Undoing the Traumatization of Cognition
Ryan Van Wyk asked me to write a blog about Cognitive Processing Therapy, an evidence based cognitive behavioral therapy designed to treat Posttraumatic Stress Disorder (PTSD). It can be implemented in a variety of formats, including group, individual, or combination of group and individual sessions. In the 8 years I have been using CPT, I’ve seen remarkable symptom resolution in the majority of clients I’ve worked with, clients suffering from the effects of a wide range of traumatic events including combat, physical and sexual trauma, natural disasters, accidents, and a variety of childhood abuses.
Prior to starting CPT, a thorough assessment of the client’s trauma and symptoms is critical. This helps ensure that clients are getting the right treatment for the right condition. If the assessment suggests that the client’s symptoms are better explained by other conditions (such as depression), other treatments might be more effective. While it’s not necessary to meet all of the criteria for PTSD for CPT to be effective, in general clients should have symptoms in all of the symptom clusters (re-experiencing, avoidance, changes in cognition, and hyperarousal). Untreated severe substance abuse or psychosis should be addressed before starting CPT, and imminent self-harm or suicidality should be addressed first as well.
In order to better understand how CPT works, it’s helpful to discuss the effect that trauma has on our thoughts, emotions, and behavior. When an individual experiences a life-threatening traumatic event, such as physical or sexual assault, natural disasters, terrible accidents, combat, etc., they are likely to experience the “fight, flight, or freeze response” as a result. This response is evolutionarily beneficial in the face of a life-threatening event in that it allows us to fight off or escape from a threat (or, in the case of the freeze response, minimize physical or emotional pain at the time of the threat). In other words, the fight/flight/freeze response in and of itself is not the problem and in fact can be quite helpful. However, in some cases, this fight/flight/freeze response gets associated with cues related to the event. Through a conditioning process, when that individual later experiences those cues (which could be a sight, sound, smell, even a particular time of day or year), their fight/flight/freeze response is reactivated. Often this conditioned reaction fades over time if the individual doesn’t avoid the trauma cues. However, avoidance is one of the more frequently used coping strategies and therefore the systems persist. The other things that happens is that trauma can significant affect the way an individual thinks about themselves, others, or the world in general. CPT specifically targets thoughts about safety, trust, power and control, esteem, and intimacy, as well as beliefs related to guilt and self-blame. For some, the trauma stands in sharp contrast to previously held beliefs (i.e., “I used to think the world was a safe place, now I don’t feel safe anywhere”). For others, perhaps negative life experiences led them to develop negative beliefs about themselves, others, or the world that the trauma seems to confirm (i.e., “Growing up I was always told that everything bad that happened was my fault. I guess this is my fault too.”).
CPT is divided into several phases. The first phase examines the impact of the traumatic event on the client’s beliefs about themselves, others and the world. Clients are asked to write a one-page impact statement addressing why they think the trauma happened (which often elicits the self-blame and guilt cognitions clients hold) and how it changed or perhaps strengthened their beliefs related to five trauma-related domains: safety, trust, power and control, esteem, and intimacy. This phase is where patients start to recognize their “stuck points”, in other words, the beliefs, thoughts, and perceptions that are interfering with recovery (i.e., the world is totally dangerous, I have no control over anything, if I get close to people they’ll hurt me or I’ll lose them, the trauma is my fault, etc.).
The second phase involves processing the traumatic event, in the form of a written account of their main or index trauma. Clients are asked to write the account and read it to themselves each day to achieve this. In this respect CPT is not “exposure therapy” per se; reading the account should only take a few moments, which is not enough depth to induce habituation like you’d see in an exposure therapy. Rather, writing the trauma serves two purposes: one is to help further identify stuck points, the other is to facilitate the expression and resolution of natural emotions that the client may be avoiding or suppressing. These natural emotions are thought of as being a direct result of what happens to us (i.e., sadness when we have a loss, anger when someone is trying to hurt us, fear when we’re in danger) as opposed to the emotions generated by stuck points.
The next phase involves learning tools to challenge and change the stuck points into beliefs that are more balanced, realistic, and ultimately more helpful. For example, a belief/stuck point that “Nobody can be trusted” is not uncommon, but is also not that adaptive. The opposite of that belief, “I should be able to trust everybody”, is not terribly realistic or helpful either. Helping clients get to a place where they can believe “Maybe I can trust some people with some things some of the time” is likely much more adaptive. In addition, patients are encouraged to challenge self-blame and guilt, with an emphasis on differentiating blame (which implies intent) and responsibility (which implies perhaps having a role in a situation without the outcome being the intended outcome). It’s also focused on appropriately placing blame (for example, in the case of sexual trauma, blaming the perpetrator instead of themselves).
The treatment then moves to addressing each of the five trauma themes (safety, trust, power/control, esteem, and intimacy) in turn. There is a definitive shift in the therapist’s behavior at this point; as the client becomes more and more adept and challenging their thinking, the therapist takes on more of a consultant role. Clients are encouraged to test out alternative ways of thinking about themselves, others, and the world as they continue identifying and challenging stuck points.
Finally, the last session is geared toward reviewing the course of treatment and facing the future. The course of therapy is reviewed, and any lingering stuck points are addressed. The patient is asked at this point to rewrite their impact statement, focused on what they think now about the cause of the trauma and what they think now about themselves, others, and the world. This new impact statement is read by the client to the therapist, who then reads the original impact statement back to the client. This is a powerful and moving part of the therapy, both for client and therapist. I’ve had clients reactions vary from being moved to tears by the changes in their thinking, to being shocked at hearing their original statement (“Did I really say that?”). At this point I often encourage clients to take a break from therapy to consolidate their skills and to really put into practice what they’ve learned, as well as to give them time to consider other areas of their life they might want to address. For example, some clients complete CPT and then recognize that they continue to struggle with anger issues, in which case a referral to anger management might be warranted. In other cases, they might recognize that their relationships have suffered through the years as a result of their symptoms and that they could perhaps benefit from couples therapy.
To summarize, CPT is an effective, evidence based treatment for a wide range of traumatic events. Like any other psychotherapy, it should be implemented in full collaboration with the client when they are ready to do so. It is a treatment that empowers the client to take control of their life; it’s not about telling them what to think, but helping them learn ways to challenge their thinking, to confront trauma memories, and to live the life they want to live.