouped together to form subthemes and superordinate themes. Records were maintained throughout analysis to uphold transparency and to permit themes to be able to be traced back to individual participant statements (Biggerstaff & Thompson 2008). The researcher (AM) finalised the refinement of the themes, and during this process it became apparent that some themes were not themes, and some themes were split into two more prominent and specific themes. Once this refinement was finished, the researcher checked over the quotes to clarify congruency of the superordinate themes and subthemes. A table of superordinate, key themes, and corresponding quotations from transcripts was produced. Themes were derived by the lead researcher (AM), and for purposes of triangulation these were discussed with co-author (DM).

Sample
Psychometric measures were obtained at admission, discharge, and six-month follow up from the previously discussed intensive residential treatment programme. The participants had an average reduction, at six-month follow up, of 22.5 points on a measure of PTSD (PCL-5). This is indicative of clinically significant change.

Results from Qualitative Analysis
Key themes were yielded using thematic analysis (see Table 2): cohort relationships, cohort dynamics, shared experience, and containment.

Superordinate Theme One: Cohort relationships
One of the superordinate themes that emerged from the interviews was related to the relationships and connections formed between cohort participants. The subthemes include knowing each other well, motivate and support each other, communication, sharing information and advice, and the effects of a non-cohesive cohort.
The general view was that positive relationships were beneficial during treatment and post-treatment; however, there were occasions where cohorts did not get on well or coalesce. The majority of participants reported that being within a consistent group of people, a cohort, allowed for greater knowledge about peers. Several participants mentioned that they knew how to respond and support each individual best, as they got to know each other so well.
"You-you get to know the other people if you-if you were to swap people about on a day to day basis, um, you wouldn't always know how people are reacting and you would react differently to them." -P1 "You see them at their high and their low-and thethey see you with your high, and your lows, and you just, you do-you become, uh, a close-knit team." -P5 Subtheme Two: Motivate and Support Each Other Common themes were motivation and support provided to one another by the individuals of the cohort (e.g., "we're all supporting each other"). It was also mentioned that if a cohort participant is more distant or disruptive, that the cohort still tries to help them.
"If you are struggling a bit, then you've got someone to talk to and guys will come up to you and say, 'I can see you struggling.'" -P2 "As the weeks progress, it's more and more about actually leaning on the guys for support as well." -P7

Subtheme Three: Communication
The participants stated the importance of communication with other cohort participants, within the context of both symptomology, experiences of mental health, reminiscing on military days, and general chat around the dinner table.
Communication was often lost in day-to-day life when struggling with symptoms of PTSD, so the addition of this alongside treatment was discussed as a benefit.
"But I did find that talking to people just in general and-and communicating with people, mixing with people, certainly helped in-in-in-in the-in the treatment." -P4 "Group support. So, if you can't talk to a therapist, you can talk to one of the guys." -P7 It was stated that often older veterans gave advice to younger cohort participants, as they saw themselves in the younger veterans.
"That some of the younger lads that come across to the groups and things like that and see us older ones-and think, 'Oh gawd, I don't want to be like him when I'm 50 years old'… and then bury it all." -P6 Subtheme Five: Non-cohesive Cohort Cohorts that did not have as close a bond, were perceived as getting less from treatment. Several participants mentioned that they had observed this in other cohorts, but not in their own. Participants theorized that if a cohort had less cohesiveness, or participants who did not "fit in," treatment goals may not be met.
"I could foresee where there were other cohorts. Potentially, where it wouldn't--because they might not gel or whatever the reason is-it might really screw things up a bit." -P6

Superordinate Theme Two: Cohort Dynamics
Cohort dynamics was a theme that emerged from the transcripts. This was related to the factors that can stimulate development or change within the group dynamic. The subthemes were the effect of negative moods and attitudes on the group, the combination of people in a cohort, motivation for change, and division between cohorts.

Subtheme One: Negative Moods and Attitudes
Although many positives about having the support of cohort participants were discussed, the influence of each other's moods and attitudes on the group was commonly mentioned. If participants of the cohort were struggling, or there was negativity or disruption within the group, this could "push them over the edge" and affect their own moods and engagement. Additionally, if participants of the group had a negative attitude, for example not particularly openminded or with very fixed opinions, this would impact the group.
"Someone comes out of a bad one to one and in-into a group setting they can be quite down. -And-and it could be one of the groups who's trying to build you up a bit. -It-it keeps it flat so to speak. It-it, uh, lessens it down. It takes it down a bit, yeah." -P1

