Staff Perspective: Is Accelerated Therapy for PTSD the Way of the Future?
As a therapist, it feels devastating when a patient drops out of treatment. Queue the automatic thoughts, "What did I do wrong?" "What could I have done differently?" "Am I failing my patients?" These thoughts flooded my brain when I was trained in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for patients with posttraumatic stress disorder (PTSD) (Foa et al., 2009; Resick et al., 2016).
CPT and PE are both gold-standard treatments for PTSD. They are among the most studied treatments that reduce PTSD symptoms compared to control groups (Lewis et al., 2020; Powers et al., 2010) . In addition to Eye Movement Desensitization and Reprocessing therapy, they are two of the three psychotherapies that are recommended by the Department of Veteran Affairs (VA/DoD CPGs, 2025).
CPT and PE are mostly delivered in 8-15 weekly sessions. CPT involves challenging and modifying unhelpful beliefs related to the trauma, while PE involves repeatedly confronting trauma-related memories and avoidance to habituate fear responses. Each treatment asks patients to do 1-2 hours of daily homework.
I was excited to learn these evidence-based psychotherapies during my graduate training at the VA—rates of PTSD are high in military populations, and they deserve the best care. Before diving in, I prided myself on having a near 0% dropout rate with my previous clients. My specialty was in treating depression and anxiety disorders, which are like cousins of PTSD.
But when I saw my first caseload of veterans with PTSD, my optimism quickly waned. My no-show rate shot up to almost 40%. I’d usually be 3 sessions into CPT or PE—right before really “diving into” the trauma—when patients started to reschedule, cancel, or “ghost” me entirely. Why was this happening? My process to self-reflect, “what could I have done better?” could only take me so far, since my other patients were benefiting from treatment.
Fortunately, some of my patients shared with me why they prematurely ended therapy. Several said that they stopped due to logistical reasons: not having enough time, getting a new job, or not realizing the level of commitment needed until they started. Others said they weren’t ready to confront their trauma (“It’s too much, right now.”), and some even admitted to engaging in avoidance. For patients I didn’t hear from, it’s possible that they didn’t see me, or the treatment, as the “right fit.” Or...maybe something else? Regardless, I felt defeated, and so I consulted the research literature to learn more.
Dropout Rates for CPT and PE
What I found in the research was staggering. Among combat Veterans with PTSD who served in Iraq and Afghanistan, a meta-analysis found that the overall dropout rates for trauma treatments were 36% (Goetter et al., 2015). This number mirrored my own clinical experience! More recently, in a different a meta-analysis of trauma treatments for military and veteran populations, researchers found that dropout rates were 40% for weekly CPT, and 35% for weekly PE (Penix-Smith & Swift, 2025).
These results made me feel validated. I thought, “I wasn’t the problem. The treatment schedule was.” But then, that idea disappointed me—is this really the best we can do? How can we call a treatment “gold-standard” when almost half of patients don’t finish it? Fortunately, there is light in this story. In the same meta-analysis, the researchers found that when CPT and PE were done in rapid care settings (i.e., a few weeks to a month of treatment), the dropout rates plummeted to just 9% and 6%, respectively. Is this for real? Can you actually treat PTSD in just a few weeks? And still have 90% of people complete treatment?
Enter the conversation: "massed delivery" of PTSD treatments.
What is “massed” PTSD treatment?
Massed treatment is when an evidence-based psychotherapy is delivered in 3 sessions or more per week. Given the intensity, this delivery is also called “accelerated” treatment. Massed PTSD treatments are usually done in intensive outpatient or partial hospitalization programs (IOP/PHP), as well as residential settings. However, massed treatment can be adapted into an outpatient setting.
Much of what is known about massed treatment has emerged in the last 10-15 years. As a result, there is no primary model, yet, for how to implement massed CPT and PE. For instance, some intensive care settings will bring in “supplemental” treatments for patients. These could include support via exercise programs, yoga, meditation, or seeing a nutritionist; they may also include helping a patient with other mental health difficulties, such as providing supplemental therapy for depression, anxiety, sleep, or substance use disorders.
