Intensive and massed trauma treatment formats

1. Introduction

Version followed: (a) the PSYTREC eight-day intensive trauma-focused treatment (TFT) as described by Van Woudenberg et al. (2018), Van Minnen et al. (2018) and the hybrid four-days-inpatient / four-days-remote version in the APPART protocol and trial (Voorendonk et al., 2022, 2023); (b) massed prolonged exposure (PE) as in Foa et al. (2018: 10 daily sessions over 2 weeks) and its three-week extension and intensive-outpatient variant (IOP-PE; Peterson et al., 2023) as summarised by the STRONG STAR group; (c) massed cognitive processing therapy (CPT) delivered daily inside a three-week intensive outpatient programme (IOP) with parallel group CPT, as laid out in a published day-by-day table (BMC Psychiatry, 2018). Galovski et al.'s massed CPT trial and one-week virtual massed CPT are not drawn on [uncertain].

This entry is a family of delivery formats, not a separate therapy. The trauma-focused methods themselves (PE, EMDR therapy, CPT) are delivered according to their own manuals; what the intensive formats change is dose and spacing (daily, often twice-daily, sessions over 1–3 weeks), the team around the patient (rotating therapists, daily handovers, ward or programme staff), and adjuncts (physical activity, group psychoeducation, group CPT). The core idea of change is that the same trauma-focused processing that works weekly can be compressed into a short, high-dose block, which the developers report goes with large symptom reductions and very low dropout (2.3% in the 2018 PSYTREC cohort; 5.9% in the 2023 RCT), without a preceding stabilisation or skills phase. [source: Van Woudenberg et al. 2018 abstract (DOAJ); Voorendonk et al. 2020 abstract (VU portal); Voorendonk et al. 2023; CDP Benefits of Massed PE; Peterson slides]

The detailed in-session procedures of PE and EMDR used at PSYTREC are not described in the sources used here; papers state only that therapists "followed protocols" (Oslo replication: Foa et al. 2021 PE manual, Norwegian edition; Shapiro 2018 EMDR, 3rd edition). Where section 4 gives step-level detail for PE or EMDR sessions it is marked [synthesis] and should be checked against those manuals [uncertain].

2. Framework

A. PSYTREC eight-day intensive TFT (Netherlands)

Population: adults with PTSD (CAPS-confirmed), mostly multiply traumatised (in 2016, 74.4% reported sexual abuse; 87.5% a mood disorder; 73.9% suicidal ideation; 91.2% at least one comorbid disorder). [source: Van Woudenberg et al. 2018 abstract; Van Minnen et al. 2018]
Referral and intake (pre-phase): referral from a GP, psychologist or psychiatrist; two intake sessions one week apart. Session 1: explanation, CAPS-5, Life Events Checklist (LEC-5), MINI. Between sessions: a digital self-report battery (in the APPART trial: PCL-5, insomnia, depression, emotion-regulation difficulties, dissociation (DES-II), anxiety sensitivity, quality of life, physical activity, SCL-90, personality screening, ITQ for complex PTSD, and others). Session 2: written consent after at least one week to consider. [source: Voorendonk et al. 2022 protocol]
Eligibility (APPART version): PTSD on CAPS-5, age 18+, enough Dutch to be treated. Excluded: suicide attempt in the 3 months before treatment; medically unable to walk for 30 minutes (for the activity programme). Explicitly not excluded: suicidal ideation, trauma type, comorbidity including personality disorders or psychosis. [source: Voorendonk et al. 2022 protocol; Voorendonk et al. 2023]
Treatment phase: 8 treatment days. 2018 version: 8 days within 11 days. 2022–2023 version: 2 × 4 consecutive days with 3 days off between; days 1–4 inpatient and face to face, days 5–8 fully remote (Zoom). Groups of about 15 start on a Sunday evening; a new group every two weeks. [source: Van Minnen et al. 2018; Voorendonk et al. 2022, 2023]
Daily format: one 90-minute individual PE session in the morning and one 90-minute EMDR session in the afternoon (16 TFT sessions in total), brief group psychoeducation during the day and in the evening, and supervised physical activity (in the trial, four 90-minute activity slots a day, averaging about 61 minutes in practice). PCL-5 completed every morning. [source: Voorendonk et al. 2022, 2023; Van Woudenberg et al. 2018 abstract]
Team: master's-level clinical psychologists trained in PE and EMDR, rotating: each patient sees 6–16 different therapists. [source: Van Minnen et al. 2018]
Ending: some patients finished after 4–5 days; the criterion for early completion is not given [uncertain]. Post-treatment assessment 8 days after the last day; 6-month follow-up by phone and online. [source: Voorendonk et al. 2022, 2023]
Aftercare: not described in PSYTREC sources [uncertain]. The Norwegian replication (Oslo, 8 days over 2 weeks, groups of 6, inpatient ward) returned patients to their outpatient therapist, who was asked to avoid further trauma-focused therapy for 6 months and give only supportive therapy if needed; some therapists there felt follow-up should be planned better. [source: Vaage-Kowalzik et al. 2025]

