Table 2 Example quotes from rapid matrix analysis describing initial response to CDST and suggested adaptations

Specific suggestions

“…summarize the differences between these four [communication] styles. I think very visually so I’m envisioning a four by four, like a cube, and each box: one is assertive, one is aggressive, one is passive aggressive, and then maybe a couple bullets under each one.” (clinician)

Positive overall response

“My overall impression is this could be really helpful. I’m all excited, I want to go through the groups if it comes to [PRRC].” (Veteran)

Non-specific suggestions

“In one of the role-plays in the provider’s manual it said the client can ask to talk to someone else if the provider will not communicate effectively with them. But I think, in the end, what happens when communication breaks down with a provider? How do you go about politely and professionally asking for a different provider? And at what point do you say it breaks down? Because you can’t always be asking for new providers.” (Veteran)

Importance of empowerment and decisional autonomy for Veterans

“When you’re in service and you’re not able to express your own opinions and thoughts or what have you. Being a part of the decision-making is really a step up to express that and to [have my treatment needs] heard is huge for Veterans.” (Veteran)

Barriers to Veteran engagement in CDM and CDST

Veteran: In my mind it sounds stupid. I need [my providers’] advice but I’m just nervous on asking for it. I feel like I should already know these answers

Interviewer: And does that mean that you don’t tell them as much as you would otherwise?

Veteran: Correct. Yeah, I tend to downplay a lot

“Just not set people up for disappointment too, because if we’re going to relay to them ‘if you do this stuff your provider will do everything you want’ but that’s not realistic necessarily. It reminded me of [Social Skills Training] because it comes up a lot where Veterans will say ‘well I tried everything we covered in here and it still didn’t work’ and then they get sort of deflated.” (clinician)

Communication norm mismatch between military and civilian contexts

“There have been times, certainly for myself, where- I don’t even think [I was] just accused, I think it’s an accurate assessment that I was being aggressive with people, but I didn’t understand at the time I was being aggressive. Especially shortly after I got out of the military.” (Veteran)

Overcoming psychological barriers to Veteran engagement in CDM and CDST

“Let [the Veterans] know it’s okay, that you’re not going to be shunned away from just because there’s something that [clinicians] don’t agree with.” (Veteran)

“Before you go to talk to a provider, take a moment to calm yourself. And after these interactions, if you’re feeling frustrated, do something to soothe yourself or calm yourself.” (Veteran)

Importance of easy to deliver group materials for VA PRRC clinicians

“It’s a heavy cognitive load for me anyway- running a group as you’re trying to maintain engagement, trying to deliver content, trying to the stick to the protocol, trying to rein people in who are (laughs) getting a little off- so if the manual is easy to use and clear as possible it just makes it less stressful for me to facilitate.” (clinician)