Workshop: Cognitive Processing Therapy

Workshop: Cognitive Processing Therapy
WELCOME participants to the training. If you don’t know, find out who they are (e.g., where are they from, population they work with, whether they do individual, group treatment, or both for PTSD.) How many have been trained/supervised in cognitive behavioral treatments? How many have been trained/supervised in cognitive therapy? If the group is large do this by having them hold up their hands. © Patricia A. Resick, Candice M. Monson & Kathleen M. Chard, 2006

First, let’s talk implementation
What would it take for you to try this therapy protocol? What barriers exist to impede your learning to conduct a new therapy? What can you do to facilitate your learning? Aside from the case consultation phone calls, we encourage you to set up peer group supervision meetings at your setting to discuss CPT implementation in more detail and to provide each other case consultation and support. Try audio or videotaping your therapy to get feedback in these meetings and to polish your cognitive therapy skills. Discuss with colleagues how to arrange case loads and therapy format (group/individual) to accommodate doing CPT in your setting.

Let’s start with the current criteria for PTSD
A: Stressor Criterion B: Reexperiencing C: Avoidance D: Arousal E: Time Criterion F: Functional Impairment or Distress Remember that it is an event accompanied by fear, helplessness and horror, not just fear. Need 1. Focus on flashbacks and nightmares. Ruminating about the event is not the same thing as an intrusive recollection. Need 3. We will talk a lot over the next two days about the thousands of ways that patients with PTSD avoid. Effortful avoidance and numbing appear to be quite different. Need 2. Think in terms of the range of emotions, not just fear arousal E. Symptoms need to be co-occurring for at least a month.

Symptom Criteria for PTSD
Avoidance Reexperiencing Flashbacks Thoughts, feelings & conversations Distressing recollections Dreams Activities/Places/People Amnesia Physiological reactivity Detachment 1 3 Loss of interest Psychological distress w/ reminders Restricted affect PTSD Foreshortened future 2 P T S D ost Although most of you probably have knowledge of the symptoms of PTSD, we have learned that the experience of PTSD that may not fit the current three symptom cluster, DSM-IV-based PTSD diagnosis. There have been many factor analysis studies conducted and none of them have found these three clusters. raumatic Sleep difficulties Hypervigilance tress Irritability & anger isorder Startle Arousal Concentration

A new model of posttraumatic stress disorder
Let’s reorganize the symptoms that exist in the current PTSD model and add some of the other symptoms that we have learned about since the DSM criteria were lasted voted on.

Think of PTSD as a failure to recover from a traumatic event.
If the event is severe enough, nearly everyone will have symptoms reflective of PTSD. When one reads epidemiology studies, one is left with the impression that only some people experience posttraumatic distress and other people are resilient right from the start. However, these studies don’t and probably can’t take into account the level of exposure that everyone experiences. Two people in combat or in a disaster may have experienced very different levels of threat, loss, or horror and would have had a completely different experience. If we look at the most extreme event for both women and men, rape, most people meet the symptom criteria immediately after treatment. Let’s look at some prospective studies of women who were either raped or assaulted. Let’s start with the most homogeneous severe event: rape

Normal Recovery 2 12 2 12 = Rothbaum et al = Resick et al.
Here is a prospective study conducted by Edna Foa and her colleagues with sexual assault (teal) and physical assault victims (yellow) who were assessed for symptoms of PTSD weekly from the time of the assault. This is the % of women who met the symptom criteria for PTSD at each interval. Notice, that in the most homogeneous event, rape, 94% met all the symptom criteria for PTSD at one week post-crime and that they recover naturally over the three months of the study. The assault victims, a more heterogeneous group show the same pattern but start at a lower point. The bars in pink are from a study that Patricia Resick conducted with 200 rape and assault victims inserted at the appropriate intervals. Please note, that the data map onto the other study very closely. 2 12 2 12 = Rothbaum et al = Resick et al. = Riggs et al.

PTSD Among Rape Victims
When the rape victims were divided into two groups based upon on their PTSD status at three months and then plotted for all of their assessments, a couple of things become clear. The group that recovered was not as severe to begin with and recovered smoothly over the three month period. The women who did not recover improved for the first month and then did not change significantly after that. We need to consider PTSD as a failure to recover, rather than as a psychopathology that “develops”. The PTSD group did not get worse over time; something interfered with their natural recovery. Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. & Walsh, W. (1992). A prospective examination of posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5,

So, what happens that either facilitates or hinders recovery?
The three symptom clusters of PTSD have not held up to research Let’s rearrange and think about post-trauma symptoms a bit differently There have been many factor analysis studies of the 17 symptoms of PTSD. Not one of them found the three cluster configuration that exists in the DSM. It will be many years before the DSM V is produced and there has been a great deal of research on symptoms of PTSD since the DSM-IV. In the meantime, let’s think about PTSD symptoms more functionally.

1. Intrusive images and sensations
Sensory memories Intrusions E V N T Images Nightmares Flashbacks It would probably help to focus on reexperiencing symptoms as a pure intrusion experienced as flashbacks or nightmares. These experiences are very different than intentionally thinking about the event when reminded of it, or ruminating about it. We are talking about very different brain functions when we compare intentional thought with sensory experiences. Research on people who have PTSD indicates that flashbacks are most frequently visual images, although many people also have auditory, olfactory, or tactile memories, or even pain accompanying the visual images. Traumatic nightmares are different than normal nightmare. Traumatic nightmares are intrusive memories of the event and because the person is asleep, he or she may remember or reexperience more of the story than while awake. Normal nightmares jump around much more, have less of a story line, and are often hard to describe in detail.

2. Cognitions and Cognitive Processes
Content Autobiographical memory Schemas Appraisals Assumptions Thoughts Beliefs Processes Attentional bias Rumination Assimilation Accommodation Overaccommodation Cognitions E V N T Intrusions Cognitions, distinct from intrusions, are represented by disruptions in cognitive processes and cognitive content among those with PTSD. Cognitive processes include mechanisms that become disrupted in the way in which information is attended to and categorized. We will be talking about assimilation and overaccommodation a lot in the next two days. The actual content of thinking also becomes distorted and extreme looking back at the traumatic event and forward into the future with regard to self and others. These have all been correlated with severity of PTSD.

3. Negative Affect and Hyperarousal
Intrusions Sadness Fear Emotions/Arousal disgust Anger Cognitions Hyperarousal The current arousal criterion for PTSD focuses primarily on physiological arousal or anger. However, we know that people with PTSD have many negative emotions including sadness, guilt or shame, fear, or horror. When we talk about emotions, we are talking about arousal, physiological arousal that has been labeled. However, any strong negative emotion will cause these reactions, not just fear. These strong negative emotions are associated with dysregulation of stress hormones. It is important that we move beyond thinking of PTSD as an anxiety/fear disorder to help us think about the full range of emotions and how difficult these are for our patients to experience. Startle

In normal recovery, intrusions and emotions decrease over time and no longer trigger each other
Arousal Intrusions Cognitions In people who recover from their traumatic events, intrusions, cognitions and emotions may trigger each other initially, but they decrease over time until they reach a point where they become disconnected from each other. In other words, later on something in the environment might trigger thoughts or intrusive images, but they wouldn’t elicit strong emotions any more.

However, in those who don’t recover, strong negative affect leads to escape & avoidance
Aggression Self-harm behaviors Substance abuse Binging Cognitive avoidance Behavioral avoidance Dissociation Emotional suppression Social withdrawal Behavioral inhibition Somatic complaints Emotion/Arousal Intrusions Cognitions Core reactions Those who can’t tolerate or cannot experience (process) their emotions at the time may cope with a range of escape or avoidance behaviors to stop the thoughts, images, or emotions. There are many ways that people can avoid. The list in the DSM of effortful avoidance and numbing symptoms just scratches the surface. Even being extremely busy (two jobs, taking classes, while raising children) can serve as avoidance of the trauma memory.

4. Avoidance Research supports association of a range of behaviors with affect/tension reduction: Substance abuse (Kilpatrick et al. 1997; Nishith et al. 2001) Binging (Agras & Telch, 1998; Cools et al. 1992; Polivy et al. 1994) Self-injury (Briere & Gil, 1998; Favazza & Conterio, 1989) Dissociation (Bonanno et al. 2003; Feeney et al. 2000) Social withdrawal (Riggs et al. 1998; Ruscio et al. 2002) All of these problems have been associated with PTSD and yet we sometimes don’t think to associate it with avoidance of affect or to shut down intrusive images.

Avoidance Criterion This list is not exhaustive
Any behavior that functions to escape/avoid negative trauma-related emotion meets the criterion. Aggression Self-harm behaviors Substance abuse Binging Cognitive avoidance Behavioral avoidance Dissociation Emotional suppression Social withdrawal Behavioral inhibition Somatic complaints People with strong avoidance do not process their emotions because they shut it down immediately, and they also don’t have the opportunity to examine their beliefs about the event, themselves or the world, or receive corrective information from others.

Successful Avoidance = Chronic PTSD
Aggression Self-harm behaviors Substance abuse Binging Cognitive avoidance Behavioral avoidance Dissociation Emotional suppression Social withdrawal Behavioral inhibition Somatic complaints Emotion/ Arousal Intrusions Cognitions Core reactions If escape and avoidance are successful the person with PTSD will not be triggered as often, will not think about the event and will have fewer emotions. This, of course, is one of the reasons why people with PTSD put off going to treatment for so long. They are managing their symptoms. Escape/ Avoidance

Very Successful Avoidance = Chronic Subthreshold PTSD
Escape/ Avoidance Aggression Self-harm behaviors Substance abuse Binging Cognitive avoidance Behavioral avoidance Dissociation Emotional suppression Social withdrawal Behavioral inhibition Somatic complaints Emotion/ Arousal Intrusions Cognitions Core reactions In fact, some people are so successful at avoidance that they may no longer be diagnosable. At any point in time they could return to full PTSD though because the moment their escape and avoidance behaviors are blocked or disrupted, they become symptomatic immediately.