B. Massed prolonged exposure (STRONG STAR / Foa)

Massed PE: 10 PE sessions on consecutive weekdays over 2 weeks. Session length is given as 90 minutes in the STRONG STAR slides and as 60 minutes in the Center for Deployment Psychology (CDP) toolkit [uncertain: sources differ; follow the trial's 90 minutes unless your manual version says otherwise]. Comparison standard: weekly or twice-weekly over 8–15 weeks. [source: Peterson slides; CDP toolkit]
Extended massed PE: 15 daily 90-minute individual sessions over 3 weeks, with release from duty so the patient can do daily out-of-office homework; the extra sessions allow a second index trauma. [source: Peterson slides (Peterson et al. 2023)]
IOP-PE: the same 15 × 90 minutes over 3 weeks plus eight augmentations (team-based treatment, homework completed in clinic, brief therapist feedback sessions, enhanced social support, work on the top three traumas, graduated imaginal exposure, a brief timeline review of all traumas, post-treatment boosters). [source: Peterson slides]
When to choose massed: the CDP toolkit treats standard spacing as the default because it leaves time for between-session practice, and recommends massed PE when someone needs treatment but lacks time for a standard course (e.g. upcoming deployment, training, relocation) or when competing demands threaten dropout. [source: CDP toolkit]

C. Massed CPT inside a three-week IOP

Format: a pre-programme phone call, then 15 daily individual CPT sessions (Monday–Friday for 3 weeks) with group CPT on days 2–14, daily homework, and a graduation day with discharge and aftercare planning; contact with a community provider starts in week 3. [source: BMC Psychiatry 2018, Table 5]
Sequence: week 1 = psychoeducation, Impact Statement, ABC worksheets, written trauma account ×2, Challenging Questions; week 2 = Patterns of Problematic Thinking, Challenging Beliefs worksheets, themes Safety, Trust, Power/Control, Esteem; week 3 = Intimacy, remaining stuck points, Final Impact Statement, relapse planning and handover. [source: BMC Psychiatry 2018, Table 5]
Other IOP components of that programme (e.g. other groups, family elements) are [uncertain].

Criteria for moving between phases

In all three formats progression between days is calendar-driven: the schedule is fixed in advance and the patient does not wait to "earn" the next step. [source: all format descriptions above]
Entry criterion: diagnosis confirmed with a structured interview, eligibility met, consent given after reflection time. [source: Voorendonk et al. 2022]
Within a session, moving from one memory or hotspot to the next follows the parent manual (PE: distress falls and the narrative is complete; EMDR: target fully processed). These criteria are not stated in the sources [synthesis; uncertain].
In massed CPT, the next worksheet and theme are introduced on schedule even if earlier stuck points remain; remaining assimilated stuck points are carried forward and revisited. [source: BMC Psychiatry 2018, Table 5]

