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.