Mediators and Moderators
V N T Nature Nurture Demos Events Intrusions Emotions/ Arousal Escape/ Avoidance Cognitions This slide represents hundreds of studies on mediators and moderators of PTSD that are beyond the scope of this talk. Biological variables, prior events, family environment, prior coping and thinking skills, etc. could all affect one’s response during a trauma. How one responds during the trauma can affect one’s interpretations as well as biological responses and one’s ability to process the event, after the trauma. Other people can have a profound effect on ones interpretations, coping strategies, types of avoidance etc. It should be pointed out here that sometimes avoidance is not a choice by the trauma victims. They may be in an environment in which they cannot process the event afterwards (think about it, feel their emotions etc.). I call this an externally imposed inhibition of processing. Examples would be war zone traumas or children or women who are living with their perpetrators. Post trauma environmental factors Social support (+/-) Resource strain/loss Externally imposed inhibition of processing Pretrauma

Simple versus Complex PTSD
aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Externalizing Intrusions Emotions/ Arousal Simple Cognitions We have now learned that someone’s tendencies toward internalizing (depressive or anxiety symptoms) or externalizing behaviors (anger, substance abuse etc.) will lead them to escape and avoid their trauma memories along those lines. Regardless of whether they are “internalizers” or “externalizers, people with PTSD have tendencies to engage in cognitive and behavioral avoidance. Interestingly, dissociation was not found to occur in one group more than another. So we could think of three types of PTSD; simple, internalizers or externalizers. The latter two would be complex PTSD. Drinking a few drinks before bedtime might be an indicator of complex PTSD, of an externalizing nature. People with cluster B Axis 2 personality disorders (borderline, narcissistic, histrionic) are externalizers. Social withdrawal would indicate an internalizing type of coping. Those with avoidant personalities are internalizers. Internalizing Core Reactions Coping with Escape And Avoidance Simple vs Complex PTSD

Developing Axis I and Axis II Comorbid Disorders
SUD Cluster B Bulimia ADHD Externalizing Intrusions Fear Anxiety Disorders, Avoidant-PD Emotions/ Arousal Avoidance Simple Cognitions If one did enough of these internalizing and externalizing behaviors, in their attempts to cope with the trauma, to meet the criteria for another disorder, then he/she would have a secondary comorbid disorder in addition to PTSD. Of course, if someone were to have the other disorder prior to developing PTSD then it would be a primary disorder. These other disorders are not part of PTSD but the other disorders are common comorbid disorders with PTSD. Anxious Misery MDD GAD Schizoid Somatization Internalizing Core Reactions Coping with Escape And Avoidance Simple vs Complex PTSD Comorbid Axis 1 or Axis 2 Disorders

Two examples …and why they look so different
Jim was physically abused by his father as a child. He tended to blame other people for his problems and began drinking with friends in adolescence Jen had an episode of depression in her early 20s. She grew up thinking that when things went wrong, it must have been her fault Both of them were victims of sexual abuse Let’s look at these 2 examples.

behavioral inhibition
Jim SUD Cluster B Bulimia ADHD Abuse Externalizing aggresssion self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation numbing/anhedonia social withdrawal behavioral inhibition Angry Fear Anxiety Disorders, Avoidant-PD Intrusions Emotions/ Arousal Simple “Others bad” Cognitions Anxious Misery MDD GAD Schizoid Somatization Jim, the externalizer, would have outward focused cognitions (locus of control) and would blame other people for events. Jim would subsequently experience anger and will likely choose externalized means of escape and avoidance from trauma memories and emotions. If he used substances enough to meet criteria for a substance abuse disorder, he would then have PTSD and comorbid SUD. Internalizing External- Comorbid Axis 1 or Axis 2 Disorders Coping with Escape And Avoidance Simple vs Complex PTSD Core Reactions

Jen SUD Cluster B Bulimia ADHD Abuse Sad, guilt Externalizing aggresssion self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation numbing/anhedonia social withdrawal behavioral inhibition Intrusions Fear Anxiety Disorders, Avoidant-PD Emotions/ Arousal “I’m bad” Simple Cognitions Jen, the internalizer, tends to blame herself (internal locus of control) and is more likely to withdraw and become depressed or anxious. Anxious Misery MDD GAD Schizoid Somatization Internalizing Internal- Comorbid Axis 1 or Axis 2 Disorders Coping with Escape And Avoidance Simple vs Complex PTSD Core Reactions

PTSD as a Mediator Health Social Family Work SUD Cluster B Bulimia
ADHD Externalizing Health Social Family Work Simple PTSD Intrusions Avoidance Fear Anxiety Disorders, Avoidant-PD Emotions/ Arousal Cognitions The picture does not end here. The final outcome is that PTSD and the ineffective efforts to control those symptoms leads to dysfunctional outcomes such as problems with work, family, social relationships, or health problems. It is often these problems that leads the person with PTSD to treatment. Anxious Misery MDD GAD Schizoid Somatization Internalizing Coping with Escape And Avoidance Functional Outcomes Simple vs. Complex PTSD Core Reactions Comorbid Axis 1 or Axis 2 Disorders

Treatment of PTSD aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Intrusions Emotions/ Arousal Cognitions So, if these are the basic symptoms of the PTSD response, how does someone recover? Core Symptom Clusters Escape/ Avoidance

1. Prevent Avoidance aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition Intrusions Emotions/ Arousal Cognitions Sometimes when avoidance is blocked (or ends naturally), processing the images, thoughts, and emotions can proceed naturally and no therapeutic intervention is necessary. Sometimes a social therapist in one’s life blocks the avoidance and encourages processing (“It’s time to get back out there. Let’s talk about what happened to you”). Core Symptom Clusters Escape/Avoidance

2. Intervene into one or more of core symptom clusters
Nightmare rescripting MEDs aggression self-harm behaviors substance abuse binging cognitive avoidance behavioral avoidance dissociation anhedonia/numbing social withdrawal behavioral inhibition PE Intrusions Emotions/ Arousal Cognitions However, when this doesn’t happen naturally, formal intervention may be necessary. Therapists block the avoidance by encouraging the client to actively deal with the event(s), to think about them, talk about them and feel their emotions. Then therapists usually intervene in one or more of the other symptom clusters directly. One of the reasons why different types of therapy may all be effective is that they all block the avoidance and then facilitate the processing to commence. CT CPT Escape/ Avoidance

Randomized Clinical Trials
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 1. Rape victims (Resick et al., 2002, JCCP) 2. Child Sexual abuse (Chard, 2005, JCCP) 3. Veterans (Monson et al., 2006, JCCP) 4. Rape and assault (Resick et al unpublished) So how well does CPT, the therapy we are teaching here, work with PTSD? There have been four randomized clinical trials that have included all the components needed (independent reliable assessors, random assignments to groups, trained and supervised therapists whose taped sessions are checked for adherence and competence, etc.).

Study CPT Sample Compared to: ITT Depression Comorbidity Gender/Age
Resick et al. (2002) 82 rape victims (86% had other crimes) 44% Female/32 Prolonged exposure, wait list Chard (2005) 36 adult survivors of CSA (57%> 100 incidents) 40% Female/32.8 Delayed treatment 17 wk protocol Monson et al. (2006) 30 Combat veterans (78% Vietnam) 53% 93% male/ 54.9 Treatment as usual Resick et al. (unpublished) Rape or assault 58 CPT, 51 CT, 55 WE 50% Female/35.4 Dismantling study Intent to treat (ITT) means that all participants who entered the trial are included in the analyses (we intended to treatment them no matter how much therapy they got or whether they even got any CPT). This is the most conservative analysis. All of these samples had chronic PTSD, most had multiple severe traumas and there were high rates of comorbidity. Inclusion criteria into the study were as liberal as possible to test the therapy realistically.

CAPS severity pre and post-treatment (ITT)
In all four studies, there were significant changes from pre-treatment to post-treatment. This graph shows severity of PTSD based on the CAPS, the clinical interview for PTSD. This graph includes everyone who entered the study (ITT). On average there was a 50% drop in symptoms. In Dr. Resick’s (2006) dismantling study, they tested the full CPT protocol versus the components, cognitive therapy (CPT-C) or CPT-W (written account only). The graph shows two of the three conditions that we will be teaching you, full CPT and CPT-C (or CT on these slides). The Monson study may have smaller decreases because 1) most of the participants were male, 2) they were on average 20 years older than those in the other studies, 3) they were VA patients (head injury, substance abuse, etc.) and 4) were predominantly combat veterans. We just don’t know.

CAPS severity pre and post-treatment: Tx Completers
On this graph you can see that, for the most part, the results are more dramatic for those who complete all of the therapy symptoms.

CAPS diagnosis pre and post-treatment (ITT)
On the ITT sample with everyone included, in most studies more than half of the sample lost their PTSD diagnosis (everyone had to have PTSD to enter the trial). In the veteran sample 43% lost their diagnosis.

CAPS diagnosis pre and post-treatment (Tx completers)
Across the four studies, the large majority of treatment completers lost their PTSD diagnosis.

BDI pre and post-treatment (ITT)
Depression shows similar improvements to PTSD. These are scores on the Beck Depression Inventory on the ITT samples.

BDI pre and post-treatment (TX completers)
Here is the BDI with the treatment completers. Note than even though not all dropped below the cutoff, there is a consistent decrease in symptoms. Also note that these are average effects.

Chard (2006): 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 82 residents, 59 men and 23 women admitted as cohorts of 12 Next slides compare this program with the RCT with veterans by Monson et al. (2006) More recently, Kate Chard (Cincinnati VA) has compiled effectiveness data on a residential program for PTSD. This is not research; these are clinical, program evaluation data. The whole program functions within a CPT framework so that whatever patients are doing, the staff members might challenge stuck points and help with worksheet. Chard, Unpublished data

CAPS pre and post-treatment (TX completers)
These are the residential program data on the right compared to the outpatient sample of veterans that was assessed as part of Dr. Monson’s trial.

BDI pre and post-treatment (TX completers)
Again, here are the corresponding depression scale data.

Some other findings of note…
1. Can We Cure PTSD? 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 Of course, one of the important questions we need to ask is whether the results of treatment last over time. Most studies have followed patients for 1-12 months. In Dr. Resick’s clinical trial comparing CPT and PE, she was able conduct complete assessments at least five years later.

Long term follow-ups Follow-up conducted at five + years post-treatment (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

ITT CPT and PE “cross-sectional”
This graph shows all of the participants who were available at each data point. As you can see, the gains that were made during treatment appear to have been maintained over time. CPT, N= PE, N=

CPT and PE on CAPS across 5 years (all assessments)
This graph includes only those people who attended every assessment. CPT, N= 35 PE, N= 32

CPT & PE ITT on PTSD Diagnosis at Pretreatment and long term
Rather than severity, here are the diagnostics on the CAPS. As you can see, both CPT and PE had long lasting improvements in PTSD diagnosis.

2. A Dismantling Study of the Components of Cognitive Processing Therapy Patricia A. Resick National Center for PTSD, Boston VA Healthcare System and Boston University Tara Galovski, Kelly Phipps, Mary Uhlmansiek, Jennifer Ansel and Michael Griffin University of Missouri- St. Louis Dr. Resick’s most recent treatment study, a dismantling study of CPT provides some interesting findings regarding change during treatment.

ITT CAPS Severity (no differences between groups)
This was a study of women who were either raped or assaulted. They had very high rates of both types of abuse as well as child sexual abuse. As you can see there were no significant differences between the three conditions, full CPT, CPT-W (written account only), or CPT-C (CT only) from pre to posttreatment and then over a six month follow-up.

