Why finding it difficult to engage with therapy does not necessarily mean that someone is unwilling to recover.
Seeking help after trauma can take considerable courage. Yet beginning therapy and continuing with it are not always straightforward. For some people, the prospect of talking about traumatic experiences can feel overwhelming. Others may find that therapy brings difficult memories, emotions or physical reactions closer to the surface, at a time when they are already trying hard to manage everyday life.
When someone misses appointments, struggles to engage or decides to stop attending, it can be tempting to interpret this as a lack of motivation. But is that always a fair or helpful conclusion?
Recent research invites us to look more carefully at what helps people remain engaged with psychological treatment for post-traumatic stress disorder (PTSD), and what might make that engagement more difficult.
In this article, I explore findings from a review published by the US Department of Veterans Affairs, alongside other relevant research and UK clinical guidance. I consider what these findings tell us about trauma, therapeutic relationships and recovery, and reflect on their implications for trauma-informed practice.
Understanding the challenge of engaging with trauma therapy
PTSD can develop following exposure to traumatic events. Its effects may include intrusive memories, nightmares, avoidance, heightened alertness, difficulties with sleep and persistent feelings of threat. These experiences can affect relationships, work, physical wellbeing and a person’s sense of safety in the world.
Although effective treatments are available, the process of engaging with trauma-focused therapy can be demanding.
Therapy may involve approaching memories that someone has tried hard not to think about, examining beliefs that developed in response to trauma, or gradually facing situations that have come to feel dangerous. Even when these approaches are appropriate and carefully delivered, the process can evoke distress.
This creates an important tension: the very experiences that therapy seeks to help someone process may also make it difficult for them to continue attending.
Alpert and Kehle-Forbes (2026), in their review Patient Engagement in PTSD Treatment: An Update from 2017, examine research into treatment retention and the factors that may help people remain engaged with evidence-based PTSD therapies.
Their review highlights a central point: treatment engagement cannot be understood simply by looking at the characteristics or motivation of the person seeking help. The therapeutic process, the clinician, the support available and the wider circumstances in which treatment takes place also matter.
The authors also emphasise that research into engagement is still developing. Although several potentially important factors have been identified, the evidence does not provide a simple formula for predicting who will complete treatment or which interventions will work for everyone.
Why might someone find it difficult to stay in therapy?
There is no single explanation for why a person may struggle to continue with treatment. Trauma affects people differently, and the same treatment experience can have different meanings for different individuals.
Several themes emerge from the research.
1. The fear of feeling worse before feeling better
Trauma-focused treatment can involve distressing experiences. Someone may feel more anxious before an appointment, notice an increase in intrusive memories or worry about how they will cope between sessions.
It is important not to assume that increased distress automatically means treatment is failing. Equally, distress should not automatically be interpreted as evidence that treatment is working.
What matters is understanding the person’s experience, the nature and severity of their symptoms, their functioning and whether the treatment remains appropriate and tolerable.
Kehle-Forbes et al. (2022) interviewed US veterans who had either completed or discontinued trauma-focused treatments. Both groups described difficult experiences associated with approaching trauma-related material. What distinguished their accounts was not simply whether distress occurred, but also how they interpreted their experiences, the anticipated impact on everyday functioning and the support they received during treatment.
For someone who is already struggling to sleep, work, maintain relationships or manage daily responsibilities, the prospect of feeling more unsettled may be particularly concerning.
This is one reason why conversations about expectations, pacing, support and coping between sessions are important. People need opportunities to discuss what they are experiencing and to understand the purpose of the treatment, without feeling that they must conceal their concerns or simply push through regardless of the consequences.
2. Trust does not necessarily come easily
Trauma can affect a person’s sense of safety, their expectations of other people and their ability to trust. This can be particularly significant when traumatic experiences have occurred within relationships or involved betrayal, coercion or abuse.
Talking about painful experiences requires a degree of vulnerability. For someone who has learned that vulnerability can lead to harm, opening up to another person may feel frightening, even when they consciously want help.
Trust is therefore not something that can simply be expected at the beginning of therapy. It may need to develop through consistency, collaboration, reliability and respect for the person’s boundaries.
NICE guidance recognises that people with PTSD may experience apprehension, anxiety or shame, may have difficulty developing trust, and may avoid treatment for a range of reasons. It recommends approaches that support engagement, including allowing time to build trust and following up when appointments are missed (National Institute for Health and Care Excellence [NICE], 2018).
From a trauma-informed perspective, a missed appointment can be an opportunity to understand what has become difficult, rather than an automatic reason to label someone as unmotivated.
This does not mean assuming that every missed appointment is trauma-related. It means remaining open to the possibility that there may be more to understand.
3. The therapeutic relationship matters
The research reviewed by Alpert and Kehle-Forbes (2026) explores differences between people who completed trauma-focused treatment and those who discontinued it.
