HealthPE Therapy with Peer Assistance May Boost Retention and Reduce Drop-Out Rates...

PE Therapy with Peer Assistance May Boost Retention and Reduce Drop-Out Rates Among Trauma Survivors


Roughly 50 percent of adults will experience a car accident, assault, natural disaster, or other potentially traumatic event in their lifetime1. While experiencing a trauma is horrifying, the important thing to keep in mind is that evidence-based treatments help survivors decrease their PTSD (posttraumatic stress disorder) symptoms so they can heal and recover. Two of the most effective therapies are prolonged exposure and cognitive processing.

Prolonged Exposure

Prolonged exposure (PE) is a specific type of cognitive behavioral psychotherapy. It teaches survivors to gradually approach trauma-related memories, feelings, and situations that they have been avoiding, referred to as exposures. PE works by helping survivors face their fears and confront safe situations and take more control of their life. The exposures (or facing the fears) happen in therapy sessions, as well as in homework done outside of the sessions.

Cognitive Processing

Cognitive processing therapy (CPT) is another specific type of cognitive behavioral psychotherapy. It teaches survivors to evaluate and change the upsetting thoughts that arise after a trauma, especially those related to self-esteem and self-worth, trust of others, and safety in the community and world. CPT practice also includes therapy sessions and homework. The theory behind CPT is that by changing the way we think, we may change the way we feel and behave and regain more control over our lives following a traumatic event.

Drop-Out Problem

Research shows that these treatments for PTSD are highly effective and that they have a very positive effect on the lives of the survivors who complete them2-4. However, research also suggests that between 30 and 40 percent of people drop out of treatment, with most dropping out within the first four sessions or so. This occurs even in research settings that have significantly more resources and flexibility to provide care, compared to the many community health care settings where most people receive care5,6.

Peer-Assisted PE Treatment

A new research direction in PTSD treatment focuses on how to support trauma survivors to stay longer so they get the full dose of treatment to help them recover fully. One exciting study is examining a new strategy to help boost survivors’ social support, while also boosting their engagement and retention in prolonged exposure treatment. The study is taking place at the Charleston, South Carolina, Veterans Administration (VA) in a sample of veterans of the Vietnam War, Operation Iraqi Freedom, and Operation Enduring Freedom. The study invites any veteran who previously dropped out of PE to start treatment again with the support of a veteran peer. Each veteran client is paired with a highly trained peer who has completed the treatment.

The peer provides advice, support, and encouragement to the veteran to complete their exposure goals and homework. In addition, the client and therapist call the peer during therapy sessions to do five-minute check-ins about how the exposure homework went from the peer’s perspective. These exposures are done only in mutually agreed upon spaces that are clearly safe; prior to any exposure with a peer, the veteran client discusses with the therapist the difference between discomfort arising from conditioned anxiety as part of PTSD and discomfort from inappropriate or unsafe situations.

This study has not yet resulted in clear data about how peer-assisted PE treatment might reduce drop-out rates. But initial feasibility data suggests that recruitment of interested, eligible peers was not a problem, and roughly 50 percent of veterans who had previously dropped out of PTSD treatment expressed an interest in participating. Further research needs to examine if this treatment reduces drop-out rates and how outcomes from treatment may differ from completing traditional PE.

Additional Value

This approach, which incorporates social support into the treatment of PTSD, may be particularly helpful, given how isolating a traumatic event can be. The VA setting is unique because the peers are paid positions, which makes them easier to recruit and remain accessible to therapists, especially in comparison to civilian health care settings.

Hopefully this research will continue with larger samples and in stricter studies to determine its effect. It may also pave the way for examining how peers, friends, or family members may be involved in exposure therapies for OCD, specific phobias, panic disorder, and other anxiety disorders to boost treatment engagement or treatment outcome. But this promising new direction in PTSD treatment research will ideally highlight potential new strategies to boost retention in these two effective treatments.


1. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. doi:10.1001/ archpsyc.1995.03950240066012

2. Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635-641. doi:10.1016/j.cpr.2010.04.007

3. Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., & … Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43128-141. doi:10.1016/j.cpr.2015.10.003

4. Jeffreys, M. D., Reinfeld, C., Nair, P. V., Garcia, H. A., Mata-Galan, E., & Rentz, T. O. (2014). Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic. Journal Of Anxiety Disorders, 28(1), 108-114. doi:10.1016/j.janxdis.2013.04.010

5. Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, And Policy, 8(1), 107-114. doi:10.1037/tra0000065

6. Gutner, C. A., Gallagher, M. W., Baker, A. S., Sloan, D. M., & Resick, P. A. (2016). Time course of treatment dropout in cognitive–behavioral therapies for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, And Policy, 8(1), 115-121. doi:10.1037/tra0000062

7. Hernandez-Tejada, M. A., Acierno, R., & Sanchez-Carracedo, D. (2017). Addressing dropout from prolonged exposure: Feasibility of involving peers during exposure trials. Military Psychology, 29(2), 157-163. doi:10.1037/mil0000137

Research Psychologist at VA Boston Healthcare System

Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.


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