My client does not seem to be progressing. Should I make changes to the therapy?

This is a question often heard in supervision. When it comes to Cognitive Processing Therapy and this question, there is research to help guide clinicians.

LoSavio, et al. (2019) examined unhelpful beliefs that therapist might have about CPT (in CPT language “stuck points”) and PTSD treatment. For example, “If I press my client about completing assignments, it will make them quit.” They found that if therapist had more consultation they had less of these unhelpful beliefs. Similarly, they found that greater reduction in stuck points over time predicted greater competence in CPT.

In another study Marques et al. (2019) examined modifications to CPT to address contextual or client-level challenges in routine care settings; in contrast to the research setting.


They found that fidelity-consistent modifications were associated with larger reductions in both PTSD and depression. They stated:

“The findings also suggest that effective Evidence Based Psychotherapy delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention.” (pg 357)

Fidelity-consistent: Modifications that do not change core elements of the treatment in such a way that reduces adherence to the intervention protocol or make it challenging to differentiate between treatments.

Examples of fidelity-consistent modifications include modifying the language, cultural adaptations, and lengthening sessions to more than 60 minutes.

Fidelity-inconsistent: Modifications that do alter the inclusion or delivery of core elements of the intervention protocol, and/or make it difficult to differentiate between treatments.

Examples of fidelity-inconsistent modifications include skipping components of the therapy, such as a CPT module, worksheet, or psychoeducation element. It also includes integrating other approaches or modifications that are techniques from other treatment approaches. Such as introducing mindfulness techniques.


While the temptation to change therapy can be strong when a client does not seem to be progressing the research suggests that examining our own beliefs about the client’s progress and considering changes that are consistent with the essential elements of CPT will help.

LoSavio, S.T., Dillon, K.H., Murphy, R. A. & Resick, P. A. (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes. Professional Psychology: Research and Practice. Advance online publication. PTSDpubs ID: 52080

Marques, L., Valentine, S. E., Kaysen, D., Mackintosh, M., Dixon De Silva, L. E., Ahles, E. M., Wiltsey-Stirman, S. (2019). Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. Journal of Consulting and Clinical Psychology, 87, 357-369. PTSDpubs ID: 51932

To learn more about how you can apply therapy with your client in a professional and caring manner, check out latest psychology professional devleopment workshops.