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.

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)  

Casey and her colleagues (2022) conducted a study evaluating the effectiveness of Cognitive Processing Therapy (CPT), delivered in a tertiary mental health service in Victoria, Australia. This article summarises their research findings.

We know that clients with PTSD or Complex PTSD frequently present to community mental health settings. Unfortunately, it has been estimated that in Australia, only half of those with PTSD seek therapy and of those, not all receive evidence-based interventions (Mihalopoulos et al., 2015). Organisational and clinician factors can reduce the likelihood of clients receiving effective treatment for PTSD.

CPT is an evidence-based psychological therapy with substantial empirical support although most of this is derived from non-Australian contexts. There is a lack of research on the effectiveness of CPT in Australia in non-specialist mental health settings and to date, no Australian studies have reported on changes to mental health service utilisation pre- and post- CPT.

Casey et al (2022) set out to examine the efficacy of CPT in an open design trial as part of usual care in a tertiary mental health outpatient service. Clinicians received training and supervision in CPT and formed a network of CPT clinicians who worked across the Monash Health mental health program. These clinicians received CPT referrals for PTSD clients as part of their general clinical caseload. The study specifically examined patient outcomes (PTSD and depressive symptoms) and use of mental health services (pre-CPT and following CPT). Any exacerbation in clients’ symptoms and adverse events were also documented.

A total of 223 clients were referred to the CPT program between March 2016 and July 2020. Of those assessed, the majority commenced CPT within the service (N = 158). Clients were given information about CPT and invited to receive CPT which involved 12-16 sessions of individual therapy that adhered to the CPT manual. Clients attended an average of 10.68 CPT sessions (SD = 5.87), once or twice weekly depending on client and clinicians’ availability, with number of sessions ranging from 1 to 26 sessions.

Casey and her colleagues’ (2022) results replicate international findings that CPT is a safe, effective therapy for PTSD in community mental health settings. No serious adverse events were reported for this cohort of clients throughout CPT therapy. There were statistically significant improvements on all outcome measures with typically meaningful effect sizes. Although qualified by the use of an open trial design, these findings indicated that clients significantly reduced their use of mental health services following CPT relative to pre-CPT usage. The research shows that CPT can be effectively delivered in routine mental health settings with appropriate organisational support and clinician training.

In March 2021, The Royal Commission into the Victorian Mental Health System delivered 65 recommendations in their Final Report. Over the past two years, health services have been preoccupied with responding to the COVID pandemic, but the

Victorian government is working on delivering its promise to implement all 65 recommendations. It is expected that funding for public mental health services will significantly increase over the coming years. The Commission’s recommendations are very comprehensive and include a chapter solely dedicated to the impact of trauma, with a call for our mental health and wellbeing system to better meet the needs of clients whose mental health has been affected by trauma. Casey and her colleagues have demonstrated a way in which to integrate evidence-based PTSD treatments into the standard model of mental health care.

References

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

State of Victoria, Royal Commission into Victoria’s Mental Health System, Final Report, Volume 1: A new approach to mental health and wellbeing in Victoria, Parl Paper No. 202, Session 2018–21 (document 2 of 6).

Mihalopoulos, C. et al. (2015). Is implementation of the 2013 Australian treatment guidelines for posttraumatic stress disorder cost-effective? The Australian & New Zealand Journal of Psychiatry, 49(4), 360-376. https://doi.org/10.1177/0004867414553948

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

Stirman and her colleagues (2021) conducted a pilot study of messaged-based CPT for treating PTSD. This article will summarize some of the key features of the open trial study and what it means for the future development of CPT.

What is a message-based CPT?

Using an asynchronous messaging approach, message-based CPT followed a standard CPT protocol of twelve sessions comprised of exercises and worksheets without a written trauma account. Asynchronous messaging allowed the clients to respond at their own convenience instead of being present and respond at the same time as therapists. Clients received the content in the PDF format and animated videos via Talkspace (an e-mental health platform in the USA), which presented the fundamental concepts and skills of CPT. Instead of the verbal communication by therapists, the introduction of the new materials for each session was shared through whiteboard videos. Clients were able to upload the completed worksheets to Talkspace and therapists reviewed them 5 days per week. Socratic questions were sent as a single message and clients were able to respond to them at their convenience. When necessary, 30-min video conferences, up to a maximum of three, were used to address any challenging situations or improve client engagement.

