Background One of the biggest challenges therapists face when treating post-traumatic stress disorder (PTSD) is keeping patients in therapy long enough to see improvement. Research shows that about 34% of participants drop out of randomized cognitive processing therapy (CPT) trials for PTSD (Varker et al, J Affect Disord Rep 2021;4:100093). In this study, the authors analyzed initial CPT sessions from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) to see if they could predict early departure from treatment.
Research Methodology The researchers listened to recordings from the first few therapy sessions of 53 adults enrolled in the trial. All had a primary diagnosis of PTSD based on the Clinician-Administered PTSD Scale for DSM-5. Those who were taking medication had been stable on it for at least four weeks. About half were men (50.9%) and half were women (49.1%). Most identified as White (54.7%), followed by Black (30.2%), and the rest were of other races. Around 15% were Hispanic or Latino. The study was supported by a grant from NIMH and was conducted at the VA Boston Healthcare System.
After an initial psychoeducation session on responses to trauma, participants proceeded through 11 one-hour therapy sessions which utilized Socratic questioning to identify and change negative beliefs. Therapists used a version of CPT that also involves the patient writing about traumatic events. The authors looked closely at behavior such as the avoidance of difficult topics, signs of distress, and emotional processing.
Results Using a method called CHANGE, which tracks and categorizes patient outcomes throughout treatment, the team identified key predictors of dropout. Participants who avoided tough topics were four times more likely to stop therapy. On the flip side, the data linked signs of distress and working through emotions with a tendency to remain in therapy. Simply feeling negative emotions or ruminating didn’t predict who would drop out. Patients showing high levels of physiological distress and cognitive-emotional processing were less likely to drop out by 83% and 87%, respectively.
CARLAT TAKE: While a preliminary finding, early signs of avoidance of engagement during CPT sessions for PTSD may call for extra emphasis on emotional processing and establishing a sense of safety. This approach could reduce the risk of retraumatizing patients and increase the likelihood that they will stay in therapy.
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