Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive–behavioral treatment for posttraumatic stress disorder (PTSD) and a front‐line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy–cognitive therapy only (CPT‐C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT‐C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT‐C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self‐ and clinician‐reported PTSD and self‐reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment‐wise α correction was applied, this effect did not remain significant.     

The effect of cognitive processing therapy on cognitions: Impact statement coding

This study compared the cognitions of 37 female rape survivors before and after completing cognitive processing therapy (CPT). It was hypothesized that CPT would be associated with reductions in posttraumatic stress disorder (PTSD) symptoms and problematic (i.e., assimilated and overaccommodated) thoughts as well as increases in the number of realistic (i.e., accommodated) cognitions. Cognitions were assessed via coding and analyses of participants' written impact statements at the beginning and end of treatment. Posttraumatic stress disorder symptoms were assessed with the Clinician-Administered PTSD Scale and PTSD Symptom Scale. As predicted, there were significant increases in accommodated statements and significant decreases in overaccommodated and assimilated statements. The hypothesis that cognitive changes would be related to symptom reduction was partially supported.     

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale–Interview Version and PTSD Checklist for DSM‐5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent‐to‐treat, mixed‐effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges’ gs = ?0.33 to ?1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges’ gs = ?0.78 to ?0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co‐occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.     

The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community

Military‐affiliated individuals (i.e., active duty personnel and veterans) exhibit high rates of posttraumatic stress disorder (PTSD). Although existing evidence‐based treatments for PTSD, such as cognitive processing therapy (CPT), have demonstrated effectiveness with military‐affiliated patients, there is evidence to suggest these individuals do not benefit as much as civilians. However, few studies have directly compared the effects of PTSD treatment between civilian and military‐affiliated participants. The current study compared treatment outcomes of military‐affiliated and civilian patients receiving CPT. Participants with PTSD who were either civilians (n = 136) or military‐affiliated (n = 63) received CPT from community‐based providers in training for CPT. Results indicated that military‐affiliated participants were equally likely to complete treatment, Log odds ratio (OR) = 0.14, p = .648. Although military‐affiliated participants exhibited reductions in PTSD, B = ?2.53, p < .001; and depression symptoms, B = ?0.65, p < .001, they experienced smaller reductions in symptoms relative to civilians: B = 1.15, p = .015 for PTSD symptoms and B = 0.29, p = .029 for depression symptoms. Furthermore, variability estimates indicated there was more variability in providers’ treatment of military‐affiliated versus civilian participants (i.e., completion rates and symptom reduction). These findings suggest that military‐affiliated patients can be successfully retained in trauma‐focused treatment in the community at the same rate as civilian patients, and they significantly improve in PTSD and depression symptoms although not as much as civilians. These findings also highlight community providers’ variability in treatment of military‐affiliated patients, providing support for more military‐cultural training.     

Initial Findings From Project Recover: Overcoming Co‐Occurring Eating Disorders and Posttraumatic Stress Disorder Through Integrated Treatment

This pilot study is the initial investigation of an integrated cognitive behavioral therapy (CBT) for co‐occurring eating disorders (ED) and posttraumatic stress disorder (PTSD). Following a course of intensive hospital‐based ED treatment focused on ED behavioral symptom interruption, 10 individuals with ED‐PTSD received 16 sessions of CBT that focused on maintaining improvements in ED symptoms outside of the hospital environment and integrated cognitive processing therapy for PTSD. We hypothesized that the treatment would be associated with significant improvements in PTSD symptoms, depression, and anxiety, as well as sustained improvements in ED symptomatology. There were statistically significant improvements in clinician‐rated PTSD symptoms (g av = 4.58), depression (g av = 1.37), and anxiety (g av = 1.00). As expected, there was no statistically significant change in ED cognitions (g av = .28). Reliable change analyses revealed that only 1 participant experienced deterioration in ED cognitions over the course of the integrated treatment. Of the 9 participants who were remitted from behavioral ED symptoms at the end of intensive treatment/beginning of the integrated treatment, 8 remained behaviorally remitted at poststudy treatment, which is encouraging given the high rate of rapid relapse following intensive ED treatment. Findings from this study provide preliminary support for the efficacy of an integrated CBT for ED‐PTSD.     

