This guest post is written by Julia Diehle, who is in the final year of her PhD project (supervised by dr. Lindauer and prof. Boer at the Academic Medical Center in Amsterdam). Her research project concerns a randomized controlled trial of Trauma-Focused Cognitive Behavior Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) in children with PTSD.
Treatment dropout will be the topic of next week’s #traumaresearch Twitter chat on Thursday 26 April (9pm Melbourne, 13u Amsterdam; see your local time & how to join). Julia will join us as a special guest, I hope to see many of you there! Now over to Julia:
We do not like to talk about it but treatment dropouts and “no-shows” are a big problem in trauma therapy. Actually not in trauma therapy alone, but in outpatient settings in general. About 50% of adult patients drop out of outpatient therapy¹ and the number of children dropping out of treatment seems to be even higher. Miller and colleagues² found that more than 60% of children did not complete 8 sessions of therapy and that about 17% of the children did not even return after the intake session.
It is all about long-term vs. short-term gains
Trauma-therapy is no fun and treatment gains are achieved on the long term rather than on the short term. This may play a crucial role especially in children and adolescents, who are more present-oriented than adults, who are more future-oriented. Unlike younger children, adolescents (12 years or older) carry part of the responsibility for showing up for, and completing therapy. Parents have less influence on an adolescent than on a child younger than 12. Therefore the therapist needs to convince the adolescent of the usefulness of the therapy. However, on the short term it is more convenient for the adolescent to avoid the problems resulting from a traumatic experience than confronting them. Hence he or she might stop showing up for treatment appointments and drop out of treatment.
One would expect that treatment non-completers score higher on avoidance symptoms than treatment completers. However, treatment outcome studies almost never report on these differences. Moreover, avoidance symptoms can be very difficult to capture: If you ask an adolescent, who is an “avoidance expert”, whether he or she tries not to think about the event, this adolescent may answer: ‘I do not have to because I do not think about it.’ – And you won’t score it as an avoidance symptom.
Is the social system of the patient the key?
With younger children it does not only take commitment of the child, but also of the parent to attend therapy. This commitment may be at risk if a child first gets worse during treatment before getting better. A parent might support the avoidance of the child when the child gets worse at the start and not take him or her to therapy anymore. Again you have to deal with short-term versus long-term gains. Furthermore the parent might be traumatized as well and you might have to deal with both, the avoidance of the parent, and of the child. Other barriers may arise from lack of time or resources. One example is the parent who has to leave work early to take the child to therapy. With younger children it is therefore necessary to convince the parent of the importance of trauma-therapy.
Saxe, Ellis, Fogler and Navalta (2012)³ investigated the effects of a Trauma Systems Therapy (TST) for youth on treatment dropout. The results were promising: The drop-out rate was only 10% in the TST group at the assessment after 3 months, while the dropout rate for the care as usual group was 90%. The authors argue that in TST, the involvement of the child’s social environment and treatment engagement approaches play a crucial role, which results in low dropout rates. The sample size of this study was very small with 10 children in the treatment and 10 children in the control condition. However, research on treatment drop-outs and no-shows is very scarce, especially in children.
Effective treatment also means keeping the patient in treatment
We try to make our treatments more effective and efficient, and for children who stay in treatment this is of great value. However we may want to think more about those children who drop out of treatment and how we can help them group to stay in treatment. This might cost more time and resources in the short term. But again it is all about the long-term consequences and the time and resources that we gain by treating a child today rather than in 5 years when the problems have become much worse. Approaches that involve the social system of the child/adolescent and the identification of barriers for treatment engagement may be a solution. Some children/adolescents (and their parents) also might need more time to get used to therapy and to understand the value of the treatment.
References:
¹Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24 (2), 190-195 DOI: 10.1037//0735-7028.24.2.190
²Miller, L., Southam-Gerow, M., & Allin, R. (2008). Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency Child & Youth Care Forum, 37 (4), 153-170 DOI: 10.1007/s10566-008-9058-2
³Saxe, G., Heidi Ellis, B., Fogler, J., & Navalta, C. (2012). Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout Child and Adolescent Mental Health, 17 (1), 58-61 DOI: 10.1111/j.1475-3588.2011.00626.x
Trauma Recovery Lab 
Why are there no citations from studies backing up the claimed benefits “5 years later” of keeping kids in therapy versus letting them drop out? Very cynically viewed, this is because the article is just about drumming up repeat customers for therapy, rather than concern for patient health outcomes.
‘So, you convinced an insecure, affluent parent their child was Traumatized by seeing puppy squished by the neighbor’s car– How do you convert that reactionary session into 12 long weeks of therapy, even after the child doesn’t think about puppy any more?’
Thank you for your critical view! I agree that children who do not suffer from PTSD do not need treatment. There is only a small (but significant) subgroup of children who develop symptoms and are impaired in their daily life by these symptoms. Therefore I think a good (and objective) assessment of symptoms is needed. If a child reports PTSD symptoms and impairment, there are effective and short (even 8 sessions or less) treatments that help a child to recover. Maybe on thursday we can talk a bit more about the definition of “treatment dropout”!
It doesn’t help when the therapists are flakes. My daughter was scheduled for her first session yesterday, after a 2-hour intake session. My wife called twice to confirm the appointment, and was forced to leave voicemail both times. Apparently the therapist is either too busy or too flakey to check voicemail, because when we showed up for the appointment, the therapist did not. The excuse we were offered was “Well, you should have called to confirm.” This does not inspire confidence.
Frankly I was already inclined to skepticism about the value of trauma therapy, and indeed of therapy in general. While you may feel more inclined to be frank and open when discussing problems with a stranger who you never have to see again rather than with family and friends, the therapist is not privy to insights which day-to-day contact might provide. Perhaps the high dropout rate reflects nothing more than the realization that the ability to listen and offer advice on dealing with life’s problems is pretty common, and the advice provided by expensive trained professionals is often no better than the advice one can get for free from people one already knows and loves.
That’s not helpful at all! I’m very sorry to hear about this experience with your daughter’s therapist. Hope you can find one in which you really have confidence, it’s essential.
On your second remark, I think people may need both in some cases. We know most people do recover well from a traumatic event with the help from their family and friends. They don’t need any professional help. However, in some instances, it’s just very hard to recover and people experience high levels of stress symptoms for a long time. In those cases, well-trained therapists (e.g. trauma-focused cognitive behavioral or EMDR therapists) can help. They have a number of techniques available to help process the experience that friends and family don’t have, and would ideally work together with someone’s social network to get to improve wellbeing.
Er, thanks. Turns out it wasn’t a flakey therapist, but some confusion on my wife’s part — she was apparently calling the wrong number to confirm the appointment, so leaving messages didn’t confirm what she thought it confirmed.
My daughter has been to three sessions now with the original therapist, and thinks it’s a useful exercise so far.
Oh I’m glad to read that! Hope the therapy helps your daughter well.