Cognitive Processing Therapy for Posttraumatic Stress Disorder in Rape Victims
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Posttraumatic Stress Disorder (PTSD) DSM-IV-TR Criteria. Exposed to traumatic event in which:Experienced, witnessed, confronted with event(s) that involved actual or threatened death, serious injury, threat to physical integrity of self or others Response involved intense fear, helplessness, or horror .
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1. Cognitive Processing Therapy for Posttraumatic Stress Disorder in Rape Victims

2. Posttraumatic Stress Disorder (PTSD) DSM-IV-TR Criteria Exposed to traumatic event in which: Experienced, witnessed, confronted with event(s) that involved actual or threatened death, serious injury, threat to physical integrity of self or others Response involved intense fear, helplessness, or horror Traumatic event is consistently re-experienced by: Distressing recollections Distressing dreams Acting/feeling as if the traumatic event were reoccurring Psychological distress at exposure to internal/external cues of event Physiological distress from cues

3. Criteria (cont.) Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness Avoid thoughts, feelings, conversations Avoid activities, people, places Inability to recall important aspects of trauma Markedly diminished interest/participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of foreshortened future Persistent symptoms of increased arousal Difficulty falling/staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

4. Specifications of PTSD Acute Symptoms < 3 months Chronic Symptoms > 3 months Delayed Onset Onset of symptoms at least 6 months after stressor

5. Specifications of PTSD Exposed to traumatic event and part of post-disaster interventions Knowingly been exposed recently and seek help Knowingly been exposed some time ago and have evident intermittent, delayed, or chronic symptoms Report early ?victimization experiences? through the course of treatment of another disorder Enter treatment with the ?goal? to determine if they have been ?abused? Manifest PTSD symptoms ?without the trauma?

6. Traumatic Event Specifications ?Short-Term? events Natural disaster Floods, hurricanes,earthquakes Accidental disaster Car, train accidents Fires, explosions Deliberately caused disasters/intentional Bombings, shootings,rape Terrorist attacks, robbery, industrial accidents ?Long-Term? Events Prolonged repeated trauma Natural and technological disasters Chronic illness, nuclear accident, toxic pills Intentional human design Hostage taking, POW, battered syndrome

7. Cognitive Processing Therapy (CPT) Model developed to treat specific symptoms of survivors of sexual assault 12 session structured therapy Based on information processing model of PTSD Combines main ingredient of exposure-based therapies with the cognitive components of most cognitively based therapies Cognitive portion challenges specific cognitions most likely to have been disrupted by trauma Clients given homework assignments at every session

8. CPT (cont.) Assumption of CPT is that symptoms of PTSD are caused by conflict between new information and prior schemas Danger and safety Self-esteem Competence Intimacy Cognitive conflicts account for intrusive, arousal and avoidance symptoms of PTSD

9. Components of CPT Information-Processing Fear memory must be activated New information must be provided that is incompatible with current fear structure in order for a new memory to be formed Exposure Clients write about event in detail including sensory memories, thoughts and feelings about the event Read account aloud during session, and therapist helps label feelings and identify ?stuck? points This component lasts only 2 sessions

10. CPT treatment sessions Session 1 Describe symptoms of PTSD Educate client about why symptoms developed Present overview of treatment, emphasizing homework Build rapport Give client opportunity to talk about the rape or other issues

11. CPT treatment sessions homework ?Please write at least one page about what it means to you that you were raped. Please consider the effects the rape has had on your beliefs about yourself, your beliefs about others, and your beliefs about the world. Also consider the following topics while writing your answer: safety, trust, power/competence, esteem, and intimacy. Bring this with you to the next session.?

