Extensive research consistently supports cognitive processing therapy (CPT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) for treating posttraumatic stress disorder (PTSD). However, these evidence-based psychotherapies (EBP) face criticism for being inflexible, with randomised controlled trials lacking ecological validity. Concerns have been raised about their applicability to ‘complex’ clients in real-world setting.

To address these concerns, EBPs are now implemented more broadly, sometimes deviating from the original format. La Bash, Galovski, and Stirman (2019) use the ‘Framework for Reporting Adaptations and Modifications’ (FRAME) to guide treatment modifications, specifically focusing on CPT.

Before delving into these concepts, La Bash et al. (2019) distinguish between treatment modification, adaptation, and fidelity. Treatment modifications involve changes to the protocol or delivery to enhance fit, engagement, or effectiveness. Adaptations, a type of modification, aim to maintain the essential elements driving treatment effectiveness. Fidelity is the degree to which a treatment adheres to the developer’s prescription.

La Bash et al. (2019) elaborate on why to adapt, goals, stakeholders, when to adapt, forms of adaptation, and measurement and evaluation. They stress considering these factors to maintain effectiveness and fidelity.

1. Why Adapt?

Regarding the reasons for adaptation, La Bash et al. (2019) propose responses to cultural and contextual factors, including:

• Socio-political factors (e.g., societal/cultural norms, political climate, mandates, and funding and resource allocation)
• Organizational/setting factors (e.g., available resources, billing constraints, service structure, location/accessibility, leadership support and time restraints)
• Provider characteristics (e.g., clinical judgment, cultural competency, previous training and skills, and perceptions of the intervention),
• Client characteristics (e.g., cultural factors, access to resources, comorbidity/multimorbidity, cognitive capacity, literacy level, comorbidity, immigration status)

They offer examples, such as CPT adaptations for language barriers in the Democratic Republic of congo (Bass, et al. 2013).

2. Goals of Adaption

Goals of adaptation include addressing policy constraints, improving outcomes, increasing feasibility, client satisfaction, and reducing costs. They emphasize the importance of clear goals to guide the adaptation process. For instance, Galovski et al. (2012) adapted CPT to include crisis sessions, addressing emergent life events. Chard (2005) extended and adapted the CPT protocol for individuals who experienced childhood sexual abuse.

3. Who is Involved in the Decision to Adapt?

La Bash et al. (2019) stress the importance of thoughtful involvement of stakeholders in decision-making, as their input shapes adaptation goals, forms, and timing. Key stakeholders include treatment recipients, team leaders, community members, researchers, and administrators. Input from both treatment providers and clients is critical for successful implementation, particularly focusing on enhancing engagement, comprehension, and impact. 

4. When to Adapt?

Adaptations can occur at any point in treatment with La Bash et al. (2019) recommending early planning through pre-implementation assessments. La Bash et al. (2019) suggest that thorough pre-treatment assessments allow clinicians to carefully consider the need for adaptations while preserving effective elements of the original intervention. They further suggest that consultation with experts can inform adaptations and refine interventions.

For example, in a study where CPT with implemented on a population of Bosnian refugees, a proficient, but non-native English-speaking Bosnian refugee wrote his impact statement in English. After consideration of the clinical and cultural issues at hand, the client was asked to write and read their impact statement in their native language, which facilitated stronger emotional responses initially and, over time, greater reduction in distress when repeating the narrative [Schulz, Huber, & Resick, 2006].

5. Forms of Adaption

La Bash et al. (2019) highlight the following forms of adaptions:

• Treatment content (e.g., tailoring, substituting content, changing the length of sessions, substituting treatment module, repeating treatment elements, addition or removal of treatment components)
• Delivery of the intervention (e.g., format, setting, population receiving the treatment, language used to deliver the treatment, personnel delivering the intervention, session frequency)
• Staff training strategies
• Intervention evaluation method

One of the most common forms of adaptation is tailoring or making relatively minor changes to aspects of the treatment without substantial changes to the core intervention elements. Adaptation to intervention content can also include the addition or removal of a treatment component, such as adding a module on child development relevant to survivors of childhood sexual abuse to facilitate understanding of the impact that their childhood trauma childhood trauma on their adult functioning (Chard, 2005).

