Why was the treatment discontinued? Reasons for attrition in evidence-based trauma-focused treatments.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a debilitating mental disorder. Whereas effective treatments exist, many studies report high dropout rates. OBJECTIVE: We aimed to get a better understanding of why evidence-based trauma-focused treatments are discontinued, and factors associated with problematic terminations, in a naturalistic setting. METHOD: Patients (N = 135) in outpatient mental health clinics, receiving evidence-based trauma-focused treatment, self-reported PTSD symptoms throughout their treatments. Additionally, their therapists were asked to fill out a form stating the reason(s) for treatment termination. Based on these two data sources, we classified each case according to whether the termination appeared to be problematic vs. unproblematic. Separate logistic regression analyses were then run to investigate the association between termination category and relevant variables (i.e. sex, age, baseline psychopathology, number of traumas, treatment type, and therapeutic alliance at last measurement time-point). RESULTS: Based on our categorization, most of the treatment terminations (n = 77, 57%) were deemed unproblematic (i.e. according to treatment plan and/or clinically relevant reduction in symptoms), whereas a significant minority (n = 26, 19%) could indicate problematic terminations (i.e. clinically relevant increase in symptoms, unexplained dropout, and/or above cut-off for PTSD at last measurement time-point). Some of the cases that discontinued treatment earlier than planned could be described as early responders rather than as dropouts. Of the variables included in the logistic regression model, only therapeutic alliance was found to be significantly associated with termination category. CONCLUSIONS: This study highlights the need for a more nuanced approach to defining patient dropout. Our results also suggest that therapists may reduce the chance of a problematic trauma-focused treatment termination through securing a strong working relationship with the patient.