Cognitive Processing Therapy:
What is Next?
Patricia A. Resick, Ph.D., ABPP
Duke University
patricia.resick@duke.edu
Purpose of Talk
This program will briefly describe cognitive processing therapy
and it’s variants as well as to describe how it has evolved over
time, especially in the context of the VA dissemination
project.
Recent findings and ongoing or new research projects will be
described so that participants will see where CPT is heading
over the next 5-10 years.
COGNITIVE PROCESSING
THERAPY (CPT) IS…
a short-term
evidence-based
treatment for PTSD
a specific protocol
that is a form of
cognitive behavioral
treatment
predominantly
cognitive and may
or may not include a
written account
a treatment that can
be conducted in
groups, individually,
or combination
3
FORMATS FOR CPT
CPT
(includes written trauma
account)
CPT-C
(No written account)
• Group
• Individual
• Combination
• Individual
• Group
• Combination
In new book, CPT is the version without accounts; CPT+A is with accounts
Resick, Monson & Chard (in press) Cognitive Processing Therapy for PTSD: A
Comprehensive Manual. New York: Guilford.
4
CPT+ A
VERSUS
CPT
1.
Introduction and Education
1.
Introduction and Education
2.
Meaning of the Event
2.
Meaning of the Event
3.
Identification of Thoughts and Feelings
(ABC)
3.
Identification of Thoughts and Feelings
(ABC)
4.
Remembering Traumatic Events
4.
Identification of Stuck Points (ABC)
5.
Remembering Traumatic Events
5.
Challenging Questions
6.
Challenging Questions
6.
Patterns of Problematic Thinking
7.
Patterns of Problematic Thinking
7.
Challenging Beliefs Worksheet
8.
CBW & Safety Issues
8.
Safety Issues
9.
Trust Issues
9.
Trust Issues
10.
Power/Control Issues
10.
Power/Control Issues
11.
Esteem Issues
11.
Esteem Issues
12.
Intimacy Issues and Meaning of the Event
12.
Intimacy Issues and Meaning of the Event
RANDOMIZED CONTROLLED
TRIALS OF CPT
Interpersonal Traumas
Rape (Resick et al., 2002)
Child sexual abuse (Chard,
2005)
Rape and physical assault
(Resick et al., 2008)
Interpersonal Trauma
(Galovski et al., 2012)
DRC, rape victims (Bass et al.
2013)
Interpersonal Trauma, Sleep
trial (Galovski et al., 2016)
Mixed (e.g., interpersonal,
accident) (Butollo et al. 2016)
Military/Veterans
U.S. veterans (Monson et al.,
2006)
Australian veterans (Forbes et al.,
2012)
U.S. veterans with military sexual
trauma (Suris et al., 2013)
US Veterans (Morland et al.
2014).
Active Duty (Resick et al., 2015)
US Veterans (Maieritsch et al.,
2015)
US Veterans and community
women (Morland et al., 2015)
Interpersonal/Mixed Trauma Samples
Study
TX
Sample (ITT)
Common
Comorbidities
Gender
Age
Comparison
Condition
Resick et al.
(2002)
N=171
Ind
CPT+A
62 rape survivors (86% of total
had other crimes)
MDD: 44%
SAD: 0%
Female
32 y
PE, Delayed
treatment
Chard (2005)
N=82
Grp+
Ind
CPT+A
36 adult CSA survivors (57%
recall > 100 incidents)
MDD: 40%
SAD: 1%
Female
33 y
Delayed treatment
Enhanced, 17-wk
protocol
Resick et al.
(2008)
N=150
Ind
CPT+A
53 rape or non-sexual assault
victims
MDD: 50%
SAD: 4%
Female
35 y
CPT, Written
Account
(i.e., Dismantling
study)
Galovski et al.
(2012)
N = 100
Ind
VL
CPT+A
53 adult interpersonal trauma
survivors
MDD: 48%
SAD: 0%
69%
Female
38y
Symptom
Monitoring Delayed
treatment
Bass et al.
(2013)
N = 405
Grp
CPT
157 sexual violence survivors in
Democratic Republic of Congo
(sample randomized by village)
unavailable
Female
37y
Individual Support
Galovski et al.
(2016)
N = 108
Hypnosis+
Ind
CPT+A
52 adult interpersonal trauma
survivors with sleep problems
MDD: 46%
SAD: 1%
Female
37y
Symptom
Monitoring +
CPT+A
Butollo et al.
