An examination of the therapeutic alliance, treatment engagement, and processing during symptom increases in cognitive processing therapy for posttraumatic stress disorder
Date
2025
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Publisher
University of Delaware
Abstract
Cognitive Processing Therapy (CPT) is an effective, gold-standard treatment for adult posttraumatic stress disorder (PTSD), although some clinicians are reluctant to use the treatment, and the rates of client dropout are high. These challenges often center around periods of increased distress during treatment, as clients engage with and process traumatic experiences. Research has shown the importance of constructive processing and treatment engagement in CPT; however, it is not clear how to facilitate these processes during particularly challenging sessions. This study coded the content of CPT sessions that occurred at maximum PTSD symptom increases for each client. Two observational coding measures (CHANGE and the Working Alliance Inventory-Observer Version-Short Form) were used to better understand what may be happening during these opportunities for change. The sample included 57 adults with PTSD, who received CPT as part of a non-inferiority trial that compared CPT to written exposure therapy (WET), a brief, narrative only condition. This study included the therapeutic alliance, two variables related to processing (cognitive emotional processing, capitalization), and two variables that can interfere with treatment engagement (avoidance, overgeneralization). Bivariate correlations showed that higher alliance scores for the sessions with the maximum PTSD symptom increases were associated with more client cognitive emotional processing, more capitalization, and less overgeneralization. Hierarchical multiple regression analyses showed that more cognitive emotional processing during these sessions predicted a greater number of sessions completed. Finally, latent growth curve modeling showed that higher alliance predicted a greater decrease in the slope of PTSD symptoms from baseline to 24 weeks. These findings may help to identify facilitators of change in CPT, provide practical suggestions to reduce dropout, and highlight the importance of the alliance during treatment. ☐ Keywords: PTSD, Cognitive processing therapy, therapeutic alliance, processing, treatment engagement
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Keywords
Cognitive Processing Therapy, Therapeutic alliance, Treatment engagement, Cognitive emotional processing, Posttraumatic stress disorder