Subtheme Three: Motivation for Change
Most participants reported that the intensive treatment programme was a "make or break" in regard to family life and mental health. This was a great motivation to engage in treatment and make positive changes in their life. However, participants talked about the veterans who were not as motivated for change and the negative effect this had on the group.
"I think that's where you have to be-you have to be the right people at the right time." -P8 "Why are you here, because you're-what you're doing is you're like a-you're-you're like a virus in the-in the group." -P3 Subtheme Two: Combination of People Age preferences in groups were addressed with some veterans reporting similar age as a positive based on the easier understanding between peers while others preferred mixed age groups. The effect of having a combination of theatres in a group and its impact on rivalry was mentioned. Consensus was mixed about both these influences on group dynamics.
"People say, "Well, if it's all young lads in the same cohort, that's better." Well, it might not be because actually…it might be better for…some older people in the group…and I-I was lucky to have that mix." -P3 "If there's a whole mix of different theatres…even though it's a different op, a different theatre, it's still the same." -P3

Subtheme Four: Division Between Cohorts
Participants discussed the dynamics between the different cohorts, including the division and "unnecessary rivalry" that was present between different cohorts of veterans. One participant described it as feeling like "them and us." "The only problem with the old cohorts is you do become a bit isolated it in your cohort sometimes… You know, this is my gang, and you know 'you sit over there'." -P2

Superordinate Theme Three: Shared Experience
A common theme that emerged during interviews was the feeling of having a shared experience with the other participants of your cohort. The subthemes that arose included feeling like you were "in the same boat," the unique bond shared between veterans, and having similar military experiences.
Subtheme One: "In the same boat" The participants reported the benefit of experiencing similar events related to symptoms, coping strategies, and treatment at the same time. The notion of not being alone coincided with a feeling of "being in the same boat" and sharing difficulties.
"It's just the old 'you're all in the same boat' sketch really." -P2 "It helped break down mental barriers like you're not-you're not alone. You're not suffering by yourself, you know." -P3

Subtheme Two: Unique Bond with Veterans
Participants spoke about the particular bonds that they share with other veterans, including a sense of understanding, and a feeling of safety. The difference in relationships between civilians and veterans was discussed as participants felt understood by peers, but not by civilians.
"Obviously the guys…who you're talking to-or ex-military as well--so you've already got that bond, haven't you? So, it does help massively." -P2 "You tend to open up more which you don't in civilian street, you don't-you don't do it in civilian street." -P1

Subtheme Three: Similar Military Experiences
A common theme that emerged throughout transcriptions was the impact of similar military experiences (i.e., training and deployment) on the shared experience of PTSD and then in treatment. The experience of being "institutionalised" during their military career was mentioned.
"You know that all the guys have been through the same sort of basic training as you, the-the same experiences as you, um, and-and to a degree reacting-are reacting the same way as you." -P1

Superordinate Theme Four: Containment
A shared theme that arose was the sense of containment in a residential setting. The subthemes that emerged included living in a "bubble"; support after 1:1 therapy, and learning skills.

Subtheme One: Living in a Bubble
Participants reported feeling of being "in a bubble" whilst in residential treatment. The treatment centre allowed for less worry, a sense of containment and control, and a greater commitment to treatment. Several participants reported feeling strange once treatment was completed and they were discharged into the community.
"I mean yeah, we're a little bit protected from the outside world but-um, I think that really helps to get our mindset."-P5 Subtheme Two: Support After 1:1 Therapy Benefits of having that containing support from other cohort participants and the continuous availability of staff after a 1:1 therapy session was highlighted by participants. Veterans reported being more open in therapy settings knowing that someone was keeping an eye out for them along with access to conversation if needed. There were apprehensions about safety with a lack of support (e.g., if completing treatment as an outpatient).
"I think definitely after the one-to-ones. Definitely. Um, ' cause if you needed them there, they were there. Um, you know, we'd all know when people were having their one-to-ones--and afterwards they'd come out of it and, you know, you'd be drained and everything…some people say, oh, he can take the afternoon off work afterwards or whatever. That's not what it's about. Even if you don't want to talk to someone after that--it's knowing that they're there." -P6 "If you didn't have the residential part of it, then possibly, the person may fall away from their one to one." -P4

Subtheme Three: Learning Skills
A shared subject emerged that participants learnt certain skills whilst in residential treatment, as they had the resources, support, and felt safe and contained to do so. As the participants left the treatment centre, these skills became significant to manage their symptoms and to recognise early warning signs. "I'm better able to recognize certain aspects now and I'd use coping strategy that I put in place while I was there-so I can-I can certain times. Not always but most of time I can recognize when I'm going into a bad place. -Um, but I'm a lot better at trying to pull myself back out of it before it gets too bad." -P1

Subtheme Four: The Whole Package
Participants discussed the benefits of having a "package" of tools accessible to them whilst in residential treatment. They reported feeling safe and contained enough to engage with these tools whilst in residential treatment (e.g., being able to make use of occupational therapy, art therapy, and 24/7 nursing support alongside their 1:1 therapy).
"You're all in one place so you can-you can try all the things at once rather than a bit at a time. You can use the whole toolbox in residential, you wouldn't be able to at home." -P1 "It is a package. You know it's all building bricks. Rome wasn't built in a day, and neither was PTSD resolved in a day. You need to build at it." -P8

