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.

A systematic review and meta-analysis of individual and couple therapies for posttraumatic stress disorder: Clinical and intimate relationship outcomes.

The association between symptoms of posttraumatic stress disorder (PTSD) in adults and difficulties in intimate relationships is well documented. Growing literature suggests that interpersonally-oriented therapies, such as couple and family interventions, may lead to improvements in both PTSD symptoms and intimate relationship functioning. However, it is unknown how individual PTSD treatments compare to couple/family interventions in relational outcomes. The present study was a systematic review and meta-analysis of individual and couple/family treatments to examine changes in PTSD symptoms and intimate relationship functioning. Twelve couple treatment studies with 13 unique samples and 7 individual treatment studies with 9 unique samples met inclusion criteria. No family-based treatments were identified. Meta-analytic findings indicated moderate to large reductions in PTSD symptoms for both couple and individual studies. Small but significant improvements in intimate relationship functioning across individual and couple studies were observed. Moderation analysis suggested that across both individual and couple treatment formats, trauma-focused treatments had larger effects on PTSD symptoms. Trauma-focused treatments had larger effects on intimate relationship functioning for individual studies. Military status did not moderate outcomes. This study supports the utility of both individual and couple treatment formats for treating PTSD and provides preliminary support for these modalities for also enhancing intimate relationship functioning.

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).

Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review.

Some individuals with posttraumatic stress disorder (PTSD) are at elevated risk of reexposure to trauma during treatment. Trauma-focused cognitive-behavioral therapies (CBT) are recommended as first-line PTSD treatments but have generally been tested with exclusion criteria related to risk for trauma exposure. Therefore, there is limited knowledge on how to best treat individuals with PTSD under ongoing threat of reexposure. This paper systematically reviewed the effectiveness of CBTs for PTSD in individuals with ongoing threat of reexposure. Literature searches yielded 21 studies across samples at ongoing risk of war-related or community violence (n = 14), domestic violence (n = 5), and work-related traumatic events (n = 2). Medium to large effects were found from pre to posttreatment and compared with waitlist controls. There were mixed findings for domestic violence samples on long-term outcomes. Treatment adaptations focused on establishing relative safety and differentiating between realistic threat and generalized fear responses. Few studies examined whether ongoing threat influenced treatment outcomes or whether treatments were associated with adverse events. Thus, although the evidence is promising, conclusions cannot be firmly drawn about whether trauma-focused CBTs for PTSD are safe and effective for individuals under ongoing threat. Areas for further inquiry are outlined.

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.

The Effect of Therapeutic Alliance on Dropout in Cognitive Processing Therapy for Posttraumatic Stress Disorder.

A substantial number of individuals who undergo cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) drop out before receiving a full course of treatment. Therapeutic alliance, defined as the working relationship between the therapist and client, is a dynamic process within therapy that may change over time. Research suggests that therapeutic alliance is associated with dropout in various treatments. However, no studies have yet examined the association between therapeutic alliance and dropout in CPT, and few studies have examined therapeutic alliance longitudinally over the course of treatment. Examining alliance in CPT through different methods may increase clinicians' understanding of how to tailor interventions to prevent treatment dropout. The present study examined the association between therapeutic alliance and treatment dropout among 169 participants in a randomized implementation effectiveness trial. In total, 33.1% of clients dropped out over the course of CPT, and nearly half of these individuals dropped out during the first six sessions. Continuous-time survival analysis results indicated that mean ratings of alliance significantly predicted treatment dropout, Wald χ2 (1, N = 167) = 4.08, Exp(ß) = .64, p = .043, whereas initial alliance, late alliance, and change in alliance over treatment did not. These findings suggest that overall therapeutic alliance is an important predictor of dropout from CPT.

Assessing posttraumatic stress disorder with close others' collateral reports: Convergence with self- and clinician reports.