How was the study conducted?

A total of twenty-eight participants, who resided in the US, scored a 33 or above on the PTSD Checklist (PCL-5) and were not at high risk for suicidal thoughts and/or behaviors, were recruited to the CPT-text group via Talkspace and signed up to the platform through CPT-trained therapists. The study also had a comparison group that used messaging therapy using other therapeutic approaches and followed a similar format of asynchronous messaging with therapist review on 5 days per week. Participants in both groups had similar PTSD symptom profiles at baseline. CPT-text group completed a PCL-5 to measure PTSD symptoms and PHQ-8 to assess depression symptoms on a weekly basis.

What were the main findings?

The primary goal of the study was to assess the feasibility, engagement, and effectiveness of the message-based CPT format. Below are the important findings of the study:

• Most participants in the CPT-text group showed clinically significant improvement with the PCL-5 mean scores from pre- to post-treatment decreased two-fold.
• CPT-text group showed rapid symptom improvement compared to those in the comparison group.
• Among 25 CPT-text clients who completed the PHQ-8, comorbid depressive symptoms were reduced significantly from pre to post treatments with a large treatment effect.
• Clients and therapists appeared to write less to each other in CPT-text group compared to massage therapy using other modalities.
• The average time took to complete the CPT-text protocol was less than that of face-to-face CPT sessions.
• The drop-out rate of CPT-text (37%) was similar to that seen in face-to-face CPT studies.
• Better client engagement was seen in the CPT-text group most likely due to the daily check-in by the therapist.
• CPT-text was feasible to implement as less time was spent on messaging with minimal video sessions to deliver the content and skills.

What are the implications of this study?

Digital mental health platforms could overcome barriers of stigma, cost, transportation and inconvenience in accessing traditional PTSD treatments. Despite the few limitations, this study certainly demonstrates positive outcomes of adapting CPT to an online platform, adding to the growing literature that shows internet-based PTSD interventions are feasible and effective in treating PTSD. With therapist guidance, PTSD treatments like CPT have a higher potential of expanding the opportunities to provide treatment to remote locations and underserved communities with limited mental health services.

Reference:

Stirman, S. W., Song, J., Hull, T. D., & Resick, P. A. (2021). Open Trial of an Adaptation of Cognitive Processing Therapy for Message-Based Delivery. Technology, Mind, and Behavior, 2(1). https://doi.org/10.1037/tmb0000016

The increased risk for suicide in those experiencing from PTSD is well known. For example, Gradus et al., 2010 studied of a large sample of the Danish population (n = 208,918). They reported persons with PTSD had 5.3 times the rate of death from suicide than persons without PTSD. This included after adjustment for gender, age, marital status, income, and pre-existing depression diagnoses. Similarly, several others have noted an elevated suicide risk in those experiencing chronic PTSD; Tarrier & Gregg (2004), Krysinska & Lester (2010), Pompili et al., (2013).

Many clinicians fear that by treating PTSD they may push a client too far and trigger strong emotional reactions that lead to suicidal ideation, and an attempt. But what does the research say?

This blog will review some of the research related to CPT for PTSD and suicidal ideation.

2017

In her study of Effect of Group vs Individual Cognitive Processing Therapy in Active-Duty Military Seeking Treatment for Posttraumatic Stress Disorder Resick et al. (2017) also assessed suicidal ideation. Her team’s study had an exclusion criterion that consisted of suicidal or homicidal intent or psychosis. They measured suicidal ideation using the Beck Scale for Suicidal Ideation (BSSI). The BSSI is purported to measure three factors:

1. Active Suicidal Desire
2. Specific Plans for Suicide
3. Passive Suicidal Desire

Resick et al. (2017) reported that the proportions of suicidality as measured by the BSSI dropped in both group and individual treatment arms during treatment (overall effect of time, χ2  2 = 13.0; P = .002).

