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. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: J Trauma Stress. 2023 Mar 29;36(2):397–408. doi: 10.1002/jts.22924

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion

Elizabeth Alpert 1,2, Joseph K Carpenter 1,2, Brian N Smith 1,2, Mercedes G Woolley 1, Chelsea Raterman 3, Courtney C Farmer 4, Shannon M Kehle-Forbes 1,5,6, Tara E Galovski 1,2
PMCID: PMC10228524  NIHMSID: NIHMS1882072  PMID: 36987703

Abstract

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = −.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients’ cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Posttraumatic stress disorder (PTSD) is associated with numerous deleterious outcomes for individuals and society (Watson, 2019). Fortunately, evidence-based PTSD treatments are available (Galovski et al., 2021). Cognitive processing therapy (CPT; Resick et al., 2017) is one of the PTSD treatments with the most empirical support (Cusack et al., 2016) and has been strongly recommended across clinical practice guidelines (e.g., American Psychological Association, 2017; Department of Veterans Affairs [VA] & Department of Defense, 2017).

Effect sizes for symptom reduction during CPT are moderate to high (Cusack et al., 2016). However, a significant number of patients retain a PTSD diagnosis after treatment (Steenkamp et al., 2015), and rates of dropout are high (Cooper et al., 2018). Not surprisingly, many of the patients who drop out of treatment do not receive an adequate dose of therapy and, as a result, do not experience optimal symptom improvement (Berke et al., 2019; Holmes et al., 2019). Further research is needed to identify factors contributing to CPT outcomes, including symptom response and treatment completion. In particular, identifying malleable factors that promote or impede recovery will inform care delivery and enhance outcomes.

Most research examining predictors of CPT outcomes has focused on demographic and pretreatment characteristics. Identified demographic and pretreatment predictors of worse treatment response include older age (Resick et al., 2020), African American race (Resick et al., 2021), and more severe baseline PTSD (e.g., Resick et al., 2021) and depressive symptoms (Kline et al., 2021; Resick et al., 2021), among others. Variables that have predicted dropout in CPT include younger age (Kehle-Forbes et al., 2016; Rizvi et al., 2009) and lower educational attainment (Rizvi et al., 2009).

There have been multiple calls to move beyond demographic and baseline clinical characteristics to examine processes that occur during treatment as predictors of outcomes (Cooper et al., 2018; Rubel et al., 2017; Youn et al., 2019). It is important to examine such processes because they are potentially malleable and can serve as treatment targets to improve outcomes. Examining in-session therapy process variables linked to theorized mechanisms of change in CPT, including patient and therapist process variables in cognitive, affective, and interpersonal domains, can yield valuable information about treatment processes that predict symptom response and treatment completion in CPT.

Cognitive process variables

A core putative mechanism of symptom change in CPT is shifts in maladaptive posttraumatic cognitions (e.g., self-blame or exaggerated negative beliefs about the self, others, or the world; Resick et al., 2017). Consistent with the cognitive theory underpinning CPT (Beck & Dozois, 2011; Ehlers & Clark, 2000), more reductions in negative posttraumatic cognitions during treatment, assessed via self-report measures and the coding of written narratives, have predicted better symptom outcomes (e.g., Dondanville et al., 2016; Schumm et al., 2015). Overgeneralized beliefs and negative cognitions about the self have been shown to predict treatment dropout, whereas self-blame cognitions are protective against dropout (Alpert et al., 2020; Holder et al., 2019). Less attention has been paid to in-session processes related to cognitive change that could impact CPT outcomes.

One variable of potential importance to patients' cognitive change is cognitive flexibility, defined as one’s ability to modify their perspective based on new information (Moore & Malinowski, 2009). Although cognitive flexibility has not yet been examined in the context of CPT, higher levels assessed via self-report have been associated with less severe PTSD symptoms (Joseph & Gray, 2011; Keith et al., 2015). In addition, Alpert et al. (2021) coded session recordings of prolonged exposure therapy (PE), another gold-standard PTSD treatment, and found that lower cognitive rigidity, the inverse of cognitive flexibility, predicted higher degrees of symptom improvement. In light of these findings and given that CPT is designed to facilitate cognitive change via the exploration of new information and evidence to elicit more balanced beliefs, cognitive flexibility could play an important role in facilitating recovery in CPT.

