My guess would be that most clinicians would think that trauma therapy would take a long time. This case study shows otherwise. More on that below.
Why CPT in a week
Previous research has shown that there are often practical barriers to attending therapy for PTSD. Browne et al. (2019) reported that greater than one five of their sample (> 20%) cited difficulty with scheduling appointments as the reason for non-attendance across treatments. Other barriers commonly cited (> 15%), included transportation and therapy taking too much time.
Jennifer Smith, and colleagues’ (2020) study reported, time constraints, such as being unable to take time off work or not having time for treatment, wait times at clinics, clinic location and hours, distance to the clinic, transportation issues, were barriers attendance.
Being able to offer therapy in a flexible manner can open up opportunities for clients to receive treatment. The standard once a week therapy session is etched into the psyche of most psychologist. But does it have to be so?
Intensive treatment – the research so far
Bryan, and colleagues (2018) treated Military Servicemembers and Veterans with PTSD or subthreshold PTSD (N = 20) for 12 sessions of individual CPT over 2 weeks. Similarly, Elizabeth Goetter (2020) and her team examined the effectives of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) for military service personnel in an intensive treatment program delivered over two-week period. Most of the initial research on CPT has been conducted with twice weekly sessions, over a six week period.
Will my client cope?
Some other important points to consider in regard to intensive treatment. Just in case you are thinking; “How will the client manage all that stress”. The stress of talking out the trauma intensively.
Holder et al. (2019) study of CPT found that clients attended more sessions when they higher levels of negative cognitions about self-blame. They also found that no baseline symptoms predicted treatment dropout. Hence, someone feeling bad attended more sessions. Similarly, Rizvi et al. (2009) found that affective states (i.e., depression, trait anger, global guilt) did not predict treatment dropout. Once again more bad feeling, not predicting dropout. Of course the assumption here is that bad feeling will happen, and bad feeling is the cause of drop out.
CPT in a week
Philip Held and team ( 2020) presented a case study. Hence it is important to keep in mind that N = 1. That said here is a summary of their findings of CPT in a week – CPT-5.
What they did
Each day, the client received two 50-minute CPT sessions for a total of 10 sessions. The client chose morning appointments, with one hour between. The client completed the assigned practice in the waiting room during the hour break.
The client completed the PTSD and PHQ-9 every day to assess PTSD and depression symptoms. The client was instructed to rate his symptom severity for only the past 24 hours. This is in contrast to the standard past week rating. They also completed the Trauma-Related Guilt Inventory.
Following the completion of CPT-5, the client was referred back to his original treatment provider. They received continued care in the form of fortnightly appointments. A CPT-booster approach or general Cognitive Behavioural Therapy was used.
What they found
After Session 4 symptoms for PTSD and depression were below diagnostic cut-offs.
PCL-5 reduced from 58 at baseline to 34
PHQ-9 reduced from 19 at baseline to 9
Held and colleagues (2020) reported that the clients “symptom trajectory was similar to those reported in larger studies of traditional CPT (e.g., Galovski et al., 2012) with symptoms reducing after Session 4 once assimilated stuck points had been sufficiently challenged.” Pg 8
Graphs of the following data are at the bottom of the page.
One-week post-treatment appointment
PCL-5 score: 32
PHQ-9 score: 8
Two week follow up
The client did not attend his two weeks post treatment follow up. He later reported he had been experiencing interpersonal conflict with his ex-wife. This led to a brief period of binge-drinking.
Four week follow up
PCL-5 score: 39
PHQ-9 score: 16
The client had abstained from alcohol for the past week. However, his depression symptoms were significantly elevated (close to baseline). In contrast to this the client stated, “I don’t really think about [index trauma] anymore, it’s really more about what’s going on in my life now”.
Six week follow up
PCL-5 score: 24
PHQ-9 score: 8
Eight week follow up
PCL-5 score: 14
PHQ-9 score: 3
The client reported that he had been accepted into a local university. Where he planned to pursue his bachelor’s degree. He stated that “I’ve tried and failed at this before, but I feel like my head is actually in the right place now”.
PTSD symptom severity by treatment day as measured by the PTSD Checklist for DSM-5.
Depression symptom severity by treatment day as measured by the Patient Health Questionnaire-9.
Trauma-related guilt cognitions by treatment day as measured by the Trauma-Related Guilt Inventory.
Images used under the fair use doctrine, Section 107 of the Copyright Act (U.S.)
Summary
While more research needs to be done. This particular case suggests there are multiple options for the treatment time frame when using CPT. More options such as this gives clients more opportunity for treatment. This is assuming clinicians are able to mange schedules also and are willing to try this modality. This might mean a cognitive shift for clinicians who may have the “therapy once a week” mantra in their psyche.
References
Browne, K. C., Chen, J. A., Hundt, N. E., Hudson, T. J., Grubbs, K. M., & Fortney, J. C. (2019). Veterans self-reported reasons for non-attendance in psychotherapy for posttraumatic stress disorder. Psychological Services. Advance online publication. PTSDpubs ID: 1516900
Bryan, C. J., Leifker, F. R., Rozek, D. C., Bryan, A. O., Reynolds, M. L., Oakey, D. N., & Roberge, E. (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. PTSD pubs ID: 50809
Galovski TE, Blain LM, Mott JM, Elwood L, & Houle T (2012). Manualized therapy for PTSD: flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968–81. 10.1037/a0030600 [PubMed: 23106761]
Goetter, E. M., Blackburn, A. M., Stasko, C., Han, Y., Brenner, L. H., Lejeune, S., Tanev, K. S., Spencer, T. J., & Wright, E. C. (2020, September 10). Comparative Effectiveness of Prolonged Exposure and Cognitive Processing Therapy for Military Service Members in an Intensive Treatment Program. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000956
Held, P., Klassen, B. J., Small, C. F., Brennan, M. B., Horn, R. V., Karnik, N. S., Pollack, M. H., & Zalta, A. K. (2020). A Case Report of Cognitive Processing Therapy Delivered over a Single Week. Cognitive and behavioral practice, 27(2), 126–135. https://doi.org/10.1016/j.cbpra.2019.07.006
Holder, N., Holliday, R., Wiblin, J., LePage, J. P., & Suris, A. (2019). Predictors of dropout from a randomized clinical trial of cognitive processing therapy for female veterans with military sexual trauma-related PTSD. Psychiatry Research, 276, 87-93. PTSDpubs ID: 52240 A
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.
Rizvi, S. L., Vogt, D. S., & Resick, P. A. (2009). Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behaviour Research and Therapy, 47(9), 737. doi:http://dx.doi.org/10.1016/j.brat.2009.06.003
Smith, J. R., Workneh, A., & Yaya, S. (2020). Barriers and Facilitators to Help-Seeking for Individuals With Posttraumatic Stress Disorder: A Systematic Review. Journal of traumatic stress, 33(2), 137–150. https://doi.org/10.1002/jts.22456
