Cognitive Processing Therapy for PTSD

Oh my, this is too big for a brief answer. I suggest that you read the manual (Resick, Monson & Chard, 2017). You can find it at cptforptsd.com or Guilford publishers. I am attaching the draft of chapter I wrote on cognitive therapies. It is a cognitive model that does not assume PTSD to be only about fear and anxiety. We see all different emotions based on how the person thinks about the cause of the event. We help them to examine their thinking about the the causes and effects of the trauma and if their thoughts change, their emotions and other symptoms of PTSD change.

PE is an exposure therapy (imaginal and behavior exposure), CPT is a cognitive therapy. The difference between CT-PTSD by Ehlers and Clark and CPT is that CPT is a more structured protocol.

Cognitive theory. Cognitive change not extinction of fear. I suggest that you read the manual or a chapter on CPT. Attached is a chapter on PTSD from a cognitive perspective.

Cognitive therapy was influenced heavily by Aaron Beck. That is the bulk of the therapy, progressive worksheets and Socratic dialogue. At the end of therapy there are two behavioral assignments, giving and receiving compliments and doing something nice/worthwhile for oneself each day. The goal of these assignments is increased self-esteem, finding out what they want to do when they aren't avoiding with their PTSD and to interact with other people more.

There are a number of benefits. We have found that sticking to the protocol keeps both the therapist and patient from avoiding working with the PTSD trauma and wandering off to other topics. Fidelity to the manual has been shown to increase outcomes. It is a systematic approach that teaches the patient a new way to think in a more balanced and fact-based way. We want to stay on topic so that they can develop the skills of cognitive and emotional examination and they can get to the point where they can effectively come to more balanced fact-based alternative thoughts they can practice rather than the extreme statements they are accustomed to thinking. Ultimately, we want them to take over as their own therapist.

It depends on how you define a core theme. As an example, if patients are taught when they are young that they are stupid or that everything that happens to them is their fault, that can become a core belief that is activated when they experience a traumatic event. They will assume it happened because they are stupid or that it must be their fault. Core beliefs generalize into habits to many events in everyday life and are underlying patients emotions and actions. In CPT we talk about core beliefs when we hear patients having the same Stuck Points over and over across situations. In the second half of treatment, any of the over-accommodated beliefs (safety, trust, power/control, esteem and intimacy) are focused on as common themes that are disrupted by traumatic events. Some patients have more of some than others and any of them if generalized widely can become core beliefs.

Self-loathing and shame are a major focus in CPT. Beyond self-blame, shame is a big predictor of who will have PTSD and we would conceptualize self-loathing and shame as core beliefs about one as a person. Once we recognize a core belief, whenever we do in therapy, we explain it and don't try to challenge it as a large concept but do worksheets and notice whenever that is a theme. If you can alter thoughts about one daily or trauma event at a time and they realize that it wasn't their fault or doesn't have to mean anything about them as a person, the core belief starts to fall under the weight of all of the evidence to the contrary. Pointing out the pattern and noticing when it occurs and assigning worksheets on specific events works much better than trying to challenge it as a global concept. The patients need to come to understand that the traumatic events happened in spite of them, not because of them, and only means something about the perpetrator- the one who had the intent.

You start CPT with the single trauma that produces the most PTSD symptoms (index event). Once you have resolved their assimilated stuck points (distorted thought about the cause(s) of the event), it is possible to start weaving other traumatic events into therapy and with the worksheets. Often the patient will have similar stuck points across traumas so if you start with the worst, the new thinking will generalize to thoughts and emotions about other events. If there is an event that is quite different then it is important to get any new stuck points onto their stuck point log to work on them as well. CPT is very amenable to working on multiple traumas.

We have always included complex trauma histories in our research and clinic patients using CPT. the majority of patients who seek treatment have multiple traumas including child sexual abuse. CPT is very amenable to multiple traumas. Regarding the question about pre-verbal trauma they found out via a sibling, my question to you is whether they have PTSD from it? Fragmented memories can happen for many reasons including dissociation, being drugged or drunk as well as learning about it. CPT is a cognitive therapy about their thoughts and emotions about the traumatic event(s), not a recitation of every detail of the trauma. The impact statement is about the meaning of the event. What does it mean that they learning this? What impact has it had on them. I wouldn't do CPT+A, which I have largely given up since the 2008 dismantling study showed that there was no value added and a slower trajectory when patients wrote their accounts. I would do CPT without the written accounts. See the manual (Resick, Monson, and Chard, 2017).

