‘Undoing a knot’: a qualitative study of massed 1-week Cognitive Processing Therapy

ABSTRACT

Introduction: Intensive or massed Cognitive Processing Therapy (CPT) for posttraumatic stress disorder (PTSD) has been found to result in significant PTSD symptom reductions. However, few studies to date have used qualitative approaches to systematically evaluate client reflections about massed treatment approaches for PTSD. To address this gap, the present study aimed to improve our understanding of trauma survivors’ reflections following the completion of 1-week CPT.

Method: We conducted semi-structured interviews with seven trauma survivors within 3-months of the completion of 1-week CPT. We used the scissor-and-sort technique to identify themes and subthemes in the qualitative data.

Results: Using the scissor-and-sort technique, we generated five main themes and associated subthemes from the data. The main themes were: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.

Conclusion: Collectively, our results suggested that 1-week CPT was feasible and led to changes in PTSD symptoms and improved cognitive and affective coping skills.

HIGHLIGHTS

• Scant research has examined client reflections about massed treatment approaches for PTSD.

• Among participants who completed a semi-structured interview about their experiences with 1-week CPT for PTSD, we generated five themes: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.

• Collectively, our results suggested that 1-week CPT was feasible and led to changes in PTSD symptoms and improved cognitive and affective coping skills.

Introducción: La terapia de procesamiento cognitivo (TPC) intensiva o masiva para el trastorno de estrés postraumático (TEPT) ha demostrado reducir significativamente los síntomas del TEPT. Sin embargo, hasta la fecha pocos estudios han utilizado enfoques cualitativos para evaluar sistemáticamente las reflexiones de los clientes sobre los enfoques de tratamiento masivo para el TEPT. Para abordar esta brecha, el presente estudio tuvo como objetivo mejorar nuestra comprensión de las reflexiones de los sobrevivientes de trauma después de completar una semana de TPC.

Método: Se realizaron entrevistas semiestructuradas a siete sobrevivientes de trauma dentro de los tres meses posteriores a la finalización de TPC de una semana . Se utilizó la técnica de recorte y clasificación para identificar temas y subtemas en los datos cualitativos.

Resultados: Utilizando la técnica de recorte y clasificación, se generaron cinco temas principales y subtemas asociados a partir de los datos. Los temas principales fueron: (a) habilidades tangibles, (b) factibilidad, (c) proceso terapéutico, (d) presentación de síntomas y (e) expectativas de tratamiento.

Conclusión: En conjunto, nuestros resultados sugieren que la TPC de una semana era viable y condujo a cambios en los síntomas del TEPT y mejoras en las habilidades cognitivas y afectivas de afrontamiento.

引言：已发现针对创伤后应激障碍 (PTSD) 的强化或集中认知加工疗法 (CPT) 可显著减轻 PTSD 症状。 然而，至今很少有研究使用定性方法系统评估客户对 PTSD 集中治疗方法的看法。为了致力于这一不足，本研究旨在提高我们对创伤幸存者在完成 1 周 CPT 后反馈的理解。

方法：我们在完成为期 1 周 CPT 后的 3个月内对 7 名创伤幸存者进行了半结构化访谈。我们使用剪刀和排序技术来识别定性数据中的主题和子主题。

结果：使用剪刀和排序技术，我们从数据中生成了五个主要主题和相关子主题。主要主题是：(a) 实用技能，(b) 可行性，(c) 治疗过程，(d) 症状表现，以及 (e) 治疗期望。

结论：总体上，我们的结果表明 1 周CPT 可行，会改变 PTSD 症状，并且提高认知和情感应对技能。

KEYWORDS:

• Intensive treatment
• PTSD
• qualitative
• massed treatment
• cognitive processing therapy

PALABRAS CLAVE:

• tratamiento intensivo
• TEPT
• cualitativo
• tratamiento masivo
• terapia de procesamiento cognitivo

关键词:

• 强化治疗
• PTSD
• 定性的
• 集中治疗
• 认知加工疗法

Evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT; Resick et al., 2017), have been shown to be effective at reducing PTSD symptoms in the short- and long-term (Asmundson et al., 2019; Cusack et al., 2016; Kline et al., 2018; Ragsdale et al., 2020; Resick et al., 2012). Treatment is generally delivered once or twice per week, taking approximately three months to successfully complete a full course of therapy. A growing body of research is suggesting that evidence-based treatments for PTSD can be delivered via an intensive or massed format, which involves daily treatment sessions for 1–3 weeks (Held et al., 2019; Ragsdale et al., 2020; Sciarrino et al., 2020). Massed treatments for PTSD, delivered as standalone treatments or in conjunction with adjunctive services, have been found to be effective (Ragsdale et al., 2020; Sciarrino et al., 2020). Standalone massed PTSD treatments have been shown to produce clinically significant reductions in PTSD and depression symptom severity (Ehlers et al., 2014; Foa et al., 2018; Galovski et al., 2021; Held, Kovacevic, et al., 2022; Oprel et al., 2021). Previous research has found this format to be acceptable by participants, as demonstrated by high completion rates and no reported adverse effects. While the majority of research suggests that massed treatments for PTSD have high utility, limited research has examined trauma survivors’ reflection about their experiences with massed treatment approaches for PTSD.

Even when considering traditional weekly PTSD treatments, few studies have examined client reflections about their perspectives about weekly PTSD treatments. Prior qualitative studies have largely focused on provider perspectives, client reasons for dropout from trauma treatment, or general client perspectives on trauma (Etingen et al., 2019; Hundt et al., 2020; Price et al., 2016). However, few studies have used qualitative methods to examine client perspectives regarding weekly treatment for PTSD. One study found that veterans (N = 20) completing a 12-week group exposure therapy for PTSD reported benefiting from hearing other group members discuss imaginal exposure exercises, which involve confronting trauma-related memories and fears (Mott et al., 2013). A second study found that women with histories of childhood trauma (N = 10) completing cognitive behavioural therapy reported the importance of group solidarity (e.g. feeling supported and encouraged by others) and safety of the therapeutic environment (Hegarty et al., 2022). Women also reported experiencing changes in self-blame for traumas, feeling safe in the present moment, increased optimism for the future, the need to adapt to telehealth (which was the modality for the treatment), and continued benefit following treatment completion. Another study found that participants completing virtual individual CPT for PTSD (N = 16) described the positive and negative aspects of participant’s own environment, the importance of therapeutic alliance, technicalities and practicalities of the virtual and treatment format (e.g. session length and timing), personal accountability (e.g. finding the time and space, attendance, and deciding to move forward), and positive and negative factors that impacted how they measured change (Ashwick et al., 2019). Results suggested that weekly therapy for PTSD was feasible and acceptable.

Few studies have examined participant reflections about the feasibility, acceptability, and appropriateness of standalone, massed CPT for PTSD. In a case study, a veteran who successfully completed 1-week CPT found the treatment format to be tolerable (Held et al., 2020). He reported the 1-week treatment format allowed him to confront his avoidance and to better retain the information learned from sessions. Another study compared perceptions of treatment outcomes among women survivors of interpersonal trauma who completed 1-week CPT (n = 6) versus weekly CPT (n = 6) (Galovski et al., 2021). Perceptions of treatment outcome were measured by a 20-item questionnaire assessing satisfaction with the treatment (acceptability), therapeutic rapport (acceptability), opinions about the treatment’s effectiveness in treating PTSD and related impairment (perceived helpfulness), and perceptions of attendance and treatment tolerability (tolerability). Results indicated that women completing 1-week CPT reported high acceptability, perceived helpfulness, and tolerability of the treatment, which was similar to the ratings provided by women who completed weekly CPT. Additionally, one study found that active duty military members (n = 4) reported that CPT delivered in five days was tolerable (Morris et al., 2022). All studies to date examining massed CPT found that participants do not report any adverse events (Galovski et al., 2021; Held et al., 2020; Held, Kovacevic, et al., 2022; Morris et al., 2022).

