Enduring intensity for healing: the patient perspective of intensive outpatient treatment for PTSD

ABSTRACT

Background:

Prolonged exposure is widely regarded as a first-line treatment for alleviating symptoms of post-traumatic stress disorder (PTSD); however, it is often associated with high dropout rates and may not always be sufficiently efficacious. Intensified treatment has been suggested as a solution to increase treatment efficacy and reduce dropout rates, but little is known about patients’ preferences for this type of treatment.

Objective:

To investigate patients’ experiences of prolonged exposure delivered in an intensive format (iPE).

Method:

Semi-structured interviews were conducted with 12 participants after completion of iPE.

Results:

Thematic analysis of the data yielded one overarching theme ‘Brutal Yet Worth It,’ accompanied by five subthemes: Building Blocks of Commitment, Strength through collective support, Overcoming challenges of the intensive treatment week, Therapeutic gains of the intensive treatment, and Facilitating and Enabling Treatment Progress. The participants described short-term discomfort and demands, contrasted with the recognition of substantial benefits that extended beyond PTSD symptom reduction. The interplay of individual attributes and experience of social support emerged as crucial factors shaping the experience.

Conclusions:

Participants described the iPE experience as intense and demanding, yet transformative and worthwhile in the interviews. These findings highlight the complex and multifaceted experiences of patients undergoing PE delivered in an intensive format. The findings could offer valuable insights for designing more well-received PTSD treatments, leading to enhancements in the overall quality of intensified treatment approaches.

HIGHLIGHTS

• Patients experienced intensive prolonged exposure (iPE) as emotionally demanding yet highly meaningful, describing the treatment as “brutal yet worth it.”

• Therapeutic gains extended beyond symptom reduction, including personal growth, increased self-awareness, and renewed hope.

• Group support, therapist availability, and the structured format were perceived as critical facilitators of treatment success and sustained engagement.

1. Introduction

Post-traumatic stress disorder (PTSD) inflicts a considerable psychological and medical burden that often becomes chronic when untreated. Clinical guidelines advocate for trauma-focused cognitive–behavioural therapy (CBT-T) such as prolonged exposure (PE) for PTSD as first line treatment (Hamblen et al., 2019). However, the substantial dropout rate from treatment, ranging from 16% to 52% (Imel et al., 2013; Lewis et al., 2020; Varker et al., 2021), is believed to contribute to the modest response rate of approximately 60% in CBT-T (Loerinc et al., 2015). Imel et al. (2013) found a correlation between dropout rates and the number of sessions, suggesting that shorter treatment durations may improve patient retention. Conventional CBT-T unfolds over months with weekly sessions, entailing a large time frame for the possibility of disruptions (Foa et al., 2018). An intensive approach featuring shorter gaps between sessions could potentially mitigate the avoidance of trauma triggers resulting in more rapid symptom relief and minimized disturbances. While evidence supports intensive treatments for improving response, hastening recovery, and reducing dropout rates, the patient experience of this approach remains relatively underexplored (Sciarrino et al., 2020).

Previous studies on weekly delivered PE highlight that treatment is seen as interrupting participants’ daily life and work schedules, especially when employer support is absent. Common factors leading to dropout involve scepticism about PE's efficacy and expectations of quicker symptom improvement. Individuals who discontinue treatment often mention a lack of progress in the initial sessions and express concerns about the emotional challenges of exposure exercises (Hundt et al., 2017). Intensive treatment formats, involving daily or even multiple sessions a day, during a shorter treatment period of one or several weeks, have been found to be appreciated by patients since they reduce avoidance, boost motivation, and result in rapid and meaningful symptom relief. However, taking part in treatment ‘full-time’ has also been found to be exhausting and lead to emotional and physical fatigue, as well as increased anxiety (Sherrill et al., 2022).

