Download Workshop: Cognitive Processing Therapy

VA Training in
Evidence-Based
Psychotherapies
VAPTC EBP Presentation
1
Background
• In recent years, health care policy has incorporated evidencebased practice as a central tenet of health care delivery
(Institute of Medicine, 2001)
• The VA developed a Mental Health Strategic Plan in response
to the President’s New Freedom Commission on Mental
Health report (2004)
• The Mental Health Strategic Plan calls for the implementation
of EBPs at every VAMC in the country
VAPTC EBP Presentation
2
Goals of VA Training in EBPs
• To train VA staff from multiple disciplines in
evidence-based psychotherapies
• To augment psychotherapies already being
offered in VA medical centers
VAPTC EBP Presentation
3
VA Dissemination and Training
in EBPs
•
•
•
•
•
•
•
Cognitive Behavioral Therapy (CBT) for Depression
Acceptance and Commitment Therapy (ACT) for Depression
Cognitive Processing Therapy (CPT) for PTSD
Prolonged Exposure (PE) for PTSD
Social Skills Training (SST) for severe mental illness (SMI)
Integrative Behavioral Couple Therapy (IBCT)
Family Psychoeducation (FPE)
– Behavioral Family Therapy (BFT)
– Multi-Family Group Therapy (MFGT)
VAPTC EBP Presentation
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EBP Presentations for Interns and
Postdoctoral Fellows
• VA EBP rollout training has been focused on
staff
• VA Psychology Training Council (VAPTC)
developed a workgroup in 2009 to focus on
developing EBP didactics for interns and
postdoctoral fellows
VAPTC EBP Presentation
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Goals of these EBP Presentations
• To provide a basic working knowledge of each
of the rollout EBPs
• To provide the foundation for trainees to seek
out further training and supervision in the
EBPs they intend to implement
VAPTC EBP Presentation
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Limitations
• This presentation will not provide equivalent
training to the EBP rollouts
• This presentation will not provide the skills to
implement the treatment without further
training and supervision
VAPTC EBP Presentation
7
CPT slides are adapted from a presentation by Kathleen M. Chard, Ph.D.
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 or
individually
9
FORMATS FOR CPT
CPT
(includes written trauma
account)
CPT-C
• Group
• Individual
• Combination
• Individual
• Group
(No written account)
10
CPT IN THE VA
CPT is recovery focused
• Underlying expectation is that veterans can &
will recover versus be permanently disabled
• CPT teaches people how to be their own
therapist when future problems arise
• CPT is changing the expectancies of veterans &
staff
Regarding contact hours/year, 12 weekly
appointments is = seeing veterans monthly for a year
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A Focus on Cognitive Theory of PTSD
Throughout their lives, people are taking in information
through all of their senses.
We work to organize all of that information (words,
categories, schemas, etc.) in an attempt to understand,
predict and control.
Most people are taught the “just world belief” (good behavior
is rewarded and mistakes/bad behavior is punished) by
parents, teachers, religions, culture.
In the face of trauma, we often revert back to the just world
belief.
A Focus on Cognitive Theory of PTSD
These beliefs work as long as there is no contradictory
information.
The experience of trauma is so significant that you can’t
ignore it.
Intrusive symptoms occur as a result of the inability to
integrate the information effectively
.
13
A Focus on Cognitive Theory of PTSD
Once the trauma is over, it is a memory.
People have three possibilities when processing the trauma:
• The information matches and is incorporated (assimilation).
• They change too much and interpret everything in light of this new
information (over-accommodation).
• They change their view of the world/themselves to incorporate the
new information in a balanced, reality-based way (accommodation).