Resick et al. (2017) study also reported on adverse events. Seventeen psychological events were judged by the participants to be at least possibly related to the study, and these occurred because of increased symptoms evoked by baseline assessment procedures (4 patients) or the trauma focus of therapy (7 patients in group CPT and 6 patients in individual CPT).  Resick et al. (2017) described that most of the psychiatric adverse events were common symptoms of PTSD observed in the study population (military with PTSD).

During the study, two unsuccessful suicide attempts occurred in patients randomized to group CPT (one before the start of treatment and one during treatment); neither was judged to be study related as per participant report.

Resick et al. (2017) summarised that Cognitive Processing Therapy did not increase suicidal ideation on the BSSI or reported adverse effects despite the trauma focus. In fact, they observed a significant and steady decrease in suicidal ideation in both treatment formats.

2018

Holliday et al. (2018) completed a preliminary examination of decreases in suicide cognitions after Cognitive Processing Therapy among veterans with posttraumatic stress disorder due to military sexual trauma ( see below for more info on MST).

The study had some limitations due to a small sample size. Holliday et al. (2018) had 32 participants in their sample, 22 (68.8%) completed all 12 sessions of CPT, with an average of 9.94 (SD = 3.27) CPT sessions completed.

They used the Suicide Cognitions Scale (SCS). This measure is an 18-item self-report questionnaire composed of three latent factors of suicide-specific beliefs:

1. unbearability (e.g., “I can’t stand this pain anymore”)
2. unlovability (e.g., “I am completely unworthy of love”)
3. unsolvability (e.g., “suicide is the only way to solve my problems”)

Participants were administered the SCS at 1 week, 2 months, 4 months, and 6 months posttreatment. During CPT and posttreatment participants experienced a significant reduction in beliefs regarding:

• unbearability (b = −3.15, t[31] = −4.72[.67], p < 0.001)
• unlovability (b = −2.20, t[31] = −4.05[.54], p < 0.001)
• unsolvability (b = −1.22, t[31] = −2.49[.49], p = 0.019)

The study had limitations due to the small sample size. However, the authors concluded:

“These findings provide preliminary evidence that a standard course of CPT may have the potential to reduce suicide specific beliefs in veterans with MST-related PTSD.” pg 577

2021

Roberge et al. (2021) examined the effect of using CPT to treat veterans experiencing PTSD and suicidal ideation. The participants in her groups study screened well above the PCL-5 threshold (33) for PTSD, with a mean PCL-5 score of 50.70 (SD = 13.77).

The sample characteristics included:

• 42% current suicidal ideation
• 5% history of attempted suicide
• 46% low risk
• 10% acute risk of suicide

Roberge and colleagues 2021 also used two different categorisations methods to define elevated and low risk. These methods considered combinations of the following factors:

• history of suicide attempts
• absence of attempt
• recent and/or current suicidal ideation
• absence of recent and/or current suicidal ideation

They determined that most veterans who engaged in CPT were at increased risk for suicide as determined by these clinical factors. Given a picture says a thousand words this graph from the study shows the effects of CPT treatment for the various groups over a course of CPT for PTSD

Other important finding that Roberge and colleagues 2021 reported included;

• High risk veterans were just as likely to complete treatment as low risk veterans.
• Suicide risk groups experienced similar levels and rate of PTSD symptom change over the course of treatment.
• On average, veterans reported clinically significant reduction of PTSD symptoms.

Of particular interest to clinicians concerned about risk is Roberge and colleagues’ statement about treatment safety.

“Three veterans (1.0%) engaged in suicidal behaviour (i.e., suicide attempt) between treatment initiation and the chart review process (i.e., August 2020). Of these veterans, all endorsed suicidal ideation at the time of treatment initiation, and two had prior histories of suicide attempts. Two veterans’ attempts occurred approximately seven months after CPT, whereas the other veteran’s attempt occurred in the month following their first and only CPT session. According to local records, to date, no veterans who engaged in CPT between 2016 and 2018 have died by suicide.” (p.4)

Summary

CPT for PTSD can be safely and effectively delivered to individuals with increased risk for suicide and appears to result in a reduction in ideation as well as PTSD symptoms.

What is Military Sexual Trauma (MST)

Survivors of MST often work alongside their perpetrators and the can have the experience that the military does not take action. There can be negative consequences for reporting MST and stigma. MST happens in the context of the military hierarchy. MST can happen in the context of operations where fellow soldiers are protecting each other’s lives when in danger.