12. CPT treatment sessions Session 2 Discuss the meaning of the event Help client begin to label emotions and recognize thoughts See connection between self statements and feelings Homework A-B-C worksheets to begin to identify what she was telling herself and what her emotions were

13. CPT treatment sessions Session 3 Review homework (A-B-C worksheet), do not challenge thoughts yet Praise client for their ability to identify and label thoughts and feelings Continue to build rapport and being supportive to help client get through the most difficult sessions which are to come next

14. CPT treatment sessions Homework ?Please write about the actual rape. Be sure to include feelings, thoughts and emotions during the event. Also attend to these thoughts which you have addressed here in the A-B-C worksheet. If you are unable to finish the account in one sitting, just draw a line where you stopped. When you are ready to begin again, read what you already wrote and then continue. Try to begin this detailed account as soon as possible. If there are parts you can?t remember, just draw a line and then continue with the next instance you remember. Read the account to yourself everyday until the next session.?

15. CPT treatment sessions Session 4 Read account of rape aloud and discuss Assess ?stuck? points Homework Client is instructed to write the account again, adding any details she might have left out the first time Record any thoughts and feelings in parentheses Session 5 Review second account focusing on the additives or alterations Begin to challenge assumptions Homework Complete challenging questions worksheet

16. Challenging Questions Sheet 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:_____________________________________________

17. 1. What is the evidence for and against this idea? 2. Are you confusing a habit with a fact? 3. Are your interpretations of the situation too far removed from reality to be accurate? 4. Are you thinking in all-or-none terms? 5. Are you using words or phrases that are extreme or exaggerated? (i.e. always, forever, never, need, should, must, can't and every time) 6. Are you taking selected examples out of context? 7. Are you making excuses? (e.g. I'm not afraid, I just don't want to go out; The other people expect me to be perfect; or I don't want to make the call because I don't have time) 8. Is the source of information reliable? 9. Are you thinking in terms of certainties instead of probabilities? 10. Are you confusing a low probability with a high probability? 11. Are your judgments based on feelings rather than facts? 12. Are you focusing on irrelevant factors?

18. After analyzing single beliefs, the therapist introduces another worksheet to help the client determine if she has faulty thinking patterns that may cut across situations. She is asked to notice and record examples of patterns such as overgeneralizing, mind-reading, or emotional reasoning (e.g., "I feel fear so I must be in danger").

20. CPT treatment sessions Session 6 Review ?Challenging Your Beliefs? questionaire Introduce ?Faulty Thinking Patterns list? Homework Read over Faulty Thinking Patterns list and think of examples Session 7 Reviewed ?Faulty Thinking Patterns list? Introduced ?Challenging Beliefs Worksheet? Homework Complete worksheets for beliefs and feelings First safety module introduced and completed

21. CPT treatment sessions Session 8 Review challenging beliefs worksheet Trust module Homework Worksheets on trust Session 9 Review worksheets Power/control module Homework Worksheets on power/control

22. CPT treatment sessions Session 10 Review homework Esteem module Introduce ?Identifying Assumptions list? Homework Challenging Beliefs worksheets on any items from Identifying Assumptions list Worksheets on esteem stuck points Practice giving and receiving compliments every day Do one thing nice for herself everyday Session 11 Review worksheet Intimacy module Homework Worksheets on intimacy Rewrite the meaning of the event, like before

23. CPT treatment sessions Session 12 Review homework Compare first homework to current to show progress and first A-B-C worksheet Client discusses goals for future Follow-Up 1 wk post-therapy assessment 3 mos. follow-up assessment

24. Background Information After the assault 94% of rape victims meet symptomatic criteria for PTSD 3 months after the assault 47% still meet PTSD criteria 17 years after the assault On average, 16.5% still meet criteria for PTSD An estimated 25% of American women experience rape at some point in their lifetime Let me first begin by presenting you with , a little background information. The results of a previous 1990 study, conducted by Rothbaum, Foa, Murdock, Riggs, and Walsh, showed that immediately after the assault, 94% of rape victims met symptomatic criteria for PTSD. 3 months after the assault, 47% still met PTSD criteria. 17 years following the assault, on average, 16.5% still met criteria for PTSD. Furthermore, a 1983 study by Koss concluded that approximately 25% of American women experienced rape at some point in their lifetime. Let me first begin by presenting you with , a little background information. The results of a previous 1990 study, conducted by Rothbaum, Foa, Murdock, Riggs, and Walsh, showed that immediately after the assault, 94% of rape victims met symptomatic criteria for PTSD. 3 months after the assault, 47% still met PTSD criteria. 17 years following the assault, on average, 16.5% still met criteria for PTSD. Furthermore, a 1983 study by Koss concluded that approximately 25% of American women experienced rape at some point in their lifetime.

