Flexible Applications of Cognitive Processing Therapy: Evidence-Based Treatment Methods

By Tara E. Galovski, Reginald D.V. Nixon and Debra Kaysen

Flexible Applications of Cognitive Processing Therapy: Evidence-Based Treatment Methods provides a detailed roadmap on how to apply therapy to a wide-range of complex patients. Starting with an exploration of the development of CPT, the book then segues into a practical discussion on flexible adaptations of therapy. Dissemination and implementation of CPT is covered next, and the book concludes with directions for future research. It provides clinical guidance on treating PTSD with patients who express high levels of anger, shame, guilt, and other forms of emotionality, while also providing insight on research on the effectiveness of CPT on other comorbid disorders.

The book also reviews the outcomes of clinical trials of CPT inside and outside the United States, including examining modifications and outcomes in a diverse array of patient populations.

• Traces the history and development of cognitive processing therapy (CPT)
• Outlines empirically-supported modifications to CPT
• Looks at international applications of CPT in diverse patient populations
• Discusses common challenges to therapy outcome and how to overcome them

• Language: English
• Publisher: Academic Press
• Release date: Apr 4, 2020
• ISBN: 9780128168851

Tara E. Galovski

Director of the Women’s Health Sciences Division of the National Center for PTSD and Associate Professor in the Department of Psychiatry at Boston University School of Medicine, Dr. Galovski’s research explores the effects of exposure to traumatic events and looks to continue the development of psychological interventions designed to treat PTSD and comorbid psychiatric disorders. She has conducted clinical trials funded by the National Institutes of Health, Department of Defense, Veterans Health Administration, and Substance Abuse and Mental Health Services Administration within a variety of populations exposed to different types of trauma including combat, sexual trauma, domestic violence, community violence, and motor vehicle accidents. She also co-created and developed WoVeN, a national social support network for women Veterans. She currently is an Associate Editor on the Journal of Traumatic Stress. She is a national trainer of CPT and has disseminated the intervention across numerous patient populations and healthcare systems.

Book preview

Flexible Applications of Cognitive Processing Therapy

Evidence-Based Treatment Methods

Tara E. Galovski

National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, Boston, Massachusetts, United States

Reginald D. V. Nixon

College of Education, Psychology & Social Work, Flinders University, Adelaide, SA, Australia

Debra Kaysen

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States

Contents

Cover

Title page

Copyright

About the authors

Foreword

Acknowledgments

Part I: Cognitive Processing Therapy: Supporting Evidence

Chapter 1: The face of PTSD

Abstract

What is PTSD?

Clinical complexities

The toll of PTSD

Cognitive processing therapy

Overview of the book

Case studies

Setting the stage

Chapter 2: Ancestral roots: The origins of CPT

Abstract

The role of avoidance

Cognitive theory

Cognitive theory in clinical practice

The role of emotion

Summary

Chapter 3: Treatment development: The early years

Abstract

CPT randomized clinical trials

Summary

Chapter 4: Emerging as an effective therapy: CPT is put to the test

Abstract

CPT is effective across a myriad of settings and diverse patient groups

Why do patients get better?

PTSD is not the only domain that improves after CPT

CPT in the context of violence

Summary

Part II: Flexible Administrations of the CPT Manual

Chapter 5: Challenges to optimal therapy outcomes

Abstract

Walking the fine line between fidelity and flexibility

The clinical value of continuous assessment

Recovery beyond the core symptoms of PTSD

Challenges to optimal treatment outcomes (COTOs)

Case formulation approach and cognitive therapy

Expand CPT to specifically target COTO-related stuck points

Diverging from the protocol

Content of the divergence

Resuming CPT

Summary

Chapter 6: Therapy is hard: Improving patient engagement and working through avoidance

Abstract

Difficulty getting started: tenuous patient engagement

Strategies to increase engagement at the outset of therapy

Augmenting CPT at the outset of therapy

Addressing CPT engagement during therapy: The brief session

Finally, when to terminate therapy

The importance of language

Other issues that impact engagement

CPT concepts are too complex for my patient

Summary

Chapter 7: Navigating rough waters: Managing common challenges across the four cornerstones of CPT

Abstract

Cornerstone 1: Emphasis on practice work between sessions

Cornerstone 2: Promoting the expression of natural emotions

Cornerstone 3: Prioritizing assimilated stuck points before over-accommodated stuck points

