Cognitive Processing Therapy (CPT): An evidenced-based approach to healing trauma

Post-Traumatic Stress Disorder (PTSD): It is a moment frozen in time, something so cataclysmic and life-altering that the human brain is unable to process in a healthy way, necessitating the application of treatments like Cognitive Processing Therapy (CPT).

Rather than fading as memories tend to do, their precise details dulled around the edges by time, these particular events remain fresh, as do the emotions and associated with them. Recall can be sudden and fierce, and the symptoms can be crippling.

For years, PTSD was considered the exclusive domain of combat veterans, but with a greater understanding of the condition, mental health workers have begun to see that life traumas experienced by civilians can also be a catalyst: The death of a loved one, a horrific car wreck, abuse and more. Cognitive Processing Therapy (CPT), is a psychotherapy designed specifically to treat PTSD, and according to the Department of Veterans Affairs [1], “it teaches you how to evaluate and change the upsetting thoughts you have had since your trauma. By changing your thoughts, you can change how you feel.”

The History of PTSD: Historical Origins

Cognitive Processing Therapy (CPT) As Dr. Matthew J. Friedman, senior advisor and former executive director of the National Center for PTSD, writes [2], “Exposure to traumatic experiences has always been a part of the human condition. Attacks by saber tooth tigers or twenty-first century terrorists have likely led to similar psychological responses in survivors of such violence.”

While epic battles, conflicts and skirmishes were heralded in the literature of the ancient Greeks, even then some writers recognized that fighters suffered from conditions now associated with PTSD. In a 2000 article for the journal Dialogues in Clinical Neuroscience [3], Dr. Marc-Antoine Crocq recounts a translation by the Greek philosopher Herodotus, who wrote about the battle of Marathon around 440 BC. In detailing the combat of the Athenian Epizelus, Herodotus writes that he “was in the thick of the fray and behaving himself as a brave man should, when suddenly he was stricken with blindness, without blow of sword or dart; and this blindness continued thenceforth during the whole of his afterlife … it is noteworthy that the symptoms are not caused by a physical wound, but by fright and the vision of a killed comrade, and that they persist ewer the years.”

Crocq goes on to point out numerous examples of PTSD-like symptoms throughout history:

The Icelandic tome “Gisli Súrsson Saga,” which describes how “the hero dreams so frequently of battle scenes that he dreads obscurity and cannot stay alone at night”;
An example from the Hundred Years War written in 1388 by Jean Froissart that describes a man “who could not sleep near his wife and children, because of his habit of getting up at night and seizing a sword to fight oneiric enemies”;
The works of the Bard himself, whose character Mercutio described something similar to PTSD in Act 1, Scene 4 [4], when he waxes about the fairy Queen Mab, who visits the unsuspecting at night: “Sometime she driveth o’er a soldier’s neck /And then dreams he of cutting foreign throats / Of breaches, ambuscadoes, Spanish blades, / Of healths five fathom deep, and then / Drums in his ear, at which he starts and wakes / And, being thus frighted, swears a prayer or two / And sleeps again.”

PTSD Comes Into Focus

However, it wasn’t until the 19^th century that what would come to be diagnosed at PTSD was given serious consideration, starting with the American Civil War. In a 2015 article in Smithsonian Magazine [5], writer Tony Horwitz points out that “military and medical officials in the 1860s had little grasp of how war can scar minds as well as bodies. Mental ills were also a source of shame, especially for soldiers bred on Victorian notions of manliness and courage.”

In the 1958 book “Doctors in Grey: The Confederate Medical Service,” author H.H. Cunningham writes [6] that “psychoneurosis were caused by a combination of past experiences and the sympathy that soldiers received behind the lines … actual battle experiences, it appears, are not as important as secondary mental processes in the causation.” By war’s end, Medical Director William Carrington urged Surgeon General Samuel Moore to establish a hospital to treat veterans for cases of “lunacy and dementia,” Cunningham writes, but the physical carnage of that conflict mostly overshadowed the psychiatric wounds sustained.