Our research group recently conducted a feasibility study on intensified prolonged exposure (iPE), showing feasibility and preliminary effectiveness in a Swedish outpatient psychiatric setting. The current study aims to explore the patient perspective of iPE, given the relatively underexplored nature of the patient experience of the treatment format. The findings have the potential to shape upcoming implementation approaches and enhance treatment acceptability of iPE.

2. Method

This study utilized a qualitative design to explore participants’ experiences with intensive Prolonged Exposure (iPE) therapy. Semi-structured interviews (N = 12) were conducted and analysed using reflexive thematic analysis, following the framework outlined by Clarke and Braun (2021). The study adhered to the Consolidated Criteria for Reporting Qualitative Research guidelines to ensure rigour and transparency in the qualitative research process (Tong et al., 2007). The study obtained ethical approval from the National Ethical Review Board in Sweden (ID: 2021-06004-01). The study was conducted as part of an uncontrolled feasibility study on iPE (N = 33) (in prep).

2.1. Participants

The participants in the main trial (N = 33) were recruited through a publicly funded outpatient psychiatric unit in Sweden. Inclusion criteria for the study encompassed meeting the criteria for PTSD, as per the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, evaluated by the Clinician Administered PTSD Scale version 5 (Weathers et al., 2018), being aged 18 or above, being fluent in Swedish, and providing signed informed consent. Additionally, participants with stable psychotropic medication doses for a minimum of 4 weeks prior to study entry were eligible. Exclusion criteria consisted of having other serious comorbidities as the primary concern (such as ongoing substance dependence, untreated bipolar disorder, psychotic symptoms, severe depression, or high suicidal risk). Participants engaging in ongoing trauma-focused psychological treatment or facing ongoing trauma-related threats, like living with a violent spouse, were also excluded. Following the participants’ completion of iPE by the first two cohorts of participants in the study, either author SF or MP initiated phone communication to schedule interviews aimed at gathering insights into the patient perspective of iPE. One participant opted not to participate in the interviews, two were unreachable for scheduling, and four did not attend their scheduled interviews. The number of interviews was determined based on the principle of information power, meaning that data collection was concluded when we assessed that the material contained sufficient breadth and depth to answer the research question (Malterud et al., 2016). Given our focused research question, the relatively homogeneous background of the participants, and the richness of the interview data, information power was deemed sufficient at twelve interviews.

2.2. Treatment

The treatment is based on the original treatment protocol for prolonged exposure (Foa et al., 2019) but with the exception that instead of weekly sessions, the treatment is delivered over five working days, Monday to Friday, with scheduled treatment activities lasting approximately eight hours each day at the recruitment site. This concentrated treatment period is followed by three 60-minute individual booster sessions spaced two, four, and eight weeks apart. The entire treatment period spans 9 weeks.

During the intensive treatment phase, the schedule encompasses nine individual 60-minute sessions, concentrating on imaginal exposure and emotional and cognitive processing of the traumatic event. Additionally, five group sessions, lasting 120 min each, offer general information, treatment rationales, and psychoeducation about trauma and PTSD through lectures and emphasizes practical work with in vivo exposure exercises. Group sessions typically consist of around ten participants and are facilitated by two therapists, with the specific therapists rotating daily. To maintain a supportive and focused environment, participants are provided with clear guidelines to avoid sharing personal trauma details during these sessions. Twice daily, participants have designated individual work time to focus on their chosen tasks. Though two therapists are available for support during these periods, participants largely work independently on imaginal and in vivo exposure. Throughout the intensive treatment week, regular short breaks and a more extended lunch break (including free lunch) are provided. No homework is given.

2.3. Procedure

The interviews were conducted between February and May 2023 and were scheduled to occur shortly after the completion of treatment. The duration of the interviews ranged from 45 to 80 min, with an average length of 55.8 min (SD = 14.8). Two interviews were conducted in-person at the recruitment site, while the remaining ten interviews were carried out over the telephone by the authors SF or MP none of whom were involved in the main trial and had no interaction with the participants before or after the interview. A transcription key was established before transcription, to maintain consistent interpretation and reporting of non-verbal expressions during the interviews. Audio recordings of the interviews were transcribed verbatim by the conducting author and then reviewed by the second author for accuracy. The transcripts were not returned to the informants for comments or corrections.