3. Guiding principles

Trauma-focused from day one, no stabilisation phase. PSYTREC gives no prior skills training. Meaning: do not delay processing to build coping skills unless there is a specific contraindication. [source: Voorendonk et al. 2020 abstract]
Inclusive selection, narrow exclusions. Suicidal ideation, complex PTSD, personality disorder, psychosis and dissociation do not exclude. Recent suicide attempt (under 3 months) does. Meaning: screen for recent attempts and acute medical limits, not for complexity. [source: Voorendonk et al. 2022; Voorendonk et al. 2020 abstract] Other programmes are stricter (Oslo excludes psychotic or bipolar disorder, active substance-use diagnosis and an ongoing abusive or threatening situation): name which rules you follow. [source: Vaage-Kowalzik et al. 2025]
Massing: high dose in a short time. Daily (PSYTREC: twice-daily) sessions. Meaning: schedule the whole course before starting and protect it from interruptions. [source: Van Woudenberg et al. 2018 abstract; Peterson slides]
Protocol fidelity. Therapists deliver PE and EMDR as manualised; in Oslo, on-site PE and EMDR supervisors checked fidelity. Meaning: intensive formats change the timetable, not the method. [source: Voorendonk et al. 2023; Vaage-Kowalzik et al. 2025]
The team, not one therapist, holds the treatment. Therapists rotate, with brief daily handovers and a structured shared file. Meaning: write clear notes after every session; never keep key information in your head. [source: Van Minnen et al. 2018; Vaage-Kowalzik et al. 2025]
Physical activity as a non-therapeutic adjunct. Moderate intensity (60–70% of maximum heart rate), supervised, with no body-awareness, exposure, relaxation or mindfulness elements added. Meaning: activity fills the day and supports wellbeing; do not turn it into a therapy session. The RCT found no added effect of activity compared with creative tasks, so it is optional rather than essential. [source: Voorendonk et al. 2022, 2023]
Measure daily. PCL-5 every morning (PSYTREC); heart rate and perceived exertion in activity. Meaning: use the numbers in handovers. [source: Voorendonk et al. 2022]
Informed, unhurried consent. At least a week to consider before signing. Meaning: let the patient decide on the intensive format with full information about how demanding it is. [source: Voorendonk et al. 2022, 2023]
Choose massed when it fits the person's situation. Standard spacing is the default in the military guidance; massed when time is constrained or dropout risk is high. Meaning: discuss spacing as a shared decision (STRONG STAR now offers PE, CPT or WET, massed or spaced, in person or telehealth). [source: CDP toolkit; Peterson slides]
Protect homework time. Massed PE patients who went straight back to duty had too little time for daily homework; later versions released them from duty or moved homework into the clinic. Meaning: build homework hours into the day. [source: Peterson slides]
Plan the hand-back. Aftercare, booster sessions or a community provider are arranged before the end (Rush IOP, IOP-PE), or the referrer is told what to do (Oslo). Meaning: brief the referrer before day 1, not after discharge. [source: BMC Psychiatry 2018, Table 5; Peterson slides; Vaage-Kowalzik et al. 2025]
Use peers. Group psychoeducation (PSYTREC), group CPT (Rush) and enhanced social support (IOP-PE). Meaning: use the cohort as a resource while keeping trauma detail out of non-processing groups. The second part of this is [synthesis]. [source: Voorendonk et al. 2023; BMC Psychiatry 2018 Table 5; Peterson slides]

4. Intervention inventory

Group A covers the PSYTREC eight-day programme, group B massed and intensive-outpatient PE, group C massed CPT in a three-week IOP, and group D the elements shared by all formats.

A1. Two-stage intake and consent (PSYTREC)

Purpose: confirm PTSD, map trauma history and comorbidity, check exclusions, and give time for an informed decision about a demanding format.
Steps: (1) Take the referral from a GP, psychologist or psychiatrist. (2) Intake 1: explain the programme (daily timetable, therapist rotation, inpatient and remote days, activity programme); administer CAPS-5, LEC-5 and MINI. (3) Send the digital self-report battery to complete before intake 2 (PTSD, complex PTSD, depression, sleep, dissociation, emotion regulation, quality of life, physical activity). (4) Check exclusions: suicide attempt in the last 3 months; medically unable to walk 30 minutes. (5) Intake 2, at least a week later: answer questions, obtain written consent, confirm the start date (a Sunday evening). [source: Voorendonk et al. 2022 protocol] Collecting the trauma list and the patient's "worst" memories at intake so the first sessions can start without delay is [synthesis].
Example language (illustrative): "For eight days you will spend most of your time working on your memories, twice a day, with different therapists from the same team. It is hard work, and it is short. Take the week to think it over before you sign."
Watch for: ambivalence voiced only as practical obstacles; a recent attempt hidden behind "I'm fine now" (ask directly about dates); a current threatening situation (exclusion in Oslo, not stated at PSYTREC) [source: Vaage-Kowalzik et al. 2025]. It is working when the patient can say back the timetable and agrees to attend every session.

A2. Daily group psychoeducation (PSYTREC)

Purpose: explain PTSD and the rationale for daily exposure and EMDR; keep motivation up between sessions.
Steps: short group sessions during the day and in the evening on each treatment day; in the activity arm the content also covers the benefits of physical activity (in the control arm, of creative tasks). [source: Voorendonk et al. 2022, 2023] Specific topics are not listed in the sources [uncertain]. Suggested topics: what PTSD is, why avoidance keeps it going, what to expect after sessions (tiredness, more dreams, stirred-up memories), sleep, and planning for after the programme [synthesis].
Example language (illustrative): "Feeling worse in the evening after a session is common and is not a sign that it isn't working. Tomorrow morning we pick up where you left off."
Watch for: patients swapping trauma details in the group; redirect them to the individual sessions [synthesis].