The Great War, however, began to bring PTSD into focus. “Shell shock,” a term coined by World War I soldiers, took a tremendous toll on troops in the conflict. According to the American Psychological Association [7], “symptoms included fatigue, tremor, confusion, nightmares and impaired sight and hearing. It was often diagnosed when a soldier was unable to function and no obvious cause could be identified. Because many of the symptoms were physical, it bore little overt resemblance to the modern diagnosis of post-traumatic stress disorder.” Charles S. Myers, appointed as a consulting psychologist to the British Expeditionary Forces, conducted field research in France and ultimately concluded that “these were psychological rather than physical casualties, and believed that the symptoms were overt manifestations of repressed trauma.”

While other physicians attempted to attribute “shell shock” to the physical effects of combat, Myers insisted the wounds were emotional in nature. However, his hypothesis received pushback from military brass, and despite the wound designation of “nervousness” assigned to the syndrome’s victims, by the end of the war, “shell shock” was frowned upon as an official nomenclature, according to a 2015 article in the Journal of Mental Health and Human Behaviour [8].

PTSD Is Recognized

Cognitive Processing Therapy (CPT) Throughout the conflicts of the 20^th century, the psychiatric casualties of war continued to be debated, but the condition continued to persist: According to a 2018 article in The Washington Post [9], “the U.S. Army recorded three times as many psychological breakdowns as it had in the First World War. More than 300,000 men were discharged with psychiatric symptoms — 43 percent of all men discharged for medical reasons.”

The condition was labeled “combat exhaustion” or “combat fatigue,” and the article goes on to point out that during the Vietnam War, “American soldiers came home with what psychiatrists began calling ‘delayed psychiatric trauma’ and ‘post-Vietnam syndrome.’ Symptoms often emerged months or even years after a soldier’s tour of duty, and often included a shared set of symptoms: nervousness, anger, excessive emotional reactions, sleeplessness, intense guilt and shame and intrusive flashbacks and nightmares.”

As America came to grips with the Vietnam War and its aftermath, the mental health community finally recognized PTSD as an official disorder in 1980, when it was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the first time. According to Dr. Rachel Yehuda, writing for a 2003 article in the journal Psychiatric Times [10], “Prior to 1980, stress-related symptoms were generally viewed as transient and not requiring intensive treatment. This was in keeping with the pervasive feeling that, with time, people ought to be able to ‘get over’ the effects of a traumatic experience and ‘move on’ without noticeable impairment … (but) the diagnosis of PTSD was meant to pave the way for an improved understanding of the long-term, and possibly even permanent, impact of trauma exposure.”

With additional research, according to the Department of Veterans Affairs [2], the diagnosis was modified to show that “PTSD is relatively common. Recent data shows about 4 of every 100 American men (or 4%) and 10 out every 100 American women (or 10%) will be diagnosed with PTSD in their lifetime.” In addition, it’s no longer classified as an Anxiety Disorder because it is “sometimes associated with other mood states (for example, depression) and with angry or reckless behavior rather than anxiety. So, PTSD is now in a new category, Trauma- and Stressor-Related Disorders.”

The History of Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy (CPT) According to the DSM, PTSD includes four different symptoms:

“Re-experiencing” or “intrusion,” in which the patient relives the traumatic event;
Avoidance of situations, individuals or circumstances that are reminders of the event;
Negative changes in beliefs and feelings;
“Hyperarousal,” or over-reactivity to situations, often described as anxiety.

According to the VA [2], “most people experience some of these symptoms after a traumatic event, so PTSD is not diagnosed unless all four types of symptoms last for at least a month and cause significant distress or problems with day-to-day functioning.” Over time, mental health professionals have come to understand that while the origins of PTSD are directly related to combat and military service, “PTSD is not exclusive to this type of trauma,” according to the National Alliance for the Mentally Ill [11]. “In the U.S., about eight million people experience PTSD. While any traumatic experience can lead to PTSD, there are a few types of trauma that are the most common. Examples include sexual assault/abuse, natural disasters, accidents/injuries to self or other, or being in a life-threatening situation.”