The manner in which therapists attempt to facilitate cognitive change during CPT may also be important to treatment response. Socratic dialogue—the use of open-ended questions that guide patients to consider alternative perspectives—is a core strategy used to facilitate cognitive change (Beck et al., 1979). In the only study to examine this technique in CPT, higher therapist skill in Socratic dialogue predicted higher levels of PTSD symptom improvement across treatment (Farmer et al., 2017). Because this study did not include patient process variables (e.g., cognitive flexibility or change in negative cognitions) as predictors, it is possible that the effects were reflective of patient-level factors or interactions between patient and therapist processes.

Affective process variables

Another theorized facilitator of change during CPT is the expression of natural emotion related to trauma (Resick et al., 2017). Although not specific to PTSD, meta-analytic findings have shown a consistent association between emotional expression during therapy sessions and treatment outcomes, particularly for observer-rated emotional expression (Peluso & Freund, 2018). In CPT, studies have shown that more description of negative trauma-related emotions in impact statements and trauma accounts written between sessions predicts a higher likelihood of sudden gains (Sloan et al., 2022) and treatment completion (Alpert et al., 2020). In addition, studies have shown associations between symptom outcomes and emotional activation during PE sessions as assessed via self-report and physiological measures (Asnaani et al., 2016; Cooper et al., 2017). The coding of PE sessions has also revealed that more in-session facial expressions of fear predict better treatment outcomes (Foa et al., 1995).

Therapist skill in encouraging patients to experience trauma-related emotions may also relate to treatment outcomes. This therapeutic skill is part of the CPT protocol (Resick et al., 2017), but it has rarely been examined as a predictor of outcomes. In an examination of therapist skill in eliciting natural emotions during CPT, Farmer et al. (2017) did not observe any association with symptom outcomes. However, this variable is worth additional study, particularly in the context of examining patient emotional expression alongside therapist behavior.

Interpersonal process variables

One interpersonal process variable that is particularly relevant to trauma-focused therapy is patient avoidance of engaging with their therapist. Patient engagement in the therapeutic process is considered critical to effective psychotherapy and is often evaluated in terms of homework compliance and session attendance (Holdsworth et al., 2014). In CPT, the avoidance of homework tasks has predicted less symptom improvement (Stirman et al., 2018) and increased dropout (Alpert et al., 2020; Stirman et al., 2018). Examining in-session patient avoidance of engagement with the therapist (e.g., minimal responses to questions) could provide a more nuanced assessment of engagement-related processes that are likely to impede response.

On the therapist side, therapeutic alliance has consistently predicted treatment outcomes in CPT (Keefe et al., 2022; Sijercic et al., 2021), but specific therapist behaviors that facilitate a strong alliance have received little attention (Ellis et al., 2018). Therapists’ expressions of empathy during sessions may be a key process in developing a strong alliance and facilitating patient engagement, particularly for trauma survivors who can have difficulty developing trusting relationships (Thwaites & Bennett-Levy, 2007). One-time patient ratings of therapist empathy were found to predict outcomes in cognitive behavioral therapy for depression (Burns & Nolen-Hoeksema, 1992), but to our knowledge, no study of PTSD treatment has examined the association between therapist expression of empathy during sessions and treatment outcomes.

Current study

The current study sought to examine in-session, observer-rated patient and therapist process variables in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom response and treatment completion across the CPT protocol. Observational coding of therapy session recordings provided nuanced data about patient and therapist processes throughout treatment. Consistent with CPT's treatment targets, theorized mechanisms of change, and prior findings, we hypothesized that the following patient factors would predict more PTSD symptom response and higher rates of treatment completion: higher levels of cognitive flexibility, more expression of emotion (i.e., sadness, fear, and anger), and less avoidance of engagement with the therapist. We further hypothesized that the following therapist factors would predict better outcomes: more use of Socratic dialogue, more encouragement of patient affect, and more expression of empathy. This approach to examining predictors of outcomes can point to key processes of symptom change and treatment completion in CPT that are potentially malleable and may indicate targets to increase patient benefit.

