Clinician's Corner: Cognitive Processing Therapy: Cross-Cultural Considerations
Patricia A. Resick, PhD, ABPP
August 16, 2015
Cognitive Processing Therapy (CPT) is a flexible cognitive therapy protocol based on the theory that people don’t recover from traumatic events because they draw faulty conclusions about the causes and meaning of the events. This results in them being “stuck” with their PTSD symptoms.
CPT can be used individually or in groups, with or without written accounts. Although the typical protocol is 12 sessions, preferably implemented twice a week for 6 weeks, there is an outcome-based variable length protocol that was developed by Galovski et al. (2012) that is now being tested with active military personnel. Through this variable length CPT the majority of civilian participants completed treatment in an average of 9 sessions, though a minority needed up to 18 sessions to achieve a good end state.
After an education session, clients are asked to write a statement about why they think the traumatic event (starting with the worst PTSD event) happened and what it means about themselves and the world, especially with regard to safety, trust, power/control, esteem and intimacy. The product of the impact statement is developed into a “Stuck Point” log which is used throughout the therapy to teach clients the difference between facts and thoughts, and what emotions are related to their thoughts. Using a progressive series of worksheets, clients are taught, through Socratic questioning, how to examine their thoughts and assumptions and develop more balanced fact-based thinking. The goal is for the client to learn a new way of thinking about events in general, and to become their own therapist.
Cognitive Processing Therapy was first developed with rape victims (Resick et al. 2002; 2012) and then tested with female victims of any type of interpersonal trauma (Resick et al. 2008). Not surprisingly, the content of the resulting stuck points were often self-focused (e.g., “what did I do to deserve this?”; “I can’t trust my own decisions…”), because in “rape culture” the victim is often blamed for the event. Although there have been many changes in laws and in the availability of services, more progress in this regard is still needed.
By 2006, the first study with Veterans (predominantly Vietnam Veterans) was published (Monson et al. 2006), and with each step the question of whether the CPT protocol should be changed for the new population arose. Chard (2005) did expand the protocol to include an additional number of sessions, a group, and individual therapy for survivors of child sexual assault. We learned that there were no differences between patients with or without child sexual or physical abuse with the 12 session protocol overall (Resick, Suvak & Wells, 2014). Frequency but not severity or duration of sexual abuse predicted drop-out, but not outcomes. In examining the CPT dismantling study, it was found that the version without the written accounts worked best.
Lester et al. (2010) examined drop-out and outcomes across female Caucasian and African-American clients across the Resick et al. (2002 and 2008) studies and found that while African-American clients were more likely to drop-out of treatment, they did equally well in the intent-to-treat analyses and improved more than Caucasians who dropped out of treatment. The authors speculated that cultural messages against receiving therapy may have motivated them to achieve as much as possible in the shortest time possible.
Military Culture
As the VA began disseminating CPT across the country, it added information about military culture to its training. As we began conducting CPT research with active military members we found that the military culture was even stronger than anticipated, because they were still living within it and were implicitly or explicitly being taught ‘rules’ that may work in a combat setting but may not prove viable at home or once discharged. The CPT protocol didn’t change, but the content of assumptions and stuck points often varied because of the difference in some of the traumas (e.g., seeing people killed or killing), the expectations that mental health treatment signifies defeat, and ongoing expectations about war.
As examples, an implicit or explicit message that military members receive is that “if everyone does their job correctly, everyone will be OK.” After an event in which people are injured or killed, an after-action debriefing is conducted which reinforces the idea that the outcome was preventable. This may be reassuring to those who have to go into battle, but it is not considered that everyone could have done their jobs correctly and there still could be a bad outcome. The word ‘responsibility’ can also be misconstrued. While it makes sense to tell military leaders that they are responsible for the people under their command, it is not reasonable to expect that they have total control over everything their unit members do or encounter. It is not uncommon to hear a unit leader say, “I wasn’t there, but it is my fault that one of my men was killed. I must not have trained them well enough.” This person is not considering that no matter how much training someone has, they cannot control everything in the situation. There are other people involved.
Along with the concept that other people are involved in the traumatic event, with military trauma there is the possibility of erroneous other blame. If someone believes that “if everyone does their job correctly, everyone will go home,” and they believe that they did their job correctly; they may look to others in their periphery to blame. A soldier might blame his unit commander for sending him to a particular location in which he took fire or a friend was killed.
