Allegiance effects in cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD): a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA flow diagram of the study selection process.

Table 1. Study characteristics.

	Study ID	Number of Authors	Population description	Total participants	Trauma type	Non-CPT Condition	CPT Condition	Additional Condition	Primary Outcome Measure
1	Sloan et al. (2018)	4	veteran and nonveteran adults with primary PTSD and stable medication (outpatient)	126	mixed: (highest: adult nonsexual assault) combat, sudden death/violence to friend, adult/child sexual/nonsexual assault, motor vehicle crash, other accident w injury	Written exposure therapy	CPT	0	CAPS-5
2	Resick et al. (2002)	5	female rape victims	171 (ITT)	adult sexual assault (at least 3 months prior, at least one incident)	Prolonged exposure	CPT	minimal attention wait list (MA)	CAPS
3	Forbes et al. (2012)	8	community military veterans	59 (ITT)	military and other comorbid trauma	Treatment as usual (varied; 14% supportive counselling, 52% non trauma-focused symptom management, 34% CBT including exposure)	CPT	0	CAPS
4	Bohus et al. (2020)	12	female survivors of child sexual abuse who also met at least 3 DSM5 criteria for BPD	200	child sexual abuse	DBT-PTSD	CPT	0	CAPS-5
5	Litz et al. (2021)	7	(active duty) deployed marines and sailors with current PTSD diagnosis (DSM-IV)	122 (ITT)	military	Adaptive disclosure	CPT-C (CPT minus written trauma account)	0	CAPS-IV
6	Monson et al. (2006)	6	veteran, chronic military-related PTSD	60 (ITT)	military	Waitlist control	CPT	0	CAPS
7	Surís et al. (2013)	5	veterans with military sexual trauma (MST)	86 analysed (129 enrolled including those withdrawn/not completed)	military sexual trauama	Present-centred therapy	CPT	0	CAPS
8	Maxwell et al. (2016)	6	adults with PTSD	16 (no dropouts or missing data)	mixed (child/adult physical/sexual abuse, witnessing violent death of loved one, and others)	Memory specificity training	Group CPT	0	MPSS-SR
9	Galovski et al. (2012)	5	adults with PTSD	100 (ITT)	physical or sexual child or adult abuse	Symptom monitoring delay treatment	MCPT	0	CAPS
10	Dedert et al. (2019)	6	adults with PTSD who smoke 10 or more cigarettes per day	40	veteran, trauma unspecified	Present-centred smoking cessation therapy (PS), based on ICSC	Combined CPT and smoking cessation (CPTS)	0	CAPS-5
11	Butollo et al. (2016)	4	adults with PTSD related to trauma that occurred in adulthood	141	mixed (accident, interpersonal, loss, medical, other)	Dialogical exposure therapy	CPT	0	IES-R
12	Resick et al. (2015)	11	active duty military personnel	108	deployment-related trauma (except one who cited childhood sexual abuse)	Group present-centred therapy	CPT-C	0	PCL-S
13	Resick et al. (2008)	6	adult women with PTSD	150 (ITT)	mixed (child/adult physical/sexual abuse, mostly multiple traumas)	Written account	CPT	CPT-C	CAPS
14	Chard (2005)	1	women with at least one incident of child sexual abuse	71	child sexual abuse	Minimal attention waitlist	CPT-SA (sexual assault specific)	0	CAPS-SX
15	Sloan et al. (2022)	9	active duty military personnel	169	military	Written exposure therapy	CPT-C	0	CAPS-5
16	Watkins et al. (2023)	10	middle-aged adults (40–65) with PTSD	112	mixed (childhood physical or sexual trauma, adult physical or sexual trauma, military)	Waitlist control	CPT	0	PCL-5
17	Kelly et al. (2021)*	4	women veterans	104	military sexual trauma	Trauma-sensitive yoga	CPT	0	PCL-5
18	Schnurr et al. (2022)	35	veterans	916	military	Prolonged exposure	CPT	0	CAPS-5
19	Kearney et al. (2021)	4	veterans	184	military (combat, sexual, assault, accident, sudden death)	Loving-kindness meditation	CPT-C	0	CAPS-5
20	Simpson et al. (2022)	10	comorbid AUD and PTSD, mixed veteran and civilian	101	mixed	Relapse prevention	CPT	Assessment only	CAPS-5

Table 2. Allegiance scoring tool.

Item	Value	Description
1	+1	If author advocates for treatment or developed treatment
2	+1	If #1 is true, and authors supervised the therapists, were the therapists in their own condition, or the therapists were extensively trained in the treatment
3	+1	If therapists received more supervision/training than other treatment
4	+1	If greater face-to-face dosage compared with other treatment
5	−1	If supervisor is not a recognised expert in treatment
6	−1	If treatment protocol manual was altered by removing ingredient(s) or changing order in a theoretically deleterious manner
7	−1	If therapists were proscribed from responding in ways a reasonable therapist would routinely do AND proscription was egregious (i.e., proscription was judged to be deleterious to treatment)

Researcher allegiance coding was adapted from Goldberg and Tucker (2020), who adapted the tool from Yulish et al. (2017). Only the order of items was edited, to allow for ease of data extraction and scoring. If an item was unclear, it was coded as zero.

Figure 2. Forest plot of effect sizes for cognitive processing therapy (N = 20 studies).

The posttreatment scores for (Sloan et al., 2018) were at 12 weeks for cognitive processing therapy (CPT) and 6-weeks for written exposure therapy (WET), given that the WET intervention was only a 6-week intervention.

The above forest plot includes 17 studies with an active comparison group (including treatment as usual; TAU) and three studies with a waiting list comparison group. The summary effect size should thus be interpreted with caution.

AD = adaptive disclosure; CPT = cognitive processing therapy; DBT = dialectical behaviour therapy; PCT = present-centered therapy; PE = prolonged exposure; TAU = treatment as usual; WA = written accounts; WET = written exposure therapy; WL = waiting list.

Figure 3. Regression plot of effect size on allegiance difference scores.

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Data availability statement

The data used in the present study are available from the authors upon request.