Does accelerated CPT and PE work?
The short answer—yes, but research is still emerging.
In multiple randomized clinical trials, massed PE was found to be just as effective as weekly PE for reducing PTSD symptoms at 3-months (Dell et al., 2023; Foa et al., 2018) . Importantly, treatment gains are also similar between massed PE and standard PE after 1-year follow-up (Dell et al., 2023).
There is less research on massed CPT, but initial work shows that it is effective for reducing PTSD symptoms (Baez et al., 2026.; Held et al., 2023) . However, there is a soon-to-be published randomized clinical trial that shows massed CPT is, indeed, as effective as standard CPT in a U.S. military population (Wachen et al., in press). One interesting finding is that CPT can be delivered effectively in 1-week, 2-week, and 3 week formats (Held et al., 2022, 2023).
Lastly, interview research shows that providers really enjoy doing massed PTSD treatments—you have the chance to see a patient make improvements in 2-3 weeks vs. waiting 3-4 months. That said, providers emphasize that the healthcare system needs to provide a reasonable infrastructure for massed treatment to be feasible; this includes protected time for preparation, documentation, and having supportive leadership (Wells et al., 2026).
Who is appropriate for massed treatment?
The inclusion and exclusion criteria are the same as CPT and PE: patients who meet PTSD criteria and have sufficient memory of the traumatic event is appropriate. These treatments are not appropriate for patients with imminent threat of suicidal or homicidal behavior, current and serious self-injurious behavior, current psychosis, or at imminent risk of domestic violence or assault. However, once these conditions or circumstances are addressed, a patient may be appropriate.
Questions to Be Answered
The initial data on massed PTSD therapies are promising. But a few questions remain unanswered before widespread adoption:
- How long are treatment gains maintained?
- How do providers feel about massed compared to standard treatment?
- What are the best ways to implement massed CPT and PE?
- What is the most economical way to implement these treatments?
- How can providers be reimbursed for massed treatment?
- What is the feasibility for community outpatient providers to implement massed treatment?
A Bright Future
Accelerating treatments are...accelerating. There is good reason for patients and providers to be excited about the future. Patients and providers, alike, can now make similar progress in a few weeks, rather than months. If the last decade was focused on innovation PTSD treatments for massed delivery, then I hope the next decade sees the widespread adoption and dissemination of these promising interventions.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.
Andrew Devendorf, Ph.D., is a Military Behavioral Health Psychologist with the Henry M. Jackson Foundation for the Advancement of Military Medicine. He serves as a subject matter expert in suicide prevention for the VA SAFEGUARD project.
References
Baez, L., Huberty, J., Yourell, J., Jewell, C., Lin, E., Kaysen, D., Cutts, L., Noori, S.,
Rosenthal, I., & Chard, K. (n.d.). Effectiveness of massed cognitive processing
therapy for posttraumatic stress disorder: A retrospective analysis. Journal of
Traumatic Stress, n/a(n/a). https://doi.org/10.1002/jts.70045
Dell, L., Sbisa, A. M., Forbes, A., O’Donnell, M., Bryant, R., Hodson, S., Morton, D.,
Battersby, M., Tuerk, P. W., Wallace, D., & Forbes, D. (2023). Effect of massed v.
standard prolonged exposure therapy on PTSD in military personnel and
veterans: A non-inferiority randomised controlled trial. Psychological Medicine,
53(9), 4192–4199. https://doi.org/10.1017/S0033291722000927
Foa, E. B., Chrestman, K. R., & Gilboa-Schechtman, E. (2009). Prolonged Exposure
Therapy for Adolescents with PTSD Emotional Processing of Traumatic
Experiences, Therapist Guide. Oxford University Press, USA.
Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., Mintz, J.,
Young-McCaughan, S., Borah, E. V., Dondanville, K. A., Fina, B. A., Hall-Clark,
B. N., Lichner, T., Litz, B. T., Roache, J., Wright, E. C., Peterson, A. L., & for the
STRONG STAR Consortium. (2018). Effect of Prolonged Exposure Therapy
Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD
Symptom Severity in Military Personnel: A Randomized Clinical Trial. JAMA,
319(4), 354–364. https://doi.org/10.1001/jama.2017.21242
Held, P., Kovacevic, M., Petrey, K., Meade, E. A., Pridgen, S., Montes, M., Werner, B.,
Miller, M. L., Smith, D. L., Kaysen, D., & Karnik, N. S. (2022). Treating
posttraumatic stress disorder at home in a single week using 1-week virtual
massed cognitive processing therapy. Journal of Traumatic Stress, 35(4),
1215–1225. https://doi.org/10.1002/jts.22831
Held, P., Smith, D. L., Pridgen, S., Coleman, J. A., & Klassen, B. J. (2023). More is not
always better: 2 weeks of intensive cognitive processing therapy-based treatment
are noninferior to 3 weeks. Psychological Trauma: Theory, Research, Practice,
and Policy, 15(1), 100–109. https://doi.org/10.1037/tra0001257
Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological
therapies for post-traumatic stress disorder in adults: Systematic review and
meta-analysis. European Journal of Psychotraumatology, 11(1), 1729633.
https://doi.org/10.1080/20008198.2020.1729633
Penix-Smith, E. A., & Swift, J. K. (2025). The protocol matters: A meta-analysis of
psychotherapy dropout from specific PTSD treatment approaches in U.S. service
members and veterans. Psychological Trauma: Theory, Research, Practice, and
Policy. https://doi.org/10.1037/tra0002070
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.
https://doi.org/10.1016/j.cpr.2010.04.007
Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive Processing Therapy for
PTSD: A Comprehensive Manual. Guilford Publications.
Wells, S. Y., Kehle-Forbes, S. M., Shapiro, A., Murray, R. D., Dedert, E. A., Woolson, S.,
Calhoun, P. S., & Jackson, G. L. (2026). Providers’ and administrators’
perspectives of massed posttraumatic stress disorder (PTSD) treatment in
Veterans Affairs (VA) PTSD outpatient clinics. Psychological Services.
https://doi.org/10.1037/ser0001018
As a therapist, it feels devastating when a patient drops out of treatment. Queue the automatic thoughts, "What did I do wrong?" "What could I have done differently?" "Am I failing my patients?" These thoughts flooded my brain when I was trained in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for patients with posttraumatic stress disorder (PTSD) (Foa et al., 2009; Resick et al., 2016).
CPT and PE are both gold-standard treatments for PTSD. They are among the most studied treatments that reduce PTSD symptoms compared to control groups (Lewis et al., 2020; Powers et al., 2010) . In addition to Eye Movement Desensitization and Reprocessing therapy, they are two of the three psychotherapies that are recommended by the Department of Veteran Affairs (VA/DoD CPGs, 2025).
CPT and PE are mostly delivered in 8-15 weekly sessions. CPT involves challenging and modifying unhelpful beliefs related to the trauma, while PE involves repeatedly confronting trauma-related memories and avoidance to habituate fear responses. Each treatment asks patients to do 1-2 hours of daily homework.
I was excited to learn these evidence-based psychotherapies during my graduate training at the VA—rates of PTSD are high in military populations, and they deserve the best care. Before diving in, I prided myself on having a near 0% dropout rate with my previous clients. My specialty was in treating depression and anxiety disorders, which are like cousins of PTSD.
But when I saw my first caseload of veterans with PTSD, my optimism quickly waned. My no-show rate shot up to almost 40%. I’d usually be 3 sessions into CPT or PE—right before really “diving into” the trauma—when patients started to reschedule, cancel, or “ghost” me entirely. Why was this happening? My process to self-reflect, “what could I have done better?” could only take me so far, since my other patients were benefiting from treatment.
Fortunately, some of my patients shared with me why they prematurely ended therapy. Several said that they stopped due to logistical reasons: not having enough time, getting a new job, or not realizing the level of commitment needed until they started. Others said they weren’t ready to confront their trauma (“It’s too much, right now.”), and some even admitted to engaging in avoidance. For patients I didn’t hear from, it’s possible that they didn’t see me, or the treatment, as the “right fit.” Or...maybe something else? Regardless, I felt defeated, and so I consulted the research literature to learn more.
