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Effects of Cognitive Processing Therapy on PTSD-Related Negative Cognitions in Veterans With Military Sexual Trauma Ryan Holliday, M A*f; Jessica Link-Malcolm, PhD*; Elizabeth E. Morris, PhD*; Alina Sun's, PhD*f
ABSTRACT Treating post-traumatic stress disorder (PTSD) related to military sexual trauma (MST) continues to be a priority in veteran populations. Because negative cognitions (NCs) contribute to PTSD severity and treatment, further understanding of how PTSD and related NCs can be addressed and changed within an MST sample is important. Our study analyzed 45 participants who received either cognitive processing therapy (n = 32) or present centered therapy (n = 13). Participants who received cognitive processing therapy had significantly lower NCs scores post-treatment and at follow-up sessions than participants in the present centered therapy condition (p < 0.05). In addition, NCs were positively correlated with PTSD severity (p < 0.05). Implications for future research are discussed for both MST-related and non-MST-related PTSD.
INTRODUCTION Military sexual trauma (MST) is defined by the Department of Veteran Affairs' as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of the victim, or the relationship of the perpetrator.” It is important to note that MST is not a clinical diagnosis, but rather, it is a traumatic event of a sexual nature that occurs while a person is on active duty, that often results in post-traumatic stress disorder (PTSD).2 Moreover, because of the prevalence of and negative consequences of MST3 in both returning military personnel and veterans, research related to clinical treatment of MSTrelated PTSD is critical. Specifically, MST-related PTSD has been shown to have numerous negative health associations including comorbid psychiatric disorders (e.g., depression and substance use dis orders), cardiovascular health problems, and socioeconomic difficulties (for a complete review see Surfs et al3). As such, treatment of MST-related PTSD continues to be a priority in clinical treatment settings including Veteran Affairs Medical Centers (VAMCs). One of the most commonly utilized treatments for PTSD at both VAMCs and non-VAMCs is cognitive processing therapy (CPT). CPT is an evidence-based treatment (EBT) that has been found to be significantly more effective at treating PTSD than other forms of psychotherapy and phar macotherapy.4 CPT is a form of cognitive behavioral therapy that was originally developed for civilian survivors of rape5 that has been adapted by the Veterans Health Administration to treat MST and combat-related PTSD.6 7 CPT effectively treats PTSD by having the patient recognize cognitive “stuck points,” which are negative/distorted cognitions related to the ♦Veteran Affairs North Texas Health Care System, 4500 South Lancaster Road, Room 116A, Dallas, TX 75216. tDepartment of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390. doi: 10.7205/MILMED-D-13-00309
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patient’s trauma(s). Over the course of CPT treatment, the therapist teaches the patient how to challenge negative cogni tions (NCs). The patient learns how irrational interpretations of the traumatic experience maintain PTSD symptoms and nega tively affects beliefs about self and the world. Through cogni tive restructuring, reductions in PTSD symptoms will occur.4 NCs may inhibit a patient’s ability to fully engage in the treatment process. Furthermore, higher levels of NC’s are associated with greater severity of PTSD symptoms.8-12 Since its development, CPT has demonstrated effective ness in multiple populations, including survivors of MST.13 Despite the wide breadth of knowledge regarding CPT’s effi cacy in treating PTSD 4’6,7'13-16 a review of the literature revealed only one published study which examined the effects of CPT on reducing the number of NCs.17 These researchers reported that CPT was effective at reducing NCs in a sample of high school students who had experienced a traumatic event.17 To date, no published studies have exam ined the effects of CPT on NCs in patients diagnosed with PTSD or in survivors of MST. Several critical issues were investigated in this study; we examined the relationship between NCs and symptom severity among veterans diagnosed with PTSD related to MST and assessed the effects of two interventions on clinical outcomes in this population. We had three hypotheses: (1) Veterans treated with CPT would demonstrate a greater reduction in NCs compared to those treated with a nontrauma-focused treatment (Present-centered therapy, PCT); (2) treatment with CPT would result in sustained symptom reduction over the pre- and post-treatment (PT) evaluations; and (3) the number of reported NCs would be positively correlated with measures of symptom severity among Veterans diagnosed with PTSD related to MST.
METHOD Participants
The study was conducted at a large Southwestern VAMC. Participants were recruited via posted advertisements,
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST recruitment letters, and clinician referral. Participants received monetary compensation for their participation. Inclusion criteria were as follows: (1) veteran status with a diagnosis of MST-related PTSD, (2) MST occurrence at least 3 months prior, (3) MST identified as the most distressing PTSD-related trauma, (4) at least one clear memory of the MST, and (5) no changes to psychiatric medication in the past 6 weeks. Exclusion criteria were as follows: (1) sub stance dependence/abuse in the past 3 months, (2) current psychotic symptoms, (3) unstable bipolar disorder, (4) severe cognitive impairment, (5) concurrent enrollment in an EBT for PTSD, (6) involvement in a violent intimate partner rela tionship, and/or (7) significant suicidal/homicidal ideation. The study was approved by the Institutional Review Board of the Veteran Affairs North Texas Health Care System, and all participants gave their written consent before taking part in the study. One-hundred twenty-one participants were randomized to receive either CPT or PCT. Four masters or doctoral level female therapists (therapist A, B, C, and D) provided therapy to study participants. Two doctoral-level therapists adminis tered the study measures and were blinded to the patient’s therapy condition. Before analyzing data, therapist fidelity was assessed for both conditions.18 To ensure accurate administration of the manualized ther apies, a random selection of session videos from each thera pist was rated by an independent reviewer from 1 (poor) to 7 (excellent). As previously discussed (see Surfs et al13), ther apist D demonstrated poor fidelity (M = 3.30, SD = 0.87) in the CPT condition and was removed from analysis. However, upon further analysis of therapist fidelity, therapist C was found to have significantly lower fidelity (M = 4.44, SD = 0.77) in the CPT condition than therapists A (M = 5.04, SD = 0.52) or B (M - 5.26, SD = 0.60). Similar results were found in terms of PCT fidelity, with therapist D (M = 4.25, SD = 0.67) having significantly lower ratings than therapist A (M = 5.09, SD = 0.85), B (M = 5.53, SD - 0.37), and C (M - 4.86, SD = 0.79). However, no significant difference was observed between therapists A, B, and C in terms of PCT fidelity. Because the accuracy of psychotherapeutic administration is strongly related to the effectiveness of EBTs,19-21 it was decided that only the data from therapists with average fidelity ratings of 5 (good) or better would be included in data analy ses. Therefore, therapists C and D’s data were excluded, leaving 45 participants (n = 32 for CPT and n = 13 for PCT).