A3. Intensive prolonged exposure session (morning, 90 min)

Purpose: emotional processing of the trauma memory through repeated, detailed revisiting, done daily.
Source status: PSYTREC states one 90-minute PE session each morning, delivered to protocol; the Oslo replication cites Foa et al. (2021). In-session steps are not described in the sources used; the steps below are a [synthesis] of the general structure of imaginal exposure and must be checked against the PE manual [uncertain]. In the APPART protocol, no exposure was done during physical activity. [source: Voorendonk et al. 2022, 2023; Vaage-Kowalzik et al. 2025]
Steps ([synthesis]): (1) Read the handover notes and the morning PCL-5; agree which memory or hotspot is today's target. (2) Brief check-in: sleep, reactions since yesterday, any safety concerns. (3) Imaginal revisiting: the patient recounts the memory in detail and in the present tense, eyes closed if tolerable, repeating it several times within the session; the therapist asks for distress ratings at intervals and prompts for sensory detail, thoughts and feelings. (4) Once the full narrative has been covered, focus repeatedly on the worst moments (hotspots). (5) Processing discussion: what the patient noticed, what has changed, what meaning the event carries. (6) Record notes for the next therapist: memory worked on, hotspots, peak and end distress, avoidance noticed, next target.
Example language (illustrative): "Go back to the moment the door opened. What do you see now? … Stay with it. On a scale of 0 to 100, how strong is it?"
Watch for: skipping or summarising the worst part (avoidance); flat recounting with no emotion (under-engagement); signs of dissociation (see section 5). It is working when hotspots get more detailed, distress at the start of the session falls from day to day, and the daily PCL-5 goes down.

A4. Intensive EMDR session (afternoon, 90 min)

Purpose: process trauma memories (often different memories or hotspots from those in PE) using the standard EMDR procedure, done daily.
Source status: PSYTREC states one 90-minute EMDR session each afternoon delivered to protocol; the Oslo replication cites Shapiro (2018). Target selection, the specific Dutch protocol and any use of future-oriented targets are not described in the sources [uncertain]. A case series on intensive EMDR for complex PTSD is not drawn on [uncertain]. [source: Voorendonk et al. 2022, 2023; Vaage-Kowalzik et al. 2025]
Steps ([synthesis], general EMDR session structure; check against your EMDR protocol): (1) Handover check and choice of target memory. (2) Assessment of the target: image, negative belief, preferred belief, emotion, distress rating, body location. (3) Sets of bilateral stimulation (e.g. eye movements) with brief check-ins between sets, letting associations run and going back to the target when the chain stalls. (4) When distress about the target is minimal, install the preferred belief and do a body scan. (5) Close: if the target is incomplete, close down safely and note where processing stopped. (6) Write the handover.
Example language (illustrative): "Bring up the picture and the words 'I'm powerless'. Notice where you feel it. Follow my fingers … Take a breath. What comes up now?"
Watch for: looping (the same image and feeling returning set after set); losing touch with the room. It is working when distress about the target falls and the preferred belief feels more true.

A5. Combining PE and EMDR in one day

Purpose: two different trauma-focused methods each day, which the developers report gives large effects with low dropout.
Steps: PE in the morning and EMDR in the afternoon, each 90 minutes, 16 sessions over 8 days; physical activity or tasks scheduled before, after or around the sessions (in the trial the order varied for practical reasons). [source: Voorendonk et al. 2022, 2023] How the team divides memories between the two methods is not described [uncertain]. A practical rule: keep a shared memory list in the file, mark which memories each method has worked on, and agree targets at the daily handover [synthesis].
Watch for: the patient "saving" the hardest memory for one method or one favoured therapist [synthesis].

A6. Therapist rotation with daily handover

Purpose: the team, not one person, carries the treatment. 6–16 therapists per patient at PSYTREC; 11–12 in Oslo.
Steps: (1) Assign different therapists across sessions and days. (2) Each treatment day, before session 2, the team meets for about 5 minutes per patient to pass on what happened in session 1. (3) Keep a structured written patient file (targets, ratings, hotspots, risk, plan). (4) Oslo variant: a daily one-hour meeting of therapists and ward staff to check fidelity, review progress and plan the next sessions; on-site PE and EMDR supervisors. [source: Van Minnen et al. 2018; Vaage-Kowalzik et al. 2025]
Example language (illustrative): "I'm Anna, I'll be your therapist this morning. Yesterday's EMDR session finished on the moment in the car, so that is where we start."
Watch for: patients who would rather have one therapist. In the 2016 cohort 14% said they would have preferred one therapist, and 62% rated the relationship with the team as good or very good. [source: Van Minnen et al. 2018] It is working when each session starts at the point where the previous one ended, with no re-telling of history.

