Cognitive Processing Therapy: E2i

Cognitive Processing Therapy (CPT) is an evidence-based, cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Through individual or group sessions of CPT, clients learn to recognize and challenge unhelpful thoughts and beliefs related to trauma. Positive Impact Health Centers and Western North Carolina Community Health Services implemented CPT as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017 to 2021. CPT participants had increased engagement in care and retention in care from enrollment to 12 months.

Decatur, GA

Duluth, GA

Marietta, GA

Asheville, NC

Evidence-Based Intervention
Support service delivery model
Retention in HIV medical care
Treat
People with a history of trauma
RWHAP SPNS
RWHAP-funded clinic or organization; Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

Research indicates that 30 to 50 percent of people with HIV meet criteria for PTSD.1,2 Among people with HIV, PTSD negatively affects HIV disclosure, medication adherence,3 and physical health.4 CPT is an evidence-based intervention adapted by HIV experts in collaboration with community members to improve health outcomes. CPT provides cognitive behavioral treatment to reduce posttraumatic stress symptoms. Through CPT sessions delivered by a behavioral health therapist, clients learn to recognize and address the effects of trauma on their thoughts and feelings. By reducing symptoms of PTSD, CPT may help clients with HIV have better HIV health outcomes.

“Because PTSD is associated with adverse effects on HIV health outcomes, people with HIV who have PTSD are among those most in need of interventions that address trauma.”

Core Elements
PTSD assessment and symptoms monitoring

All participants were screened with a standard, validated PTSD screening tool. Clients who screened positive were then further evaluated by a behavioral health therapist. Clients with a PTSD diagnosis were enrolled in the intervention and were screened weekly to monitor changes in their PTSD symptoms. Clients who no longer had PTSD symptoms were evaluated to conclude CPT treatment.

Cognitive processing therapy (CPT) sessions

CPT was delivered by a behavioral health therapist trained in CPT at each of the intervention sites, either on an individual basis or to a small, static group. Individual sessions lasted 50 to 60 minutes and group sessions were 90 minutes. The intervention protocol recommended that each person participating in the intervention receive 12 sessions on a weekly or biweekly basis. However, treatment can be customized for people based on their needs. Some participants received up to 24 sessions, while others received fewer. CPT experts highly recommend delivering a minimum of six sessions per client or group.

Socratic dialogue

CPT therapists used Socratic dialogue to help clients reach understanding themselves, rather than telling them how to act, think, or feel.  

In CPT, Socratic dialogue techniques include questions to:

  • Clarify—For example, “What do you mean when you say...?”
  • Probe for assumptions—For example, “How did you come to this conclusion?”
  • Explore evidence—For example, “How do you know this?”
  • Explore deeper beliefs—For example, “What does this mean about you that the trauma happened to you?”
Identifying and addressing “stuck points”

In CPT, “stuck points” are intrusive, unrealistic, or unhelpful thoughts that are related to trauma. These stuck points prevent recovery from PTSD. With the help of their therapist, people participating in the intervention identified their stuck points and challenged their established narratives around these ideas. Examples of common stuck points include: “It’s my fault the trauma happened,” and “It’s going to happen again.”

Outcomes

The E2i initiative enrolled 34 clients in CPT across the implementation sites and measured HIV care continuum outcomes at enrollment and 12 months. CPT participants had increased engagement in care and retention in care from enrollment to 12 months, although improvements were not statistically significant. Given that clients already had high levels of engagement, prescription of ART, and viral suppression at time of enrollment, it is likely that there was not a sufficient sample size to observe statistically significant changes.

Category Information
Evaluation data HIV treatment records of the 34 clients enrolled in CPT
Measures Engagement in HIV care, retention in HIV care, receipt of ART, viral suppression
Results
  • Engagement in care increased from 90% to 96%
  • Clients on ART remained steady at 100%
  • Retention in care increased from 67% to 84%
  • Viral suppression decreased slightly from 90% to 85% most likely due to small sample size and already high levels of viral suppression at time of enrollment

Source: Cognitive Processing Therapy: E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

Planning & Implementation

Develop a delivery plan. Prior to starting the intervention, both sites developed a delivery plan. This included identifying a space to perform CPT that was comfortable, private, safe, and welcoming. Sites also outlined key elements of their intervention, such as whether CPT would be delivered individually or in a group, how often sessions would meet, how long they would run, whether sessions would be offered virtually, and how many therapists would be needed to keep up with the demand. 

Recruit and train core staff. CPT requires at least one behavioral health therapist to conduct CPT sessions with clients. However, the implementation sites recruited new or existing staff to serve other important functions of the intervention. This included a program manager to oversee screening and referrals and RN care managers to help with the screening and referrals. Staff participated in a two-day CPT training workshop delivered by an approved training company. Staff should also be trained in trauma-informed care for people with HIV. 

Recruit clients. Sites reviewed medical records to identify existing clients diagnosed or suspected of having PTSD. However, sites also implemented universal PTSD screening in order to identify potential candidates for CPT among existing clients who were not yet diagnosed or suspected of having PTSD. Clients interested in participating in the intervention completed a validated PTSD screening tool and met with a therapist if they were not already diagnosed with PTSD. Once provisionally enrolled in the intervention, all clients met with a therapist to assess their PTSD symptoms and decide if CPT was an appropriate treatment plan for them.

Two sites participated in the CPT E2i initiative. Learn more about their implementations below.

Positive Impact Health Centers (Decatur, Duluth, and Marietta, GA)

Western North Carolina Community Health Services (Asheville, NC)

Sustainability
  • Both implementation sites reported that CPT was straightforward to implement, and that full implementation was highly feasible within one year. 
  • Costs incurred by the sites were related to planning and implementation, including hiring new personnel, training, supplies, incentives, and outreach activities. For more information, see the implementation guide.
  • Achieving sustainability for the implementation sites involved applying for grants and accessing available reimbursement options. For reimbursement by third party payors, Outpatient Mental Health Current Procedural Terminology Codes for individual psychotherapy (90834 for 45 minutes with a client) or group psychotherapy (code 90853) are appropriate billing codes for CPT. Mental health counseling is a core medical service that may be supported with RWHAP funds.
Lessons Learned
  • Standardize trauma screening across all clients. Implementation sites that systematically screened all clients for trauma reported the CPT activities at their site increased over time, while an implementation site that did not universally screen clients reported that CPT activities declined over time. 
  • Provide ongoing training on trauma-informed care for all staff. Providing this training helps to integrate CPT and the principles of trauma-informed care into practice at the implementation sites. 
  • Build in steps to prepare clients for CPT.  Sites can prepare clients for engaging in time intensive and trauma-focused sessions, by providing general counseling to improve readiness for CPT, or by allowing multiple pre-treatment sessions to build trust and rapport with the therapist and increase comfort with the idea of discussing their trauma.
Contact
Positive Impact Health Centers
Western North Carolina Community Health Services

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