Random Regression of PDS
However, when we look at the session data, there are significant differences between the groups. The groups are the same until week 2, which is after four hours of therapy. At this point, the CPT and CPT-W groups have written their accounts once. The CPT-C group has improved significantly compared to those groups. At week 3, the CPT group has finished the account writing with Socratic questioning by the therapist, they have now caught up with the CPT-C group but the CPT-W group is still significantly more symptomatic than the CT group. The CPT-W group continues to lag behind and only catches up at the post-treatment assessment and six month follow-up. So, while the groups end up in the same place, the trajectory of change is different. If you have a patient who is completely resistant to going over the account in detail (written or oral), please consider doing CPT-C. Note that he CPT-C dropout rate was the lowest. This is also a good option for group therapy. * * * * *

Cognitive Processing Therapy
Resick, P.A., Monson, C.M., & Chard, K. M. (2006) Cognitive Processing Therapy Veteran/Military Version Produced by VA Office of Mental Health, VA National Center for PTSD/ VA Boston Healthcare System and Cincinnati VA Medical Center ORIENT participants to the materials on hand. This will maximize the audience’s ability to follow along during the subsequent session-by-session synopsis of the therapy, MAKE sure participants have their manual in front of them, including various handouts and veteran examples, and that the materials are organized by session. This step is particularly important if the materials have been sent electronically because sometimes individuals will organize their printed copies differently. It is sometimes difficult for therapists to leave a training with a good overall idea of what takes place in each session because the reference for that is essentially the entire treatment manual. REFER to the summaries of each session that precedes the session content. These handouts can also be helpful to illustrate the expected timing/pacing of each session as time estimates for each section are indicated.

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. Although it is certainly possible to use the CPT protocol for those who are sub-threshold (a symptom or two short of full diagnosis), this protocol would not be appropriate for those who do not have PTSD at all but have some other disorder. Cognitive therapy (without WE) can be used for depression or anxiety. A s part of a pre-treatment assessment, initial interview, or even a transition with a longer-term patient, you should consider strategies for how to present CPT in order to maximize your patient’s confidence in the therapy. In this process, it is important to describe the rationale for CPT and get your patient’s commitment to completing the therapy in full. This process of getting “informed consent” is not just relevant in research settings. You may wish to use a treatment contract in order to get written commitment from their patients in addition to their verbal commitment (in manual).

Other pretreatment 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? SUD- if not in a protected environment (e.g., residential program), probably not good to implement immediately after detox. Some stablization is helpful. If abusing, try to contract to refrain, especially during practice assignments. Dissociation improves along with other PTSD, so unless severe, can proceed. If severe, work on dissociation first, with affect tolerance and grounding skills. Adapt protocol to oral, tape account, stick with ABC with low literacy, education, intelligence etc. Try to have medications stable Can start as soon as assessment is completed (1-3 session). If established patient, need a transition for 1-3 sessions) No reason not to treat if someone has time to fit in before redeployment. If only a few sessions possible, then do CPT- As long as not acting out, no special skills. If severe affect regulation problems, DBT skills helpful first. Consultation group can answer questions as they come up

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 We strongly recommend that patients complete a pre-treatment assessment, including brief self-report measures that may be completed weekly throughout the treatment process, as well as more in-depth measures to be completed minimally at pre- and post-treatment. Most patients (75%) show a sudden gain at some point in treatment. That is the turning point you are looking for and may signal a shift from working on the trauma itself to working on their overgeneralized beliefs about themselves and the world. If you don’t assess the patients regularly, you will not know when you have gotten to the heart of the PTSD.

Structuring Sessions Brief update (mood and PTSD symptoms)
Objective symptom measures Complete Practice Assignment Review (“How did your practice go?” 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 LEAD a brief discussion about the general structure of CPT sessions. With few exceptions, each session follows the same framework: checking in on changes in symptoms (e.g., utilization of PCL or other self-report PTSD symptom scale) , recording practice assignment compliance, reviewing understanding of material from the previous session, setting an agenda for the session, reviewing and working with material from practice assignments, discussing new content, assigning new practice assignments, providing a summary of the session and asking for feedback.

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

Session 1. Symptoms and Rationale
Describe symptoms of PTSD (handout) PTSD as a disorder of non-recovery Fight-flight-freeze reactions Cognitive theory of PTSD Just world belief Assimilation versus over-accommodation Goal of accommodation After going over the PTSD criteria and eliciting examples, you should use the handout to explain how intrusive images, thoughts, and emotions all trigger each other and how avoidance stops them from processing further. Describe PTSD as a disorder resulting from non-recovery from exposure, not something that “develops” per se. Mention that something got the survivor “stuck” that prevented their recovery. Describe the natural fear reactions that occur when faced with a traumatic situation (fight-flight-freeze) Describe how thoughts start out as simple categories and become more complex over time but that they can be stalled out by trauma. Person makes assumptions about what the trauma means and then doesn’t change them because they avoid thinking about it. Introduce the idea of the “just world belief.”

Assimilation Traumatic event is remembered differently to preserve original beliefs and assumptions Modified memory of the traumatic event doesn’t fit with emotions experienced Creates disconnect between the memories and the emotions Original Belief Rape=Stranger Traumatic Event Raped by friend Assimilation Misunderstanding It is useful to discuss assimilation as a process of engaging in undoing or self-blame for the trauma (e.g., “Why me?” or “I’m being punished”). Statements to look for with assimilation: “If only I had…” “I should have…” “I let it happen…” “It’s my fault… “I shouldn’t have…” “I can’t accept it…” “Why me?” or “Why not me?” are two sides of the same coin—the just world belief. Undoing and Self-Blame

Over-accommodation Overall beliefs and assumptions about self and the world change too much following the traumatic event and are no longer accurate Original Belief World=Safe Traumatic Event Assaulted Over-accommodation World=Dangerous Over-accommodation typically involves generalizing trauma-based reactions to non-traumatic situations (e.g., “I can never trust anyone again.”). These beliefs often fit into the themes that constitute the final five sessions of CPT. The goal of CPT is to encourage accommodation, which involves accepting that the traumatic event occurred and discovering ways to successfully integrate the experience into the individual’s life (e.g., “In spite of this bad event happening to me, I am a good person.”).

Therapist Explaining Cognitive Theory
Session 1 Therapist Explaining Cognitive Theory “Carol” At this time, you may choose to INTRODUCE the video “Therapist Explaining Cognitive Theory.” To show how a therapist might introduce the cognitive theory behind CPT to her patient, I am going to show you this next video. PLAY video and follow with a brief discussion of what was shown. Discussion Questions for “Therapist Explaining Cognitive Theory”: In what way did the therapist explain cognitive theory that was simple for patients to understand? What analogies or words did she use that were particularly helpful? How would you handle a client who is not on board? You will want to go over the course of the therapy and the rationale for CPT with your patient, being sure to emphasize the importance of the patient’s full commitment to the process. ASK participants if they have any questions on the rationale for CPT. Participants who fully understand the rationale are much more likely to feel capable and interested in initiating CPT with a patient upon returning to their clinical practice. Note that they videos will show that CPT works well with diverse therapist styles.

Types of emotions Goal for natural emotions Goal for manufactured emotions Choosing index traumatic event Discuss natural versus manufactured emotions. Emphasize that the goal of the therapy is to feel those natural feelings that have not been allowed to be felt and expressed, whereas the goal for manufactured emotions is to change the cognitions that are manufacturing them. The analogy of a fire is helpful in describing the difference (i.e., if you let the fire burn, it only dies out; if you keep throwing on logs, the fire will burn, and perhaps burn hotter and higher). The next part of Session 1 is to ask patients for a very brief description of the index trauma if you haven’t heard it before. It is critically important to keep this description to less than five minutes. Patients who reveal too much in the first session often feel highly vulnerable after the fact and may not return after that. Present the parameters of how to choose the index traumatic event if there are multiple traumatic events – what thoughts intrude the most? What images are most disturbing? What do they attempt to avoid the most? What is the content of their dreams or flashbacks? Discuss why the therapist should choose the most traumatic event first.

Selecting Worst Trauma
Session 1 Selecting Worst Trauma “Matt” You may choose to INTRODUCE the video “Selecting Worst Trauma.” One potential challenge may arise during the selection of the worst trauma. In this next video clip, I will show you how a therapist helps a patient select the most appropriate trauma for his practice assignment. The chosen trauma is not the trauma that was initially mentioned by the patient as one of his worst events. PLAY video and follow with a brief discussion of what was shown. Discussion Questions for “Selecting Worst Trauma” What trauma first seemed to be Matt’s worst trauma? How did the therapist help him select his worst trauma? Why would this trauma be identified as his worst trauma? Since the first few sessions help to build a relationship and set the scene for challenging aspects of trauma-based beliefs, delving into the details of the trauma in Session 1 would be premature.

Stuck points Handout Log Anticipating avoidance and increasing practice compliance Overview of treatment You should go over the stuck point handout with the patient in session. This handout highlights how ways of thinking keep people “stuck” in their PTSD symptoms. Note how traumatic experiences can either disrupt one’s beliefs or confirm pre-existing negative beliefs. Also, you should keep a log of the patient’s stuck points to also share with the patient. Encourage the therapist to anticipate the patient’s avoidance with the patient. Underscore the time involved in therapy sessions versus in the patient’s everyday life as a rationale for out-of-session practice. An overview of the 12 sessions should be provided.

Session 1. Group Notes Discuss group rules
Allow patients to create their own and add to their list (e.g. confidentiality, timeliness, no cross talking) Discuss patient responsibilities in group Attending, participating, doing practice Ask if group members would like a phone list (if outpatient group) As I mentioned, CPT is often administered in group settings. For each session, I will review some of the issues that are specific to group therapy. In Session 1, the patients are asked to create group rules. Typically people who have been in groups before are quick to throw out some rules. The co-leaders should make sure that rules are appropriate and should add to the list as necessary. Common rules include confidentiality, being on time, not talking while someone else is talking, and no fighting. It’s important to select a group that harmonizes; manage group time effectively so that you get to each group member Choose clients who are comfortable with group format and can manage the trauma account Combined group and individual CPT: assign practice assignment in group; review it in individual; allow as much time in between as possible.

Session 1. Group Notes Discuss group rules
Allow patients to create their own and add to their list (e.g. confidentiality, timeliness, no cross talking) Discuss patient responsibilities in group Attending, participating, doing practice Ask if group members would like a phone list (if outpatient group) Next, leaders discuss patient responsibilities including attendance. We advise strongly stating the need for attendance and creating a policy that if anyone misses more than two sessions they will be asked to drop out of the group and wait until the next group starts. Due to the time-limited nature of CPT we also stress the need to participate in group and do the assignments. Finally, ask group members if they would like to be on a confidential phone list. We usually recommend first names only and many patients give their cell phone number instead of their home phone if they are worried about family member reactions. Not all patients must be on the phone list, but even patients who opt out in the beginning often ask to be added later. Both the group rules and the phone list are typed up by staff for hand out in the next session. If they want to socialize outside the group, everyone should be invited so formation of cliques is discontinued.