Collectively, massed CPT for PTSD has been found to be well tolerated and beneficial among trauma survivors. However, no studies to date have used qualitative interviews to thoroughly examine client reflections about massed treatment approaches for PTSD. Patient voices about their experiences with PTSD treatment can help inform (1) what factors may impede or facilitate engagement in treatment and (2) how to improve trauma care (d’Ardenne & Heke, 2014). Qualitative research is also needed to guide implementation efforts to increase access to efficacious treatment approaches for PTSD. To address this gap, the present study aimed to improve our understanding of trauma survivors’ experiences following the completion of 1-week CPT. We assessed participants’ experiences of 1-week massed CPT using semi-structured interviews. The interviews were intended to be exploratory in nature to further extrapolate participants’ perspectives in detail.

1. Methods

1.1. Participants and procedures

Data for the present study were collected from a community sample of trauma-exposed individuals (N = 24) who completed 1-week CPT between June 2019 and June 2021 (Held, Kovacevic, et al., 2022). Most participants identified as White (70.83%), non-Hispanic (87.50%), and female (70.83%). Participants ranged in age from 20 to 63 (M = 38.42, SD = 12.20). Majority of our participants completed treatment (N = 23) and the majority (N = 20 of 23) exhibited clinically significant changes in PTSD symptoms. See full demographic details and results in Held, Kovacevic, et al. (2022). All 24 participants who started treatment were invited for the semi-structured interviews. Of these 24 participants, seven participants (29.17%) completed the semi-structured interviews. Three of the seven participants interviewed identified as male (42.86%), three identified as female (42.86%), and one identified as non-binary (14.29%). Five identified as non-Hispanic and White (71.43%), one as non-Hispanic and Black (14.29%), and one as Hispanic and Black (14.29%). The average age was 36.14 years old (SD = 12.55) and ranged from 21 to 53 years. The most common trauma type was sexual assault (71.43%).

Participants were eligible to enrol in the study if they were at least 18 years of age, resided in Illinois, United States, met criteria for PTSD or subthreshold PTSD (defined as meeting all but one PTSD criteria) based on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013), and agreed to attend two virtual sessions per day over the course of one week. Participants were excluded if they reported current drug or alcohol use within the past three months that would require medical observation if discontinued, current legal action related to the index trauma, current homicidal or suicidal ideation with an active plan and intent, serious or unstable medical illness with possibility of hospitalization, a significant cognitive impairment that would prevent full participation in the study, a change in psychotropic medications in the past month, or current or a history of psychosis or mania. Eligible participants could not have completed trauma-related psychotherapy within three months prior to the study.

Participants were recruited from the community in a large Midwestern city and surrounding areas via online ads, clinician referrals, and from outpatient clinic waitlists. One week following treatment completion, all 24 participants were offered the opportunity to share feedback and reflect on their experience in treatment through a semi-structured interview, which was framed as an optional component of the study (see details in measures section). Interviews were scheduled based on participant availability; six took place within one month of treatment completion, and one interview was conducted two months posttreatment. The interview protocol was developed by study staff for the purposes of this study. Semi-structured interviews were audiotaped and transcribed verbatim by individuals with at least a bachelor’s degree. Any potentially identifying information was removed during the transcription process. All study procedures were approved by the Rush University Medical Center Institutional Review Board (IRB number 18101206).

During phone screening, assessments, or therapy sessions, participants were screened for suicide and other emergent needs. Clinicians were trained to follow a protocol that would allow participants’ needs to be addressed, including referrals for additional services. Participants were also provided with the opportunity to engage with three booster sessions. A small minority of participants (25%) utilized booster sessions (Mdn = 2.5 sessions).

