Cognitive processing therapy for posttraumatic stress disorder in first responders and veterans: Flexing the approach with explicit case formulation

There is a need to improve psychological interventions for first responders and veterans with posttraumatic stress disorder (PTSD). We conducted an open trial integrating explicit case formulation (CF) within cognitive processing therapy (CPT) in a sample primarily composed of first responders (N = 29). Participants attended weekly CPT sessions with explicit CF, where CF guided deviations (if required) from standard CPT delivery (CPT-CF). PTSD diagnosis and self-reported PTSD symptoms, depressive symptoms, and quality of life utility scores were key variables assessed at pretreatment, posttreatment, and 3-month follow-up for all participants. Of the 28 participants who started therapy, 23 completed treatment. Intent-to-treat analyses indicated significant reductions and sizeable effects at posttreatment for clinician-rated and self-reported PTSD outcomes, g = 2.48–2.50, and self-reported depressive symptoms, g = 1.37, and quality of life, g = 0.99. Effects for secondary variables ranged from small (alcohol misuse: g = 0.32) to large (sleep, g = 0.71; anger, g = 0.74; unhelpful trauma beliefs: g = 1.11). Clinical gains were maintained at 3-month follow-up. Among the 23 participants available at follow-up, 82.6% (n = 19) met good end-state functioning for PTSD, and none met the criteria for PTSD. Seven participants had moderate-to-major deviations from CPT during treatment but largely demonstrated similar outcomes to those who did not. The study replicates prior CPT-CF work among civilians, finding it to be acceptable to participants and not diluting positive outcomes of standard CPT. Future research requires randomized trials and an expansion of this approach with other trauma populations.