A review of Vogt, Kumar & Lee’s article ‘Examining Functioning and Wellbeing Outcomes in PTSD Outcome Research. PTSD Research Quarterly 34(3)

CPT is a treatment for PTSD and as such, the PCL-5 is the primary outcome measure. Clinicians also frequently include a measure of depression to monitor improvements in these symptoms, as whilst CPT does not directly target depression, for many participants, clinically significant improvements are noted. 

Clients frequently subjectively report feeling lighter, doing more and increasing their participation in activities of daily living post treatment. However, this is not routinely objectively measured.  

It is important to consider the focus of functional impairment and wellbeing measures. By definition, the former tends to limit attention to the negative end of the spectrum from very to not at all impaired, whereas wellbeing measures mostly capture the broader range of experience from poor to excellent. However, the term wellbeing is used very broadly and can include general measures of overall life circumstances such as happiness/positive experiences, together with domain-specific items such as health, social, financial and vocational options. The authors argue that it is important to consider both overall and domain-specific aspects when evaluating wellbeing.  

When considering wellbeing outcomes in the PTSD literature, the majority is provided via veteran studies. Much of this research focused on the functional impairment associated with PTSD with findings revealing negative implications of PTSD for multiple aspects of functioning and well-being. This highlights the need to evaluate not only PTSD symptom severity but also whether improvement in or return to premorbid levels of functioning is achieved post treatment. This is also pertinent when considering motivation and engagement to undertake treatment, as many participants report improvements in broader functioning and wellbeing are equally or even more clinically meaningful to them than symptom reduction. These outcomes are related however, as symptom reduction is seen as a requirement to undertake work functions or with regard to improving their relationships (Benfer & Litz, 2023; Hinton, M et al., 2020; Kearney & Simpson 2015).  

Whilst there is limited research into the impact of PTSD treatment on these outcomes, initial evidence indicates that treatment for PTSD does lead to improvements in functional outcomes. These effects can be more modest than symptom reduction and tend to occur in the second half of treatment following symptom decline and are particularly salient where clients no longer meet diagnostic criteria for PTSD (Benfer & Litz 2023; Bonfils et al., 2022). 

It may also be useful to consider these factors when considering the timing and engagement of PTSD treatment. Where individuals have a high personal or family load, meeting basic needs may take precedence over accessing and participating in PTSD treatment. Additionally, recent studies provide some preliminary evidence to support the utility of assessing wellbeing. Fivecoat et al., (2023) report that those with social support may feel more able and confident to undertake treatment. Radstaak et al., (2022) indicated that individuals who reported higher levels of emotional, social and psychological wellbeing at baseline showed greater benefit from PTSD treatment.  

Recent Australian studies have also begun to incorporate functional outcome measures.  Both a South Australian doctoral randomised controlled trial providing CPT for PTSD (Elizabeth, 2020) and a Victorian public mental health service implementing CPT for PTSD (Casey et al., 2022) utilised the ORS (Outcome Rating Scale) (Miller & Duncan 2000) & SRS (Session Rating Scale) (Johnson et al., 2000) to consider patient experience of PTSD treatment and functional outcomes. The ORS is a commonly used measure of a client’s adjustment that includes a continuum on the domains of an individual’s personal, relationship, social and overall wellbeing with higher scores indicating better adjustment. In keeping with other preliminary research reporting functional outcomes, both these studies observed significant increases in ORS scores relative to pre-treatment following CPT.

When participating in CPT, many clients and clinicians report the significance of the initial and final Impact Statement as a core and enriching part of the treatment process. The impact statement is a 1-2 page written piece completed as a homework assignment by the client after Session 1 and again prior to Session 12. It talks about the impact the trauma has had on the individual’s life in terms of their sense of self, others and the world considering the key themes of safety, trust, power and control, esteem and intimacy.  

It is noteworthy to consider that final impact statement commonly encapsulates the meaning the client attaches to the changes achieved throughout treatment. Much of the time this is related to changes in how they see themselves, relationships with others and their sense of safety in the world together with their improved ability to relate and function within it. This is a moving and private written statement but could perhaps inform consideration of how to capture these functional and wellbeing outcomes objectively as a part of treatment evaluation.  

