Trauma-focused psychotherapies, such as prolonged exposure and cognitive processing therapy, are the
most effective forms of treatment for posttraumatic stress disorder.
Prolonged Exposure (PE) is a therapeutic approach that gradually exposes individuals to trauma-related memories, feelings, and situations within a safe environment.
The primary goal of PE is to decrease the anxiety and emotional response associated with these traumatic memories, helping individuals process their experiences and reduce the distress caused by the trauma.
Cognitive Processing Therapy, or CPT, is a form of therapy for people with PTSD that targets the negative thoughts and beliefs brought on by the trauma.
Through this therapy, individuals are guided to identify and challenge these distortions, ultimately aiming to change how they view themselves, the world around them, and the traumatic event itself.
Hundt, N. E., Ecker, A. H., Thompson, K., Helm, A., Smith, T. L., Stanley, M. A., & Cully, J. A. (2020). “It didn't fit for me:” A qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans. Psychological Services, 17(4), 414–421
Key Points
- This qualitative study examined veterans’ self-reported reasons for dropping out of prolonged exposure (PE) or cognitive processing therapy (CPT) for PTSD.
- The largest category of barriers was therapy-related reasons (71%), including lack of buy-in, believing treatment was not working, alliance issues, or switching to a different treatment.
- Practical barriers (57%) and finding treatment “too stressful” (32%) were also common reasons for dropout.
- Despite dropout, many veterans (61%) reported positive experiences with their therapist and half were willing to try PE or CPT again.
- The research provides valuable insights into real-world barriers to evidence-based PTSD treatment completion, but has limitations such as recruitment from a single clinic.
Rationale
Trauma-focused therapies like PE and CPT are considered the most effective treatments for PTSD (APA, 2017; Veterans Health Administration and Department of Defense, 2017).
However, dropout remains a significant problem, with rates as high as 50% in VA outpatient PTSD clinics (Miles & Thompson, 2016).
Prior research has examined demographic and clinical predictors of dropout (e.g., Harpaz-Rotem & Rosenheck, 2011; Mott, Mondragon, et al., 2014), but no studies have qualitatively explored veterans’ self-reported reasons for dropping out of PE or CPT in routine practice.
Understanding the patient’s perspective is crucial for efforts to implement these treatments fully.
Method
This qualitative study recruited 28 veterans from a VHA PTSD clinic who completed 1-7 sessions of PE or CPT before dropping out.
Participants completed semi-structured telephone interviews about their experiences, which were audio-recorded, transcribed, and coded by two raters using grounded theory.
The interview guide queried experiences seeking PTSD care, reasons for dropout, and attitudes about treatment. Recruitment continued until data saturation was reached.
Sample
Participants were primarily male (61%), African American (61%), had a mean age of 45, and had a variety of index traumas, including combat (29%), military sexual trauma (25%), and non-military trauma (18%). Most dropouts were from CPT (64%) vs PE (36%).
Data Analysis
The study used grounded theory, a method for developing theory from data, to analyze interview transcripts from participants.
Two coders independently reviewed the transcripts and then created a codebook together to ensure consistent coding. They then coded all transcripts and resolved any disagreements.
The analysis focused on identifying themes and how often they appeared, as well as how often different themes appeared together.
Results
The most commonly reported barriers fell into four main categories:
Therapy-related barriers (71%)
Therapy-related barriers included issues such as lack of buy-in to the treatment rationale or specific therapy tasks, believing that the treatment was not working, alliance issues with the therapist, or deciding to switch to a different treatment approach.
“I couldn’t have asked for a better therapist…They told me CPT is kinda like the best for you…I was like, uhh, well, I guess I’ll do it because I don’t want to do something that doesn’t fit me.”
The quote illustrates how some veterans felt pressured to engage in a treatment that didn’t feel like the right fit for them, even if they liked their therapist.
This mismatch between the veteran’s preferences and the chosen therapy could lead to disengagement and eventual dropout.
Practical barriers (57%)
Practical barriers were related to logistical challenges that made it difficult for veterans to attend and complete treatment.
“When it came to the point where it was jeopardizing my job, you know, the therapy come later, man. I gotta get paid.”
The quote highlights how demands of employment could conflict with therapy, forcing veterans to choose between their job and mental health treatment.
Other practical barriers included issues like caregiving responsibilities or transportation difficulties.
Emotional barriers (43%)
These barriers involved finding the treatment too emotionally challenging or stressful to tolerate.
“I just couldn’t do it . . . it was too much, every time I played it (the trauma recording) back or heard it, I felt like I was in it again.”