Measures The Post-traumatic Cognitions Inventory (PTCI)22 was used to assess for trauma-related NCs. The PTCI is a self-report instrument with 36 items that assess how much the partici pant agrees with each statement from 1 (totally disagree) to 7 (totally agree). The PTCI generates a general NCs score as well as scores on three subscales: (1) NCs about self, (2) NCs about the world, and (3) NCs about self-blame. The PTCI has
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good internal consistency (PTCI total score, Cronbach’s a = 0.97; NCs about self, Cronbach’s a = 0.97; NCs about the world, Cronbach’s a = 0.88; self-blame, Cronbach’s a = 0.86) and test-retest reliability (PTCI total score, p = 0.74; NCs about self, p = 0.75; NCs about the world, p = 0.89; self blame, p = 0.89). “ The PTCI subscales also have strong convergent validity with similar NC measures on the Per sonal Beliefs and Reactions Scale (PBRS).22’23 For example, the NCs about self subscale was significantly related to the self-scale of the PBRS (p = 0.085), the NCs about the world subscale was significantly related to the others (p = 0.64) and safety (p = 0.65) scales of the PBRS, and the self blame subscale was significantly related to the self-blame (p = 0.50) scale of the PBRS.22 The PTSD Checklist-Military (PCL-M)24 was used to assess for PTSD severity. The PCL-M is a self-report mea sure that is commonly utilized to assess a patient’s PTSD symptom severity over the course of treatment. The PCL-M is a 17-item self-report measure of PTSD symptom severity, with each item scored from 1 (Not at all) to 5 (Extremely). The PCL-M has strong test-retest reliability (/- = 0.96)25 and concurrent validity to measures of PTSD including the Mississippi Scale for Combat PTSD (r = 0.93)25,26 and the Clinician Administered PTSD Scale (CAPS; r = 0.93).25,27 The CAPS is clinician administered instrument that is one of the “gold-standard” measures used to diagnose PTSD as well as to measure PTSD symptom severity.27,28 The CAPS is a 30-item semi-structured interview used to assess the frequency and intensity of PTSD symptoms. The CAPS has strong inter-rater reliability (k = 0.95-1.00) and strong con current validity to other measures of PTSD including the PCL-M (r = 0.93) and Mississippi Scale for Combat-related PTSD (r = 0.70, r = 0.81).27,28 Although the PCL-M and the CAPS correlate highly, we administered both measures because patients sometimes differ in their level of disclosure during self-report compared to clinician administered interviews.29 This method ensures that both patient and clinician perceptions of PTSD symptoms are assessed. In addition, measurement of PTSD severity with both the PCL-M and the CAPS is commonly utilized in clini cal PTSD research (see Surfs et al13 and Monson et al30). Strong internal consistency was observed at baseline within our sample for all administered measures (PTCI, Cronbach’s a = 0.94; PTCI subscale NCs about self, Cronbach’s a = 0.94; PTCI subscale NCs about the world, Cronbach’s a = 0.91; PTCI subscale self-blame, Cronbach’s a = 0.78; PCL-M, Cronbach’s a = 0.91; CAPS, Cronbach’s a = 0.85).
Procedure Following informed consent, participants underwent a base line assessment that included administration of the PTCI, CAPS, PCL-M, and a demographics form. Participants then received 12 weekly 1-hour sessions of either CPT or PCT (a comparison condition that did not address NCs and instead
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Effects ofCPT on PTSD-Related Negative Cognitions in Veterans With MST focused on general support and psychoeducation31). After psychotherapy completion, participants were readministered the PTCI, CAPS, and PCL-M 4 subsequent times (1 week, 2 months, 4 months, and 6 months PT). DATA ANALYSES Statistical analyses were conducted using SPSS, version 19.32 Baseline characteristics were compared via independent sam ple t tests for continuous measures (e.g., age and education) a n d j 2 analyses for qualitative measures (e.g., gender, ethnic ity, and attrition). To examine treatment efficacy, a 2 (treat ment) x 5 (assessment session) repeated measure ANOVA was calculated on scores from the PTCI (total score and subscale scores). Post hoc independent sample t tests were used to assess for any differences between the treatment conditions at specific time points. Within-condition PTCI differences over the course of treatment were tested via dependent sample t tests. To determine if the number of NCs
TABLE I.