Dropout Rates for CPT and PE
What I found in the research was staggering. Among combat Veterans with PTSD who served in Iraq and Afghanistan, a meta-analysis found that the overall dropout rates for trauma treatments were 36% (Goetter et al., 2015). This number mirrored my own clinical experience! More recently, in a different a meta-analysis of trauma treatments for military and veteran populations, researchers found that dropout rates were 40% for weekly CPT, and 35% for weekly PE (Penix-Smith & Swift, 2025).
These results made me feel validated. I thought, “I wasn’t the problem. The treatment schedule was.” But then, that idea disappointed me—is this really the best we can do? How can we call a treatment “gold-standard” when almost half of patients don’t finish it? Fortunately, there is light in this story. In the same meta-analysis, the researchers found that when CPT and PE were done in rapid care settings (i.e., a few weeks to a month of treatment), the dropout rates plummeted to just 9% and 6%, respectively. Is this for real? Can you actually treat PTSD in just a few weeks? And still have 90% of people complete treatment?
Enter the conversation: "massed delivery" of PTSD treatments.
What is “massed” PTSD treatment?
Massed treatment is when an evidence-based psychotherapy is delivered in 3 sessions or more per week. Given the intensity, this delivery is also called “accelerated” treatment. Massed PTSD treatments are usually done in intensive outpatient or partial hospitalization programs (IOP/PHP), as well as residential settings. However, massed treatment can be adapted into an outpatient setting.
Much of what is known about massed treatment has emerged in the last 10-15 years. As a result, there is no primary model, yet, for how to implement massed CPT and PE. For instance, some intensive care settings will bring in “supplemental” treatments for patients. These could include support via exercise programs, yoga, meditation, or seeing a nutritionist; they may also include helping a patient with other mental health difficulties, such as providing supplemental therapy for depression, anxiety, sleep, or substance use disorders.
Does accelerated CPT and PE work?
The short answer—yes, but research is still emerging.
In multiple randomized clinical trials, massed PE was found to be just as effective as weekly PE for reducing PTSD symptoms at 3-months (Dell et al., 2023; Foa et al., 2018) . Importantly, treatment gains are also similar between massed PE and standard PE after 1-year follow-up (Dell et al., 2023).
There is less research on massed CPT, but initial work shows that it is effective for reducing PTSD symptoms (Baez et al., 2026.; Held et al., 2023) . However, there is a soon-to-be published randomized clinical trial that shows massed CPT is, indeed, as effective as standard CPT in a U.S. military population (Wachen et al., in press). One interesting finding is that CPT can be delivered effectively in 1-week, 2-week, and 3 week formats (Held et al., 2022, 2023).
Lastly, interview research shows that providers really enjoy doing massed PTSD treatments—you have the chance to see a patient make improvements in 2-3 weeks vs. waiting 3-4 months. That said, providers emphasize that the healthcare system needs to provide a reasonable infrastructure for massed treatment to be feasible; this includes protected time for preparation, documentation, and having supportive leadership (Wells et al., 2026).
Who is appropriate for massed treatment?
The inclusion and exclusion criteria are the same as CPT and PE: patients who meet PTSD criteria and have sufficient memory of the traumatic event is appropriate. These treatments are not appropriate for patients with imminent threat of suicidal or homicidal behavior, current and serious self-injurious behavior, current psychosis, or at imminent risk of domestic violence or assault. However, once these conditions or circumstances are addressed, a patient may be appropriate.
Questions to Be Answered
The initial data on massed PTSD therapies are promising. But a few questions remain unanswered before widespread adoption:
- How long are treatment gains maintained?
- How do providers feel about massed compared to standard treatment?
- What are the best ways to implement massed CPT and PE?
- What is the most economical way to implement these treatments?
- How can providers be reimbursed for massed treatment?
- What is the feasibility for community outpatient providers to implement massed treatment?