A7. Supervised physical activity programme

Purpose: an active, non-therapeutic counterweight to processing sessions.
Steps: (1) Screen for basic fitness (able to walk 30 minutes). (2) In-person days: begin and end each day with an outdoor walk at moderate intensity; other slots offer one activity each (e.g. ball games, ultimate frisbee, mountain biking, boxing, rowing ergometer, resistance training). (3) Remote days: individual walks, live online group sessions (e.g. boxing, dancing), home cycling. (4) Target 60–70% of maximum heart rate; check with a heart-rate monitor and a perceived-exertion rating after each slot. (5) Instructors with movement-science training and PTSD experience; groups made up only of patients from the programme. (6) No body awareness, exposure, relaxation or mindfulness built in. [source: Voorendonk et al. 2022, 2023] The 2023 RCT found no difference in PTSD outcome between activity and seated creative tasks. [source: Voorendonk et al. 2023]
Example language (illustrative): "This hour is just exercise. You don't need to talk about anything; aim to be slightly out of breath."
Watch for: injury, medical limits, exercise used as avoidance before a session. Offering the seated alternative (A8) when activity is unsuitable is [synthesis] based on the RCT result.

A8. Non-physical activity alternative (creative and cognitive tasks)

Purpose: structured time between sessions without exertion. This was the control condition, and it did as well as activity.
Steps: seated tasks such as painting, clay, crochet, themed assignments, board games or reading, mainly indoors; at home or in online groups on remote days; no therapeutic content. [source: Voorendonk et al. 2022, 2023]
Watch for: isolation or rumination during unstructured time [synthesis].

A9. Daily symptom monitoring

Purpose: track response through the course and feed the handover.
Steps: PCL-5 each morning; after each activity slot, perceived exertion and heart rate; mid-treatment questionnaires after day 4; full assessment 8 days after the end and at 6 months. [source: Voorendonk et al. 2022] Using a rise in PCL-5 or new risk items as a trigger for a team discussion that day is [synthesis].

A10. Hybrid inpatient-to-remote delivery

Purpose: four days face to face (with the group and on site) and four remote days at home via video.
Steps: patients go home after day 4, complete questionnaires digitally, and continue PE, EMDR, psychoeducation and activities online on days 5–8. [source: Voorendonk et al. 2022, 2023] Check privacy at home, an internet connection, and a plan if the connection drops during processing [synthesis].
Watch for: missed online sessions, interruptions at home, family pressure [synthesis].

B1. Massed PE (10 sessions in 2 weeks)

Purpose: the full PE course compressed into daily sessions for people who cannot attend for 2–3 months.
Steps: (1) Check the indication: time pressure or dropout risk (CDP). (2) Book 10 consecutive weekdays, one session a day (90 minutes in the trial; the CDP toolkit says 60 [uncertain]). (3) Deliver the standard PE components in order (psychoeducation, imaginal exposure with processing, in vivo exposure, recording review), at daily spacing. (4) Assign daily homework: listening to the session recording and in vivo exercises. [source: Peterson slides; CDP toolkit] How the content of each session is allocated across the 10 days is not given in the sources [uncertain]. A practical plan is to cover rationale and the in vivo hierarchy on days 1–2, start imaginal exposure by day 2–3, and use the remaining days for imaginal exposure and hotspots [synthesis].
Example language (illustrative): "Because we meet every day, homework has to fit between today and tomorrow: one listen to today's recording and one item from your list."
Watch for: in the trial, patients who went back to duty straight after each session had too little time for homework, and more than one index trauma was hard to fit into 10 sessions. [source: Peterson slides] It is working when homework is done every day and distress during imaginal exposure falls over successive sessions.

B2. Extended massed PE (15 sessions in 3 weeks)

Purpose: room for a second trauma and for daily homework.
Steps: 15 daily 90-minute individual sessions over 3 weeks; the patient is released from other duties for the full 3 weeks so daily out-of-office homework can be done; move to a second trauma if needed once the first is processed. [source: Peterson slides (Peterson et al. 2023)]
Watch for: using the extra days to avoid the index trauma by switching memories too early [synthesis].