Session 1. Practice Assignment
“Please write at least one page on why you think this traumatic event occurred. You are not being asked to write specifics about the traumatic event. Write about what you have been thinking about the cause of the worst event. Also, consider the effects this traumatic event has had on your beliefs about yourself, others, and the world in the following areas: safety, trust, power/control, esteem, and intimacy. Bring this with you to the next session. Also, please read over the handout I have given you on stuck points so that you understand the concept we are talking about.” EXPLAIN the practice assignment for Session 1 (Impact Statement). For the Session 1 practice assignment, patients are asked to handwrite a description of how their worst trauma has affected their lives. This is the Impact Statement. This Impact Statement should include a discussion of each of the five primary themes that will be addressed later in CPT including safety, trust, power/control, esteem, and intimacy as well as their beliefs about the cause of the event. It is important for you to be clear that the assignment is not to write a description of the trauma itself. In some cases, patients have been so anxiously anticipating the written account (as described to them in the informed consent process), that they misunderstand the unique Impact Statement assignment.

Establishing rapport early in this session is key to getting the patient’s “buy-in” for the treatment and ensuring full participation in the therapy. Session 1 is about education and increasing motivation for therapy. Repetition of statements such as, “We find this therapy is very effective” are not only true, but can help patients gain confidence in the process.

Session 1a. Traumatic Bereavement
Patient reads Impact Statement and therapist begins to identify stuck points Therapist provide education on normal bereavement Therapist looks for stuck points that are interfering with normal bereavement Therapist reviews Myths of Mourning Handout Therapist assigns practice assignment on Impact Statement related to traumatic bereavement If this session is added, the therapist will go ahead and have the patient read the Impact Statement assigned in Session 1. The therapist then provides education on normal bereavement and looks for stuck points that are interfering with normal bereavement in the patient. The Myths of Mourning Handout is an exceptionally good tool for further identifying the extent to which a patient may be experiencing traumatic grief. This handout serves as a framework for both identifying any common myths about how one “should” progress through the mourning process as well as providing a framework for the therapist to educate the patient about normal grieving. It is often during this educative process that specific grief-related cognitive distortions come to light. The patient is asked to write an Impact Statement related to traumatic bereavement as the practice assignment for Session 2.

Session 2. Impact statement
Patient reads impact statement. Discuss implications of statement. Review material from first session. Introduce events-thoughts-feelings relationship. At the beginning of Session Two, patient is asked to read the impact statement aloud and the first portion of the session is spent discussing the implications of their statements. If your patient has not done his or her practice assignment, there are several steps that the therapist should take: First, the problem of avoidance should be discussed, emphasizing that in order for CPT to work the patient must commit fully. Second, the therapist should have the patient complete the assignment orally in the session. Third, it should be reassigned for the next session. Finally, the protocol should continue as prescribed with next assignment. Thus, a patient who avoided now has two practice assignments rather than desired effect of avoiding indefinitely. This same strategy should be implemented with any other assignment that is avoided. If the therapist postpones continuing the protocol, they will be inadvertently colluding with the avoidance and reinforcing procrastination. The next assignment should be assigned regardless of the quality of the practice assignments also. ASK participants if they have any questions regarding non-compliance of practice assignment.

Session 2. Patient reads impact statement
If patient doesn’t do practice assignment 1. Discuss the role of avoidance in maintenance of symptoms 2. Have the patient say what they would have written if they had done so 3. Therapist asks patient to write impact statement for next week 4. Therapist also assigns the next practice assignment as well. This is the first practice assignment. It is very important that the therapist respond carefully if the patient did not do the assignment to write the impact statement. If the therapist reassigns the impact statement but does not go on to add the next assignment, then the procrastination will have been reinforced. The therapist may need to explain the rationale for treatment again and explain why avoidance is not a good coping strategy, but is in fact a symptom that helps maintain the disorder.

Session 2. Patient reads impact statement
Goal: Patients examine the impact of the traumatic event on their lives. Therapist’s role is to determine whether this has been achieved and to use this examination to increase motivation for change Help identify stuck points in statement Ask about other areas that were not touched upon Highlight connection between thoughts and feelings The role of the therapist in the processing of the impact statement is two-fold: to highlight the connection between the patient’s thoughts and feelings and to help the patient start to identify some of his/her stuck points. Again, the goal is for the patient to examine how the traumatic event has had an impact on his/her life. The therapist needs to determine if the patient has done that sufficiently in this practice assignment. The therapist should ask about any topics that were left out of the essay. The therapist and patient should start a list of stuck points (see stuck point log). BEGIN talking about Socratic Questioning The therapist can begin some gentle Socratic questioning about self-blame or undoing that emerges. At the sign of any resistance, back off and point out that it is an important topic that will be addressed later. This is primarily a check for cognitive flexibility and to plant the idea that there maybe different ways to view the situation.

Impact Statements Being Processed “Carol”, “Matt”, & “Stacy”
Session 2 Impact Statements Being Processed “Carol”, “Matt”, & “Stacy” At this point, you may choose to INTRODUCE one or more of the videos of impact statements being processed. I will now play a video of a patient reading his/her statement. As you watch the video, try to listen for evidence of stuck points during this illustration just as you would in a therapy session and write down as many as you can. PLAY one or more of the videos and follow with a brief discussion of what was shown. Discussion Questions for Videos “Impact Statement Being Processed”: What were the stuck points of the patient? Which were assimilation vs. over-accommodation? What else did you notice while watching the impact statements?

Session 2. Introduce ABC worksheet
Using an example from the impact statement or something that the patient has mentioned, introduce the concept of labeling events, thoughts and emotions. Use an example from life of how most events are open to interpretation. Put on worksheet.

A-B-C Sheet Date: ___________ patient #: ______
ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Introduce the connection between events, thoughts, and feelings and explain the use of the ABC sheet. HAND OUT a sample ABC sheet. ASK participants to complete one from one of their own patients’ perspectives or from the perspective of a patient show in the previous video clip. NOTE: Therapists who have had cognitive-behavioral training will find this element of CPT quite similar to techniques they have used in the past. Therapists without this previous experience will likely not be as adept at discussing these relationships and using written handouts as illustrative tools. At the end of the session, you will assign the practice assignment for this session, which involves completing ABC sheets daily, including at least one related to the traumatic event. Is it reasonable to tell yourself “B” above? _____________________ _________________________________________________________ What can you tell yourself on such occasions in the future? ________________________________________ _____________________________________________________________________________

Session 2. Group Notes Introduce check-in and asking for group time ideas Pass out written group rules Have members read impact statements to group and look for stuck points Pass out phone list and ask everyone to call the person below them on the list In group therapy, the therapist starts the group by introducing the ideas of check-in and taking group time. Check-in is a brief check-in where patients go around the room and in 10 words or less state how they are doing and letting the leaders know if they will need time from the group that day to address an issue. This practice keeps the group moving without having one person immediately begin monopolizing the group or stating a crisis of the week. It also allows the group leaders to set the agenda by identifying how many people will need to focus on something specific in the group that day.

“Please complete the A-B-C Worksheets to become aware of the connection between events, your thoughts, feelings, and behavior. Complete at least one worksheet each day. Remember to fill out the form as soon after an event as possible. Complete at least one worksheet about the worst traumatic event. Also, please use the Identifying Emotions Handout to help you determine what emotions you are feeling.”

Session 3. Events, Thoughts & Emotions
Review A-B-C sheets. Using Socratic questions, help patient generate alternative thoughts and consequent feelings. Gently begin to challenge undoing or self-blame statements. INTRODUCE what happens in Session 3. In session 3, the ABC sheets completed for practice are reviewed and you should begin using Socratic questioning more intentionally to assist patients in identifying and beginning to confront stuck points. Specifically, the primary goal in this session is to begin to challenge undoing or self-blame statements and to assist patients in beginning to generate alternative ways of thinking. NOTE: During training, the major objective is to educate participants on how to conduct Socratic questioning, a skill that can sometimes be elusive even to experienced cognitive-behavioral therapists. Taking a “Columbo” approach is more effective than taking a more directive, typically argumentative, approach.

A-B-C Sheet Date: ___________ patient #: ______ Mr.A
ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” I get hit by an IED How did I make it and the guy next to me lost his leg? Confused Scared. Here are some examples of ABC sheets that have been filled out by patients. READ columns on the following sample ABC sheets so participants develop an idea of how they might be completed. Is it reasonable to tell yourself “B” above? _____________________ _____________________________________________________________________ What can you tell yourself on such occasions in the future? ___________________________ __________________________________________________

A-B-C Sheet Date: ___________ patient #: ____ Mr. B___
ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Child dies in my arms. “It was my fault that she died.” I feel incompetent and helpless. I avoid holding children and getting close to anyone. Is it realistic to tell yourself “B” above? _No. I did what I could to save her.____ What can you tell yourself on such occasions in the future? It wasn’t my fault. I did the best I could for her.

A-B-C Sheet Date: ___________ patient #: ____ Ms. C
ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” My grandfather abused me and I was hurt by other men in different ways “It was my fault because I looked like my grandmother and mother. All men cannot be trusted. Guilt Fear Rage Disgust Is it realistic to tell yourself “B” above? _The guilt was unreasonable- it wasn’t my fault- All men can’t be trusted is an unreasonable statement. What can you tell yourself on such occasions in the future? Each man is an individual- some men can’t be trusted, but not all.

ABC Worksheet: Showing Link Between Words and Emotion
Session 3: ABC Worksheet: Showing Link Between Words and Emotion “Matt” After a patient has read his/her ABC Worksheet, you will want to start processing it with him/her. You may choose to INTRODUCE the video of Matt processing his ABC Worksheet at this time and follow with a brief discussion of what was shown. I will now show you a video that shows the therapist processing an ABC sheet with “Matt”. Note how the therapist works with the patients to show the link between words and emotion. Discussion Questions for video “ABC Worksheet: Showing Link Between Words and Emotion”: How did the therapist show the patient the relationship between his beliefs (words) and his emotion? How did the therapist start to use Socratic Questioning to challenge the patient’s belief?

Session 3. Socratic questions
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) At this point in therapy, you will want to keep the Socratic Questioning gentle. You don’t want to challenge strongly maladaptive statements. Rather, try to clarify the link between thoughts and feelings, and work gently with assimilation.