Cornerstone 4: Socratic questions

Honing your Socratic questioning skills

Challenges in generating alternative thoughts

Chapter 8: Complex trauma histories

Abstract

Complex trauma and complex PTSD

Concerns, decision paths, and strategies

The practical stuff

Summary

Chapter 9: Managing emotional dysregulation

Abstract

Optimal levels of emotional engagement

Managing over-arousal and big emotion in session

My patient is just numb—managing lack of emotion in session

Managing dissociation in and out of session

Dysregulation into regulation

Chapter 10: Addressing comorbid disorders and conditions

Abstract

The importance of a good history and good case conceptualization

CPT for individuals with comorbid mood disorders

CPT with comorbid panic disorder

CPT with comorbid substance use disorders

Managing characterological features during CPT

CPT with medical comorbidities

Summary

Part III: Dissemination and Implementation of CPT

Chapter 11: Applications of CPT in diverse populations and across cultures

Abstract

Applications of CPT in diverse populations and across cultures

Culture and evidence-based therapies

The impact of gender, race, and ethnicity on CPT outcomes in the United States

Use of adapted CPT within the United States

CPT hits the road: Applications of CPT outside of the United States

CPT’s core features appear culturally robust

Chapter 12: Administering CPT across health care systems and clinical settings

Abstract

Strategies in disseminating and implementing CPT across systems

Summary

Chapter 13: Future frontiers

Abstract

Where to now?

Treatment engagement, patient choice, and matching

CPT and future innovations

Future clinical research

Conclusion

Index

Copyright

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About the authors

We (Drs. Galovski, Nixon, and Kaysen) all began our CPT journey at the birthplace of CPT—the Center for Trauma Recovery (CTR) at the University of Missouri—St. Louis. Dr. Kaysen was the first of us to be introduced to CPT as Dr. Resick’s graduate student in the very early days when CPT was being compared to PE in the first randomized clinical trial. Dr. Nixon was also mentored by Dr. Resick at the CTR during his postdoctoral fellowship. Dr. Galovski next joined the CPT family as a research professor and served as project director of the CPT dismantling study just as Dr. Nixon was leaving to return to Australia and Dr. Resick left CTR to take the position of the Director of Women’s Health Sciences Division of the National Center for PTSD. Since those early days participating in the development of CPT in the first clinical trials establishing its, efficacy, all three of us have gone on to develop, test, and practice CPT across a wide variety of settings and patient populations.

Between us, we have conducted 15 CPT trials as coinvestigators, served as consultants on an additional 15+ trials, published over 225 peer-reviewed papers and chapters on CPT and related topics, and forged new paths and improved overall outcomes for more survivors of trauma by developing 8 additional CPT trials as principle investigators. We have been funded by NIH, DoD, VA, NHMRC, SAMHSA, DVA, ARC, USAID foundations, and local-funding agencies. All three authors were among the original team of CPT investigators to develop the large-scale CPT dissemination effort within the United States. VHA that serves as a model for additional rollouts in which we participated or led across the US DoD, at the state level (TX, MO, CO) and we continue to disseminate CPT as national and international trainers.

Between three of us we have worked clinically with, or conducted clinical trials across, numerous trauma populations including survivors of sexual assault, torture, veterans (combat and military sexual trauma), active duty military, sexual minority women, first responders, MVA/accidental injury, and acute survivors. This work has been conducted within the US populations as well as with Iraqi’s, Congolese, native Americans, and Australians. We have served as consultants for well over 1000 practicing clinicians in a variety of contexts and as primary mentors for over 30 trainees at the undergraduate, graduate, and postdoctoral levels and secondary mentors for countless other. Readers can always google us to see what we are up to next! Individually, we thought we would each speak to what specifically drive us to this type of work.

