Cognitive Processing Therapy: Beyond the Basics

CPT

CPT-C

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

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

Consistent with the finding that the cognitive restructuring appears to be the primary active components of CPT, Sobel, Resick, and Rabalais (2009) assessed the change in cognitions among rape survivors over the course of CPT. The investigators assessed this change by comparing the content of the two impact statements. This study indicated that there was a significant increase in the number of accommodated clauses in the final impact statement; and the number and percent of accommodated clauses were significantly negatively related to a change in self-reported PTSD symptoms. In other words, the more an individual is able to change their thinking to accommodate new information, the greater their decrease of PTSD symptoms. The study also showed a significant decrease in the number of over-accommodated, assimilated, informational, and total clauses. The percent of over-accommodated clauses were significantly positively related to a change in self-reported PTSD symptoms. Thus, the better able individuals are to alter their drastic change of beliefs, the greater their decrease in PTSD symptoms. Findings from this study provide support for the theoretical rationale for CPT in that modifying existing beliefs to more accurately reflect the traumatic experience results in a decrease PTSD symptoms.

Who Does CPT Work for?

Several studies have examined predictor variables regarding treatment outcome, including treatment dropout. Rizvi, Vogt, and Resick (2009) investigated factors related to cognition (level of education, intelligence, and age) and mood states associated with PTSD (anger, guilt, and depression) on treatment outcome. These variables were examined as they were hypothesized to affect the ability to adopt new ways of thinking and that negative mood states may interfere with the processing of traumatic memories. The study demonstrated that level of education, intelligence, and age did not affect treatment efficacy for the entire sample. Furthermore, age was related to treatment outcome when analyzed by treatment condition (CPT and PE). Younger age was associated with the best outcomes in CPT, whereas older age was related to the best outcomes in PE. These findings are consistent with those of Resick et al.’s (2008), whose additional findings revealed a trend for older age to be related to poorer treatment outcome in CPT.

Results also indicated that comorbid negative mood states did not affect treatment efficacy, suggesting that these mood states do not interfere with the emotional and cognitive processing of traumatic memories. Although higher depression and guilt scores were associated with higher PTSD symptom scores, participants evidenced a proportional reduction in PTSD over time, resulting in comparable scores to those with lower levels of depression and guilt. These findings again were similar to those of Resick et al. (2008), suggesting that higher scores on negative comorbid mood states were still able to show improvement in PTSD symptom scores.

Several factors emerged in relation to treatment dropout. Younger age and lower intelligence were related to treatment dropout, which is consistent with findings by Resick et al. (2008). Participants with lower education also trended towards greater rates of treatment dropout. Higher trait anger did not impact CPT; however, participants with higher trait anger were more likely to drop out of PE.

Iverson, Resick, Suvak, Walling, and Taft (2011) examined the influence of current interpersonal violence (IPV), which was defined as experiencing an act of IPV within the past year, on treatment outcome among women. The study showed that those who experienced current IPV were less likely to begin treatment than those who did not experience current IPV. However, if women who experienced current IPV did begin treatment, IPV was not predictive of treatment completion. Results also indicated that women who experienced more frequent IPV showed greater reductions in PTSD and depression symptoms over the course of treatment. However, their symptom levels at the 6-month follow-up were comparable to those who experienced less frequent IPV. Collectively, these findings suggest that if women who experienced current IPV engage in CPT—including those who experience frequent IPV—are able to reduce their PTSD and depression symptoms over the course of the study and at follow-up.

Modifications of CPT for Specific Populations

Alterations have been made to the original CPT format to accommodate various populations. As the dismantling study (Resick et al., 2008) illustrated, CPT (cognitive therapy and the written account) did not improve upon the results of either component alone and the cognitive aspect of CPT (CPT-C) yielded significantly lower scores than the written account condition. In sum, this finding indicates that CPT-C is an effective modification of CPT for treating PTSD. CPT-C may be the preferred treatment option when individuals are noncompliant with the written account, lack a clear memory of the traumatic event, or have significant writing difficulties. Furthermore, CPT-C has been demonstrated to be effective for veterans with PTSD and a history of traumatic brain injury (TBI; Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011), particularly with moderate to severe histories of TBI where lasting impairments are more commonly experienced.

CPT has also been adapted for child abuse survivors (CPT-SA; Chard, 2005). This adaptation was developed to address particular issues often presented by child abuse survivors, including attachment and developmental history. Topic areas added to the adapted protocol include sexual intimacy, assertiveness/communication, and social support. The CPT-SA protocol includes seventeen 90-min group therapy sessions and 60-min individual therapy sessions for the first 9 weeks of treatment and then again during the last week (session 17). The format is designed to allow patients to fully process their traumatic events with their individual therapist, which also decreases the risk of vicarious traumatization in group therapy sessions. Furthermore, individual therapy sessions are not scheduled from weeks 10 to 16, which encourages the patient to rely on the group and their own coping strategies—rather than the therapist. The group format also encourages appropriate social interactions and the opportunities to practice skills learned in the context of therapy.

Chard (2005) compared CPT-SA to a minimal attention wait-list control group. Results indicated that individuals who received CPT-SA showed significant improvement on clinician-assessed PTSD symptoms and self-reported PTSD, depressive, and dissociation symptoms. Furthermore, findings showed large effect sizes for change for the CPT-SA group as compared to the minimal attention group. In addition to changes from pre- to posttreatment, positive treatment outcomes regarding PTSD, depression, and dissociation remained for at least 1 year following treatment completion.

CPT has also been employed as a treatment modality for traumatized refugees in a community setting and shown to be an effective treatment (Schulz, Resick, Huber, & Griffin, 2006). This finding is particularly noteworthy as traumatized refugees often experience numerous and severe traumatic events, increasing their risk for developing psychological problems (Nicholl & Thompson, 2004). The Schulz et al. (2006) study evaluated 53 refugees who had pre- and posttreatment data. None of the participants were fluent in English and interpreters were utilized for approximately half of the participants. Several modifications were made to accommodate special considerations for this population. First, the majority of treatment sessions (83 %) occurred in the participant’s homes. A second modification was that the length of treatment and duration of sessions were negotiated. The average length of sessions was 1.5–2 h and the average number of sessions was 17 (which included 3–4 assessment sessions). It should be noted that the number of sessions negotiated was comparable to the established 12 sessions in the CPT manual although the duration of sessions differed.

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