The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Cognitive Processing Therapy (CPT) is an evidenced based intervention for the treatment of PTSD and related conditions in adults and adolescents. CPT is a type of Cognitive Behavioural Therapy (CBT). It focuses primarily on identifying patients “stuck points” (i.e. patient specific thoughts about the trauma, and the implications of the trauma), and challenging these stuck points, particularly those associated with self-blame, hindsight bias, and humiliation. Consequently, patients undergoing CPT are able to challenge negative thoughts associated with the trauma, arrive at a more accurate interpretation of the trauma event, resulting in a reduction of trauma effect on life.
CPT is typically delivered over 12 sessions, but can be delivered over 8-15 sessions, depending on patient’s needs. Sessions are delivered weekly over 60 minutes for individual sessions, over 90 minutes for group sessions (6-10 patients per group), or in combined individual and group sessions. Components of the CPT sessions include psychoeducation; identifying and understanding thoughts and feelings about the traumatic event; learning skills to challenge maladaptive thoughts and beliefs; and addressing five areas of thinking most likely disrupted by trauma (i.e. safety, intimacy, trust, control/power, and self-esteem). Depending on patient’s decision, written account of the trauma event may or may not be included as part of the intervention, as the focus of CPT is on patient’s thoughts of the trauma and not on the specific details of the trauma. There is a homework component to CPT (including writing tasks and worksheet completion) as it provides opportunities for patients to address stuck point outside of the sessions.
Fidelity
NICE recommends that trauma focused CBT interventions should be delivered by trained practitioner(s) with ongoing supervision, typically over 8-12 sessions (or more if clinically indicated). It is necessary that CPT is delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure consistency in delivery of intervention.
The CPT Therapist Adherence and Competence Protocol—Revised (Macdonald, Wiltsey-Stirman, Wachen, Resick, 2014) or the original format Therapist adherence and competence (TAC; Nishith & Resick, 1994) can be used to assess fidelity. Raters should have experience treating PTSD with CPT https://cptforptsd.com/achieving-provider-status/; https://www.ptsd.va.gov/professional/articles/article-pdf/id51932.pdf; https://www.sciencedirect.com/science/article/pii/S0005789416000368?via%3Dihub.
Modifiable Components
The CPT for PTSD comprehensive manual is available in English, and has been translated into multiple languages including Arabic, Chinese, Spanish, French, and Kurdish. CPT can be delivered face-to-face (e.g. outpatient clinic setting, community setting, residential treatment programmes), virtually (via tele-videoconferencing), or via mobile apps (e.g. CPT coach, PTSD coach). CPT, in form of Developmentally adapted CPT (D-CPT), has been developed for use in adolescents for the treatment of abuse-related posttraumatic stress disorder (PTSD). https://pubmed.ncbi.nlm.nih.gov/24101403/;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4055428/; https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2730003; https://link.springer.com/content/pdf/10.1007/s10567-013-0156-9.pdf. Depending on patients’ decision, written account of the trauma event may or may not be included as part of therapy. CPT has been shown to be effective in reducing PTSD symptoms in special populations including people with borderline personality disorder, comorbid alcohol use disorders, and those with traumatic brain injury. CPT has also been shown to improve symptoms of comorbidities associated with PTSD (including depression, health related concerns, sleep impairment), and in the treatment of complex PTSD.
Supports - Rating: 2
2 - Minimally Supported
Limited resources are available beyond a curriculum or once-off training
Implementation support
There is currently no implementation support provided through funded programmes in NHS Scotland.
Implementation support is provided by the CPT developer, co-developers, and CPT consultants. Supports provided include clinician CPT training, consultation, and access to programme resources (including CPT worksheet, client and therapist book, handouts, and CPT manual). Training and support can be accessed via the official website for Cognitive Processing Therapy (CPT). Free, self-paced online CPT training is also available to mental health professionals via the Medical University of South Carolina site.
Licence Requirements
Licence requirements not confirmed.
Start-up Costs
Costs for delivery of CPT include costs of 2-day live webinar training charged at $459.99 (includes training and CPT manual); Cognitive Behavioural Therapy Worksheets at $19.99; and CBT Deck for Clients and Therapists (Book) at $14.99. Other costs for clinician seeking to achieve provider status include consultation costs charged at $2000 (per clinician) for 15 individual CPT consultations, or $1000 (per clinician) for 20 group consultations. Self-paced CPT training can be freely accessed online via the Medical University of South Carolina site.
Building Staff Competency
Qualifications Required
CPT is typically delivered by mental health professionals who have training in Cognitive Behaviour Therapy. One practitioner delivers CPT in individual format, while up to two practitioners deliver CPT in group format (6-10 participants per group).