1.1.1. 1-week virtual massed Cognitive Processing Therapy

One-week CPT was delivered in ten total sessions, twice per day from Monday to Friday (Held, Kovacevic, et al., 2022). Study clinicians were postdoctoral psychology fellows or psychologists who received 2-day CPT training by a national trainer (further details can be found in Held, Kovacevic, et al., 2022). Treatment sessions were generally scheduled from 9AM-5PM. Each 50-minute CPT session was followed by at least 30- to 60-minutes to complete practice assignments, depending on scheduling. Participants unable to reschedule sessions during five consecutive days were permitted to reschedule remaining sessions into the following week. Minor modifications to the CPT protocol were made to condense treatment into 1-week, as described by Held, Kovacevic, et al. (2022). Following completion of CPT, participants were given the option to schedule up to three CPT booster sessions which needed to be completed prior to their 3-month follow-up assessment.

1.2. Measures

1.2.1. Semi-structured interview

Interviews (each approximately 30–60 min) were conducted virtually between 1-week and 2-months following the last scheduled CPT session. All participants were offered the opportunity to be interviewed regardless of whether they completed treatment; however, the seven participants interviewed completed all 10 sessions of 1-week CPT. Research assistants with at least a bachelor’s degree conducted all interviews and were trained by a PhD-level psychologist in qualitative interviewing (BH) as well as in trauma and massed PTSD treatments (PH). The semi-structured interview consisted of questions related to participants’ perceptions of 1-week CPT. First, participants were asked to describe their overall experience in 1-week CPT (‘Please tell me, in as much detail as possible, about your experiences, good or bad, of intensive CPT’) and what they found ‘most helpful’ and ‘most challenging.’ Next, participants were asked about treatment impact (‘How has your participation in intensive CPT, positively or negatively, affected your life/daily functioning’) and treatment expectations (‘What were your expectations prior to starting intensive CPT?’; ‘In what ways did intensive CPT meet your expectations?’; and ‘In what ways did intensive CPT not meet your expectations?’). Participants were then asked about tolerability and feasibility of 1-week CPT (‘How tolerable did you find intensive CPT? Why?’; ‘How feasible did you find intensive CPT? Why?’) and for ways to make 1-week CPT more tolerable and feasible. Additionally, participants were asked about treatment challenges, whether they had thought about not completing treatment and, ‘[i]f so, what helped [participants] continue and complete treatment?’ Finally, participants were asked what they would change about 1-week CPT and for ‘additional feedback’ about their experience. Follow-up questions were used throughout the interview to obtain necessary details to further enhance understanding.

1.3. Analytic strategy

1.3.1. Qualitative coding protocol

Transcripts were iteratively read and analysed by seven team members. The team consisted of two psychologists (MK and BW) and five research assistants (JT, MM, CS, JS, and RM). We used the ‘scissor-and-sort’ technique to analyse the transcripts on a computer with a word-processing program (Stewart et al., 2007). Specifically, team members read through the transcripts to familiarize themselves with the data and identify relevant subsections pertaining to participants’ experiences of 1-week massed CPT. After reviewing the transcripts, we independently generated initial codes based on the questions asked in the interview. We highlighted text (e.g. phrases, sentences, longer exchanges) in the transcripts that was associated with the initial codes. Through discussion, we came to a consensus regarding the main codes from the transcripts. Next, we used the initial codes to independently generate themes and associated subthemes. We supported our themes and subthemes with specific text (e.g. phrases, sentences, longer exchanges) that was highlighted, so that all relevant text was cut and sorted together under the themes or subthemes. Again, we discussed these themes/subthemes as a team and came to a consensus via discussion. Once the analysis was completed, each theme and subtheme was reviewed, described, and supported with a direct quotation from the interviews.

2. Results

We generated five main themes from the individual interviews reflecting participants’ reactions to 1-week CPT. The main themes include: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations. Main themes may have two additional subthemes, which describe a unique component related to the main themes. We provide an explanation of how participants in our sample perceived each of these main themes and associated subthemes.