3. Measures

The semi-structured interview guide, designed to explore participants’ experiences with iPE treatment, was specifically developed for this study by the first author (MB). It was informed by clinical experience gained from the main trial and other similar interview studies conducted in treatment trials (Bragesjö et al., 2021, 2024). The guide underwent three iterative revisions using an inductive approach, incorporating feedback from practice interviews conducted as role plays by authors SF and MP. These practice sessions were instrumental in refining both the language and the sequencing of questions.

The interview guide consisted of open-ended questions structured around seven key areas. The first area explored participants’ general impressions and engagement with the intervention, such as their overall experience and level of engagement during the treatment. The second area focused on expectations and outcomes, addressing participants’ pre-treatment expectations and whether these were met. The third area examined practical aspects of the treatment, including the schedule, structure, and adequacy of resources. The fourth area investigated experiences with specific treatment components, such as psychoeducation, in vivo exposure, and imaginal exposure, and their perceived value.

The fifth area addressed social aspects of the intervention, exploring participants’ experiences working with therapists and in group sessions. The sixth area focused on perceived effects of the treatment, both positive and negative, and how these were experienced. The final area sought feedback and recommendations for improvement, including suggestions for changes to the treatment format and elements participants felt were important to retain.

4. Data analysis

Reflexive thematic analysis was chosen to analyse the data, which is an appropriate methodology for gaining profound insights into human behaviour, therapeutic interactions, and illness behaviours (Johnson & Waterfield, 2004). The framework outlined in Clarke and Braun (2021) was followed using six phases of analysis: (1) familiarizing with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining themes, and (6) producing a report. The study employed a realist framework, aiming to capture and present the parents’ experiences and perceptions as they were conveyed during the interviews.

The analysis was conducted collaboratively by multiple researchers, each bringing their own perspectives to enrich the interpretation of the data. Following the interviews, the two authors SF and MP read all the transcripts and engaged in reflexive discussions to explore how their perspectives influenced theme development. They individually marked interview transcripts, not to reach agreement, but to deepen the analytic process by considering different interpretations. These insights were discussed in detail and refined through iterative engagement with the data, with MB and RE contributing further interpretative layers. All authors approved the results. Informants did not provide feedback on the final thematic model. Themes were labelled and illustrated with quotes from the transcripts. To protect participants’ anonymity, all quoted individuals were assigned pseudonyms in the manuscript.

4.1. Reflexivity

Reflexivity is a cornerstone of qualitative research, recognizing that researchers inevitably bring their own perspectives, experiences, and assumptions into the research process (Braun & Clarke, 2023). Rather than aiming for detachment or objectivity, we acknowledge that researcher subjectivity is integral to meaning-making and has shaped the design, data collection, and interpretation of this study. This section outlines the research team’s backgrounds, our engagement with reflexivity, and the steps taken to enhance transparency in the analytic process.

The research team consists of two clinical psychologists, a specialist nurse, and a psychiatrist, all with expertise in PTSD, OCD, trauma-focused treatments, and qualitative methodologies, as well as two master's students in psychology. The first author, MB, is a clinical psychologist, a certified trainer in PE, and the developer of the iPE treatment format. With extensive experience as a PE therapist, MB has an in-depth understanding of the treatment model, which inevitably influenced both the development of the interview guide and the interpretation of participant experiences. While this expertise provided valuable clinical insight, it also required ongoing reflexive engagement to remain open to participants’ perspectives, including potential critiques of the treatment format. The two interviewers, SF and MP, were master's students in psychology and had no prior therapeutic engagement with the participants. Their relative distance from the treatment context may have facilitated a more neutral stance during the interviews, allowing them to explore participant experiences without the same degree of preconception. Author RE is an experienced qualitative researcher with prior expertise in reflexive thematic analysis. RE played a key role in critically reviewing the coding and theme development, encouraging a broader interpretative lens and helping to ensure that multiple perspectives were considered in the analysis. This iterative process of discussion and reflection contributed to the study’s depth, preventing any single perspective from dominating the findings.