Training Requirements
There is currently no funded training in CPT available in NHS Scotland. Practitioners accessing training through private training agencies receive two full days of live webinar training that cover session-by-session content of the cognitive processing therapy approach. Following training, registered mental health professionals, with psychotherapy in scope of practice, who would like to gain CPT Provider Status and/or CPT quality rated provider status are required to participate in individual or group consultation (4-8 practitioners per group); initiate at least 4 individual CPT cases or 2 CPT groups or a combination of both; complete 2 individual cases or 2 CPT groups or 1 CPT group and 1 individual case; and be competent in the use of standardised instrument for weekly assessment of PTSD symptoms within 3 months of the training sessions.
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
Practitioners can receive consultation from CBT consultants with expertise in CPT through private routes. Consultants answer clinical questions practitioners may have, and provide support and feedback. Consultation is delivered remotely, on a weekly basis.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
CPT is a type of Trauma-Focused Cognitive Behavioural Therapy (Trauma focused-CBT). Evidence of clinical effectiveness for CPT and other interventions within the TF-CBT class have been explicitly detailed in the National Institute for Health and Care Excellence (NICE) evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention and treatment of PTSD.
Theory of Change
CPT is founded on information/ emotional processing theory of PTSD and social cognitive theory of PTSD. Information/ emotional processing theory of PTSD poise that PTSD emerges from the development of a fear network in memory of the traumatic event, which in turn elicit avoidance and escape behaviours on exposure to reminders of the trauma. It proposes that enabling people to repetitively face their traumatic memory would result in desensitisation of their fear, and alteration of their fear structure.
Social cognitive theory of PTSD goes beyond the elicitation of fear networks, as it also addresses the development of other related primary emotions (sadness, anger) that are a direct response to the trauma, and secondary emotions (e.g. shame, guilt) that develop from misconstrued thoughts and interpretations of the trauma. Social cognitive theory of PTSD therefore focuses on cognitive content, cognitive interpretation, and the effects of cognitive misinterpretation on emotions and behaviours.
The CPT approach is underpinned by both theories, and it has been shown to be effective in treating PTSD and related conditions.
Children and Young People - Rating:
Children and Young People: Research design and number of studies
Eleven RCTs evaluated trauma-focused CBT interventions against wait-list control for the prevention of PTSD in children and young people with ongoing exposure to trauma. Three RCTs evaluated trauma-focused CBT interventions against treatment-as-usual for the delayed treatment (>3 months) of non-significant PTSD symptoms. Nineteen RCTs evaluated trauma-focused CBT interventions against wait-list control, no treatment, or treatment as usual. These nineteen studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in children and young people when the interventions were delivered as delayed treatment (>3months). Evidence of effectiveness of all interventions classed as CBT with trauma focus (including CPT) were combined and evaluated in meta-analyses, as they apply the same approach and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.
Children and Young People: Outcomes achieved
Compared to wait-list control, no treatment, or treatment as usual, the following outcomes were observed;
- Significant reduction in PTSD symptoms following delayed treatment (>3months) for single incident trauma and multiple incident trauma, and trauma with unclear multiplicity. Effects were observed at endpoint, and sustained at 1-3 months follow-up, and up to 12-months follow-up (3)
- Significant reversal of PTSD diagnosis following delayed treatment, for single and multiple incident traumas, at end point and at 1-3 months follow-up (3)
- Significant increase in number of people much/very much improved at endpoint, after delayed treatment, for single incident trauma and multiple incident trauma (3)
- Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (3)
- Significant reduction in depression symptoms following delayed treatment (>3 months), for single and multiple incident traumas at end point. Overall effect, inclusive of all multiplicities of index trauma, sustained for up to 1-year follow-up (3)
- Significant reduction in emotional and behavioural problems (for multiple index traumas) following delayed treatment. Effects were observed at endpoint for internalising problems, and at 3-months follow-up, 6-months follow-up, and 2-years follow-up for externalising problems (3)
- Significant improvement in overall effect on quality of life following delayed treatment (3)
- Significant reduction in functional impairment following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint, and sustained at 3-months and 12-months follow-up (3)
- Significant improvement in global functioning following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint for single and multiple incident trauma, and sustained at 3-months follow-up for multiple incident trauma (3)
- Significant reductions in PTSD symptoms, in PTSD diagnosis, in functional impairment, and in symptoms of comorbidities associated with PTSD (including depression and anxiety) in children and young people with ongoing exposure to trauma (4)
Significant reductions in PTSD symptoms and depression symptoms in children and young people with non-significant PTSD symptoms (4)
Adults - Rating: 5
Adults: Research design and number of studies
Eight RCTs evaluated trauma-focused CBT interventions (alone or in addition to treatment-as-usual or psychoeducation) against treatment-as-usual, attention placebo, psychoeducation, waitlist, or no treatment, for the early prevention (initiated ≤ 1 month) of PTSD in adults. Six RCTs evaluated trauma-focused CBT interventions against wait-list, attention-placebo or psychoeducation for the delayed treatment (>3 months) of non-significant PTSD symptoms in adults. Thirty RCTs evaluated trauma-focused CBT interventions against wait-list control or no treatment control. These thirty studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in adults when the interventions were delivered as early treatment (1-3 months) or delayed treatment (>3months). Evidence of effectiveness of all interventions classed as trauma-focused CBT interventions (including CPT) were combined and evaluated in meta-analyses, as they apply the same approach and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.
