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C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD A SHLEE W HITEHEAD, LPC, CADC CPT P ROVIDER PTSD CLINICAL TEAM P ORTLAND VA M EDICAL C ENTER E VIDENCE -B.

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Presentation on theme: "C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD A SHLEE W HITEHEAD, LPC, CADC CPT P ROVIDER PTSD CLINICAL TEAM P ORTLAND VA M EDICAL C ENTER E VIDENCE -B."— Presentation transcript:

1 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD A SHLEE W HITEHEAD, LPC, CADC CPT P ROVIDER PTSD CLINICAL TEAM P ORTLAND VA M EDICAL C ENTER E VIDENCE -B ASED A PPROACHES TO PTSD AND A SSOCIATED C ONDITIONS IN V ETERANS

2 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD O VERVIEW OF TODAY ’ S PRESENTATION History of CPT Theory, Rationale & Goals The Essential Ingredients Structure of CPT CPT Resources

3 CPT is a cognitive therapy for PTSD Published by Resick & Schnicke(1993) Over 20 years of clinical practice, initially focused on trauma of rape. Resick, Monson & Chard expanded to fit veteran/military population (2006) VA Office of Mental Health Services began CPT training roll-out to VA providers focused on military trauma. C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD ORIGINS OF CPT

4 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD THEORY BEHIND CPT Based on Social Cognitive Theory Traumatic Events can dramatically alter basic beliefs about the world, the self and others. Focuses on how trauma survivors integrate traumatic events into their overall belief system through assimilation or accomodation Not incompatible with Information/ Emotional Processing Theories Expands the range of emotional responses that can be addressed in treatment.

5 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD SOCIAL COGNITIVE THEORY OF TRAUMA 5 major dimensions that may be disrupted by traumatic events: 1) Safety 2) Trust 3) Power and Control 4) Esteem 5) Intimacy

6 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD CPT RATIONALE PTSD symptoms are attributed to a "stalling out" in the natural process of recovery What interferes with natural recovery from PTSD? Avoidance Behaviors reinforce Distorted beliefs about the trauma and become Generalized to current life situations Cognitive-focused techniques are used to help patients move past stuck points and progress toward recovery.

7 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD CPT GOALS Process natural emotions (other than fear) in clients with PTSD. Address the content of the meaning derived from the traumatic memory. Accomodation - accepting that the traumatic event occurred and discovering ways to successfully integrate the experience into the one’s life (e.g., “In spite of this bad event happening to me, I am a good person.”). Accommodation reflects balanced thinking.

8 W HEN TO I MPLEMENT CPT AND P RE -T REATMENT I SSUES TO C ONSIDER Recommended for clients with: PTSD and comorbid diagnoses (e.g., depression, anxiety, substance use, TBI) Not Recommended for clients with: Active suicidal behavior Current Psychosis No memory of the trauma event

9 F ROM ENGAGEMENT TO RETENTION MI techniques Client needs to believe that improvement is possible Client needs to believe that he has the ability to tolerate therapy (skills) Desire to approach outweighs desire to avoid Therapist adherence to protocol

10 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD THE ESSENTIAL INGREDIANTS The Impact of the Event Identifying Stuck Points Identifying and resolving assimilated beliefs Challenging and balancing overaccomodated beliefs. Use of Socratic Questioning Processing natural emotions related to the trauma

11 SO… WHAT ARE STUCK POINTS? T HOUGHTS & INTERPRETATIONS ABOUT THE T RAUMATIC EVENT A UTOMATIC - D ISTORTED - M AY OCCUR BENEATH ONE ’ S AWARENESS Thoughts not Feelings Black and White All or Nothing Thought behind the “golden rule” If/Then statements Not always “I statements”

12 S TUCK POINTS IN 5 DIMENSIONS SAFETY I cannot protect myself/others. The world is completely dangerous. TRUST Other people should not trust me. The government cannot be trusted. POWER/CONTROL I must control everything that happens to me. People in authority always abuse their power. ESTEEM I deserve to have bad things happen to me People are by nature evil and only out for themselves. INTIMACY I am unlovable because of the trauma. If I let other people get close to me, I'll get hurt again.

13 P RACTICE A SSIGNMENT – T HE IMPACT STATEMENT “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.”

14 T HE IMPACT STATEMENT – MST EXAMPLE “The overall feeling of what it means to have been assaulted is the feeling that I must be bad or a bad person for something like this to have occurred. I feel it will or could happen again at any time. I feel only safe at home. The world scares me and I think it unsafe. I feel all people are more powerful than I, and am scared by most people. I view myself as ugly and stupid. I can’t let people get real close to me. I have a hard time communicating with people of authority, so plainly I haven’t been able to work. I don’t trust others when they make promises. I find it hard to accept that these events have happened to me.”

