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Cognitive Processing Therapy for PTSD

In a previous blog, we went over the advantages of Prolonged Exposure treatment for PTSD. This blog goes in depth about another kind of treatment, Cognitive Processing Therapy.

CPT is a trauma focused therapy drawing on social cognitive theory and informed emotional processing theory. CPT assumes that following a traumatic event, survivors attempt to make sense of what happened, often leading to distorted cognitions regarding themselves, the world, and others. In an attempt to integrate the traumatic event with prior schemas, people often assimilate, accommodate, or over-accommodate. Assimilation is when incoming information is altered in order to confirm prior beliefs, which may result in self-blame for a traumatic event. An example of assimilation is “because I didn’t fight harder, it is my fault I was assaulted.” Accommodation is a result of altering beliefs enough in order to accommodate new learning (e.g., “I couldn’t have prevented them from assaulting someone”). Over-accommodation is changing ones beliefs to prevent trauma from occurring in the future, which may result in beliefs about the world being dangerous or people being untrustworthy (e.g., “because this happened, I cannot trust anyone”). CPT allows for cognitive activation of the memory, while identifying maladaptive cognitions (assimilated and over-accommodated beliefs) that have derived from the traumatic event. The main aim of CPT is to shift beliefs towards accommodation.

CPT consists of 12 weekly sessions that can be delivered in either individual or group formats. Generally, CPT is composed of CT and exposure components. Clients work to identify assimilated and over-accommodated beliefs and learn skills to challenge these cognitions through daily practice. Initial sessions are focused on psycho-education about the cognitive model and exploration of the patient’s conceptualization of the traumatic event. The individual considers: (1) why the traumatic event occurred; and (2) how it has changed their beliefs about themselves, the world and others regarding safety, intimacy, trust, power/control and esteem. The original version of CPT included a written trauma account where the patient described thoughts, feelings and sensory information experienced during the traumatic event. However, following evidence from recent dismantling studies, the most recent version of the protocol does not include the written trauma narrative. CT skills are introduced through establishing the connection between thoughts, feelings, and emotions related to the individual’s stuck points (maladaptive cognitions about the event) and learning ways to challenge cognitions that are ineffective. These skills are used to examine and challenge their maladaptive beliefs. CPT concludes with an exploration on the shifts in how the individual conceptualizes why the traumatic event occurred, focusing on the shift to accommodation rather than assimilation and over-accommodation.

The guidelines and strong research evidence suggest that PE, CPT and trauma-focused CBT should be the first line of treatment for PTSD whenever possible, considering patient preferences and values and clinician expertise. Research examining patient preferences suggests that individuals prefer PE, CPT and trauma-focused CBT to other treatments. Analog studies have demonstrated that participants have preferences for CT and exposure therapy over psychodynamic psychotherapy, EMDR, and therapies using novel technologies (e.g., virtual reality, computer-based therapy). In addition, results from studies examining clinical samples show that patients prefer psychotherapy, such as PE and CBT, to medication. Findings are similar among veteran and military samples, with soldiers showing greater preference for PE and virtual reality exposure (VRE) to paroxetine or sertraline, and veterans in a PTSD specialty clinic showing greater preference for CPT to other psychotherapies, PE to nightmare resolution therapy and PCT, and both PE and cognitive-behavioral conjoint therapy were preferred to VRE.

Future directions in PTSD treatment research include identifying ways to enhance effective treatments including among particular populations (e.g., military), keeping individuals engaged in treatment (i.e., reducing dropout), and determining individual factors predicting response/nonresponse. Avoidance symptoms are a core feature of  PTSD and maintain PTSD over time. Thus, it is not surprising that the dropout rate for PTSD treatment is high across treatment modalities. In addition, a portion of individuals do not respond adequately to PTSD treatment. One potential future direction is medication-enhanced psychotherapy for PTSD. Medication could potentially strengthen learning and memory, inhibit fear, and facilitate therapeutic engagement.


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