Navigating under pressure: psychotherapists' experiences in a randomized controlled trial of posttraumatic stress disorder related to childhood maltreatment.

Objective: Randomized controlled trials (RCTs) are considered essential for establishing the efficacy of psychotherapies. However, these settings present practical challenges and conflicts, which have contributed to a gap between science and practice. To date little is known about how psychotherapists experience participation in RCTs and why they are hesitant to engage, therefore, we aimed to explore these issues.

Method: This qualitative study is nested in a multicenter RCT within the ENHANCE research network, comparing two trauma-focused psychotherapies for adults with posttraumatic stress disorder related to childhood maltreatment (PTSD-CM). Interviews were conducted with study therapists from either cognitive behavioral or psychodynamic backgrounds and were analyzed using critical-constructivist Grounded Theory methodology.

Results: Analysis revealed one core category, centering around the pressure and negative emotions that therapists experienced and their attempts to manage the challenges triggering these feelings. Four clusters contributed to this core category: (1) negotiating tension between study protocol and patients' needs, (2) struggling with short-term treatment-manuals, (3) facing insecurities of deviating from everyday practice, and (4) developing greater trauma competence, given that participation in the study was subjectively experienced as successful.

Conclusion: Results underscore the importance of balancing research requirements with therapeutic flexibility and highlight the need for intensive training, particularly in PTSD-CM contexts.