METHOD

Participants

The present study included data from two National Institutes of Health–funded randomized clinical trials examining the efficacy of CPT in survivors of interpersonal violence (ClinicalTrials.gov Identifiers: NCT00630578 and NCT00725192). For further details of study procedures and outcomes, please see Galovski et al. (2012, 2016). The present sample included 70 adults with PTSD who received CPT. To meet the inclusion criteria for the parent trials, participants had to be at least 18 years old and meet the PTSD criteria per the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000). In addition, their index traumatic event must have occurred at least 3 months prior to enrollment. Exclusion criteria included current DSM-IV substance dependence, current suicidal behavior or intent, current experience of intimate partner violence or stalking, or previous CPT. All participants were asked to maintain a stable dose of psychiatric medication during the study period. One study only included women who endorsed high levels of trauma-related sleep difficulty, though participants across trials endorsed similarly high levels of sleep difficulty. Participants could be engaged in other psychotherapies as long as they were not trauma-focused. Because the purpose of session coding was to examine in-session variables across treatment, participants were selected for coding and included in the current sample if they attended at least one CPT session and had no more than one missing or damaged recording across all sessions attended regardless of the number of sessions. Of the 149 participants who began CPT, 70 (47.0%) were included in the present sample. In total, 549 sessions were coded (M = 7.84 sessions per participant, SD = 4.13, range: 1–12).

There were 47 participants (67.1%) who completed treatment, defined as completing 12 or more sessions. Only one trial from which data were used allowed participants to complete sessions beyond the 12-session CPT protocol; thus, only the first 12 sessions from both trials were coded. The mean participant age was 37.01 years (SD = 11.08, range: 19–68), and the sample was predominantly female (n = 60, 85.7%). Regarding race, 34 participants (48.6%) identified as White, 33 (47.1%) as Black or African American, one (1.4%) as Native American, one (1.4%) as Asian, and one (1.4%) as “other.” Eight participants (11.4%) reported their ethnicity as Hispanic or Latino. The majority of the sample (81.5%) was single, separated, divorced, or widowed; the minority (18.6%) was married or cohabitating. Participants had completed 8–23 years of education (M = 13.8, SD = 2.69), and 22.8% of the sample held a degree from a 4-year university. Most participants (68.6%) reported an annual income of $20,000 or less.

Procedure

After providing informed consent, all participants received CPT, a trauma-focused cognitive therapy that traditionally consists of 12 weekly 60-min sessions. Sessions are designed to target patients' stuck points (i.e., maladaptive beliefs that develop after trauma exposure and maintain PTSD symptoms) through Socratic dialogue, written assignments, and progressive worksheets. Both parent trials used the CPT protocol developed by Resick and colleagues (2010), which includes written trauma accounts. Participants completed measures of PTSD severity at pretreatment, posttreatment, and every treatment session. All treatment sessions were video-recorded. Eight master’s- or doctoral-level therapists delivered CPT across both trials. All therapists attended a CPT workshop led by the principal investigator as well as weekly case consultations.

This research was reviewed and approved by the institutional review boards (IRBs) at the University of Missouri, St. Louis, and VA Boston Healthcare System and was conducted per recognized ethical standards.

Measures

PTSD symptoms

The Posttraumatic Stress Diagnostic Scale (PDS; Foa et al., 1997) was used to assess PTSD severity. The PDS is a self-report measure consisting of 17 items assessing the frequency of DSM-IV PTSD symptoms (American Psychiatric Association, 2000). Items are scored on a 4-point Likert scale ranging from 0 (never) to 3 (5 times a week or more). The PDS has demonstrated good internal consistency, test–retest reliability, and convergent validity with the PTSD diagnosis from the Structured Clinical Interview for DSM-IV (Foa et al., 1997). The PDS was used in the present study because it was administered at every treatment session in addition to pretreatment and posttreatment; thus, for participants who were missing the posttreatment assessment (e.g., due to early dropout), the last available PDS score could be used in the analyses. In the present sample, internal consistency for the PDS was high at pretreatment, Cronbach’s α = .86, and posttreatment, Cronbach’s α = .96.

In-session therapist and patient process variables

Therapist.

The Cognitive Processing Therapy Therapist Adherence and Competence Protocol—Revised was used to capture therapist process variables during CPT sessions. The present study used a revised version (Farmer et al., 2017; Resick et al., 2002) of the original adherence and competence form (Nishith & Resick, 1997). The manual is designed to assess fidelity across theorized critical components of CPT. Adherence and competence for each component were rated at each session. The current study used the competence ratings (i.e., therapist skill level) of therapists’ use of Socratic dialogue, encouragement of the patient’s natural affect, and expression of empathy. Responses were rated on a 7-point Likert scale ranging from 1 (poor) to 7 (excellent).

