Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making.

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings.

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes.

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1-3 and one session from Sessions 4-7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18-0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.

Temporary PTSD symptom increases among individuals receiving CPT in a hybrid effectiveness-implementation trial: Potential predictors and association with overall symptom change trajectory.

OBJECTIVE: Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. METHOD: We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. RESULTS: Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. CONCLUSIONS: The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Effect of PTSD Symptom Change on Suicidal Ideation in a Combined Military and Civilian Sample Engaged in Cognitive Processing Therapy.

In light of the well-established relationship between posttraumatic stress disorder (PTSD) and suicidal ideation (SI), there has been a push for treatments that simultaneously improve symptoms of PTSD and decrease SI. Using data from a randomized controlled hybrid implementation-effectiveness trial, the current study investigated the effectiveness of Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016) on PTSD and SI. The patient sample (N = 188) was diverse in military and veteran status, gender, and comorbidity, and 73% of the sample endorsed SI at one or more points during CPT. Participants demonstrated significant improvement in SI over the course of CPT. Multilevel growth curve modeling revealed a significant association between PTSD symptom change and change in SI. Results from cross-lagged multilevel regressions indicated that PTSD symptoms predicted SI in the next session, yet SI in a given session did not predict PTSD symptoms in the next session. Potentially relevant clinical factors (i.e., military status, gender, depression diagnosis, baseline SI, study consultation condition) were not associated with the relationship between PTSD symptoms and SI. These results add to the burgeoning literature suggesting that evidence-based treatments for PTSD, like CPT, reduce suicidality in a range of individuals with PTSD, and that this reduction is predicted by improvements in PTSD symptoms.

A Glimpse into the "Black Box": Which Elements of Consultation in an EBP are Associated with Client Symptom Change and Therapist Fidelity?

Background: Consultation is an implementation strategy that improves delivery and clinical outcomes for Cognitive Processing Therapy (CPT), an evidence-based practice (EBP) for posttraumatic stress disorder (PTSD). However, little is known about the specific components of consultation that influence the fidelity of treatment delivery or clinical outcomes. Methods: The current study examined whether specific activities performed during CPT consultation meetings were associated with better fidelity to the CPT protocol among 60 newly trained therapists or improved clinical outcomes among 135 clients treated by these therapists. Consultation activities that fall under three broad categories (discussion of the application of CPT to individual cases, review/feedback on fidelity, and technical difficulties) were measured by consultant checklists for each consultation session. Treatment fidelity (adherence to the protocol and competence of delivery) was rated by trained observers for a random sample of therapists' CPT sessions following consultation. The self-reported PTSD Checklist-IV assessed PTSD symptom change. Results: Multilevel regression analyses indicated that higher therapist consultation attendance predicted a greater decrease in their clients' PTSD symptoms and that attendance was not associated with observer-rated treatment fidelity. Discussion of the application of specific CPT strategies was the only consultation activity that was significantly associated with greater improvement in PTSD symptoms. Lastly, no consultation activities were significantly associated with treatment fidelity. Conclusions: Our findings suggest that specific consultation strategies such as emphasizing the discussion of the application of specific CPT strategies to individual cases during consultation meetings may be effective in improving the clinical outcomes of CPT.

Patterns of change in physical functioning and posttraumatic stress disorder with cognitive processing therapy in a randomized controlled implementation trial.

Background: Physical health concerns (e.g. chronic pain, fatigue) are common among clients with posttraumatic stress disorder (PTSD). Prior research has indicated that clients report improved physical functioning and fewer physical health symptoms after receiving Cognitive Processing Therapy (CPT) for PTSD. However, less is known about the impact of physical functioning on the clients' PTSD symptom improvement in CPT. Objective: The current study examined the patterns of change of and between physical functioning and PTSD symptoms over the course of CPT among a diverse military, veteran, and community sample. Method: We collected clients' (N = 188) physical functioning and PTSD symptom severity prior to and during CPT using the 12-Item Short Form Health Survey and the PTSD Checklist. We used multilevel modelling to 1) evaluate the impact of baseline physical functioning on the PTSD symptom trajectory, 2) examine the trajectory of physical functioning, and 3) assess the dynamics between physical functioning and PTSD symptoms over the course of CPT. Results: Our multilevel analyses indicated that 1) physical functioning significantly improved for those with low levels of functioning prior to treatment, 2) poorer baseline physical functioning predicted slower improvements in PTSD symptoms, and 3) poorer physical functioning in one session predicted less PTSD symptom improvement by the next session. Conclusions: Our findings demonstrate that while physical functioning can interfere with PTSD symptom improvement, physical functioning can also improve over the course of CPT. In light of the interconnected nature of physical health and PTSD symptoms, clinicians may need to attend to lower levels of physical functioning when providing CPT or other trauma-focused therapies. Future research to determine whether specific treatment adaptations may benefit such clients is needed.

