CONTINUED  EXPLORATION  OF  EVIDENCE-­‐BASED  TREATMENTS  FOR  PTSD  

COGNITIVE  PROCESSING  THERAPY    

ASHLEE  WHITEHEAD,  LPC,  CADC  CERTIFIED  CPT  PROVIDER  PTSD  CLINICAL  TEAM  

PORTLAND  VA  MEDICAL  CENTER���  

Contemporary  Mental  Health  Treatment  For  Returning  Veterans  Portland  State  University    

CONTINUED  EXPLORATION  OF  COGNITIVE  PROCESSING  THERAPY            25  %  of  OIF/OEF  veteran  VA  Health  Care  users  have  been  diagnosed  with  PTSD  –  120,000    (FY  2009)  

  Research  consistently  reveals  that  MH  providers  deliver  Evidence  Based  Psychotherapies  (EBPs)  for  PTSD  at  low  rates…    

 

WHY?    

  Some  obstacles  to  implementing  EBPs  for  PTSD    Maintenance  view  of  PTSD    Worry  about  retraumatization  with  exposure      Therapist  self-­‐efXicacy    Client  participation  and  interest  

SOLUTION?    

 Implementation  of  VHA  MH  Strategic  Plan  (2006)   National  Initiatives  for  Disseminating  PTSD  Treatment:    Prolonged  Exposure  &  Cognitive  Processing  Therapy    

 All  veterans  with  PTSD  have  access  to  CPT  or  PE      

  EBP  Coordinator  “champion”  at  every  VA  

  “Buy-­‐in”  from  MH  leadership  

Impact  of  EBP  Implementation  Initiative    2,700  VA  MH  providers  trained  (May  2010)    96%  of  VAs  providing  CPT  or  PE;  72%  providing  both   Average  decline  of  30%  (20  pts)  on  PTSD  Checklist  (n=474)  

  Therapist  conXidence  levels  increase  pre  to  post  training  

  Case  studies  and  Xirst  hand  clinical  experience    demonstrate  signiXicant  positive  clinical  impact  on  veterans  who  receive  EBPs  

INCREASING  POSITIVE  OUTCOMES  W/EBPS  

  Therapist  Self-­‐EfXicacy!    PTSD  Psychoeducation:  Desire  to  approach  outweighs  desire  to  avoid.  

  Client  needs  to  believe  that  improvement  is  possible  and  he  has  the  ability  to  tolerate  therapy  (skills).  

  Strategic  Goal  Setting:  Develop  a  personalized  plan  based  on  what  the  client  needs  to  maximize  their  chance  of  success  in  treatment.    

  Assess  barriers  (SI,  Substance  Use,  TBI,  Support  System,  Psychosocial  stressors).    

  Consider  residential,  individual  vs.  group  

CPT  –  a  quick  review     Cognitive  Processing  Therapy  is  a  12-­‐session  treatment    based  on  a  social  cognitive  theory  of  PTSD  that  focused  on  the  meaning  individuals  make  in  response  to  the  traumatic  event  and  how  people  cope  as  they  try  to  regain  a  sense  of  mastery  or  control  over  their  lives  (Resick  &  Schnicke,  1993).    

 Over  20  years  of  clinical  practice,  initially  focused  on  trauma  of  rape.  In  2006  was  expanded  to  Xit  veteran/military  population  (Resick,  Monson,  Schnurr).  

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  Behaviors  

reinforce      Distorted  beliefs  about  the  trauma              and  become  

                           Generalized  to  current  life  situations    

 Cognitive-­‐focused  techniques  are  used  to  help  Clients  move  past  stuck  points  and  progress  toward  recovery.  

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  Veterans  per  group  •  Includes  a  brief  written  trauma  account  component,  along  with  ongoing  practice  of  cognitive  techniques  

Individual  CPT   Group  CPT  

COGNITIVE  PROCESSING  THERAPY  (CPT)  FOR  PTSD      THE  ESSENTIAL  INGREDIANTS  

 The  Impact  of  the  Event  

  Identifying  Stuck  Points    

  Identifying  and  resolving  assimilated  beliefs    

 Challenging  and  balancing  overaccomodated  beliefs.    

 Use  of  Socratic  Questioning    

 Processing  natural  emotions  related  to  the  trauma  

COGNITIVE  PROCESSING  THERAPY  (CPT)  FOR  PTSD        5  major  dimensions  that  may  be  disrupted  by  traumatic  events:  1)  Safety  2)  Trust  3)  Power  and  Control  4)  Esteem  5)  Intimacy  

 

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SESSION  1.  PTSD  SYMPTOMS  AND  RATIONALE  

 Types  of  emotions   Goal  for  natural  emotions   Goal  for  manufactured  emotions  

 Choosing  index  traumatic  event   Practice  Assignment:  Impact  Statement  

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SESSION  2.  IMPACT  STATEMENT   Goal:  Client  examines  the  impact  of  the  traumatic  event  on  their  lives.    