Patient.

For the current study, an additional section was added to the CPT adherence and competence measure to assess in-session patient behaviors. Observable patient behaviors used in this study were cognitive flexibility (i.e., the ability to integrate new information and evidence to alter stuck points and generate more flexible beliefs) and avoidance of engagement with the therapist (i.e., lack of participation, minimal responses, and/or nonverbal gestures of disinterest). Cognitive flexibility was rated on an 8-point Likert scale ranging from 0 (completely resistant) to 7 (open mind), and avoidance of engagement with the therapist was rated on an 8-point Likert scale ranging from 0 (not at all) to 7 (extreme/completely).

The Client Emotional Arousal Scale III (CEAS-III; Warwar & Greenberg, 1999) was used to assess the intensity of participants’ emotional arousal during therapy sessions. The CEAS-III is an observer-rated measure used to assess the expression of 15 emotions. Each item is rated on a 7-point Likert scale ranging from 1 (person does not express any emotions) to 7 (arousal is extremely intense). The measure instructs raters to provide a peak (i.e., the highest emotional arousal) and a modal rating (i.e., average arousal during a session) for each emotion. The CEAS-III has demonstrated good reliability (Warwar & Greenberg, 2000). The current study rated only sadness, fear, and anger to decrease rater burden. For the present analyses, we used the peak ratings to capture the highest levels of emotional arousal participants displayed at any time during each session.

Session coding

Two doctoral candidates with 3 years of experience delivering CPT coded all session recordings using the Adherence/Competence Protocol and CEAS-III. First, the raters watched a complete set of 12 tapes with a national CPT expert unaffiliated with the study to establish interrater reliability. An intraclass correlation coefficient (ICC) was calculated to assess interrater reliability, and raters achieved 96% agreement. Raters coded a participant's complete set of session tapes rather than individual tapes. Each rater independently coded just over half of all tapes (Rater 1: 55%, Rater 2: 57%). To ensure ongoing reliability, raters double-coded 12% of tapes, and the CPT expert coded 9%. Raters and the expert met weekly to reduce rater drift. ICCs were calculated using two-way mixed-effects models assessing multiple raters' consistency (Koo & Li, 2016) for patient cognitive flexibility, ICC = .64; patient sadness ICC = .80; patient fear ICC = .40; patient anger ICC = .65; patient avoidance of engaging with the therapist, ICC = .56; therapist Socratic dialogue, ICC = .82; therapist encouragement of patient affect, ICC = .77; and therapist empathy, ICC = .43. For some variables, the restriction of range likely contributed to underestimates of agreement (Hallgren, 2012). For variables with ICCs below .75 (i.e., poor-to-moderate; Koo & Li, 2016), the percentage of interrater agreement within 2 points on the 7- or 8-point Likert scales reflected high interrater reliability in the context of the full scale; this applied to patient avoidance of engaging with the therapist (94.7%), patient cognitive flexibility (96.3%), patient fear (98.9%), patient anger (100.0%), and therapist empathy (100.0%).

Data analysis

Descriptive statistics were calculated using SPSS (Version 26). Regression models were estimated using Mplus (Version 7; Muthén & Muthén, 2012) using maximum likelihood estimation (MLE). To test the hypothesis that patient and therapist factors would predict PTSD symptom response, a linear regression predicting posttreatment PTSD symptoms was conducted, controlling for pretreatment PTSD symptoms. For 22 participants, a posttreatment PTSD assessment was not available; 20 of these participants dropped out before the end of treatment. To account for missing data, we identified pretreatment variables associated with missingness at posttreatment to inform covariate selection and used MLE, which produces unbiased estimates using all available data. As a secondary analysis, we estimated an additional linear regression using participants’ last available session score as the dependent variable. We view this score as a meaningful measurement of participants' final reported level of PTSD symptom severity, and using available weekly data allowed for a more precise assessment of participants' PTSD severity at the end of their treatment course regardless of treatment completion or the availability of a score at the posttreatment assessment. Average scores across sessions for all patient (i.e., cognitive flexibility, avoidance of engaging with the therapist, sadness, fear, anger) and therapist (i.e., use of Socratic dialogue, encouragement of patient affect, empathy) predictor variables were calculated. Effect sizes were calculated as standardized beta coefficients, with small, medium, and large effects interpreted as values less than .02, between .02 and .05, and greater than .05, respectively (Acock, 2014).

