Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists.

Abstract

Objective: Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. Method: Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. Results: Therapists relied on stereotypes of poor adherence to understand veterans’ experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans’ needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists’ interviews. Conclusions: Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs.

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

“…Patients expressed concerns about the potential adverse impact of the treatment on their psychosocial functioning during and after treatment. 52 , 80 , 81 , 92 Patients discussed feeling conflicted about complying with the treatment as this often competed with their on-going “real-world” responsibilities. I felt very overwhelmed, and I felt very lost and very frantic in what I had to do [for therapy].…”

“…Several studies 50 , 80 , 86 , 87 highlighted the importance of providing psychoeducation regarding PTSD symptoms, the treatment’s rationale, and its expected effects to positive outcomes. I really do not understand CPT.…”

“…Studies also reported the significance of managing patient’s pre-treatment expectations and considering the degree of alignment between the treatment’s rationale, procedures, and patient’s needs. 80 , 82 , 88–90 They [the clinicians] just want to go into the past, but we need or what I need is how to cope with what I have right now, and then everyday civilian life, instead of just regressing and getting to the roots. 88 …”

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

“…Clinicians might partner with patients to manage treatmentrelated distress and jointly explore risk of negative consequences of treatment, as well as possible benefits of treatment despite a potential temporary increase in difficulty, in order to reframe potentially exaggerated expectancies and to prevent negative outcomes from occurring. Clinicians are often unaware of the types of concerns that may contribute to poor outcomes (Meis et al, 2023), so asking patients about their concerns throughout treatment can provide the opportunity to intervene more effectively, whether through problemsolving (Shulman et al, 2019) or another adjunctive procedure, or through bolstering PE or CPT elements (e.g., challenging treatmentinterfering stuck points, empowering patients to engage in exposure) to retain patients in care. Kehle-Forbes et al (2022) reported findings from this sample related to interpretations of ongoing or worsening symptoms as well as concerns about the impact of treatment on functioning.…”

“…We also examined beliefs patients reported having in early treatment sessions compared to during active components of treatment. Qualitative research can help to better elucidate the multifaceted processes of treatment engagement and outcomes by allowing us to learn from patients' experiences to identify relevant processes that may not have been previously examined (Meis et al, 2023). Identifying treatment-related beliefs and interpretations occurring during treatment that differentiate treatment discontinuers from completers, and further, PTSD− completers from PTSD+ completers, can help us develop interventions to both keep patients engaged in treatment and ensure they benefit from care.…”