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Objective: Many patients drop out of treatments for posttraumatic stress disorder (PTSD); some clinicians believe that trauma-focused treatments increase dropout. Method: We conducted a meta-analysis of dropout among active treatments in clinical trials for PTSD (42 studies; 17 direct comparisons). Results: The average dropout rate was 18%, but it varied significantly across studies. Group modality and greater number of sessions, but not trauma focus, predicted increased dropout. When the meta-analysis was restricted to direct comparisons of active treatments, there were no differences in dropout. Differences in trauma focus between treatments in the same study did not predict dropout. However, trauma-focused treatments resulted in higher dropout compared with present-centered therapy (PCT), a treatment originally designed as a control but now listed as a research-supported intervention for PTSD. Conclusion: Dropout varies between active interventions for PTSD across studies, but variability is primarily driven by differences between studies. There do not appear to be systematic differences across active interventions when they are directly compared in the same study. The degree of clinical attention placed on the traumatic event does not appear to be a primary cause of dropout from active treatments. However, comparisons of PCT may be an exception to this general pattern, perhaps because of a restriction of variability in trauma focus among comparisons of active treatments. More research is needed comparing trauma-focused interventions to trauma-avoidant treatments such as PCT. (Contains 2 figures.)

Objective: Various factors contribute to the effective implementation of evidence-based treatments (EBTs). In this study, cognitive processing therapy (CPT) was administered in a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinic in which training and supervision were provided following VA implementation guidelines. The aim was to (a) estimate the proportion of variability in outcome attributable to therapists and (b) identify characteristics of those therapists who produced better outcomes. Method: We used an archival database of veterans (n = 192) who completed 12 sessions of CPT by therapists (n = 25) who were trained by 2 nationally recognized trainers, 1 of whom also provided weekly group supervision. Multilevel modeling was used to estimate therapist effects, with therapists treated as a random factor. The supervisor was asked to retrospectively rate each therapist in terms of perceived effectiveness based on supervision interactions. Using single case study design, the supervisor was interviewed to determine what criteria she used to rate the therapists and emerging themes were coded. Results: When initial level of severity on the PTSD Checklist (PCL; McDonald & Calhoun, 2010; Weathers, Litz, Herman, Huska, & Keane, 1993) was taken into account, approximately 12% of the variability in the PCL at the end of treatment was due to therapists. The trainer, blind to the results, identified the following characteristics and actions of effective therapists: effectively addressing patient avoidance, language used in supervision, flexible interpersonal style, and ability to develop a strong therapeutic alliance. Conclusions: This study adds to the growing body of literature documenting the importance of the individual therapist as an important factor in the change process. (Contains 2 tables.)

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