Spring 2026 Issue

Keeping Veterans in PTSD Treatment
By Mark D. Coggins, PharmD, BCGP, FASCP
Social Work Today
Vol. 26 No. 2 P. 22

What Social Workers Can Do to Turn Dropout Into Engagement

The Veteran in the Parking Lot
The engine of Daniel’s truck hummed softly, a steady backdrop to the storm of emotions churning inside him. His Texas license plates caught the morning light as he sat in the VA parking lot, having arrived unusually early for his third session of cognitive processing therapy (CPT).

Yet he couldn’t bring himself to open the door. His hands gripped the steering wheel as if it were the only solid thing in reach. The clinic entrance stood ahead—quiet, ordinary, and impossibly daunting. It felt less like a doorway and more like a threshold he wasn’t sure he could cross.

A tightness wrapped around his chest, and his hands trembled despite his effort to appear calm. Since beginning therapy, the nightmares had grown sharper, not softer. The homework assignments felt like mountains, each page forcing him to revisit memories he had spent years trying to bury. Even thinking about the ambush sent a wave of anxiety through him, rising fast and threatening to pull him under.

Still, he had smiled at his wife that morning and told her he was “fine.” He had sat across from his therapist and spoken with steady conviction about his commitment to the process. But here, in the stillness of the parking lot, the truth pressed in: He wasn’t sure he had the strength to walk through those doors again.

This moment—a quiet crossroads—is one many veterans face in their journey to heal from PTSD. It isn’t a loss of faith or a lack of courage. It’s the weight of trauma-focused therapy, the emotional climb it demands, and the real-life pressures that make each step feel heavier. Veterans often find themselves suspended between hope and uncertainty, wanting to move forward yet overwhelmed by the path ahead. And still, within that struggle lies the possibility of brighter days and the chance to reclaim a life that feels whole again.

What the New Evidence Shows About Dropout
A recent meta-analysis published by the American Psychological Association examined 181 studies involving 124,092 US service members and veterans receiving psychotherapy for PTSD.1 The findings are both sobering and enlightening.

Dropout Rates in PTSD Therapy Are Common but Inconsistent
Overall, 25.6% of veterans dropped out of PTSD psychotherapy across the studies analyzed.1 However, the dropout rates varied significantly depending on the type of treatment used.

Trauma-Focused Weekly Therapies Have the Highest Dropout Rates
• CPT: 40.1%
• Prolonged Exposure (PE): 34.7%
• Virtual Reality Exposure Therapy: 37.2%

These therapies are effective, but they are emotionally demanding and often difficult for individuals to continue.

Non-Trauma-Focused Weekly Therapies Have Better Retention
• Present-Centered Therapy (PCT): 16.1%
• Mindfulness-Based Stress Reduction (MBSR): 17.4%

These approaches focus on stabilization and coping skills without requiring immediate exposure to trauma.

Group-Based Exposure Therapy Has the Lowest Dropout Rate
• Group exposure therapy: 6.9%

The benefits of peer connections are undeniable.

Intensive Outpatient Programs (IOPs) Significantly Reduce Dropout
• IOPs using CPT or PE: 5.5% to 8.5%

Compressing treatment into a shorter timeframe helps reduce avoidance and fosters momentum.

Comorbid Substance Use Disorder (SUD) Nearly Doubles Dropout Risk
• PTSD + SUD dropout: 46.4%

This finding is especially relevant for social workers.

Importantly, the overall data suggests that dropout is not a reflection of the veteran’s inability to engage; rather, it indicates a mismatch between the veteran’s needs and the treatment format.2 Social workers can directly influence this mismatch.

Why Trauma-Focused Therapies Cause Dropout
Trauma-focused therapies such as CPT and PE are among the most effective treatments for PTSD, but they can also be the most challenging to complete. The very aspects that make these therapies effective—exposure, cognitive restructuring, and confronting avoided memories—can also make them emotionally overwhelming.2

Veterans often experience the following:

• symptom spikes in the first three to six sessions;
• increased nightmares and heightened arousal;
• resurfacing feelings of shame, guilt, or moral injury;
• intensified avoidance behaviors;
• a fear that “therapy is making me worse”;
• difficulty completing assigned homework; and
• a sense of being unprepared for the emotional burden.

