Intensive therapy for PTSD is a relatively recent innovation. Trials have been conducted across all the major trauma focussed therapies (find reference). This includes Prolonged Exposure (PE) (Dell et. al. 2021 & Dell et. al 2023), Eye Movement Desensitisation and reprocessing (EMDR) & Prolonged Exposure (PE) combined (Auren et. al 2022, Van Woudenberg et al. 2018) and Cognitive Processing Therapy (CPT) (Bryan et. al 2018)
Both clinicians and clients may wonder if intensive therapy might be more difficult to tolerate. I am sure many a trauma clinician has experienced the discussion that goes something like this…
“So can I space out my sessions so that I have time to recover before the next one, can we make it two weeks in between. I am not really sure I could tolerate coming in more often, I don’t really know how I could handle it.”
These sentiments exist even without any discussion of intensive forms of therapy.
What is Intensive Cognitive Processing Therapy (CPT) for PTSD?
Intensive CPT, also known as massed CPT includes therapy where participants attend three or more sessions per week . This includes delivering the entire protocol in time frames from one week to three weeks. (Galovski et al., 2022; Held et al., 2023; Sciarrino et al., 2020; Wachen et al., 2024).
Why do intensive or massed trauma focus therapy?
There are some advantages to completing therapy in an intensive format. For one, it can fit into the busy life of many people. Taking time out of work in one block may be easier for some people to organise than once a week for 12 weeks.
It may increase the access to services for those who live in remote locations. Especially if the service is unavailable in their area. I once had a client travel from New Zealand to Australia to attend therapy in an intensive format.
In addition, massed CPT has lower dropout rates compared to traditional weekly and twice-weekly CPT. Clients may see results more quickly (Wright et al., 2023). Similarly, the fact that they will be seeing their therapist “tomorrow” may leave less opportunity for avoidance to interfere with treatment and may feel more supportive. A client may leave a session knowing if they feel bad, they will not have to wait long to discuss it.
But will my client feel worse? A valid question, given that many clients don’t like the idea of feeling worse and worry about feeling worse sticking. What does the research tell us about increase in symptoms?
Will intensive CPT make my client feel worse?
A study by Daniel Szoke and colleagues (2025) examined rates of symptom exacerbation in clients undergoing intensive or massed CPT for PTSD. Their study examined rates of symptom exacerbation in two samples undergoing massed CPT: veterans (N = 499) and community members (N = 69). They used the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) to measure symptom exacerbation.
Exacerbation was calculated based on changes from one assessment point to the next during treatment. Clinically reliable exacerbation, was defined as a PCL-5 score increase greater than 8.83 points in consecutive measurements taken throughout treatment.
They found that at symptom increase occurred at least once in 27.3% of veterans and 21.7% of community members during treatment. They also reported that only 1.4% of veterans and 5.8% of community members reported reliably elevated symptoms from baseline at the end of treatment. Furthermore, they described that the most common exacerbation timeline was a temporary increase.
Cavet emptor
As is the case with research there are limitations to consider, the authors outlined the following limitations:
- The veteran sample received adjunctive services, which may have had an impact on their low rates of symptom exacerbation.
- The community sample were participating in a clinical trial, where conditions were likely more controlled than in traditional community treatment settings. This could partially account for the low rates of exacerbation in this group.
- Although the veteran sample was relatively large (N = 499), the community sample had fewer participants (N = 69), which may have limited the reliability of the results presented.
Summary – will my client feel worse if they do intensive CPT?
For the majority of clients there is no clinically meaningful symptom increase, and where symptom exacerbation occurs these exacerbations are mostly temporary.
References
Auren, T. J. B., Klæth, J. R., Jensen, A. G., & Solem, S. (2022). Intensive outpatient treatment for PTSD: An open trial combining prolonged exposure therapy, EMDR, and physical activity. European Journal of Psychotraumatology, 13(2), 2128048. doi:10.1080/20008066.2022.2128048
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(12), 2070–2081. https://doi.org/10.1002/jclp.22651
Dell, L., Sbisa, A. M., Forbes, A., O’Donnell, M., Bryant, R., Hodson, S., … Forbes, D. (2023). Effect of massed v. standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial. Psychological Medicine, 53(9), 4192–4199. doi:10.1017/S0033291722000927
Dell, L., Sbisa, A. M., O’Donnell, M., Tuerk, P. W., Bryant, R., Hodson, S., Morton, D., Battersby, M., Forbes, A., & Forbes, D. (2021). Massed versus standard prolonged exposure for posttraumatic stress disorder in Australian military and veteran populations (RESTORE trial): Study protocol for a non-inferiority randomized controlled trial. Contemporary clinical trials, 107, 106478. https://doi.org/10.1016/j.cct.2021.106478
Galovski, T. E., Werner, K. B., Weaver, T. L., Morris, K. L., Dondanville, K. A., Nanney, J.,Wamser-Nanney, R., McGlinchey, G., Fortier, C. B., & Iverson, K. M. (2022). Massed cognitive processing therapy for posttraumatic stress disorder in women survivors
of intimate partner violence. Psychological Trauma: Theory, Research, Practice, and Policy, 14(5), 769–779. https://doi.org/10.1037/tra0001100
Held, P., Smith, D. L., Pridgen, S., Coleman, J. A., & Klassen, B. J. (2023). More is not always better: 2 weeks of intensive cognitive processing therapy-based treatment are noninferior to 3 weeks. Psychological Trauma: Theory, Research, Practice, and Policy, 15(1), 100–109. https://doi.org/10.1037/tra0001257
Sciarrino, N. A., Warnecke, A. J., & Teng, E. J. (2020). A systematic review of intensive empirically supported treatments for posttraumatic stress disorder. Journal of Traumatic Stress, 33(4), 443–454. https://doi.org/10.1002/jts.22556
Szoke, D., Ptak, M., Pridgen, S., Smith, D. L., & Held, P. (2025). Low rates of symptom exacerbation during and after massed cognitive processing therapy across veteran and community samples. Journal of Traumatic Stress, 1–8. https://doi.org/10.1002/jts.23158
Van Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., Lee, C. W., van Minnen, A., & De Jongh, A. (2018). Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder. European Journal of Psychotraumatology, 9(1), 1487225. doi:10.1080/20008198.2018.1487225
Wachen, J. S., Morris, K. L., Galovski, T. E., Dondanville, K. A., Resick, P. A., & Schwartz, C. (2024). Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial. Contemporary Clinical Trials, 136, Article 107405. https://doi.org/10.1016/j.cct.2023.107405