25. Cognitive Processing Therapy for Sexual Assault Victims Resick and Schnicke (1992) I examined two research studies that focused on the effectiveness of cognitive processing therapy for posttraumatic stress disorder in sexual assault survivors. This first study, which was conducted in 1992 by Resick and Schnicke, is titled Cognitive Processing Therapy for Sexual Assault Victims. I examined two research studies that focused on the effectiveness of cognitive processing therapy for posttraumatic stress disorder in sexual assault survivors. This first study, which was conducted in 1992 by Resick and Schnicke, is titled Cognitive Processing Therapy for Sexual Assault Victims.

26. Purpose & Hypothesis Purpose Examine the effectiveness of CPT in a group format in the treatment of chronic PTSD Condition 1: wait list (WL) Condition 2: cognitive processing therapy (CPT) Hypotheses CPT would be effective in treating PTSD CPT would also be effective in treating symptoms of depression The purpose of this study was to examine the effectiveness of CPT as a treatment for chronic PTSD. CPT was administered in a group format. Two conditions were included in this study. The first condition was a wait list condition, while the second condition was the CPT condition. The authors hypothesized that CPT would be effective in treating PTSD. They also hypothesized that CPT would be effective in treating symptoms of depression, as well. The purpose of this study was to examine the effectiveness of CPT as a treatment for chronic PTSD. CPT was administered in a group format. Two conditions were included in this study. The first condition was a wait list condition, while the second condition was the CPT condition. The authors hypothesized that CPT would be effective in treating PTSD. They also hypothesized that CPT would be effective in treating symptoms of depression, as well.

27. Method Participants 39 female victims of rape or attempted rape 19 in the CPT condition 20 in the WL condition Inclusion criteria Raped at least 3 months previously No incest victims No severe competing pathology Self-reported significant PTSD symptomatology 39 female victims of rape or attempted rape participated in this study. 19 females completed the CPT condition, while 20 female participants were placed on a wait list. Inclusion criteria is as follows: female participants must have been raped at least three months prior to the start of the study, victims of incest were not allowed to participate, participants could not have any severe competing pathology, and they must currently report suffering from significant PTSD symptoms. 39 female victims of rape or attempted rape participated in this study. 19 females completed the CPT condition, while 20 female participants were placed on a wait list. Inclusion criteria is as follows: female participants must have been raped at least three months prior to the start of the study, victims of incest were not allowed to participate, participants could not have any severe competing pathology, and they must currently report suffering from significant PTSD symptoms.

28. Measurement Instruments Symptom Checklist-90-Revised (SCL-90-R) Impact of Event Scale (IES) PTSD Symptom Scale Self Report (PSS-SR) Beck Depression Inventory (BDI) Social Adjustment Scale (SAS) Structured Clinical Interview for the DSM-III-R-Non patient Version (SCID) Several assessment instruments, which have demonstrated success in prior research with rape victims, were used. I?ll briefly give you a description of each of these measurements. The first, the symptom checklist 90 revised is a 90-item likert scale used extensively with rape victims. The impact of event scale is a 15-item scale consisting of two subscales: cognitive intrusion and avoidance. The PTSD symptom scale self report is a 17-item scale with three subscales representing DSM 3 criteria for PTSD. The Beck Depression Inventory is a 21-item self-report questionnaire, which is widely used for assessment of depression. The Social Adjustment Scale is used for assessing the social functioning of depressed women. The Structured Clinical Interview for the DSM 3 Non patient version is a diagnostic interview developed from criteria on the DSM 3 revised. Each of these assessments demonstrate good psychometric properties. Several assessment instruments, which have demonstrated success in prior research with rape victims, were used. I?ll briefly give you a description of each of these measurements. The first, the symptom checklist 90 revised is a 90-item likert scale used extensively with rape victims. The impact of event scale is a 15-item scale consisting of two subscales: cognitive intrusion and avoidance. The PTSD symptom scale self report is a 17-item scale with three subscales representing DSM 3 criteria for PTSD. The Beck Depression Inventory is a 21-item self-report questionnaire, which is widely used for assessment of depression. The Social Adjustment Scale is used for assessing the social functioning of depressed women. The Structured Clinical Interview for the DSM 3 Non patient version is a diagnostic interview developed from criteria on the DSM 3 revised. Each of these assessments demonstrate good psychometric properties.