References

Holliday, R., Holder, N., Monteith, L. L., & Surís, A. (2018). Decreases in suicide cognitions after cognitive processing therapy among veterans with posttraumatic stress disorder due to military sexual trauma: A preliminary examination. Journal of Nervous and Mental Disease, 206(7), 575–578. https://doi.org/10.1097/NMD.0000000000000840

Jaimie L. Gradus, Ping Qin, Alisa K. Lincoln, Matthew Miller, Elizabeth Lawler, Henrik Toft Sørensen, Timothy L. Lash, Posttraumatic Stress Disorder and Completed Suicide, American Journal of Epidemiology, Volume 171, Issue 6, 15 March 2010, Pages 721–727, https://doi.org/10.1093/aje/kwp456

Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: a systematic review. Archives of suicide research : official journal of the International Academy for Suicide Research, 14(1), 1–23. https://doi.org/10.1080/13811110903478997

Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M., & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease, 201(9), 802–812. https://doi.org/10.1097/NMD.0b013e3182a21458

Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., & Mintz, J. (2017). Effect of group vs. individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74(1), 28–36. https://doi.org/10.1001/jamapsychiatry.2016.2729

Roberge, E.M., Harris, J.A., Weinstein, H.R., & Rozek, D.C. (2021). Treating veterans at risk for suicide: An examination of the safety, tolerability, and outcomes of cognitive processing therapy. Journal of Traumatic Stress.

Tarrier, N., & Gregg, L. (2004). Suicide risk in civilian PTSD patients–predictors of suicidal ideation, planning and attempts. Social psychiatry and psychiatric epidemiology, 39(8), 655–661. https://doi.org/10.1007/s00127-004-0799-4

Parts of this blog also appeared on https://psychpd.com.au/category/ptsd/

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.

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.

Larsen and colleagues (2020) examined this question in a community sample of participants receiving CPT. Previous investigations had been primarily in randomized clinical trials. The concern with these trials has been that the participants and therapists are in some way different to the “average” community-based clinic. For example, therapists may be receiving more specialised training and participants may receive more frequents sessions.

Larsen et al (2020) community sample were receiving weekly treatment and attending in community settings such as private practice or government funded agencies. Therapists had attended a standardized 2-day CPT workshop and were participating in consultation.

Larsen’s group (2020) found that in their sample most participants experienced at least one symptom exacerbation during treatment (67.3%), and 26.9% experienced more than one exacerbation. They highlighted a few important points.

1. Symptom increases did NOT predict:

• Treatment noncompletion
• Posttreatment PTSD symptom levels
• Loss of probable PTSD diagnosis.
• The trajectory of PTSD symptoms over the course of treatment.

2. Those with symptom exacerbations showed no less change in PTSD symptoms over the course of treatment (than those without symptom exacerbation).

3. Demographic variables examined were NOT associated with exacerbations

• Age
• Gender
• Years of education
• Employment status
• Military enrolment
• Veteran status

4. Diagnostic variables examined were NOT associated with exacerbations:

• Depression
• Anxiety
• Substance use
• Personality disorder

5. Strategies used to train clinicians did NOT predict exacerbations.

Summary

Larsen and colleagues provided an important Clinical Impact Statement that can be a useful guide.

“It is relatively common to experience temporary symptom increases during participation in cognitive processing therapy and other trauma-focused therapies. Our results indicate that these symptom increases may be common but are not problematic for overall treatment prognosis. Clinicians can be encouraged that clients can benefit from trauma-focused treatment even if they experience symptom exacerbations during therapy.”

This article also appeared on the blog by Dr Jon Finch, The clinician’s PTSD blog which includes articles about PTSD in general.

Reference

Larsen, S. E., Mackintosh, M.-A., La Bash, H., Evans, W. R., Suvak, M. K., Shields, N., Lane, J. E. M., Sijercic, I., Monson, C. M., & Wiltsey Stirman, S. (2020, January 23). Temporary PTSD Symptom Increases Among Individuals Receiving CPT in a Hybrid Effectiveness-Implementation Trial: Potential Predictors and Association With Overall Symptom Change Trajectory. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000545