To test the hypothesis that patient and therapist factors predicted treatment completion, a logistic regression using the same predictor variables was conducted predicting completion (1) versus dropout (0). Effect sizes were calculated as odds ratios (ORs), with values of 1.68 or greater or 0.60 or below, 3.47 or greater or 0.29 or below, and 6.71 or greater or 0.15 or below interpreted as small, medium, and large effects, respectively (Chen et al., 2010).

Patient age and educational attainment were included as covariates in all models because they were correlated with symptom outcomes and treatment completion, income was included because it predicted missingness of posttreatment PTSD scores beyond the influence of age and educational attainment, and gender was included given meta-analytic findings that men demonstrate poorer symptom response in trauma-focused treatments (Wade et al., 2016).

RESULTS

Descriptive analyses and intercorrelations

Descriptive statistics (i.e., means, standard deviations, and ranges) for predictor and outcome variables and their intercorrelations are presented in Table 1. Of note, higher ratings of patient avoidance of engaging with the therapist were significantly associated with lower patient cognitive flexibility, r = −.35; more patient expression of anger, r = .25; and less therapist use of Socratic dialogue, r = −.24. All of the therapist factors (i.e., use of Socratic dialogue, encouragement of patient affect, and expression of empathy) were significantly and positively correlated, rs = .37–.44.

TABLE 1.

Descriptive statistics and intercorrelations among predictor and outcome variables

Variable 1 2 3 4 5 6 7 8 9 10 11
1. PT cognitive flexibility – −.25* −.23 −.23 −.35** .08 .10 .15 −.16 −.57*** −.54***
2. PT sadness – .45** −.06 −.02 .10 .21 .14 .14 .13 .12
3. PT fear – −.07 −.02 .08 .11 −.01 −.23 .18 .17
4. PT anger – .25* .16 .16 .05 −.20 −.05 −.10
5. PT avoid engaging with TH – −.24* .07 −.02 −.07 .37** .41***
6. TH Socratic dialogue – .37** .38** −.24* −.25 −.37**
7. TH encourage PT affect – .44** .21 −.10 .00
8. TH expression of empathy – .05 −.09 −.16
9. PTSD pretreatmenta – .42** .47***
10. PTSD posttreatmenta,b – 1.00***
11. PTSD last availablea,b –
M 4.40 2.08 1.20 1.16 0.61 3.02 4.70 5.22 32.41 12.15 15.64
SD 0.97 1.31 0.43 0.35 1.00 0.96 1.34 0.62 8.38 13.60 14.70
Minimum 1.89 1.00 1.00 1.00 0.00 1.00 0.40 4.00 12.00 0.00 0.00
Maximum 7.18 6.00 3.18 2.83 4.00 4.64 6.92 6.70 48.00 48.00 51.00
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Note. PT = patient, TH = therapist, PTSD = posttraumatic stress disorder.

a

Self-reported PTSD symptoms were assessed using the Posttraumatic Diagnostic Scale for DSM-IV.

b

Posttreatment and last available PTSD symptom scores were perfectly correlated because the posttreatment score was used as the last available score for participants who completed a posttreatment assessment.

*

p < .05.

**

p < .01.

***

p < .001.

Predictors of symptom response

Lower ratings of patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35, both predicted lower levels of self-reported PTSD symptoms at posttreatment, controlling for pretreatment PTSD symptom level. Standardized beta values indicated that a 1–standard deviation increase in fear corresponded with a .32–standard deviation higher posttreatment PTSD score, and a 1–standard deviation increase in avoidance of engaging with the therapist corresponded with a .35–standard deviation higher posttreatment PTSD score, holding other variables constant. The results are presented in Table 2. Less patient fear, β = .23, and avoidance of engaging with the therapist, β = .28, also predicted the last available PTSD score, as did higher ratings of patient cognitive flexibility, β = −.33. The results are presented in Supplementary Table S1. Patient sadness and anger and therapist use of Socratic dialogue, encouragement of patient affect, and expression of empathy did not predict PTSD outcomes. Models explained 60% of the variance in posttreatment PTSD symptoms, R2 = .60, F(12, 30) = 7.27, p < .001, and 64% of the variance in last available PTSD scores, R2 = .64, F(12, 49) = 9.00, p < .001.