was associated with the PTSD symptom severity, a Pearson’s correlation was calculated. RESULTS At baseline, there were no significant differences between treatment condition for any demographic variables except for age and education (see Table I). No significant differences were found between the two treatment conditions on the PTCI total score or on any of the subscale scores at the baseline evaluation (see Table II). There were also no signif icant baseline differences between the two groups on measures of PTSD severity (CAPS and PCL-M total Score). No signifi cant differences were found based on gender or ethnicity for CAPS, PCL-M, PTCI total score, or PTCI subscale scores at any session. However, participants in the CPT condition were significantly younger and more educated than participants in the PCT condition. Because the two treatment groups differed significantly in age and educational level, both variables were
Demographic Information
Total (N = 45) Variable Age Years of Education Gender (Female) Ethnicity White, Nonhispanic Black, Nonhispanic White, Hispanic American Indian Pacific Islander Other
CPT (n = 32)
PCT (n = 13)
M
SD
M
SD
M
SD
44.91 14.18 % 75.60
9.72 2.09 n 34
42.69* 14.59* % 71.90
10.15 1.98 n 23
50.38* 13.15* % 84.60
5.88 2.08 n ii
46.70 33.30 4.40 2.20 2.20 8.90
21 15 2 1 1 4
40.60 34.40 6.30 3.10 3.10 9.40
13 11 2 1 1 3
61.50 30.80 0.00 0.00 0.00 7.70
8 4 0 0 0 1
CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy. *p < 0.05.
TABLE II.
Comparison of PTCI Scores Between Treatment Conditions Over the Course of Treatment
PTCI Total Score M Baseline CPT PCT 1 Week PT CPT PCT 2 Months PT CPT PCT 4 Months PT CPT PCT 6 Months PT CPT PCT
NCs About Self SD
M
NCs About the World
Self-Blame
SD
M
SD
M
SD
153.88 162.62
32.90 32.25
4.40 4.82
1.12 1.25
5.79 5.87
0.99 1.10
4.19 4.05
1.47 1.45
121.14* 155.55*
39.51 35.25
3.35* 4.58*
1.33 1.31
4.96* 5.92*
1.24 0.95
3.20 3.60
1.33 1.91
114.32*** 167.89***
37.59 38.62
3.10*** 5.05***
1.17 1.41
4.90f 6.00+
1.57 1.00
2.97'f 3.96f
1.38 1.61
116.86** 159.91**
40.91 26.17
3.23** 4.67**
1.34 1.15
4.81** 6.14**
1.55 0.70
3.10 3.78
1.22 1.64
114.86** 157.82**
42.20 42.07
3.14** 4.59**
1.38 1.42
4.91+ 5.87f
1.45 1.40
2.91 4.05
1.31 2.18
PTCI, Post-traumatic Cognitions Inventory; NCs, Negative cognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post treatment. fp < 0.10, *p < 0.05, **p < 0.01, ***p < 0.001.
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST used as covariates when examining treatment effects. The repeated -measure ANCOVA revealed that neither variable had any effect on the PCTI total or subscale scores. No significant differences were found for PTCI scores or its subscales between participants who withdrew from or completed the study. In addition, a / 2 analysis revealed that there was no differential withdrawal between the two treat ment conditions,/2 (1, N = 45) = 1.19,p - 0.275.
scores at 1 week, 2 months, 4 months, and 6 months PT compared to participants in the PCT condition. In addition, participants in the CPT condition showed significant withincondition decreases from baseline to 6 months PT, while participants in the PCT condition did not. NCs About the World A repeated measure ANCOVA of NCs about the world revealed a significant main effect of treatment condition, F(l,25) = 4.69, p = 0.04, partial p 2 = 0.16, indicating that participants in the CPT condition reported significantly fewer NCs about the world. However, there was no main effect of time, F(4,22) = 0.66, p = 0.63, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 1.42, p = 0.26, partial p 2 = 0.21. Follow-up t tests (Table II) revealed that participants in the CPT condition had significantly lower scores at 1 week and 4 months PT, and nonsignificant trends at 2 months and 6 months when compared to participants in the PCT condition. In addi tion, participants in the CPT condition showed significant within-condition decreases from baseline to 6 months PT, while participants in the PCT condition did not.
PTCI Total Score A repeated measure ANCOVA of the PTCI total score revealed a significant main effect of treatment condition, F(l,25) = 6.40,p = 0.018, partialp 2 = 0.20. Results indicated that participants in the CPT condition showed greater reduc tions of their PTCI total score compared to participants in the PCT condition. However, there was no main effect of time, F(4,22) = 0.67, p = 0.62, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 1.17, p = 0.35, partial p 1 = 0.18. Follow-up t tests (see Table II) revealed that participants in the CPT condition had significantly lower scores at 1 week, 2 months, 4 months, and 6 months PT compared to the PCT condition. In addition, participants in the CPT condition showed significant withincondition decreases from baseline to 6 months PT, while participants in the PCT condition did not.
Self-Blame A repeated measure ANCOVA of self-blame did not reveal a significant main effect of treatment condition, F(l,25) = 2.00, p = 0.17, partial p 2 = 0.07, indicating that participants in the CPT condition did not differ from those in the PCT condition in levels of self-blame. Moreover, there was no main effect of time, F(4,22) = 0.71, p = 0.60, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 0.95, p = 0.45, partial p 2 = 0.15. Follow-up t tests (Table II) revealed a nonsignificant trend with participants in the CPT condition reporting lower scores than participants in the PCT condition at 2 months. In addition, participants in the CPT condition showed significant within-condition decreases
NCs About Self A repeated measure ANCOVA of NCs about self revealed a significant main effect of treatment condition, F(l,25) = 5.93, p = 0.022, partial p 2 = 0.19, indicating that participants in the CPT condition reported significantly fewer NCs about self. However, there was no main effect of time, F(4,22) = 0.29, p = 0.88, partial p 2 = 0.05, and no significant interaction between treatment condition and time, F(4,22) = 1.67, p = 0.19, partial p 2 = 0.23. Follow-up t tests (Table II) revealed that participants in the CPT condition had significantly lower TABLE III.
