Contemporary Mental Health Treatment For Returning Veterans
Portland State University
CONTINUED EXPLORATION OF EVIDENCEBASED TREATMENTS FOR PTSD
COGNITIVE PROCESSING THERAPY
ASHLEE WHITEHEAD, LPC, CADC
CERTIFIED CPT PROVIDER
PTSD CLINICAL TEAM
PORTLAND VA MEDICAL CENTER
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
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 confidence levels increase pre to post
training
 Case studies and first hand clinical experience
demonstrate significant positive clinical impact on
veterans who receive EBPs

INCREASING POSITIVE OUTCOMES W/EBPS
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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
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).
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
Individual CPT
Group CPT
• 12 x 50-minute structured
sessions
• Participants complete outof-session practice
assignments
• Sessions typically
conducted weekly or biweekly
• Includes a brief written
trauma account along with
ongoing practice of
cognitive techniques
• 12 x 90-120 minute
structured sessions
• Participants complete outof-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
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
THE ESSENTIAL INGREDIANTS
 The
Impact of the Event
 Identifying
Stuck Points
 Identifying
and resolving assimilated beliefs
 Challenging
beliefs.
 Use
and balancing overaccomodated
of Socratic Questioning
 Processing
trauma
natural emotions related to the
COGNITIVE PROCESSING THERAPY (CPT) FOR PTSD
5 major dimensions that may
be disrupted by traumatic
events:
1)
2)
3)
4)
5)
Safety
Trust
Power and Control
Esteem
Intimacy
SESSION 1. PTSD SYMPTOMS AND RATIONALE
Types
of emotions
 Goal for manufactured emotions
Choosing
index traumatic event
Practice Assignment: Impact
Statement
11
 Goal for natural emotions
SESSION 2. IMPACT STATEMENT
 Goal:
12
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
A
“Something happens”
BELIEF
B
“ I tell myself something”
CONSEQUENCE
C
“I feel something”
Is it reasonable to tell yourself “B” above?
_______________________________________________________________________
_______________________________________________________________________
What can you tell yourself on such occasions in the future? ____________________
_____________________________________________________________________________
SESSION 3. EVENTS, THOUGHTS & EMOTIONS
 Goal:
15
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 selfblame statements.
 Practice Assignment: Written Account/ABC
sheets
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?”
SESSION 4. FIRST ACCOUNT
 Goal:
17
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
SESSION 5. SECOND ACCOUNT
 Goal:
18
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?
SESSION 6. CHALLENGING QUESTIONS
 Goal:
20
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:
SESSION 7. PROBLEMATIC PATTERNS

Goal: Client continues to learn skills to help them identify
and challenge stuck points and patterns of maladaptive
thinking
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
22
 Client
Column A
Column B
Situation
Automatic Thoughts
Write automatic
thought or belief that
precedes your
emotion(s).
Rate belief in each
automatic thought(s)
below from 0-100%.
Describe the event
leading to the
unpleasant
emotion(s).
I was hurt by the
trauma.
Column C
Column D
Column E
Column F
Challenging your
automatic thoughts
Disruptive Thinking
Patterns
Alternative Thoughts
Decatastrophizing
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.
Evidence for:
There is no
Something must
be wrong with me evidence that
something is wrong
that I am still
bothered by this. with me.
Evidence against:
70%
I don’t see anything
wrong with other
combat survivors,
even if they are
upset by the
trauma
Emotions
Specify sad, angry,
etc., and rate the
degree you feel
each emotion from
0-00%.
Sad
Scared
75%
50%
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
Scared
40%
10%
SESSION 8. CBW AND SAFETY
Client
 Practice
Module
Assignment: CBWs and read Trust
24
and therapist review challenging
belief worksheets.
Client and therapist discuss safety
issues.
Therapist introduces Trust module.
SESSION 9. CBW AND TRUST
 Client
25
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
SESSION 10. CBW AND POWER AND CONTROL
 Client
26
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
SESSION 11. CBW AND ESTEEM
 Client
27
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
SESSION 12. INTIMACY AND FINAL IMPACT
 Client
28
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/

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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 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 CognitiveBehavioral 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