Sacred Journey - Cognitive Processing Therapy

Sacred Journey is a culturally adapted cognitive behavioral, trauma-focused treatment for women

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Sacred Journey is a culturally adapted version of an evidenced-based treatment, Cognitive Processing Therapy (CPT), that was developed for use with American Indian women. Sacred Journey is a manualized cognitive behavioral trauma-focused treatment for women with post-traumatic stress disorder (PTSD) symptoms, high-risk sexual behavior, and substance use. Participants were randomized to the Sacred Journey Intervention or a 6-week wait-list group. Participants in the CPT group were offered 13 sessions of individual face-to-face therapy; the average number of sessions was 6.1. The treatment focused on identifying maladaptive and inaccurate beliefs related to the trauma, specifically emphasizing distorted beliefs about the cause of the event and overgeneralized beliefs about self, others, and the world.

Outcomes

Estimates of changes or differences in alcohol-related problems and the stability of those changes or differences. 

Medium/Mixed Level of Change

Participants in the intervention group demonstrated medium to large reduction in the frequency of alcohol use. 

There were three significant effects among the six outcomes tested. Participants who received CPT immediately showed significant, large reductions in the frequency of alcohol use, PTSD symptoms, and high-risk sexual behavior as compared to the wait-list group. Reductions in PTSD symptoms and alcohol problems were associated with the number of counseling sessions attended.

Costs

Two domains estimating start-up and ongoing expenses. 

Mid-range start-up and ongoing costs for staff time, training, and continued supervision. 

Assuming some access to treatment infrastructure, including clinic space and community-based providers who appeared to be providing services in the clinics already, the initial start-up cost is likely to be mid-range. Training providers in CPT involves hiring experts who can provide at least a week of training and be available to supervise. After the initial set up, the cost to deliver and supervise the intervention would continue to be moderate. Ongoing costs include continued staff time to administer 13 sessions, ongoing expert training, and supervision to ensure the treatment is delivered effectively.

Cultural Engagement

Two indicators of cultural and Tribal/community contributions. 

Strong Tribal-academic partnership led to a high level of cultural adaptation of the intervention. 

This research was initiated in response to a request from Tribal leaders to address community behavioral health concerns. The cultural adaptation of the intervention occurred over a 2-year period. Barriers for the community providers in using the original CPT manual were removed, including simplifying the language and making the manual shorter and easier to read. Cultural elements included Indigenous beliefs and community values regarding spirituality, death, family, Tribe-specific historical trauma, and the role of Elders and cultural activities as social and cultural support.

AI/AN females were recruited for the study that was conducted at behavioral health clinics in the Pacific Northwest. 

Participants were 73 female American Indian/Alaska Native (AI/AN) Tribal members, ages 18 to 60 years, with some heavy drinking or illicit substance use and symptoms of post-traumatic stress disorder. The intervention was delivered in two rural behavioral health clinics in the Pacific Northwest, one on a reservation and one adjacent to the reservation.

Staffing Needs

Credentials and/or background of personnel who delivered the intervention. 

Not Specified

Community providers were trained for a week in Cognitive Processing Therapy. 

There was no information provided about the background or credentials of the community providers who delivered the intervention. They received 1 week of CPT training and received detailed weekly supervision from a clinical psychologist.

Research Design

Methods employed to gather research data. 

Randomized controlled experimental design

Developmental stage of research

Stage of development of the evidence supporting this intervention. 

Mid Stage

This was a rigorous feasibility study with promising outcomes for alcohol and PTSD symptoms. 

This feasibility randomized control trial made use of a moderate-sized pilot sample comparing CPT to a wait-list group. CPT has been demonstrated to be effective in randomized clinical trials in other populations; this is the first trial in AI/AN women. The research design was rigorous with randomization and significant results for alcohol use, PTSD symptoms, and sexual risk behavior. The sample was small and treatment retention was an issue, but consistent with other treatments with similar focus.

Potential

Narrative offered by expert reviewers providing overall comments or evaluations about the intervention. 

The study findings indicate that a trauma-focused, evidence-based intervention can be culturally adapted and successfully implemented in AI/AN communities. 

CPT significantly reduced alcohol use frequency, PTSD symptom severity, and high-risk sex behaviors in this study. The work shows promising signs of efficacy and acceptability of culturally adapted CPT for Native women. A larger-scale multisite trial with a longer follow-up would help build confidence in the wider applicability of this trauma-focused treatment.

References

Primary 

Pearson CR, Kaysen D, Huh D, Bedard-Gilligan M. Randomized control trial of culturally adapted cognitive processing therapy for PTSD substance misuse and HIV sexual risk behavior for Native American women. AIDS Behav . 2019;23(3):695-706. https://pubmed.ncbi.nlm.nih.gov/30607757 . https://doi.org/10.1007/s10461-018-02382-8 .

Secondary 

Pearson CR, Smartlowit-Briggs L, Belcourt A, Bedard-Gilligan M, Kaysen D. Building a Tribal-academic partnership to address PTSD, substance misuse, and HIV among American Indian women. Health Promot Pract . 2019;20(1):48-56. https://pubmed.ncbi.nlm.nih.gov/29506417 . https://doi.org/10.1177/1524839918762122 .

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