Correlations Between the PTCI and PTCI Subscales to the CAPS and PCL Over the Course of Treatment
PTSD Outcome Measure Baseline CAPS PCL 1 Week PT CAPS PCL 2 Months PT CAPS PCL 4 Months PT CAPS PCL 6 Months PT CAPS PCL
PTCI Total Score
NCs About Self
NCs About the World
0.40** 0.61***
0.43** 0.63***
0.31* 0.54***
0.06 0.09
0.62*** 0.61***
0.58** 0.56**
0.57** 0.67***
0.45* 0.35
0.82***
0.80*** 0.83***
0.73***
0.50** 0.61***
0.65***
0.64*** 0 7 5 ***
0.23
0.60*** 0.71***
0.38* 0.48**
0 .8 6 * * *
0.67***
0 7 4 ***
q
7 2 ***
0.73***
0.75***
0 . 79* * *
q
7 9 ***
Q
7J
***
Self-Blame
0 .2 2
PTCI, Post-traumatic Cognitions Inventory; CAPS, Clinician Administered PTSD Scale; PCL, PTSD Checklist; PTSD, Post-traumatic stress disorder; NCs, Negative cognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post-treatment. *p < 0.05, **p < 0.01, ***p < 0.001.
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST
from baseline to 6 months PT, while participants in the PCT condition did not. NCs and PTSD Statistically significant relationships were found between the PTSD severity measures (PCL-M and CAPS) and PTCI total score, NCs about self, and NCs about the world at all assess ment sessions (Table III). In addition, statistically significant relationships were found between self-blame and the PTSD severity measures at 1 week (CAPS only), 2 months, and 6 months PT, but not at baseline or 4 months PT. DISCUSSION This study is the first to provide data on the effectiveness of CPT in reducing NCs in Veterans with MST-related PTSD. Regarding the first hypothesis, we found that CPT was sig nificantly more effective at reducing a participant’s general NCs, NCs about one’s self, and NCs about the world when compared to PCT. Trends toward significantly greater reduc tions in self-blame were also observed within participants in the CPT condition in comparison to participants in the PCT condition. For the second hypothesis, we found that CPT was effective at significantly reducing NCs pre-post treatment, with significant reductions between baseline NCs and all sessions PT found. This finding was not replicated in the PCT condition. In addition to demonstrating the overall superiority of CPT in decreasing NCs associated with PTSD in an MST sample, our results also supported our third hypothesis that NC’s would be positively correlated with PTSD severity. Consistent with previous studies,8-12 we found strong posi tive correlations between NCs (total score, NC-self, NCworld) and PTSD severity (as measured by the PCL-M and CAPS). In addition, significant positive correlations were found between the self-blame subscale and PTSD severity at three of the five sessions. These results are consistent with previous studies on the effects of NCs.9 Furthermore, they highlight the need to address NCs in Veterans with PTSD related to MST. The results from these analyses should be interpreted care fully, given the exclusion of a large portion of the study sample because of poor therapist fidelity. As a result, the data from participants under the two therapist’s care were excluded from the analyses. As a consequence, the results from this study should be replicated before any firm conclu sions can be made about treatment outcomes, although the statistical analyses completed indicate that CPT is superior to PCT in reducing NCs in this sample of Veterans with MSTrelated PTSD. Furthermore, the correlational analyses sug gest that a higher number of NCs are associated with greater severity of PTSD. MST-related PTSD can be a challenging disorder to effec tively treat. As demonstrated by Suris et al,13 although CPT is effective, when compared with outcomes in other populations
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with PTSD, Veterans with MST did not improve as quickly as other populations with PTSD who engage in CPT. Vet erans with MST appear to resemble those described by Galovski et al,33 who characterized patients who are slower to improve as “partial responders” and determined that they are likely to require additional sessions to attain optimal benefit. Despite the noted methodological limitations in our study, it appears that 12 sessions of CPT can successfully reduce the severity of NC’s in Veterans with PTSD related to MST. Further research is necessary to determine if 12 ses sions is optimal in reducing NCs, or if additional sessions would provide further reduction and benefit.
ACKNOWLEDGMENTS The grant support for this study was provided by the Veterans Administration Rehabilitation Research and Development Service.