References 

Benfer, N., Litz, B.T. (2023). Assessing and addressing functioning and quality of life in PTSD. Current Treatment Options in Psychiatry 10, 1–20. doi:10.1007/s40501-023-00284-8 

Bonfils, K. A., Tennity, C. L., Congedo, B. A., Dolowich, B. A., Hammer, L. A., Haas, G. L. (2022). Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis. Journal of Anxiety Disorders, 89, 102576. doi:10.1016/j.janxdis.2022.102576 

Casey.M., Yates.K., Tulchinsky.M., Zheng,A., Perera,D., Miller,M. & Nixon, R.D.V. (2022) Posttraumtic stress isorder and service utilisation outcomes following delivery of Cognitive Processing Therapy in a community mental health setting.  Clinical Psychologist, DOI: 10.1080/13284207.2022.2128642 

Elizabeth, M. (2020) The Effectiveness of combining Cognitive Processing Therapy with a Case Formulation Approach in the Treatment of Posttraumatic Stress Disorder – A Randomised Controlled Trial.  A thesis submitted to Flinders Univerwith in partial fulfilment of the requirements for the degree of Doctor of Philosophy (Clinical Psychology), College of Education, Psychology and Social Work.

Fivecoat, H. C., Lookatch, S. J., Mavandadi, S., McKay, J. R., & Sayers, S. L. (2023). Social factors predict treatment engagement in veterans with PTSD or SUD. The Journal of Behavioral Health Services & Research, 50(3), 286–300. doi:10.1007/s11414-022-09823-2 

Gallagher, M. W., Phillips, C. A., D’Souza, J., Richardson, A., Long, L. J., Boswell, J. F., Farchione, T. J., & Barlow, D. H. (2020). Trajectories of change in well-being during cognitive behavioral therapies for anxiety disorders: Quantifying the impact and covariation with improvements in anxiety. Psychotherapy, 57(3), 379–390. doi:10.1037/pst0000283 

Hinton,M., O’Donnell, M., Cowlishaw, S., Kartal, Z., Metcalf, O., Varker,T., McFarlane, A.C., Hopwood, M., Bryant, M.A., Forbes,D., Howard,A., Lau,W., Cooper, J & Phelps, A.J. (2020) Defining PTSD recovery: Benchmarking symptom change against wellbeing indicators (2021) Stress & Health, 37(3), 547-556.

Kearney, D. J., Simpson, T. L. (2015). Broadening the approach to posttraumatic stress disorder and the consequences of trauma. JAMA, 314(5), 453–455. doi:10.1001/jama.2015.7522

Radstaak, M., Hüning, L., Lamers, S., Bohlmeijer, E. T. (2022). Examining well-being in posttraumatic stress disorder treatment: An explorative study. Journal of Traumatic Stress, 35(3), 914–925. doi:10.1002/jts.22798 

Vogt, D., Kumar,S.A., Lee,L.O (2023) Examining Functioning and Wellbeing Outcomes in PTSD Treatment Outcome Research. PTSD Research Quarterly; 34(3)  

Recognition of the links between PTSD and chronic pain have been well established. The complex mechanisms and factors which predispose and perpetuate these inter-related conditions continue to be investigated, however a shared vulnerability, mutual maintenance and the role of avoidance common to both appear to offer explanatory models (Murphy et al., 2022). In clinical settings, identification of patients who meet diagnosis for both chronic pain and PTSD is a priority. Optimal treatment pathways remain a clinical challenge requiring further research.  

Prevalence

Prevalence statistics amongst veterans are more readily available. Among those with PTSD, Murphy et al., (2022) report an estimated 25-80% may also experience chronic pain, together with higher levels of pain intensity, catastrophising, disability and health care utilisation. For those with chronic pain as a primary diagnosis 9% experience comorbid PTSD, increasing to 20% for those with chronic widespread pain (Murphy et al., 2022). Prevalence information for individuals in primary care or pain clinics is more difficult to ascertain as PTSD prevalence data is not routinely collected. A recent quality initiative to document prior trauma exposure was undertaken at a Victorian multidisciplinary pain clinic. Patients were not directly asked about their trauma histories, but any reference to traumatic events was noted during the multidisciplinary assessment on a trauma events checklist. Up to 35% of presenting patients had PTSD, with an even greater number referring to previous traumatic events (Lydall-Smith et al., 2020). Given the method of data collection, this is likely to be an underestimation.