Adaptations are also being explored to better address the needs of active-duty military personnel, including a condensed 3-week PE protocol (Peterson et al, 2018), a condensed 2-week CPT protocol (Bryan, 2018), and a version of CPT in which the health care professional delivers CPT in the client’s home (Peterson, Resick et al, 2018).

6. Measurement and Evaluation

Measurement and evaluation methods include continuous quality improvement, program evaluation, open trials, and randomized control trials. La Bash et al. (2019) emphasise that thoughtful, theory-informed adaptations, supported by research and program-level evaluation, are essential for successful implementation.

Through their framework La Bash et al. (2019) highlight that treatment adaptations are not something that should occur on a whim, or purely ‘intuitively’ but that for adaptions to be successfully implemented they must be informed by theory, research, and program-level evaluation.

References:

Bass, J.K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., et al. (2013) Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182–2191.

Bryan, C.J., Leifker, F.R., Rozek, D.C., Bryan, A.O., Reynolds, M.L., Oakey, D.N., et al. (2018). Examining the effectiveness of an intensive, 2-week treatment program for military personnel and veterans with PTSD: results of a pilot, open-label, prospective cohort trial. Journal of Clinical Psychology, 74, 2070-2081.

Chard, K.M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971.

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.

Peterson, A.L., Foa, E.B., Blount, T.H., McLean, C.P., Shah, D.V., Young-McCaughan, S., et al. (2018). Intensive prolonged exposure therapy for combatrelated posttraumatic stress disorder: design and methodology of a randomized clinical trial.  Contemporary Clinical Trials, 72,126–136.

Peterson, A.L., Resick, P.A., Mintz, J., Young-McCaughan, S., McGeary, D.D., McGeary, C.A., et al. (2018). Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD. Contemporary Clinical Trials, 73, 27–35.

Schulz, P.M., Huber, L.C., Resick, P.A. (2006). Practical adaptations of cognitive processing therapy with Bosnian refugees: implications for adapting practice to a multicultural clientele. Cognitive and Behavioral Practice, 3(4), 310–321.

The Hippocratic promise, “first, do no harm” is a central theme within the treatment of trauma. Whilst it is natural, and even expected that our patients will have their own fears and scepticisms towards trauma treatment, potentially the most harmful concerns and doubts are those help by practitioners. Although cognitive processing therapy (CPT) is an effective, gold-standard treatment for posttraumatic stress disorder (PTSD), many practitioners still retain concerns such as, CPT will make their patients worse, whether their patients are too complex to benefit from a manualised treatment, and whether their patients are ready to face their trauma.

During CPT training, therapists are taught the importance of identifying and challenging patients’ unhelpful beliefs. However, less is often said about the importance of challenging our own unhelpful therapist stuck points. LoSavio, Dillon, Murphy, and Resick (2019) examined how therapists’ concerns about CPT or, in other words, therapist stuck points, influenced CPT training outcomes. LoSavio et al (2019) suggested that therapist stuck points may influence outcomes in two main ways:

1. Therapist stuck points may prevent therapist from training or using CPT
2. Even when CPT is used, therapist stuck points may impact the way in which CPT is delivered (i.e., missing key elements, or delivering therapy in an overly cautious way), consequently stopping patients from receiving a potent dose of CPT

LoSavio et al (2019) examined 57 therapists participating in a CPT Training Collaborative. CPT training spanned 12 months including three in-person workshops, and weekly, group phone consults. Therapist stuck points were assessed at three times points (Time 0) post workshop one; Time 1) post workshop two, four-months later; and Time 2) eight-months later). Assessed outcomes included therapists’ completion of training, fidelity to the CPT protocol (assessed from session recordings), and ongoing use of CPT after the training.

