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An Introduction to Cognitive Processing Therapy (CPT)

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Telsie Davis

on 25 May 2015

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Transcript of An Introduction to Cognitive Processing Therapy (CPT)

Empirical Support for CPT
Whose appropriate for CPT?
PTSD & Sub-threshold PTSD
all types of traumatic events
3months to 60 years post-index trauma
4th grade education and IQ of 75
PTSD with comorbid disorders (MDD, Anxiety)

CPT has been implemented after clinical consideration for:
Co-morbid Substance Use Disorders
Co-morbid Borderline Personality Disorder

Exclusion Criteria:
treatment-interfering comorbidities and circumstances

How CPT Works
Dissipation of natural emotions
Changing manufactured emotions
Eliminating over-generalization (i.e. assimilation and over-accommodation) which leads to avoidance and maintains PTSD

Remembering the Trauma
Have patient
read trauma account
and express emotions
Identify and begin challenging assimilation stuck points (i.e., self-blame and hindsight bias)
Review ABC worksheets
Assign 2nd Trauma Account
Continue with ABC worksheets for CPT-C

Session 6:
Review the Challenging Questions Worksheets (CQW)
Continue to identify and challenge stuck points
Introduce and assign the
Patterns of Problematic Thinking Worksheet

Session 7:
Review the Patterns of
Problematic Thinking (PPT) worksheet
Introduce the
Challenging Beliefs Worksheet
Introduce the Safety Module

An Introduction to
An Introduction to CPT for PTSD
An Introduction to CPT for PTSD
Founder & Director of The Davis Center, LLC
Presented by
Telsie A. Davis, PhD
is a gold standard, evidence-based treatment for Posttraumatic Stress Disorder (PTSD)
is a short-term, manualized COGNITIVE-behavioral therapy
is a "how to" intervention for helping clients recover from their trauma
CPT Formats
(with exposure)
cognitive only
CPT has a recovery focus
PTSD is a disorder of non-recovery
Natural decline of PTSD symptoms over time
Common Therapist Barriers to CPT
(Addis, Wade, & Hatgis, 1999)
1. Effect on working alliance
2. Unmet client needs
3. Competence and job
4. Treatment credibility
5. Restriction of clinical
6. Feasibility of manualized

“Changing your mind can change your body.”
(Keller et al., 2012)

“Your body believes you.”
(Jamieson et al., 2013)

Clients are expected to recover from PTSD
Clients are expected to become their own therapist
People typically do not get worse!
CPT believes clients can get better and stay better even after treatment because they become their own therapist.
Identifying Stuck Points
Stuck points are thoughts that keep the client STUCK in PTSD.

They are NOT 100% accurate but are believed by the client to be 100% true.

These beliefs are typically negative and over-generalized.
CPT and Cognitive Theory
Beliefs help us understand, predict, and control
“Just World Belief”
Other belief paradigms: Strong Black Woman and Warrior ethos
Beliefs hold if no contradictory information
Trauma disputes or confirms previous beliefs
Integrating trauma leads to cognitive errors

When should CPT protocol begin?
New patient
1-3 pre-treatment sessions
Depends on cultural and clinical context

Established patient
when no significant improvement for some time, good time to reassess
explain rationale for changing treatments
explain how new protocol differs from the old

Functional Model of PTSD
CPT and Emotions
Natural Emotions
Emotions any one would feel following an event.
Lose a loved one: grief. Physically assaulted: fear. Mistreated: anger.
CPT Goal:
allow client to feel these emotions so they will resolve

Manufactured Emotions:
Emotions that stem from the interpretation of an event.
I didn't fight enough: shame. I should have been the one to die: guilt.
CPT Goal:
change the cognitions that are manufacturing the emotions.

