Evidence-Based Treatments for PTSD: Cognitive Processing Therapy Brian L. Meyer, Ph.D. Interim Associate Chief Mental Health Clinical Services McGuire VA Medical Center Richmond, VA May 19, 2015
Disclaimer The views expressed in this presentation are solely those of the presenter and do not represent those of the Veterans Health Administration, the Department of Defense, or the United States government.
Disclosure The author has no conflicts of interest to disclose.
Evidence-Based Treatments for PTSD Cognitive Processing Therapy Prolonged Exposure Eye Movement Desensitization and Reprocessing
Cognitive Processing Therapy: The Basics
Origins Cognitive Processing Therapy (CPT) was developed in 1993 by Patricia Resick and Monica Schnicke to treat PTSD in rape victims CPT is a 12 session, manualized protocol It is almost entirely a cognitive intervention
Phases of CPT Initial Assess impact of trauma Teach connection between thoughts and feelings Middle Written account of trauma Explore meaning of trauma Identify stuck points Final Examination of evidence for thoughts and beliefs Challenge beliefs Reassess impact of trauma
CPT Sessions 1. Introduction and education 2. Meaning of the event 3. Identification of thoughts and feelings (ABC) 4. Remembering traumatic events 5. Remembering traumatic events 6. Challenging questions 7. Patterns of problematic thinking 8. Safety issues 9. Trust issues 10. Power/control issues 11. Esteem issues 12. Intimacy issues and meaning of the event
There s More to CPT Exposure to trauma story Homework between sessions Number of sessions is expandable
How does CPT work? CPT challenges avoidance Changing the interpretation of the traumatic event changes the emotions resulting from the event Clients learn not to over-generalize on the basis of a traumatic event to themselves, all people, or the world
A-B-C Worksheet
Stuck Points Are thoughts/beliefs that become automatic and habitual Keep a person stuck from recovering from PTSD May not be fully accurate Often use extreme language May be a person s understanding of why a trauma happened May be about The person Others The world
Stuck Points Typically Are Thoughts, not feelings Concise All or nothing Black and white If/then statements Thought behind the moral statement Not always I statements
Examples of Stuck Points It is my fault my buddy got killed I am to blame for my abuse I have to be always on guard I have to control everything to be safe If I think about the trauma, I ll go crazy I am permanently damaged by my trauma Other people can t be trusted Other people can t understand me The world is a dangerous place
Challenging Questions What is the evidence for the thought/belief? What is the evidence against it? Is it habit or fact? Are you including all of the information about it? Are you using all or none reasoning? Is the thought extreme or exaggerated?
Challenging Questions Are you focused on only one piece of information? Is the source of the information dependable? Are you confusing possible with likely? Is the belief based on feelings or facts? Are you focusing on unrelated parts of the situation?
Patterns of Problematic Thinking Jumping to conclusions Exaggerating or minimizing Ignoring important parts Oversimplifying Over-generalizing Mind-reading Emotional reasoning
Challenging Beliefs Worksheet
Forms and Formats of CPT
Forms of CPT CPT for rape survivors (Resick and Schnicke, 1993) Multiple Channel Exposure Therapy for PTSD and panic attacks (Falsetti et al., 2001) CPT-Sexual Abuse (Chard, 2005) CPT-Military (Resick, Monson, & Chard, 2007, 2014) CPT-Cognitive (Resick et al., 2008)
23 CPT Compared to CPT-C CPT 1. Introduction and Education 2. Meaning of the Event 3. Identification of Thoughts and Feelings (ABC) 4. Remembering Traumatic Events 5. Remembering Traumatic Events 6. Challenging Questions 7. Patterns of Problematic Thinking 8. CBW Safety Issues 9. Trust Issues 10. Power/Control Issues 11. Esteem Issues 12. Intimacy Issues and Meaning of the Event CPT-C 1. Introduction and Education 2. Meaning of the Event 3. Identification of Thoughts and Feelings (ABC) 4. Identification of Stuck Points (ABC) 5. Challenging Questions 6. Patterns of Problematic Thinking 7. Challenging Beliefs 8. Safety Issues 9. Trust Issues 10. Power/Control Issues 11. Esteem Issues 12. Intimacy Issues and Meaning of the Event
CPT Formats Individual (12 sessions) Group (12 sessions) Group + Individual (26 sessions over 17 weeks)
CPT Has Been Used in Inpatient treatment Residential treatment Outpatient treatment
Who Does CPT Work For?