In the qualitative study by Kehle-Forbes et al. (2022), people who completed treatment described receiving more treatment-specific support from their therapists. They also described more flexible and personalised approaches, alongside a sense that their therapist was working with them towards a shared goal.
The researchers also identified the importance of support from other members of the care team and from people in the participants’ lives.
These findings do not mean that the therapist alone determines whether someone completes treatment. Nor do they suggest that a warm relationship can replace an appropriate, evidence-based intervention.
Rather, they highlight that how treatment is delivered may matter alongside what treatment is offered.
Sayer et al. (2022) examined engagement in evidence-based PTSD therapies among more than 18,000 veterans treated by 2,709 therapists within the US Veterans Health Administration. Their findings suggested that differences between therapists accounted for a proportion of the variation in early discontinuation and the likelihood of patients receiving an adequate course of treatment.
The study does not establish precisely which therapist characteristics account for these differences. Nevertheless, it reinforces the importance of examining the therapeutic process, rather than attributing treatment discontinuation entirely to the person seeking help.
A therapeutic relationship can provide a setting in which distress is acknowledged, difficulties are discussed openly, and treatment decisions are made collaboratively. It can also provide an opportunity to review whether the approach is meeting the person’s needs.
For me, this is an important reminder that clinical expertise involves more than knowing which interventions are recommended. It also involves attending to how the person experiences the therapeutic process.
4. Life does not stop while someone is in therapy
Psychological treatment takes place within the context of a person’s actual life.
Someone may be managing caring responsibilities, financial pressures, employment difficulties, health problems, unstable housing or ongoing contact with people associated with their trauma. They may have limited practical support or find it difficult to make time for appointments.
These are not peripheral considerations. They can directly affect someone’s capacity to attend sessions, complete between-session tasks and manage the emotional demands of treatment.
The review by Alpert and Kehle-Forbes (2026) discusses research linking longer waits between assessment and treatment initiation with greater discontinuation in a specialist Veterans Affairs setting.
It also highlights the importance of practical support and the wider social environment. Meis et al. (2019), for example, examined the role of support people during trauma-focused treatment. Their findings suggest that the nature of the support offered can matter, including whether significant others help someone manage the demands of treatment.
A person can want treatment, understand its potential benefits and still face barriers that make continuing difficult.
This is a reminder that engagement is not solely an individual responsibility. Access to timely, consistent and appropriate care matters too.
Is stopping therapy a sign that someone does not want to get better?
Not necessarily.
A decision to stop attending may reflect fear, practical difficulties, concerns about the treatment approach, a sense of not being understood, or a belief that the demands of treatment have become unmanageable.
It may also reflect a considered decision that a particular treatment, therapist or service is not the right fit.
These possibilities need to be explored rather than assumed.
Research has not identified one consistent set of individual characteristics that reliably explains treatment discontinuation. Maglione et al. (2022), in a systematic review of 19 studies examining treatment retention among veterans, found that the quality of evidence was low or insufficient for most potential predictors. More positive treatment expectations and older age were among the factors supported by moderate-quality evidence, but many other proposed predictors remained uncertain.
Importantly, the review did not find that greater PTSD symptom severity consistently predicted discontinuation.
This matters because simplistic explanations can place the burden entirely on the person seeking help.
Describing someone as resistant, difficult or unmotivated may obscure the questions that could be more useful:
- What is making treatment difficult?
- What does the person understand about the process?
- Are their concerns being heard?
- Are there practical barriers?
- Does the treatment need to be adapted or reconsidered?
These questions do not remove the person’s agency or responsibility for their decisions. They help create a more balanced understanding of what is happening.
Treatment engagement is complex, and the reasons someone continues or discontinues therapy may change over time. A formulation that considers the person’s experiences, needs and circumstances can be more helpful than assuming that a single explanation applies to everyone.
Does everyone need a long period of preparation before trauma-focused therapy?
This is an area where careful interpretation of the evidence is particularly important.
Some approaches to trauma treatment include an initial period of psychoeducation, coping skills and preparation. Such work may be valuable for some people, depending on their needs and circumstances.
However, the review by Alpert and Kehle-Forbes (2026) describes mixed findings from studies examining preparatory interventions before trauma-focused treatment. Some studies found benefits for particular preparatory approaches, while others did not find that preparation improved completion or clinical outcomes.
For example, Dedert et al. (2021) examined a preparatory group intervention for veterans attending a specialist PTSD clinic. The study did not find that participation in the preparatory group improved subsequent treatment completion, and those who entered trauma-focused treatment without first attending the group experienced greater symptom reduction. Because this was not a randomised comparison of preparation versus no preparation, the findings need to be interpreted cautiously.