To further enhance transparency, we engaged in ongoing reflexive discussions throughout the analytic process, documenting our reflections on how our backgrounds and assumptions influenced theme development. By explicitly considering our positions in relation to the data, we sought to acknowledge and navigate our subjectivity rather than eliminate it. When determining the number of interviews, we applied the principle of information power, aiming to collect sufficient data to gain a deep understanding of participants’ experiences without conducting more interviews than necessary (Malterud et al., 2016). Through continuous reflections within the research team, we identified when the material had achieved adequate variation and depth to address the study’s objectives.

5. Results

Twelve participants, aged 21–56 years (M = 38.3, SD = 11.3), were interviewed for this study. The majority of participants were female (83%), and the most frequently reported index trauma was exposure to sexual violence, experienced by 75% of the sample (Table 1).

Table 1.

Clinical characteristics and sociodemographic of the sample (N = 12).

Gender, n (%)	Women	10 (83)
	Men	2 (17)
Age	Mean (SD)	38 (11)
	Range	?
Highest education, n (%)	College/university	10 (33)
	High school	15 (53)
Occupational status, n (%)	Working full time	6 (50)
	On sick leave	4 (33)
	Unemployed	2 (17)
Type of trauma, n (%)	Sexual violence	9 (75)
	Interpersonal violence	2 ()
	Physical assault	1 (17)

5.1. Brutal yet worth it

The thematic analysis revealed one overarching theme, ‘Brutal Yet Worth It,’ accompanied by five subthemes: Building Blocks of Commitment, Strength through collective support, Overcoming challenges of the intensive treatment week, Therapeutic gains of the intensive treatment, and Facilitating and Enabling Treatment Progress. These themes capture the essence of participants’ experiences, linking the key aspects of the data. Participants consistently described iPE as an emotionally intense and demanding process, requiring them to confront challenging emotions and memories. Despite these difficulties, they emphasized that the experience was ultimately rewarding, offering significant therapeutic benefits. Many participants highlighted the substantial commitment and effort needed to engage fully with the treatment, noting that this dedication was key to achieving meaningful progress. The rewards extended beyond symptom reduction, encompassing personal growth, increased self-awareness, and a renewed sense of hope for the future. This juxtaposition of emotional difficulty and transformative outcomes underscored the unique nature of the intensive treatment format. The themes and subthemes are detailed below with illustrative quotes from individual informants, providing insights into the multifaceted nature of their experiences. An overview of the hierarchical structure of themes and subthemes is presented in Figure 1.

Figure 1.

An overview of the hierarchical structure of themes and subthemes.

5.2. Building blocks of commitment

Participants’ own unique experiences with iPE were significantly shaped by their existing knowledge, attitudes, and available resources within and outside themselves. The impact of prior knowledge influenced perspectives on psychoeducational content, the requirement for guidance in trauma processing, staying committed and how to handle the emotional burden associated with treatment.

Linda: I didn't use the binder with psychoeducational material much, but I noticed that many others found it helpful to read. I think it depends on how much you already know. I was fairly well-informed before the treatment started […]. So, I had a fairly good idea of what to expect right from the beginning.

Participants brought very different expectations regarding the treatment's demands and anticipated results. While some described that they were ready for a demanding week, many felt surprised by the actual challenge. Some expected quick improvement, while others saw the intensive treatment week as part of a larger effort for longer-term benefits.

Josefin: I mean, my expectations, you know, they were like, thinking it'd be this quick fix that just sorts out everything, but I get it, things like this don't just happen overnight. Going for a treatment week, I realized, doesn't magically fix everything.

