There is a lot of research on dropout from PTSD EBPs. Here is a brief summary of what the research overwhemingly suggests:
- Dropout is generally not related to treatment intolerance, but other factors (scheduling, external commitments, etc)
- There is some evidence that some "dropouts" may actually be early completers--people who d/c the treatment as they felt it was no longer needed.
I definitely agree that how you frame the treatment and get buy-in from the patient is of utmost importance. I'm in the VA and don't have any trouble getting people to agree to CPT or PE. I've developed a way to explain the rationale for these treatments that makes sense to me and one that I genuinely believe. I am very upfront that the patient has to choose this and can't just do it because I'm telling them to, but it's also the gold standard and the only thing that is going to actually treat the trauma symptoms. Most of my patients finish CPT. PE has a lower completion rate but usually it's due to outside commitments--PE takes a TON of time. I've said this elsewhere in SDN, but think about it: attending a 90 min session weekly, completing 3 in vivo exposure assignments (at least 30 min each) daily, listening to a 40ish minute imaginal recording daily, and listening to a 90 min session recording weekly. It's a lot.
I also think a lot of the issues we see with getting patient buy-in and adherence to PE/CPT is due to fragilization of patients and clinicians' own distress while delivering PE (it's not a fun treatment to deliver, by any means). Research suggests that very few people are not actually ready to engage in PTSD EBPs, but well-meaning clinicians will often unnecessarily delay effective treatment. Also, yes, the EMDR crowd is not helping with their demonization of PE and CPT. The other thing is, it's hard to authentically sell PE unless you believe it works, and it's hard to really believe it until you see it working. Even if the research is so convincing, delivering the therapy is so counter-intuitive and in the short-term feels the opposite of what therapists want to do, which is help their patients feel better. And if you are a therapist, you won't see it working until you have completed a case or two... which is hard to do if you can't authentically sell it. It's a Catch-22. Heck, I believe very strongly in PE, have completed cases, and I still always feel like a jerk after the first imaginal session.