Weekly spacing can unintentionally reinforce avoidance. A veteran may spend six days trying not to think about their trauma, only to be asked to confront it again during the therapy session on day seven. This is where dropout occurs—not because the therapy lacks effectiveness, but because the veteran feels overwhelmed, unsupported, or mismatched to the therapy format.2

The Veteran Perspective: Why They Stay, Why They Leave
Veterans often describe the decision to remain in or leave trauma-focused therapy as a constant pull between the desire to heal and the instinct to avoid emotional pain.3 Early sessions can feel overwhelming or “flooding,” with sudden spikes in distress that leave many unsure whether the intensity reflects therapeutic progress or personal unraveling.4 This uncertainty is frequently compounded by a sense of isolation, as veterans often believe they are the only ones struggling or reacting strongly, unaware that symptom increases are common during trauma processing.5 Many also report feeling unprepared for the emotional demands of homework assignments, particularly when revisiting traumatic memories alone at home, which can feel exhausting or destabilizing.6 Practical barriers—such as missing work, arranging childcare, or traveling long distances to appointments—further strain engagement and contribute to early dropout.7

These experiences do not reflect a lack of commitment; they reflect the reality that trauma work is demanding, and veterans often carry heavy burdens outside the therapy room. Understanding these pressures helps social workers anticipate dropout risk and intervene early.

Preparing Veterans for Trauma-Focused Work
Social workers are uniquely positioned to prepare veterans for the emotional realities of trauma-focused therapy.8 This preparation emphasizes relational, educational, and stabilizing approaches rather than clinical ones.

Normalize the Emotional Intensity
Veterans often mistake early spikes in symptoms as signs of failure. Social workers can help reframe this experience by stating the following:

• “It’s common to feel worse before feeling better.”
• “Your brain is doing significant work—this discomfort is part of the healing process.”
• “You’re not doing it wrong. You’re engaging in something challenging.”

Explain Avoidance as a Symptom, Not a Character Flaw
Avoidance is a core feature of PTSD. When veterans understand this, they experience less shame and gain greater agency.

Use Motivational Interviewing to Explore Ambivalence
Ask questions such as the following:

• “What worries you most about continuing treatment?”
• “What would it mean for you to complete this treatment?”
• “What support would make this feel more manageable?”

Set Expectations About Homework and Exposure Exercises
Many veterans drop out because they feel unprepared for the demands of therapy. Social workers can break tasks into manageable steps.

Build a Support Plan for the First Four to Six Sessions
This period often sees the highest dropout rate. A support plan may include the following:

• transportation assistance;
• a family member checking in;
• a brief call or text from a case manager;
• a list of coping strategies; and
• a crisis plan.

Coordinate With Clinicians
Social workers can provide insights into housing instability, substance use, family stress, or logistical barriers that clinicians may not fully understand.

How Social Workers Strengthen the Therapeutic Alliance
The therapeutic alliance is the strongest predictor of treatment completion across mental health settings.9 Veterans often disclose fears or doubts to social workers that they hesitate to share with clinicians.

When social workers validate these concerns and encourage open communication, they help repair ruptures before they lead to dropout. They also help veterans articulate their needs, adjust pacing, or address triggers between sessions.

This relational support often becomes the anchor that keeps veterans connected to treatment during the most challenging phases.

Matching Veterans to the Right Treatment Format
One of the key findings from the APA analysis is that the format of therapy matters as much as the specific protocol.1 Veterans do not respond uniformly to weekly individual therapy; many benefit from formats that offer structure, peer support, or compressed timelines.

Group-Based Exposure Therapy:
Group formats provide shared identity, peer accountability, reduced shame, normalization of symptoms, and a sense of solidarity. Group exposure therapy had the lowest dropout rate of all weekly formats.

IOPs: IOPs reduce avoidance by compressing treatment into two to four weeks, providing daily structure, minimizing time between sessions, and offering multidisciplinary support. Veterans who struggle with weekly therapy often thrive in these programs.