Best/Less Optimal Practices in
Session 3: Best/Less Optimal Practices in Socratic Questioning “Chazz” You may wish to start this agenda item, by INTRODUCING the video “ Best/Less Optimal Practices in Socratic Questioning.” In this next video, you will see a therapist processing an ABC Worksheet with her patient, who is portrayed by an actor. The patient, Chazz, is a Iraq war veteran whose worst trauma was shooting into a car that refused to stop at a checkpoint despite the use of warning shots. After the shooting, a distraught man exited the car, and Chazz discovered he had killed a pregnant Iraqi women and her young child inside the car. This video is made up of 4 short clips. All of the clips start with Chazz reading what he has written on his ABC Worksheet. Then, each clip will be followed by the therapist responding in a different way and manner. As you watch, try to note the differences in the therapist’s response in each of the 4 clips, and how that affects the outcome. Note to Trainer: The 4 clips, in this order, depict questioning that is: 1) too validating; 2) off-track; 3) convincing; 4) best practice in Socratic questioning

Best/Less Optimal Practices in
Session 3: Best/Less Optimal Practices in Socratic Questioning “Chazz” Discussion Questions for “Best/Less Optimal Practices with Socratic Questioning” What was the statement from the ABC Worksheet that the therapist focused on? (i.e. “murdered innocent people.”) How did the therapist try to challenge (or not) this statement in each of the clips? What was the outcome that resulted from this approach? How did the therapist correctly use Socratic questioning in the fourth clip? What issues around blame and responsibility arose in these clips? How were they addressed? As you discuss the last question, you may want to CONTINUE with a discussion about issues of blame and responsibility. SEE FAQ’s at the end of this manual for this discussion.

Role-playing Activity with
ABC Worksheet You may choose to CONDUCT a role-playing activity at this point using the ABC sheets participants just completed. Options for Role-Playing Activity with ABC Sheets: Trainer-led: It may be helpful to have two trainers do an expert role play rather than involve participants initially. This suggestion is partly based on the fact that participants may have varying levels of understanding of Socratic questioning and trainers may find it difficult to observe every participant-pair in the room, limiting the effectiveness of basic participant role plays. In these expert role plays, one effective strategy is for the trainer playing the therapist to step out of character at “decision-point” moments and get suggestions from the audience for which direction to go in to maximize effectiveness of the line of questioning. Participant Pairs: Participant role plays may be effective in cases where participants are more advanced cognitive-behavioral therapists who have a good understanding of Socratic questioning and in cases of small groups of participants. If these participant role plays are used, trainers should observe each pair for at least a few minutes to monitor progress and also to generate ideas for suggestions to share to the group. After the role-playing is done, ASK participants to share their experiences from the activity, including the issues that arose (e.g., examples of beliefs and stuck points) and how they were addressed.

A-B-C Sheet Date: ___________ patient #: ______
ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Sample ABC sheet for to project during role-playing activity. Is it reasonable to tell yourself “B” above? _____________________ _________________________________________________________ What can you tell yourself on such occasions in the future? ________________________________________ _____________________________________________________________________________

Session 3. Group Notes Check-in/Group time
Process the A-B-C sheets – each member shares at least one. Make process statement regarding silence and how that continues the trauma. Discuss ways patients avoid in group (e.g., story telling, silence, disruptive behavior). Have patients call the person 2 down on the phone list. In group therapy, by this point it is usually apparent that some members are more silent than others. It is good to have a discussion about silence by asking the group how staying silent is related to the trauma. The leaders can point out that many times people are given direct and/or indirect cues to stay silent after a trauma (e.g. family, friends, perpetrator, military). But staying silent often perpetuates the problem instead of alleviating it, but not allowing the individual to receive support or to feel understood. It may be helpful to suggest that in order for all members to benefit equally from group, the more quick to vocalize individuals might want to try counting to three to allow the quieter folks time to talk. You can also ask what stuck points people may have about talking in group, such as, “my ideas are stupid”, “no one wants to hear what I have to say”, “I don’t have anything new to add.” The therapist should break eye contact with the speaker so that others in the group are empowered to respond first.

“Please begin this assignment as soon as possible. Write a full account of the traumatic event and include as many sensory details (sights, sounds, smells, etc.) as possible. Also, include as many of your thoughts and feelings that you recall having during the event. Pick a time and place to write so you have privacy and enough time. Do not stop yourself from feeling your emotions. If you need to stop writing at some point, please draw a line on the paper where you stop. Begin writing again when you can, and continue to write the account even if it takes several occasions.“ Read the whole account to yourself every day until the next session. Allow yourself to feel your feelings. Bring your account to the next session. Also, continue to work with the A-B-C Worksheets every day.” INTRODUCE the practice assignment for Session 3 (the written account) Practice assignment: to write a vivid account of the traumatic event and read it aloud every day. While many therapists will have already identified an “index trauma” through pre-treatment assessment or the brief discussion in session one prior to the assignment of the impact statement, those who haven’t will need to do so at this point. Strategies for identifying this event in individuals who are multiply traumatized: Which one was the worst? Which one causes the most reexperiencing symptoms? Which event do they avoid thinking about or talking about the most?

EXPLAIN the concept of the written account in CPT.
The goal of the account is to allow natural emotions (e.g., fear, anger) to run their course and to assist with identifying stuck points that may benefit from the cognitive interventions to follow. NOTE: Trainers should plan to address therapist concerns about exposure techniques, including a discussion of how even in cases where symptoms are temporarily increased, the end result is typically a significant reduction in PTSD symptoms. Thus, when patients start having more intrusive thoughts or stronger emotions, they are doing exactly what they should be doing at this point in the therapy. As these natural emotions do run their course, the symptoms will not only subside, but typically start a significant downward trend continuing through the remainder of therapy. In cases where patients are experiencing particularly high levels of anticipatory anxiety, you can suggest completing an ABC sheet on the situation of writing the account before ending the session to minimize avoidance of the assignment.

Assignment of Written Account
Session 3 Group Therapy: Assignment of Written Account You may choose to INTRODUCE Video “Group Therapy – Assignment of Written Account” at this point. In both group and individual therapy, patients may have questions and doubts about completing the account. This next video depicts the assignment of the written account in a group therapy. As you watch the video, look for specific questions and concerns that are raised by the patients. Discussion Questions for Video “Group Therapy- Assignment of Written Account”: What question or concerns did patients have about the assignment? (e.g., felt they had more than one traumatic account, fear that they couldn’t “handle” writing it;” had more a “general experience” than one trauma, confidentiality of written account) How did the therapist address these issues or concerns? What were some of the dynamics in the group that helped the therapist or made it more challenging to address concerns?

Session 4. First Account Patient reads account aloud to therapist.
After patient reads account, patient 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. INTRODUCE what happens in Session 4. At the start of session 4, patients are asked to read their written account aloud. The therapist and patient then discuss reactions to writing and reading it. Finally, the therapist gently challenges assimilation issues (self-blame and hindsight bias). If the patient does not bring in the account, have him/her do it orally in session after discussing problem of avoidance again.Then reassign with problem solving about removing barriers. If the account is incomplete, wait until the person stops reading, let them finish feeling emotions, then go back in and try to fill in the missing parts. Notice if the person glossed over a section.

Review the goals of the Account.
Here are the goals of the written account. The key to successful Socratic questioning is knowing where the line of questioning is headed. If you have an end point in sight (e.g., getting patient to acknowledge lack of responsibility or intent), you can keep asking questions directing the patient down this path. However, it is important to maintain the questioning format in order to allow patients to come to insights on their own.

Reading of Written Account: Recovery from Mistakes “Victor”
Session 4 Reading of Written Account: Recovery from Mistakes “Victor” You may now choose to INTRODUCE video “Reading of Written Account: Recovery from Mistakes.” I am now going to play a video that shows a patient reading his account. Note what the therapist does during the reading of the account. [stop after black screen and discuss] Discussion Questions for Video “Reading of Written Account: Recovery from Mistakes”: What did the therapist do during the reading of the account? Did she do anything wrong? What? Why was it wrong? The therapist realizes her mistake and corrects it… PLAY second part of the Video. Discuss the difference. Generally, the role of the therapist at this point should be to “get out of the way.” Asking questions after an account is completed is fine, but doing so during the reading typically derails patients from fully experiencing and expressing their emotions, a primary goal of the task. After reading, allow patient to sit with emotions, then label. Then later, move to stuck points and Socratic questioning.

Written Accounts with Initial and Socratic Questioning
Session 4 Written Accounts with Initial and Socratic Questioning “Carol” (2 clips) and “Matt” You may choose to INTRODUCE videos on written accounts with initial and Socratic questioning. This next video(s) will show patients reading the end of their written account and the therapist processing the written account with Socratic Questioning. Note how the therapist uses Socratic questioning to challenge self-blame statements and hindsight bias. Discussion Questions for Videos on written accounts with initial and Socratic questioning: For the video with Carol’s written account, what is her affect (discuss emotional numbing of “Carol”) What were some of the statements made in the written account that the therapist started to challenge in the video(s)? How did she challenge them? EXPLAIN the practice assignment for Session 4. You may wish to further illustrate this assignment by noting areas within the video clip that may require additional attention. The practice assignment is to rewrite the trauma account with greater detail and attention to emotions, again reading it every day.

Session 4. Group Notes Check-in/ Group time
Discuss what is was like to write accounts. What new Stuck Points were found? For mixed traumas - remind patients not to share explicit details of their trauma in group Continue using ABC sheets and help challenge stuck points regarding self-blame, undoing, other assimilation. Call 3 down on the phone list If you are conducting a mixed-trauma group the members do not discuss their trauma accounts per se in group, but spend time talking about what it was like to do the practice assignment and thus can normalize each other’s reaction to the assignment. This is also a time when they begin to see that they all have many of the same stuck points and that they are not alone. Therapist should model Socratic questioning as they discuss the stuck points that emerge from account or on ABC sheets. Focus should continue to be on self-blame, “if onlys”, How many of the group were able to shift their thinking about the event when they put it back into context (who they were at the time, what the circumstances, their intentionality, etc.)

“Write the whole incident again as soon as possible. If you were unable to complete the assignment the first time, please write more than last time. Add more sensory details, as well as your thoughts and feelings during the incident. Also, this time write your current thoughts and feelings in parentheses (e.g., “I’m feeling very angry”). Remember to read over the new account every day before the next session. Also, continue to work with the A-B-C Worksheets every day.”

Session 5. Second Account
Patient reads second account of incident. Patient and therapist continue to process any remaining self-blame or undoing. Therapist introduces Challenging Questions Worksheet. INTRODUCE what happens in Session 5. In session five, the patient reads the second account of the traumatic event with continued processing of remaining self-blame or undoing. While this is technically the last of the formal written account assignments, therapists may actually request that patients re-write or at least continuing reading their account daily. This process is important in cases where the patient’s PTSD symptoms haven’t declined (thus the importance of continuous measurement of symptoms) and it is clear that they haven’t experienced any emotions at home or in the session. Alternatively, therapists may assign the writing/reading of a new account if the patient has an additional traumatic event that wasn’t resolved by working with the index trauma.

