1. Contemporary Mental Health Treatment For Returning Veterans
Portland State University
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

2. 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-efficacy
Client participation and interest

3. Implementation of VHA MH Strategic Plan (2006)
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

4. 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 confidence levels increase pre to post training
Case studies and first hand clinical experience demonstrate significant positive clinical impact on veterans who receive EBPs

5. Increasing positive outcomes w/EBPs
Therapist Self-Efficacy!
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

6. 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 fit veteran/military population (Resick, Monson, Schnurr).

7. 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.
PTSD as a disorder of non-recovery: A perspective of PTSD as a “stalling-out” of the normal trauma-recovery process rather than the development of a unique psychopathology. This perspective is based on the evidence that PTSD symptoms are nearly universally observed immediately following serious traumatic stressors, with most individuals achieving recovery over the course of several months. Those who remain symptomatic after several months are considered to have stagnated in this normal recovery process and can be diagnosed with PTSD.

8. Cognitive Processing Therapy (CPT) for PTSD STRUCTURE 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 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
So in order to reduce all of those distressing natural emotions in PTSD (like fear, anger, sadness) we work as a team with Clients to help them stop avoiding those feelings and allow them to run their normal course.
We also pay very close attention to what people are telling themselves that results in manufactured emotions like shame, guilt, etc. Together, with our trauma survivors, we challenge any thoughts that we decide are inaccurate (remember that we called these stuck points?) and come up with more accurate thoughts. Once a more adaptive, accurate thought is embraced, then the manufactured emotion disappears (if I am no longer blaming myself, I no longer feel guilty).
We target those assimilated stuck points of self-blame and undoing early on in therapy and then move on to the over-accommodated beliefs in the later stages of CPT.

9. 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

10. Cognitive Processing Therapy (CPT) for PTSD
5 major dimensions that may be disrupted by traumatic events:
Safety
Trust
Power and Control
Esteem
Intimacy
5 CPT Themes: Five general themes of over-accommodation specifically are addressed in the last 5 sessions of the CPT protocol. Each session includes psychoeducation, where a theme is discussed in relation to self and others, and a theme-related practice assignment. Specific theme-related stuck points are identified and targeted for practice assignment and in-session work.
• Safety – Beliefs regarding one’s own ability to control events and protect self/others from harm and the dangerousness/harmful intentions of others.
• Trust – Adopting a healthy balance of trust and mistrust. This includes both trust of one’s own perceptions/judgments and the reliability of other’s promises, intentions, and behavior.
• Power/Control – Beliefs of one’s own capability to meet challenges as well as the ability to maintain power and control outcomes in the context of interpersonal relationships. This also includes the extent to which others have control over one’s life.
• Esteem – Perspectives of self-worth and the worth of others. This includes personal needs of being understood and respected as well as fostering realistic views, and challenging rigid/stereotypical views, of others.
• Intimacy – Fostering of self-intimacy (the ability to soothe oneself and be alone without feeling lonely or empty) and ability to connect with others. This also focuses on the innate human desire for closeness with others.

11. 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

12. 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

13. 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.

14. 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? ____________________
_____________________________________________________________________________

15. 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

16. SOCRATIC QUESTIONS
Clarification “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?”

17. 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

18. 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

19. Challenging Questions 1
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?

20. 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

21. 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:

22. 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 first of 5 modules: Safety.
Practice Assignment: CBWs and read Safety module

23. Challenging your automatic thoughts Disruptive Thinking Patterns
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 %
Scared %
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
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 %
Scared %

24. 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

25. 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

26. 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

27. 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

28. 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

29. What is the risk of not doing an Evidence Based Treatment for PTSD?
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?”

30. 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
Eligibility/Enrollment (503) , ext
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 x A screening interview will be required as a condition of admission.

31. 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
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)

32. 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 Ph: Ext