Massed Cognitive Processing Therapy in Active-Duty Military: A Case Series

Despite consistent evidence that Cognitive Processing Therapy (CPT) is an efficacious treatment for posttraumatic stress disorder (PTSD), the effects among active-duty service members and veterans have been smaller than for civilians. Modifications to standard delivery may be needed to increase treatment engagement and completion, which could improve outcomes in this population. Delivering CPT in a massed format may reduce barriers to care and enable more rapid symptom reduction, yet clinicians and patients may have concerns about the tolerability and practicality of such interventions. This case series describes a course of CPT delivered in 5 days in a mixed group and individual format among 4 active-duty military service members as part of a larger randomized clinical trial. Although the pattern of symptom change differed between patients, most demonstrated clinically significant reductions in PTSD and depression symptoms during the 5-day treatment. Patients reported that the pace was tolerable and that the mixed group and individual format was beneficial. Although further research is needed to understand the longer-term outcomes of massed CPT, this therapy format has important implications for the future delivery of treatments for PTSD.     

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12–16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 – 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.     

Trauma-Related Cognitions and Cognitive Emotion Regulation as Mediators of PTSD Change Among Treatment-Seeking Active-Duty Military Personnel With PTSD

Trauma-related cognitions about the self and the world have been identified as a mediator of posttraumatic stress disorder (PTSD) change during prolonged exposure (PE) therapy. However, the extent to which negative cognitions mediate PTSD change in other PTSD treatments is unclear. In addition, previous studies have not tested alternate mediators of PTSD change during PE. In a sample of 216 treatment-seeking active-duty military personnel with PTSD, the present study examined the specificity of the negative cognition mediation effect in both PE and present-centered therapy (PCT). In addition, we examined another possible mediator, cognitive emotion regulation. Lagged mediational analyses indicated that negative cognitions about the self and world and the unhelpful cognitive emotion regulation strategy of catastrophizing each significantly mediated change in PTSD from baseline to 6-month follow-up. In a combined model, the mediating effect of catastrophizing was greater than negative cognitions about the world, and similar to negative cognitions about the self. Moderated mediation analyses revealed that the effect of catastrophizing was greater in PE than in PCT. Findings show that trauma-related cognitions and, to a greater degree, the emotion regulation strategy catastrophizing, both mediate PTSD change. Further research is needed to determine whether these mediating variables represent mechanisms of therapeutic change.     

A Single-Arm Meta-Analysis of Cognitive Processing Therapy in Addressing Trauma-Related Negative Cognitions

Cognitive Processing Therapy (CPT) is a first-line treatment for posttraumatic stress disorder designed to address cognitive “stuck points” connected to a patient’s trauma-related negative cognitions (NCs). Although CPT has well-established efficacy, the ability of CPT to address NCs remains understudied. The purpose of this study was to conduct a single-arm meta-analysis to determine the overall effect of CPT in attenuating NCs pre- to posttreatment across multiple clinical trials. A review of the existing literature was performed with only peer-reviewed clinical trials included in the meta-analysis. Nine studies with data from 583 participants were entered into the meta-analysis. CPT was found to have a large effect size in reducing NCs from pre- to posttreatment. Findings are limited by the single-arm nature of analyses and heterogeneity in included trial methodology (e.g., gender, trauma type, civilian versus veteran).     

Cognitive Processing Therapy for Incarcerated Adolescents with PTSD

Summary

Despite increased recognition of trauma's association with conduct disorders, trauma treatment for the conduct-disordered population has been neglected. This study evaluated the effect of short-term, cognitive processing therapy (CPT) treatment on self-reported symptoms of trauma, such as anxiety, depression, intrusion, avoidance, and numbing. After treatment, the CPT group showed significant declines in these symptoms, while the wait-list control group did not.     

The Effect of PTSD Symptom Change on Suicidal Ideation in a Combined Military and Civilian Sample Engaged in Cognitive Processing Therapy

In light of the well-established relationship between posttraumatic stress disorder (PTSD) and suicidal ideation (SI), there has been a push for treatments that simultaneously improve symptoms of PTSD and decrease SI. Using data from a randomized controlled hybrid implementation-effectiveness trial, the current study investigated the effectiveness of Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016) on PTSD and SI. The patient sample (N = 188) was diverse in military and veteran status, gender, and comorbidity, and 73% of the sample endorsed SI at one or more points during CPT. Participants demonstrated significant improvement in SI over the course of CPT. Multilevel growth curve modeling revealed a significant association between PTSD symptom change and change in SI. Results from cross-lagged multilevel regressions indicated that PTSD symptoms predicted SI in the next session, yet SI in a given session did not predict PTSD symptoms in the next session. Potentially relevant clinical factors (i.e., military status, gender, depression diagnosis, baseline SI, study consultation condition) were not associated with the relationship between PTSD symptoms and SI. These results add to the burgeoning literature suggesting that evidence-based treatments for PTSD, like CPT, reduce suicidality in a range of individuals with PTSD, and that this reduction is predicted by improvements in PTSD symptoms.     