REFERENCES 1. Department of Veteran Affairs. Military Sexual Trauma. 2004. Available at http://wwwl.va.gov/vhi/docs/MST_www.pdf; accessed July 17, 2013. 2. Suris A, Lind L: Military sexual trauma: a review of prevalence and associated health consequences in veterans. Trauma Violence Abuse 2008; 9(4): 250-69. 3. Suris A, Holliday R, Weitlauf J, North C: The veteran safety initiative writing collaborative. Military sexual trauma in context of veterans’ life experience. Fed Pract 2013; 30(suppl.3):16s-20s. 4. Watts B, Schnurr P, Mayo L, Young-Xu Y, Weeks W, Friedman M: Meta-analysis of the efficacy of treatments for post-traumatic stress disorder. J Clin Psychiatry 2013; 74(6): e541-e50. 5. Resick P, Schnicke M: Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol 1992; 60: 748-56. 6. Resick P, Monson C, Chard K: Cognitive processing therapy: veteran/ military version. Department of Veterans Affairs, Washington DC, 2007. Available at http://www.alrest.org/pdf/CPT_Manual_-_Modified_for_ PRRP(2).pdf. 7. Sharpless B, Barber J: A clinician’s guide to PTSD treatments for returning veterans. Prof Psychol Res Pr 2011; 42(1): 8-15. 8. Agar E, Kennedy P, King N: The role of negative cognitive appraisals in PTSD symptoms following spinal cord injuries. Behav Cogn Psychother 2006; 34(4): 437-52. 9. Blain LM, Galovski TE, Elwood LS, Meriac JP: How does the posttraumatic cognitions inventory fit in a four-factor post-traumatic stress disorder world? An initial analysis. Psychol Trauma 2012; 5(6): 513-20. 10. Moser J, Hajcak G, Simons R, Foa E: Post-traumatic stress disorder symptoms in trauma-exposed college students: the role of traumarelated cognitions, gender, and negative affect. J Anxiety Disord 2007; 21(8): 1039-49. 11. Olatunji B, Elwood L, Williams N, Lohr J: Mental pollution and PTSD symptoms in victims of sexual assault: a preliminary examination of the mediating role of trauma-related cognitions. J Cogn Psychother 2008; 22(1): 37-47. 12. Shahar G, Noyman G, Schnidel-Allon I, Gilboa-Schechtman E: Do PTSD symptoms and trauma-related cognitions about the self constitute a vicious cycle? Evidence for both cognitive vulnerability and scarring models. Psychiatry Res 2013; 205(1-2): 79-84. 13. Suris A, Link-Malcolm J, Chard K, Ahn C, North C: A randomized clinical trial of cognitive processing therapy for veterans with military sexual trauma. J Trauma Stress 2013; 26(1): 28-37. 14. Chard K, Schuster J, Resick P: Empirically supported psychological treatments: cognitive processing therapy. In: The Oxford handbook of
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Effects of Cognitive Processing Therapy on PTSD-Related Negative Cognitions in Veterans With Military Sexual Trauma Ryan Holliday, M A*f; Jessica Link-Malcolm, PhD*; Elizabeth E. Morris, PhD*; Alina Sun's, PhD*f
ABSTRACT Treating post-traumatic stress disorder (PTSD) related to military sexual trauma (MST) continues to be a priority in veteran populations. Because negative cognitions (NCs) contribute to PTSD severity and treatment, further understanding of how PTSD and related NCs can be addressed and changed within an MST sample is important. Our study analyzed 45 participants who received either cognitive processing therapy (n = 32) or present centered therapy (n = 13). Participants who received cognitive processing therapy had significantly lower NCs scores post-treatment and at follow-up sessions than participants in the present centered therapy condition (p < 0.05). In addition, NCs were positively correlated with PTSD severity (p < 0.05). Implications for future research are discussed for both MST-related and non-MST-related PTSD.
INTRODUCTION Military sexual trauma (MST) is defined by the Department of Veteran Affairs' as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of the victim, or the relationship of the perpetrator.” It is important to note that MST is not a clinical diagnosis, but rather, it is a traumatic event of a sexual nature that occurs while a person is on active duty, that often results in post-traumatic stress disorder (PTSD).2 Moreover, because of the prevalence of and negative consequences of MST3 in both returning military personnel and veterans, research related to clinical treatment of MSTrelated PTSD is critical. Specifically, MST-related PTSD has been shown to have numerous negative health associations including comorbid psychiatric disorders (e.g., depression and substance use dis orders), cardiovascular health problems, and socioeconomic difficulties (for a complete review see Surfs et al3). As such, treatment of MST-related PTSD continues to be a priority in clinical treatment settings including Veteran Affairs Medical Centers (VAMCs). One of the most commonly utilized treatments for PTSD at both VAMCs and non-VAMCs is cognitive processing therapy (CPT). CPT is an evidence-based treatment (EBT) that has been found to be significantly more effective at treating PTSD than other forms of psychotherapy and phar macotherapy.4 CPT is a form of cognitive behavioral therapy that was originally developed for civilian survivors of rape5 that has been adapted by the Veterans Health Administration to treat MST and combat-related PTSD.6 7 CPT effectively treats PTSD by having the patient recognize cognitive “stuck points,” which are negative/distorted cognitions related to the ♦Veteran Affairs North Texas Health Care System, 4500 South Lancaster Road, Room 116A, Dallas, TX 75216. tDepartment of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390. doi: 10.7205/MILMED-D-13-00309
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patient’s trauma(s). Over the course of CPT treatment, the therapist teaches the patient how to challenge negative cogni tions (NCs). The patient learns how irrational interpretations of the traumatic experience maintain PTSD symptoms and nega tively affects beliefs about self and the world. Through cogni tive restructuring, reductions in PTSD symptoms will occur.4 NCs may inhibit a patient’s ability to fully engage in the treatment process. Furthermore, higher levels of NC’s are associated with greater severity of PTSD symptoms.8-12 Since its development, CPT has demonstrated effective ness in multiple populations, including survivors of MST.13 Despite the wide breadth of knowledge regarding CPT’s effi cacy in treating PTSD 4’6,7'13-16 a review of the literature revealed only one published study which examined the effects of CPT on reducing the number of NCs.17 These researchers reported that CPT was effective at reducing NCs in a sample of high school students who had experienced a traumatic event.17 To date, no published studies have exam ined the effects of CPT on NCs in patients diagnosed with PTSD or in survivors of MST. Several critical issues were investigated in this study; we examined the relationship between NCs and symptom severity among veterans diagnosed with PTSD related to MST and assessed the effects of two interventions on clinical outcomes in this population. We had three hypotheses: (1) Veterans treated with CPT would demonstrate a greater reduction in NCs compared to those treated with a nontrauma-focused treatment (Present-centered therapy, PCT); (2) treatment with CPT would result in sustained symptom reduction over the pre- and post-treatment (PT) evaluations; and (3) the number of reported NCs would be positively correlated with measures of symptom severity among Veterans diagnosed with PTSD related to MST.