Theories

Murphy et al., (2022) proffer three possible theoretical contributions to understanding the co-occurrence of PTSD and persistent pain. The first is the shared vulnerability model which suggests that anxiety sensitivity and a fear response to physiological sensations predisposes to both conditions. There is also some support for a potential role of central sensitisation as an underlying mechanism of shared vulnerability. Central sensitisation is an amplification of neural signalling in the central nervous system. It is noteworthy that one potential contributor to developing central sensitisation is childhood adversity, which is also common to the development of PTSD. Importantly, it is the impact of the trauma that is related in the development of chronic pain. In Cognitive Processing Therapy (CPT), the impact of the trauma also holds clinical significance.  Further complicating this process are the shared neurobiological factors that underlie chronic pain and PTSD and are related to mediating emotional distress and physiological threat. There is increasing research interest into the longer term mental and physical health impacts of Adverse Childhood Events, which shape the development of both physiological and emotional responses to stress (Finlay et al., 2022).

The mutual maintenance model considers the ways in which both conditions perpetuate each other.  Similarities in the way patients with both conditions appraise and attend to threatening and painful stimuli, are sensitive to anxiety and tend to relate pain as a reminder of trauma together results in the adoption of avoidance to minimise both pain and trauma symptoms. This links strongly to fear-avoidance models where hypervigilance, fear and behavioural avoidance are magnified, with increased distress, secondary deconditioning and decreased functioning. For example, patients with persistent pain have heightened psychophysiological responses such as heart rate and muscle tension to both trauma-related and environmental stimuli.  Liedl & Knaevelsrud (2008) report that those who experienced a trauma with physical injury were eight times more likely to develop PTSD. In addition, cognitive appraisal of both the trauma and the experience of chronic pain play a crucial role in the severity and maintenance of both conditions, particularly where avoidance is a mutual coping strategy.

Addressing hypervigilance and safety behaviours is also a shared requirement. Beliefs regarding safety following a trauma result in an elevated state of arousal and attempts to minimise any further occurrence. Similarly, pain patients also exhibit heightened arousal states and behaviours such as body scanning contribute to an increased awareness of any somatic irregularity.

Treatment

Exposure strategies common to PTSD treatment models target the avoidance by assisting patients to process their traumatic and feared experiences so they are able to reinterpret the situation and see it as part of their past. Similarly, exposure strategies are also helpful in treating or managing persistent pain where patients are encouraged to engage in physical activities previously avoided due to the fear of activating more pain or re-injury. This is achieved by allowing them to gradually focus and cope with uncomfortable physiological sensations and reduce fear avoidance beliefs. Given these overlapping symptom profiles, it is essential that therapy initially comprises psychoeducation regarding the development and maintenance of PTSD and chronic pain. Following this, several treatment modalities have been highlighted by Murphy and colleagues (2022).

The first and most common is the sequential model (Angelakis et al., 2020) where the Pain and PTSD conditions are addressed separately and in a linear fashion. This has been demonstrated with other comorbidities such as depression, eating disorders and substance use disorders. Murphy et al, (2022) suggest there is limited evidence advising which condition to prioritise, whereas Angelakis indicated a benefit in addressing PTSD prior to depression. Where no clear guidance is present, client preference or identification of which disorder is most distressing / disabling can be the criteria. Complications include the remaining disorder worsening or interfering with that being treated and referral to the subsequent treatment being interrupted, or not proceeding due to system or client factors.

The parallel model treats each disorder concurrently with a provider or team addressing each area of care. However, these treatments usually operate independently without a unified whole person treatment plan which limits efficiency and the unified focus on shared factors. Complications include mixed messages, differing priorities and emphases. In addition, the multiple appointments and homework may be overwhelming both physically and emotionally impacting successful outcomes for either or both conditions.

A combined or integrated model addresses pain and PTSD simultaneously with a single treatment team who hold expertise in both conditions. Whilst not broadly available, it best encompasses the biopsychosocial, whole person framework with coordinated care. Treatment in this model relies on evidence based therapies and cognitive behavioural principles with demonstrated effectiveness in both conditions, emphasising a focus on the shared role of fear-avoidance in both pain and PTSD. Some recent studies indicate this treatment pathway is promising but future research is required to better understand effectiveness and potential for implementation. One option may be to formalise offering concurrent PTSD treatment in interdisciplinary pain programs. Another may be to further develop the 12 session integrated treatment trialled by Otis and colleagues (2009) using components of CPT for PTSD and CBT for pain management. Given the high prevalence of comorbidity in these two conditions, further research to better guide intervention is warranted.