CPT Pre-Treatment Tasks
Goal: Preparing the client for treatment
CPT Session 2: Meaning of the Event
Process Impact Statement & Identify stuck points (do not challenge)
Review CPT rationale and Session 1 content (if needed)
Educate about connection between thoughts and feelings
Introduce ABC Worksheets
Session 1: Introduction & Education
Develop positive working alliance
Educate about PTSD symptoms and depression
Give rationale for cognitive treatment of PTSD
Elicit treatment compliance
Assign stuck point log
Identification of Thoughts and Feelings
Primary Tasks of Session 3
Review ABC worksheets
Introduce 'changing thoughts can change intensity of emotions'
Use Socratic Questioning to gently challenge self-blame and guilt (i.e. assimilated stuck points)
Assign first trauma account
Continue with ABC worksheets

Second Trauma Account
Have patient read 2nd trauma account
for continued processing of natural emotion and addressing assimilation stuck points (self-blame, hindsight, or thought of undoing)
Introduce the Challenging Questions Worksheets
(CQW) to help client begin to challenge their own thinking using Socratic questions
Assign another trauma account if needed
Introduce CQWs for CPT-C
Session 10:
Review Challenging Beliefs Worksheets on Power and Control.
Introduce Esteem Module.
Assign daily practice of giving and receiving compliments and doing at least one nice thing for self each day.

Session 9: Trust Issues
Review Challenging Beliefs Worksheets on self- and other-trust
Introduce the Power and Control module

Session 8: Safety
Review Challenging Beliefs Worksheets
Review the Safety Module
Introduce the Trust Module and the concepts of self- and other-trust

Session 11: Esteem
Review the Challenging Beliefs Worksheets on esteem and other topics.
Review the compliments and self-care client has experienced
Introduce Self- and Other-Intimacy module
Assign new Impact Statement

Therapeutic Challenges
& Questions
Client notes they understand cognitively but are having difficulty managing their emotions
Client reports they are not ready to end treatment
Clients fail to bring their homework to last session
Other questions?
Randomized Controlled Trials
• Resick et al., 2008 (Index trauma: rape and physical assault)
• Resick et al., 2012 (Index trauma: Rape)
• Galovski et al., 2012 (Index trauma: Sexual and physical assault)
• Suris et al., 2012 (Index trauma: Military Sexual Trauma)
Recent RCTs
CPT in the Congo
Bass et al., 2013
Congolese survivors of sexual violence
7 villages (157 women) given CPT
8 villages (248 women) given individual support
Providers had HS education
Assessment at baseline, post-tx, 6 mos f/u
CPT Dismantling Study
Patricia A. Resick, Lauren Williams, Robert Orazem, Cassidy Gutner
ISTSS & ABCT, Nov., 2005

Long-Term Follow-up of CPT
successful avoidance

= chronic PTSD
very successful avoidance = chronic sub-threshold PTSD

Fight-Flight-Freeze Response
PTSD symptoms
How avoidance maintains PTSD
Why CPT & other EBTs for PTSD work
changing interpretations about trauma to fit beliefs, focused on past
change beliefs to the extreme to make sense of the trauma, focused on present and future
Accommodation:Healthy Recovery
Flexibly including the trauma into belief system.

"Bad things sometimes happen to good people."
"Good people make mistakes."
"I have power over many things but not all things."

A survivor believed she was basically a good person, living right and being fair to people. After she was raped, she made sense of the trauma through the thought, “I must have done something to deserve this… I must’ve gave off some signals or sent him the wrong message… the dress I was wearing was way to short.”
Assimilation or Over-accommodation?
A survivor of Hurricane Katrina had low self-esteem prior to the storm. He believed, “When bad
things happen to me, it’s because I didn’t do something right!” When he lost everything as a result of Katrina, he made sense of it all by stating, “I deserved it!”
Assimilation or Over-accommodation?
A trauma survivor had prior beliefs that the world is safe and that people can be trusted. After being physically assaulted by a romantic partner, he concluded, “People will betray you! – You can’t trust anyone!”
Assimilation or Over-accommodation?
A woman experienced childhood sexual abuse and grew up believing that the world was a dangerous place. Sexually assaulted later in life, this survivor said, "I knew all men were dangerous, and this is more evidence I was right!"
Assimilation or Over-accommodation?
Not a stuck point:

Why not?

