Homework - Dr. Laurel Shaler

Laurel Shaler, PhD, LISW-CP
 Posttraumatic Stress Disorder
 Cognitive Processing Therapy
 Integration of Faith
 Questions and Answers
Post-Traumatic Stress Disorder, or
PTSD, is a reaction to a traumatic event.
 According to the DSM-IV, in order to be
diagnosed with PTSD, you must have
the following symptoms:
1.) You have been exposed to a traumatic event
 experienced, witnessed, or were confronted with an event
or events that involved actual or threatened death or
serious injury, or a threat to the physical integrity of
yourself or others)AND your response involved intense
fear, helplessness, or horror.
Diagnosis continued
2.) You re-experience the event in at least one way:
 Recurrent recollections of the event.
 Recurrent distressing dreams of the event.
 Feeling as if the event was recurring, such as in
 Experience intense distress when exposed to triggers
3.) You avoid triggers associated with the trauma & numb in
three or more of the following ways:
 Avoid anything associated with the trauma.
Can’t recall an important aspect of the trauma.
Decreased interest in activities
Range of emotions is restricted.
Sense of foreshortened future.
Diagnosis Continued
4.) You have at least 2 increased physical arousal
 Difficulty falling or staying asleep.
 Irritability or outbursts of anger.
 Difficulty concentrating.
 Hypervigilance.
 Exaggerated startle response.
5.) All of the symptoms have lasted for more than
one month.
6.) As a result, you are significantly distressed,
and your functioning is impaired.
Changes in DSM-V
PTSD was moved from “Anxiety Disorders”
to “Trauma and stressor-related disorders”
 “Fear, helplessness, horror” was removed
(does not help improve diagnostic
 The three clusters are now four (intrusion,
avoidance, negative alterations in
cognitions and mood, and alterations in
arousal and reactivity)
Changes in DSM-V
Self-blame and negative emotional state were
added as possible symptoms under negative
Reckless/destructive behavior was added to
criterion E (under “alterations in arousal”)
Subtype “with dissociative symptoms” was added
Pre-school subtype (children under 6) was added
Reference: NCPTSD
Assessment Tool
PTSD Checklist (PCL)~17 item
questionnaire on a 5 point Likert scale.
Scores of 50-85 are generally
considered significant for PTSD.
However, this is self-administered.
Issues of minimizing and exaggerating
must be considered.
Treatment-Cognitive Processing Therapy
CPT was developed by Patricia Resick in the early
1990s. It combines cognitive therapy and trauma
processing (Resick, et al., 2009). I
Conducted via individual or group therapy and is
often completed in 12 weekly sessions.
Cognitive therapy helps “understand how certain
thoughts about your trauma cause your stress and
make your symptoms worse” (www.VA.gov/PTSD,
2009). It also helps to identify negative thoughts,
replace them, and cope with the upsetting
A recent study found psychotherapy more effective
than medication for the treatment of PTSD (Watts,
et all 2013).
The Dept of VA recommends CBT (in the forms of
PE or CPT) and EMDR as psychotherapy
treatments for PTSD.
Research continued
Four randomized clinical trials have been
conducted on CPT.
 Rape victims (Resick et al., 2002)
○ CAPS went down over 30 points
 Child sexual abuse (Chard, 2005)
○ CAPS went down over 40 points
 Veterans (Monson, 2006)
○ CAPS went down almost 25 points
 Rape and assault (Resick et al., 2008)
○ CAPS went down over 40 points
Treatment ( CPT continued)
PTSD Checklist (PCL)
Set agenda
Describe symptoms of PTSD
Client gives examples of symptoms
Explain PTSD theory (flight, fight, freeze)
Explain Cognitive Theory
Assimilation (change memories to fit beliefs)
Over-Accommodation (change beliefs about the world)
Types of emotions (natural vs. manufactured)
Treatment (CPT continued)
Client gives “public version” of most traumatic event
Describe the course of therapy and the rationale
~Recognize and modify old thoughts and feelings
~Accept reality of event
~Change beliefs enough to accept
~Feel emotions about event
Stuck Points and Log
Anticipate avoidance and increase compliance
Overview of each session
Homework: Impact statement (Why client thinks event
happened and how views about self, others, and world have
changed as a result).
Treatment (CPT continued)
Client completes PCL
Client reads impact statement (If not written, complete orally)
Discuss implications of statement
Begin to identify stuck points
Identify and see connections among events-thoughts-feelings
~Six basic emotions (angry, disgusted, ashamed, sad,
scared, and happy)
~Interpretation of events and self-statements (examples of
being snubbed on street )
Treatment (CPT continued)
Introduce A-B-C Worksheets and fill one out together
Homework: A-B-C sheets
Check-in with client regarding reaction to session
*Optional: Traumatic Bereavement Session. If completing, have
client write impact statement related to loss instead of
completing A-B-C sheets. Session 2a will be completed after
session 2 and before session 3. After reviewing the impact
statement related to bereavement, return to A-B-C sheets.