Subtheme Five: Treatment Intensity
The intensity of treatment was regarded as a positive of residential treatment to allow the veterans to focus and get in the mindset of therapy. The intensity was also seen as timeefficient and similar to their military experience.
"I think as-as ex-service or service personnel--we prefer intense." -P6 "You're constantly going-because you're constantly battling it, you're constantly fighting-you're winning that fight." -P3

Discussion
This study aimed to qualitatively investigate the impact and experiences of being a part of a cohort undergoing and successfully completing an intensive residential treatment for PTSD in military veterans.

Superordinate Theme One: Cohort Relationships
The theme emerged from participants discussing the particular aspects of having peer relationships and its added benefits in treatment. Participants spoke about knowing how to specifically help or support each person in the group based on this connection. The veteran would identify individual needs (e. g., eagerness to communicate, whether to approach a peer or leave them alone, etc.). Participants described the cohort relationships as mutually beneficial. If the veterans were in a less consistent group of individuals, they would be unfamiliar with personal preference and struggle to provide or receive peer support. The theme of motivating and supporting each other arose within the framework of being a team, or a group, and having a sense of camaraderie. This sense of camaraderie would lead to them to lean on each other for support after therapy. The theme of communication centred around socialising with each other and chatting about general life or treatment specific topics. Communication was defined as sharing information and advice on symptoms and strategies and was considered mutually beneficial.
This supports previous research stating the benefits of the social aspects of group therapy, in particular with veterans with PTSD that have experienced isolation as a result of their symptoms (Crowe & Grenyer, 2008;Freedberg, 2008).
This theme also focused on observations the participants had made of the other inpatient cohorts, for instance witnessing non-cohesive groups. It was perceived that having a cohesive group was "lucky," and that those who underwent treatment in a group that was not cohesive did not gain as much from therapy. This parallels the findings that group cohesion significantly predicts outcomes (Ellis et al., 2014); however, in this study it is perception of outcome.

Superordinate Theme Two: Cohort Dynamics
This theme reflected the discussions around factors that could influence change within the group dynamic. The first three subthemes are related to the impact of veterans in the cohort, the dynamic, and the impact on demographics in the cohort.
Participants discussed the impact of each other's negative moods or attitudes on the rest of the group. If a veteran returned to the group feeling negative after a difficult 1:1 session, it would leave the group feeling down or flat. It was proposed that this could potentially make participants of the group "worse," presumably with regards to mood and treatment progress. Another study found that if a participant of a group experienced an episode of anger, the episode could provoke counter-aggression from other participants impacting the therapeutic process (Stone, 2009).
For this study there was discussion focused on lack of motivation as much of the cohort were "riding all their hopes" on this treatment programme. Gaining access to treatment was described as "make or break," so when cohort participants lacked commitment, frustration escalated within the group. Frustration was based on the notion that if a veteran was not as motivated, they should not be part of the programme. This reiterates findings from Crowe and Grenyer (2008) stating that the benefits from being part of a cohesive group depends on the veteran's willingness to engage.
The impact of demographics within a cohort was discussed, particularly with concerns to age and military deployment. This was split in opinion, as some participants viewed a same aged cohort as beneficial while others preferred a mixture of age and experience.
This theme also discoursed the dynamics between cohorts. Overall, cohorts were described as a positive aspect of treatment; however some described it as feeling a bit isolated from anyone not in the cohort and that there could be rifts between cohorts.

Superordinate Theme Three: Shared Experience
A theme that emerged was the benefit of having a shared experience. This again supports the findings that the social aspects of group therapy are beneficial to treatment outcomes (Crowe & Grenyer, 2008).
Many participants spoke about the benefits of feeling like they are "in the same boat" (i.e., going through the same thing at the same time). "Being in the same boat" appeared to bring a level of comfort and motivation to the individuals, specifically related to the feeling of "not being alone." "Sharing" and "not feeling alone" has been reported to benefit of veterans diagnosed with PTSD (Mellotte et al., 2017;Pearson et al., 2019).
This feeling of a shared experience was extended to the particular bond between veterans and their shared military experiences. The unique bond between veterans was reported as their underlying understanding of what each of them have been through, along with past and current experiences. This understanding was discussed as absent with civilians. The difficulty of "opening up," sharing, and explaining things to civilians was highlighted, whereas this was not needed with veteran peers. This aided treatment as participants felt more comfortable talking without having to explain themselves.
Shared military experiences were spoken about with regards to training and deployment. This shared experience appeared to increase the feeling of safety (i.e., "squaddies" will always have each other's back).