2.1. Main theme 1: tangible skills

The majority of participants completing 1-week CPT identified learning tangible skills that allowed them to identify and manage thoughts and feelings in a new way. For instance, one participant stated: ‘I was given takeaway tangible, applicable tools that were packed and ready to go.’ Another participant reported, ‘[1-week CPT] really positively affected [my life]. It’s taught me how to have reservation before leaning totally into an emotion. And analysing everything. Then kind of processing emotions into these levels before.’

Several participants explained how skills obtained from 1-week CPT facilitated better understanding of their thoughts and behaviours across different facets of their day-to-day lives. For example, one participant indicated: ‘Some of the things we worked on as far as strategies and the exercise and [worksheets] … they let me look at some things more insightfully, like almost instantaneously.’ Similarly, another participant stated: ‘But it really makes me see this thought pattern has progressed into other parts – the majority, all my life. Like overthinking, black and white thinking, things like that were such a pattern that I kept having.’

2.2. Main theme 2: feasibility

Participants explained that it was feasible to engage in daily treatment, but they also acknowledged challenges to the treatment format, such as balancing treatment with their daily schedules (e.g. work, family responsibilities). Participants reported regularly attending to treatment-related responsibilities, such as homework, despite such challenges.

2.3. Subtheme 1: engagement barriers

Participants reported being able to continue to engage in day-to-day activities, such as attending work and completing midterms, while engaged in 1-week CPT due to the virtual nature of treatment and the COVID-19 pandemic. However, they also acknowledged potential challenges associated with engaging in daily treatment if they had less flexibility in their schedules. As one participant noted: ‘Because of the pandemic, [treatment] was much easier because I am working from home and I have so much more flexible time. But, if I was still going to work every day, it would not have been as feasible.’ Another participant stated: ‘A schedule that isn’t just 9–5 would probably be something that would be beneficial to other people.’

2.4. Subtheme 2: 1-week CPT format

Participants stated finding benefit as a result of engaging in daily treatment because of the 1-week CPT format. For instance, one participant indicated: ‘Even though toward the end of the week I was still procrastinating a little bit, it was still less than if I would’ve had a week to do it. I was still getting [homework] done before my meetings.’ This participant reported that the daily sessions allowed her to tackle her procrastination and she reported always completing her homework while also tending to other important tasks in her life (e.g. work). While the 1-week CPT format was noted as a benefit, the shortened format also presented challenges, including that a lot of information was covered in a short amount of time and that homework was time-consuming. For example, one participant stated: ‘My schedule was tight, I’d have sessions almost back-to-back. The most challenging [part] was trying to the get the work done.’ Another noted, ‘It took a while to get the homework done.’ Of note, participants generally reported engaging in homework assignments after each session despite scheduling challenges.

2.5. Main theme 3: therapeutic process

Participants indicated building rapport with their therapists quickly. Participants also reported that 1-week CPT encouraged self-reflection in relation to trauma memories and patterns throughout their life.

2.6. Subtheme 1: rapport

Participants explained that they were able to build rapport with their therapists very quickly. Participants also largely stated enjoying having someone to talk to about the impact of their traumas on their lives. For example, one participant reported: ‘There was no pressure. Everything just felt very comfortable from start to finish.’ Another participant stated: ‘[This experience] was kind of like undoing a knot … it didn’t just all of a sudden come apart. It was like, ‘[together] let’s just take layer, after layer, after layer.’

2.7. Subtheme 2: self-reflection

Participants indicated that 1-week CPT encouraged them to approach trauma memories and patterns throughout their life. One participant stated: ‘Sitting back and actually looking at your life instead of blowing it off was eye-opening.’ Another participant indicated: ‘I think the most challenging part was just really looking inside my entire self and trying to pick out some pretty deep stuff out.’ Participants also reported that increased self-reflection helped them realize they may benefit from further therapy to address remaining symptoms/problems. For example, one participant stated: ‘[Participating in this study] made me think I should probably continue some more counseling after this.’