Participants identified several individual barriers during the treatment week that influenced their readiness for the treatment. For example, social challenges arising from comorbidities hindered group participation and the ability to comprehend instructions and information. Some participants, although reporting to feel confidence in the treatment format, voiced the need to address more index traumas than the intensive treatment week allows.

Emelie: It'd be nice if they don't dwell too much on a single memory, but rather set the tone from the start that, ‘Yes, I'm willing to discuss these memories,’ without making it seem like it's only one memory. People have been through absolute hell for years, you know. It's not just about one memory causing all this.

Sustaining commitment throughout the week proved challenging, particularly as the workload and emotional burden intensified. Engagement levels were reported to vary, with some participants experiencing a gradual increase or decrease in involvement as the week progressed. These fluctuations were described across the entire intensive treatment week.

Josefin: I was fully committed, like a hundred percent all in, because something like this, you can't just do halfway. I mean, why even bother with treatment if you're not going to give it your all?[… ] You're delving into stuff you've buried deep down, so it's a lot to handle. There were days when I thought, ‘Nope, can't handle it anymore, I'm done, can't do this.’ But still, you know, you kind of pulled yourself together and just went for it, like, ‘Here we go.’

Some found it hard to catch up on missed studies after the intensive treatment, while others saw no major impact. For participants with work employment, sick leave and employer flexibility were described as vital. Limited social support and inability to get help with daily tasks or pet care were seen as challenges. Those with a strong network highlighted that as part of their success in treatment.

Wilma: I stayed with a relative the whole week. I told them, ‘Hey, I need your support because I'm going through this really intense treatment.’ Honestly, if I had been alone, it would've been really tough. I think I might have struggled a lot because it's just so demanding.

5.3. Strength through collective support

Participants described that the support from both the group and therapists facilitated the treatment effect and made them feel secure. The group format was well-received, offering benefits like community and support. Yet, for some, the group format posed social challenges. Participants emphasized therapist support as crucial during the intensive treatment week, valuing the presence of multiple therapists for accessibility and increased security.

Annika: It was incredibly nice to have this staff of psychologists. We almost kind of laughed when they started lining up, this row of psychologists. But I just thought, ‘Oh, so many. These will go well. This will go well.’. It wouldn't have worked otherwise. It had not been possible to keep everything together. When you started to feel that you were falling apart, there was always someone there who asked, ‘Would you like to talk a bit?’.

Two participants cited lack of security in the interactions with their therapist as a barrier. One participant noted that gender influenced safety due to the trauma involving sexual violence. Another struggled with a sudden change of therapist, leading to disappointment and uncertainty.

Elin: She was kind, there was nothing wrong with her, but I didn't feel safe. It was just hard that it became a completely different person, I felt that we didn't really get along there.

Opening up about their trauma to the therapist during the individual sessions was identified by several participants as a central component of their intensive treatment week.

Emelie: I can tell you, I was really relieved. It was a lot for me, and it felt so good to finally open up to my therapist about that memory I needed to discuss. It's like this huge weight lifted off my chest. You see, not everyone has someone they can share these emotions with. Some people go through their trauma all by themselves and it's really tough. But having someone there to listen and understand, it made a huge difference for me.

5.4. Overcoming challenges of the intensive treatment week

The intensive treatment week was consistently depicted as intense, demanding, and exhausting, yet participants recognized it as a directed effort. Many expressed a sense of accomplishment for their invested efforts and the challenges they overcame during the week. Participants shared a positive view of the intensive format, believing its concentration contributed to its effectiveness, with the frequent pace enhancing emotional processing compared to spaced-out sessions. The contrary view, that the intensive format made it overwhelming and excessively intense, was also described.