References

Angelakis, S., Weber, N., & Nixon, R.D.V. (2020) Comorbid posttraumatic stress disorder and major depressive disorder: The usefulness of a sequential treatment approach within a randomised design. Journal of Anxiety Disorders, 76

Finlay.S., Roth, C., Zimsen, T., Bridson, T.L., Sarnyai, Z., & McDermott, B. (2022) Adverse Childhood Experiences and Allostatic Load: A Systematic Review. Neuroscience and Biobehavioural Reviews, 136.

Liedl, A., & Knaeelsrud, C. (2008) Chronic Pain & PTSD: the Perpetual Avoidance Model and its treatment implication. Torture 18(2)

Lydall-Smith, S., Bowler, M., Funke, A., Alexiou, T., Griffiths, K., White, B., & Field, D. (2020) Poster presented to the New Zealand Pain Conference.

Murphy, J.L., Driscoll, M.A., Odom, A.S. & Hadlandsmyth, K. (2022) Post Traumatic Stress Disorder & Chronic Pain. PTSD Research Quarterly 33(2)

Otis, J.D., Keane, T.M., & Kerns, R.D (2003) An examination of the relationship between chronic pain and post-traumatic stress disorder. Journal of Rehabilitation Research and Development 40(5), 397-405

With the ongoing demands of the pandemic, the constructs of moral distress and injury have drawn increasing attention. This has been particularly salient amongst health care workers but can be considered pertinent for everyone who has lived through this extraordinary series of experiences.

The Australian Red Cross have published guidelines to support communities before, during and after Collective Trauma Events. One of the authors Kate Brady wrote an article at the conclusion of Melbourne’s first extended lockdown in 2020 that argued the pandemic and its associated impacts could be considered Collective Trauma Events (CTE’s).

Traditionally, these have been understood to be disasters such as bushfire, flood, or mass trauma events linked to violence. A CTE is defined as an event which irrespective of the hazard, results in a blow to the basic tissues of social life that damages the bonds between people and impairs the prevailing sense of community. Critically, they must have an impact on the broader community and challenge peoples’ typical understanding of the way the world works (Brady, Randrianarisoa & Richardson, 2018).

This in turn requires us to consider the continuum of impact experienced by individuals. It  has been well documented that Covid19 has disproportionately affected those already more disadvantaged in society. The recent differentials in stay at home orders in Sydney highlighted the varied lockdown impact by local geographic area. Women have been reported to have shouldered greater burden from care provision and home schooling and young peoples’ increased levels of psychological distress has been well documented. In contrast, in some states the interruptions have been far less disruptive. Thus, whilst there are simultaneous impacts which are complex and compounding, disasters affect people differently. Brady et al., (2021) have written of the hierarchies of affectedness after disasters which are determined externally but also by the differing perspectives of groups of individuals who experienced them. Rob Gordon’s research on social bonding and de-bonding following a disaster is also relevant.

This same lens can be applied to moral injury defined as the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations (Phoenix, 2020). This too exists on a spectrum. Whilst all moral stressors violate a person’s beliefs about what is right and just
or wrong and unjust, and all give rise to moral emotions, their potential for enduring harm or impairment are a function of severity.  Moral challenges tend to be common, frustrating but convey minimal harm or impairment, whereas moral distress occurs less frequently but has a moderate risk of harm. Moral injury, whilst rare carries a high risk of potential harm and can result in PTSD symptoms. Fortunately, not all individuals who experience moral distress or injury will develop PTSD as some with the provision of Psychological First Aid and good personal and organisational support will sufficiently process their experience. It is also possible that for some this experience may result in increased moral strength and post traumatic growth where useful learnings can be embedded in future practice.

However, the negative impacts of moral injury include feelings of guilt, shame, anger and disgust together with reduced empathy. There can be intrapersonal outcomes such as lowered self esteem resulting in beliefs about being bad, damaged, unworthy or weak. Interpersonal outcomes include loss of faith in people, withdrawal, avoidance and lack of trust, anger and blame. Existential and spiritual outcomes such as a loss of faith or belief in the ‘just world’ can occur and the individual can experience difficulty in occupational functioning, motivation and sense of purpose.  There are clearly parallels in the above expressions which are commonly seen in stuck points highlighted by people undertaking CPT for PTSD.

