POSTTRAUMATIC STRESS DISORDER: COGNITIVE PROCESSING THERAPY

Marcel O. Bonn-Mi l ler, Ph.D.

Center of Excel lence in Substance Abuse Treatment and Education, Phi ladelphia VAMC

Department of Psychiatry, University of Pennsylvania Perelman School of Medicine

National Center for PTSD & Center for Health Care Evaluation, VA Palo Alto Health Care System

COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD OVERVIEW OF TODAY’S PRESENTATION

History of CPT

Theory, Rationale & Goals

The Essential Ingredients

Structure of CPT

CPT Resources

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 ORIGINS OF CPT

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 TheoriesExpands 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) Safety2) Trust3) Power and Control4) Esteem5) 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 Behaviorsreinforce

Distorted beliefs about the traumaand 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.

• Accommodation - 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 behaviorCurrent PsychosisNo memory of the trauma event

From engagement to retention

MI techniquesClient 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 INGREDIENTS• The Impact of the Event

• Identifying Stuck Points

• Identifying and resolving assimilated beliefs

• Challenging and balancing over-accommodated beliefs.

• Use of Socratic Questioning

• Processing natural emotions related to the trauma

Stuck points in 5 dimensionsSAFETY

•  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”

NOW WHAT DO I BELIEVE?????

TRAUMA

I was raped in the military

Innocent people were killed

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Assimilation• Traumatic event is remembered differently to preserve original

beliefs and assumptions

• Modified memory of the traumatic event doesn’t fit with emotions experienced

• Creates disconnect between the memories and the emotions

Original BeliefRape=Stranger

Traumatic EventRaped by friend

AssimilationMisunderstanding

Undoing and Self-Blame

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Over-accommodation

Overall beliefs and assumptions about self and the world change too much following the traumatic event and are no longer accurate

Original BeliefPeople=Good

Traumatic EventWar Atrocities

Over-accommodationPeople=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.

Over-accommodate- 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.

Over-accommodate

- Government cannot be trusted.

- Nowhere is safe (I must stay on guard at all times).

- I am powerless.

SOCRATIC QUESTIONING

Used to challenge stuckpoints Helping not telling (the wisdom is within

the person) Guided discovery. Getting patient to ask the questions

themselves Helping them become aware of

inconsistencies ABC’s

Ask Be on their team Think Critically 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

• Understanding changes in beliefs

• Learning skills

• Learning about PTSD symptoms

• Becoming aware of thoughts & feelings about the trauma

Cognitive Processing Therapy (CPT) for PTSD STRUCTURE OF CPT SESSIONS

• 12 x 50-minute structured sessions

• Participants complete out-of-session practice assignments

• Sessions typically conducted weekly or bi-weekly

• Includes a brief written trauma account along with ongoing practice of cognitive techniques

• 12 x 90-120 minute structured sessions

• Participants complete out-of-session practice assignments

• Typically conducted by 2 clinicians

• 8-10 patients per group• Includes a brief written trauma

account component, along with ongoing practice of cognitive techniques

Individual CPT Group CPT

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 BELIEF CONSEQUENCE A B C

“Something happens” “ I tell myself something” “I feel something”

Does it make sense to tell yourself “B” above? _____________________________________________________________________ ____________________________________________________________________________________________________________ What can you tell yourself on such occasions in the future? ___________________________________________________ ____________________________________________________________________________________________

What thoughts did you have about coming to this presentation today?

Let’s make the event:Coming here today What emotions come

up with those thoughts?

Practice