29. Treatment CPT treatment sessions Conducted in groups 5, 6, and 8 participants 12 weekly sessions 90 minute duration CPT treatment sessions consisted of 12 weekly session lasting 90 minutes in duration. These sessions were conducted in groups of 5, 6, and 8 participants. Participants in each of the treatment sessions were assessed at pretreatment, 1 week posttreatment, 3 month follow up, and 6 month follow up.CPT treatment sessions consisted of 12 weekly session lasting 90 minutes in duration. These sessions were conducted in groups of 5, 6, and 8 participants. Participants in each of the treatment sessions were assessed at pretreatment, 1 week posttreatment, 3 month follow up, and 6 month follow up.

30. Results At posttreatment None of the CPT women met criteria for PTSD At 3 month follow-up 2 of the CPT women met criteria for PTSD At 6 month follow-up None of the CPT women met criteria for PTSD According to the results, at posttreament, none of the women receiving CPT met criteria for PTSD. At 3 month follow-up, two of the women receiving CPT met criteria for PTSD. Furthermore, at 6 month follow-up, one of the women receiving CPT met criteria for PTSD, once again. The authors never stated a reason for the regression in progress of the two individuals during 3 month follow up. According to the results, at posttreament, none of the women receiving CPT met criteria for PTSD. At 3 month follow-up, two of the women receiving CPT met criteria for PTSD. Furthermore, at 6 month follow-up, one of the women receiving CPT met criteria for PTSD, once again. The authors never stated a reason for the regression in progress of the two individuals during 3 month follow up.

31. Conclusions CPT resulted in significant improvement in both PTSD and depressive symptoms CPT improvement maintained over 6 months WL condition showed no significant improvement Overall, the author?s hypotheses were supported. CPT resulted in significant improvement in both PTSD and depressive symptoms when implemented in a 12 session group format. The improvements noted in CPT completers in symptoms and social functioning were maintained over a 6 month period. Additionally, the wait list condition did not demonstrate any significant improvements during any of the assessment periods. Overall, the author?s hypotheses were supported. CPT resulted in significant improvement in both PTSD and depressive symptoms when implemented in a 12 session group format. The improvements noted in CPT completers in symptoms and social functioning were maintained over a 6 month period. Additionally, the wait list condition did not demonstrate any significant improvements during any of the assessment periods.

32. Limitations No random assignment of participants CPT vs. other treatments CPT as group therapy vs. individual therapy The authors stated several limitations of this study and implications for future research in this area. First, participants in this study were not randomly assigned. This created a quasi-experimental design. For a true experimental design, random assignment of participants would have to occur. Second, CPT was not compared with other treatments, therefore the superiority of CPT as a treatment for sexual assault victims can not be assessed. Furthermore, since CPT consists of two components: exposure and cognitive therapy, the author?s were unable to determine the importance of each of these components separately or the effectiveness of their combination. In addition, since CPT was administered as group therapy rather than individual therapy, it is unknown how these formats might compare against one another. Each of these limitations were addressed in the next study, which is a follow-up to this one. The authors stated several limitations of this study and implications for future research in this area. First, participants in this study were not randomly assigned. This created a quasi-experimental design. For a true experimental design, random assignment of participants would have to occur. Second, CPT was not compared with other treatments, therefore the superiority of CPT as a treatment for sexual assault victims can not be assessed. Furthermore, since CPT consists of two components: exposure and cognitive therapy, the author?s were unable to determine the importance of each of these components separately or the effectiveness of their combination. In addition, since CPT was administered as group therapy rather than individual therapy, it is unknown how these formats might compare against one another. Each of these limitations were addressed in the next study, which is a follow-up to this one.

