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Center for Care Delivery and Outcomes Research

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Health Services Research & Development Service                                                                                    February 2019 

Veterans Encouraged by a Loved One to Face Distress are More Likely to Stay in PTSD Treatment

CITATION: Meis L, Noorbaloochi S, Hagel Campbell E, et al. Sticking It Out in Trauma-Focused Treatment for PTSD: It Takes a Village. Journal of Consulting and Clinical Psychology. March 2019;87(3):246-256.

BACKGROUND: Trauma-focused treatments (TFTs) for PTSD result in clinically significant symptom relief for many patients. VA has committed considerable time and resources to ensure that two such therapies – cognitive processing therapy (CPT) and prolonged exposure (PE) – are widely available. Both therapies conceptualize PTSD as a disorder of avoidance and focus on facing versus avoiding trauma-related distress. Initiation rates for this type of treatment among Veterans with PTSD at VA facilities are low, and an important minority of those who begin these psychotherapies do not complete treatment (one in three Veterans drop out of trauma-focused treatment). Social system factors may be especially important to understanding these dropout rates, yet when and how family relationships influence PTSD treatment dropout remains unknown. This study examined two support system factors in predicting treatment dropout: Social control (direct efforts by loved ones to encourage Veterans to participate in treatment and face distress) and PTSD symptom accommodation (changes in loved ones’ behavior to reduce Veterans’ PTSD-related distress). Veterans initiating CPT or PE across four VA hospitals received a mailed survey. Veterans were asked to nominate a close friend, significant other, or family member to complete a similar mailed survey. This study included 272 Veterans and 272 loved ones.


  • Veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than Veterans who did not have such encouragement, even after accounting for individual-level predictors of dropout, such as Veterans’ attitudes, therapeutic alliance, and symptom severity.
  • There was a significantly greater likelihood of treatment dropout when loved ones reported greater symptom accommodation, but associations did not persist after controlling for other predictors.


  • Clinicians should consider routinely assessing to what degree Veterans entering trauma-focused treatments have encouragement by a close loved one to participate in activities that may be distressing.
  • Further work is needed to deepen our understanding of how social control influences psychotherapy retention so that interventions can be developed to optimize social control efforts that help Veterans complete trauma-focused treatment.


  • The mailed survey format prevented investigators from asking Veterans about how a family member may encourage or discourage approaching activities, thoughts, and feelings specific to the Veteran’s personal trauma history. This could have attenuated associations between dropout and either social control or accommodation.


AUTHOR/FUNDING INFORMATION: This study was partly funded by HSR&D (RRP 12-229). Drs. Meis, Noorbaloochi, and Hagel Campbell are part of HSR&D’s Center for Care Delivery and Outcomes Research in Minneapolis, MN.