TABLE 2.

Linear regression results predicting posttreatment posttraumatic stress disorder symptoms

Variable B 95% CI SE β z p
Pretreatment PTSD 0.60 [0.11, 1.09] 0.25 .36 2.41 .016
PT age 0.20 [−0.01, 0.41] 0.11 .16 1.86 .063
PT education 0.53 [−1.43, 2.49] 1.00 .05 0.53 .598
PT gendera −2.85 [−15.50, 9.79] 6.45 −.07 −0.44 .658
PT income −0.20 [−1.82, 1.41] 0.82 −.03 −0.25 .804
PT cognitive flexibility −4.56 [−9.71, 0.60] 2.63 −.33 −1.73 .083
PT sadness −0.98 [−3.36, 1.39] 1.21 −.09 −0.81 .417
PT fear 10.50 [2.11, 18.89] 4.28 .32 2.45 .014
PT anger −2.66 [−10.49, 5.16] 3.99 −.07 −0.67 .505
PT avoid engaging with TH 4.90 [0.65, 9.14] 2.17 .35 2.26 .024
TH Socratic dialogue −0.15 [−6.00, 5.71] 2.99 −.01 −0.05 .961
TH encourage PT affect −0.57 [−4.53, 3.39] 2.02 −.05 −0.28 .778
TH expression of empathy −2.64 [−7.19, 1.91] 2.32 −.12 −1.14 .256
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Note: CI = confidence interval; PT = patient; TH = therapist; Self-reported PTSD symptoms were assessed using the Posttraumatic Diagnostic Scale for DSM-IV.

a

Coded as 0 = male, 1 = female.

Predictors of treatment completion

A higher likelihood of treatment completion was predicted by more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Odds ratios indicated that a 1-point increase in therapist use of Socratic dialogue corresponded with a 6.75-times higher likelihood of treatment completion, and a 1-point increase in therapist encouragement of patient affect corresponded with an 89% lower likelihood of completing treatment, holding other variables constant. Patient avoidance of engaging with the therapist, cognitive flexibility, sadness, fear, anger, and therapist expression of empathy did not predict treatment completion. Results are presented in Table 3.

TABLE 3.

Logistic regression results predicting treatment completion (1) or dropout (0)

Variable B SE z p OR 95% CI
PT age 0.16 0.08 2.06 .040 1.17 [1.01, 1.36]
PT education −1.33 0.70 −1.91 .056 0.26 [0.07, 1.03]
PT gendera 1.08 1.34 0.81 .419 2.94 [0.22, 40.21]
PT income 0.53 0.37 1.44 .149 1.71 [0.83, 3.53]
PT cognitive flexibility 1.39 0.95 1.45 .146 4.00 [0.62, 25.88]
PT sadness 0.90 0.48 1.87 .061 2.46 [0.96, 6.29]
PT fear −0.66 1.31 −0.51 .613 0.52 [0.04, 6.71]
PT anger 4.25 2.20 1.94 .053 69.97 [0.95, 5,176.40]
PT avoid engaging with TH 0.24 0.64 0.37 .714 1.27 [0.36, 4.46]
TH Socratic dialogue 1.91 0.68 2.81 .005 6.75 [1.79, 25.54]
TH encourage PT affect −2.19 0.84 −2.62 .009 0.11 [0.02, 0.58]
TH expression of empathy 1.59 1.03 1.54 .123 4.89 [0.65, 36.74]
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Note. OR = odds ratio; CI = confidence interval; PT = patient; TH = therapist.

a

Coded as 0 = male, 1 = female.

DISCUSSION

This study examined in-session patient and therapist processes across cognitive, affective, and interpersonal domains as predictors of symptom response and treatment completion in CPT. Considered together, less patient fear and avoidance of engaging with the therapist predicted better PTSD symptom response at posttreatment and the last available assessment, and cognitive flexibility predicted the last available PTSD score, highlighting the importance of patients' cognitions, emotions, and engagement with the therapist in CPT. Increased therapist use of Socratic dialogue and less therapist encouragement of patient affect predicted a higher likelihood of treatment completion, highlighting the role of therapist behaviors in patient retention in care.