B3. IOP-PE augmentations

The STRONG STAR IOP-PE adds eight elements to extended massed PE. Only their names are given in the source. The descriptions of how to carry each one out are [synthesis] and should be checked against Peterson et al. (2023) [uncertain]. [source: Peterson slides]

Team-based treatment: more than one clinician shares the case and the team reviews it regularly. Shared notes as in A6 [synthesis].
Homework done in clinic: recording review and in vivo work scheduled during programme hours, in a quiet room or with staff, so it is not left to the evening. Example (illustrative): "Your 1 pm slot is listening to this morning's recording here."
Brief therapist feedback sessions: short check-ins after homework to review ratings and fix problems the same day.
Enhanced social support: involving a support person or peers to encourage attendance and homework.
Top three traumas: plan imaginal exposure for up to three index memories rather than one.
Graduated imaginal exposure: begin with a less detailed or less intense version of the memory and build up to full detail and hotspots.
Brief timeline review of all traumas: a short chronological overview early on, used to choose the top three and show how the events connect.
Post-treatment boosters: scheduled follow-up sessions after the 3 weeks to consolidate gains and catch relapse.

C1. Pre-programme orientation call (massed CPT IOP)

Purpose: introduce the programme and CPT, and deal with motivation, barriers and support needs before day 1.
Steps: phone call covering the CPT rationale, expectations, obstacles and needed supports; check the patient's reaction to the call; invite questions in the meantime. [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "What might get in the way of being here every day for three weeks? Let's sort that out now."

C2. Day 1 individual session: education, Impact Statement assignment

Steps: agree the agenda and introduce the daily check-in; explain PTSD symptom clusters, the fight-flight-freeze response, the cognitive model and the role of natural versus manufactured emotions; brief look at the index (worst) event; explain stuck points; discuss expected avoidance and readiness for group; homework: write the Impact Statement (the meaning the event has for the patient's beliefs about self, others and the world). [source: BMC Psychiatry 2018, Table 5]
Watch for: an index event that is not actually the most distressing one [synthesis].

C3. Impact Statement reading and Stuck Point Log

Steps: the patient reads the Impact Statement aloud; identify and log stuck points (beliefs that keep the patient stuck); separate events, thoughts and feelings; introduce ABC worksheets; homework: three ABC worksheets on assimilated stuck points (self-blame, "should have"). [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "'It was my fault because I froze.' Let's put that in the log as a stuck point we'll come back to."

C4. Socratic questioning on the index event

Steps: review the ABC worksheets, separating thoughts from feelings; use Socratic questions about the index event to produce alternative explanations, focusing first on assimilated stuck points; keep updating the log. [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "What did you know at that moment, not afterwards? … Given that, what could you actually have done?"
Watch for: the therapist arguing or persuading instead of asking questions [synthesis].

C5. Written trauma account (two versions, read aloud)

Steps: homework after day 3: write a first account of the index trauma; day 4: the patient reads it aloud with feeling; the therapist identifies stuck points, challenges them with Socratic questions, and explains the difference between responsibility and blame; homework: write a second account; day 5: read the second account and discuss how it differs from the first. [source: BMC Psychiatry 2018, Table 5] This follows the CPT+A (with written account) variant; offering CPT without the account is a separate option not covered in this table [synthesis].
Watch for: accounts that leave out the worst moment, and reading without emotion. Ask the patient to slow down and stay with the feeling [synthesis].

C6. Challenging Questions Worksheet

Steps: introduced on day 5; the patient uses a set of questions to examine one stuck point at a time; homework: three worksheets; reviewed on day 6 with a focus on remaining assimilated stuck points. [source: BMC Psychiatry 2018, Table 5]

C7. Patterns of Problematic Thinking Worksheet

Steps: introduced on day 6; the patient identifies recurring thinking habits (e.g. jumping to conclusions) across stuck points; one worksheet as homework; reviewed on day 7. [source: BMC Psychiatry 2018, Table 5]

C8. Challenging Beliefs Worksheets and the five themes

Steps: introduced on day 7 with the first theme, Safety; then one theme a day: Trust (day 8), Power/Control (day 9), Esteem (day 10), Intimacy (day 11); each day: review worksheets, deal with remaining assimilated and theme-related stuck points, help the patient produce balanced alternative beliefs, homework: three worksheets plus the module for the theme. Days 12–13: remaining stuck points, still three worksheets a day. [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "You wrote 'No one can be trusted.' What is the evidence for and against that, including the people around you this week?"
Watch for: over-accommodated beliefs (overgeneralised beliefs about danger, trust or control) emerging as assimilated ones resolve; worksheet fatigue under a three-a-day load [synthesis].