Dr. Galovski’s story: As an eternal optimist but also a firm realist, I do believe that people can move through truly horrific and almost unspeakable events and get to the other side. After doing this work as a practicing clinical psychologist and scientist for nearly 20 years, I have had the privilege of seeing lives change for the better. We all know that we cannot undo the past, but we can make our worlds big enough to hold even the worst of experiences and still live our best lives. As therapists, we have the honor to accompany our patients on this journey, but the journey is theirs. I can honestly say that I have been awed by the strength and fortitude of the survivors who found the courage to walk through the doors of the CTR in St. Louis and do this difficult work. It was an extremely difficult decision to leave the remarkable CTR and come to Boston, but I felt compelled to give back to the Veterans who have served us so well, and particularly to our women Veterans, and can do exactly that in my current capacity as the Director of the Women’s Health Sciences Division of the National Center for PTSD and as an Associate Professor at Boston University School of Medicine. There is much work to be done and I am excited to continue to tackle this challenge of moving the needle ever further toward recovery from PTSD.

Dr. Nixon’s story: I am often asked how I came to work in the area of trauma and why. I completed one of my clinical training placements at a specialist PTSD unit (St John of God Hospital, North Richmond). There I was inspired by the determination of those who had received the worst deck of cards that life could throw at them. Yet they, as well as the people I have worked with since, have shown me that with the right environment and help, incredible amounts of recovery is possible. I was also fortunate enough to be mentored early in my career by two leaders in our field, Dr. Richard Bryant and Dr. Patricia Resick, seeing firsthand the quality of their work and dedication to improving our knowledge of how best to help those after trauma. It is this background that drives my desire to further contribute to the traumatic stress field, a contribution that will not just reduce suffering but results in people having the opportunity to live and enjoy the lives they deserve.

Dr. Kaysen’s story: I come from a large, diverse, opinionated, and loving family scattered all over the world. On top of that I have added in an equally large chosen family. That family also had an ethos of service. Within that beautiful network I have also seen people I love dearly touched by traumatic events, how it has affected them, and how they have made it through. Those stories helped pull me into the trauma field. When I entered graduate school and discovered the CTR and my graduate school mentor, Dr. Patricia Resick, I knew I had found my clinical and research home. That passion for helping facilitate recovery, respecting people’s natural resilience, and embracing the knowledge and diversity of people across the globe has driven my own work and has led me from the University of Washington to Stanford, where I am honored to help support the next generation of clinicians and researchers in the trauma field.

Foreword

Flexible Applications of Cognitive Processing Therapy, is a lovely companion to the treatment manual Cognitive Processing Therapy for PTSD: a Comprehensive Manual. It is authored, not only by researchers and CPT trainers, but by three therapists who have extensive experience in conducting CPT in varied practice settings: Tara E. Galovski, Reginald D. V. Nixon, and Debra Kaysen. All three of these skilled clinicians and researchers have added to the evolution of CPT to new formats and populations while keeping the heart of the therapy intact. Although the original treatment manual says comprehensive, by that we meant the basic CPT manual for different populations and formats and all of the materials needed to complete individual, group, or variable length treatment (without or with the trauma account). It could not cover in detail all of the various additional problems that individual patients bring to the therapy room (or refuse to) that could undermine treatment. This volume adds to that manual by providing rich information on clinical considerations that can arise with a population that not only has PTSD, but life circumstances and comorbid symptoms that can stymie therapists and affect their ability to complete this evidence-based treatment with fidelity.

The first few chapters review the symptoms of PTSD, what CPT consists of, and the theoretical background. The research supporting CPT follows and then the book moves into dealing with specific challenges such as dealing with avoidance and managing common problems that are encountered with patients. Then the book moves into more difficult client situations such as conducting CPT with those with complex trauma histories, managing emotional dysregulation from extreme numbing and dissociation to the opposite pole, such as strong anger. There is a chapter on comorbid disorders and how to decide which to treat first, the PTSD or other disorders and how to manage treating both simultaneously when called for. There is a chapter on dissemination including working within agencies and systems. Finally there are chapters on diverse populations and cross-cultural adaptations as well a peek into the future of CPT.

This book is not a replacement for the treatment manual—it does not explain how to implement CPT—but devotes entire chapters to topics that were given only a paragraph or two in the treatment manual, due to page limitations. It also updates the research findings that have emerged to guide treatment since the treatment manual was published. For those who do not have ongoing access to consultation by experts, answers to typical situations, and more in-depth discussion of possible strategies for handling common and less common problems, when to deviate from the protocol without losing fidelity, and adaptations that have been made that maintain the crucial elements of CPT are all included. Throughout the book, several case study examples are followed to add richness to the explanations and suggestions for possible interventions.