We have never excluded people with dissociative symptoms with their PTSD. We find that dissociation decreases as their PTSD improves. Dissociation is a form of avoidance of last resort that usually starts in childhood when fight-flight is not possible. That said, if someone is highly dissociative and cannot even talk about their trauma, you may need to spend a couple of sessions on grounding techniques. The patient needs a good rationale for not dissociating (bad for their health and puts them in greater danger) and it is helpful if you can find a time that the didn't dissociate- what did they do? Keeping them in the here and now is important. Have them stand up or answer some simple questions. Kate Chard suggests using a can of cold soda on the neck if they are starting to dissociate. I like them to have an index card or use a list of questions on their phone that they can read. I am attaching an article in which we looked at the effects of treatment depending on their dissociation. We found that those who had high dissociation did better with the version of CPT in which they write their accounts but those with no or lower levels of dissociation did better in the version without written accounts. Those with high dissociation probably dissociated during the trauma and they need to put the fragments of the story back together with a beginning, middle and end so that the cognitive therapy can proceed.

In the DSM-IV and DSM-5 we did not find there to be a separate category of complex PTSD. Most of our patients have other comorbid symptoms and complicated trauma histories. The DSM-5 also added some items to address some of the common "complex" symtoms. I am a big fan of variable length CPT which doesn't just stop at 12 sessions but adds more sessions as needed. We rarely need more than 18 sessions but that is good if someone has a core belief that needs more work. I have some articles in cptforptsd.com (look under resources) that look at CPT outcomes with those with personality disorders or childhood sexual assault and they did fine. I am also going to add one or two articles here that show that adolescents who have lots of prep work before receiving treatment did not show improvement with all the extra work through the midtreatment assessment but then improved markedly with the CPT. The other article (if I can attach two) shows that CPT improves executive functioning, which we knows calms down the amygdala (feedback loop), so CPT is in fact teaching affect regulation.

You should try to do the CPT protocol as is, although if you know that the patient has ongoing post-concussive symptoms, you might introduce the concept of variable length therapy in case you need extra sessions. Our research has found that there are no differences in outcomes overall, but those with TBI do better in individual than group therapy. You may need to adjust depending on whether your patients have have problems with memory, concentration, learning new information, etc. TBI is not just one thing. If a patient has problems understanding the Challenging Questions Worksheet or Challenging Beliefs Worksheet, we have alternative forms in the manual (Resick, Monson & Chard, 2017). You can also have them re-read their worksheets regularly or post sticky notes around their house to remind them of their alternative thoughts. They may need more repetitions and practice.

They can be harder when the patient had intent for the action that caused the PTSD. It is also a therapist issue. Our goal in this case is NOT to have them conclude that it wasn't their fault (unless it turns out that it really wasn't) but to go back to the context. For combat, did they kill people before military, have they killed people since? What was the context that day? Why did they kill that person/people? Were they trying to protect their fellow soldiers? What did they know? If they hadn't shot, what might have happened? If their thought is "I have killed someone, so I am a monster", we are trying to 'right size' it. Good people can do bad things. I had a client who I was treating for child sexual abuse who admitted during treatment that he had raped someone. My first question was whether he was still doing it. That would have changed the course of therapy. He said no, it happened only once when he was 18. Strange as it sounds, my second question was "why did you stop?" He said he realized it was wrong. So I pointed out that he had changed and wasn't the same person he had been. He said there was so much abuse in his neighborhood as a child including being forced to have sex with a little girl that he never knew when he was a victim or perpetrator. We talked about age of consent. I did point out that at 18, he was responsible and didn't try to take his guilt away, but have him feel it and think about how he wanted to be now. We talked about being a good citizen given that he couldn't do any restitution to the victim. We right-sized it in the context of his life. Many prisons implement CPT with prisoners for crimes they have committed and have PTSD from. The perpetrators in which CPT is not appropriate is if they don't have PTSD about the event. If they don't have guilt and remorse, they are not going to benefit from treatment.

In a follow-up that was conducted 5-10 year after completing CPT, we examined women who had recovered and then looked to see how many had PTSD at the long term follow-up. For the whole sample who had CPT, 78% did not have PTSD at the follow-up. Of those who did not have PTSD at the end of treatment, 20% met criteria for PTSD at the long term follow-up. We only looked at relapse by diagnosis, not by decrease to a good end state and then relapsed to much higher scores. The problem of diagnosis only could be changing just one answer to the criteria questions. There is only so much you can put into a paper though. I can't think of any other studies that we examined relapse per se. the Larson 2016 article looked at exacerbations of specific symptoms during treatment (about 20% of those with CPT with written accounts and 15% of those who did CPT without accounts. However, they seemed to do fine by the end of treatment with equal clinically significant improvements and no difference in drop-out.