C9. Group CPT (parallel to individual)

Purpose: peer learning and support alongside individual sessions.
Steps: day 2: agenda, introductions, group rules, rationale (cognitive model, types of emotion, the biology of PTSD), the point that people respond to trauma differently, the value of peer support; members share Impact Statements (days 2–4); from day 4: Socratic questioning in the group with up to two members practising per session; day 5: experience of writing the account; days 6–13: practice challenging stuck points (assimilated, then over-accommodated, then trauma themes); day 14: Final Impact Statements, review of progress, future goals and strategies. [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "Today two people will work on a stuck point with the group asking the questions. Keep to thoughts and meanings, not the details of what happened."
Watch for: comparison of trauma severity among members; graphic detail in group [synthesis].

C10. Final Impact Statement, graduation and handover

Steps: day 13 homework: Final Impact Statement; day 14: read it aloud, compare with the first, review progress and set goals; from day 11: contact a community provider near the patient; day 15 (graduation): review the course, the discharge plan, referrals and the aftercare plan. [source: BMC Psychiatry 2018, Table 5]
Example language (illustrative): "Let's read your first Impact Statement and today's side by side. What has shifted?"

D1. Choosing the format with the patient

Purpose: match spacing to the person.
Steps: (1) Ask about time constraints, distance, work or duty release and support at home. (2) Explain the standard and massed options (and PE, CPT or WET, in person or telehealth, as STRONG STAR's shared-decision model offers). (3) Consider massed if time is limited or dropout risk is high; prefer spacing if daily homework time cannot be protected. (4) Consider the intensive PSYTREC-type format for severe, multiply-traumatised or complex-PTSD patients without a recent suicide attempt. [source: CDP toolkit; Peterson slides; Voorendonk et al. 2020 abstract, 2022] Weighing these factors into a single decision is [synthesis].

D2. Aftercare and boosters

Steps: brief the referrer before the start; arrange the follow-up assessment (post and 6 months, PSYTREC); boosters (IOP-PE); community provider and aftercare plan (CPT IOP). If following the Oslo model, ask the outpatient therapist to give supportive therapy only and no new trauma-focused treatment for 6 months. [source: Voorendonk et al. 2022; Peterson slides; BMC Psychiatry 2018 Table 5; Vaage-Kowalzik et al. 2025] The 6-month pause is a local rule from a single programme; offering further trauma-focused work earlier to patients with residual PTSD at follow-up is a reasonable alternative [synthesis; uncertain].

5. Handling problems

The sources report outcomes and logistics, not clinical problem-handling. Unless a source tag is given, the guidance below is [synthesis].