Challenge of Patient Not Wanting to Do Written Account
Session 4 Group Therapy: Challenge of Patient Not Wanting to Do Written Account You may choose to INTRODUCE video “Group therapy – challenge of patient not wanting to do written account” at this point. Discussion Questions for Video “Group Therapy- Challenge of Patient Not Wanting to Do Written Account”: What reason did the patient (“Martin”) give for not wanting to do his second written account? How did being in a group therapy setting help to address this challenge (i.e., what did other patients say?) What did the therapists say to help convince him to try? NOTE: After addressing potential challenges in getting patients to complete their written account, you may wish to take a break before starting the training item on the “Art of Socratic Questioning.” TELL patients that you will be discussing the Challenging Questions sheet, which is first introduced to patients at the end of Session 5, at the end of the day and first thing tomorrow, after spending some more time on Socratic Questioning.

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? Are your interpretations of the situation too far removed from reality to be accurate? Are you thinking in all-or-none terms? After addressing any remaining questions or concerns about the written account element of CPT, DESCRIBE the second half of the therapy, starting with the introduction of the Challenging Questions Sheet at the end of session five. REVIEW a sample challenging questions sheet. The challenging questions are to be targeted to one specific thought (written at the top of the page) as opposed to the upcoming Patterns of Problematic Thinking which are more generalized ways of thinking. Not all questions will apply to every situation. ASK participants to work through the challenging questions on a specific thought related to one of their own patients or a case carried through the training because the challenging questions can sometimes be difficult to tease apart.

Challenging Questions Continued
Are you using words or phrases that are extreme or exaggerated? (i.e., always, forever, never, need, should, must, can’t and every time). Are you taking selected examples out of context and only focusing on one aspect of the event? 7. Is the source of information reliable? Are you confusing a low probability with a high probability? Are your judgments based on feelings rather than facts? 10. Are you focusing on irrelevant factors? REVIEW the practice assignment for Session Five. The practice assignment for session five is twofold. Patients are asked to complete a Challenging Questions Sheet every day. They are also asked to write a new trauma account if there is a second index trauma or to re-write and/or read the initial account if the patient’s emotional distress has not lessened. It is recommended that patients keep reading their trauma accounts until they can do so with very little emotional distress (therapist may need to help the patient differentiate numbness from being finished processing the emotions).

If needed, normalize that all emotions are permitted in group, including anger at group leaders. Discuss. Do 1 challenging questions sheet together in group on a common topic such as “I am never safe” or “ I don’t trust other people.” Have patients call anyone on phone list. Some patients feel frustrated with the therapist at this point for making them do the accounts again. In addition, patients may begin rubbing each other the wrong way due to personality differences. At this time it is good to make a process statement that all emotions are acceptable and then asking the group about their stuck points that keep them from feeling or expressing their emotions in a healthy way. The group does one challenging questions together. Find a stuck point that most individuals in the group can relate to. Give all members a blank worksheet and a pen and have them right down their answers to the questions. It is helpful to have a dry erase board also to write on for those individuals who are slower to write than others.

“Please choose one stuck point each day and answer the questions on the Challenging Questions Worksheet with regard to each of these stuck points. There are extra copies of the Challenging Questions Worksheets provided, so you can work on multiple stuck points. If you have not finished your accounts of the traumatic event(s), please continue to work on them. Read them over before the next session and bring all of your worksheets and Trauma Accounts to the next session.” ASSIGN out-of-training practice for Day 2 of Training: Completing a Challenging Questions Sheet.

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. The patient and therapist begin this session by reviewing the Challenging Questions Sheets to question single statements or beliefs. For patients who had difficulty challenging their beliefs, therapists should be prepared to utilize Socratic questioning to further this challenging process. Use the worksheets as a tool for the patient to question their own assumptions. Therapist does not need to keep listening to the account in the session but should check to see that the client is still reading it every day if needed. If the client is still avoiding, numb, or still has strong emotions, then he or she should keep reading. When he or she is bored with it, it is time to stop. Other events can be written about in the background but don’t need to be.

Role-Playing Activity on Challenging Questions Worksheet
You may choose to CONDUCT a role-playing activity at this point to allow participants to practice processing a Challenging Questions Sheet with a patient: Options for Role-Playing Activity with Challenging Questions Sheet Trainer-led: You can ask for a volunteer to join you at the front of the room. Ask him/her to share their Challenging Questions Sheet with other participants and then role-play the processing of the worksheet with the participant. Participant Pairs: This option is optimal because it allows everyone to practice the use of Socratic Questioning with a worksheet and to being developing the skills to use it. If these participant role plays are used, trainers should try to observe each pair for at least a few minutes to monitor progress and also to generate ideas for suggestions to share to the group. After the role-playing is done, ASK participants to share their experiences from the activity, including the issues that arose (e.g., examples of beliefs and how challenging questions were answered) and how the person who played the “therapist” processed the worksheet using Socratic Questioning.

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. In session six, the therapist also introduces the Patterns of Problematic Thinking Worksheet in order to identify the patient’s typical problematic ways of thinking. It is important to understand the distinction between using the challenging questions for a single thought and identifying problematic thinking patterns through troublesome habits of thinking. Often, patients will identify a couple of problematic thinking patterns that they continually find themselves engaging in. Finding these patterns assists patients with recognizing that thoughts are not necessarily facts, thus making the need for restructuring the distressing beliefs more apparent. Understanding a typical habit of thinking can also help the patients recognize how they can move down the wrong path. They may be able to catch themselves sooner. Assigned practice is for the patient to look for examples of Patterns of Problematic Thinking in his/her daily interactions.

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. Encourage the client to notice when they think about the trauma if there are typical patterns of responded as well.

Have members share a Challenging Questions worksheet with the group. Do another one as a group if needed. As they do multiple worksheets, are they detecting any themes across them? Have patients discuss items they wish they would have brought up in past groups. Have patients call anyone on the list. Have group members share a Challenging Questions worksheet . If someone gets stuck, have the group members help answer the questions. If needed, do another common stuck point with the whole group. Ask the group members to look over their worksheets and notice if any consistent themes appear; particular stuck points that keep coming up? Have they accepted the event and finished feeling their emotions? Ask patients if they are not bringing up topics or questions in prior groups that they wish they had. Talk about stuck points that might get in the way of asking for help. Talk about expectations group members might be placing on themselves to have made more gains at this point in therapy.

“Consider the stuck points you have identified thus far and find examples for each of the problematic thinking patterns listed on the worksheet in your day to day life (or over the course of the next week). Look for specific ways in which your reactions to the traumatic event may have been affected by these habitual patterns. Continue reading your accounts if you still have strong emotions about them.” If client had difficulty with the Challenging Questions Worksheet, therapist may want to assign another one as well as the Patterns of Problematic Thinking Worksheet. In CPT-C, the patient is asked in Session 6 to focus the Challenging Beliefs Worksheet on the worst traumatic event as well as everyday events. The Safety Module is not assigned until the next session, Session 7, and the two versions of the therapy are identical thereafter.

Session 7. Problematic Patterns
Patient and therapist review Patterns of Problematic Thinking. Therapist introduces Challenging Beliefs Worksheets. Therapist introduces Safety module. In Session 7, you begin by reviewing the Patterns of Problematic Thinking Worksheet and noting which were most commonly experienced and the affect of having these automatic patterns. Ask the patient how these patterns relate to their stuck points and have stopped them from processing the traumatic event completely. You will then introduce the Challenging Beliefs Worksheets. These worksheets are the culmination of the cognitive work learned up to this point. Show the patient how all of the previous worksheets fit into this new worksheet. (e.g., ABC sheet, challenging questions, problematic thinking patterns). In fact, only the last column consists of new material. Aside from working on previous stuck points about the trauma, the patient is also asked to think about safety and complete at least one worksheet on that theme.

REVIEW and EXPLAIN the Challenging Beliefs Worksheet.
A. Situation B. Thoughts 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% C. Emotion(s) Specify sad, angry, etc., and rate how strongly you feel each emotion from 0-100% Evidence? Habit or Fact? Interpretations not accurate? All or none? Extreme or exaggerated? Out of context? Source unreliable? Low versus high probability? Based on feelings or facts? Irrelevant factors? Jumping to conclusions Exaggerating or minimizing Disregarding important aspects Oversimplifying Overgeneralizing Mind reading Emotional reasoning G. Re-rate how much you now believe the thought in Column B from 0-100% H. Emotion(s) Now what do you feel? 0-100% Jumping to conclusions Exaggerating or minimizing Disregarding important aspects G. Re-rate old thoughts At this point, you may want to HAND out sample worksheets or HAVE participants complete one themselves. You may choose to HAVE participants complete a CBW using an example of a patient who believes “Because I killed, I am dangerous.” This example can later be used in a role-playing activity on the CBW and safety. REVIEW and EXPLAIN the Challenging Beliefs Worksheet.

Challenging Beliefs Worksheet A. Situation B. Thoughts
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% I feel uncomfortable and unsafe with Asian people While I was in VN I couldn’t tell friend from foe. It was impossible to tell who was the enemy and might try to kill me. 80% C. Emotion(s) Specify sad, angry, etc., and rate how strongly you feel each emotion from 0-100% Fear 70%, Anger 50%, Frustration 50% Evidence? For: This did happen in VN.. Against: That was a long time ago in a totally different environment. Habit or Fact? It has become a habit to distrust all people, especially Asians. Low versus high probability? There is a low probability that any Asian would try to harm me. Based on feelings or facts? My feelings are derived from my service in VN. Are they relevant today? They are not relevant today. Irrelevant factors? Jumping to conclusions I am drawing the conclusion that all Asian people are untrustworthy and dangerous to me. Exaggerating or minimizing Disregarding important aspects Oversimplifying Overgeneralizing Mind reading Emotional reasoning Because I feel scared around Asian people, I am in danger around them. Because of my time in VN, I have some understandable, but irrelevant, feelings around Asian people. As a group, they are not dangerous to me. 90% G. Re-rate how much you now believe the thought in Column B from 0-100% 40% H. Emotion(s) Now what do you feel? 0-100% Fear 50% Anger 20% Frustration 30% Jumping to conclusions Exaggerating or minimizing Disregarding important aspects Column A, the situation, is open to current life events as well as directly trauma-related situations. In Column B, though patients might write down multiple beliefs, therapists should help identify one belief to carry through the remainder of the worksheet. Make this belief as specific as possible. Patients are now asked to rate how much they believe this thought, so this may require some explanation. For example, earlier in the therapy a patient may have believed the thought 100%, but at this point, he may already start out at a smaller percentage than that. The goal is to simply reduce this percentage by the end of the worksheet. The bottom of that column is Section C, which asks for a list of the emotions caused by the thought(s), including rating the strength of each emotion. Challenging the problematic thought starts in Column D, where the challenging questions are asked of the thought that is most strongly held/most problematic. Patients may need to refer back to the challenging questions sheet although they are abbreviated here for convenience. In Column E, the relevant problematic thinking patterns are listed; you are looking for relevant typical patterns here. Finally, the new information for the patient is held in Column F. For the first time, they are directly asked to generate an alternative thought and to re-rate the strength of their original belief and emotions.