(2016)
N= 148
Variable
length
Gestalt v
CPT+A
67 German adults with PTSD
from mixed traumas
Affective 52%
Anxiety 49%
Somatoform 15%
67%
Female
Dialogical Exposure
Therapy (Gestalt)
Military/Veteran Samples
Study
TX
Sample (ITT)
Common
Comorbidities
Gender
Age
Comparison
Condition
Monson et al.
(2006)
N=60
Ind
CPT+A
30 US veterans with military
trauma
(78% Vietnam War)
MDD: 53%
SAD: 3%
93% Male
55 y
Treatment as usual
Forbes et al.
(2012)
N=59
Ind
CPT+A
30 Australian veterans with
military trauma
(67% Vietnam War)
MDD: 80%
SAD: 43%
93% Male
53 y
Treatment as usual
Suris et al.
(2013)
N=86
Ind
CPT+A
52 US veterans with military
sexual trauma
unavailable
85%
Female
46 y
Present Centered
Therapy
Grp CPT
Telemedicine
61 US Veterans
(67% Vietnam)
MDD: 33%
SAD: 17%
Male
56y
In person CPT
56 US Active Duty Military
unavailable
93% Male
32y
Present Centered
Therapy
45 OIF/OEF US Veterans
MDD: 44%
SAD: 4%
93% Male
31y
In Person CPT
63 Women
(20% Veterans)
MDD: 30%
SAD: 3%
Female
46y
Morland et al.
(2014)
N = 125
Resick et al.
(2015)
N = 108
Grp
CPT
Maieritsch et al.
(2015)
N = 90
Ind CPT+A
Tele-Medicine
Morland et al.
(2015)
N = 126
Ind CPT
Telemedicine
In person CPT
A RANDOMIZED CLINICAL TRIAL TO
DISMANTLE COMPONENTS OF CPT FOR
PTSD IN FEMALE VICTIMS OF
INTERPERSONAL VIOLENCE
PATRICIA RESICK, TARA GALOVSKI, MARY UHLMANSIEK,
CHRISTINE SCHER, GRETCHEN CLUM, YINONG YOUNG-XU
2008, JCCP
Dismantling Study
Participants
Trauma History
Chronicity Co-morbidity
150 Women
Majority with multiple
traumas:
• Adult Sexual Assault:
(80.7%)
• Adult Physical Assault:
(84.1%)
• Domestic Violence:
(60.7%)
• Child Physical Abuse:
(73.8%)
• Child Sexual Abuse:
(78.1%)
Average time
since index
trauma:
14.6 years
Index Event:
• Adult Sexual Assault
(31.3%)
• Child Sexual Assault
(38%)
• Adult Physical Assault
(23.3.%)
• Child Physical Assault
(7.3%)
• 50% Depression
• 20% Panic
Disorder
• Minimal Substance
Abuse (2 women)
• Not currently
Suicidal/Homicidal/
Psychotic
10
Dismantling Study Conditions
CPT+A
• 12 sessions/60
min/2x week
• Full Protocol
CPT-Cognitive only
(CPT)
Written Account
(WA)
• 12 sessions/ 60
min/2x week
• Removed the
written account (2
sessions)
• Extra time spent
reviewing cognitive
therapy
components
• 7 sessions/ 1st
week was two 60
minute sessions; 5,
120-min weekly
sessions
• 1-hour writing
account
• 1-hour
reading/processing
with therapist
11
RANDOM REGRESSION OF PDS
35
CPT+A
30
WA
CPT
25
20
15
10
5
0
baseline
week1
week2
week3
week4
week5
week6
post-treatment 6 mo follow-up
12
Manualized Therapy for PTSD:
Flexing the Structure of
Cognitive Processing Therapy
Tara E. Galovski, Leah M. Blain, Juliette M.
Mott, Lisa Elwood, and Timothy Houle , JCCP,
2012
Completer is defined when individuals reach good end state
functioning. Can we improve outcomes by better tailoring
the dose of therapy?
Objective: Determine how
many sessions were needed to
reach “good end state
functioning” (i.e., PDS<20 &
BDI-II<10)
Modified version of CPT+A
• Treatment continued until
participant reached good
end state functioning
• 18 sessions max
• Could end before 12
sessions (standard # of
sessions)
Number of sessions to good
end-state functioning
8%
26%
58%
8%
early
late
12 sessions
non-responders
Dissemination
VA- largest and first dissemination project.
