Veterans’ reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination.

Abstract

Premature dropout from posttraumatic stress disorder treatment (PTSD) hinders treatment response. Studies have primarily used quantitative methodology to identify factors that contribute to Veterans’ premature dropout, which has yielded mixed results. Qualitative methods provide rich data and generate additional hypotheses about why Veterans discontinue PTSD treatment. This study aimed to understand Veterans’ reasons for dropping out of prolonged exposure therapy (PE) and to examine if there are differences in reasons for dropout between three delivery modalities: in-home, in-person (IHIP), office-based telehealth (OBT), or home-based telehealth (HBT). Twenty-two Veterans who dropped out of PE from a parent randomized clinical trial participated in individual qualitative interviews about potential contextual and individual factors related to discontinuation. Team-based coding was used to conduct open and focused coding. Themes were generated that described factors that influenced Veterans’ dropout from PE and constant comparison was used to explore differences in reasons between the three modalities. Most Veterans had multiple reasons for dropping out and reasons were similar across delivery modalities with few differences. Practical barriers (e.g., scheduling difficulties), attitudes toward mental health providers and therapy (e.g., stigma), psychological and physical health factors (e.g., perceived worsening of symptoms, pain), and the therapeutic context (e.g., disliking aspects of PE) contributed to Veterans’ decisions to drop out from PE. Veterans in OBT reported more types of practical barriers than Veterans in HBT and IHIP. These findings can help generate hypotheses about interventions that may promote engagement and future studies should continue to study how to reduce dropout.

Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination.

“…As participants moved into the active components of treatment, PTSD− and PTSD+ completers generally expressed self-efficacy in being able to engage in the tasks of treatment, whereas discontinuers expressed less self-efficacy. A previous study also found that some discontinuers of PE expressed low self-efficacy in being able to handle the difficult emotions involved in therapy (Wells et al, 2023). In the present study, many discontinuers described their doubt as contributing to their decision to discontinue treatment.…”

“…Yet little is known about how treatment-related cognitions during treatment may impact treatment outcomes. Treatment-related beliefs and interpretations that have been related to early discontinuation include low buy-in to the treatment rationale early in treatment (Hundt et al, 2020;Taylor, 2003), perceptions that ongoing symptoms mean treatment is not working (Kehle-Forbes et al, 2022), worry that treatment will have a negative impact on functioning (Kehle-Forbes et al, 2022), low selfefficacy in being able to handle the difficult emotions involved in therapy (Wells et al, 2023), and perceptions that treatment is not worth the distress involved (Hundt et al, 2017(Hundt et al, , 2020. A few studies have also examined relationships between treatment-related beliefs and symptom response.…”

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

“…Studies highlighted patients’ interpersonal difficulties with clinical staff and, in group-based interventions with their peers, as factors influencing engagement in treatment and outcomes. 70 , 82 , 91–93 At times these gave rise to patient feelings of disconnection and invalidation. 80 I was pissed off that people were trying to desensitize me to something horrible that happened because it almost seems like, ‘Oh you’re overreacting just think about, just be around it enough and you won’t feel that way anymore.…”

Examining veterans’ preferences for how to deliver couples-based treatments for posttraumatic stress disorder: Home-based telehealth or in-person?

“…On the one hand, safety, privacy, and comfort could create conditions that facilitate the therapeutic process, while on the other hand, avoidance can interfere with treatment outcomes and can maintain PTSD symptoms. Reducing avoidance while supporting engagement is particularly important for couples-based PTSD treatment; given studies have found that 30–48% of veterans drop out from cognitive behavioral conjoint therapy (Morland et al, 2022; Pukay-Martin et al, 2021) and that avoidance is associated with dropout from trauma-focused PTSD treatment (Wells et al, 2023). Clinicians may discuss at the outset of therapy how to create a safe therapy environment while also considering how to minimize avoidance.…”