Session 7. Introduce Safety
Beliefs related to Self Belief you can protect yourself from harm and have some control over events Associated symptoms include anxiety, intrusive thoughts about danger, irritability, startle responses, intense fears about future dangers At the end of this session, you will introduce the first of five modules about themes typically relevant to traumatized individuals. While the modules are designed to apply to a broad range of circumstances and are sequential in nature, some modules may be more relevant than others to specific patients. While all should be addressed at least at a cursory level, you and your patient can emphasize those themes that are most useful. In this session, the Safety module is introduced. You may wish to discuss some of the types of beliefs patients hold about safety related issues. Remember that each theme is to be explored with regard to self and others. Self safety would be concerns veterans may have about their ability to keep themselves safe.

Session 7. Introduce Safety
Beliefs related to Others Belief abut dangerousness of other people and expectancies about the intent of others to cause harm, injury, or loss Symptoms include avoidant or phobic responses, social withdrawal They may also have concerns about the level of dangerousness in others and over-estimate their level of risk. ASK participants to generate examples of safety concerns (e.g. walking the perimeter of their homes each night; thinking that others are actively trying to harm them).

Have each person identify their most problematic thinking patterns and talk about how they affect one’s life. Do Challenging Beliefs Worksheet together as a group on a common stuck point such as “I must be on guard or bad things will happen to me” Have group members go around the room and identify the problematic thinking patterns they tend to engage in the most. Members will begin to see how much they are alike in their response. How do these relate to their stuck points about the traumatic events? Ask members to discuss ways they can avoid falling into these patterns. Leave at least 25 minutes to do 1 CBW together. Pick a stuck point that would be fairly common to all of the members. Give each group member a blank page and a pen and have them write down their own answers. Use of a dry erase board would also be helpful.

“Use the Challenging Beliefs Worksheets to analyze and confront at least one of your stuck points each day. Please read over the module on safety and think about how your prior beliefs were affected by the [event]. If you have safety issues related to yourself or others, complete at least one worksheet to confront those beliefs. Use the remaining sheets for other stuck points or for distressing events that have occurred recently.” DESCRIBE the practice assignment for Session 7 The practice assignment is for the patient to read the safety module and complete Challenging Beliefs Worksheets on stuck points daily, with at least one related to safety. With the introduction of these modules comes a greater emphasis on problems with over-accommodation, whereas the first six sessions were more focused on addressing assimilation. All the building blocks of the therapy beginning with the ABC sheet culminate in this ability to generate alternative, more realistic thoughts and then rate the strength of that belief against their old belief. Finally, the patient should notice how he/she feels when challenging the old thought and generating a more balanced one. The therapist needs to reinforce the notion that these thoughts should be evidence-based and realistic, not just “positive thinking.” ENSURE that participants fully understand all the components of the Challenging Beliefs Worksheet as the remainder of CPT utilizes this worksheet by taking any questions. Again, having participants complete a worksheet is an excellent test of their gained skills. NOTE: At some point in the discussion of these last five sessions, you will want to show at least one of the available video clips of a patient and therapist working through a completed worksheet is recommended.

Session 8. CBW and Safety Patient and therapist review worksheets.
Patient and therapist discuss safety issues. Therapist introduces Trust module. INTRODUCE Session 8. The session begins with a review of the completed worksheets, focusing specifically on safety issues. If the patient did not complete a worksheet directly related to the trauma, this should be done in the session. Most important concept in working with safety issues is to consider the probability of a bad thing happening. Patients with PTSD tend to over estimate the probability that something will happen. You cannot say that they are safe, but you can have them look over their lives and give a more realistic estimate of the likelihood (daily, weekly, monthly, yearly, decades) of something traumatic happening.

Using Challenging Beliefs Worksheet to Address Safety
Session 8 Using Challenging Beliefs Worksheet to Address Safety “Stacy” You may choose to INTRODUCE video “Using Challenging Beliefs Worksheet to Address Safety” This next video(s) will model the use of the Challenging Beliefs Worksheet to address safety. Discussion Questions for Video “Using Challenging Beliefs Worksheet to Address Safety”: What was the issue related to safety that “Stacy” addressed in her CBW? How did the therapist help her process her CBW?

Role-Playing Activity on
CBW and Safety Issues You may choose to CONDUCT a role-play activity at this point, using the CBW that participants filled out earlier (if they filled it out for a patient who believes “I am dangerous because I killed”). After the role-playing is done, ASK participants to share their experiences from the activity, including how the “therapist” in the role-play reinforced the notion that these thoughts should be evidence-based and realistic.

Session 8. Introduce Trust
Beliefs related to Self Belief you can trust or rely upon one’s own perceptions or judgments. Important part of self-concept and serves important self-protection function. Associated symptoms include feelings of self-betrayal, anxiety, confusion, overcautious, inability to make decisions, self-doubt. When introducing trust, begin to introduce the concept of different types of trust and that all fall on a continuum. The question for the therapist to ask is “trust with regard to what?” “Because I made a mistake in this situation, I can’t trust my judgment in any way” is a common self-trust stuck point. First, the therapist needs to establish that the patient indeed made a mistake (it is likely that in the traumatic event, they may not have had another viable option). If this has been thoroughly explored, the therapist can challenge why one event should be generalized to all other situations in life. Generate ways in which the patient has been able to trust him or herself, even if it is something small or mundane. Any exceptions to an extreme statement can be used to move the patient away from that extreme. Help the patient to see how a more moderate statement feels compared to the extreme statement.

Session 8. Introduce Trust
Beliefs related to Others Belief that the promises of other people or groups with regard to future behavior can be relied upon. A person needs to learn a healthy balance of trust and mistrust and when each is appropriate. Associated symptoms include disillusionment, fear of betrayal, anger and rage, suspiciousness, fleeing from relationships. In what ways can you trust particular other people (secrets, loaning money, attacking you, not using information against you, being there when they say they will be, etc.)? [Refer to star drawing in manual] Teach the concept of starting at a zero point (no information) rather than starting with complete distrust or complete trust. Collect information over time through your experiences or watching how they are with others. Just because you might not completely trust someone in one way doesn’t mean you can’t trust him other ways. This might be a good time to introduce the idea of giving people second chances after giving them feedback on their mistakes.

Each member discusses their Challenging Beliefs Worksheet. Encourage patients to help each other identify dysfunctional thinking. Do a Challenging Beliefs Worksheet together as a group if needed. What risks do you take in group and in your daily life? If this were the last group what would you regret not getting out of group? Ask group members to begin commenting when they hear other groups members make extreme statements or use problematic thinking patterns. Do a CBW together if group is still having difficulty understanding the concepts. Focus on trust issues. Ask one or both of the process statements about taking risks and what would they regret not getting out of the group is the group ended today. Use these statements to motivate patients to address more of their core beliefs or to extrapolate what they are learning to more areas of their lives.

“Please read the Trust Module and think about your beliefs prior to experiencing [event] as well as how the event changed or reinforced those beliefs. Use the Challenging Beliefs Worksheets to continue analyzing your stuck points. Focus some attention on issues of self or other-trust, as well as safety, if these remain important stuck points for you.”

Session 9. Trust Issues Patient and therapist review practice on trust issues and other completed Challenging Beliefs Worksheets. Therapist introduces Power/Control module. INTRODUCE Session 9. In Session 9, the patient and therapist begin by reviewing practice assignment on trust issues and other completed worksheets. When the patient (or patient and therapist) comes up with an effective worksheet, ask the her to re-read it so that it starts to feel more comfortable. At session 7-9, it is not uncommon for client to say “I know that this makes sense to say it this way, but I feel…” This indicates that the client has reached a midway point. Emotions are attached to the old way of thinking and the new way of thinking is still unfamliar. Therapist should reassure the patient, that as he practices the new, more balanced way of thinking, it will become more comfortable and will seem more natural.

Role-Playing Activity on
CBW and Trust You may choose to CONDUCT a role-playing activity on using the CBW to address trust at this point. You can either allow participants to fill out a CBW with a participant who believes that he/she “can’t trust anything the government does” or fill one out prior to the training, and hand out copies to participants for the role-plays. After the role-playing is done, ASK participants to share their experiences from the activity, including how the “therapist” in the role-play reinforced the notion that these thoughts should be evidence-based and realistic.

Session 9. Introduce Power/Control
Beliefs related to Self Belief you can solve problems and meet challenges. Associated with capacity for self-growth. Belief one must be in control of oneself at all times Belief one is helpless to control anything Symptoms include numbing, avoidance of emotions, passivity, hopelessness, depression, self-destructive patterns, outrage when events seem out of control. The therapist then introduces the power/control module, asking the patient to begin thinking about ways in which his or her traumatic experience has influenced beliefs about their own power/control as well as that of others. With regard to self, this involves the belief that one can solve problems and meet challenges as well as beliefs that one must be in control of oneself at all times or the belief that one is helpless to control anything. The therapist should again pose “Control with regard to what? Emotions? Other people?” It is very difficult to challenge a large or vague concept. Bring it down to specific events to challenge.

Session 9. Introduce Power/Control
Beliefs related to Others Belief that others have more control than you do; that others have power or attempt to control you. Associated symptoms include passivity, submissiveness, lack of assertiveness, or conversely, anger, controlling behavior. With regard to others, this is the belief that others have power or control over you and that you are helpless to effect change. Again, for veterans, beliefs about the government or about authority more generally may arise here.

Each person shares at least one Challenging Beliefs Worksheet Discuss cues that someone is trustworthy Identify trust beliefs by using the thoughts they had of each other when group first started compared to current thoughts Have trust discussion similar to individual session, but ask for more group member input. Talk about the way in which PTSD can create illogical trust beliefs by asking members to talk about how their beliefs about each other or even the co-leaders are different now than when they first started the group. What made them change? What could they do next time when they meet someone new?

“Use the Challenging Beliefs Worksheets to continue to address your stuck points. After reading the Power/Control Module and thinking about it, complete worksheets on this topic.” DESCRIBE the practice assignment for Session 9 For practice the patient is to read the esteem module and complete worksheets on stuck points with at least one on control.

Session 10. Power and Control
Patient and therapist review control/power issues and other Challenging Beliefs Worksheets Therapist introduces Esteem module. INTRODUCE Session 10. In session 10, control/power issues and other worksheets are reviewed. If the patient has a perception of no control, have her list all of the decision she made since she got up in the morning (whether to hit the snooze alarm, wash hair, dress, eat, etc.). It doesn’t take long for her to realize how much control she does have. Conversely, she can’t control traffic, the weather, other people, etc.