This prompts the query as to the applicability of CPT to treat PTSD arising from moral injury. Much of the existing research has emerged from the military setting and combat related PTSD which is also where moral injury was initially described. Griffin et al., (2019) conducted an integrative review of the literature on moral injury. They report mixed evidence as to the degree in which morally injurious outcomes are associated with specific PTSD symptom clusters. However, they cited the work of Bryan et al., (2017) who suggested a PTSD profile which included startle reflex, memory loss, flashbacks, nightmares and insomnia, where the moral injury profile included guilt, shame, anger particularly where perceived betrayal was present, anhedonia and social alienation.

The review considered the application of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) as treatment for moral injury. Whilst CPT was not specifically designed for this application, it is considered that its focus on accepting naturally occurring emotions, challenging unrealistic cognitions and using socratic questioning may assist in providing a context for the event and promote perspective taking. There remains debate in the pre- pandemic literature as to the best way to define moral injury in addition or separate to PTSD and how best to apply the existing evidence based treatment modalities. However, it does appear that the constructs as described by Bryan et al., are common to those addressed by CPT which would position it well as treatment option in this area.

A recently published review in PTSD Quarterly by Maguen and Norman (2021) considered the dearth of research outside of the military setting,  and the need for clearer definitions of the constructs and assessment tools and longitudinal studies. Hines et al., (2021) reported on trends in moral injury, distress and resilience factors among healthcare workers at the beginning of the Covid-19 pandemic. Findings included that the improvement of workplace support and lowering of workplace stress may protect healthcare workers from adverse emotional outcomes.

It remains to be seen how much of the current reported psychological distress amongst healthcare workers will require formal intervention as opposed to psychological first aid which has been recommended as a first line approach. It is pleasing to see that in response to the pandemic challenges, many health networks in Victoria have set up staff wellbeing supports and normalized access of mental health support for both individuals and teams to mitigate the very real impacts of moral challenge and distress consistently being encountered.

References

Brady, K. 2020 . Dear Australia, Your sympathy helps but you can’t quite understand Melbourne’s lockdown experience. The Conversation, online article, Oct 2020.

Brady, K, Randrianarisoa, A & Richardson, J 2018 Best practice guidelines: Supporting communities before, during and after collective trauma events. Australian Red Cross. Carlton, VIC

Bryan, C. J ., Bryan, A.O., Roberge, E., Leifker, F.R. & Rozek, D.C. (2017) Moral injury, posttruatic stress disorder and suicidal behaviour among national guard personnel.. Psychological Trauma: Theory, Research, Practice and Policy, 10, 36-45.

Griffin, B.J., Purcell, N., Burkman, K., Litz, B.T., Bryan, C.J., Schmitz, M., Villierme, C., Walsh, J., Maguen, S. (2019) Moral Injury: An Integrative Review. Journal of Traumatic Stress, 32, 350-362.

Gordon, R. (2004) The social system as site of disaster impact and resource for recovery. The Australian Journal of Emergency Management (19)4

Hines,S.E., Chin, K.H., Glick, D.R. & Wickwire, E.M. (2021) Trends in moral injury, distress, and resilience factors among healthcare workers wat the beginning of the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18, 488

Maguen, S. & Norman, S.B (2021) Moral Injury. PTSD Quarterly, 32(5)

Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre for Excellence – PTSD (2020).  Moral Stress Amongst Healthcare Workers During Covid19: A Guide to Moral Injury

Smallwood,N., Karimi.L., Bismark,M., Lutland.M., Johnson,D., Dharmage,S.C., Barson,E., Atkin,N., Long,C., Ng,I., Holland,A., Munro,J.E., Thevarajan,I., Moore, C., McGillon,A., Sandford,D & Willis,K. (2021) High levels of psychosocial distress among Australian frontline healthcare workers during the Covid19 pandemic: a cross-sectional survey. General Psychiatry, 34.

Smallwood, N., Pascoe,A., Karimi,L & Willis,K. (2021) Moral Distress and perceived community views are associated with mental health symptoms in frontline health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health,18,8723.

