Many clinicians in Australia would describe themselves as eclectic and strongly believe in being client centred and being responsive to a client’s current needs and goals. So, what does that mean when delivering a treatment that has a session by session protocol? What happens if a client experiences a crisis, doesn’t engage with some elements of the protocol, wants to finish early or keeps bringing up issues that are not related to processing a traumatic memory or addressing PTSD?
In this article we’ll summarise the research around some key issues that impact on treatment fidelity and outcomes.
Do I need to do the full 12 sessions of the protocol?
While the CPT protocol has a 12 sessions worth of material, many CPT therapists will say that some clients will not need the full protocol while other clients may require more sessions. And this is correct. There is evidence that some clients will recover early while others will require more time. A seminal study by Galovski et al. (2012) found that 58% of clients required less than 12 sessions of CPT to have significant improvements in posttraumatic symptoms and depression, while 34% required between 13 to 18 sessions to recover. Other studies describe delivering CPT across a varied number of sessions. For example, Chard et al. (2005) developed a 16 session protocol for survivors of child sexual abuse and more recent research with veterans and military personnel has shown that CPT can be delivered flexibly for up to 24 sessions (Resick et al. 2020). Other studies have shown that clients that finish early can still benefit from CPT (LoSavio et al. 2019).
Monitoring client progress is an important aspect of maintaining hope, motivation and therapeutic alliance in CPT. It can also help set up a conversation about expectations about recovery and what improvements in symptoms look like from the therapists and client’s point of view. In fact, the CPT manual suggests that from the start clients and therapist discuss using the PCL-5 to monitor symptoms, and that if scores on the PCL drop below 20, the therapist can consider talking about finishing the therapy early (Resick, Monson & Chard, 2017).
So, there is flexibility in the length of CPT, provided that the therapist and client have a way of discussing and monitoring progress and symptom change so that the completion of the protocol is based on a systematic and shared understanding of symptom improvement.
Do I need to do the full protocol or can I just use elements of CPT?
The developers of CPT have indicated that there are central elements to the therapy (Resick, Monson & Chard, 2017), specifically the effective use of Socratic questioning, prioritising assimilated over over-accommodated stuck points; ensuring that practice assignments are completed outside of sessions and that clients are able to get in touch and express affect related to trauma and day-to-day experiences associated with stuck points. One research study examined if delivering the whole protocol with fidelity (where the therapist delivers each session as prescribed by the manual and demonstrates a reasonable level of competence) or whether delivering the core elements of CPT with fidelity impact on client outcomes (Farmer et al. 2016). The authors found that that fidelity when delivering some of the core aspects of CPT, especially high competency in Socratic questioning and prioritising assimilated stuck points was associated with improvements in PTSD symptoms. However, therapist fidelity did not impact significantly on session-by-session outcomes. This suggests that fidelity and competence in delivering these core elements across the CPT protocol may be more important than session-by-session fidelity. Another study also found that competence in Socratic questioning was associated with a reduction in PTSD symptoms (Marques et al., 2019).
It is important to note that the Farmer et al. (2016) study had a reasonably small sample, that therapists in the trial demonstrated high fidelity overall and that it did not measure what the client did (for example completion of homework which some CPT experts have associated with improvements in outcomes).
So, what is the conclusion for therapists wondering what aspect of CPT is important to recovery? At this stage we know that overall fidelity matters, but that competence in Socratic questioning and the priority we give to addressing certain type of stuck points are probably critical to recovery from PTSD.
Can I stop the protocol to deal with crises?
Crises such as losing external safety (e.g., loss or imminent loss of safe housing or increase in family violence risk), increased risk of suicide attempt or serious self-harm or psychiatric hospitalisations can at times interrupt CPT. Clients can also see daily life stressors and conflicts as crises, particularly when they have experienced complex and developmental trauma. The question for many therapists is when is it OK to interrupt the protocol for addressing this latter type of crisis?
Given that fidelity appears to be important for client outcomes and that maintaining motivation and momentum for a client which has to face and manage avoidance symptoms can also be a challenge, it is important to have a way to limit interruptions in CPT. One way to do this is to develop a shared understanding of what constitutes a crisis that would necessitate off-protocol sessions when preparing clients for CPT. This makes it easier when a client presents at a session in crisis to collaboratively assess whether to go on with the protocol or have a session that addresses the present crisis. CPT experts also recommend that, wherever possible, crises be addressed using CPT skills and elements (e.g., identifying and challenging stuck points associated with situation). They also agree that returning to the protocol as soon as possible is beneficial. A book by Galovski, Nixon & Kaysen (2020) provides practical descriptions of how to use CPT in a flexible manner and provides clinical guidance on treating PTSD with patients presenting with a range of comorbid issues.
Conclusion
While there is quite a bit of flexibility in how CPT can be delivered, it does require commitment from both therapist and client to a sustained and systematic intervention focussing on processing a traumatic event. It is therefore important to get the client on board and to help them understand the rationale for CPT. The client needs to understand how CPT aligns with their recovery goals and have a shared understanding of what recovery looks like with their therapist. This will make it easier to work within the structure of CPT.
References
Farmer C.C., Mitchell K.S., Parker-Guilbert K., Galovski T.E. (2017). Fidelity to the cognitive processing therapy protocol: evaluation of critical elements. Behaviour Therapy, 48, 195–206.
Galovski, T., Nixon R., Kaysen. (2020). Flexible Applications of Cognitive Processing Therapy. Evidence-Based Treatment Methods. Academic Press.
Galovski, T. E., Blain, L., Mott, J., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80, 968–981.
LoSavio, S. T., Dillon, K. H., Murphy, R. A., Goetz, K., Houston, F., & Resick, P. A. (2019). Using a Learning Collaborative Model to Disseminate Cognitive Processing Therapy to Community-Based Agencies. Behavior Therapy, 1, 36.
Marques L., Valentine S.E., Kaysen D., Mackintosh M.A., Dixon De Silva L.E. …Wiltsey-Stirman S. (2019). Journal of Consulting and Clinical Psychology, 87, 357-369.
Resick P., Wachen J., Dondanville K., LoSavio s., S. Young-McCaughan, … Mintz J. (2021), Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors, Behaviour Research and Therapy, 141, https://doi.org/10.1016/j.brat.2021.103846
Resick P., Monson, C. & Chard, K. (2017). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. London: The Guildford Press.