METHOD Participants
The study was conducted at a large Southwestern VAMC. Participants were recruited via posted advertisements,
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST recruitment letters, and clinician referral. Participants received monetary compensation for their participation. Inclusion criteria were as follows: (1) veteran status with a diagnosis of MST-related PTSD, (2) MST occurrence at least 3 months prior, (3) MST identified as the most distressing PTSD-related trauma, (4) at least one clear memory of the MST, and (5) no changes to psychiatric medication in the past 6 weeks. Exclusion criteria were as follows: (1) sub stance dependence/abuse in the past 3 months, (2) current psychotic symptoms, (3) unstable bipolar disorder, (4) severe cognitive impairment, (5) concurrent enrollment in an EBT for PTSD, (6) involvement in a violent intimate partner rela tionship, and/or (7) significant suicidal/homicidal ideation. The study was approved by the Institutional Review Board of the Veteran Affairs North Texas Health Care System, and all participants gave their written consent before taking part in the study. One-hundred twenty-one participants were randomized to receive either CPT or PCT. Four masters or doctoral level female therapists (therapist A, B, C, and D) provided therapy to study participants. Two doctoral-level therapists adminis tered the study measures and were blinded to the patient’s therapy condition. Before analyzing data, therapist fidelity was assessed for both conditions.18 To ensure accurate administration of the manualized ther apies, a random selection of session videos from each thera pist was rated by an independent reviewer from 1 (poor) to 7 (excellent). As previously discussed (see Surfs et al13), ther apist D demonstrated poor fidelity (M = 3.30, SD = 0.87) in the CPT condition and was removed from analysis. However, upon further analysis of therapist fidelity, therapist C was found to have significantly lower fidelity (M = 4.44, SD = 0.77) in the CPT condition than therapists A (M = 5.04, SD = 0.52) or B (M - 5.26, SD = 0.60). Similar results were found in terms of PCT fidelity, with therapist D (M = 4.25, SD = 0.67) having significantly lower ratings than therapist A (M = 5.09, SD = 0.85), B (M = 5.53, SD - 0.37), and C (M - 4.86, SD = 0.79). However, no significant difference was observed between therapists A, B, and C in terms of PCT fidelity. Because the accuracy of psychotherapeutic administration is strongly related to the effectiveness of EBTs,19-21 it was decided that only the data from therapists with average fidelity ratings of 5 (good) or better would be included in data analy ses. Therefore, therapists C and D’s data were excluded, leaving 45 participants (n = 32 for CPT and n = 13 for PCT).
Measures The Post-traumatic Cognitions Inventory (PTCI)22 was used to assess for trauma-related NCs. The PTCI is a self-report instrument with 36 items that assess how much the partici pant agrees with each statement from 1 (totally disagree) to 7 (totally agree). The PTCI generates a general NCs score as well as scores on three subscales: (1) NCs about self, (2) NCs about the world, and (3) NCs about self-blame. The PTCI has
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good internal consistency (PTCI total score, Cronbach’s a = 0.97; NCs about self, Cronbach’s a = 0.97; NCs about the world, Cronbach’s a = 0.88; self-blame, Cronbach’s a = 0.86) and test-retest reliability (PTCI total score, p = 0.74; NCs about self, p = 0.75; NCs about the world, p = 0.89; self blame, p = 0.89). “ The PTCI subscales also have strong convergent validity with similar NC measures on the Per sonal Beliefs and Reactions Scale (PBRS).22’23 For example, the NCs about self subscale was significantly related to the self-scale of the PBRS (p = 0.085), the NCs about the world subscale was significantly related to the others (p = 0.64) and safety (p = 0.65) scales of the PBRS, and the self blame subscale was significantly related to the self-blame (p = 0.50) scale of the PBRS.22 The PTSD Checklist-Military (PCL-M)24 was used to assess for PTSD severity. The PCL-M is a self-report mea sure that is commonly utilized to assess a patient’s PTSD symptom severity over the course of treatment. The PCL-M is a 17-item self-report measure of PTSD symptom severity, with each item scored from 1 (Not at all) to 5 (Extremely). The PCL-M has strong test-retest reliability (/- = 0.96)25 and concurrent validity to measures of PTSD including the Mississippi Scale for Combat PTSD (r = 0.93)25,26 and the Clinician Administered PTSD Scale (CAPS; r = 0.93).25,27 The CAPS is clinician administered instrument that is one of the “gold-standard” measures used to diagnose PTSD as well as to measure PTSD symptom severity.27,28 The CAPS is a 30-item semi-structured interview used to assess the frequency and intensity of PTSD symptoms. The CAPS has strong inter-rater reliability (k = 0.95-1.00) and strong con current validity to other measures of PTSD including the PCL-M (r = 0.93) and Mississippi Scale for Combat-related PTSD (r = 0.70, r = 0.81).27,28 Although the PCL-M and the CAPS correlate highly, we administered both measures because patients sometimes differ in their level of disclosure during self-report compared to clinician administered interviews.29 This method ensures that both patient and clinician perceptions of PTSD symptoms are assessed. In addition, measurement of PTSD severity with both the PCL-M and the CAPS is commonly utilized in clini cal PTSD research (see Surfs et al13 and Monson et al30). Strong internal consistency was observed at baseline within our sample for all administered measures (PTCI, Cronbach’s a = 0.94; PTCI subscale NCs about self, Cronbach’s a = 0.94; PTCI subscale NCs about the world, Cronbach’s a = 0.91; PTCI subscale self-blame, Cronbach’s a = 0.78; PCL-M, Cronbach’s a = 0.91; CAPS, Cronbach’s a = 0.85).
