Transcript Workshop: Cognitive Processing Therapy

EVIDENCE-BASED APPROACHES TO PTSD
AND ASSOCIATED CONDITIONS IN VETERANS
COGNITIVE PROCESSING THERAPY
(CPT) FOR PTSD
ASHLEE WHITEHEAD, LPC, CADC
CPT PROVIDER
PTSD CLINICAL TEAM
PORTLAND VA MEDICAL CENTER
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
OVERVIEW OF TODAY’S PRESENTATION

History of CPT

Theory, Rationale & Goals
 The
Essential Ingredients
 Structure
 CPT
of CPT
Resources
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
ORIGINS OF CPT
 CPT
is a cognitive therapy for PTSD
 Published by Resick & Schnicke(1993)

Over 20 years of clinical practice, initially focused on trauma
of rape.
 Resick,
Monson & Chard expanded to fit
veteran/military population (2006)

2006 - VA Office of Mental Health Services began
CPT training roll-out to VA providers focused on
military trauma.
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
THEORY BEHIND CPT

Based on Social Cognitive Theory
 Traumatic Events can dramatically alter
basic beliefs about the world, the self
and others.
 Focuses on how trauma survivors
integrate traumatic events into their
overall belief system through
assimilation or accomodation

Not incompatible with Information/
Emotional Processing Theories
 Expands the range of emotional
responses that can be addressed in
treatment.
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
SOCIAL COGNITIVE THEORY OF TRAUMA
5
major dimensions that
may be disrupted by
traumatic events:
1)
2)
3)
4)
5)
Safety
Trust
Power and Control
Esteem
Intimacy
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
CPT RATIONALE
 PTSD
symptoms are attributed to a "stalling out"
in the natural process of recovery
 What
interferes with natural recovery from
PTSD?
Avoidance Behaviors
reinforce
Distorted beliefs about the trauma
and become
Generalized to current life situations
 Cognitive-focused techniques
are used to help
patients move past stuck points and progress
toward recovery.
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
CPT GOALS
 Process natural
emotions (other than
fear) in clients with PTSD.
 Address the
content of the meaning
derived from the traumatic memory.
 Accomodation
- accepting that the
traumatic event occurred and discovering
ways to successfully integrate the
experience into the one’s life (e.g., “In
spite of this bad event happening to me, I
am a good person.”). Accommodation
reflects balanced thinking.
WHEN TO IMPLEMENT CPT AND
PRE-TREATMENT ISSUES TO CONSIDER

Recommended for clients with:


PTSD and comorbid diagnoses (e.g., depression,
anxiety, substance use, TBI)
Not Recommended for clients with:
Active suicidal behavior
 Current Psychosis
 No memory of the trauma event

FROM ENGAGEMENT TO RETENTION





MI techniques
Client needs to believe that improvement is
possible
Client needs to believe that he has the
ability to tolerate therapy (skills)
Desire to approach outweighs desire to
avoid
Therapist adherence to protocol
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
THE ESSENTIAL INGREDIANTS
 The
Impact of the Event
 Identifying
Stuck Points
 Identifying
and resolving assimilated beliefs
 Challenging
beliefs.
 Use
and balancing overaccomodated
of Socratic Questioning
 Processing
trauma
natural emotions related to the
SO… WHAT ARE STUCK POINTS?
THOUGHTS & INTERPRETATIONS ABOUT THE TRAUMATIC EVENT
AUTOMATIC - DISTORTED - MAY OCCUR BENEATH ONE’S AWARENESS
Thoughts
not Feelings
Black and
White
All or
Nothing
Thought
behind the
“golden rule”
If/Then
statements
Not always “I
statements”
STUCK POINTS IN 5 DIMENSIONS
SAFETY


I cannot protect myself/others.
The world is completely dangerous.
TRUST

Other people should not trust me.

The government cannot be trusted.
POWER/CONTROL

I must control everything that happens to me.

People in authority always abuse their power.
ESTEEM

I deserve to have bad things happen to me

People are by nature evil and only out for themselves.
INTIMACY

I am unlovable because of the trauma.

If I let other people get close to me, I'll get hurt again.
PRACTICE ASSIGNMENT – THE IMPACT STATEMENT
“Please write at least one page on why you think
this traumatic event occurred. You are not
being asked to write specifics about the
traumatic event. Write about what you have
been thinking about the cause of the worst
event. Also, consider the effects this traumatic
event has had on your beliefs about yourself,
others, and the world in the following areas:
safety, trust, power/control, esteem, and
intimacy.”
THE IMPACT STATEMENT – MST EXAMPLE
“The overall feeling of what it means to have
been assaulted is the feeling that I must be
bad or a bad person for something like this to
have occurred. I feel it will or could happen
again at any time. I feel only safe at home.
The world scares me and I think it unsafe. I
feel all people are more powerful than I, and
am scared by most people. I view myself as
ugly and stupid. I can’t let people get real
close to me. I have a hard time
communicating with people of authority, so
plainly I haven’t been able to work. I don’t
trust others when they make promises. I find
it hard to accept that these events have
happened to me.”
HOW TO GET “STUCK”
Prior beliefs can be disrupted or reinforced by the trauma
EXAMPLE: The Just World Belief
“GOOD THINGS HAPPEN TO GOOD PEOPLE & BAD THINGS
HAPPEN TO BAD PEOPLE”
Innocent people
were killed
I was raped in the
military
NOW WHAT DO I BELIEVE?????
ASSIMILATION

Traumatic event is remembered differently to preserve
original beliefs and assumptions
16
Original Belief
Rape=Stranger
Traumatic Event
Raped by friend
Assimilation
Misunderstanding
Modified memory of the traumatic event doesn’t fit with
emotions experienced
 Creates disconnect between the memories and the emotions