The answer to your question is found in a reexamination of my research by a colleague to examine that very question. CPT with or without written accounts and PE were compared overall and within sessions. An exacerbation was considered an increase of over 6 points on the self-report PTSD. Only a minority of patients had an exacerbation and because the sample was so small, there were no significant differences. Although those with an exacerbation tended to have higher scores than those without, they did show clinically significant improvement. In my 2008 study, I found that CPT without accounts had a 15% lower dropout rate and there was no value added in the end with the written accounts, so I have been advocating for CPT without accounts since then.

Of course. But keep in mind that some studies show high dropout rates and some don't. There are much lower dropout rates in civilian samples than in veteran samples in many studies. In many studies, the rate is no higher than any other problem we treat. We are also finding that treating PTSD over a shorter period of time results in lower dropout rates. Given a good rationale for treatment is a skill that therapists need to learn. I also advocate for doing CPT without written accounts because the dropout rate tends to be lower and the client focuses on their thoughts and feelings about the trauma rather than the gory details that may in fact be irrelevant to why they have PTSD. They may be blaming themselves or stuck on the just world belief, not the details of what happened. Finally, we have also found that some people drop out because they are better. We have found that in two studies. I have attached one of those studies here.

Three different problems. 1. intimidating. We start with simple worksheets and build on them. Remind the patients that you are not grading them. You just want to understand what they have made of their traumatic events- their thoughts and feelings. If they get responses in the wrong columns, gently correct and remind them that they weren't taught this in school. This is a therapist skill issue. 2. Complicated. If you are following the protocol, then the worksheets build progressively so they should build and not be too complicated. However, if they are struggling with literacy or brain injury, we have alternative worksheets in the manual that have been simplified. 3. impersonal. If they were impersonal we would have them filled out already. They are the opposite of impersonal. Everyone has different experiences, thoughts and emotions and these worksheets are a blank vehicle for the patient to sort through what they think and feel and to give the therapist the opportunity to understand them better. Once they look at the completed (and possibly corrected worksheet) they can see right in front of them why they have been stuck in their PTSD.

You want to stick to the protocol as much as you can. I just pointed out in my last answer that fidelity is important. However, we do have alternative forms for low literacy and adaptations had to be made in different cultures. They did so while keeping the bones and heart of CPT. I am adding the famous study of CPT in the Democratic Republic of Congo (Bass et al., 2013) and Luana Marques' adaptation for low literacy and cultural differences among Latinx in Boston.

Therapist competence matters for all forms of therapy and CPT is no different. The more competent and experienced that a therapist is in implementing CPT, the better their outcomes and lower the dropout. Ability in Socratic Questioning and addressing assimilation before overaccommodation appear to be the two most important factors. That said, we do have research that fidelity to the protocol is more important than competence of the therapist. Many of the effectiveness studies that have been published in VA and civilian settings have reported on therapists' first cases while under consultation. The improvements among patients are large. Wandering off of the protocol is associated with poorer outcomes.

Aside from all of the training you can get (manual, workshop, upcoming on-line course, case consultation), if you have not worked in the trauma field before, you have to remember that is their trauma. They need to feel their own emotions. You need to remember to focus on their thoughts and not put yourself in their shoes too much and visualize their trauma or you will burn out.

We have never added anything like DBT to CPT and have not found it to be necessary. In out research comparing CPT and PE, we examined borderline personality in two ways. One was to look at baseline high vs. low borderline symptoms to see how they responded to CPT for PTSD (Clarke, et al, 2008). Although those with higher borderline symptoms started with higher PTSD, then ended up the same. The other study looked at a variety of personality disorders over a long term followup for PTSD with CPT. Five different personality disorders were shown to improve based on improvement in PTSD, including BPD. In an earlier answer I referred to and attached an article of adolescents with child trauma histories by Rosner et al. (JAMA, 2020) that did start with components of DBT and found no improvement until they started CPT. However, there has never been a study that has started with DBT and then added CPT with severe borderline personality patients so I do not know if it would be helpful.

I have no idea why EMDR works. That seems like a reasonable hypothesis, but keep in mind that EMDR also includes exposure and cognitive components and there have been several studies that have not found the bilateral stimulation to be important.