Treatment (CPT continued)
Treatment (CPT continued)
Treatment (CPT continued)
Client completes PCL
Review A-B-C sheets (label thoughts vs. emotions,
point out mismatches, look for stuck points)
Using Socratic questions, help client generate
alternative thoughts and consequent feelings.
Treatment (CPT continued)
Gently begin to challenge stuck points
Discuss A-B-C worksheet related to trauma
Introduce Trauma Account
Homework: Full trauma account; Daily reading of
trauma account; Daily completion of A-B-C
Treatment (CPT continued)
Client completes PCL
Client reads Traumatic Account aloud to
Client and therapist discuss reactions to writing
and reading account.
Identify Stuck Points and challenge
Review A-B-C sheets
Homework: A-B-C sheets; Rewrite traumatic
account with more detail and read daily.
Treatment (CPT continued)
Client completes PCL.
Client reads second account of incident.
Identify differences between first and second
Any progress?
Therapist introduces challenging questions sheet
and completes example
Homework: Complete “Challenging Questions”
sheets daily
Treatment (CPT continued)
Treatment (CPT continued)
Treatment (CPT continued)
Client completed PCL
Client and therapist review Challenging
Questions Worksheets
Assist client in analyzing and confronting stuck points.
Therapist introduces “Patterns of Problematic Thinking”:
~Does client have tendency towards specific patterns?
~Describe how patterns become automatic.
Homework: ID stuck points and find examples
of each pattern. Complete worksheet daily.
Treatment (CPT continued)
Patterns of Problematic Thinking:
 1.) Drawing conclusions when evidence
is lacking or even contradictory.
 2.) Exaggerating or minimizing the
meaning of an event.
 3.) Disregarding important aspects of a
 4.) Oversimplifying events or beliefs as
good/bad or right/wrong.
Treatment (CPT continued)
5.) Over-generalizing from a single
 6.) Mind Reading (assume people are
thinking negatively of you when there is
no evidence of this).
 7.) Emotional Reasoning (you have a
feeling and assume there must be a
Treatment (CPT continued)
Client completes PCL.
Client and therapist review Patterns of Problematic
~Strong tendencies towards specific patterns?
~Discuss how these patterns may have affected
reactions to trauma.
~Replace with other, more adaptive, cognitions.
Therapist introduces Challenging Beliefs Worksheets:
~Rate strength of belief and emotion; Use Challenging
Questions and Patterns of Problematic Thinking;
Generate new statements
Treatment (CPT continued)
Treatment (CPT Continued)
Therapist introduces Safety module.
~Self: Belief that you can protect yourself from harm
and have some control over events. Symptoms of
negative self-safety include anxiety, irritability, started
responses, and intense fears.
~Others: Belief about dangerousness of other people
and of expectancies about the intent of others to cause
harm, injury, or loss. (Avoidance and Social W/D)
~ Homework: Read Safety module and
complete worksheets on stuck points using
at least one on safety.
Treatment (CPT continued)
Clients completes PCL.
Client and therapist review Challenging Beliefs
Client and therapist discuss Safety
Therapist introduces Trust module (see next slide)
Homework: Read trust module and complete
worksheets on stuck points using at least one on
Treatment (CPT Continued)
Trust Module:
 Self: Belief that one can trust or rely on one’s own
perceptions. Symptoms of negative self-trust beliefs
including anxiety, confusion, and self-doubt.
 Others: Belief that promises of other people can be
relied on with regards to future behavior. A person
needs to learn a healthy balance of trust and
mistrust and when each is appropriate. Symptoms of
negative others-trust includes disappointment in
others, fear of relationships and betrayal, anger at
betrayers, and fleeing.
Treatment (CPT continued)
Client completes PCL
Client and therapist review homework
on trust issues and other completed
Discuss how trust falls on a continuum (star
Therapist introduces power/control module.
Treatment (CPT continued)
Self: Belief that you can solve problems and meet
challenges. Symptoms include numbing,
avoidance of feelings, hopelessness and
Others: Belief that you can control future outcomes
in relationships and that you have some power.
Symptoms include passivity, submissiveness, and
inability to maintain relationships.
Homework: Read power/control module and
complete worksheets on stuck points using at least
one on power/control.
Treatment (CPT continued)
Client completes PCL.
Client and therapist review power/control issues and
Challenging Beliefs Worksheets.