2.8. Main theme 4: changes in symptom presentation

Participants reported experiencing significant changes in their symptoms of PTSD, depression, and anxiety. For example, one participant noted: ‘I haven’t been as anxious. I’ve probably been like 70% less anxious.’ Another participant stated: ‘The difference of who I was and how my symptoms were coming up before and after treatment were as drastic as what the numbers [scores of self-reported PTSD symptom severity] that were being read to me.’ Participants also reported significant changes in their functioning and how they manage day-to-day stressors and events. For instance, one participant indicated: ‘Afterwards I did kind of notice some things happening in my life that I might’ve thought ‘this is a disaster, it’s terrible,’ before, felt easier to deal with, [now].’ Furthermore, participants also reported that significant others (e.g. family, spouses) were also able to notice a change within them. For example, one participant noted, ‘I just know that my family, specifically my husband, he is extremely happy. He like saw a difference in me right away.’ Exceptions were noted, as at least one participant reported that they did not experience significant changes in symptoms.

2.9. Main theme 5: treatment expectations

Participants indicated varying mindsets and expectations about how much change they would make in 1-week CPT.

2.10. Subtheme 1: varying mindset prior to CPT

Participants indicated varying mindsets about what would happen during 1-week CPT; however, the majority of participants recognized the necessity of diving into treatment and becoming vulnerable quickly. For instance, one participant stated: ‘If you want to benefit from [treatment], you just have to let your guard down. I think everyone should probably focus on that if they’re going to go into therapy.’ Similarly, another participant noted: ‘I was nervous going into it, but within minutes I realized how much I needed it.’

2.11. Subtheme 2: amount of change

Participants reported varying expectations about how much change they would make after the completion of 1-week CPT. Some participants indicated expecting to see significant changes in their lives. For instance, one participant noted: ‘I guess what expectation I had is that I would feel like a very revolutionary change. And that was what I felt.’ On the other hand, other participants did not expect to make significant changes. One participant stated: ‘I have to admit, I told other people, I really did not think that something would make as much of a difference as it did. But it really makes me see this thought pattern has progressed into other parts – the majority, all of my life.’

3. Discussion

While previous research has documented the efficacy of standalone intensive or massed treatments for PTSD, limited research exists regarding trauma survivors’ experiences following the completion of standalone massed CPT. We assessed participants’ experiences of 1-week massed CPT using semi-structured interviews. Our results (N = 7) showed five major themes related to 1-week CPT: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.

We found that participants reported being able to learn tangible skills to process thoughts and emotions in a new way in as little as one week of CPT. Participants reported having better insight into negative, automatic thinking patterns impacting their day-to-day lives. Our results are consistent with the underlying theory of CPT, which emphasizes the prominent role of negative thoughts that prevent recovery from PTSD, termed stuck points (Resick et al., 2017). CPT also encourages individuals to learn and use strategies, such as emotion regulation (i.e. identify natural versus manufactured emotions) and cognitive restructuring, to process through trauma-related distress. Our results are also consistent with previous research highlighting that negative cognitions decrease throughout massed treatments for PTSD (Zalta et al., 2018). We extend the literature by showing that the 1-week format allows for participants to grasp tangible cognitive restructuring skills that can be used in their day-to-day lives. It seemed that trauma survivors completing 1-week CPT accomplished what they generally accomplish in traditional, weekly CPT, in a shorter time frame.

We also found that participants reported building rapport with their therapists quickly. They stated feeling comfortable during the course of therapy as they were opening up about trauma. This is consistent with previous research showing that throughout a 2-week intensive treatment programme, participants reported being able to continuously develop strong rapport (Held, Meade, et al., 2022). Similar accounts of strong therapeutic rapport were also reported by trauma-exposed women completing 1-week CPT (Galovski et al., 2021). We found that our participants completing 1-week CPT reported high levels of self-reflection and going deep in a short time span. Our study results extend the literature by suggesting that the 1-week treatment format allows for the development and maintenance of general therapy skills, including rapport.