 Help  identify  stuck  points  in  statement   Ask  about  other  areas  that  were  not  touched  upon   Highlight  connection  between  thoughts  and  feelings  

 Introduce  ABC  Sheets   Practice  Assignment:  ABC  Sheets,  Stuck  Point  Log  

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.    

A-B-C Sheet���

ACTIVATING EVENT BELIEF CONSEQUENCE

A B C ��� “Something happens” “ I tell myself something” “I feel something”

       

      

       

  Is it reasonable to tell yourself “B” above? _______________________________________________________________________ _______________________________________________________________________ What can you tell yourself on such occasions in the future? ____________________ _____________________________________________________________________________

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SESSION  3.  EVENTS,  THOUGHTS  &  EMOTIONS  

 Goal:  Client  learns  to  recognize  relationship  between  event/thought/emotion  and  to  work  through  stuck  points  

 Review  A-­‐B-­‐C  sheets.   Using  Socratic  questions,  help  Client  generate  alternative  thoughts  and  consequent  feelings.  

 Gently  begin  to  challenge  undoing  or  self-­‐blame  statements.  

 Practice  Assignment:  Written  Account/ABC  sheets  

SOCRATIC  QUESTIONS  

Clari?ication  “What  do  you  mean  when  you  say…?”  Probing  Assumptions  “How  did  you  come  to  this  

conclusion?”  Probing  Reasons  and  Evidence  “Would  these  reasons  

stand  up  in  a  reputable  newspaper/  court  of  law  as  evidence?”  

Questioning  Viewpoints  and  Perspectives  “What  alternative  ways  of  looking  at  this  are  there?”  

Analyzing  Implications  and  Consequences  “Then  what  would  happen?  What  would  it  mean  if  you  gave  up  that  belief?”  

Questions  About  the  Question  “What  is  the  point  of  asking  that  question?”  

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SESSION  4.  FIRST  ACCOUNT   Goal:  Client  uses  the  account  to  process  natural  emotions  and  also  continue  identifying  and  working  through  stuck  points  

 Client  reads  account  aloud  to  therapist.   After  Client  reads  account,  Client  and  therapist  discuss  reactions  to  writing  it/reading  it.  

 First  work  on  emotions.  Sit  with  them,  name  them.  

 Then  therapist  gently  challenges  self-­‐blame  and  hindsight  bias.  

 Practice  Assignment:  Rewrite  Account  

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SESSION  5.  SECOND  ACCOUNT   Goal:  Client  uses  the  2nd  account  to  process  natural  emotions  and  also  continue  identifying  and  working  through  stuck  points  

 Client  reads  second  account  of  incident.   Client  and  therapist  continue  to  process  any  remaining  self-­‐blame  or  undoing.  

 Therapist  introduces  Challenging  Questions  Worksheet.  

 Practice  Assignment:  CQWs  

Challenging    Questions        1.  What  is  the  evidence  for  and  against  this  belief?  2.  In  what  ways  does  this  belief  confuse  a  habit  with  a  fact?        3.  In  what  ways  does  your  belief  distort  what  really  happened?        4.  In  what  ways  might  you  be  thinking  in  all-­‐or-­‐none  terms?        5.  What  types  of  exaggerated  or  extreme  words  or  phrases  are  you  using  in  this  belief?      

6.  In  what  ways  does  this  belief  take  selected  examples  out  of  context?    

 7.  What  types  of  excuses  might  you  be  making?  How  are  you  being  dishonest  with    yourself?    

 8.  How  reliable  is/are  the  source(s)  of  information?        9.  Is  this  belief  a  certainty  or  a  probability?  How  so?    10.  In  what  ways  might  you  be  confusing  a  low  probability  with  a  high  probability?  

 11.  In  what  ways  is  the  belief  based  on  feelings  rather  than  facts?    12.  In  what  ways  is  this  belief  focusing  on  irrelevant  factors?  

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SESSION  6.  CHALLENGING  QUESTIONS   Goal:  Client  learns  how  to  challenge  stuck  points   Client  and  therapist  review  Challenging  Questions  Worksheets  to  question  single  statements  or  beliefs.  

 Therapist  introduces  Patterns  of  Problematic  Thinking  Sheet  to  see  if  there  are  typical  patterns  of  cognition.  

 Practice  Assignment:  CQWs  &  Problematic  Patterns  Sheets  

Patterns  of  Problematic  Thinking  1.  Jumping  to  conclusions:  2.  Exaggerating  or  minimizing:  3.  Disregarding  important  aspects:  4.  Oversimplifying:  5.  Over-­‐generalizing:  6.  Mind  reading:  7.  Emotional  reasoning:  

 

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SESSION  7.  PROBLEMATIC  PATTERNS   Goal:  Client  continues  to  learn  skills  to  help  them  identify  and  challenge  stuck  points  and  patterns  of  maladaptive  thinking  

 Client  and  therapist  review  Patterns  of  Problematic  Thinking.  

 Therapist  introduces  Challenging  Beliefs  Worksheets.  