This is a concept,
not a thought. I
dentify what the person thinks about trust. You might ask him/her what about ‘trust’ is a problem.

Possible related stuck points:
“I can’t trust anyone.” “If I let anyone get close to me, I will get hurt.” “I can never trust my judgment.”

Not a stuck point:
“I fight with my daughter all the time.”

Why not?

This is describing a behavior,
not a thought.
Identify what the person was thinking before, during, and after the occurrence.

Possible related stuck points:
“I don’t mean anything to her.” "I'm unlovable."

Not a stuck point:
“I feel lonely.”

Why not?

This is describing a feeling,
not a thought. You can ask the client what they are telling themselves that makes them feel that way in order to help them identify potential stuck points.

Possible related stuck points:
“If I go on a date, I will get hurt.” “All relationships end up hurting you.”

Make sure the stuck point is one concise thought
Put statement into the “If…., then…” format and have the client fill in the blank
Stuck points are hard to challenge when vague. Make more specific by asking, “How did you come to this conclusion?
Good Stuck Point Structure:
Phases of CPT Treatment
(assessment and pre-treatment issues)
Education regarding PTSD, thoughts, and emotions
(Sessions 1 – 3)
Processing the trauma
(Sessions 4 – 5)
Learning to challenge
(Sessions 6 – 7)
Addressing trauma themes – safety, trust, power/control, esteem, and intimacy
(Sessions 8 – 12)
Facing the future
(Session 12 and one-month follow-up session)
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

CPT Individual Sessions
Identify index trauma
Assessment of PTSD and other co-morbid conditions
Describe CPT rationale
Get client buy-in
CPT Treatment Contract
Discuss the structure of CPT Sessions
Getting client ready for treatment.
(SESSIONS 1 – 3)

Cognitive Theory of PTSD (CPT Rationale)
Why they have PTSD and how it will be treated.
Discussion Questions

• In what way did the therapist explain cognitive theory that was simple for patients to understand?

• What analogies or words did she use that were particularly helpful?

• How would you handle a client who is not on board?

Assign Impact Statement for Homework
“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. Bring this with you to the next session. Also, please read over the handout I have given you on stuck points so that you understand the concept we are talking about.”

Impact Statement
“The overall feeling of what it means to have been sexually assaulted is that I must be bad or a bad person for something like that to happen. I do believe in karma and what goes around comes around. I think it happened because I was being too friendly and let him get too close to me. The truth is I was drunk, and that’s why I it happened. I don’t feel safe because if it could happen with somebody I trusted, it could happen again to me. I shouldn’t have trusted him. He took away my dignity. I do not trust people and I only feel completely safe at home. I don’t trust myself to get in relationships because I make wrong judgments about people. I see myself as damaged and believe I will be alone forever. But I rather that than being hurt again.”
Impact Statement
“The overall feeling of what it means to have been sexually assaulted is that I must be bad or a bad person for something like that to happen. I do believe in karma and what goes around comes around. I think it happened because I was being too friendly and let him get too close to me. The truth is I was drunk, and that’s why I it happened. I don’t feel safe because if it could happen with somebody I trusted, it could happen again to me. I shouldn’t have trusted him. He took away my dignity. I do not trust people and I only feel completely safe at home. I don’t trust myself to get in relationships because I make wrong judgments about people. I see myself as damaged and believe I will be alone forever. But I rather that than being hurt again.”
1st Trauma Account Assignment
“Please begin this assignment as soon as possible. Write a full account of the traumatic event and include as many sensory details (sights, sounds, smells, etc.) as possible. Also, include as many of your thoughts and feelings that you recall having during the event. Pick a time and place to write so you have privacy and enough time. Do not stop yourself from feeling your emotions. If you need to stop writing at some point, please draw a line on the paper where you stop. Begin writing again when you can, and continue to write the account even if it takes several occasions.“ Read the whole account to yourself every day until the next session. Allow yourself to feel your feelings. Bring your account to the next session.
Also, continue to work with the A-B-C Worksheets every day.”