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self‐reported and clinician‐assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty‐six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present‐centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed‐effects model analysis revealed a significant interaction between groups (p = .05, d = ?0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self‐reported, but not clinician‐assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre‐ and posttreatment effect sizes were mostly moderate to large (d = 0.30–1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self‐reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.     

Associations Between Functioning and PTSD Symptom Clusters in a Dismantling Trial of Cognitive Processing Therapy in Female Interpersonal Violence Survivors

This study conducted secondary analyses of a published trial and sought to determine if different domains of psychosocial functioning (e.g., daily living, work, nonfamily relationships) improved following trauma‐focused treatment for posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT), an empirically supported treatment that involves evaluating trauma‐related beliefs and written trauma accounts, was compared to its components: CPT without the written accounts or written accounts only in a sample of 78 women with PTSD secondary to interpersonal violence. Overall and individual domains of functioning significantly improved with treatment and results were similar across treatment groups, Fs (2, 150) ≥ 11.87, ps < .001. Additionally, we investigated whether changes in different PTSD symptom clusters were associated with outcomes in domains of psychosocial functioning, after collapsing across treatment condition. Multiple hierarchical linear regression analyses revealed that overall clinician‐assessed PTSD symptom reduction was associated with outcomes in all domains of functioning, βs = .44 to .68, ps < .001. Additionally, improvements in the emotional numbing symptom cluster were associated with outcomes in the nonfamily relationships domain, β = .42, p < .001, and improvements in the hyperarousal symptom cluster were associated with outcomes in the overall, daily living, and household tasks domains, βs = .34 to .39, ps < .01. Results suggest that it may be important to monitor improvements in emotional numbing and hyperarousal symptoms throughout treatment to increase the likelihood of changes in psychosocial functioning.     

Comparing Response to Cognitive Processing Therapy in Military Veterans With Subthreshold and Threshold Posttraumatic Stress Disorder

Research suggests that subthreshold posttraumatic stress disorder (PTSD) symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. However, it does not appear that any studies to date have investigated whether subthreshold PTSD can effectively be treated with evidence‐based, trauma‐focused treatment. Accordingly, we tested response to cognitive processing therapy (CPT) in 2 groups of military veterans receiving care at a VA outpatient specialty clinic, 1 with subthreshold PTSD at pretreatment (n = 51) and the other with full, diagnostic PTSD (n = 483). Multilevel analysis revealed that both groups experienced a significant decrease in PTSD symptoms over the course of therapy (the full and subthreshold PTSD groups experienced an average decrease of 1.79 and 1.52 points, respectively, on the PTSD Checklist with each increment of time, which was coded from 0 at pretreatment to 13 at posttreatment). After controlling for pretreatment symptom severity, a between‐groups difference was not found. These results suggest that CPT is an effective form of treatment among military veterans, and that its effectiveness does not differ between subthreshold and threshold groups.     

The Impact of Childhood Abuse Among Women With Assault‐Related PTSD Receiving Short‐Term Cognitive–Behavioral Therapy