Although multisource assessment of posttraumatic stress disorder (PTSD) is considered best practice, past studies have either compared convergence between clinician interview and self-report or self- and close other collateral report of PTSD symptoms without clinician interview. Familial and interpersonal relationships are consistently found to be associated with an individual's psychological recovery following a traumatic event. Thus, it is important to understand the extent to which close others' collateral reports converge with clinician and self-reports of PTSD. This study compared self-, collateral, and clinician reports of PTSD symptom severity. Recently trauma-exposed individuals (N = 117) were assessed using the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) and completed the past-month PTSD Checklist-Specific Stressor (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993). Close others (N = 117) completed the PCL for close others (PCL-CO; Monson, 2012) that assessed their perceptions of the trauma-exposed individual's PTSD symptoms. There were significant positive correlations among PCL, PCL-CO, and CAPS total and symptom cluster scores (rs = .36-.80). Correlations were significantly stronger between clinician and self-report ratings than self-report and collateral ratings. The weakest correlations were between the PCL and PCL-CO assessing hyperarousal symptoms, r = .36, p < .01, and CAPS and PCL-CO assessing intrusive symptoms, r = .37, p < .01. Self-report measures may provide reliable PTSD assessment when clinician semistructured assessment is unfeasible. Convergence between close others' collateral and clinician and collateral and self-assessment was comparatively weak. Hyperarousal and intrusive symptoms may be more difficult for collaterals to observe and report. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review.

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post-operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty-four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post-operative period before significant problematic eating behaviours and weight regain occur.

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 systematic review of cognitive and behavioral treatments for individuals with psoriasis.

Background: Although there are effective dermatological treatments for psoriasis, a proportion of individuals also experience psychological distress not addressed by these treatments. Psychological factors may be targeted by cognitive behavioral therapy (CBT) which may in turn also decrease psoriasis severity.Method: A systematic review using PsycINFO, PubMed, and SCOPUS databases was performed in 2019 to examine the efficacy of treatments that delivered psychotherapy with a major cognitive/behavioral component to patients with psoriasis. Quality of included studies was assessed.Results: Nine randomized controlled trials with 8 unique samples met inclusion criteria. Study quality ranged from fair to good. Half of the studies found improved psoriasis severity following treatment. Several studies found improvements following treatment in anxiety, depression, and stress. The studies that reported non-significant findings on psychological outcomes had samples with healthy baseline psychological functioning. Nearly all studies that examined quality of life as an outcome found improvements following treatment.Conclusion: CBT as an adjunct to conventional dermatological treatments may be particularly beneficial for individuals with more severe pretreatment psychopathology in improving psoriasis severity, anxiety, and depression symptoms. CBT appears to be generally effective in improving quality of life. Greater methodological rigor is needed in future research.

Examining patterns of dose response for clients who do and do not complete cognitive processing therapy.

Trauma-focused therapies, including Cognitive Processing Therapy (CPT; Resick et al., 2016), are effective at reducing clients' PTSD symptoms. A limitation to these treatments, however, is client completion of them. The current study examined temporal patterns of treatment non-completion and the relationships among non-completion, PTSD, and overall mental health functioning outcomes, among clients in a randomized controlled CPT implementation trial. Two models of symptom change were tested: 1) dose-effect model (i.e., clients uniformly improve with additional sessions at a negatively accelerating rate); and 2) the good-enough level model (i.e., clients remain in therapy until they have achieved sufficient improvement, thus clients who attend fewer sessions improve at quicker rates). Results indicated that 42% of clients did not complete treatment, with most discontinuing between sessions two and five. Data did not fit the dose-effect or good-enough level model. Rather, clients who improved at a greater rate in their PTSD symptoms and overall mental health functioning attended more sessions. The average client had the best outcomes when they completed all 12 sessions. Identifying clients who may be at risk for discontinuing treatment, and making a concerted effort toward retaining them, is imperative to reduce non-completion rates and ultimately improve client outcomes.

Internet-Delivered Early Interventions for Individuals Exposed to Traumatic Events: Systematic Review.