Flexible Applications of Cognitive Processing Therapy demonstrates well that an evidence-based brief manualized treatment for PTSD need not be rigid and disregarding of client needs. The authors do an excellent job of providing advice to therapists about how to adjust the protocol to the ongoing circumstances of the patients’ lives and then how to return to treating PTSD with CPT without meandering off course. This book is very clear and a helpful addition to the implementation of CPT in clinical practice and should sit on the shelf next to the treatment manual for easy access to expert guidance.

Patricia A Resick, PhD, ABPP

Professor of Psychiatry and Behavioral Sciences

Duke University Medical Center

Acknowledgments

Tara E. Galovski sends much love and thanks to Jim, Saige, Hope, and Sam. Above all else, you are my Team G’lov and my future self is really quite jealous of my current self.

To Mark Rider, how many people get to name their dad as both their hero and their best friend? I am forever honored to be your daughter. I miss you.

And to Adrienne, your light continues to shine in ways that are unimaginable and indescribable. Too soon, too short, but so powerful. You inspire me to do this work better, every day, truly.

Reginald D. V. Nixon would like to thank his family—Julie, Anna, and Will—for their support and tolerance, especially when he is busy with that work stuff. He would also like to thank his mentors, colleagues, and students who have over the years either given sage advice, been valued collaborators, or simply kept him on task.

Debra Kaysen would like to thank first and foremost her partners, Carter and Karla, and her son Evan for their seemingly endless patience and support. She would like to thank the Sacred Journey Community and the Healing Season’s Community for including her in the work we have done together. To the brilliant women of the Trauma Recovery Innovation Program (Drs. Stappenbeck, Lindgren, and Bedard-Gilligan), I adore you all and am eternally grateful for the inspiration, wisdom, and giggles you have brought to my life.

All three authors would like to acknowledge that none of this work could be done if Patti Resick had not written this beautiful therapy. We want to thank the larger CPT family as well the trainers, scientists, and clinicians around the globe. We learn so much from you and always appreciate your support and wisdom. We also want to acknowledge the various institutions, which have housed and supported our projects as well as all of the agencies that have funded our studies, allowing this work to continue and grow. Finally, and perhaps most importantly, we want to express our appreciation and gratitude to all of the trauma survivors who participated in our studies. You have paved this path and made the journey to recovery possible for so many more to follow.

Part I

Cognitive Processing Therapy: Supporting Evidence

Chapter 1: The face of PTSD

Chapter 2: Ancestral roots: the origins of CPT

Chapter 3: Treatment development: The early years

Chapter 4: Emerging as an effective therapy: CPT is put to the test

Chapter 1

The face of PTSD

Abstract

Treating posttraumatic stress disorder (PTSD) is complicated and complex. The disorder itself includes 20 symptoms categorized into four different clusters. Impairment in functioning across major life domains is also readily apparent in PTSD clinical presentations and, indeed, is a requirement for meeting criteria for the disorder. To add to the complexity of PTSD, the disorder rarely occurs in isolation with other types of mental illness, such as depression, panic disorder, and substance use disorders that are quite often diagnosed along with PTSD. Further, patients presenting with PTSD can look very different from one another in terms of the types of exposures to traumatic events, family histories, social support systems, and physical health complications. This chapter seeks to describe PTSD and provides three case vignettes to illustrate the unique nature of each patient presenting with PTSD.

Keywords

PTSD

treating PTSD

clinical case vignettes

cognitive processing therapy

DSM-5 PTSD criteria

clinical complexities

Chapter outline

What is PTSD?

Clinical complexities

The toll of PTSD

Cognitive processing therapy

Overview of the book

Case studies

Case 1: Anna’s story

Case 2: Steve’s story

Case 3: Julie’s story

Setting the stage

References

What is PTSD?