The quote vividly captures how some veterans experienced a resurgence of distress when engaging in exposure-based exercises, feeling as if they were reliving the trauma.
This understandable desire to avoid such intense emotional reactions could motivate veterans to drop out of treatment prematurely.
System barriers (14%)
These barriers reflected challenges veterans faced navigating the larger healthcare system, such as difficulties with scheduling appointments, long wait times, or negative experiences with providers outside the PTSD clinic.
While not always directly related to the PTSD treatment itself, these system-level frustrations could make it harder for veterans to engage in a full course of therapy.
Insight and Depth
This study provides a nuanced perspective by directly asking veterans for their reasons for dropping out.
It suggests that even if veterans are initially willing to try PE/CPT despite some ambivalence, issues with the therapy itself are most likely to lead to dropout.
Emotional barriers and lack of “fit” may trigger the urge to avoid, which is central to PTSD.
At the same time, many reported positive aspects of therapy, indicating that negative experiences alone may not fully explain dropout.
Strengths
- The study used rigorous qualitative methods, strict inclusion criteria, and coders achieved high inter-rater reliability.
- Interviews were thorough, ranging from 27-65 minutes.
- Recruitment continued until saturation, increasing confidence that the most important themes were captured.
Limitations
- The sample came from a single VA clinic, so barriers may differ by region or treatment setting.
- Only 25% of eligible dropouts participated, introducing potential selection bias.
- Self-report is subject to biases and inaccurate recall.
- The sample size precluded statistical examination of differences between PE and CPT dropouts.
Clinical Implications
VA should continue efforts to increase access to PE/CPT through extended hours and telehealth.
Providers may need to spend more time explaining the rationale, address ambivalence, and tailor treatments to individual needs. Those who find exposure too distressing may benefit from a phase-based approach to build coping skills first.
However, delaying trauma-focused therapy for patients who could complete it may reduce access and inadvertently send the message that avoidance is effective. More research is needed to determine which patients need additional preparation.
Efforts to improve retention should incorporate veteran perspectives and focus on veteran-centered care.
Further research should examine dropout in more diverse, larger samples and test strategies to target specific barriers.
PTSD is a challenging disorder to treat, and effectively engaging patients is complex, but incorporating patient perspectives is an essential place to start.
References
Primary reference
Hundt, N. E., Ecker, A. H., Thompson, K., Helm, A., Smith, T. L., Stanley, M. A., & Cully, J. A. (2020). “It didn’t fit for me:” A qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans. Psychological Services, 17(4), 414–421
Other references
American Psychological Association (APA). (2017). Clinical practice guidelines for the treatment of posttraumatic stress disorder (PTSD) in adults. Washington, DC: Author.
Harpaz-Rotem, I., & Rosenheck, R. A. (2011). Serving those who served: Retention of newly returning veterans from Iraq and Afghanistan in mental health treatment. Psychiatric Services, 62, 22–27. http://dx.doi.org/10.1176/ps.62.1.pss6201_0022
Miles, S. R., & Thompson, K. E. (2016). Childhood trauma and posttraumatic stress disorder in a real-world Veterans Affairs clinic: Examining treatment preferences and dropout. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 464–467. http://dx.doi.org/10.1037/tra0000132
Mott, J. M., Mondragon, S., Hundt, N. E., Beason-Smith, M., Grady, R. H., & Teng, E. J. (2014). Characteristics of veterans who initiate and complete cognitive processing therapy and prolonged exposure for PTSD. Journal of Traumatic Stress, 27, 265–273. https://doi.org/10.1002/jts.21927
Veterans Health Administration and Department of Defense. (2017). VA/DoD clinical practice guideline for the management of post-traumatic stress. Washington, DC: Author.
Suggested Socratic questions
- How might a veteran’s specific type of trauma (e.g. combat vs sexual trauma) influence their likelihood of dropping out of PE or CPT? What are some ways treatments could be adapted for different trauma types?
- The study found a large overlap between veterans reporting emotional barriers (finding treatment too stressful) and therapy-related barriers (e.g. lack of buy-in). How might these two factors influence each other bidirectionally over the course of therapy?
- Many dropouts still reported positive feelings about their therapist and a willingness to try therapy again. What factors do you think determine whether a dropout experience increases or decreases the likelihood of future treatment engagement?
- Delaying trauma-focused treatment to build coping skills may reduce access for those who could have completed the treatment. How should providers balance these risks and benefits when recommending a treatment plan after a patient has dropped out once before?
- What are some ways the VA healthcare system could address the practical barriers many veterans reported, such as work and family obligations? How would you design the ideal accessible, veteran-centered PTSD treatment program?