Using Challenging Beliefs Worksheet to Address Control
Session 10 Using Challenging Beliefs Worksheet to Address Control “Carol” You may choose to INTRODUCE video ““Using Challenging Beliefs Worksheet to address control” This next video(s) will model the use of the Challenging Beliefs Worksheet to address control. Discussion Questions for Video “Using Challenging Beliefs Worksheet to Address Control”: What was the issue related to control that ““Carol”” addressed in her CBW? How did the therapist help her process her CBW?

Session 10. Introducing Esteem
Beliefs related to Self Belief in your own worth. Being understood, respected, and taken seriously is basic to the development of self-esteem. Symptoms include depression, guilt, shame, self-destructive behavior. The therapist will then introduce the esteem module and the new behavioral assignments to enhance esteem to serve as relapse prevention for depressive symptoms (behavioral activation with pleasant events scheduling to facilitate social engagement. Self-esteem has to do with belief in your own worth. Like the other concepts the patient needs to break it down into smaller components and think in terms of a continuum. Have the patient think about the various roles in his life. Are they all equal and does he behave the same in all of them? How does he vary across situations within a role? Focus on and challenge specific events as “proof” of bad worth. Perfectionists have a pass-fail system (100%= A, 99%=F). How would you feel about a teacher who did that? Why do you? Assume that 90% is an A and 80% is a B. So what was your grade yesterday? Last week? Last month? Assign worksheets to examine these concepts.

Session 10. Introducing Esteem
Beliefs related to Others Beliefs about other people that match the reality of the other person and are revised as new information is received. Examples: People are uncaring, indifferent, selfish People are bad, evil, or malicious. Symptoms include anger, contempt, bitterness, cynicism, isolation or withdrawal, antisocial behavior. Other-esteem involves having beliefs about other people that match the reality of the other person and are revised as new information is received. You may need to deal with the government under this category. Who is the government? (Hint. This term is too big too). The postal carrier?, the ambulance driver? Your representative to the state legislature? We the people? “People in authority” is also a typical stuck point that falls under other esteem. This may have arisen during the military but has overgeneralized to anyone perceived to be in this category (employers, parents, doctors, etc.). The strategy is the same as many other concepts. Get your foot in the door by finding an exception, then don’t allow the patient to say “all” or “everyone” again. Have them notice the difference in their emotional reactions when they say “all” (rage) versus “some” (irritation).

Discuss ways of giving and taking power negatively and positively. Have group members generate ways in which they do all 4 of these, perhaps even in the group. Have group members talk about ways that they continue to take or give power away negatively and positively at home and in the group. Talk about the stuck points that create this behavior. Have patients do CBW’s on any stuck points that are identified in group as part of their practice assignment.

“After reading the Esteem Module, use the worksheets to confront stuck points regarding self- and other-esteem. In addition to the worksheets, practice giving and receiving compliments during the week and do at least one nice thing for yourself each day (without having to earn it). Write down on this sheet what you did for yourself and who you complimented.” DESCRIBE the practice assignment for Session 10. The assigned practice assignment includes reading the esteem module and completely the worksheets, including at least one on esteem. In addition, the patient is asked to practice giving and receiving compliments and doing nice things for themselves as a way to build esteem. This additional assignment can be easily overlooked as it is unique in these last five sessions. However, it is very useful in assisting patients with recognizing potentially difficulties with esteem. This assignment can be extended into the next session if it seems to be particularly helpful.

Session 11. Esteem Issues Patient and therapist review esteem issues and other Challenging Beliefs Worksheets. Patient and therapist review other practice. Therapist introduces Intimacy module. INTRODUCE Session 11. In session 11, the patient and therapist begin by reviewing esteem issues and other worksheets. Review what it was like giving and receiving compliments. Did these activities generate any stuck points? Were they able to take in the compliments? If they are not their own best source of information, can they look to see how people are reacting and what they are saying (without mind reading?). How was it to engage in pleasant activities. Did they feel good about it or that they didn’t “deserve it”? If so, challenge the stuck points. Reassign the daily compliments and doing nice things for self for life.

Using Challenging Beliefs Worksheet to Address Esteem
Session 11 Using Challenging Beliefs Worksheet to Address Esteem “Stacy” You may choose to INTRODUCE the video “Using Challenging Belief Worksheet to Address Esteem” at this point. This next video(s) will model the use of CBW to address esteem. Discussion Questions for Video “Using Challenging Beliefs Worksheet to Address Esteem”: What was the issue related to esteem that “Stacy” addressed in her CBW? How did the therapist help her process her CBW?

Session 11. Introducing Intimacy
Beliefs related to Self Self-intimacy is ability to soothe and calm oneself. Reflected in the ability to be alone without feeling lonely or empty. Associated symptoms include inability to comfort or soothe self, fear of being alone, feeling of inner emptiness or deadness, use of external sources of comfort, needy or demanding relationships. The therapist then introduces the intimacy module. Self-intimacy is the ability to soothe and calm oneself, and rely on ones own internal resources whereas If the patients feel “weird”, “different”, or don’t know who they are anymore, use examples, such as leaving college, moving out of adolescence, or retiring to talk about transitions we all make when we are not quite sure who we are and we have to go through a process of rediscovery. If the traumas had not happened, they would be going through this process anyway. Now that they don’t have to spend all of their time and energy holding their memories and emotions back, who would they like to be? What would they like to do or learn? What could they do in the future to self soothe when they are upset instead of eating, picking up the phone, drinking, or spending? (Hint. They could use a worksheet).

Session 11. Introducing Intimacy
Beliefs related to Others Need for intimacy, connection, and closeness is a basic human need. This can be damaged through insensitive, hurtful, or non-empathic responses from others. Associated symptoms include loneliness, emptiness or isolation, inability to connect with others. Other-intimacy involves feelings about relationships including, but not limited to, sexual relationships. After discussing intimacy, this is a good time for the therapist to suggest any remaining stuck points that haven’t been sufficiently addressed and to assign them specifically as the final session is imminent.

Discuss pressure group members may be putting on themselves to be further along in treatment or comparing themselves to each other Discuss worry they may have about aftercare Pressure patients may be putting on themselves may have intensified even more at this point. Strong comparisons may be arising in patients who had done no comparing in the past. Often patients who were most reticent to do the treatment, and thus had a late start with their accounts or their sheets, are often the most affected by this issue at this point. Talk about options for aftercare. The most common referrals if further treatment is needed are a few sessions of individual CPT to challenge more cognitions, marriage counseling, aftercare CPT group that focuses on further challenges, or relapse prevention groups.

“Use the Intimacy Module and Challenging Beliefs Worksheets to confront stuck points regarding self- and other-intimacy. Continue completing worksheets on previous topics that are still problematic. Please write at least one page on what you think now about why this traumatic event(s) occurred. Also, consider what you believe now about yourself, others, and the world in the following areas: safety, trust, power/control, esteem, and intimacy.” DESCRIBE the practice assignment for Session 11. For the practice assignment, the patient is asked to read the intimacy module and complete worksheets including at least one on intimacy. In addition, a final assignment designed to wrap-up the therapy process is given: the writing of a new impact statement. This final impact statement allows patients to recognize changes in the way they view the meaning of the event and how it currently affects them in the areas of safety, trust, power/control, esteem, and intimacy.

Session 12. Intimacy and Final Impact
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 INTRODUCE Session 12. The session begins with a review of the intimacy worksheets, noting any remaining stuck points. Then, the patient reads his new impact statement. The therapist contrasts this statement with the initial impact statement as a way of reviewing progress. The therapist and patient should review what was learned in the therapy and the skills and stuck points that remain for the patient to continue to work on. The goal is for the patient to become her own therapist. She/he should be given fresh worksheets to use along with a reminder to continue and not avoid this new way of thinking. Recommendation: Set up an appointment in a month for a booster session.

Final Impact Statement
Session 12 Final Impact Statement “Carol” You may want to INTRODUCE the video “Carol reading final impact statement” at this point. If participants have become familiar with “Carol” through other video clips, they will have a greater appreciation for how far she has come in only 12 sessions in terms of moving from assimilation and over-accommodation to accommodation. In discussing the impact statement, the patient and therapist review the course of therapy and skills learned. The therapy concludes with identification of future goals and issues which still need attention. DISCUSS how to work with patients on identifying remaining stuck points that they may wish to continue working on as they become their own therapist. ADDRESS potential concerns from participants about termination taking place in such a short time. Essentially, by having a time-limited treatment, patients are continually reminded of their upcoming termination. The therapist and patient should make note of the session number each week, allowing for processing of this throughout the therapy.

You will want to spend some time in the last session reviewing all the concepts and skills that have been introduced over the course of therapy. Remind the patient that her success in recovering will depend on her persistence in continuing to practice her new skills and resistance to returning to old avoidance patterns or problematic thinking patterns. Any remaining stuck points should be identified and strategies for confronting them should be reiterated. Ask patients to reflect on the progress and changes they have made during the course of therapy and encourage them to take credit for facing and dealing with a very difficult and traumatic event. The therapist should also discuss goals for the future. Patients should be reminded that if they encounter a reminder and have a flashback, nightmare, or sudden memory they had not accessed before, that it doesn’t mean that they are relapsing. In response to any of these intrusive experiences, the patient should be encouraged to write an account if needed or to work with his worksheets. He should be encouraged to experience his natural emotions and check his thoughts to make sure they are not extreme.

It is recommended that after completing the protocol, whether conducted weekly or twice a week, the therapist set up a follow-up appointment for a month or two into the future. The patient should be encouraged to continue to use her Challenging Beliefs Worksheets on any remaining stuck points. The follow-up session should include the same assessment measures that were used during treatment and can be used to get the patient back on track or to reinforce gains. This practice is also helpful in instilling in patients the notion of episodes of care. They are encouraged to work as their own cognitive therapist on their stuck points and daily events that arise, and then present for treatment when they have difficulty resolving a stuck point or recent event. A specific goal-oriented piece of work can be done, and then they are encouraged to continue using the skills they develop in the therapy episodes.

Patients read new Impact Statements Ask group members to identify changes they have seen occur in each other Discuss ways of staying in touch after the group ends Each member reads his/her impact statement to the group and reflects on ways that they have changed over the past few weeks. Members are then asked to talk about changes they have seen in each other. Often group members do not see how much of a change they have made and it is more meaningful when a group member points it out than when a co-leader points it out. Make sure each group member is addressed in this exercise. Have group discuss ways that they can continue to get support after the group is over, e.g. doing their sheets, calling each other, calling one of the group leaders if they have a question.

Recommended Readings for Learning Cognitive Therapy Approach
Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Wright, J., Basco, M., & Thase, M. (2006). Learning cognitive-behavior therapy: An Illustrated guide. New York: American Psychiatric Press. END the training by taking any additional questions and asking participants to fill out any necessary evaluation forms.

Workshop: Cognitive Processing Therapy

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