Cognitive Factors in the Maintenance of PTSD

Abstract

Cognitive behavioural therapies have the strongest empirical support as the treatments of choice for Post-traumatic Stress Disorder (PTSD). Despite the relative efficacy of these treatments compared to other psychological treatments, and no treatment, a large proportion of PTSD patients retain their diagnosis after treatment. In this article, a review of cognitive factors that are suggested to be responsible for the maintenance of PTSD in unimproved patients is presented. Among these factors are: anger and rage, guilt and shame, attentional bias and memory bias, negative attributional style, low self-efficacy, cognitive avoidance, dysfunctional schemas, catastrophic interpretations of intrusive recollections and pathological trauma memory structures. In the discussion section, suggestions about how therapy programmes might be modified in order to maximize cognitive change are provided.     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents’ mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.     

Intensive Cognitive Processing Therapy Associated With Reduced PTSD Treatment Dropout in a Case-Controlled Study of Treatment-Seeking Veterans

Cognitive Processing Therapy (CPT) is an empirically supported psychotherapy for posttraumatic stress disorder (PTSD). The complex issue of treatment attrition is a frequently cited concern regarding CPT and other evidence-based psychotherapies for PTSD. The current study investigated the feasibility and effectiveness of “intensive” CPT, a treatment-consistent modification of CPT in which sessions are conducted more frequently than standard protocol. Fifty-four military veterans (20% female; M_age = 46; 80% Caucasian) seeking outpatient treatment for PTSD were included in this study. Patients who elected to receive intensive CPT (n = 27) were matched with archival records of individuals who received standard CPT (n = 27). Patients across treatment conditions were matched based on baseline symptom severity as measured by the PTSD Checklist for DSM-5 (PCL-5; M_PCL-5 = 52.61). Treatment outcomes were compared and longitudinal multilevel modeling was used to compare rate of symptom change over time. Patients who elected to engage in intensive CPT were twice as likely to complete treatment (88.9%) as those who received standard CPT (44.4%), X²(1, N = 54) = 12.00, p = .001. On average, intensive CPT patients completed treatment in about 25% of the time as standard CPT patients (33.8 days vs. 125.7 days). Patients in intensive CPT also demonstrated greater benefit: 81.4% reported a clinically significant improvement in PCL-5 scores compared to 51.8% of those in standard CPT, X²(1, N = 54) = 5.33, p = .020, φ = −0.314. Intensive and standard CPT performed comparably in regard to final PCL-5 score, change over time, and screening cutoff. In addition, there were no differences in treatment outcomes based on licensure status of the provider nor whether treatment was delivered in person or virtually. Intensive CPT represents a novel, treatment-consistent adaptation that was utilized to treat a group of veterans with PTSD with minimal treatment dropout. Patients who elected to engage in more frequent treatment were more likely to complete treatment, did so in one quarter of the time, and reported similar to better treatment outcomes. Providers may consider encouraging their patients to participate in treatment as frequently as they are able. However, preliminary findings are based on a nonrandom sample and design limitations temper conclusions.     

Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen’s d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.     

Adapting Cognitive Processing Therapy for PTSD for People With Disabilities: A Case Study With a U.S. Veteran

Many veterans receiving treatment for PTSD in the VA health care system are also living with a disability and utilize assistive technologies for communication and/or mobility. While evidence-based treatments for PTSD have been disseminated in VA hospitals nationwide, clinicians may have concerns about implementing these treatments with people with disabilities or question how to adapt evidence-based protocols to facilitate successful outcomes. This clinical case study details the treatment of a 48-year-old male U.S. veteran with a diagnosis of military-related PTSD and significant functional and communicative complexities characteristic of locked-in syndrome. The study implemented an adapted protocol of Cognitive Processing Therapy (CPT), a first-line evidence-based psychotherapy for PTSD with unknown application to people with disabilities. CPT protocol structure, length, and delivery was adapted to accommodate the veteran’s assistive devices and functional abilities. The veteran experienced a clinically significant reduction in PTSD symptoms over the course of treatment, suggesting successful application of the adapted protocol. In addition to symptom reduction, the veteran reported advances in his ability to tolerate emotional distress while engaged in goal-directed behavior and improved interpersonal functioning. Results suggest that CPT can be adapted and effective in instances where the presence of disability and multiple assistive technologies impact standard treatment implementation. This information is valuable in its potential ability to make evidence-based psychotherapies more accessible and disability-sensitive. Clinical recommendations for using and adapting CPT for people with disabilities are provided.     

Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

A Case Study of Cognitive-Behavioral Conjoint Therapy for Combat-Related PTSD in a Same-Sex Military Couple

Military deployments to Iraq and Afghanistan are associated with increased risk for posttraumatic stress disorder (PTSD), depression, and relationship impairment. Unfortunately, the perceived stigma associated with seeking deployment-related behavioral health care in military settings has been a significant barrier to care. Historically, active-duty military service members involved in same-sex intimate relationships have experienced further stressors and barriers to care related to additional stigma and lack of social support. Prior federal regulations excluded sexual minorities from openly serving in the military, thereby limiting the available behavioral health services for same-sex couples. Since this ban was lifted after the repeal of the U.S. policy known as "Don’t Ask, Don’t Tell" in 2010, gay and lesbian service members have increased opportunities to obtain behavioral health care. One therapy that is newly available to sexual minority military couples is Cognitive-Behavioral Conjoint Therapy (CBCT), which effectively addresses co-occurring PTSD and relationship dysfunction. This case study illustrates the use of CBCT for the treatment of deployment-related PTSD in a same-sex active-duty military couple. After completing all 15 CBCT sessions, the couple reported clinically meaningful changes in the service member’s PTSD symptoms, which was maintained at the 2-month follow-up. The results of this case study indicate that CBCT for PTSD can have positive treatment outcomes with military same-sex couples. Further clinical implications are discussed.     

Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Moral injury refers to acts of commission or omission that violate individuals’ moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations—thus, morally injurious events are often implicated in the development of posttraumatic stress disorder (PTSD) for military service members and veterans. Although prolonged exposure (PE) and cognitive processing therapy (CPT) have been well established as effective treatments for veterans who are struggling with PTSD, it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this paper is to detail how the underlying theories of PE and CPT can account for moral injury-based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

PTSD Severity and Cognitive Reactions to Trauma Among a College Sample

ABSTRACT

Two hundred twenty-one undergraduate education students were assessed to determine trauma history and cognitive responses to traumatic events. Participants completed a demographic questionnaire, the Cognitive Distortions Scale, and the PTSD Symptom Scale (for those reporting a trauma history). The most common types of traumatic events were domestic violence, natural disasters, and severe transportation accidents. Differences in cognitive distortions of individuals with and without a trauma history also were assessed. Individuals with a trauma history were significantly higher on Preoccupation with Danger and Self-Blame subscales. Number of previous traumatic events and the subscale of Preoccupation of Danger significantly predicted PTSD severity.     

Cognitive Correlates of Social Phobia Among Children and Adolescents

We examined different cognitive phenomena in relation to social phobia among children (aged 7 to 11) and adolescents (aged 12–16) separately. Fifty socially phobic youths were compared to 30 normal control children on measures of social anxiety, social expectation as well as self- and observer-rated performance during two social tasks involving a same-aged peer. Additionally, a video-mediated recall procedure was conducted immediately following the two behavioral tasks to examine specific types of self-talk. Results indicated that socially phobic youths had lower expectations of their performance and rated their actual performance worse than controls during a social interaction task, but not a read-aloud task. Self-ratings of decreased performance among socially phobic youths were corroborated by blind observers. Although differences in specific types of self-talk were found between the two groups, these findings were generally moderated by age. Furthermore, certain cognitive symptoms associated with the disorder were more commonly found among older socially phobic youths. The current findings highlight the importance of considering developmental factors in the presentation and treatment of social phobia in youths.     

Cigarette Use,Smoking Cessation,and Quit Intentions Among Active-Duty Military Personnel in Taiwan

This study investigates the impact of a variety of sociodemographic, behavioral, and contextual risk factors on cigarette use, abstinence success, and intentions to quit based on a survey of active-duty military personnel in Taiwan. Being male and of lower educational background increased the likelihood of tobacco use. About 80% of current smokers showed intention to quit in the immediate future, whereas stress and depression were leading causes for cigarette smoking and relapse. Other prominent predictors include attention to antismoking advertising, health concerns, social pressure, and support for a tobacco-free military. Implications for effective antismoking campaigns in the Taiwanese military are discussed.