Help client gain a balanced view of power/control
~Ways of Giving Power
Positive: Being altruistic and helping others
Negative: Basing actions solely on others. Always
placing needs of others above own.
~Ways of Taking Power
Positive: Being assertive, Setting boundaries, and Being
honest with others.
Negative: Giving ultimatums, Testing limits, Aggressive
Treatment (CPT Continued)
Therapist introduces esteem module.
Self: Belief in own worth. Examples of negative selfesteem beliefs include “I am bad”, “I am damaged”, “I
am worthless”. Symptoms include depression, guilt,
and shame.
Others: Beliefs about how much you value other
people. Negative beliefs include thinking people are
bad, evil, uncaring, indifferent, etc. Symptoms include
anger, bitterness, isolation, etc.
Homework: Read esteem module and complete
worksheets on stuck points using at least one on
esteem. Client also practices giving compliments and
doing nice things for self.
Treatment (CPT continued)
Client completes PCL and discuss compliment and
pleasant activities.
Client and therapist review esteem issues and
Challenging Beliefs Worksheets
~Does client believe s/he is permanently damaged or is
s/he a perfectionist?
Therapist introduces intimacy module.
~Self: Ability to soothe and calm self. Symptoms
associated with negative self-intimacy beliefs include
inability to comfort and soothe self, fear of being alone,
external sources of comfort, needy.
Treatment (CPT Continued)
Others: Capacity to be intimately connected
with others. Symptoms associated with
negative others-intimacy beliefs include
loneliness, isolation, and failure to connect
with others.
Homework: Read intimacy module and
complete worksheets on stuck points using at
least one on intimacy. Client also writes new
impact statement.
Treatment (CPT continued)
Client completes PCL.
Client and therapist review intimacy
Client reads new impact statement.
Client and therapist review course of
therapy and skills learned.
Veteran is given blank copies of worksheets for
continued use.
*A four week follow-up is scheduled.*
At 12th session, schedule a 4 week
 Have client complete PCL at 4 week
 Determine if there is anything else the
client needs to work on.
 Congratulate client on completing CPT
and encourage client to continue using
learned skills.
Cognitive Processing Therapy-Cognitive (CPTC) is conducted without the written account of
trauma. Only A-B-C sheets are assigned for
practice during Sessions 2 and 3.
Sessions 4-7 are in a slightly different order:
~Session 4: Identification of Stuck Points
~Session 5: Challenging Questions
~Session 6: Patterns of Problematic Thinking
~Session 7: Challenging Beliefs
Group can be facilitated using CPT or CPTCognitive.
 Information session and letter of
commitment can be helpful.
 Eight-Ten members, 90 minutes long.
 Group members do not read their impact
statements or trauma accounts aloud in
Group can be conducted with one or two
facilitators. If one facilitator, a break can be
taken in the middle of group to allow time
to review practice assignments.
 Pros: efficient, group dynamics, opportunity
for trust building, helps with avoidance
 Cons: difficult to stay on task, potential
negative dynamics (ex. Monopolizing
Christian Integration
Spirituality as a whole:
 A 2008 study found large effect sizes for
“reducing PTSD symptom severity,
psychological distress, and increasing
quality of life” when studying “mantram
repetition” (repeating a sacred word/phrase
through the day). Small group of 29 of who
completed the study. (Bormann, Thorp,
Wetherell, & Goishan in PTSD Research
Quarterly, 2012).
Christian Integration
A 2011 meta-analysis of 46 studies (N =
3,290) compared psychological and
spiritual outcomes to:
 1.) A control condition (such as only assess.)
 2.) An alternate treatment (non-religious)
 3.) A dismantling design (example: CBT vs
CBT with religious accommodation
Reference: Worthington, E., Jr., Hook, J., Davis, D., &
McDaniel, M. (2011). Religion and spirituality. Journal of
Clinical Psychology: In Session, 67(2), 204-214.
Christian Integration
 Those in religiously accommodated
psychotherapies showed “greater
improvement than those in alternate secular
psychotherapies on psychological (d = .26)
and spiritual (d = .41) outcomes.”
 On dismantling, psychological outcome was
the same but spiritual outcomes showed
greater improvement (d = .33).
Reference: Worthington, E., Jr., Hook, J., Davis, D., & McDaniel, M. (2011). Religion and
spirituality. Journal of Clinical Psychology: In Session, 67(2), 204-214.
Christian Integration
Weaknesses of research:
 We don’t know that the theology of the
therapist matched that of the client.
 Amount of spiritual accommodation was
 Research was mostly facilitated with
theologically conservative clients.
 Most research was on CBT (a pro for CPT!)
Reference: Worthington, E., Jr., Hook, J., Davis, D., & McDaniel, M. (2011). Religion and spirituality.