Jenny: The advantage is that you can't distance yourself. You start in the morning, continue with your individual therapist, and even when you want to pull away, you're right back there. You can't really distance yourself, which I actually found helpful. Normally, I'm good at that, at switching off. But here, there's no chance to do that, and I think that's what I needed. To get closer to this. So, I think that was a strong point of this treatment.

Furthermore, several participants acknowledged that while they personally find the intensive format satisfying, they recognized that it may not be suitable for everyone.

Wilma: I'm really the type of person who is like this ‘yes, now we bite the sour apple’, or ‘pull the band-aid off’ or whatever you want to say. I honestly believe it's better to just go along with it, or it varies depending on the kind of person you are. For some people this might become overly intense, making it challenging if they require time to process between sessions. However, I personally think that's a positive aspect, and I think the risk of dropping out is less and so.

The workload during the intensive treatment week was perceived as heavy by most, but attitudes towards the pace of treatment varied. Some preferred it to have been even faster, while others found it overwhelming. Stress about pace was linked to fatigue that affected the participants’ effort.

Fredrik: From my perspective, I didn't think much about the pace. I thought more about the actual experience of it – that I showed up, that I was on time, that I made these meetings for me. Time passed so quickly that you were shocked. You were here in the morning and then it was morning and afternoon. For me, it felt like when I came here, time went by so fast.

Participants consistently depicted the intensive treatment week as emotionally draining and challenging. All participants described facing unpleasant emotions, like anxiety and low mood. Imaginal exposure was consistently mentioned as the most challenging aspect although the participants could see the benefits in the long run.

Annika: It was absolutely the toughest thing I've done in my entire life. It was so incredibly heavy the first few days that I felt ‘I don't know if I can handle this’.

Additionally, certain participants emphasized that during the intensive treatment week, they confronted distressing realizations about the personal significance of living with PTSD, for example when working with in vivo exposure hierarchies.

Jenny: I thought that creating the list [exposure hierarchy] was hard. It was hard because you realize what you are not doing […] what you want to do but don't. To see in black and white how one's illness limits one.

Participants displayed diverse coping strategies during the intensive treatment week, each handling the workload and emotional weight differently. Some sought family support, while others prioritized exercise or minimized daily demands. The extent of practical consequences varied among participants. Some participants described that they were able to maintain routines outside treatment, while others struggled to continue regular life during the intensive week. Those feeling that the rest of their life was on pause attributed it to workload, emotional strain, and side effects, limiting time for exercise, chores, and social activities.

Josefin: I can say that I had a pile of dishes for about four days and I'm still a person who is quite pedantic and who likes to keep things clean and tidy at home. But then it really happened that I … On Monday when I got home – I kind of just lay in bed and was completely, I mean COMPLETELY, exhausted. I don't even know how to explain, but you really were exhausted.

5.5. Therapeutic gains of the intensive treatment

Participants described an overall improvement during the treatment period, both in reduction om symptoms of PTSD and on more general level, a sense of healing and personal growth.

Wilma: [Going into treatment] is not something I would wish on my worst enemy, but I also understand how beneficial it was. It was a challenging treatment, but it made a difference. It was worth it. The first day I really hated it, but by the second day, it got easier, and even more so on the third day. I noticed that ‘shit, my symptoms are actually improving,’ which was amazing. I'm sorry, I'm getting a bit emotional … It was truly incredible. I never thought I could overcome this, but the treatment helped. It was intense but valuable. If you asked me, yes, I would go through it all again.

Participants described that they gained new insight, stemming from newly acquired knowledge in the treatment material, exposure exercises and interactions with fellow patients during the intensive week that helped them gain more self-compassion about themselves. Another significant gain, underscored as a crucial effect of the treatment, by participants is the presence of hope – hope that healing is attainable and the belief that recovery is possible.

Wilma: Towards the end, I noticed that my symptoms started to decrease. (…) I don't have as many nightmares and I feel that it wasn't my fault, what happened. I have much less guilt and shame. Then it's still hard, but that shame and guilt part, that it's gone is big for me and I feel a little more hope for the future.