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SOCIAL COGNITIVE THEORY OF PTSD
Beliefs
≈
Trauma
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ASSIMILATION - PRE-EXISTING POSITIVE BELIEFS
It is a just
world
Beliefs
People can be
trusted
≈
STUCK
I am in control
I must have done
something bad to
deserve this
Trauma
It is my
fault
I could have
prevented this
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ASSIMILATION - PRE-EXISTING NEGATIVE BELIEFS
I am a bad
person
People cannot
be trusted
Beliefs
≈
STUCK
I have no control
over anything
I deserved it
Trauma
I knew I
shouldn’t
have
trusted
him/her
See, I have no
control
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OVER-ACCOMMODATION
I have no
control at all
Beliefs
I am in
control
≈
I was
unsafe
Trauma
STUCK
The world is
The world is safe
completely unsafe
I was
powerless
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ACCOMMODATION
Good
Bad things
happen to people do
bad things
good people
A bad thing
happened
to me
RECOVERY
Beliefs
Trauma
I have power over I can take steps to
many things, but
protect myself,
not all things
but no one is
100% safe
I was
unsafe
I was
powerless
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IDENTIFYING STUCK POINTS
Assimilation
Over-accommodation
(about the
past/trauma)
(about present and
future)
Undoing, (“if only, should have”)
Conclusions, implications of trauma
guilt or blame about trauma
(“never, always, no one”, all re: 5 themes)
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Stuck points are usually:
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So what about emotions?
There are two types of
emotions
Natural emotions emanate directly
from the event and are hard-wired
• fight-flight response→fear-anger
• losses→sadness
• disgust→withdrawal
Manufactured emotions are
produced by thoughts and beliefs
• Self-blame thoughts→guilt
• Other-blame thoughts→anger or rage
The therapist needs to
determine which kind of
emotion it is
If natural, clients need to
feel and let it run its
course. Natural emotions
dissipate quickly.
If manufactured, clients
need to change their
thinking.
So how does CPT work?
Challenging avoidance
Dissipation of natural emotions
Change in thinking about meaning of event
changes manufactured emotions instantly
(no habituation required)
Clients learn to not over-generalize their
thinking about a single bad event to all
people or to themselves (just because an
event has bad consequences, it doesn’t have
to have big implications)
RESEARCH ON CPT
There have been four randomized clinical
trials of CPT and several effectiveness
studies. See the manual for the exact
references.
Randomized Clinical Trials
Rape victims (Resick et al., 2002, JCCP)
Child sexual abuse (Chard, 2005, JCCP)
Veterans (Monson et al., 2006, JCCP)
Rape and assault (Resick et al., 2008, JCCP)
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CAPS SEVERITY PRE- AND POST-TREATMENT (TREATMENT
COMPLETERS)
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BDI SEVERITY PRE- AND POST-TREATMENT (TREATMENT
COMPLETERS)
26
CHARD (2007): EFFECTIVENESS OF CPT IN VA
RESIDENTIAL PROGRAM
• 7-week residential program
• CPT conducted twice a week in individual and
group treatment
• 23 other hours of psych. programming
• Pre-post data on 154 residents, 122 men and 32
women admitted as cohorts of 12
• Next slides compare this program with the RCT
with veterans by Monson et al. (2006)
Chard, Unpublished data
27
CINCINNATI RESIDENTIAL PROGRAM
*
**
N=
140
77
142
61
139
73
PCL (MADISON) AND CAPS (CINCINNATI) ACROSS
ERAS
Madison
Cincinnati
Some other findings of note…
1. Long-term follow-up of a clinical trial
comparing CPT and PE.
Patricia A. Resick, Lauren Williams
Robert Orazem and Cassidy Gutner
ISTSS & ABCT, Nov., 2005
LONG TERM FOLLOW-UPS
• Follow-up conducted at five+ years posttreatment (M= 6 yrs, range 5-10)
• 171 women were in the intent-to-treat sample
• We did not locate 25 and 3 were deceased
• Of the 143 we located:
17 refused to participate (12%)
2 were located but were not appropriate
• We conducted at least the diagnostic interviews
on 124 and have complete assessments on 119
• 88% participation rate
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CPT AND PE “CROSS-SECTIONAL”
(INTENT-TO-TREAT)
CPT, N= 83
PE, N= 88
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55
50
51
41
39
63
64
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CPT & PE ITT ON PTSD DIAGNOSIS AT
PRE-TREATMENT AND LONG TERM
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COGNITIVE PROCESSING THERAPY
SESSION BY SESSION
Cognitive Processing Therapy
Veteran/Military Version
Resick, P. A., Monson, C. M., & Chard, K. M. (2008)
Produced by VA Office of Mental Health, VA National Center for PTSD/ VA
Boston Healthcare System and Cincinnati VA Medical Center
CPT VERSUS CPT-C?