Socratic Questioning
A disciplined form of questioning that guides the client in analyzing and drawing conclusions about their thinking.
Evaluate those consequences:
‘What’s the effect of thinking or believing this? What could be the effect of thinking differently and no longer holding onto this belief?’
"I will stay by myself and be alone forever."
‘Imagine a loved one in the same situation or if they viewed the situation this way, what would you tell them?’ "
It wasn’t their fault, the man was just a bastard!"
Conceiving reasonable alternatives:
‘What might be another explanation or viewpoint of why the trauma happened? What other reason might there be for why he raped you?
“He was a bastard!”
Synthesizing Questions:
“How does what you now say about why you were raped influence your thinking that ‘if you are friendly, people will hurt you’”?

So not all people?.
“No. Just the bastards.”
Statement: “I don’t feel safe”
Possible Stuck Point: “If you are friendly, people will hurt you.”
Possible Alternative Belief:
“If you are friendly, bastards will hurt you.”

Judith Beck, 1995, Pendensky, 1993)
(SESSIONS 4 – 5)
Session 4 Assignment
“Write the whole incident again as soon as possible. If you were unable to complete the assignment the first time, please write more than last time. Add more sensory details, as well as your thoughts and feelings during the incident. Also, this time write your current thoughts and feelings in parentheses (e.g., “I’m feeling very angry”). Remember to read over the new account every day before the next session.
Also, continue to work with the A-B-C Worksheets every day.”

Therapeutic Challenges
Client reports increased symptoms
Client refusing to read the trauma account
Therapist avoidance
The client does not read the Trauma Account with emotion
The client shuts down in the middle of reading the Trauma Account
The therapist becomes overwhelmed with emotion

Session 5 Assignment
Please choose one stuck point each day and answer the questions on the Challenging Questions Worksheet with regard to each of these stuck points. If you have not finished your accounts of the traumatic event(s), please continue to work on them. Read them over before the next session and bring all of your worksheets and Trauma Accounts to the next session.”

(SESSIONS 6 – 7)

Session 6 Assignment
“Consider the stuck points you have identified thus far and find examples for each of the problematic thinking patterns listed on the worksheet in your day to day life (or over the course of the next week). Look for specific ways in which your reactions to the traumatic event may have been affected by these habitual patterns.
Continue reading your accounts if you still have strong emotions about them.”

If PTSD symptoms have not significantly decreased, this may indicate the core conflict has yet to be resolved.
Continue to work on index trauma using CQW
Review PTSD scale to see which symptoms are still most problematic
Check on content nightmares and/or other intrusions for clues about where patient might be stuck
Therapeutic Challenges
Safety Module
Beliefs related to self:
Belief you can protect yourself from harm and have some control over events
Associated symptoms
: anxiety, intrusive thoughts about danger, irritability, hyperstartle, intense fears about future dangers

Beliefs related to others:
Belief abut dangerousness of other people and expectancies about the intent of others to cause harm, injury, or loss
Associated symptoms:
avoidant or phobic responses, social withdrawal

SAFETY stuck points:
I cannot protect myself/others.
The world is completely dangerous.