A Bright Future
Accelerating treatments are...accelerating. There is good reason for patients and providers to be excited about the future. Patients and providers, alike, can now make similar progress in a few weeks, rather than months. If the last decade was focused on innovation PTSD treatments for massed delivery, then I hope the next decade sees the widespread adoption and dissemination of these promising interventions.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.
Andrew Devendorf, Ph.D., is a Military Behavioral Health Psychologist with the Henry M. Jackson Foundation for the Advancement of Military Medicine. He serves as a subject matter expert in suicide prevention for the VA SAFEGUARD project.
References
Baez, L., Huberty, J., Yourell, J., Jewell, C., Lin, E., Kaysen, D., Cutts, L., Noori, S.,
Rosenthal, I., & Chard, K. (n.d.). Effectiveness of massed cognitive processing
therapy for posttraumatic stress disorder: A retrospective analysis. Journal of
Traumatic Stress, n/a(n/a). https://doi.org/10.1002/jts.70045
Dell, L., Sbisa, A. M., Forbes, A., O’Donnell, M., Bryant, R., Hodson, S., Morton, D.,
Battersby, M., Tuerk, P. W., Wallace, D., & Forbes, D. (2023). Effect of massed v.
standard prolonged exposure therapy on PTSD in military personnel and
veterans: A non-inferiority randomised controlled trial. Psychological Medicine,
53(9), 4192–4199. https://doi.org/10.1017/S0033291722000927
Foa, E. B., Chrestman, K. R., & Gilboa-Schechtman, E. (2009). Prolonged Exposure
Therapy for Adolescents with PTSD Emotional Processing of Traumatic
Experiences, Therapist Guide. Oxford University Press, USA.
Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., Mintz, J.,
Young-McCaughan, S., Borah, E. V., Dondanville, K. A., Fina, B. A., Hall-Clark,
B. N., Lichner, T., Litz, B. T., Roache, J., Wright, E. C., Peterson, A. L., & for the
STRONG STAR Consortium. (2018). Effect of Prolonged Exposure Therapy
Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD
Symptom Severity in Military Personnel: A Randomized Clinical Trial. JAMA,
319(4), 354–364. https://doi.org/10.1001/jama.2017.21242
Held, P., Kovacevic, M., Petrey, K., Meade, E. A., Pridgen, S., Montes, M., Werner, B.,
Miller, M. L., Smith, D. L., Kaysen, D., & Karnik, N. S. (2022). Treating
posttraumatic stress disorder at home in a single week using 1-week virtual
massed cognitive processing therapy. Journal of Traumatic Stress, 35(4),
1215–1225. https://doi.org/10.1002/jts.22831
Held, P., Smith, D. L., Pridgen, S., Coleman, J. A., & Klassen, B. J. (2023). More is not
always better: 2 weeks of intensive cognitive processing therapy-based treatment
are noninferior to 3 weeks. Psychological Trauma: Theory, Research, Practice,
and Policy, 15(1), 100–109. https://doi.org/10.1037/tra0001257
Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological
therapies for post-traumatic stress disorder in adults: Systematic review and
meta-analysis. European Journal of Psychotraumatology, 11(1), 1729633.
https://doi.org/10.1080/20008198.2020.1729633
Penix-Smith, E. A., & Swift, J. K. (2025). The protocol matters: A meta-analysis of
psychotherapy dropout from specific PTSD treatment approaches in U.S. service
members and veterans. Psychological Trauma: Theory, Research, Practice, and
Policy. https://doi.org/10.1037/tra0002070
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.
https://doi.org/10.1016/j.cpr.2010.04.007
Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive Processing Therapy for
PTSD: A Comprehensive Manual. Guilford Publications.
Wells, S. Y., Kehle-Forbes, S. M., Shapiro, A., Murray, R. D., Dedert, E. A., Woolson, S.,
Calhoun, P. S., & Jackson, G. L. (2026). Providers’ and administrators’
perspectives of massed posttraumatic stress disorder (PTSD) treatment in
Veterans Affairs (VA) PTSD outpatient clinics. Psychological Services.
https://doi.org/10.1037/ser0001018