Antecedentes: Los problemas de salud física (ej. dolor crónico, fatiga) son comunes entre los clientes con trastorno de estrés postraumático (TEPT). La investigación previa ha indicado que los clientes reportan una mejoría en el funcionamiento físico y menos síntomas de salud física después de recibir Terapia de Procesamiento Cognitivo (CPT, por su sigla en inglés) para TEPT. Sin embargo, se sabe menos sobre el impacto del funcionamiento físico sobre la mejoría de los síntomas de TEPT de los clientes en la CPT.Objetivo: El presente estudio examinó los patrones de cambio del funcionamiento físico y los síntomas de TEPT, por separado y entre sí, en el curso de la CPT en una muestra diversa de militares, veteranos y personas de la comunidad.Método: Recolectamos el funcionamiento físico y la severidad de los síntomas de TEPT de los clientes (N=188) antes y durante la CPT, utilizando el Cuestionario Corto de Salud de 12 items y la Lista de chequeo de TEPT. Utilizamos un modelo multinivel para 1) evaluar el impacto del funcionamiento físico basal sobre la trayectoria de los síntomas de TEPT, 2) examinar la trayectoria del funcionamiento físico, y 3) evaluar la dinámica entre el funcionamiento físico y los síntomas de TEPT en el curso de la CPT.Resultados: Nuestros análisis multinivel indicaron que 1) el funcionamiento físico mejoró en forma significativa en quienes tenían bajos niveles de funcionamiento antes del tratamiento, 2) un peor funcionamiento físico basal predijo una mejoría más lenta de los síntomas de TEPT, y 3) un peor funcionamiento físico en una sesión predijo una menor mejoría sintomática en la siguiente sesión.Conclusiones: Nuestros hallazgos demuestran que mientras que el funcionamiento físico puede interferir con la mejoría de los síntomas de TEPT, el mismo también puede mejorar en el curso de la CPT. A la luz de la naturaleza interconectada de la salud física y lossíntomas de TEPT, los clínicos pueden necesitar poner atención a niveles más bajos de funcionamiento físico cuando proveen CPT u otras terapias centradas en el trauma. Se requiere futura investigación para determinar si estos clientes se pueden beneficiar de adaptaciones de tratamiento específicas.

Bidirectional Relationships Between Posttraumatic Stress Disorder and Social Functioning During Cognitive Processing Therapy.

This study investigated temporal relationships between posttraumatic stress symptoms and two indicators of social functioning during cognitive processing therapy. Participants were 176 patients (51.5% female, M age = 39.46 [SD = 11.51], 89.1% White, 42.6% active duty military/veteran) who participated in at least two assessment time points during a trial of cognitive processing therapy. Posttraumatic stress disorder (PTSD) symptoms (PTSD Checklist for DSM-IV) and interpersonal relationship and social role functioning problems (Outcome Questionnaire-45) were assessed prior to each of 12 sessions. Multivariate multilevel lagged analyses indicated that interpersonal relationship problems predicted subsequent PTSD symptoms (b = .22, SE = 0.09, cr = 2.53, p = .01, pr = .46) and vice versa (b = .05, SE = 0.02, cr = 2.11, p = .04, pr = .16); and social role functioning problems predicted subsequent PTSD symptoms (b = .21, SE = 0.10, cr = 2.18, p = .03, pr = .16) and vice versa (b = .06, SE = 0.02, cr = 3.08, p < .001, pr = .23). Military status moderated the cross-lag from social role functioning problems to PTSD symptoms (b = -.35, t = -2.00, p = .045, pr = .16). Results suggest a robust association between PTSD symptoms and social functioning during cognitive processing therapy with a reciprocal relationship between PTSD symptoms and social functioning over time. Additionally, higher social role functioning problems for patients with military status indicate smaller reductions in PTSD symptoms from session to session.

Correction to: The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial.

The article "The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial", written by Iris Sijercic, Jeanine E. M. Lane, Cassidy A. Gutner, Candice M. Monson and Shannon Wiltsey Stirman, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 28 August 2019 with open access. With the author(s)' decision to step back from Open Choice, the copyright of the article changed on 30 August 2019 to © Springer Science+Business Media, LLC, part of Springer Nature 2019 and the article is forthwith distributed under the terms of copyright.

The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial.

A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.

A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes.

This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.

An uncontrolled trial of a present-focused cognitive-behavioral conjoint therapy for posttraumatic stress disorder.

OBJECTIVE: The efficacy of a present-focused version of cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) was examined in a community sample. METHOD: Seven couples completed pretreatment assessments, including measures of clinician-, self- and partner-rated PTSD symptoms and relationship satisfaction. Six couples completed present-focused CBCT for PTSD and all posttreatment assessments. A seventh couple terminated their relationship prior to completing treatment; therefore, they completed posttreatment symptom measures, but not ratings of relationship satisfaction. RESULTS: Results revealed significant decreases in PTSD symptoms that were associated with medium-to-large effect sizes. Medium effect sizes for changes in relationship satisfaction were found, though were only significant for partners. CONCLUSION: Results from this pilot study suggest that present-focused CBCT for PTSD may be a promising alternative for individuals who are unwilling to engage in a trauma-focused treatment.