Wachen, J.S., Dondanville, K.A. & Resick, P.A (2017) Correcting misperceptions about Cognitive Processing Therapy to treat Moral Injury: A Response to Gray and Colleagues. Cognitive and Behavioural Practice, 24, 388-392.

A common concern expressed when planning CPT treatment is ‘when is the right time to start’. This is particularly the case for clients presenting with comorbid conditions and complex trauma histories where the themes of patient readiness, level of distress and dropout are expressed. There are two key considerations that emerge. The first is treating CPT where there is complexity; the second being whether stabilisation and management of other conditions should be completed prior to initiating CPT.

The question of complexity is frequently raised as a treatment complication, with genuine concerns that the presence of other conditions may inhibit or impact the treatment of PTSD with CPT. In practice, this is often found to be a clinician stuck point, with considerable evidence now supporting client’s abilities to complete CPT when comorbid diagnoses are present. These include depression, substance use, borderline personality disorder, and traumatic brain injury (TBI), and in our clinical settings, functional neurological disorder (FND) & somatic conditions have also been present. Multiple RCT’s have been conducted with broad inclusion criteria such as dissociation, panic, personality disorder, depression and substance use (for review, see Galovski, Nixon, & Kaysen, 2020). No differences in PTSD treatment gains have been found between those with or without borderline personality disorder diagnosis (Resick et al., 2002). Kaysen et al. (2014) found no outcome differences in those with current or past histories of alcohol use disorders and those without. To enhance outcomes for clients presenting with complexity, tailoring the dose of CPT therapy might need to be considered, with Galovski (2012) finding that an additional 26% of participants achieved a positive end state level of symptoms when given extra sessions (to a maximum of 18). This approach has been echoed with good result in an Australian outpatient public mental health clinic (in Victoria) where CPT is offered as part of routine care.

With complexity comes the question as to whether initial stabilisation is needed prior to commencing CPT. A recent study conducted in a US Veterans Affairs specialty PTSD clinic found that contrary to the intended role of preparatory treatments, they were actually associated with a worse treatment response for those who later received a trauma focused evidence-based psychotherapy such as CPT or Prolonged Exposure (Dedert et al., 2020). Participants who went directly into an Evidence Based Protocol (EBP) had a better treatment response for PTSD and depressive symptoms. In addition, the authors report that only a quarter of those enrolled in preparatory treatment progressed to engaging in a trauma focused EBP. Whilst it should be noted that this study did not have random allocation, and thus it is possible that veterans with greater levels of avoidance self selected into preparatory treatments and were also then less engaged in the subsequent EBP, the results add to the body of evidence that many patients benefit from immediate provision of evidence based treatments and do not always require stablisation or preparatory skill building work. As Dedert and colleagues note, there is a lack of data detailing what constitutes ‘readiness’ to benefit from trauma focused treatment, while in contrast, data indicate that clinical worsening occurs during waitlist conditions. These findings underscore the importance of shared decision making and treatment planning with clients to prioritise engagement in evidence based treatment early in the course of contact with clinical services.

References

Clarke, S.B., Rizvi, S.L., & Resick, P.A. (2008). Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims. Behavior Therapy, 39, 72-78.

Dedert, E.A., LoSavio, S.T., Wells, S.Y., Steel, A.L., Reinhardt, K., Deming, C.A., Ruffin, R.A., Berlin, K.L., Kimbnrel, N.A., Wilson, S.M., Boeding, S.W., & Clancy, C.P. (2020, August 27). Clinical Effectiveness Study of a Treatment to Prepare for Trauma‐Focused Evidence‐Based Psychotherapies at a Veterans Affairs Speciality Posttraumatic Stress Disorder Clinic. Psychological Services. Advance online publication http://dx.doi.org/10.1037/ser0000425

Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968-981. doi:10.1037/a0030600

Galovski, T.E., Nixon, R.D.V., & Kaysen, D. (2020). Flexible Applications of Cognitive Processing Therapy:Evidence‐Based Treatment Methods. Cambridge, MA, USA: Elsevier Science, an imprint of Academic Press.

Kaysen, D., Schumm, J., Pedersen, E.R., Seim, R.W., Bedard-Gilligan, M., & Chard, K (2014). Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders. Addictive Behaviour, 39(2): 420-7.

Resick, P,A., Nishith, P.,  Weaver, T.L., Astin, M.C & Feuer, C.A  (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and  Clinical Psychology, 70(4): 867-79.