The evidence therefore does not support a universal assumption that everyone must complete a separate preparation phase before beginning trauma-focused therapy.
Equally, it would be misleading to conclude that preparation is never needed.
The appropriate approach depends on the individual, the treatment being considered, the person’s current circumstances and the clinical assessment.
NICE guidance recommends trauma-focused cognitive behavioural interventions delivered by trained practitioners with appropriate supervision. For people with complex needs, the guidance highlights the importance of allowing additional time to establish trust, considering safety and stability, and addressing barriers to engagement (NICE, 2018).
The distinction is between individualised preparation that serves a clear therapeutic purpose and a blanket requirement that might unnecessarily delay access to appropriate treatment.
Preparation should be guided by clinical need and the evidence for the intervention being offered, rather than by a single rule applied to everyone.
What does this mean for trauma-informed practice?
My postgraduate training in Traumatology and PTSD has strengthened my interest in understanding trauma within the wider context of a person’s life, relationships and psychological responses.
A trauma-informed perspective encourages us to consider not only what someone is experiencing, but also how those experiences may have shaped their expectations of safety, relationships and help-seeking.
When someone struggles to engage with therapy, this perspective encourages curiosity rather than premature judgement.
It also raises important questions for practitioners:
- Have we explained the treatment clearly, including what the person might find difficult and what support is available?
- Are we listening to the person’s concerns about the pace, focus or impact of therapy?
- Are we considering practical barriers and the person’s wider circumstances?
- Are we reviewing whether the therapeutic approach remains appropriate?
- Are we working collaboratively, with the person’s informed participation in decisions about their care?
These questions are relevant not only to individual therapy but also to supervision, service design and the wider systems in which psychological care is provided.
The research does not suggest that there is one perfect way to keep everyone engaged. Indeed, the authors conclude that more high-quality research is needed, and that the processes supporting engagement may differ between individuals and treatments.
The challenge is therefore to move beyond assumptions and develop a more thoughtful understanding of what helps each person participate in treatment that is appropriate for them.
A professional reflection: what trauma-informed practice asks of us
Having worked as a psychotherapist since 2007, and as a clinical supervisor since 2015, I have developed a sustained interest in how trauma affects a person’s understanding of themselves, their relationships and their sense of safety in the world.
My postgraduate training in Traumatology and PTSD has further developed my understanding of the complexity of traumatic stress, including the ways in which trauma can affect emotional regulation, interpersonal relationships and a person’s capacity to manage everyday life.
One of the things I consider particularly important in trauma-informed practice is the need to remain curious about the meaning of a person’s responses. What might appear to be avoidance, reluctance or difficulty engaging can have a different meaning when understood in the context of the person’s experiences and the strategies they have developed to cope.
This does not mean assuming that every difficulty is caused by trauma, or that every therapeutic challenge can be resolved by changing the approach. It means being willing to explore what is happening rather than reaching a conclusion too quickly.
The research discussed in this article reinforces the importance of that position. It encourages practitioners to look beyond the question of whether someone completes treatment and consider the relationship between the person, the therapeutic approach, the clinician and the circumstances in which treatment takes place.
As a psychotherapist and clinical supervisor, I see this as an important area for ongoing professional reflection. We need to consider not only the interventions we use, but also how we communicate, how we respond when someone struggles, and whether we are creating opportunities for people to discuss their concerns openly.
Evidence-based practice and a compassionate therapeutic relationship are not competing priorities. The challenge is to bring clinical knowledge, careful assessment and an understanding of the individual together in a way that supports meaningful therapeutic work.
For me, trauma-informed practice requires us to hold two things in mind at the same time: the importance of effective treatment and the importance of understanding the person receiving it.
People should not have to demonstrate that they are easy to help before their difficulties are taken seriously. Our responsibility is to approach those difficulties with professional curiosity, appropriate clinical judgement and respect for the person’s individual circumstances.
That is not a substitute for evidence-based treatment. It is part of considering how evidence-based treatment can be delivered thoughtfully, collaboratively and responsibly.
Recovery is about more than completing a course of treatment
Treatment completion is an important research outcome, but it is not the same thing as recovery.
A person may complete a course of therapy without achieving all the changes they hoped for. Another person may benefit from treatment but decide, with appropriate support, that a different approach is needed. Someone else may need further treatment or ongoing support following clinical reassessment.
Alpert and Kehle-Forbes (2026) make an important distinction in their conclusions: improving treatment retention does not always translate into better clinical outcomes.
The ultimate aim is not simply to keep people attending. It is to help them experience meaningful improvements in symptoms, functioning and quality of life.
That requires attention to both the effectiveness of the intervention and the experience of receiving it.
For people seeking help, it is worth remembering that finding therapy difficult does not mean that recovery is beyond reach. It may mean that something needs to be understood, discussed or reconsidered.