As previously reported by Held, Kovacevic, et al. (2022), we found that most participants reported experiencing significant decreases in their PTSD, depression, and anxiety symptoms after 1-week CPT. Participants also reported being able to see these shifts in their day-to-day functioning. Our results are consistent with previous research documenting improvements in symptoms and functioning as a result of completing massed treatments for PTSD (Ehlers et al., 2014; Galovski et al., 2021; Held, Kovacevic, et al., 2022; Smith et al., 2022). As described earlier, our qualitative interviews also indicated that participants perceived having tangible skills to manage their symptoms, which may be a reason as to why participants were experiencing clinically significant changes. Collectively, our results suggest that participants completing 1-week CPT generally experience a meaningful amount of change in a short time span, which is consistent with quantitative study results (Held, Kovacevic, et al., 2022).

Participants reported being able to make time within their schedules for daily treatment and finding benefit as a result of 1-week CPT. Participants specifically highlighted how the 1-week format combatted avoidance-related barriers, including procrastinating and avoiding processing trauma-related thoughts and emotions, which has been highlighted in a case study (Held et al., 2020). Our results are consistent with previous research showing high treatment completion rates among trauma survivors engaged in intensive treatments in general and 1-week CPT (Galovski et al., 2021; Held, Kovacevic, et al., 2022). However, participants also acknowledged challenges that arose, including needing to balance completing their treatment homework with other responsibilities. Further research is needed to determine what alterations to the treatment format may be needed for some trauma survivors to address barriers to treatment.

There were several limitations that need to be considered. The sample was small, homogenous (e.g. largely White sexual assault survivors), and was recruited from a single-arm design. The homogeneity of the sample may have precluded capturing the varied perspectives and experiences from participants of different backgrounds and trauma histories. Findings may be less transferable to other more diverse populations. This study was also conducted during the COVID-19 pandemic, which may have impacted which participants engaged in the research study in general and participants’ perceptions of the feasibility of 1-week CPT. Furthermore, not all participants who completed 1-week CPT participated in the qualitative semi-structured interviews. The majority of the participants completed treatment and experienced clinically significant shifts during treatment. Thus, it remains unclear the specific reasons as to why participants opted out of the semi-structured interviews. It remains unknown if additional themes from participants who did not complete the semi-structured interview exist. Future studies would benefit from additional recruitment strategies after treatment completion and at follow-up to enhance completion rates of interviews. Thus, further qualitative research is needed to determine trauma survivor’s perspectives of 1-week CPT, particularly from trauma survivors of diverse backgrounds in different treatment settings (e.g. community health centres).

Despite these limitations, the present study highlighted that trauma survivors completing 1-week CPT were largely able to obtain tangible CPT skills, exhibited positive therapeutic rapport with their clinicians, and described significant changes in their symptoms and day-to-day life. These are many of the key components obtained from traditional, weekly CPT. Many trauma survivors described the format as feasible and that the treatment format exceeded their expectations. Thus, based on trauma survivors’ perspectives, 1-week CPT allowed them to obtain these achievements in a matter of days. Future research is needed to discern factors that impede and facilitate implementation of massed treatment formats for PTSD from trauma survivors of diverse backgrounds in different treatment settings (e.g. community health centres).

Acknowledgements

We would like to thank the participating veterans and their families, as well as acknowledge the administrators, research assistants, and clinicians at the Road Home Programme.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Merdijana Kovacevic receives grant support from the Chicago Chronic Condition Equity Network [C3EN; P50MD017349-01]. Philip Held receives grant support from Wounded Warrior Project®, the Department of Defense [W81XWH-22-1-0739], and the Agency for Healthcare Research and Quality [R21 HS028511]. The content is solely the responsibility of the authors and does not necessarily represent the official views of Wounded Warrior Project®, the Department of Defense, the Agency for Healthcare Research and Quality, the National Institute on Minority Health and Health Disparities or any other funding agency.