This study examined the effect of child sexual or physical abuse on brief cognitive–behavioral therapy treatments with adults with posttraumatic stress disorder (PTSD). We analyzed secondary data from two randomized controlled trials (Resick, Nishith, Weaver, Astin, & Feuer, 2002; Resick et al., 2008) that included women with PTSD who did or did not have child sexual abuse (CSA) or child physical abuse (CPA) histories to determine whether childhood abuse impacted dropout rate or reduction in PTSD symptoms. In Study 1, presence, duration, or severity of CSA was not associated with dropout; however, frequency of CSA significantly predicted dropout (OR = 1.23). A significant CPA Severity × Treatment Group interaction emerged such that CPA severity was associated with greater dropout for prolonged exposure (PE; OR = 1.45), but not cognitive processing therapy (CPT; OR = 0.90). Study 2 found no differences in dropout. Study 1, comparing CPT and PE among women who experienced at least 1 rape found no differences in outcome based on childhood abuse history (r_p²s = .000–.009). Study 2, a dismantling study of CPT with women seeking treatment for adult or child sexual or physical abuse found that for those with no childhood abuse, CPT‐C, the cognitive‐only version of CPT, had an advantage, whereas both forms of CPT worked best for those with higher frequency of childhood abuse; the effect size was small.     

The Effect of Sleep Disorders,Sedating Medications,and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis

Cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) is an effortful process requiring engagement in cognitive restructuring. Sleep disorders may lead to avoidance of effortful tasks and cognitive performance deficits. We explored whether sleep disorders, as assessed by polysomnography, were consistently associated with treatment response in combination with other factors. This study included 32 U.S. veterans who were examined both before and after CPT for combat‐related PTSD. We employed a novel, case‐comparative technique, fuzzy set qualitative comparative analysis (fsQCA), to identify combinations of fuzzy and crisp factors (recipes) that achieve a clinically significant outcome. Approximately one‐quarter of cases experiencing clinically significant change were either (a) Vietnam era veterans without sedating medications, moderate sleep disordered breathing, and severe depression; or (b) non–Vietnam era veterans with sedating medications and without severe periodic limb movements (or significant periodic limb movement arousals). Recipes involving the absence of the relevant sleep disorder were associated with the highest coverage values. These results using fsQCA (a) provide valuable information about the heterogeneity of CPT response and (b) suggest that sleep disorders are important factors to consider in theoretical discussions of who responds to CPT for PTSD.     

Impact of Self‐Blame on Cognitive Processing Therapy: A Comparison of Treatment Outcomes

Research suggests that cognitive processing therapy (CPT) may be a particularly well‐suited intervention for trauma survivors who endorse self‐blame; however, no study has examined the impact of self‐blame on response to CPT. Accordingly, the current study compared response to CPT between two groups of veterans seeking residential treatment for posttraumatic stress disorder (PTSD). In one group, participants endorsed low self‐blame at pretreatment (n = 133) and in the other group, participants endorsed high self‐blame (n = 133). Results from multilevel modeling analysis suggest that both groups experienced significant reductions in PTSD symptoms as measured by the PTSD Checklist, B = ?1.58, SE = 0.11; 95% CI [?1.78, ?1.37]; t(1654) = ?14.97, p < .001. After controlling for pretreatment symptom severity and additional covariates, there was no difference in treatment response between the low‐ and high‐self‐blame groups, Time × Self‐blame interaction: B = 0.18, SE = 0.12; 95% CI = [?0.06, 0.42]; t(1646) = 1.49, p = .138. This suggests that CPT is an effective treatment for individuals exposed to trauma, regardless of level of self‐blame.     

Fear of Losing Emotional Control Is Associated With Cognitive Processing Therapy Outcomes in U.S. Veterans of Afghanistan and Iraq

Evidence‐based treatments for posttraumatic stress disorder (PTSD) can reduce symptoms and improve veterans’ psychological health. Unfortunately, many veterans leave treatment before receiving maximum benefit. Fear of emotions is related to severity of PTSD, and changes in fear of emotions are correlated with changes in PTSD symptoms. This study built upon the literature linking greater fear of emotions to PTSD severity by examining whether pretreatment fear of emotions, measured by the Affect Control Scale, was associated with completion of cognitive processing therapy (CPT) and severity of posttreatment PTSD in a sample of 89 U.S. veterans who had served in Afghanistan and Iraq. About 60% of veterans completed 10 or more therapy sessions. A logistic regression on 51 of the 89 subjects that more fear of anxiety at pretreatment was associated with decreased likelihood of completing treatment, OR = 0.93, 95% CI [0.87, 1.00]. Of those veterans who completed treatment, higher fear of anger at pretreatment was negatively related to severity of PTSD posttreatment (β = ?.29, p = .037), in a model with the other predictors. Assessing veterans for fear of anxiety and anger before CPT and teaching emotion regulation skills to those in need may reduce treatment dropout.     

