A randomized controlled trial of Cognitive Processing Therapy for 18-35-year-olds with co-occurring post-traumatic stress and substance use disorders.

Cognitive processing therapy (CPT) is a 'gold-standard' cognitive behavioral therapy that has been effective in reducing symptoms of PTSD that have developed after experiencing a variety of traumatic events including child abuse, combat, rape and natural disasters (Resick et al., 2016). CPT is a 12-session protocol that will be delivered by a team of trained clinicians (primarily case managers supervised by a board-approved, endorsed clinical psychologist) on an individual, twice-weekly basis, over 6 weeks, with 60-minute sessions. Sessions are delivered through telehealth (video-based) format. Session 1 - The goals for the first session of CPT are to engage the client in treatment and provide psychoeducation on the relationship between PTSD and substance use. The therapist also explains the rationale behind CPT: giving client’s tools to examine their thoughts and emotions, feeling the natural emotions arising from the trauma, and changing thoughts around trauma that are keeping client’s stuck (referred to as stuck points in CPT). Sessions 1-3 - Sessions 1-3 will focus on preparing the client for CPT and identifying stuck points that have interfered with the client’s recovery after their trauma(s), including the role of substance use. These sessions are foundational to developing the client’s association between thoughts and feelings and the client is taught to identify and self-monitor these associations. Sessions 4- 5 - The goal for these sessions are for the client to be able to label events, thoughts, and emotions and to understand the connections among them. These sessions will also introduce categorising thoughts objectively as well as challenging the client’s individual thoughts that can be related to the trauma or substance use behaviour. Sessions 6-8 - The first goal of these sessions are to teach the clients to become their own cognitive therapists based on the techniques learned thus far in therapy. Secondly, the clients are asked to identify their patterns of problematic thinking in relation to the traumatic event(s) and substance use. These sessions also begin to challenge core beliefs related to the traumatic event. Sessions 9-12 - The primary goals of the remainder of the sessions is to continue challenging the clients trauma related beliefs as well as examine the themes of Safety, Trust, Esteem, Intimacy and Power and Control related to the traumatic event. In addition, the client and therapist continue to integrate any unresolved ‘stuck points’ relevant to the index trauma. A modification which will be made at the end of treatment from the original protocol will be to add relapse prevention into the clients final sessions. Treatment fidelity of the intervention will be monitored through: a) de-identified audio recordings which will be assessed at the end of treatment by independent CPT clinicians, b) session checklists for clinicians during sessions, and c) weekly supervision of clinicians by a trained, board-approved clinical supervisor specializing in the delivery of CPT.