Table 2.

Iterative development of the Spanish CPT Manual—Version 2

Stage 3: Preliminary Adaptation Test	Stage 4: Adaptation Refinement	Stage 5: Cultural Adaptation Trial
Difficult to use. Many providers perceived the manual as difficult to use, even if they had already used the English language version. One provider believed that, “The treatment manual in Spanish...is very different from the one in English...It's like a different procedure.” Another provider identified discrepancies between specific session protocols in the manual and felt that these discrepancies hampered her ability to faithfully deliver the intervention. In general, providers were “confused,” or “taken by surprise” by the differences between the English CPT Manual and the Spanish CPT Manual—Version 1.	Terminology. Based on the qualitative data integration, several terms used in the original CPT Spanish language manual were identified as either being poor translations (e.g. “pattern” to “patron”) or nonsensical words (e.g. “stuck point” to “punto de estacionamiento”).	Difficult to use. Some providers perceived the Spanish CPT Manual—Version 2 as difficult to use, although there were far fewer comments about challenges using this iteration of the manual than there were about using the Spanish CPT Manual—Version 1. One provider remarked that the Spanish used in the Spanish CPT Manual—Version 2 was different from the Spanish that she spoke, and thus she, “Thought, ‘Well how would I say it?’ And...just did my own script.” Another provider believed that, “The Spanish worksheets are different than what we've learned (in English),” and, as a result, felt that she was “not doing a good job teaching them.” In addition, a provider reported finding typographical errors in the Spanish CPT Manual—Version 2, which they felt hampered their comprehension of the manual and ability to use it with clients.
	Manual layout. Providers reported that one of the strengths of the English language manual is its visual organization. For example, each section is well-organized, with section headings, a readable font size, and other visual cues that assist in material comprehension. The Spanish language manual was adapted to mirror these aspects of the English language manual. Additionally, we added delineated checklists for session agendas, and separated therapist considerations from the bulk of the session material. These changes were made to facilitate provider administration of the intervention to clients.
In addition, providers felt that many specific concepts from the manual were difficult to explain in Spanish or lacked suitable Spanish translations. Multiple key terms (e.g. stuck points) were translated in ways that didn't make sense to clients and didn't accurately reflect the meaning of the term.
Fit with literacy and education level of clients. Providers felt that the language used in the manual was inappropriate for their clients’ levels of education and verbal comprehension abilities. One provider stated that the vocabulary used on worksheets, “Just didn't make sense” to her client and, “could be far more basic.” Another provider believed that the language used in the intervention materials, “Seem[ed] to overwhelm” her client and that, “when she goes home, she gets very confused with (the worksheets).” A third provider felt that, “Some of the language...is kind of confusing, even for myself, a college-level fluent Spanish speaker.” Multiple providers stated that their clients had low levels of education and that they had to simplify the language they used to facilitate client comprehension. This was confirmed by statements made by clients, such as, “I didn't work on this (homework) because I don't get it...I'm not familiarized with all these terms.”	Clinical examples. We added example dialogue that might be more related to the types of trauma often experienced by clients in community health centers, such as community violence, domestic violence, physical assault, and gang violence. Worksheets and handouts were also revised accordingly.	Fit with literacy and education level of clients. Although no providers explicitly reported poor fit with regard to client literacy and education levels of the Spanish CPT Manual—Version 2, there were a few mentions of clients being confused by session materials and homework assignments. One provider, for example, noted that their client couldn't complete a worksheet because they were “baffled by the diagram. It requires a little interpretation.” In addition, there were multiple instances of patients expressing confusion about session materials and homework assignments. A patient told their provider, that, “I read this (homework assignment) like ten times, and I don't know what I had to write.” Another patient, speaking about their homework from the previous week, admitted that “I didn't understand it and I didn't do it.” Overall, however, only a small handful of providers or patients expressed any concerns about the fit of the new version of the Manual with client literacy and education levels.
	Integration of CPT-DRC Manual. To address prominent concerns regarding literacy level of the material, we integrate another adaptation of the CPT manual, developed for use with clients with low education and literacy.
	Handouts and worksheets. Homework difficulty and compliance was one of the biggest barriers to implementation of CPT Spanish in this trial. In order to address the concerns of the providers and clients in this study, we revised client handouts and worksheets to be more easily understood, both visually and linguistically. In addition to changing the terminology, as discussed previously, we altered the formatting of the worksheets, and provided visual cues so that clients would be able to more easily complete homework outside of session.
Cultural relevance of Clinical Examples. The Spanish CPT Manual—Version 1 was translated from the English CPT Manual developed for the veteran's health administration (Resick, Monson, & Chard, 2008a). The English CPT Manual provides several client dialogue examples that pertain exclusively to veterans. Although some therapists may be able to create novel and relatable examples for their clients based on these veterans examples, many providers expressed difficulty with this task.

Note. CPT = Cognitive Processing Therapy; CPT-DRC=Cognitive Processing Therapy—Democratic Republic of Congo.