Participants also shared an increased sense of freedom, ability to engage in activities that were once perceived as triggering and avoided, such as using public transportation during busy hours or shopping in crowded stores.

Fredrik: I feel more active now. After the treatment on Friday, we wrapped up around half past five, and for me, that's like late afternoon – quite exhausting. I hopped on the bus and started feeling the trauma hitting me. But when I went to the store and did some shopping at *name of grocery store*, it was during the time when most folks were done with work, so the store was pretty busy. No issues, I'd say.

5.6. Facilitating and enabling treatment progress

Adapting treatment to address each person's psychiatric complexity and unique needs was something participants stressed as vital. Some participants who identified themselves as having complex trauma or complex PTSD expressed the need for the inclusion of more psychoeducative material on that and asked for more time to process repeated or prolonged traumas, suggesting increased flexibility in the number of follow-up session. Participants with other types of comorbidities and functional impairments similarly emphasized the necessity for enhanced flexibility and tailored consideration of individual circumstances.

Johan: I think there should be some sort of checkpoint, especially if you need a format tailored just for you. Like, they could take into account stuff like my ADHD. When things speed up or if there are multiple things to follow or tricky questions, I tend to lose track.

In general, participants express high levels of satisfaction with the treatment facilities, planning, and materials. However, they also voiced that having access to a designated space to rest, if required, would have been helpful. Some also communicated that the treatment schedule could have been more flexible and based on individual needs, particularly in terms of adjusting the balance between individual sessions and allocated time for personal work or in vivo exposures.

Emelie: In the mornings, we had an hour with our therapist. Honestly, I think that time should be extended. [… ] I mean, that's the whole point of being there, right? To receive guidance from others, process things together, and maybe gain some new perspectives.

Recognizing the treatment's demands, participants suggested taking measures to increase the energy level during the intensive week. Being relieved of the need to plan for lunch was described as a factor that conserved energy. Recommendations also included integrating exercise or active breaks.

Emelie: I think it should be offered at the introduction, that those who want physical activity during the week can have it. And that you can go to physical activity in a group or, for example, swim, go to the gym or go for a walk. That you include it, so that it's not the same schedule every day, i.e. ‘Now it's exposure and now it's exposure again and then it's exposure and exposure again’. That you vary it a little more.

Participants express the need for more structured guidance during group sessions for in vivo exposure and help in planning individual-linked exposures exercises.

Wilma: Definitely one of the most difficult exercises was creating effective the in vivo list within such a short period. I believe another person also brought this up – having a chance to go over these [in vivo] exposure exercises with your individual therapist before the in vivo sessions would have been really useful. Because grasping how to implement them during the exercises was pretty hard. It kind of felt challenging to translate theory into practice. So having some guidance beforehand would have been really valuable.

When engaging in group activities, explicit guidelines were established, such as refraining from discussing specific details about one's own trauma. Participants found this clarity valuable, with some viewing these conduct rules as essential for their participation and feeling secure within the group setting.

Anette: [The rules of conduct] were the good thing. You didn't have to talk about things, it was great. Otherwise I wouldn't be able to participate. I wouldn't. As I said before, I find it difficult to be in a group and that I can't handle talking about what happened in a group. At least I made it now.

6. Discussion

The aim of this study was to explore how patients experience an intensified treatment format of PE (iPE). Participants described benefits that are largely consistent with the idea behind intensive treatment. In line with the observations made by Sherrill et al. (2022) the participants in our study appreciated the intensive nature of iPE, as its structure limits distractions and avoidance, and swift progress enhances motivation and engagement and offers a more rapid symptom relief. This positive perception also resonates well with Sherrill et al. (2022) observations about the appreciation of intensive treatment for delivering meaningful outcomes over a shorter period. Notably, participants expressed varying attitudes toward the treatment's pace, indicating the importance of individualized consideration in managing treatment intensity.