LoSavio’s group (2019) found that having more negative views towards CPT was associated with lower likelihoods of training completion, worse fidelity, and lower likelihoods of using the CPT one-year post-training. They found:
• Therapist stuck points reduced over the course of training, especially for those who attended a higher number of consultation calls
• Higher therapist stuck points at the end of training, and less reduction of therapist stuck point over the course of training was associated with a lower likelihood of completing the training
• Less reduction in therapist stuck points over the course of training was associated with worse treatment fidelity and lower likelihood of continued use of CPT (and treating a lower number of CPT patients)

LoSavio et al recommend that consultants address therapist stuck points in an open and direct manner and that they commend therapists for pursuing new training despite reservations. They also stress the importance of normalising therapist stuck points, and discussing how the identification of one’s own stuck points is a valuable part of development. The authors recommend 1) the use of CPT worksheets to challenge therapist stuck points, 2) the use behavioural experiments, 3) reading and reviewing relevant literatures, 4) engaging in ongoing case discussions, and 5) providing a list of common therapist stuck points at the beginning of training (see Appendix).

LoSavio et al’s findings (2019) demonstrate the need for therapists to continue to monitor their own concerns and doubts surrounding their use of CPT, and to recognise how such doubts can reduced the fidelity of their practice. LoSavio et al, state: “These findings suggest that therapist beliefs about treatment have important implications, and trainers, consultations and supervisors should consider measuring and discussing them during training to correct mistaken assumptions and potentially improve treatment success and the availability of effective treatments”.

Reference:
LoSavio, R. A., Hillon, K. H., Murphy, R. A., & Resick, P. A. (2019). Therapist Stuck Points During Training in Cognitive Processing Therapy: Changes over Time and Associations with Training Outcomes. Professional Psychology: research and Practice, 50(4), 255-263.

Appendix
Therapist Stuck Point Items

1. Clients never really recover from PTSD.
2. I need to implement the CPT therapy components perfectly for treatment to work.
3. The structure of CPT gets in the way of rapport-building.
4. CPT won’t work for clients with childhood trauma.
5. Clients need preparatory treatment before they are ready to deal with their trauma.
6. Clients won’t be able/willing to do the amount of homework involved in CPT.
7. CPT won’t work for clients with multiple traumas.
8. CPT teaches clients many helpful skills for managing PTSD symptoms.
9. My clients would improve more if they worked with a more experienced CPT provider than me.
10. Having clients focus on one trauma is invalidating.
11. CPT is a good choice of therapy for a client with PTSD.
12. CPT won’t work for clients with comorbidities (e.g., substance use disorders, depression).
13. CPT is too narrow in focus.
14. Clients won’t like CPT’s structured approach.
15. Clients I treat with CPT are very likely to improve.
16. Clients don’t need to talk about their trauma to recover from PTSD.
17. CPT puts too much work on clients.
18. CPT should be stopped if clients have suicidal ideation.
19. CPT helps clients effectively process their traumatic experiences.
20. If I press my client about completing assignments, it will make them quit.
21. It’s harsh to make clients talk about their trauma.
22. CPT poses a serious risk of making clients worse.
23. I have the skills and knowledge to implement CPT effectively.
24. CPT is not individualized to the client.
25. CPT can improve clients’ comorbid symptoms (e.g., depression, anger) in addition to their PTSD symptoms.
26. I won’t be able to keep my client talking about one traumatic event.
27. CPT doesn’t delve deep enough (e.g., into clients’ histories, motivations, etc.).
28. CPT can be used to effectively treat chronic PTSD symptoms.
29. Clients with PTSD are very likely to benefit from CPT.
30. If I have the CPT manual out in session, it suggests I’m not competent.
31. Clients won’t be able/willing to focus therapy on one traumatic event.
32. CPT is a safe treatment for PTSD (i.e., it does not cause harm).
33. CPT doesn’t let me use creativity or clinical intuition.
34. CPT works for clients who have experienced multiple traumatic events.
35. Clients need to resolve their other mental health issues (e.g., substance use, suicidal ideation, borderline personality disorder) before they begin CPT. 36. If I address my client’s avoidance, it will damage our relationship.
36. The evidence is clear that CPT works for PTSD.