Procedure Following informed consent, participants underwent a base line assessment that included administration of the PTCI, CAPS, PCL-M, and a demographics form. Participants then received 12 weekly 1-hour sessions of either CPT or PCT (a comparison condition that did not address NCs and instead
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Effects ofCPT on PTSD-Related Negative Cognitions in Veterans With MST focused on general support and psychoeducation31). After psychotherapy completion, participants were readministered the PTCI, CAPS, and PCL-M 4 subsequent times (1 week, 2 months, 4 months, and 6 months PT). DATA ANALYSES Statistical analyses were conducted using SPSS, version 19.32 Baseline characteristics were compared via independent sam ple t tests for continuous measures (e.g., age and education) a n d j 2 analyses for qualitative measures (e.g., gender, ethnic ity, and attrition). To examine treatment efficacy, a 2 (treat ment) x 5 (assessment session) repeated measure ANOVA was calculated on scores from the PTCI (total score and subscale scores). Post hoc independent sample t tests were used to assess for any differences between the treatment conditions at specific time points. Within-condition PTCI differences over the course of treatment were tested via dependent sample t tests. To determine if the number of NCs
TABLE I.
was associated with the PTSD symptom severity, a Pearson’s correlation was calculated. RESULTS At baseline, there were no significant differences between treatment condition for any demographic variables except for age and education (see Table I). No significant differences were found between the two treatment conditions on the PTCI total score or on any of the subscale scores at the baseline evaluation (see Table II). There were also no signif icant baseline differences between the two groups on measures of PTSD severity (CAPS and PCL-M total Score). No signifi cant differences were found based on gender or ethnicity for CAPS, PCL-M, PTCI total score, or PTCI subscale scores at any session. However, participants in the CPT condition were significantly younger and more educated than participants in the PCT condition. Because the two treatment groups differed significantly in age and educational level, both variables were
Demographic Information
Total (N = 45) Variable Age Years of Education Gender (Female) Ethnicity White, Nonhispanic Black, Nonhispanic White, Hispanic American Indian Pacific Islander Other
CPT (n = 32)
PCT (n = 13)
M
SD
M
SD
M
SD
44.91 14.18 % 75.60
9.72 2.09 n 34
42.69* 14.59* % 71.90
10.15 1.98 n 23
50.38* 13.15* % 84.60
5.88 2.08 n ii
46.70 33.30 4.40 2.20 2.20 8.90
21 15 2 1 1 4
40.60 34.40 6.30 3.10 3.10 9.40
13 11 2 1 1 3
61.50 30.80 0.00 0.00 0.00 7.70
8 4 0 0 0 1
CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy. *p < 0.05.
TABLE II.
Comparison of PTCI Scores Between Treatment Conditions Over the Course of Treatment
PTCI Total Score M Baseline CPT PCT 1 Week PT CPT PCT 2 Months PT CPT PCT 4 Months PT CPT PCT 6 Months PT CPT PCT
NCs About Self SD
M
NCs About the World
Self-Blame
SD
M
SD
M
SD
153.88 162.62
32.90 32.25
4.40 4.82
1.12 1.25
5.79 5.87
0.99 1.10
4.19 4.05
1.47 1.45
121.14* 155.55*
39.51 35.25
3.35* 4.58*
1.33 1.31
4.96* 5.92*
1.24 0.95
3.20 3.60
1.33 1.91
114.32*** 167.89***
37.59 38.62
3.10*** 5.05***
1.17 1.41
4.90f 6.00+
1.57 1.00
2.97'f 3.96f
1.38 1.61
116.86** 159.91**
40.91 26.17
3.23** 4.67**
1.34 1.15
4.81** 6.14**
1.55 0.70
3.10 3.78
1.22 1.64
114.86** 157.82**
42.20 42.07
3.14** 4.59**
1.38 1.42
4.91+ 5.87f
1.45 1.40
2.91 4.05
1.31 2.18
PTCI, Post-traumatic Cognitions Inventory; NCs, Negative cognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post treatment. fp < 0.10, *p < 0.05, **p < 0.01, ***p < 0.001.
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST used as covariates when examining treatment effects. The repeated -measure ANCOVA revealed that neither variable had any effect on the PCTI total or subscale scores. No significant differences were found for PTCI scores or its subscales between participants who withdrew from or completed the study. In addition, a / 2 analysis revealed that there was no differential withdrawal between the two treat ment conditions,/2 (1, N = 45) = 1.19,p - 0.275.
scores at 1 week, 2 months, 4 months, and 6 months PT compared to participants in the PCT condition. In addition, participants in the CPT condition showed significant withincondition decreases from baseline to 6 months PT, while participants in the PCT condition did not. NCs About the World A repeated measure ANCOVA of NCs about the world revealed a significant main effect of treatment condition, F(l,25) = 4.69, p = 0.04, partial p 2 = 0.16, indicating that participants in the CPT condition reported significantly fewer NCs about the world. However, there was no main effect of time, F(4,22) = 0.66, p = 0.63, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 1.42, p = 0.26, partial p 2 = 0.21. Follow-up t tests (Table II) revealed that participants in the CPT condition had significantly lower scores at 1 week and 4 months PT, and nonsignificant trends at 2 months and 6 months when compared to participants in the PCT condition. In addi tion, participants in the CPT condition showed significant within-condition decreases from baseline to 6 months PT, while participants in the PCT condition did not.
PTCI Total Score A repeated measure ANCOVA of the PTCI total score revealed a significant main effect of treatment condition, F(l,25) = 6.40,p = 0.018, partialp 2 = 0.20. Results indicated that participants in the CPT condition showed greater reduc tions of their PTCI total score compared to participants in the PCT condition. However, there was no main effect of time, F(4,22) = 0.67, p = 0.62, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 1.17, p = 0.35, partial p 1 = 0.18. Follow-up t tests (see Table II) revealed that participants in the CPT condition had significantly lower scores at 1 week, 2 months, 4 months, and 6 months PT compared to the PCT condition. In addition, participants in the CPT condition showed significant withincondition decreases from baseline to 6 months PT, while participants in the PCT condition did not.