Superordinate Theme Four: Containment
Participants commonly talked about feelings of containment whilst undergoing residential treatment. The concept of inpatient treatment feeling like "living in a bubble" or feeling isolated from the world was discussed as a posi-tive phenomenon in that it heightened the feeling of containment, safety, control, and commitment to treatment. However, the positive phenomenon also produced posttreatment dependency as the veterans found returning to "normal" life felt difficult and strange.
It was commonly mentioned that a crucial benefit of residential treatment was the support after a 1:1 therapy session. Participants talked about feeling safer to open up in therapy, knowing there was someone who would have an eye out for them afterwards and serve as a shoulder to lean on, even if this was in the middle of the night. Many expressed their worries that this is not the same with outpatient therapy and that they would not have felt safe to open up or that they would have been worried about their safety when travelling home.
Participants reported that they felt contained and safe enough in the residential setting to be able to learn and practice new skills, such as coping strategies and grounding. They felt that learning this in a closed and supportive environment allowed them to learn what works for them, and then apply this once leaving treatment to recognise early warning signs and cope with day-to-day life. This is a similar experience to what was reported about being able to make use of the "whole package" whilst in residential treatment. Participants reported the beneficial impact of feeling safe enough to engage with all the available resources, such as 24/7 staff and other therapy modalities (i.e., occupational therapy, art therapy, etc.). These extra resources were described as being "building bricks" to dealing with their PTSD.
This theme also encompassed the intensity of residential treatment. Participants regarded the intensity as a positive that allowed them to stay in a focused, committed mindset and "thrash out" their therapy. Intensity in treatment was preferred as it aligned with their military training. This preference has previously been supported in previous research suggesting that intensive PTSD treatment programmes could improve the efficacy and engagement (Schnyder et al., 2015).

Strengths and Limitations
There were a number of limitations to the current study. All of the participants were British, older age, and male veterans who had been employed in the Army. These demographics limits the study`s ability to generalise to veterans of other genders, age, nationalities, ethnicities, time in the military, or branch of the military. Future research may want to include population groups already identified as impacted by treatment barriers, including service women or Commonwealth veterans (Mellotte et al., 2017).
The study did not collect information on ethnicity; however, the participants represented an accurate sample of those veterans with most complex needs (Stevelink et al., 2018). In addition, information was not available for date of diagnosis, health history, and treatment history. This would have been beneficial to consider in light of the findings and their implications.
Finally, sampling design and procedure may be biased towards veterans with a higher level of functioning and greater resources (e.g., access to a telephone, ability to answer, etc.). However, the study aimed to sample veterans who experienced, and maintained, clinically significant gains which indivertibly could overlap with veterans of higher functioning. Future studies should consider investigating the impact of the veteran cohort on treatment resistant veterans in group and individual therapy settings.

Conclusion
This study investigated the impact of being a participant of a veteran cohort whilst undergoing group therapy in a residential setting treatment for PTSD. Previous research has quantitatively found an impact intensive residential treatment and the current study aimed to get a deeper understanding of veteran cohort within a residential treatment program.
Our findings highlighted the benefit of becoming a closeknit group as participants built strong relationships and knew how to best respond to each individual in terms of communication support and advice. This was an experience unique to inpatient group therapy. The findings include the impact of certain factors on the group dynamics, such as age, and their effect on each individual's mood and treatment progress. It was found that veterans who experienced negative moods or attitudes, or were not as motivated to address their difficulties, could impact the group dynamics negatively. This impact caused frustrations and low moods. The combination of veterans in the group could affect the dynamic, particularly with regards to age and deployment theatre. The study found several positives of being part of a cohort, but these were limited to the group.
The results revealed that participants felt they had a shared positive experience with each other. The unique bond between veterans was seen as an important part of feeling safe within treatment and their similar military experiences enabled them to relate to each other.
Lastly, there was an impact of feeling contained whilst undergoing inpatient treatment. The feeling of "living in a bubble" allowing the veterans to open up more, feel focussed, and in control. The notion of having constant support appeared to create a safe place throughout the trauma-focused therapy. Feelings of containment allowed the veterans to implement new skills and to access other available therapies, including occupational therapy, and art therapy. Per the veterans' reports, treatment intensity was similar to the intensity of military life. The veterans found treatment intensity all-encompassing and reported that it allowed them to focus on treatment and "get it done." The study highlights the benefit of being part of a veteran cohort, the support, safety and shared experience this provides, which has a clinical implication for future veteran cohorts. Similarly, residential treatment reflects what veterans are used to and thus enables them to feel comfortable, contained, and supported to undergo treatment for PTSD. The findings should be taken into consideration given the current financial climate where more cost-effective treatments (e.g., outpatient settings) are more common.