Randomized Controlled Trials of CPT 27 Interpersonal Traumas Rape (Resick et al., 2002) Group CPT Child sexual abuse (Chard, 2005) Group and Individual CPT-SA Rape and physical assault (Resick et al., 2008) Individual CPT Military/Veterans U.S. veterans (Monson et al., 2006) Individual CPT Australian veterans (Forbes et al., 2012) Individual CPT U.S. veterans with military sexual trauma (Suris et al., 2013) Individual CPT
Several metaanalyses have found CPT to be an effective treatment for PTSD (Vickerman & Margolin, 2009; Ougrin, 2011; Jonas et al., 2013; Ehring et al., 2014) CPT Is Effective
CAPS Score 90 80 70 60 50 40 30 20 10 0 Clinician-Assisted PTSD Scale Severity for Different Traumas Resick et al. (2002) Chard (2005) Monson et al. (2006) Resick et al. (2008; CPT) Forbes et al. (2012) Galovski et al. (2012) Pre Suris et al. (2013) Post Trauma Rape Child Sexual Abuse Combat U.S. Rape and Assault Combat Australia Rape, Assault, Child Abuse, Domestic Violence Military Sexual Trauma Healy, 2014
Further Populations CPT Works for PTSD with panic attacks (Falsetti et al., 2001) Incarcerated adolescents (Ahrens & Rexford, 2002) Complex trauma (Resick et al., 2003) PTSD with trauma-related guilt in rape survivors (Nishith et al., 2005) War refugees (Schulz et al., 2006) Vietnam and Iraq/Afghanistan veterans (Chard et al., 2010) PTSD with mild traumatic brain injury (Chard et al., 2011) Child sexual abuse, child physical abuse, rape, physical assault, domestic violence (Galovski et al., 2013)
CPT Effectiveness is Limited by Lack of safety (homelessness, living in violent homes or neighborhoods) Active substance abuse 20-25% dropout rates Chronicity of PTSD Success rates are 67-75% Moral injury
CPT vs. Other PTSD Treatments
CPT Shows Better Results Than Relaxation or supportive counseling (Resick, 2001) Written accounts of trauma (Resick et al., 2008) Treatment as usual (Alvarez et al., 2011)
CPT vs. Prolonged Exposure Several studies have compared CPT with Prolonged Exposure (PE): Female rape survivors (Nishith et al., 2005; Gutner et al., 2013) Veterans (Jeffreys et al., 2014) Meta-analyses (Vickerman & Margolin, 2009; Ougrin, 2011; Jonas et al., 2013; Ehring et al., 2014) All prospective studies comparing the two treatments find no significant differences Only Jeffries et al. (2014), who examined historical records of veterans, found PE to be superior
Advantages of CPT vs. PE CPT may be better for non-fear cognitions CPT fits better with DSM 5 conception of PTSD CPT is better for guilt and depression (Nishith et al., 2005) CPT may be less threatening than PE CPT has a lower dropout rate than PE, 32% vs. 44% (Jeffries et al., 2014) CPT group format is more efficient than PE There are multiple versions of CPT and only one of PE CPT works for complex trauma as well as simple trauma (Resick et al., 2003), while PE works on one trauma
Advantages of PE vs. CPT Only a single manual has to be learned in PE PE may be better for fear-based cognitions PE may have stronger effects for veterans (Jeffries et al., 2014)
CPT vs. Eye Movement Desensitization and Reprocessing There are no prospective or retrospective studies comparing CPT and Eye Movement Desensitization and Reprocessing (EMDR) Meta-analyses show no significant differences between the two (Vickerman & Margolin, 2009; Ougrin, 2011; Jonas et al., 2013; Ehring et al., 2014), although they note that there are fewer randomized controlled trials using EMDR
Advantages of CPT vs. EMDR CPT is manualized, while EMDR is not Easier to learn It can be learned via books and the Internet CPT is learned in 2.5-4 days in a row, while EMDR is learned over two 2.5 day weekends six months apart CPT may be less threatening than EMDR CPT group format is more efficient than EMDR CPT may be more efficient than EMDR when a traumatic brain injury is present CPT is time-limited
Advantages of EMDR vs. CPT One size does not fit all Only two manuals must be learned in EMDR Multiple additional protocols are available EMDR has no homework, while CPT does For single traumas, EMDR may be faster EMDR also focuses on images, emotions, and body sensations Body sensations may continue even when cognitions change EMDR also includes resource building techniques and skills EMDR has several national and international organizations that train and provide infrastructure, support, and knowledge dissemination
Resources
CPT Manual Resick, P., & Schnicke, M. (1993) Cognitive Processing Therapy for Rape Victims
Internet Resources http://www.istss.org/cognitiveprocessingtherapycpt.htm and http://www.ptsd.va.gov/public/treatment/therapymed/cognitive_processing_therapy.asp and http://www.deploymentpsych.org/treatments/cognitiveprocessing-therapy-cpt Brief overviews of CPT with links http://maketheconnection.net/ and http://www.ptsd.va.gov/apps/aboutface/questions--whattreatment-was-like-for-me.html Video stories of veterans who have received CPT
Web Training Courses https://cpt.musc.edu/ http://www.deployment psych.org/onlinecourses/cpt
CPT Coach App
Contact Brian L. Meyer, Ph.D. Brian.Meyer@va.gov