Non-Trauma-Focused Therapies (PCT, MBSR): These are ideal for veterans who are not ready for trauma exposure, face unstable housing or employment, struggle with active substance use, and need stabilization before trauma work.

Weekly Individual Therapy: This is still appropriate for veterans who have strong readiness, have stable lives, prefer one-on-one work, and have completed prior stabilization.

A Simple Matching Guide for Social Workers
• High avoidance + strong peer identity: Group exposure
• Chaotic life circumstances: IOP
• Low readiness: PCT or MBSR
• High readiness + stability: CPT or PE

The Role of Peer Support and Veteran to Veteran Connection
Peer support is one of the most powerful tools for keeping veterans engaged in PTSD treatment.10 Many veterans report that they feel most understood by other veterans who “speak the same language.” Peer specialists can normalize the challenges of trauma-focused therapy, share their own journeys, and offer encouragement during the difficult early sessions. Group-based exposure therapy leverages this dynamic by reducing shame and increasing accountability. Even outside formal treatment, peer check-ins, buddy systems, and veteran led support groups reinforce engagement. Social workers can strengthen retention by integrating peer support into treatment plans.

Managing Comorbidities That Drive Dropout
The strongest predictor of dropout in the APA analysis was the combination of PTSD and SUD.1 Veterans with active substance use often need stabilization before trauma work.

Stabilization Before Trauma Work
Veterans may require harm reduction strategies, medication-assisted treatment, detox support, and relapse prevention planning.

Integrated Care Coordination
Social workers bridge mental health, addiction services, primary care, housing programs, and legal support.8

A Three Visit Stability Plan
Before trauma exposure begins:

1. Address immediate safety and withdrawal risks.
2. Build a harm reduction plan.
3. Coordinate with addiction specialists.

Addressing Social Determinants That Quietly Sabotage Treatment
Dropout is not solely emotional; It is logistical.5 Many veterans leave therapy because life circumstances intervene.

Transportation Barriers: Social workers can assist with VA travel reimbursement, rideshare vouchers, community partnerships, and telehealth setup.

Housing Instability: Veterans without stable housing cannot focus on trauma exposure. Social workers can connect them to HUD VASH, emergency lodging, state veteran housing programs, and local nonprofits.

Family Stress: Caregiving duties, marital conflict, and childcare challenges can derail treatment.

Employment Conflicts: Social workers can assist with FMLA guidance, workplace accommodations, and scheduling flexibility.

Digital Access: Telehealth requires a working device, reliable internet, and a private space.

A Barriers Checklist for Social Workers
• Do you have reliable transportation?
• Do you feel safe where you’re living?
• Do you have someone at home who supports your treatment?
• Does your work schedule conflict with therapy?
• Do you have access to a device and the internet?

Cultural and Identity Factors in Veteran Engagement
Cultural identity shapes how veterans engage with PTSD treatment.7,11 Veterans from rural communities may carry norms around self reliance. Veterans from Hispanic, Black, or Native communities may have experienced discrimination or institutional mistrust.

Women veterans—especially those who experienced military sexual trauma—face unique barriers. LGBTQ+ veterans may worry about stigma or past negative experiences with providers.

Social workers can bridge these gaps by acknowledging cultural context, validating lived experiences, and ensuring veterans feel seen and respected.10 Even small adjustments—such as offering choice in provider gender or connecting veterans with culturally aligned peer groups—can dramatically improve engagement.

A Practical Engagement Framework for Social Workers
This framework can be used by VA social workers, community providers, and state level veteran agencies.

A. Assess Readiness
Explore fears, misconceptions, and avoidance patterns.

B. Identify Dropout Risk Factors
• Substance use
• Housing instability
• Low social support
• High avoidance
• Prior negative experiences

C. Match Treatment to the Veteran
Use the APA findings to guide format selection.1

D. Build Engagement Supports
• Weekly check-ins
• Homework support
• Family involvement
• Crisis planning

E. Monitor Early Warning Signs
• Cancelled sessions
• Missed homework
• Emotional numbing
• Increased substance use
• Withdrawal from social supports

Policy and Systems Recommendations
The APA findings have clear implications for systems level change.1

• Expand Access to IOPs: These programs dramatically reduce dropout.