Workshops, Case Consultation, on-line enhancement course,
advanced lectures that are posted on SharePoint.
Moved from centralized training to regional.
Provider roster:
Workshop, at least two cases or a group, case consultation,
program evaluation
3384 VA and Vet Center clinicians are rostered.
Since then, VA systems in Canada (Monson) and Australia
(Forbes) have also implemented dissemination projects as
well.
(Kaysen) Implementation trial in North Kivo, Congo
Non-VA dissemination
Statewide programs
Examples: Texas, Oklahoma, Pennsylvania, Wyoming (like
the VA program)
North Carolina: Learning Collaborative
Leadership engagement throughout
Application process
On-line course (MUSC course)
Workshop (n=60)
Weekly consultation calls, monthly affinity call
(everyone on the call with a specific topic)
Two other workshops during the year
Goal is quality-rated provider level (pass recorded
sessions with fidelity ratings)
More local trainings
County or city-wide trainings or Universities
Examples: Imperial County, CA
University of Buffalo, Rutgers Counseling Center
Because of requests by individuals we (Resick,
Chard, Monson) are trying to provide
workshops and two levels of provider roster
Provider
Quality-rated provider
www.CPTforPTSD.com
Research on Dissemination
There have been a number of articles examining
participants or records reviews of dissemination efforts.
There is also research on the dissemination process
itself.
Monson: Studied dissemination of CPT in VA in Canada
Marques: Examining the iterative process of disseminating
CPT among Latinos in Boston
Wiltsey-Stirman is studying the use of worksheet review to
see if it can be used to determine fidelity as well as
listening to recorded sessions (not efficient for large
numbers of trainees).
Current RCT Projects
All randomized controlled trials unless otherwise
mentioned
STRONG STAR Consortium
(Resick) Group versus Individual CPT
(Peterson & Resick) In-home versus in-office versus telehealth
equipoise design
(Resick and Wachen) Variable length CPT (not an RCT)
Up to 24 sessions to get to good end-state
Predictors of length and outcome of therapy include
neuropsychological testing (cognitive flexibility),
internalizing/externalizing
Other demographics and military variables.
(Sloan) Written Exposure Therapy versus CPT
Five sessions of written exposure (no processing, no homework).
CPT is control condition.
Consortium to Alleviate PTSD (CAP)
(McGeary & Penzien) Posttraumatic headache study
(patients from polytrauma clinic at VA)
Comparing headache treatment, CPT, and TAU
(Taylor and Resick) CPT and CBTi for PTSD and
Insomnia/nightmares
CBTi for 6 weeks (weekly), then CPT for 6 weeks (2/wk)
CPT for 6 weeks(2/wk), then CBTi for 6 weeks (weekly)
CPY for 6 weeks (2/wk), then more CPT (weekly)
Sleep studies and actigraphy as well as PTSD assessment.
Other comparative studies
(Schnurr, Chard & Ruzak) CERV- PTSD: CSP
591
Comparison of CPT+A and PE as trained and
implemented in VA
900 patients at 17 sites. 4 therapists at each site.
Variable length by 2 sessions either way.
(Sloan) WET vs. CPT+A with civilians and
veterans
(Chard) CPT+A versus PCT among veterans.
PTSD and Comorbidity
(Watkins and Beckham) The effects of CPT on cardiac
functioning.
(Pearson) Native American Women with PTSD and AUD;
CPT vs. waitlist control
(Kaysen and Simpson) CPT vs. Relapse Prevention among
men and women (civilians & veterans) with PTSD and
AUD.
(Dedert) smoking cessation versus smoking cessation with
concurrent CPT for PTSD + smoking
International
(Bohus & Steil) RCT for PTSD and borderline
personality.
4 site German study, up to 36 sessions
DBT skills, then PE versus variable length CPT.
(Rosner & Steil) Adolescent CPT vs general
counseling
(Ito). Japanese RCT comparing CPT with
Rogarian therapy.
CPT Resources
FOR INDIVIDUAL OR
GROUP MANUAL OR
PATIENT MATERIALS
INFO ON WORKSHOPS
•www.CPTforPTSD.com
NON-VA PROVIDER
ROSTER
CPTweb
Introductory Video
• http://cpt.musc.edu
White board intro
• www.ptsd.va.gov/public/index.as
p
Free download of CPT
Coach in iTunes
• CPT coach includes all of the
assignments, reminders, etc.