Undoing and Self-Blame
OVER-ACCOMMODATION
 Overall
17
beliefs and assumptions about self and the
world change too much following the traumatic event
and are no longer accurate
Original Belief
People=Good
Traumatic Event
War Atrocities
Over-accommodation
People=Evil
“I WAS RAPED IN THE MILITARY”
Assimilate
- It wasn’t really
rape.
- Because I didn’t
fight harder, the
rape is my fault.
- I am worthless
because I
couldn’t control
what
happened.
Accommodate
- I wasn’t in a
position
where I could
fight back at
the time.
- Some men can
be trusted.
- I have control
over how to
handle this.
Overaccomodate
- If I let other
people get close
to me, I'll get
hurt again.
- Men are
dangerous and
can’t be trusted.
- I must control
everything that
happens to me.
“INNOCENT PEOPLE WERE KILLED”
Assimilate
- I should have
prevented it.
- It was my
fault.
- I deserve to
have bad
things happen
to me.
- It didn’t really
happen.
Accommodate
- Mistakes were
made.
- Although lives
were lost,
many lives
were saved.
- Sometimes
bad things
happen to
good people.
Overaccomodate
- Government
cannot be
trusted.
- Nowhere is safe
(I must stay on
guard at all
times).
- I am powerless.
SOCRATIC QUESTIONING
“IUsed
to challenge
stuckpoints
don’t
see the
point in
 Helping not telling (the wisdom is
asking
allperson)
these
within the
Guided discovery.
could
questions.
Getting patientI to
ask thehave
questions
themselves
pointed
out the flaws in
 Helping them become aware of
the
client’s thinking and
inconsistencies
changed
ABC’s
her mind much
 Ask
more
quickly
by
taking
a
 Be on their team
more
direct
 Think
Criticallyroute!”
about their logic
PROCESSING THE IMPACT STATEMENT
“Now, let’s go back to the Impact
Statement you wrote. What kinds of
things did you write about when
thinking about what it means to you
that the assault happened to you?
What feelings did you have as you
wrote it?”
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
CPT THERAPY HAS 4 MAIN PARTS
Learning about PTSD symptoms
Becoming aware of thoughts & feelings about the trauma
Learning skills
Understanding changes in beliefs
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
STRUCTURE OF CPT SESSIONS
Individual CPT
Group CPT
• 12 x 50-minute structured
sessions
• Participants complete outof-session practice
assignments
• Sessions typically
conducted weekly or biweekly
• Includes a brief written
trauma account along with
ongoing practice of
cognitive techniques
• 12 x 90-120 minute
structured sessions
• Participants complete outof-session practice
assignments
• Typically conducted by 2
clinicians
• 8-10 Veterans per group
• Includes a brief written
trauma account
component, along with
ongoing practice of
cognitive techniques
THE INDIVIDUAL SESSIONS ARE:
Session 1: Introduction and Education
 Session 2: The Meaning of the Event
 Session 3: Identification of Thoughts and Feelings
 Session 4: Remembering the Traumatic Event
 Session 5: Identification of Stuck Points
 Session 6: Challenging Questions
 Session 7: Patterns of Problematic Thinking
 Session 8: Safety Issues
 Session 9: Trust Issues
 Session 10: Power/Control Issues
 Session 11: Esteem Issues
 Session 12: Intimacy Issues and Meaning of the Event

A-B-C Sheet
Date: _________ Name: ________________
ACTIVATING EVENT
A
“Something happens”
Let’s make the
event:
Coming here today
BELIEF
B
“ I tell myself something”
What thoughts did you
have about coming to
this presentation
today?
CONSEQUENCE
C
“I feel something”
What emotions come
up with those
thoughts?
Does it make sense to tell yourself “B” above? _____________________________________________________________________
____________________________________________________________________________________________________________
What can you tell yourself on such occasions in the future? ___________________________________________________
____________________________________________________________________________________________
A-B-C Sheet
Date: _________ Name: ________________
ACTIVATING EVENT
A
“Something happens”
No let’s change the
event to:
Using evidencebased therapies in
PTSD
BELIEF
B
“ I tell myself something”
What thoughts do you
have about using
EBTs?
CONSEQUENCE
C
“I feel something”
What emotions come
up with those
thoughts?
Does it make sense to tell yourself “B” above? _____________________________________________________________________
____________________________________________________________________________________________________________
What can you tell yourself on such occasions in the future? ___________________________________________________
____________________________________________________________________________________________
A PROMOTIONAL VIDEO
HOW TO REFER A CLIENT TO CPT

Cognitive Processing Therapy is available through VA
Medical Centers, including through the Portland
VAMC PTSD Clinical Team (PCT) for eligible veterans.

Portland VA Medical Center http://www.portland.va.gov/


Eligibility/Enrollment (503) 220-8262, ext. 55289
Admission to the PCT requires a consult from the
veteran's Mental Health Provider at the Portland VA
Medical Center. If the veteran does not have a Mental
Health Provider, the first step would be to call the Mental
Health Access Clinic at 503-220-8262 x56479. A
screening interview will be required as a condition of
admission.
ADDITIONAL RESOURCES

An online CPT review course is available through
the Medical University of South Carolina at
https://cpt.musc.edu/index

National Center for PTSD http://www.ptsd.va.gov/

Cognitive Therapy for Posttraumatic Stress Disorder by
Shipherd, Street, and Resick in Chapter 5 of CognitiveBehavioral Therapies for Trauma, Second Edition by
Victoria M. Follette PhD and Josef I. Ruzek (2007)