There are more data on yoga than the other two with some minor effects on PTSD, but I wonder why you would want to add them. What would they add to the CPT and how would you measure whether they help or hurt the CPT? So, my view is that it doesn't fit the CPT theoretical model and I would try that first before adding therapies that have not been properly tested.

These are two different concepts. it is possible to have posttraumatic growth and still have PTSD. You may have more compassion for other people but still have flashbacks, avoidance, self-blame when it comes to yourself etc. We don't find that posttraumatic improves PTSD, but they might be more concerned about the welfare of others. On the other hand, if someone improves in their PTSD symptoms, they may be able to 'get out of their own head" and focus more on those around them. I look for cognitive growth first, more balanced thinking, and then perhaps there will be a change in their view of others. In my research we did not find them to be highly correlated.

We typically measure PTSD, depression and some other things for specific comorbidities among clients. For formal diagnosis and research we use an interview, the CAPS. the PCL-5 is a self-report measure that is available in the CPT treatment manual. For depression, we use the PHQ-9, which is also free.

Look at the cptforptsd.com website under the training tab. We have had to switch to web based workshops during the pandemic. We have a non-VA roster for those who complete a qualified workshop and six months of case consultation.

Please check cptforptsd.com and look in the training tab. Workshops and consultation that are open are listed there. AT the moment, because of the pandemic, workshops are being done by web. They do include opportunities for role play and watching videos. We usually require in-person workshops to qualify for consultation leading to provider status but have changed to adapt to the realities of the pandemic. As more workshops become available, they will be listed on the website.

Yes, it has been used in VA residential programs since about 2007 and there is a program at Rush. I'm sure there are probably other residential programs. I did some CPT training a few years ago for residential programs for eating disorders and PTSD.

Have you looked at cptforptsd.com? That is the website for non-VA. We are adding more live web-based workshops and consultation for licensed providers because of the pandemic so keep checking back there if any of the listed workshops have sold out.

Well, first of all, I don't recommend weekly CPT if you can do it twice a week (M-Th or Tu-F). All of my research has been with twice a week. Cassidy Gutner did an analysis of those we tried to do twice a week on actual length of time it took to complete the protocol. Sometimes people cancel or no-show or have competing appointments and can't make twice a week. She found that those with less time between sessions did better. I will attach that article. However, there has been more interest anyway in doing intensive CPT because people can take a week or two off of work and get their treatment done quickly. We know that it lowers the dropout rate but we don't yet know with research whether it is equal to CPT done over a longer period of time. I suppose spreading it out might allow more time for practice assignment completion and doing the therapy in the context of their lives. It could just increase avoidance however- one of the reasons why I don't likely weekly sessions (yes, I know that some agencies won't allow twice weekly sessions). One of my colleagues is currently conducting a randomized controlled trial comparing 5 day CPT with 6 week. It will be a couple of years before we know if they are equivalent. Craig Bryan In Utah (soon to be at Ohio State) has been conducting 2 week CPT as has Phillip Held at Rush. They have both published case studies. If you want to hear a two-week version of CPT, This American Life broadcast an episode called "Ten Sessions". A reporter flew from NY to the University of Washington to be treated by Debra Kaysen and taped her experience. You get to hear bits of sessions and her reactions to receiving the treatment and how she is doing now. It is a free download podcast.

I would give them a choice after describing the available therapies if therapists are trained in more than one treatment. Some people would choose WET and some would choose PE or CPT. It also depends on comorbidity. We know that WET is noninferior to CPT with regard to PTSD, but we don't yet know about guilt, shame, anger, alcohol abuse etc. It could be used as stepped care, if there are limited therapists, but the patients should know that there are other options also.

Yes, there have been four studies of CPT comparing in person with telehealth. They worked equally well. A group of us have written an article that should be in the Journal of Traumatic Stress giving advise/tips of how to do telehealth CPT effectively. The revisions of that article are being submitted this week so hopefully it will be available on-line soon.

That is a good question that we don't have an answer to yet. We know that in wars medics and those who have to handle bodies develop high rates of PTSD. I wouldn't be at all surprised if medical care workers, who are overwhelmed with cases and inadequate protection that leaves them in danger would develop PTSD. Having COVID-19 itself might not cause PTSD any more than other diseases which don't usually cause PTSD. Being forced into danger, feeling helpless, believing that you are guilty of giving it to someone who died, could be indicators to look for. I'm sure there will be a lot of research over the next few years.