You may have heard the adage, If you’ve seen one, you’ve seen ‘em all! This saying could not be further from the truth when considering clinical presentations of posttraumatic stress disorder (PTSD). The unique nature of each individual trauma and the nuances of the context in which that trauma occurred, coupled with prior trauma history and comorbid disorders and conditions, all contribute to the unique and variable clinical presentations that clinicians will grapple with when treating trauma survivors suffering from PTSD. The diagnostic criteria for PTSD was recently expanded in the Diagnostic and Statistical Manual, 5th Edition (DSM-5: American Psychiatric Association, 2013) to include 20 symptoms distributed over four clusters. The sheer number of symptoms and the number of possible combinations of symptoms that can result in the diagnosis of PTSD attests to the variability in clinical presentations that a therapist may observe across patients presenting with the exact same diagnosis. For example, one patient suffering from PTSD may appear withdrawn and emotionally numb or shutdown while another may present as quite emotional and have difficulty containing that emotion throughout the therapy sessions. A third patient may exhibit a significant fearful and anxious demeanor and may dissociate frequently when presented with reminders of the trauma while a fourth patient may become angry and even volatile during and outside the session. Given the heterogeneity in the diagnostic criteria and the variability that therapists observe across clinical presentations, it may be difficult to imagine how one single therapy can possibly be effective across all of these different manifestations of one disorder.

Clinical complexities

Adding to the clinical challenges inherent in treating this disorder, PTSD rarely occurs in isolation, meaning that it is quite common for multiple additional disorders to co-occur with PTSD, including substance use disorders, insomnia, major depression, and/or personality disorders. Indeed PTSD is less likely to present as a sole diagnosis than it is to present with one or more comorbid conditions (Bradley, Greene, Russ, Dutra, & Westen, 2005). It can be quite challenging for the treating therapist to first differentially diagnose various disorders, which often present with overlapping symptoms, and then develop a cohesive treatment plan. This treatment planning could involve decisions about prioritizing which disorder to treat first or deciding to treat multiple disorders simultaneously. Similarly, there are often additional necessary considerations as to what types of comorbid presentations are likely to interfere with successful engagement in CPT or whether these conditions could lead to CPT being iatrogenic. Conversely, the therapist might consider whether the treatment of PTSD may actually alleviate the symptoms of other comorbid conditions. For example, a typical conundrum faced by PTSD therapists is comorbid PTSD and substance use disorders. A patient might be using alcohol or substances to diminish the pain of the PTSD symptoms. In this case, the PTSD symptoms may be a clear cause of alcohol misuse. Treating the PTSD symptoms as the primary target of care should then logically not only decrease the PTSD symptoms, but also decrease the need to use the substance. However, a therapist could also grow concerned that by engaging with the trauma memory, the patient’s distress could increase and, in turn, increase the need for even more self-medication through substance misuse. These and other clinical conundrums will be discussed in detail later in this book.

In addition to comorbid psychiatric conditions, a host of other complicating factors can also contribute to the challenges inherent in treating PTSD. For example, many trauma survivors sustain injuries during their traumatic event (e.g., assaults, combat, motor vehicle accidents) and lingering physical limitations, such as traumatic brain injuries or reproductive health complications, chronic pain, scarring, and other related health difficulties can serve as additional stressors warranting clinical attention—as well as constant reminders of the trauma triggering PTSD symptoms.

Likewise, trauma survivors’ functioning can be significantly impacted by the traumatic event and these impairments in functioning can, in turn, have detrimental effects on relationships resulting in the crumbling of support systems. PTSD can interfere with trauma survivors’ ability to secure and keep gainful employment; traumatic events such as car crashes and natural disasters can include property loss and damages—all resulting in financial difficulties. Financial difficulties are not only a constant source of additional stress, but can prevent people from accessing resources such as therapy. Living with PTSD symptoms, and the additional stressors that surround PTSD, can create significant stress on existing relationships, further depleting the trauma survivors’ resources and supports. In sum, PTSD can interfere with just about every aspect of people’s lives. We see the worlds of trauma survivors suffering from PTSD grow smaller and smaller as they work hard to avoid anything that reminds them of their traumatic event. We see our patients struggle with PTSD-related fears for their own safety and that of their loved ones to the extent that it prevents them from living the lives they want to live. And we see these struggles expand to encompass all aspects of individuals’ functioning, further increasing their overall traumatic stress burdens.

The toll of PTSD

PTSD, by definition, presents significant challenges to patient engagement and retention. In order to be successful, trauma-focused therapy must break through the avoidance inherent in the diagnosis of PTSD and include an element of accessing the trauma memory. In essence, we are asking patients to do precisely what they most adamantly do not want to do—think about the worst thing that ever happened to them. In fact, it is not unusual for the therapist to be the first person to whom trauma survivors disclose their traumatic experience. It is also not uncommon for patients to initiate treatment for traumas that had occurred on average a decade and a half ago (Resick et al., 2008; Galovski, Blain, Mott, Elwood, & Houle, 2012). While studies report the average number of years from index trauma to treatment, it is also important to note the substantial range of time since trauma across patients. While trauma survivors certainly seek treatment secondary to fairly recent events, it is not uncommon for patients to seek treatment decades after his/her trauma. Living with PTSD clearly impairs functioning and, as years of suffering with the disorder go by, the chronicity can contribute to significant personal and community costs as trauma survivors struggle with the burden of PTSD symptoms.

