Considerations for Therapists in Addressing Trauma Related Beliefs in Setting up CPT Therapy for Success.

It is well known that those who complete trauma focused therapy have better symptom reduction than those who disengage. Dropout rates average approximately one-third of those who commence treatment. In addition, some who complete treatment and experience improvement may still retain their diagnosis of PTSD. Recent qualitative research by Alpert et al. (2024) sheds light on a critical factor that may play a role in these outcomes, i.e., clients’ beliefs and reactions during therapy. This is important as clients come to treatment with expectations, fears and interpretations which influence their engagement and therapeutic outcomes. It is hoped these findings will assist therapists in how to best set up trauma focused therapy for success and to work with their clients in addressing concerns both before and during trauma focused treatment.

Most studies seeking to understand discontinuation and non-response have focused on demographics as predictors. Other than a younger age these factors have not proven to be instructive. This paper moved to identifying processes during treatment that relate to outcomes and factors that affect discontinuation. The method involved reviewing qualitative data collected previously (Kehle-Forbes et al., 2022) with a group of veterans who received either Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) as routine care. 126 veterans who either discontinued (n=66) or completed (n=60) group or individual treatment were contacted to participate in a 90-minute phone interview to discuss their experience in PE or CPT. Interviews focused on factors contributing to completing or discontinuing treatment and the challenges experienced.

Treatment related beliefs and interpretations that have been related to early discontinuation include: low buy-in to the treatment rationale and that it is not worth the stress involved; ongoing symptoms interpreted as treatment not working and worry that entering treatment will result in being overwhelmed or have a negative impact on daily functioning.

Five distinct but interconnected themes emerged that impacted completion of treatment:

1.     Perceived helpfulness of treatment

Discontinuers (those who discontinued treatment) were more likely to express the view that something in the treatment was not helpful, e.g. ‘I wasn’t able to focus on the rest of my day as I was still reliving memories’.

This early doubt is understandable as many clients have had previous unsuccessful attempts at treatment. It is possibly less difficult to manage than unrealistic expectations which can lead to disappointment and cessation.

2.     Self-efficacy in engaging in treatment

Discontinuers were more likely to have increased worry and decreased confidence regarding their resources to manage the therapy practice tasks or intense emotional experiences.

It is useful to explore both client doubts and confidence to assist in planning for obstacles.

3.     Anticipatory anxiety and concerns

Issues such as showing emotion in front of others, worry about being judged, a fear of not being able to handle treatment, or of negative consequences such as relapsing into depression or substance use were reported.

Discussions re normalising temporary distress and reassurance that these factors can be addressed and managed throughout treatment are important.

4.     Interpretations of ongoing symptoms

Discontinuer’s interpretations of ongoing PTSD symptoms were more negative which impacted their confidence in the efficacy of the treatment.

For example, a spike in a PTSD symptom measure score like the PCL-5 may be related to successfully addressing a stuck point, but is misinterpreted as the therapy not working. Therapists can intervene early by reassuring clients that this is a part of the healing trajectory.

5.     Perceived consequences of treatment on functioning

And finally, discontinuers had more concerns re the impact on their functioning at work, school, home or in their relationships.

This can be addressed by early planning: scheduling homework sessions to best fit with lifestyle and family commitments, building in distress tolerance and coping strategies and involving support systems where possible.

Implications for Treatment

Ask About Beliefs Early and Often

Discontinuers were initially more confident that treatment would be helpful but then as it progressed described more aspects of treatment as unhelpful. Disappointment and unmet expectations are likely to contribute to dropout. It is therefore important to address client expectations regarding their chosen PTSD treatment early in the process. This is particularly important where there may be a belief that treatment may result in an immediate response and solution to problems.

Validate and Reframe

Hope is important throughout treatment especially during more challenging elements.  Addressing beliefs regarding treatment impact and effectiveness as they arise assists in maintaining confidence in the process. This can be achieved by exploring the underlying reasons for these beliefs and addressing them as treatment related stuck points.

Plan For Distress

Exploring the difference between not wanting to complete a difficult task and not being able to can positively impact self-efficacy. Discuss what symptom exacerbation may look like and how to cope.

Empower Through Collaboration

Therapists who were able to convey encouragement and empowerment to help client success in treatment tasks were experienced by clients as supportive.  Similarly, when clients express the feeling that they ‘won’t be able to handle’ an element of the therapy, empathise with the difficulty and seek to understand it. This validation can assist in exploring the feared consequences and in reframing their ability to tolerate and overcome the perceived difficulties.

Consider Flexible Formats

Massed sessions (multiple sessions during the week) or adjunctive supports may help those worried about functional impact by keeping the momentum going (in the case of massed/intensive format).

Those clients who completed trauma focused treatment were able to report that treatment was eventually helpful even if they experienced some initial, transient worsening of symptoms. It is possible discontinuers may disengage when their distress is highest and before seeing any longer-term benefit which highlights the importance of addressing a client’s trauma related beliefs before and during the early phase of treatment.

Clinicians are often unaware of the types of concerns that may contribute to poor outcomes, therefore this paper which provides early research into the factors that may interrupt effective treatment and contribute to client drop out is a timely piece of work that will assist in enhancing engagement and completion rates.

Some suggested examples of setting up for success that emerged from this research include:

• Giving the opportunity for Q and A’s prior to therapy particularly where a trauma focused therapy will be a change in format to what the client is used to.

• Providing some psychoeducation to family members about what to expect and how to support their loved one.

• Providing a clear outline of what the therapy involves to address anticipatory anxiety,

• Holding problem solving discussions on how best to manage homework tasks, e.g., timing, location.

• Addressing client concerns re level of functioning prior to commencement where possible, e.g., timing of sessions (not immediately before work), frequency (more frequent sessions assists in retention), psychoeducation re expected responses to treatment components.

Reference:

Kehle-Forbes, S.M., Ackland, P.E., Spoont, M.R., Meis, L.A., Orazem, R.J., Lyon, A., Valenstien-Mah, H.R., Schnurr, P.P., Zickmund, S.L., Foa, E.B., Chard, K.M., Alpert, E., Polusny, M.A. (2022) Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout. Behaviour Research and Therapy, 154