33. A Comparison of Cognitive-processing Therapy With Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress Disorder in Female Rape Victims Resick, Nishith, Weaver, Astin, and Feuer (2002) As I just stated, this second study, which was conducted in 2002 by Resick, Nishith, Weaver, Astin, and Feuer, was a follow-up to the previous one. This study is titled ?A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims?As I just stated, this second study, which was conducted in 2002 by Resick, Nishith, Weaver, Astin, and Feuer, was a follow-up to the previous one. This study is titled ?A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims?

34. Purpose & Hypothesis Purpose Compare effectiveness of three treatment conditions: Condition 1: minimal attention wait list condition (MA) Condition 2: cognitive processing therapy (CPT) Condition 3: prolonged exposure (PE) Hypothesis CPT would be more effective than PE The purpose of this study was to conduct a contolled trial in order to compare individually administered cognitive processing therapy with prolonged exposure, and a minimal attention wait list condition, for the treatment of posttraumatic stress disorder in victims of rape. The hypothesis of this study was simply that CPT would be more effective than PE in treating symptoms of PTSD. The purpose of this study was to conduct a contolled trial in order to compare individually administered cognitive processing therapy with prolonged exposure, and a minimal attention wait list condition, for the treatment of posttraumatic stress disorder in victims of rape. The hypothesis of this study was simply that CPT would be more effective than PE in treating symptoms of PTSD.

35. Method Participants 171 women randomized into the trial 41 received CPT 40 received PE 40 on MA Exclusion criteria: Raped less than 3 months ago Changes in medication Substance dependence 171 women were randomized into 1 of the 3 conditions. 41 participants received CPT, 40 received PE, and 40 were put on the minimal attention wait list. Exclusion criteria included: being raped less than 3 months prior to the beginning of the study, changes in medication, and current dependence on drugs or alcohol. 171 women were randomized into 1 of the 3 conditions. 41 participants received CPT, 40 received PE, and 40 were put on the minimal attention wait list. Exclusion criteria included: being raped less than 3 months prior to the beginning of the study, changes in medication, and current dependence on drugs or alcohol.

36. Measurement Instruments Interviews Clinician Administered PTSD Scale (CAPS) Structured Interview for DSM-IV (SCID) Standardized Trauma Interview Self-Report Scales PTSD Symptom Scale (PSS) Beck Depression Inventory (BDI) Trauma-Related Guilt Inventory (TRGI) Several psychological assessments, each with good psychometric properties, were used in this study, as well. The group of interview assessments included: the clinician administered PTSD scale, which is a diagnostic instrument that measures PTSD. The structured interview for the DSM 4 is based on criteria from the DSM 4. And the standardized trauma interview is a structured interview covering the following topics: demographics, information concerning the rape, within crime reactions, trauma history, social support, and treatment history. The self report measurements include: the PTSD symptom scale and the Beck Depression Inventory, which I?ve already previously described, and the trauma related guilt inventory, which is a 32-item likert inventory that applies three scales to assess distress, global guilt, and guilt cognitions. Several psychological assessments, each with good psychometric properties, were used in this study, as well. The group of interview assessments included: the clinician administered PTSD scale, which is a diagnostic instrument that measures PTSD. The structured interview for the DSM 4 is based on criteria from the DSM 4. And the standardized trauma interview is a structured interview covering the following topics: demographics, information concerning the rape, within crime reactions, trauma history, social support, and treatment history. The self report measurements include: the PTSD symptom scale and the Beck Depression Inventory, which I?ve already previously described, and the trauma related guilt inventory, which is a 32-item likert inventory that applies three scales to assess distress, global guilt, and guilt cognitions.