Adults: Outcomes Achieved
- Significant reduction in PTSD symptoms following early treatment (1-3 months) and delayed treatment (>3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reversal of PTSD diagnosis following early and delayed treatment, for single and multiple incident traumas, at end point and up to 8-months follow-up
- Significant reduction in depression symptoms following early and delayed treatment (>3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reduction in dissociative symptoms and functional impairment following delayed treatment. Effects on both outcomes were observed at endpoint, while sustained effect on functional impairment was observed at 6-months follow-up (1)
- Significant reduction in relationship difficulty and significant improvement in global functioning following delayed treatment (1)
- Significant improvement in quality of life following delayed treatment. Sustained effect was observed at 3-months follow-up (1)
- Significant reduction in PTSD symptoms, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (i.e. <1 month) (2)
Significant reductions in PTSD symptoms, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following delayed initiation of intervention (i.e. > 3months) in adults with below threshold PTSD symptoms (2)
Need
Comparable Population
Cognitive Processing Therapy (CPT) is an evidenced based trauma-focused therapy for the treatment of PTSD and related conditions in adults. CPT, in form of Developmentally adapted CPT (D-CPT) has been developed for use in adolescents for the treatment of abuse-related posttraumatic stress disorder (PTSD). Effectiveness of CPT was assessed within the wider trauma-focused CBT (CBT-T) class. CBT-T interventions were shown to be effective in the early prevention (initiated ≤ 1 month) of PTSD in adults; in the delayed treatment (>3 months) of non-significant PTSD symptoms in adults; as well as in the early and delayed treatment of PTSD in adults. Effectiveness has also been shown in the prevention of PTSD in children and young people with ongoing exposure to trauma; in the delayed treatment (>3 months) of non-significant PTSD symptoms in children and young people; as well as in the delayed treatment (>3months) of PTSD in children and young people.
Desired Outcome
Trauma-Focused Cognitive Behavioural Therapy (Trauma Focused-CBT) interventions, including CPT, have been shown to effectively reduce acute stress disorder diagnosis, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (≤1 month). Trauma Focused-CBT interventions have also been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) and delayed treatment (≤ 3months). Effects have been sustained at follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Cognitive Processing Therapy (CPT) is an evidenced based interventions for the treatment of PTSD and related conditions in adults and adolescents. CPT, a type of trauma focused Cognitive Behavioural Therapy (CBT), is based on information/ emotional processing theory of PTSD and social cognitive theory of PTSD.
Priorities
Cognitive Processing Therapy (CPT) is a trauma-focused psychological intervention that aims to reduce PTSD symptoms and other corollary symptoms in adults and adolescents. It focuses on helping people challenge unhelpful negative thoughts associated with the trauma, resulting in a change in interpretation of the trauma event, and a reduction of trauma effect on life. CPT, in form of Developmentally adapted CPT (D-CPT), has been developed for use in adolescents for the treatment of abuse-related posttraumatic stress disorder (PTSD).
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
CPT is typically delivered by mental health professionals who have trained in cognitive behavioural therapy. CPT is typically delivered weekly, over 12 sessions. One practitioner delivers CPT in individual format, while one or two practitioners deliver CPT in group format (6-10 participants per group). To support CPT delivery, practitioners receive two full days of live webinar training that cover session-by-session content of the cognitive therapy approach. Practitioners seeking CPT Provider Status and CPT quality rated provider status will be required to meet further requirements.
Technology Support
Practitioner training is delivered virtually (via live webinar workshops), consultation is provided remotely, and self-paced CPT training is accessed online. CPT delivery could be face-to-face, virtually (via tele-videoconferencing) or via mobile apps (e.g. CPT coach, PTSD coach).
Administrative Support
CPT is delivered in 8-15 sessions (but typically in 12 sessions). One session is delivered weekly in individual, group, or combined formats. Face-to-face therapy sessions can be held in several settings including outpatient clinic setting, community setting, and in residential treatment programmes.
Financial Support
Costs required for delivery of CPT include costs of 2-day live webinar training charged at $459.99 (includes training and CPT manual); Cognitive Behavioural Therapy Worksheets at $19.99; and CBT Deck for Clients and Therapists (Book) at $14.99. Other costs for clinician seeking to achieve provider status include consultation costs charged at $2000 (per clinician) for 15 individual CPT consultations, or $1000 (per clinician) for 20 group CBT consultations. Self-paced CPT training can be freely accessed online via the Medical University of South Carolina site.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
