Evidence-Based Approaches to PTSD and Associated Conditions in Veterans

1. Cognitive Processing Therapy (CPT) for PTSDAshlee Whitehead, LPC, CADCCPT ProviderPTSD clinical teamPortland VA Medical Center Evidence-Based Approaches to PTSD and Associated Conditions in Veterans

2. Cognitive Processing Therapy (CPT) for PTSDOverview of today’s presentation • History of CPT • Theory, Rationale & Goals • The Essential Ingredients • Structure of CPT • CPT Resources

3. Cognitive Processing Therapy (CPT) for PTSDORIGINS 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.

4. Cognitive Processing Therapy (CPT) for PTSDTHEORY 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.

5. Cognitive Processing Therapy (CPT) for PTSDSOCIAL COGNITIVE THEORY OF TRAUMA • 5 major dimensions that may be disrupted by traumatic events: • Safety • Trust • Power and Control • Esteem • Intimacy

6. Cognitive Processing Therapy (CPT) for PTSDCPT 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 pointsand progress toward recovery.

7. Cognitive Processing Therapy (CPT) for PTSDCPT 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.

8. 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

9. 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

10. Cognitive Processing Therapy (CPT) for PTSDTHE ESSENTIAL INGREDIANTS • The Impactof the Event • Identifying Stuck Points • Identifying and resolving assimilatedbeliefs • Challenging and balancing overaccomodatedbeliefs. • Use of Socratic Questioning • Processing naturalemotions related to the trauma

11. SO… WHAT ARE STUCK POINTS?Thoughts & interpretations about the Traumatic eventAutomatic - Distorted - May occur beneath one’s awareness

12. 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.

13. 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.”

14. 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.”

15. 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????? Innocent people were killed TRAUMA I was raped in the military

16. 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 Assimilation Original Belief Rape=Stranger Traumatic Event Raped by friend Assimilation Misunderstanding Undoing and Self-Blame

17. Over-accommodation • Overall 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

18. “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.

19. “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.

20. 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 “I don’t see the point in asking all these questions. I could have pointed out the flaws in the client’s thinking and changed her mind much more quickly by taking a more direct route!”

21. 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?”

22. Cognitive Processing Therapy (CPT) for PTSDCPT therapy has 4 main parts Learning about PTSD symptoms Becoming aware of thoughts & feelings about the trauma Learning skills Understanding changes in beliefs

23. Cognitive Processing Therapy (CPT) for PTSDSTRUCTURE OF CPT SESSIONS Individual CPT Group CPT • 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 Veterans per group • Includes a brief written trauma account component, along with ongoing practice of cognitive techniques

24. 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

25. Let’s make the event: Coming here today • What thoughts did you have about coming to this presentation today? • What emotions come up with those thoughts?

26. No let’s change the event to: Using evidence-based therapies in PTSD • What thoughts do you have about using EBTs? • What emotions come up with those thoughts?

27. A promotional video

28. 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.

29. 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 PTSDhttp://www.ptsd.va.gov/ • Cognitive Therapy for Posttraumatic Stress Disorder byShipherd, Street, and Resick in Chapter 5 of Cognitive-Behavioral Therapies for Trauma, Second Edition by Victoria M. Follette PhD and Josef I. Ruzek (2007)