As a result, Cognitive Processing Therapy (CPT) is an effective tool to treat both populations. CPT was developed, in fact, to “treat posttraumatic stress in sexual assault survivors,” according to the online mental health directory GoodTherapy [12]: “CPT, a form of cognitive behavioral therapy, was developed from two primary theories: P. J. Lang’s information processing theory and the social cognitive theory of PTSD.”

Lang’s theory, GoodTherapy describes, is that PTSD is precipitated by memories of a trauma that lead to “feelings of fear and ultimately, escape and avoidance behaviors. In other words, when a person experiences a stimulus that elicits memories of a traumatic event, a fear network is activated in the memory. The person then attempts to avoid or escape this fear, but this attempt generally has the unintended effect of maintaining the fear.”

The social cognitive theory is a broader one that takes into account “relevant emotional responses,” or the ability of individuals to “perceive and cope with a traumatic life event as they try to regain a sense of control in their lives following the event.” In other words, primary emotions are a direct result of the experience; secondary emotions develop from their interpretation of the experience.

The ultimate goal of CPT is to address both, according to the American Psychological Association (APA) [13]: It “helps patients learn how to challenge and modify unhelpful beliefs related to the trauma. In so doing, the patient creates a new understanding and conceptualization of the traumatic event so that it reduces its ongoing negative effects on current life.”

How Cognitive Processing Therapy (CPT) Works

Cognitive Processing Therapy (CPT) According to the authors of “Cognitive Processing Therapy for PTSD: A Comprehensive Manual” [14], “The focus is on identifying how traumatic experiences change thoughts and beliefs, and how thoughts influence current feelings and behaviors. An important part of the treatment is addressing ways of thinking that might keep individuals ‘stuck’ and get in the way of recovery from symptoms of PTSD and other problems.”

While individual approaches to CPT might differ slightly, they all follow a similar model, which begins with patients writing out an impact statement in which they dissect ways in which a specific trauma has affected their lives. Specific areas may include safety; relationships/intimacy; trust; power/control; and esteem, but from statement, therapists help patients discover those “stuck points” —ways in which the trauma has been irregularly processed by the brain.

Often, therapists see a common pattern among PTSD patients: self-assimilation, in which they take on feelings of guilt and blame for traumatic events that were essentially beyond their control; and over-accommodation, in which the roles of specific individuals related to the trauma are assigned to larger groups as a whole. For example, female sexual assault survivors may develop trust and anxiety issues with all men, or combat veterans of Vietnam may feel intense anger toward all Asians.

CPT, according to the APA, continues with a deeper dive into the trauma, and a therapist may ask a patient to write “a detailed account of the worst traumatic experience, which the patient reads in the next session to try and break the pattern of avoiding thoughts and feelings associated with the trauma. The therapist uses Socratic questioning and other strategies to help the patient question his or her unhelpful thoughts about the trauma (e.g., self-blaming thoughts) in order to modify any maladaptive thinking.” [13]

That process allows the patient to take a step back from the immediacy and intensity of the traumatic memories, so that they’re able to “identify and address unhelpful thinking,” which in turn allows patients to “use those skills to continue evaluating and modifying beliefs related to traumatic events.” At this point, the therapist is helping the patient develop the ability to use these adaptive strategies outside of treatment to improve overall functioning and quality of life. Therapists may particularly focus on safety, trust, power, control, esteem and intimacy as these are all areas that can be affected by traumatic experiences.

Ultimately, according to the Center for Deployment Psychology [15], “This cognitive restructuring process continues while identifying stuck points in larger trauma themes such as beliefs around safety, trust, power and control, self-esteem, and intimacy. In this stage of therapy, the patient really takes over the reins in session and becomes his/her own therapist with the clinician acting in more of a consultant role.”

Is Cognitive Processing Therapy (CPT) Effective?