Suicidality before or during treatment. Sources: exclude a suicide attempt in the last 3 months; suicidal ideation is not an exclusion; the 2020 complex PTSD cohort had no suicides, suicide attempts or hospital admissions during treatment. [source: Voorendonk et al. 2022; Voorendonk et al. 2020 abstract] Practice: complete a standard risk assessment at intake and agree a written safety plan; review the morning PCL-5 and any risk change at each handover; if risk rises (new intent, a plan, preparatory acts), stop processing that day, do a full risk assessment with a senior clinician, agree lethal-means counselling (safe storage or removal) and review whether to continue. [synthesis]
Dissociation in session. The dissociative subtype did not moderate outcome in intensive treatment (Zoet et al. 2018, cited in the APPART protocol) [uncertain]. Practice: keep eyes open, slow the pace and shorten exposure segments; use grounding (name objects in the room, feet on the floor, hold a cold object, state the date and place); go back to the memory once the patient can rate distress and answer questions again; note in the handover what helped so the next therapist uses it. [synthesis]
Overwhelm or distress that does not fall within a session. Practice: in PE, move to a less detailed (graduated) retelling for the rest of the session (the IOP-PE "graduated imaginal exposure" principle [source: Peterson slides]); in EMDR, use the close-down procedure in your protocol for incomplete targets; always finish with a structured closure (orientation to the present, a plan for the next hours, who to contact on the ward or remote line). Do not end the programme because of one hard session; discuss it at the team handover. [synthesis]
Avoidance and non-attendance. Practice: when a session is missed, contact the patient the same day (the next therapist can call); explore what was being avoided; restate the timetable. Inpatient staff support adherence on the ward (Oslo). [source: Vaage-Kowalzik et al. 2025] On remote days, agree a fixed login check and a call-back if there is no show. [synthesis]
Homework not done in massed formats. Sources: lack of time was the main barrier when patients returned to duty after each session; later versions released patients for 3 weeks and IOP-PE moved homework into the clinic with brief feedback sessions. [source: Peterson slides] Practice: timetable homework slots in the day and check them at the next session. [synthesis]
Several traumas, too few sessions. It is difficult to treat more than one trauma in 10 sessions; the solutions were 15 sessions, work on the top three traumas and a timeline review. [source: Peterson slides] Practice: at intake, rank memories by current distress and intrusions; plan the order; in PSYTREC-type formats, use the shared memory list across PE and EMDR. [synthesis]
Patient dislikes therapist rotation, or alliance ruptures. Sources: 14% would have preferred one therapist, while most rated the team relationship as good. [source: Van Minnen et al. 2018] Practice: explain the rotation at intake; start every session by showing you know where the previous one ended; if a patient asks to avoid a particular therapist after a rupture, discuss it in the team and avoid that pairing if possible while keeping the schedule; name the rupture openly. [synthesis]
Information loss between therapists. Practice: a structured file and a brief handover before every session (PSYTREC: about 5 minutes per patient each day; Oslo: a daily one-hour meeting). [source: Van Minnen et al. 2018; Vaage-Kowalzik et al. 2025]
Stuck points do not shift (massed CPT). Practice: go back to the Challenging Questions worksheet for core assimilated stuck points before moving on (the table allows returning to it if needed); use group practice to model Socratic questioning [source: BMC Psychiatry 2018, Table 5]; if the patient stays stuck on self-blame, re-read the trauma account looking specifically for what the patient knew at the time. [synthesis]
Worksheet overload (three a day). Practice: put quality ahead of number; one well-done worksheet on the central stuck point beats three superficial ones; tell the patient this is a deliberate adjustment. [synthesis]
Physical injury or inability to exercise. Exclude patients who cannot walk 30 minutes from the activity component [source: Voorendonk et al. 2022]; offer seated tasks instead, which did as well in the RCT [source: Voorendonk et al. 2023].
Early improvement. Some PSYTREC patients completed in 4–5 days [source: Voorendonk et al. 2023]; the criteria were not published [uncertain]. Practice: if PTSD symptoms are minimal, check for remaining memories on the list before ending; record the reason for stopping. [synthesis]
Deterioration or relapse after discharge. Practice: give the referrer a written summary (memories processed, residual stuck points or hotspots, risk), the date of the follow-up assessment, and a plan for boosters (IOP-PE model) or community care (CPT IOP model). [source: Peterson slides; BMC Psychiatry 2018 Table 5] Oslo therapists found follow-up insufficiently planned. [source: Vaage-Kowalzik et al. 2025]
Therapist strain. Oslo therapists described the work as educational but demanding, and some worried that patients might deteriorate. [source: Vaage-Kowalzik et al. 2025] Practice: limit consecutive processing sessions per therapist per day, provide on-site supervision and a debrief at day's end. [synthesis]
Ongoing danger or active substance misuse. Oslo excluded current abusive or threatening situations and active substance-use diagnoses; PSYTREC sources do not mention these [uncertain]. Practice: check for both at intake; with ongoing danger, put safety planning first and defer the intensive format. [synthesis]
Complex PTSD and the stabilisation question. Most patients classified as complex PTSD improved strongly without a stabilisation phase. [source: Voorendonk et al. 2020 abstract] Practice: do not refer complex PTSD patients for prolonged stabilisation by default; tell them that trauma-focused work comes first and deal with emotion regulation problems as they arise. [synthesis]

Sources

Sources:

Cited from the sources above (further reading, not drawn on):

Foa, E. B., et al. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel. JAMA.
Peterson, A. L., et al. (2023). Massed vs intensive outpatient prolonged exposure for combat-related PTSD.
Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019/2021). Prolonged Exposure Therapy for PTSD (therapist guide; Norwegian edition cited in Oslo).
Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures (3rd ed.).
Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD: A Comprehensive Manual (CPT worksheets and themes referred to in section 4C).
Zoet, H. A., et al. (2018). PTSD dissociative subtype and intensive treatment outcome.
Galovski, T. E., et al. (2022). Massed cognitive processing therapy; and the one-week virtual massed CPT report (IUPUI ScholarWorks record).

Further reading (not drawn on): the Taylor & Francis full text of Van Woudenberg et al. (2018), the Cambridge PDF of the massed versus standard PE non-inferiority RCT, and the ClinicalTrials.gov record NCT06645028 (Swedish 8-day programme).

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