For practitioners, it is an invitation to remain curious about the person behind the presenting difficulties, to recognise the influence of the therapeutic relationship, and to reflect on the part we play in making treatment accessible and sustainable.
Trauma can affect a person’s relationship with safety and trust. Psychological treatment should take those effects seriously.
The question is not simply whether someone can stay in therapy. It is whether we are working together to make the therapeutic process safe, meaningful and helpful enough for recovery to become possible.
References
Alpert, E., & Kehle-Forbes, S. M. (2026). Patient engagement in PTSD treatment: An update from 2017. PTSD Research Quarterly, 37(4). National Center for PTSD, U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/publications/rq_docs/v37n4.pdf
Dedert, E. A., LoSavio, S. T., Wells, S. Y., Steel, A. L., Reinhardt, K., Deming, C. A., Ruffin, R. A., Berlin, K. L., Kimbrel, N. A., Wilson, S. M., Boeding, R. C., & Clancy, C. P. (2021). Clinical effectiveness study of a treatment to prepare for trauma-focused evidence-based psychotherapies at a Veterans Affairs specialty posttraumatic stress disorder clinic. Psychological Services, 18(4), 651–662. https://doi.org/10.1037/ser0000425
Kehle-Forbes, S. M., Kimerling, R. (2017). Patient engagement in PTSD treatment. PTSD Research Quarterly. National Center for PTSD, U.S. Department of Veterans Affairs. Available through the PTSD Research Quarterly archive.
Kehle-Forbes, S. M., Ackland, P. E., Spoont, M. R., Meis, L. A., Orazem, R. J., Lyon, A., Valenstein-Mah, H. R., Schnurr, P. P., Zickmund, S. L., Foa, E. B., Chard, K. M., Alpert, E., & Polusny, M. A. (2022). Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout. Behaviour Research and Therapy, 154, Article 104123. https://doi.org/10.1016/j.brat.2022.104123
Maglione, M. A., Chen, C., Franco, M., Gizaw, M., Shahidinia, N., Baxi, S., & Hempel, S. (2022). Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review. Journal of Traumatic Stress, 35(2), 718–728. https://doi.org/10.1002/jts.22757
Meis, L. A., Noorbaloochi, S., Hagel Campbell, E. M., Erbes, C. R., Polusny, M. A., Velasquez, T. L., Bangerter, A., Cutting, A., Eftekhari, A., Rosen, C. S., Tuerk, P. W., Burmeister, L. B., & Spoont, M. R. (2019). Sticking it out in trauma-focused treatment for PTSD: It takes a village. Journal of Consulting and Clinical Psychology, 87(3), 246–256. https://doi.org/10.1037/ccp0000386
National Institute for Health and Care Excellence. (2018). Post-traumatic stress disorder (NICE guideline NG116). https://www.nice.org.uk/guidance/ng116
Sayer, N. A., Wiltsey-Stirman, S., Rosen, C. S., Bernardy, N. C., Spoont, M. R., Kehle-Forbes, S. M., Eftekhari, A., Chard, K. M., & Nelson, D. B. (2022). Investigation of therapist effects on patient engagement in evidence-based psychotherapies for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 35(1), 66–77. https://doi.org/10.1002/jts.22679
Further reading
National Center for PTSD — Engaging Patients in PTSD Treatment
A practitioner-focused resource exploring patient, therapist and service-level factors that may affect engagement in PTSD treatment.
https://www.ptsd.va.gov/professional/continuing_ed/engaging_patients_ptsd_tx.asp
National Institute for Health and Care Excellence — PTSD recommendations
UK clinical guidance on assessment, treatment planning, supporting engagement and psychological interventions for PTSD.
https://www.nice.org.uk/guidance/ng116/chapter/recommendations
Maglione et al. (2022) — Treatment retention among veterans
A systematic review examining the evidence for factors associated with staying in PTSD treatment. Particularly useful for readers who want to understand the limitations of current evidence about treatment dropout.
https://doi.org/10.1002/jts.22757
Kehle-Forbes et al. (2022) — Experiences of treatment completion and dropout
A qualitative study examining how veterans experienced trauma-focused treatment, including therapist support, flexibility, social support and concerns about the impact of treatment on everyday functioning.
https://doi.org/10.1016/j.brat.2022.104123
About the author
Lisa Harris is a psychotherapist, clinical supervisor and consultant, and a Qualified Traumatologist. She has worked as a therapist since 2007 and as a clinical supervisor since 2015. Her postgraduate training includes Traumatology and PTSD.
Lisa Harris
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Qualified Traumatologist
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Professional note: This article is intended for information and education. It does not replace an individual assessment or personalised clinical advice. Much of the research discussed concerns US military veterans receiving specialist care; findings should therefore be interpreted thoughtfully when considering other populations and treatment settings.
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