 Therapist  introduces  the  Xirst  of  5  modules:  Safety.   Practice  Assignment:  CBWs  and  read  Safety  module  

Column A Column B Column C Column D Column E Column F Situation Automatic Thoughts Challenging your

automatic thoughts Disruptive Thinking

Patterns Alternative Thoughts Decatastrophizing

Describe the event leading to the unpleasant emotion(s).

Write automatic thought or belief that precedes your emotion(s). Rate belief in each automatic thought(s) below from 0-100%.

Use the Challenging Questions sheet to examine your automatic thought or belief from Column B.

Use the Disruptive Thinking Patterns sheet to challenge your automatic thought or belief from Column B.

What else can I say instead of Column B? How else can I interpret the event instead of Column B? Rate belief in alternative thought(s) from 0-100%.

What’s the worst that could ever realistically happen based upon this event and/or belief? I could get hurt by someone.

I was hurt by the trauma.

Something must be wrong with me that I am still bothered by this. 70%

Emotions Specify sad, angry, etc., and rate the degree you feel each emotion from 0-00%. Sad 75% Scared 50%

Evidence for: There is no evidence that something is wrong with me. Evidence against: I don’t see anything wrong with other combat survivors, even if they are upset by the trauma Habit or fact?: Because of how others have treated me throughout my life it is a habit to blame myself. Reliable source?: The people who told me the trauma was all my fault are not a reliable source of information!

Disregarding important aspects of the situation: I am ignoring the fact that lots of people are upset by their traumatic experiences

It is normal to feel upset by experiencing traumatic events 70%

Even if that happened, what could I do? I can remind myself that I am worthwhile and that there are others in my life who believe this also.

Outcome

Rerate how much you believe the automatic thought(s) or belief in Column B from 0-100% 30% Specify and rate subsequent emotion 0-100%. Sad 40% Scared 10%

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SESSION  8.  CBW  AND  SAFETY   Client  and  therapist  review  challenging  belief  worksheets.  

 Client  and  therapist  discuss  safety  issues.  

 Therapist  introduces  Trust  module.   Practice  Assignment:  CBWs  and  read  Trust  Module  

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SESSION  9.  CBW  AND  TRUST   Client  and  therapist  review  practice  on  trust  issues  and  other  completed  Challenging  Beliefs  Worksheets.  

 Therapist  introduces  Power/Control  module.  

 Practice  Assignment:  CBWs  and  read  Power/Control  module    

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SESSION  10.  CBW  AND  POWER  AND  CONTROL  

 Client  and  therapist  review  control/power  issues  and  other  Challenging  Beliefs  Worksheets  

 Therapist  introduces  Esteem  module.   Practice  Assignment:  CBWs,  read  Esteem  module,  practicing  giving  and  receiving  compliments/praise,  pleasurable  activity  

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SESSION  11.  CBW  AND  ESTEEM   Client  and  therapist  review  esteem  issues  and  other  Challenging  Beliefs  Worksheets.  

 Client  and  therapist  review  other  practice.  

 Therapist  introduces  Intimacy  module.   Practice  Assignment:  CBWs,  read  Intimacy  module,  and  rewrite  impact  statement  

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SESSION  12.  INTIMACY  AND  FINAL  IMPACT  

 Client  and  therapist  review  Challenging  Beliefs  Worksheets  on  intimacy  

 Client  reads  new  Impact  Statement   Client  and  therapist  review  course  of  therapy  and  skills  learned  

 Client  and  therapist  identify  future  goals  and  issues  which  still  need  attention  

FINAL  THOUGHTS          What  is  the  risk  of  not  doing  an  Evidence  

Based  Treatment  for  PTSD?      

Instead  of  thinking  of  “My  client  can’t  do  CPT  because...”  Try,  “What  does  my  client  need  to  increase  their  chances  of  success  with  CPT?”  

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  Xirst  step  would  be  to  call  the  Mental  Health  Access  Clinic  at  503-­‐220-­‐8262  x56409.    A  screening  interview  will  be  required  as  a  condition  of  admission.      

 

REFERENCES  

 Karlin,  et.  al    Dissemination  of  Evidence-­‐Based  Psychological  Treatments  for  Posttraumatic  Stress  Disorder  in  the  Veterans  Health  Administration.  Journal  of  Traumatic  Stress  V.  23,  No.  6,  December  2010.  

  Cognitive  Therapy  for  Posttraumatic  Stress  Disorder  by  Shipherd,  Street,  and  Resick  in  Chapter  5  of  Cognitive-­‐Behavioral  Therapies  for  Trauma,  Second  Edition  by  Victoria  M.  Follette  PhD  and  Josef  I.  Ruzek  (2007)    

Ashlee  Whitehead,  LPC,  CADC  Licensed  Professional  Counselor,  PTSD  Clinical  Team  

Military  Sexual  Trauma  (MST)  Coordinator  Portland  VA  Medical  Center    

3710  SW  US  Veterans  Hospital  Rd.  Portland,  OR  97239  

Ph:  503.220.8262  Ext.  57429  Ashlee.Whitehead@va.gov