FACTORS THAT INFLUENCE THE CHOICE
– Patient may have a personal
preference
– More available research
– Account writing and sharing
full details might be
therapeutic
– Patient is wiling to write an
account
– Patient states he has little or
no memory of the event due
to avoidance (writing acct
may help recover the details)
– Time is not a factor
– Therapist believes that the
patient needs to express
avoided emotions.
– Patient may have a personal
preference
– Patient really has no
recollection of the event
– Patient refuses to write
account
– Impending redeployment/not
enough time for full protocol
– Therapist discomfort with
written account component
– Less overall time available,
want more time to develop
cognitive skills
– Conceptualization of case
warrants more cognitive
restructuring
– Conducting group therapy
PROGRESSION THROUGH WORKSHEETS
Analyze,
Information
gathering,
feelings
Impact
statement
ABC sheets
Challenge
Challenging
questions
Problematic
patterns
Change (CBW)
Challenging
Beliefs
Worksheet
Themes
Written
Account
36
PHASE 1.
PRE-TREATMENT ASSESSMENT AND
PRE-TREATMENT ISSUES
37
PRE-TREATMENT ISSUES
Please assess patients formally to
determine whether they have PTSD, and
if needed, other comorbid conditions
Describe the therapy you are offering,
how it might differ from other former
treatment
Therapist contract
38
OTHER PRE-TREATMENT ISSUES:
CPT FOR WHOM AND WHEN
Substance abuse/dependence
Self-harm/suicidality/homicidality
Dissociation
Literacy
Other comorbidity
Medications and other treatments
How early can you start?
• Risk to re-exposure (redeployment)
• Sufficient skills needed to start?
39
PRETREATMENT ISSUES- RATIONALE
AND BUY-IN THERAPIST TASKS
Motivational interviewing techniques may be
helpful (advantages and disadvantages of avoidance)
Patient needs to believe that improvement is
possible for him/her
Patient needs to believe that he/she has the ability
to tolerate therapy and has sufficient skills
Desire to approach needs to be stronger than desire
to avoid
40
RECOMMENDED ASSESSMENT MEASURES
CAPS interview for
diagnosis, frequency
and severity (pre and
post-treatment)
Self-report scales
(weekly)
• PTSD Checklist (PCL)
• Beck Depression
Inventory or other
depression checklist
www.ncptsd.va.gov
(vaww.ptsd.va.gov)
41
STRUCTURING SESSIONS
Brief update (mood
and PTSD
symptoms)
• Objective symptom
measures
• Complete practice
assignment review (“Let’s go
over your worksheets” rather
than “How was your week?”)
Review of practice
assignment
• Reviewing practice reinforces
completion
• Content is the “meat” of the
session
• Use Socratic questioning and
model challenging thoughts
• Use relevant forms
regardless of the content
42
STRUCTURING SESSIONS (CONT.)
Setting new practice assignment
• Review rationale
• Explain the concept and new
assignment
• Start assignment in session
• Problem-solve any barriers to
assignment completion
43
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SESSION 1. SYMPTOMS AND RATIONALE
1. Describe symptoms of PTSD (handout)
2. PTSD as a disorder of non-recovery
3. Fight-flight-freeze reactions
4. Cognitive theory of PTSD
• “Just world” belief
• Assimilation versus over-accommodation
• Goal of accommodation
45
SESSION 1. SYMPTOMS AND RATIONALE
5. Types of emotions
• Natural emotions result directly from eventthey are the hardwired response (goal is to
feel them and let them run their course)
• Manufactured emotions are based on
interpretations of the event (goal is to
change the thought, which changes the
emotion)
6. Choosing index traumatic event
46
SESSION 1. SYMPTOMS AND RATIONALE
7. Stuck points
• Handout
• Log
8. Anticipating avoidance and
increasing practice compliance
9. Overview of treatment
47
SESSION 2. IMPACT STATEMENT
Patient
reads
Impact
Statement
Discuss
implications
of
statement
Review
material
from first
session
Introduce
eventsthoughtsfeelings
relationship
48
A-B-C Sheet
Date: ___________ patient #: ______
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? ________________________________________
_____________________________________________________________________________
49
SESSION 3. EVENTS, THOUGHTS &
EMOTIONS
Review A-B-C Worksheets.