Consistently, and across a wide variety of settings, Cognitive Processing Therapy (CPT) has proven to be an effect psychotherapeutic tool for trauma-related issues. Consider:

A comparison of CPT vs. trauma-focused group treatment as usual (TAU) in a residential program for PTSD-affected veterans found “that veterans treated in the CPT cohort during residential treatment for PTSD demonstrated significantly more improvement, and more clinically significant improvement, than a prior cohort treated with TAU trauma-focused group therapy. These findings indicate that effective implementation of evidence-based treatment packages such as CPT is superior to TAU and suggest that CPT improved patient outcomes.” [16]
In a paper for St. Catherine University, Nicole Humble found [17] that “CPT is effective in treating posttraumatic stress disorder in both male and female victims of military sexual trauma.”
A 2012 article in the Journal of Rehabilitation Research and Development [18] found that “initial data suggest that most clinicians who have been trained in CPT have adopted it as part of their standard clinical practice, and the patients they treat are showing solid improvements in their PTSD and depressive symptomotology.”
Finally, in a 2019 paper published in the journal Frontiers in Behavioral Neuroscience [19], the authors concluded that “Research findings suggest CPT effectively treats PTSD in sexual assault survivors … veterans who served in Vietnam, Iraq and Afghanistan … and adult males with comorbid TBI (traumatic brain injury) and PTSD. CPT has been found to exhibit clinically meaningful reduction in PTSD, depression and anxiety in sexual assault and veteran samples, with results maintained at 5 and 10 year post treatment follow-up. Meta-analyses suggest that CPT is effective in significantly reducing PTSD symptoms.”

In other words, Cognitive Processing Therapy (CPT) is an evidence-based practice that has been demonstrated in repeated settings to address trauma. Whether it’s trauma caused by military combat, childhood abuse, sexual assault or natural disasters, individuals who are unable to move past these events often turn to other sources to alleviate emotional and mental anguish. Often, those sources include alcohol and drugs, which in turn bring about a host of additional problems.

To effective treat addiction and alcoholism, the source of those disorders must be addressed — and trauma is a leading cause. According to a 2014 study published in the journal Psychiatry Investigation [20], “addictive behaviors have a dissociative nature that allows individuals to manage negative and unregulated emotions,” and a presentation at the 2004 National Trauma Consortium [21] emphasized that “there is a critical need to address trauma as part of substance abuse treatment.”

CPT can be a critical tool to do that, and as more drug and alcohol rehabs move toward an integration of traditional models and evidenced-based models of therapy, it will likely play an important role in the future of addiction treatment.

SOURCES

[1]: https://www.ptsd.va.gov/understand_tx/cognitive_processing.asp

[2]: https://www.ptsd.va.gov/understand/what/history_ptsd.asp

[3]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181586/

[4]: http://www.shakespeare-online.com/plays/romeoandjuliet/romeoqueenmab.html

[5]: https://www.smithsonianmag.com/history/ptsd-civil-wars-hidden-legacy-180953652/

[6]: https://books.google.com/books?hl=en&lr=&id=fjUvVHh0VeIC&oi=fnd&pg=PR7&ots=aJH6rLip8S&sig=ro1A8Gm2Jh3hXu6aLBqCwmUWq4g

[7]: https://www.apa.org/monitor/2012/06/shell-shocked

[8]: http://www.jmhhb.org/article.asp?issn=0971-8990;year=2015;volume=20;issue=2;spage=85;epage=87;aulast=Ganesh#ref4

[9]: https://www.washingtonpost.com/news/made-by-history/wp/2018/06/26/the-wartime-origins-of-a-disorder-that-plagues-rape-victims-at-even-higher-rates-than-veterans/

[10]: https://www.psychiatrictimes.com/traumatic-stress-disorders/changes-concept-ptsd-and-trauma

[11]: https://nami.org/Blogs/NAMI-Blog/November-2017/PTSD-and-Trauma-Not-Just-for-Veterans