Challenging safety is largely about weighing mathematical probabilities
(SESSIONS 8 -12)

Introducing the Themes
For the next 5 sessions we will consider themes that may reflect areas of your life affected by the traumatic event.
Each session, I’ll ask you to consider your beliefs prior to the trauma and after.
If WE decide any theme represents stuck points for you, I will ask you to complete CBWs to begin changing your thinking.
The 5 themes are safety, trust, power & control, esteem, and intimacy.
Each theme can be considered from two directions - how you view yourself and how you view others.
The first topic we'll discuss is Safety.
Session 7 Assignment
“Use the Challenging Beliefs Worksheets to analyze and confront at least one of your stuck points each day. Please read over the module on safety and think about how your prior beliefs were affected by the [event]. If you have safety issues related to yourself or others, complete at least one worksheet to confront those beliefs. Use the remaining sheets for other stuck points or for distressing events that have occurred recently.”
Beliefs related to self:
Belief you can trust or rely upon one’s own perceptions or judgments. Important part of self-concept and serves important self-protection function.
Associated symptoms:
include feelings of self-betrayal, anxiety, confusion, overcautious, inability to make decisions, self-doubt.

Beliefs related to others:
Belief that the promises of other people or groups with regard to future behavior can be relied upon.
Associated symptoms:
include disillusionment, fear of betrayal, anger and rage, suspiciousness, fleeing from relationships.

TRUST stuck points:
I don't trust myself to judge people's character.
Men cannot be trusted.

Trust Module
Beliefs related to self:
Belief you can trust or rely upon one’s own perceptions or judgments. Important part of self-concept and serves important self-protection function.
Associated symptoms:
include feelings of self-betrayal, anxiety, confusion, overcautious, inability to make decisions, self-doubt.

Beliefs related to others:
Belief that others have more control than you do; that others have power or attempt to control you.
Associated symptoms:
include passivity, submissiveness, lack of assertiveness, or conversely, anger, controlling behavior.

POWER/CONTROL stuck points:
I must be in control at all times.
I am helpless to control anything.
Session 8 Assignment
“Please read the Trust Module and think about your beliefs prior to experiencing [the event] as well as how the event changed or reinforced those beliefs. Use the Challenging Beliefs Worksheets to continue analyzing your stuck points. Focus some attention on issues of self or other-trust, as well as safety, if these remain important stuck points for you.”

Power/Control Module
Session 9 Assignment
“Use the Challenging Beliefs Worksheets to continue to address your stuck points. After reading the Power/Control Module and thinking about it, complete worksheets on this topic.”

Beliefs related to self:
Belief in your own worth. Being understood, respected, and taken seriously is basic to the development of self-esteem.
Associated Symptoms:
include depression, guilt, shame, self-destructive behavior.

Beliefs related to others:
Beliefs about other people that match the reality of the other person and are revised as new information is received.
Associated Symptoms:
anger, contempt, bitterness, cynicism, isolation or withdrawal, antisocial behavior.

ESTEEM stuck points:
I was such a freakin' weakling!
People, by nature are only out for themselves.
Esteem Module
Session 10 Assignment
“After reading the Esteem Module, use the worksheets to confront stuck points regarding self- and other-esteem. In addition to the worksheets, practice giving and receiving compliments during the week and do at least one nice thing for yourself each day (without having to earn it). Write down on this sheet what you did for yourself and who you complimented.”
Intimacy & Meaning of Trauma
Beliefs related to self:
Self-intimacy is ability to soothe and calm oneself. Reflected in the ability to be alone without feeling lonely or empty.
Associated symptoms:
include inability to comfort or soothe self, fear of being alone, feeling of inner emptiness or deadness, use of external sources of comfort, needy or demanding relationships.

Beliefs related to others:
Need for intimacy, connection, and closeness to others is a basic human need.
Associated symptoms:
include loneliness, emptiness or isolation, inability to connect with others.

INTIMACY stuck points:
There is no way I can be sober and deal with this.
People will always let you down.

Intimacy Module
Session 11 Assignment
“Use the Intimacy Module and Challenging Beliefs Worksheets to confront stuck points regarding self- and other-intimacy. Continue completing worksheets on previous topics that are still problematic. Please write at least one page on what you think now about why this traumatic event(s) occurred. Also, consider what you believe now about yourself, others, and the world in the following areas: safety, trust, power/control, esteem, and intimacy.”