Treating PTSD is clearly complicated from the therapist perspective. Engagement in PTSD treatment is immensely challenging from the patient perspective. Fortunately, we have excellent psychological interventions that can effectively treat PTSD. These therapies are manualized and accessible, well researched, and well taught.

Cognitive processing therapy

Over the last several decades, the research on Cognitive Processing Therapy has burgeoned, earning it top ratings and designations as a first line treatment for PTSD across national and international clinical guidelines and evidence reviews (U.S. Department of Veteran Affairs and Department of Defense, 2017; American Psychological Association, 2017; UK National Institute for Health and Clinical Excellence, 2005; Australian Centre for Posttraumatic Mental Health, 2013; Bisson et al., 2019; Foa, Keane, Friedman, & Cohen, 2008; Institute of Medicine, 2007; Forbes et al., 2007). The updated CPT manual recently published (Resick, Monson, & Chard, 2017) has enhanced previous iterations, increasing the accessibility of the therapy for clinicians from all types of health care systems. The process of training in CPT has also been manualized and the training workshop, developed by national experts in CPT, has been refined over the years, leading to the widespread dissemination of CPT (Karlin et al., 2010). Best practices of learning CPT include a 2-day workshop (with an option of a third day to include a group CPT training) followed by a period of regular (weekly) consultation with a CPT expert, providing CPT trainees to ask questions on individual cases in real time as they administer the protocol to their patients. The consultation process has been found to be particularly effective in increasing therapist skill in administering the therapy (Monson et al., 2018). Meta-analytic study has quantified the effectiveness of CPT and results show that CPT emerges as one of the most effective therapies of PTSD (Steenkamp, Litz, Hoge, & Marmar, 2015; Cusack et al., 2016). Suffice it to say, we can conclude that CPT is a very effective therapy for PTSD.

However, we also know that CPT is far from perfect. We know that, despite its success, approximately one-third of patients do not lose their PTSD diagnosis after completion of therapy (Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008) and that these numbers may be even higher in specific populations such as veterans engaged in VA healthcare (Steenkamp et al., 2015). We know that our premature dropout rates are far too high and that dropout from treatment may even be higher in clinical practice settings (Schottenbauer et al., 2008). The burning question then becomes, why is a therapy that is clearly so effective for the majority of patients suffering from PTSD not effective for a sizable minority? And what can we, as clinicians, do to help move that needle further toward recovery for more of our patients?

This book seeks to expand on the session-by-session instruction provided in the CPT manual and enhance the contributions of the CPT consultation process by acknowledging and addressing clinical complexities and psychosocial stressors that can create challenges to optimal therapy outcomes (COTOs). By leveraging the available research on successful modifications of the CPT protocol to meet patients’ needs, we hope to provide clinically relevant guidance to clinicians as they grapple with attending to COTOs while administering CPT.

Balancing patient needs with fidelity to the treatment manual can feel akin to walking a tightrope. A slip in the direction of a more flexible protocol administration can jeopardize the effectiveness of the intervention; however, maintaining rigid fidelity may result in increased patient dropout or poorer, less holistic outcomes. Most of us do not have the time or bandwidth to stay abreast of every new research paper that is published on CPT. This book seeks to provide guidance on flexible approaches to the administration of CPT by relying on the literature on CPT modifications as well as leveraging our own years of experience as CPT therapists and clinical supervisors for hundreds of PTSD patients, as clinical trialists developing the CPT protocol and testing the modifications that we propose, as national CPT consultants for thousands of clinicians training in CPT worldwide over the last decade, and by incorporating the insight and tips from our CPT colleagues and community.