Conversely, participants highlighted the emotional and physical effort linked to iPE. This observation corresponds well with earlier studies that emphasized the demanding nature of trauma-focused interventions (Bragesjö et al., 2021; Hundt et al., 2017). Additionally, this consistency aligns with Sherrill et al. (2022) findings, which noted that prioritizing treatment full time can lead to exhaustion, emotional fatigue, and increased anxiety. Participants highlighted imaginal exposure as the most emotionally taxing aspect of the treatment. However, the heightened motivation and engagement fostered by the intensive format appeared to bolster their dedication to confronting their traumatic memories. This collective experience emphasizes the delicate equilibrium between the therapeutic advantages and the difficulties intrinsic to intensive treatment. It underscores the significance of tailoring approaches to everyone’s needs to optimize treatment outcomes while effectively managing its inherent demands. Social support was described as playing a central role in reducing the burden and enhancing the benefits of intensive treatment. This mirrors earlier studies showing that both support systems and patient dedication is important in the efficacy of exposure-based treatments (Hundt et al., 2017).

This study's strength lies in its use of diverse researcher perspectives throughout the analysis. Rather than seeking consensus or reliability, the involvement of multiple researchers in data collection and analysis allowed for a richer interpretative process, ensuring that various perspectives on the data were explored. Discussions were documented in a logbook to facilitate transparency in how themes were generated and refined, aligning with a reflexive thematic analysis approach. Rather than treating researcher triangulation as a means to ensure ‘accuracy,’ our approach aligned with the goal of capturing diverse perspectives within the research team and deepening engagement with the data. Participants were also given a presentation of the results and had the opportunity to provide feedback, which was considered in the analytic process. The material was revisited after final themes and subthemes were defined. To mitigate potential recall bias, interviews were conducted near the completion of the treatment. The interviews followed the sequence of treatment completion, utilizing a convenience sampling method, which may be seen as a limitation. The limited rapport between interviewers and participants can be seen as beneficial, as a close researcher-respondent relationship could introduce bias by prompting socially desirable responses and tainting the analysis with researcher preconceptions. However, it's noteworthy that the first author MB contributed to the final theme compilation, and due to her significant clinical background in PE, there could be a possibility of her pre-existing perspectives influencing the results. MB also developed the interview guide, which may have influenced the framing of questions. Additionally, the study did not incorporate reflexive processes to systematically identify and address potential biases introduced by the interviewers or coders, aside from verbal discussions among the coders during the analysis. A key consideration in qualitative research is the role of researcher subjectivity in shaping the findings. Rather than striving for objectivity or eliminating ‘bias,’ we recognize that qualitative research is interpretative, influenced by the researchers’ theoretical perspectives, prior experiences, and assumptions. To enhance transparency, we have included a dedicated Reflexivity section, outlining the research team’s backgrounds and how reflexivity was incorporated into the study.

In conclusion, this study explored patients’ experiences of completing iPE, showing a multifaceted view of a significant workload, emotional strain and a robust support in the healing process. The intensity of imaginal exposure stood out as particularly challenging, yet the heightened motivation fostered by the intensive format supported commitment, and the intensity limited avoidance, and yielded growth beyond symptom relief.

Funding Statement

This study was supported by grants at Karolinska University Hospital Huddinge, Psykiatri Sydväst. The funding body had no influence on the study design, implementation, data analysis, or interpretation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors upon request given that the request comply with Swedish and EU laws regulating protection of identifiable data.

Ethical statement

The study obtained ethical approval from the National Ethical Review Board in Sweden (ID: 2021-06004-01). The study followed the principles of the Helsinki Declaration. Participants did not receive any compensation for their participation.

Patient consent statement

All participants signed informed consent before enrollment in the study.

Clinical trial registration

Before enrolling participants, the trial was registered on ClinicalTrials.gov on 22nd December 2021 (registration ID: NCT05207462).