Review Challenging Beliefs Worksheets on intimacy.
Have client read final Impact Statement
Therapist reads original Impact Statement; compare the two statements
Review course of treatment and gains made
Identify future goals for client as they are taking over as own therapist
Schedule follow-up session
Instill the notion of episodes of care

Web-based Learning Course
All CPT handouts
National Center for PTSD free information for professionals and researchers http://www.ptsd.va.gov/professional/continuing_ed/index.asp
Request Assessment instruments like (e.g., CAPS, PCL for DSM5)

CPT and other evidence-based treatments work by having clients learn they can tolerate and control their emotions which leads to a reduction of avoidance.
Cognitive Processing Therapy
(w/o exposure)
Licensed Psychologist at Atlanta VAMC in Trauma Recovery Program
Assistant Professor, Emory University SOM, Dept. of Psychiatry & Behavioral Sciences
Resick et al., 2008
CPT has been successfully implemented with:
E.g., “I trust no one” can be refined to “If I trust others, then I’ll get hurt.”
symptom measurement
review of assigned practice
New session content and assignment (begin new assignment in session and problem solve barriers to assignment)
Primary Tasks of Session 1:
Primary Tasks of Session 2
Session 3:
Session 4:
Informational Questions:
What do you mean when you say that? How does that influence how you interact with people?
“I don’t talk to people.”
Clarifying Questions:
How are you safer if you don’t talk to people?
“They won’t get close to me and so can’t hurt me.”
Revealing the issue:
‘What evidence supports this idea? And what evidence is against its being true?’
“I befriended this guy and he raped me.”
Summarizing Questions:
“Do you feel that if you are friendly with people they will hurt you?”
Primary Tasks of Session 4 (CPT)
2nd written trauma account
Session 5:
Primary Tasks of Session 5 (CPT)
CPT and CPT-C merge at this session
Primary Tasks of Session 6
Primary Tasks of Session 7
Patterns of Problematic Thinking
Challenging Questions
Primary Tasks of Session 8
Primary Tasks of Session 9
Primary Tasks of Session 10
Primary Tasks of Session 11
Session 12:
Primary Tasks of Session 12
1. The final five sessions are similar to each other.
2. Primary tasks include a review of the CBW for challenging and correcting problematic thoughts related to each theme.
3. Therapist will introduce a new theme in each session.
Therapeutic challenge
: client reports that not all themes are relevant for them

Sell me this pen.
What if I need a pencil?
Culturally Competent Treatment
“Culture is a shared, acquired pattern of values, attitudes, beliefs, and schemata that consciously and non-consciously shape people’s identities and behaviors.” (Brown, 2008, p.153)
Adapts interventions to: (1) address cross-cultural interactions and (2) meet the culturally unique needs of the client (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003).
Cultural Competency
the question to ask:
What influence might their cultural identity have on their response to trauma?
Culturally Salient Issues
50yo Latina, Christian, Lesbian
divorced, with 2 adult children, was raped at the age of 18, after having just joined the military against the wishes of her mother and church. After she was raped, she made sense of the trauma by thinking, “I'm being punished for disobeying my mother and going against the church... I deserved this… the dress I was wearing was way to short.”
62yo White Evangelical Male,
working class, married 35 years, 3 adult children survived a gang rape and physical abuse in his early 20s during basic training. Years later would profile men and if they looked liked his attackers, he would imagine sexually brutalizing them in the manner he had been. At the VA he was labeled as aggressive and braggadocious about his fearlessness. However, his imaginations distressed him and he tearfully reported thinking, "I did things with men so I must be gay.”

57yo African American married woman
with 3 children survived childhood physical abuse, sexual assault in college and by a white officer in service. She is having interpersonal problems at work and being denied promotions. She attributed this to not socializing with co-workers or revealing anything personal about herself to her manager, stating, “You can’t trust anyone!” She presented to treatment and was labeled hostile.
Culture Counts!
Power & Control
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