15 H OW TO GET “STUCK” Prior beliefs can be disrupted or reinforced by the trauma EXAMPLE: The Just World Belief “GOOD THINGS HAPPEN TO GOOD PEOPLE & BAD THINGS HAPPEN TO BAD PEOPLE” NOW WHAT DO I BELIEVE????? I was raped in the military Innocent people were killed

16 16 A SSIMILATION 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 Undoing and Self-Blame

17 17 O VER - ACCOMMODATION Overall beliefs and assumptions about self and the world change too much following the traumatic event and are no longer accurate Original Belief People=Good Traumatic Event War AtrocitiesOver-accommodation People=Evil

18 “I WAS RAPED IN THE MILITARY ” Assimilate - It wasn’t really rape. - Because I didn’t fight harder, the rape is my fault. - I am worthless because I couldn’t control what happened. Accommodate - I wasn’t in a position where I could fight back at the time. - Some men can be trusted. - I have control over how to handle this. Overaccomodate - If I let other people get close to me, I'll get hurt again. - Men are dangerous and can’t be trusted. - I must control everything that happens to me.

19 “I NNOCENT PEOPLE WERE KILLED ” Assimilate - I should have prevented it. - It was my fault. - I deserve to have bad things happen to me. - It didn’t really happen. Accommodate - Mistakes were made. - Although lives were lost, many lives were saved. - Sometimes bad things happen to good people. Overaccomodate - Government cannot be trusted. - Nowhere is safe (I must stay on guard at all times). - I am powerless.

20 SOCRATIC QUESTIONING  Used to challenge stuckpoints  Helping not telling (the wisdom is within the person) Guided discovery.  Getting patient to ask the questions themselves  Helping them become aware of inconsistencies  ABC’s  Ask  Be on their team  Think Critically about their logic “I don’t see the point in asking all these questions. I could have pointed out the flaws in the client’s thinking and changed her mind much more quickly by taking a more direct route!”

21 P ROCESSING THE IMPACT STATEMENT “Now, let’s go back to the Impact Statement you wrote. What kinds of things did you write about when thinking about what it means to you that the assault happened to you? What feelings did you have as you wrote it?”

22 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD CPT THERAPY HAS 4 MAIN PARTS Learning about PTSD symptoms Becoming aware of thoughts & feelings about the trauma Learning skills Understanding changes in beliefs

23 C OGNITIVE P ROCESSING T HERAPY (CPT) FOR PTSD STRUCTURE OF CPT SESSIONS 12 x 50-minute structured sessions Participants complete out- of-session practice assignments Sessions typically conducted weekly or bi- weekly Includes a brief written trauma account along with ongoing practice of cognitive techniques 12 x minute structured sessions Participants complete out- of-session practice assignments Typically conducted by 2 clinicians 8-10 Veterans per group Includes a brief written trauma account component, along with ongoing practice of cognitive techniques Individual CPTGroup CPT

24 T HE INDIVIDUAL SESSIONS ARE : Session 1: Introduction and Education Session 2: The Meaning of the Event Session 3: Identification of Thoughts and Feelings Session 4: Remembering the Traumatic Event Session 5: Identification of Stuck Points Session 6: Challenging Questions Session 7: Patterns of Problematic Thinking Session 8: Safety Issues Session 9: Trust Issues Session 10: Power/Control Issues Session 11: Esteem Issues Session 12: Intimacy Issues and Meaning of the Event

25 What thoughts did you have about coming to this presentation today? Let’s make the event: Coming here todayWhat emotions come up with those thoughts?

26 What thoughts do you have about using EBTs? No let’s change the event to: Using evidence- based therapies in PTSD What emotions come up with those thoughts?

27 A PROMOTIONAL VIDEO

28 H OW TO REFER A CLIENT TO CPT Cognitive Processing Therapy is available through VA Medical Centers, including through the Portland VAMC PTSD Clinical Team (PCT) for eligible veterans. Portland VA Medical Center Eligibility/Enrollment (503) , ext Admission to the PCT requires a consult from the veteran's Mental Health Provider at the Portland VA Medical Center. If the veteran does not have a Mental Health Provider, the first step would be to call the Mental Health Access Clinic at x A screening interview will be required as a condition of admission.

29 A DDITIONAL RESOURCES An online CPT review course is available through the Medical University of South Carolina at https://cpt.musc.edu/index https://cpt.musc.edu/index National Center for PTSD Cognitive Therapy for Posttraumatic Stress Disorder by Shipherd, Street, and Resick in Chapter 5 of Cognitive- Behavioral Therapies for Trauma, Second Edition by Victoria M. Follette PhD and Josef I. Ruzek (2007)


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