Using Socratic questions, help
patient generate alternative thoughts
and consequent feelings.
Gently begin to challenge undoing or
self-blame statements.
50
SESSION 3. SOCRATIC DIALOGUE
At this point in therapy we do not
strongly challenge maladaptive
statements.
More important to help clarify
thoughts and feelings.
Work gently with assimilation
(self-blame & undoing).
51
PHASE 3.
PROCESSING THE TRAUMA
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SESSION 4. FIRST ACCOUNT
Patient reads account aloud to
therapist.
Patient and therapist discuss reactions
to writing it/reading it.
First work on emotions. Sit with them,
name them.
Therapist gently challenges self-blame
and hindsight bias. Be curious.
53
SESSION 5. SECOND ACCOUNT
Patient reads
second account
of incident
Patient and
therapist
continue to
process any
remaining selfblame or
undoing
Therapist
introduces
Challenging
Questions
Worksheet
54
Challenging Questions Worksheet
Below are a list of questions to be used in helping you
challenge your maladaptive or problematic beliefs. Not
all questions will be appropriate for the belief you
choose to challenge. Answer as many questions as
you can for the belief you have chosen to challenge
below.
Belief:_________________________________________
1. What is the evidence for and against this idea?
2. Is your belief a habit or based on facts?
3. Are your interpretations of the situation too far removed
from reality to be accurate?
4. Are you thinking in all-or-none terms?
55
Challenging Questions Continued
5. Are you using words or phrases that are extreme or
exaggerated? (i.e., always, forever, never, need,
should, must, can’t and every time)
6. Are you taking selected examples out of context and
only focusing on one aspect of the event?
7. Is the source of information reliable?
8. Are you confusing a low probability with a high
probability?
9. Are your judgments based on feelings rather than
facts?
10. Are you focusing on irrelevant factors?
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SESSION 6. CHALLENGING QUESTIONS
Patient 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
58
Patterns of Problematic Thinking
Listed below are several types of patterns of problematic
thinking that people use in different life situations. These
patterns often become automatic, habitual thoughts that
cause us to engage in self-defeating behavior. Considering
your own stuck points, find examples for each of the
patterns. Write in the stuck point under the appropriate
pattern and describe how it fits that pattern. Think about
how that pattern affects you.
1. Jumping to conclusions when evidence is
lacking or even contradictory
2. Exaggerating or minimizing the meaning
of an event
59
Patterns of Problematic Thinking
3. Disregarding important aspects of a
situation
4. Oversimplifying events or beliefs as good/bad
or right/wrong
5. Over-generalizing from a single incident
6. Mind-reading
7. Emotional reasoning
60
SESSION 7. PROBLEMATIC PATTERNS
Patient and
therapist review
Patterns of
Problematic
Thinking
Therapist
introduces
Challenging
Beliefs
Worksheets
Therapist
introduces Safety
Module
61
Challenging Beliefs Worksheet
A. Situation
B. Thought
(stuck point)
D. Challenging
Thoughts
E. Problematic
patterns
F. Alternative Thought
Describe the
event, thought
or belief leading
to the
unpleasant
emotion(s).
Write thought(s)
related to Column A.
Rate belief in each
thought below from
0-100%
(How much do you
believe this thought?)
Use Challenging
Questions to examine
your automatic
thoughts from Column
B. Is the thought
balanced and factual or
extreme?
Use the Problematic
Thinking Patterns
sheet to decide if this
is one of your
problematic patterns
of thinking.
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%
Evidence?
Jumping to conclusions
Habit or Fact?
Exaggerating or minimizing
Interpretations not
accurate?