• Increase Group-Based Exposure Therapy Offerings: Especially in regions with strong military culture.

• Invest in Engagement Training for Social Workers: Motivational interviewing, trauma-informed communication, and readiness assessment should be standard.

• Fund Transportation and Digital Access: These are not “extras”—they are treatment enablers.

• Promote Treatment Matching Policies: Veterans should not be defaulted into CPT or PE if another format is a better fit.

Closing: Returning to the Veteran in the Parking Lot
Back in the parking lot, Daniel finally turned off the engine. What made him step out of the truck wasn’t willpower. It wasn’t a sudden burst of courage. It was a call he had received the night before from his social worker—a simple check-in, a reminder that the first few sessions are the hardest, and a reassurance that he wasn’t alone.

That call changed everything.

Veterans do not drop out because they are weak. They drop out because trauma therapy is hard, life is complicated, and support systems are uneven. Social workers—across the VA, community clinics, and state agencies—are the ones who can bridge that gap.

When social workers prepare veterans for the emotional demands of therapy, match them to the right format, stabilize their lives, and walk with them through the hardest weeks, dropout becomes engagement. Avoidance becomes momentum. And therapy becomes something a veteran can finish—not just start.

The path forward requires a collective commitment. As research continues to clarify what keeps veterans in treatment, social workers stand at the center of a system capable of adapting to those insights. Every conversation, every check-in, every barrier removed becomes part of a larger effort to ensure that veterans are not navigating this journey alone. When veterans stay in treatment, they reclaim not only their health but their sense of possibility. And when social workers lead with compassion, clarity, and persistence, they help make that healing possible—one veteran, one session, one moment of courage at a time.

— Mark D. Coggins, PharmD, BCGP, FASCP, is a long term care expert and corporate pharmacy consultant for Touchstone Communities, a leading provider of senior care that include skilled nursing care, memory care, and rehabilitation for older adults throughout Texas. He’s a past director of the American Society of Consultant Pharmacists and was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the Excellence in Geriatric Pharmacy Practice Award.

References
1. Penix-Smith EA, Swift JK. The protocol matters: a meta-analysis of psychotherapy dropout from specific PTSD treatment approaches in U.S. service members and veterans [published online November 17, 2025]. Psychol Trauma. doi: 10.1037/tra0002070.

2. Not all PTSD therapies keep veterans in treatment, study warns. American Psychological Association website. https://www.apa.org/news/press/releases/2025/11/ptsd-therapies-veterans-treatment#:~:
text=In%20a%20meta%2Danalysis%20of,treatment%20for%20all%20PTSD%20therapies. Published November 2025.

3. Hundt NE, Barrera TL, Arney J, Mott JM. “It didn’t fit for me”: a qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans. Psychol Serv. 2018;15(4):409-415.

4. Mott JM, Mondragon S, Hundt NE, Beason-Smith M, Grady RH, Teng EJ. Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. J Trauma Stress. 2014;27(3):265-273.

5. Sayer NA, Friedemann-Sánchez G, Spoont M, Murdoch M, Parker LE, Chiros CE, Rosenheck R. A qualitative study of determinants of PTSD treatment initiation in veterans. Am J Psychiatry. 2009;166(12):1403-1411.

6. Garcia HA, Finley EP, Ketchum NS, Jakupcak M, Dassori A, Reyes SC. A survey of barriers to PTSD treatment in veterans. Psychol Trauma. 2011;3(1):21-26.

7. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. VA/DoD Clinical Practice Guidelines. Published 2023.

8. SAMHSA. Trauma-informed care in behavioral health services (Treatment Improvement Protocol 57). Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

9. Flückiger C, Del Re AC, Wampold BE, Horvath AO. The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy. 2018;55(4):316-340.

10. Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment Health. 2011;20(4):392-411.

11. Interian A, Ang A, Gara MA, Link B, Rodriguez MA. Stigma and treatment engagement among Latino veterans. Psychol Serv. 2011;8(1):35-43.