BACKGROUND: Over 75% of individuals are exposed to a traumatic event, and a substantial minority goes on to experience mental health problems that can be chronic and pernicious in their lifetime. Early interventions show promise for preventing trauma following psychopathology; however, a face-to-face intervention can be costly, and there are many barriers to accessing this format of care. OBJECTIVE: The aim of this study was to systematically review studies of internet-delivered early interventions for trauma-exposed individuals. METHODS: A literature search was conducted in PsycINFO and PubMed for papers published between 1991 and 2017. Papers were included if the following criteria were met: (1) an internet-based intervention was described and applied to individuals exposed to a traumatic event; (2) the authors stated that the intervention was intended to be applied early following trauma exposure or as a preventive intervention; and (3) data on mental health symptoms at pre-and postintervention were described (regardless of whether these were primary outcomes). Methodological quality of included studies was assessed using the Downs and Black checklist. RESULTS: The interventions in the 7 studies identified were categorized as selected (ie, delivered to an entire sample after trauma regardless of psychopathology symptoms) or indicated (ie, delivered to those endorsing some level of posttraumatic distress). Selected interventions did not produce significant symptom improvement compared with treatment-as-usual or no intervention control groups. However, indicated interventions yielded significant improvements over other active control conditions on mental health outcomes. CONCLUSIONS: Consistent with the notion that many experience natural recovery following trauma, results imply that indicated early internet-delivered interventions hold the most promise in future prevention efforts. More studies that use rigorous methods and clearly defined outcomes are needed to evaluate the efficacy of early internet-delivered interventions. Moreover, basic research on risk and resilience factors following trauma exposure is necessary to inform indicated internet-delivered interventions.

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.

The Role of Social Support in Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder.

The current study examined the effect of total, as well as different sources (i.e., family, friends, significant other) of, pretreatment/baseline social support on posttraumatic stress disorder (PTSD) severity and treatment response to cognitive-behavioral conjoint therapy (CBCT) for PTSD. Thirty-six patients were randomized to receive treatment immediately or to a waitlist condition. Those in the treatment condition were offered CBCT for PTSD, a couple-based therapy aimed at reducing PTSD symptoms and improving relationship functioning. PTSD symptoms were assessed at pre-/baseline, mid-/4 weeks of waiting, and posttreatment/12 weeks of waiting using the Clinician-Administered PTSD Scale, and patients self-reported on their levels of pretreatment/baseline social support using the Multidimensional Scale of Perceived Social Support. Total support, as well as social support from family and friends, was not associated with initial PTSD severity or treatment response. However, there was a significant positive association between social support from a significant other and initial PTSD severity (g = .92). Additionally, significant other social support moderated treatment outcomes, such that higher initial significant other support was associated with larger decreases in PTSD severity for those in the treatment condition (g = -1.14) but not the waitlist condition (g = -.04). Social support from a significant other may influence PTSD treatment outcomes within couple therapy for PTSD. The inclusion of intimate partners and other family members may be a fruitful avenue for improving PTSD treatment outcomes; however, future studies are needed to examine whether support can be increased with treatment and whether those improvements lead to greater PTSD symptom response.

The interpersonal context of client motivational language in cognitive-behavioral therapy.

Previous research has found that client motivational language (especially arguments against change or counterchange talk; CCT) in early therapy sessions is a reliable predictor of therapy process and outcomes across a broad range of treatments including cognitive-behavioral therapy (CBT). Existing studies have considered the general occurrence of CCT, but the present study differentiated 2 types of CCT in early CBT sessions for 37 clients with generalized anxiety disorder: (a) statements that are uttered to express ambivalence regarding change versus (b) statements that are intended to oppose the therapist or therapy. Two process coding systems were used to accomplish this differentiation. Findings indicated that a higher number of CCT statements that occurred in the presence of resistance (opposition to the therapist or therapy) were a substantive and consistent predictor of lower homework compliance and poorer outcomes, up to 1 year posttreatment. Moreover, when both types of CCT were considered together, only opposition CCT was related to outcomes, and ambivalent CCT was not significantly predictive of proximal and distal outcomes. These findings suggest that the interpersonal context in which CCT statements occur may be critically important to their predictive capacity. More broadly, the findings of this study have implications for the future study of client motivational language and underscore the clinical importance of detecting opposition CCT.