In the primary analysis, which used a conservative statistical approach to analyze all available posttreatment data, patient cognitive flexibility did not emerge as a predictor of outcome. This finding suggests the content of patients' cognitions may be more prognostic of symptom outcomes than cognitive flexibility (e.g., Dondanville et al., 2016; Schumm et al., 2015). However, cognitive flexibility did predict lower PTSD symptoms using participant-reported symptom scores at their last available assessment regardless of treatment completion status. Predicting posttreatment PTSD using MLE is a conservative approach often used in clinical trials to reduce bias in results. At the same time, this analysis did not account for the weekly PTSD scores that were collected and using weekly data to predict each individual's final reported symptom severity irrespective of dropout status yielded important additional information. The finding regarding predictors of the last available score is consistent with studies that have demonstrated associations between cognitive flexibility and less severe PTSD symptoms (Keith et al., 2015) as well as between cognitive rigidity and worse PTSD treatment outcomes (Alpert et al., 2021). Although cognitive flexibility is distinct from changes in cognition content, it may facilitate openness to cognitive change in the context of alternative information discussed in CPT sessions. Future studies can test this empirical question.

Therapist use of Socratic dialogue did not predict PTSD symptom outcomes when examined together with patient processes, including cognitive flexibility. Farmer and colleagues (2017) did observe this association, although their study did not include patient processes. When considered together, patient cognitive flexibility predicted symptom outcomes above and beyond therapist use of Socratic dialogue. Therapist use of Socratic dialogue may facilitate patient cognitive flexibility, which could, in turn, promote better outcomes. Such a mediational process could explain the present findings in light of Farmer et al.'s (2017) results. Session-by-session modeling could elucidate these patterns.

Although therapist use of Socratic dialogue did not predict symptom outcomes in the current study, it did predict treatment completion. Using Socratic rather than authoritative language in sessions can help patients challenge stuck points related to engaging in treatment and may promote engagement by inviting patients to think through issues themselves rather than therapists telling them what to think (Galovski et al., 2020).

Examining patient emotional expression across sessions showed that, contrary to hypotheses, higher ratings of patient fear across sessions predicted worse PTSD outcomes. Patient fear was coded as the peak expression in each session and averaged across sessions, so a high level of fear sustained across sessions may have reflected emotional overengagement, which can impede recovery (Foa et al., 2007). It may be more important that patients experience natural emotions at some point in treatment, rather than across sessions. Further, observational coding cannot differentiate natural emotions from manufactured emotions (i.e., emotions amplified by negative cognitions; Resick et al., 2017). Experiencing high levels of fear across sessions without relief may indicate that the observed emotions are manufactured by stuck thinking that has not been sufficiently targeted in treatment.

The observed association between increased therapist encouragement of patient affect and a higher likelihood of dropout was in the opposite direction of our hypothesis, given that the CPT protocol instructs therapists to help patients feel the natural emotions they may have been avoiding. However, it can be difficult for therapists to discern natural versus manufactured emotions, and therapist encouragement of manufactured emotion may be detrimental. Additionally, it may be that therapist encouragement of affect contributes to dropout or patient emotional avoidance may be a third variable such that patients with high levels of emotional avoidance may both elicit encouragement of affect from therapists and be more likely to drop out of treatment. Although patient avoidance of engaging with the therapist did not predict dropout, other forms of patient avoidance (e.g., homework noncompletion) have predicted dropout in other samples (Alpert et al., 2020; Stirman et al., 2018). Further research is needed to clarify the association between therapist encouragement of affect and dropout.

Of the interpersonal processes examined, less patient avoidance of engaging with the therapist predicted better PTSD outcomes, whereas therapist expression of empathy did not predict outcomes. The former finding is consistent with our hypotheses and with findings from studies examining other forms of avoidance in PTSD treatment (e.g., Alpert et al., 2020; Stirman et al., 2018). The current study extends these findings to show that in-session avoidance, specifically difficulty engaging with the therapist, is associated with worse symptom outcomes in CPT. Additionally, avoidance of engaging with the therapist was significantly correlated with lower cognitive flexibility; thus, avoidance may hinder engagement with new information or these variables may reflect an underlying difficulty in engaging with the therapy process.