Social Support Moderates the Association Between Posttraumatic Stress Disorder Treatment Duration and Treatment Outcomes in Telemedicine-Based Treatment Among Rural Veterans

For patients participating in trauma-focused psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy (CPT), pretreatment characteristics may moderate treatment effectiveness. For instance, preexisting supportive relationships may encourage skill utilization or provide contrasts to maladaptive cognitive biases highlighted in trauma-focused treatments for PTSD. Such pretreatment characteristics are important to study in rural individuals, who may experience barriers to initiating and completing treatment. The aim of this study was to examine whether pretreatment social support, measured using the Medical Outcomes Study Social Support Survey, would moderate the association between CPT duration (i.e., number of sessions attended) and change in PTSD symptoms, using data from a pragmatic randomized controlled trial of a telemedicine-based collaborative care intervention for rural veterans (N = 225). Social support moderated the association between CPT duration and PTSD symptom change, B = −0.016, SE = −.006; 95% CI [−0.028, −0.005], such that increased duration was associated with more PTSD symptom change only at average or higher levels of support. This effect was found for overall and emotional support but not tangible support. Additionally, on average, among participants who attended eight or more CPT sessions, only those at or above 1 standard deviation above the mean social support score demonstrated a reliable change in PTSD symptoms. The results indicate that the link between CPT treatment duration and treatment outcomes may be stronger for veterans with higher levels of pretreatment social support.     

The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder

This study investigated sudden gains, i.e., rapid and stable improvements, in posttraumatic stress disorder (PTSD) symptoms that may occur in cognitive–behavioral therapy. Twenty‐nine of 72 participants (39.2%) experienced a sudden gain during treatment. Mixed model ANOVAs analyzed sudden gains impact on clinician‐rated PTSD symptom severity, patient‐rated PTSD symptom severity, and patient‐rated depressive symptom severity. Sudden gains in PTSD symptomology were associated with greater reductions in PTSD symptom severity for the avoidance/numbing and hyperarousal symptom clusters at posttreatment. By 6‐month follow‐up, the sudden gains group had maintained those reductions in symptoms, but the nonsudden gains group had achieved equal reductions in symptom severity. Participants experiencing sudden gains on PTSD measures had lower depression severity at posttreatment and follow‐up.     

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%–95.1%) and posttreatment (69.1–71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.     

Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort

The authors report clinical findings from the pilot cohort of the first prospective, noninferiority-designed randomized clinical trial evaluating the clinical outcomes of delivering a cognitive-behavioral group intervention for posttraumatic stress disorder (PTSD), cognitive processing therapy (CPT), via video teleconferencing (VT) compared to the in-person modality. The treatment was delivered to 13 veterans with PTSD residing on the Hawaiian Islands. Results support the general feasibility and safety of using VT. Both groups showed clinically meaningful reductions in PTSD symptoms and no significant between-group differences on clinical or process outcome variables. In keeping with treatment manual recommendations, a few changes were made to the CPT protocol to accommodate this population. Novel aspects of this trial and lessons learned are discussed.     

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Recent studies have called attention to the need for enhancing treatment outcome in trauma‐focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic‐related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA‐positive and 276 OSA‐negative veterans were identified. Generalized estimating equations were used to compare between‐group differences in weekly self‐reported PTSD symptomatology. The OSA‐positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = −0.657). Additionally, OSA‐positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA‐positive veterans without access to CPAP (B = −0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence‐based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.     