37. Treatment Treatment sessions PE and CPT conducted twice weekly Initial 60-minute session of PE, then 90 minute sessions Two 90-minute sessions of CPT (sessions 4 & 5), 60-minute sessions for the rest Total 13 hours of treatment for each condition Both cognitive processing therapy and prolonged exposure were conducted twice weekly and completed within 6 weeks. The first session of PE lasted 60 minutes. Each subsequent session was 90 minutes in duration. For CPT, sessions 4 and 5 were 90 minutes in length, while the rest of the sessions lasted for 60 minutes. Each treatment condition spanned a total of 13 hours. Both cognitive processing therapy and prolonged exposure were conducted twice weekly and completed within 6 weeks. The first session of PE lasted 60 minutes. Each subsequent session was 90 minutes in duration. For CPT, sessions 4 and 5 were 90 minutes in length, while the rest of the sessions lasted for 60 minutes. Each treatment condition spanned a total of 13 hours.

38. Results Both CPT and PE highly successful MA condition did not result in any improvements CPT as successful as PE even though participants completed only half as much homework Both treatments appear effective for someone traumatized 30 years ago or 3 months ago CPT effective as an individual treatment The results of this study, which supported the author?s hypothesis, indicated that both CPT and PE were found to be highly successful in treating PTSD in sexual assault survivors. As projected, the minimal attention wait list condition did not result in any improvements. In addition, CPT was found to be as successful as PE, even though participants in the CPT condition only completed half as much homework as participants in the PE condition. An interesting and remarkable finding was that both treatments appear to be as effective for someone traumatized 3 months ago or 30 years ago. Overall, the author?s proved that CPT is effective as an individual treatment. The results of this study, which supported the author?s hypothesis, indicated that both CPT and PE were found to be highly successful in treating PTSD in sexual assault survivors. As projected, the minimal attention wait list condition did not result in any improvements. In addition, CPT was found to be as successful as PE, even though participants in the CPT condition only completed half as much homework as participants in the PE condition. An interesting and remarkable finding was that both treatments appear to be as effective for someone traumatized 3 months ago or 30 years ago. Overall, the author?s proved that CPT is effective as an individual treatment.

39. Limitations Participant drop-out Limited PTSD sample Dismantling of CPT There are a few limitations in this study. The participant drop-out rate was fairly high with 37 women dropping out of the study. While this is unfortunate, there were no significant differences among treatment groups. The drop-out rates for this study were typical of PTSD rape treatment samples and similar to other studies. In addition, included in the sample were individuals suffering from severe and chronic PTSD and most of the participants had been traumatized multiple times. The authors state that for their study, it was too difficult to examine the full range of variables that might affect treatment completion, however, that?s definitely an important topic for future research in this area. Furthermore, at the time of this study, CPT has only been applied to the treatment of sexual assault victims with PTSD. The author?s think that for future research, it would be interesting to examine whether or not CPT could be applied to other samples, for instance, war veterans. They believe CPT has good external validity and therefore, could be generalized to other populations. Finally, as stated in the previous study as a limitation, the two components of CPT, exposure and cognitive therapy, need to undergo dismantling studies to determine if either component is more effective or rather, the combination of the two. This research has yet to be explored.There are a few limitations in this study. The participant drop-out rate was fairly high with 37 women dropping out of the study. While this is unfortunate, there were no significant differences among treatment groups. The drop-out rates for this study were typical of PTSD rape treatment samples and similar to other studies. In addition, included in the sample were individuals suffering from severe and chronic PTSD and most of the participants had been traumatized multiple times. The authors state that for their study, it was too difficult to examine the full range of variables that might affect treatment completion, however, that?s definitely an important topic for future research in this area. Furthermore, at the time of this study, CPT has only been applied to the treatment of sexual assault victims with PTSD. The author?s think that for future research, it would be interesting to examine whether or not CPT could be applied to other samples, for instance, war veterans. They believe CPT has good external validity and therefore, could be generalized to other populations. Finally, as stated in the previous study as a limitation, the two components of CPT, exposure and cognitive therapy, need to undergo dismantling studies to determine if either component is more effective or rather, the combination of the two. This research has yet to be explored.


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