Therapist expression of empathy in sessions did not predict outcomes, which is inconsistent with our hypotheses and prior findings relating the therapeutic alliance more broadly to CPT outcomes (Keefe et al., 2022; Sijercic et al., 2021) and relating therapist empathy to outcomes in cognitive behavioral therapy for depression (Burns & Nolen-Hoeksema, 1992). This study measured therapist expression of empathy as an observer-rated, session-by-session variable rather than a global patient rating and was included in models with multiple treatment-specific process variables. The findings suggest therapist expression of empathy does not contribute unique variance above and beyond specific process variables, though it may facilitate processes that predict outcomes. Further, other aspects of the therapeutic alliance, such as agreement on therapy tasks, may relate more strongly to CPT outcomes. Additionally, restriction of range and low variability in therapist empathy ratings may partially explain the nonsignificant findings.

Taken together, these findings have preliminary clinical implications that warrant additional support from future research. The findings suggest CPT therapists might attend to patients’ low cognitive flexibility, high sustained fear, and high avoidance of engaging with the therapist as prognostic indicators; maximize the use of Socratic rather than authoritative dialogue; and use discretion when encouraging patients to experience affect. Future research is needed to clarify ways therapists can intervene effectively to increase patients’ cognitive flexibility, reduce patients’ sustained fear and avoidance of engaging, and effectively encourage patients to experience natural affect without increasing dropout risk. The extent to which the present findings generalize to other trauma-focused treatments is also an important empirical question.

A strength of the current study is the use of observational coding of session recordings, which allowed us to capture patient and therapist processes across cognitive, affective, and interpersonal domains together in the same study and elucidate which processes uniquely predicted outcomes when accounting for other variables simultaneously. However, important processes were likely missed that warrant inclusion in future research, including unobservable internal processes (e.g., a shift in perspective that a patient does not articulate, emotions that are not visible to an observer). This measurement limitation could have led to the conclusion that a variable was less conceptually important when improved measurement may have led to a different result. Additionally, low ICC values for some codes, despite high percentages of interrater agreement, could have impacted the results, as variation even within 2 points on the 7- or 8-point scales may have altered the findings. Further, the present sample was composed of mostly female survivors of interpersonal violence, one study required high trauma-related sleep difficulty, measures of DSM-IV PTSD were used, and participants were only included if they had a nearly complete set of session recordings, potentially limiting the generalizability of these findings to samples with these specifications rather than to CPT samples more broadly, as this study sought to examine. Future research is needed to determine whether these findings replicate in broader trauma samples using assessments based on DSM-5 PTSD criteria (American Psychiatric Association, 2013) and to extend the findings to outcomes at follow-up visits. Finally, the focus of this study was to examine predictors on average across sessions, so temporal relationships were not examined. The present analyses cannot rule out the possibilities that symptom reductions preceded and predicted changes in variables of interest or that changes in variables of interest reflected co-occurring symptom change. We also could not elucidate whether processes that occurred during particular parts of treatment predicted outcomes (e.g., emotional expression during trauma account sessions, therapist expression of empathy early in treatment). Future research should examine session-by-session patient and therapist variables and PTSD symptoms.

The present findings indicate that in-session patient and therapist processes across cognitive, affective, and interpersonal domains are associated with symptom outcomes and treatment completion in CPT. The results suggest that patients' cognitive flexibility, fear, and avoidance of engaging with the therapist during sessions may be prognostic indicators of symptom response over the course of treatment and that therapists’ use of Socratic dialogue and titration of encouraging patient affect are related to treatment completion. Further research is needed to elucidate these associations, including temporal sequencing and processes by which these variables relate to treatment response and dropout. Such research can refine understanding of key processes of symptom response and treatment completion in CPT and clarify strategies therapists can implement in sessions to promote optimal outcomes.

Supplementary Material

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Acknowledgments

Data used in this study were derived from two randomized controlled trials funded by the National Institute of Mental Health (R34-MH-074937) and National Center for Complementary and Integrative Health (R21-AT-004079) to Tara E. Galovski; ClinicalTrials.gov identifiers: NCT00630578, NCT00725192.

Footnotes

The views expressed are those of the authors and do not necessarily represent the position of the U.S. Department of Veterans Affairs. The authors have no conflicts of interest to declare. The authors wish to thank all study staff and participants who were involved in these trials. The authors also wish to thank Karen Mitchell for consulting on the statistical analyses.

OPEN PRACTICES STATEMENT

The study reported in this article was not formally preregistered. Neither the data nor the materials have been made available on a permanent third-party archive; requests for the data or materials can be sent via email to the final author at Tara.Galovski@va.gov.

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