Increased Mindfulness Skills as Predictors of Reduced Trauma‐Related Guilt in Treatment‐Seeking Veterans

The present study examined the predictive role of increased self‐reported mindfulness skills on reduced trauma‐related guilt in a sample of veterans over the course of residential treatment for posttraumatic stress disorder (PTSD; N = 128). The residential treatment consisted of seven weeks of intensive cognitive processing therapy (CPT) for PTSD, as well as additional psychoeducational groups, including seven sessions on mindfulness skills. Increased mindfulness skills describing, acting with awareness, and accepting without judgment were significantly associated with reductions in trauma‐related guilt over the course of treatment. Increases in the ability to act with awareness and accept without judgment were significantly associated with reductions in global guilt, R ² = .26, guilt distress, R ²= .23, guilt cognitions, R ²= .23, and lack of justification, R ²= .11. An increase in the ability to accept without judgment was the only self‐reported mindfulness skill that was associated with reductions in hindsight bias, β = −.34 and wrongdoing, β = −.44. Increases in self‐reported mindfulness skills explained 15.1 to 24.1% of the variance in reductions in trauma‐related guilt, suggesting that mindfulness skills may play a key role in reducing the experience of trauma‐related guilt during psychotherapy. Our results provide preliminary support for the use of mindfulness groups as an adjunct to traditional evidence‐based treatments aimed at reducing trauma‐related guilt, though this claim needs to be tested further using experimental designs.     

Examination of the World Health Organization Disability Assessment System as a Measure of Disability Severity Among Veterans Receiving Cognitive Processing Therapy

Cognitive processing therapy (CPT) is effective for reducing posttraumatic stress disorder (PTSD) and depression among military veterans. However, studies have not examined whether CPT is associated with reductions in disability severity. The current study examines the association between disability severity and PTSD and depression among U.S. veterans who are receiving CPT. Veterans completed measures at pre‐ and posttreatment and received CPT through a Veterans Affairs PTSD outpatient (n = 155) or residential (n = 177) program. The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 was used to assess disability severity. The WHODAS 2.0 scores were positively correlated with clinician‐ and veteran‐rated PTSD and veteran‐rated depression at pre‐ and posttreatment (r = .22 to. 60). Compared with outpatients, veterans in residential treatment had worse scores on the WHODAS Mobility scale ( = .03), but on no other WHODAS 2.0 scales. Pre‐ to posttreatment reductions were found on all WHODAS 2.0 subscales ( = .03 to .15). Reductions in PTSD and depression were positively associated with improvements on the WHODAS 2.0 Summary scale and most subscales (r = .22 to. 52). Findings suggest that the WHODAS 2.0 is a promising disability severity measure for veterans in PTSD treatment. Findings also suggest that CPT may help veterans to achieve reductions in disability severity.     

Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care

Collaborative care (CC) increases access to evidence‐based pharmacotherapy and psychotherapy. The study aim was to identify the characteristics of rural veterans receiving a telemedicine‐based CC intervention for posttraumatic stress disorder (PTSD) who initiated and engaged in cognitive processing therapy (CPT) delivered via interactive video. Veterans diagnosed with PTSD were recruited from 11 community‐based outpatient clinics (N = 133). Chart abstraction identified all mental health encounters received during the 12‐month study. General linear mixed models were used to identify characteristics that predicted CPT initiation and engagement (attendance at 8 or more sessions). For initiation, higher PTSD severity according to the Clinician Administered PTSD Scale (d = ?0.39, p = .038) and opt‐out recruitment (vs. self‐referral; d = ?0.49, p = .010) were negative predictors. For engagement, major depression (d = ?1.32, p = .006) was a negative predictor whereas a pending claim for military service connected disability (d = 2.02, p = .008) was a positive predictor. In general, veterans enrolled in CC initiated and engaged in CPT at higher rates than usual care. Those with more severe symptoms and comorbidity, however, were at risk of not starting or completing CPT.