All or none?
Extreme or exaggerated?
Out of context?
C. Emotion(s)
Specify sad, angry, etc.,
and rate how strongly
you feel each emotion
from 0-100%
Source unreliable?
Low versus high probability?
Based on feelings or facts?
Disregarding important
aspects
Oversimplifying
Overgeneralizing
G. Re-rate how much you now
believe the thought in Column B
from 0-100%
Mind reading
Emotional reasoning
H. Emotion(s)
Now what do you feel? 0-100%
Irrelevant factors?
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SESSIONS 8-12
Use the Challenging Beliefs
Worksheet throughout the rest of
therapy.
Each theme can relate to beliefs
about self or others.
Challenging should help clients move
from extreme statements to
balanced statement.
Use of the full continuum of
thoughts and emotions.
64
FORMAT FOR SESSIONS 8-12
Assess symptoms
Review module and worksheets and assist as consultant
(client takes on a greater role)
Focus on individual stuck points as well as the theme for
the session
Introduce the new theme and module
Other specific assignments for sessions 11 & 12
65
NEW ASSIGNMENTS IN ADDITION TO
CBW
Giving and
Receiving
Compliments
Purposes are
to:
• Have them interact
more with other
people and focus their
attention outward
(giving compliments is
a fairly safe
interaction)
• Listen to what other
people say to them
without filtering and
distorting
• Consider other sources
of information about
themselves
• Help dispute stuck
points about self
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SESSION 12. INTIMACY AND FINAL
IMPACT STATEMENT
Patient and therapist review
Challenging Beliefs Worksheets on
intimacy
Patient reads new Impact Statement
Patient and therapist review course
of therapy and skills learned
Patient and therapist identify future
goals and issues which still need
attention
68
SESSION 12. REVIEW AND GOALS
Review course
of therapy and
skills learned
Identify future
goals and issues
which still need
attention
69
CPT Training Program
• CPT National Training Program (new requirements as of 2010)
– Attend 2- or 3-day workshop
• Workshops consist of didactics, video case examples, role play of CPT
skills
– Participate in CPT Case Consultation
• Attend consultation calls for 6 months
• Participate in at least 75% of the calls
• More may be required depending on training needs
– Complete CPT cases according to the model
• At least 2 individual (50 min weekly sessions) OR
• At least 1 group (90-120 weekly sessions)
– Submit case notes to the CPT Program
71
Why is Consultation Important?
Attending case consultation and completing the remaining steps to
become a “CPT Provider” are required as outlined in the CPT Training
Agreement
However, there are many other reasons to attend consultation:
 Consolidates workshop learning
 Promotes use of critical thinking skills via review of specific case
examples and implementation strategies
 Provides more opportunities to practice Socratic questioning and other
CPT skills
 Builds CPT community – you can meet and learn from other CPT
clinicians
 Most importantly, helps our Veterans by teaching clinicians how to
provide the best CPT care possible
CRITERIA TO Become a CPT
Provider
 Be a licensed and credentialed VA clinician
 Attend an approved CPT workshop
 Complete a sufficient number of CPT cases to become a CPT
provider: 2 individual CPT cases or 1 CPT group following the CPT
protocol as evidenced by case notes (two different patients)
 Attend consultation calls within two weeks of your CPT training
(even if you don’t have a patient) to the completion of the last
patient/group
Criteria to become a CPT provider
 Active participation in a call is defined as: Discussion of a current
patient in CPT, including stuck points and PCL scores, and
attending the entire consultation call
 You will be asked to begin participating in weekly phone case
consultation for a minimum of one hour per week for a period of
6 months (you must attend at least 75% of the calls)
 Please inform consultant if you cannot attend your scheduled
CPT call
 Your application will then be reviewed to assess understanding
and delivery of CPT
 Your paired consultant will be the person reviewing your
application packet
Criteria to become a CPT provider
Apply for Provider status by completing the
CPT Provider application located on the
SharePoint website (address listed below):
 https://vaww.portal.va.gov/sites/cpt_community/default.aspx
 Fax all data to CPT staff at required time frames (More information to
follow)