Overview of the book

This book guides the clinician through the theory that informed the development of CPT with particular attention to how we, as clinicians, rely on theory in our case conceptualization and leverage the wisdom and guidance that theoretical underpinnings provide us at critical therapy decision points. We then trace the development of CPT in a brief review of the 20+ published randomized clinical trials to date with the goal of summarizing how well CPT fared in each study and, most importantly, what useful clinical information can be gleaned that directly informs our CPT delivery of care. We next translate the voluminous effectiveness research, uncontrolled trials, and studies to understand more precisely how to treat PTSD with CPT in the context of all different kinds of challenges to optimal therapy outcomes. We apply the same strategy to understanding how therapy might (or might not) be enhanced with modifications to better meet the needs of the full range of our diverse patients from all walks of life whom we may be treating in a variety of clinical settings and healthcare systems.

The following case vignettes provide examples of patients who might present in any type of clinical setting. We highlight both the clinical considerations that we would note at the outset of therapy that might provide us hints as to specific CPT directions we might want to pursue. We also note the potential challenges to optimal therapy outcomes that might emerge over the administration of the CPT protocol. Finally, we refer back to these cases throughout the remainder of the book to provide clinical examples of the strategies we suggest to achieve our therapy goals—recovery!

Case studies

The following case vignettes are constructed from a variety of patients’ stories across therapists and intended to represent the unique nature of each patient’s traumatic event, trauma history, social support system, psychiatric comorbidity, and clinical presentation. While there is no typical PTSD patient, the clinical cases we present here are representative of the types of complexities and challenges that we collectively, as CPT therapists, grapple with during the course of treatment for PTSD. We will return to these cases, and the clinical complexities that they pose, to use as examples throughout the book. Any similarities between these case vignettes and actual patients are entirely coincidental.

Case 1: Anna’s story

Anna is a 32-year-old Veteran who had separated from the military after 8 years of service. She joined the armed forces at age of 17—her parents signed her papers for her since she was under 18 years of age. Anna was born and raised in a small town in rural Texas about 50 miles from the Mexican border. Anna was the youngest of six and the only girl. Her family lived on 4 acres of land and her parents consistently experienced significant difficulty finding work and making ends meet. She and her brothers were often left to fend for themselves and frequently found themselves in trouble at home, school, and with the local police. Punishments at home were particularly severe, especially when her parents were drinking. Anna recalls the day a recruiter for the United States Army came to her home to talk with two of her brothers about their interest in joining the armed forces. As Anna listened, she saw a way out of her small town and her parents signed the necessary papers without hesitation. Joining the Army seemed to be an escape from a fairly desperate situation for Anna. Girls rarely finished high school in her town and several of her classmates were pregnant or had already had children by age of 17. Anna had known that she was gay since she was 12 and she believed that her sexual orientation would not be readily accepted in her small town. Joining the Army and serving her country presented a lifeline to Anna in a very difficult and seemingly dead-end environment. She and two of her brothers enlisted and began basic training 6 months later.

For the first 4 years, Anna’s experiences were everything she had anticipated and more. She thrived on the order and structure of the military and excelled in every aspect of her training and, eventually, in her service. Although she was one of the few women in her company, she considered her fellow soldiers to be her brothers. She often said that she would take a bullet for any of them and knew that they would do the same for her. Anna had never known such pride and solidarity before in her life and she thrived on the order and discipline and planned to forge her career in the military. With the attack on the United States on September 11, 2001, the United States armed forces galvanized and within 8 months, Anna was deployed to Afghanistan. Although at the time, the 1994 Direct Ground Combat Definition and Assignment Rule prohibited women from engaging in direct combat roles, the nature of the warfare in Afghanistan and Iraq blurred the definition of direct combat as the traditional front lines of battle were obscure, particularly in urban settings. Anna’s first deployment lasted 7 months and she performed admirably with commendations from her command.

Within 12 months, Anna received orders for her second deployment, this time to Iraq. In an effort to be culturally sensitive to the customs and religious beliefs of the Iraqi women, Army women were attached to Marine units and accompanied the Marine squads when they went out on patrols, which often included house-to-house searches for weapons and insurgents. This second deployment was markedly different from the first. Anna was the only female embedded in the unit and was not a Marine—a branch of service that has historically been much more male-dominated. Anna’s main function during patrols was to contain and calm the Iraqi women who, according to their religious beliefs, could not be alone in a room with male strangers such as the Marines and could not be searched for weapons by men. Anna’s job was to sequester the women in a separate room and ascertain that