Journal of Clinical Psychology: In Session, 67(2), 204-214.
Christian Integration
What is “Christian accommodation”?
 Being a Christian therapist?
 Praying for client outside of treatment?
 Praying for client in treatment?
 Treatment consistent with Christian values?
 Treatment that uses Scripture?
 Reading Bible in session?
 Answering theological questions? (Where was God when
my buddy was killed?)
 Helping the client find a church?
 Helping clients understand God?
Reference: Worthington, E., Jr., Hook, J., Davis, D., & McDaniel, M. (2011). Religion and spirituality.
Journal of Clinical Psychology: In Session, 67(2), 204-214.
Christian Integration
Christian Integration
 Assess….
○ Know your clients (faith, concerns, etc)
○ What and how much does the client want?
○ Does religious accommodation fit your client?
○ Does it fit the treatment that is most
appropriate for client?
○ Does your client improve? (PCL and spiritual
questionnaire?) Show it works.
Reference: Worthington, E., Jr., Hook, J., Davis, D., & McDaniel, M. (2011). Religion and
spirituality. Journal of Clinical Psychology: In Session, 67(2), 204-214.
Christian Integration and CPT
Because CPT deals with beliefs, it is a
good fit for those that have upsetting
thoughts and feelings related to faith.
 For example, a client might say:
 A: My best friend was killed in front of me.
 B: God doesn’t care about me or anyone in
my world.
 C: I feel angry.
Christian Integration and CPT
The client then explores that belief for
him or herself using the same method
as all other beliefs.
 The client comes to his or her own
conclusion about whether or not this is a
realistic or unrealistic belief.
Christian Therapists
As Christian therapists, we should
model for our clients.
 We can rely on God for wisdom to guide
us in our sessions.
 Dr. Siang-Yang Tan (Fuller
Seminary)has written much about CBT
and Christian integration.
Other resources
PPT can be found at:
American Psychological Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Bormann, J.E., Thorp, S., Wetherell, J.L., & Golshan, S. (2008). A spiritually
based group intervention for combat Veterans with posttraumatic stress
disorder. Journal of Holistic Nursing, 26, 109-116.
Bormann, Thorp, Wetherell, & Goishan in PTSD Research Quarterly, 2012
Center for study of traumatic stress (2009). Retrieved
Department of Veterans Affairs (2009). Retrieved from www.VA.gov/PTSD.
Figley, C. R. (2006). Assessment and treatment of post-traumatic stress
disorder. Tallahassee, FL: Figley Institute.
Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., Silva, C., & Maguen,
S. (2009). Moral injury and moral repair in war veterans: A preliminary model
and intervention strategy. Clinical Psychology Review, 29(8), 695-706.
National Center for PTSD (2012). PTSD Research Quarterly, 23, (2).
References (continued)
Resick, A. R., & Calhoun, K.S. (2001). Posttraumatic stress disorder. In
Barlow, D.H. (Ed.), Clinical handbook of psychological disorders (pp.60113). New York: The Guilford Press.
Resick, P., Monson, C., Chard, K. (2008). Cognitive processing therapist
group manual: Veteran/military version. Washington, DC: Department of
Veterans’ Affairs.
Resick, P., Monson, C., Chard, K. (2008). Cognitive processing therapy
veteran/military version: Therapist’s manual. Washington, DC: Department
of Veterans’ Affairs.
Resick, P., Monson, C., Chard, K. (2008). Cognitive processing therapy
veteran/military version: Therapist and patient materials manual.
Washington, DC: Department of Veterans’ Affairs.
Resick, P., Monson, C. & Chard, K. (2008). Workshop: Cognitive Processing
Therapy (PPT). National Center for PTSD.
Resick, P. & Schnicke, M. (1993).Cognitive Processing Therapy for Rape
Victims: A Treatment Manual. Sage Publications
References (continued)
Rothbaum, B., Kearns, M., Price, M., Malcoun, E., Davis, M., Ressler, K.,
…Houry, D. (2012). Early intervention may prevent the development of
posttraumatic stress disorder: A randomized pilot civilian study with modified
prolonged exposure. Biological Psychiatry.
Schnurr, P. et al. (2007). Cognitive behavioral therapy for post-traumatic
stress disorder in women. Journal of american medical association, 297(8),
Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., &
Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for
posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541- e550.
PILOTS ID: 41029
Williams, M. & Poijula, S. (2002). The PTSD Workbook. New Harbinger
Publications: Oakland, CA.
Worthington, E., Jr., Hook, J., Davis, D., & McDaniel, M. (2011). Religion
and spirituality. Journal of Clinical Psychology: In Session, 67(2), 204-214.

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