Self-Blame A repeated measure ANCOVA of self-blame did not reveal a significant main effect of treatment condition, F(l,25) = 2.00, p = 0.17, partial p 2 = 0.07, indicating that participants in the CPT condition did not differ from those in the PCT condition in levels of self-blame. Moreover, there was no main effect of time, F(4,22) = 0.71, p = 0.60, partial p 2 = 0.11, and no significant interaction between treatment condition and time, F(4,22) = 0.95, p = 0.45, partial p 2 = 0.15. Follow-up t tests (Table II) revealed a nonsignificant trend with participants in the CPT condition reporting lower scores than participants in the PCT condition at 2 months. In addition, participants in the CPT condition showed significant within-condition decreases
NCs About Self A repeated measure ANCOVA of NCs about self revealed a significant main effect of treatment condition, F(l,25) = 5.93, p = 0.022, partial p 2 = 0.19, indicating that participants in the CPT condition reported significantly fewer NCs about self. However, there was no main effect of time, F(4,22) = 0.29, p = 0.88, partial p 2 = 0.05, and no significant interaction between treatment condition and time, F(4,22) = 1.67, p = 0.19, partial p 2 = 0.23. Follow-up t tests (Table II) revealed that participants in the CPT condition had significantly lower TABLE III.
Correlations Between the PTCI and PTCI Subscales to the CAPS and PCL Over the Course of Treatment
PTSD Outcome Measure Baseline CAPS PCL 1 Week PT CAPS PCL 2 Months PT CAPS PCL 4 Months PT CAPS PCL 6 Months PT CAPS PCL
PTCI Total Score
NCs About Self
NCs About the World
0.40** 0.61***
0.43** 0.63***
0.31* 0.54***
0.06 0.09
0.62*** 0.61***
0.58** 0.56**
0.57** 0.67***
0.45* 0.35
0.82***
0.80*** 0.83***
0.73***
0.50** 0.61***
0.65***
0.64*** 0 7 5 ***
0.23
0.60*** 0.71***
0.38* 0.48**
0 .8 6 * * *
0.67***
0 7 4 ***
q
7 2 ***
0.73***
0.75***
0 . 79* * *
q
7 9 ***
Q
7J
***
Self-Blame
0 .2 2
PTCI, Post-traumatic Cognitions Inventory; CAPS, Clinician Administered PTSD Scale; PCL, PTSD Checklist; PTSD, Post-traumatic stress disorder; NCs, Negative cognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post-treatment. *p < 0.05, **p < 0.01, ***p < 0.001.
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Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST
from baseline to 6 months PT, while participants in the PCT condition did not. NCs and PTSD Statistically significant relationships were found between the PTSD severity measures (PCL-M and CAPS) and PTCI total score, NCs about self, and NCs about the world at all assess ment sessions (Table III). In addition, statistically significant relationships were found between self-blame and the PTSD severity measures at 1 week (CAPS only), 2 months, and 6 months PT, but not at baseline or 4 months PT. DISCUSSION This study is the first to provide data on the effectiveness of CPT in reducing NCs in Veterans with MST-related PTSD. Regarding the first hypothesis, we found that CPT was sig nificantly more effective at reducing a participant’s general NCs, NCs about one’s self, and NCs about the world when compared to PCT. Trends toward significantly greater reduc tions in self-blame were also observed within participants in the CPT condition in comparison to participants in the PCT condition. For the second hypothesis, we found that CPT was effective at significantly reducing NCs pre-post treatment, with significant reductions between baseline NCs and all sessions PT found. This finding was not replicated in the PCT condition. In addition to demonstrating the overall superiority of CPT in decreasing NCs associated with PTSD in an MST sample, our results also supported our third hypothesis that NC’s would be positively correlated with PTSD severity. Consistent with previous studies,8-12 we found strong posi tive correlations between NCs (total score, NC-self, NCworld) and PTSD severity (as measured by the PCL-M and CAPS). In addition, significant positive correlations were found between the self-blame subscale and PTSD severity at three of the five sessions. These results are consistent with previous studies on the effects of NCs.9 Furthermore, they highlight the need to address NCs in Veterans with PTSD related to MST. The results from these analyses should be interpreted care fully, given the exclusion of a large portion of the study sample because of poor therapist fidelity. As a result, the data from participants under the two therapist’s care were excluded from the analyses. As a consequence, the results from this study should be replicated before any firm conclu sions can be made about treatment outcomes, although the statistical analyses completed indicate that CPT is superior to PCT in reducing NCs in this sample of Veterans with MSTrelated PTSD. Furthermore, the correlational analyses sug gest that a higher number of NCs are associated with greater severity of PTSD. MST-related PTSD can be a challenging disorder to effec tively treat. As demonstrated by Suris et al,13 although CPT is effective, when compared with outcomes in other populations
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with PTSD, Veterans with MST did not improve as quickly as other populations with PTSD who engage in CPT. Vet erans with MST appear to resemble those described by Galovski et al,33 who characterized patients who are slower to improve as “partial responders” and determined that they are likely to require additional sessions to attain optimal benefit. Despite the noted methodological limitations in our study, it appears that 12 sessions of CPT can successfully reduce the severity of NC’s in Veterans with PTSD related to MST. Further research is necessary to determine if 12 ses sions is optimal in reducing NCs, or if additional sessions would provide further reduction and benefit.
ACKNOWLEDGMENTS The grant support for this study was provided by the Veterans Administration Rehabilitation Research and Development Service.
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