Other Cultures
The CPT manual has been translated into 10 languages. I contacted colleagues from other countries and U.S. therapists/researchers who have conducted CPT in westernized countries as well as third world nations. Most of them indicated that the major modifications needed were in the translations, because literal translations did not always make sense. The most extreme case was in the Democratic Republic of Congo, in which a randomized clinical trial was conducted (Bass et al. 2013) and the concepts from the worksheets had to be taught and memorized because of complete illiteracy and lack of paper for the participants living in a war torn country. In an interview with the New York Times (June 6, 2013), Dr. Bass stated, “If you can do this in the Congo, you can do it anywhere.” In Cambodia, stuck points became ‘Kut Caraeun’, which means thinking too much. In Iraq, the concept of esteem had to be changed to “respect” and intimacy to “caring.”
However, colleagues in Germany, Iceland, Hong Kong, Israel and Japan kept the protocol nearly identical or made minor changes. Several said that more examples in the homework assignments, especially for adolescent clients, were important. In Japan, they included drawings, because drawings are typically found in their books. Pictures and more simplified language were also used in countries in which illiteracy rates were high. In Israel, clients were encouraged to write their trauma accounts in the clinic in which they had privacy and safety. Overall, the basic message was that the “heart” of CPT was maintained, but adaptations to language and culture, usually with simplifications of the concepts and worksheets, were common.
Some articles have been written about the process of adapting CPT to other cultures. Kaysen et al. (2011) described the iterative process of adapting CPT for both untrained therapists and clients in Iraq. Although the CPT protocol did not need to be modified except for language differences, the therapists needed a great deal more practice with each of the steps of therapy. Schulz, Huber and Resick (2006) wrote about the adaptation of CPT for Bosnian refugees in the U.S. They also discussed issues in conducting therapy through interpreters. In both articles, the issues of religion, gender roles and the meaning of mental health problems emerged. Marques et al. (2015) have conducted a study comparing impact statements and stuck point logs of Latinos and non-Latinos. While they found that the cognition of the two groups were generally similar, Latinos produced fewer stuck points, which could impact treatment. Family violence or obligations, community violence and religion were prominent themes.
Culture is found in any community and therapists need to be aware of the beliefs within that culture that may be keeping the client stuck. The basic scaffolding of CPT appears to be hardy, but the content of cognition, stuck points and basic assumptions are different from place to place. Socratic questioning has been used successfully to challenge even the most rigid cultures and therapists need to keep in mind that cultures change or may be overgeneralized as stuck points.
Additional Information
PDF copies of the 12 session therapist manuals and materials manual can be obtained free of charge by emailing [email protected]. Online training can be found here. The U.S. Department of Veterans Affairs (VA) conducts workshops for its employees and mental health agencies sometimes arrange workshops. And watch for announcements of CPT workshops often held at the ISTSS Annual Meeting.
About the Author
Patricia A. Resick, PhD, ABPP, developed Cognitive Processing Therapy in 1988 while on the faculty for 23 years at the University of Missouri-St. Louis. She then spent 10 years, starting in 2003 as the Director of the Women’s Health Sciences Division of the National Center for PTSD at VA Boston and a Professor at Boston University. She is now on the faculty of Duke University Medical Center and is conducting the majority of her CPT research with active military personnel at Ft. Hood, Texas.
References
Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., Wachter, K., Murray, L. K., & Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182-2191. doi: 10.1056/NEJMoa1211853.
Chard, K.M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971. doi: 10.1037/0022-006X.73.5.965.
Galovski, T.E., Blain, L.M., Mott, J.M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968-981. doi: 10.1037/a0030600.
Grady, D. (2013, June). Therapy for victims of sexual violence shows promise in Congo. The New York Times. Retrieved from www.nytimes.com/2013/06/06/health/therapy-for-rape-victims-shows-promise.html?_r=0.
Kaysen, D., Lindgren, K., Zangana, G. A. S., Murray, L., Bass, J., & Bolton, P. (2013). Adaptation of cognitive processing therapy for treatment of torture victims: Experience in Kurdistan, Iraq. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2), 184. doi: 10.1037/a0026053.
Lester, K., Artz, C., Resick, P. A., & Young-Xu, Y. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78(4), 480. doi: 10.1037/a0019551.
Marques, L., Eustis, E. H., Dixon, L., Valentine, S. E., Borba, C. P. C., Simon, N., Kaysen, D., & Wiltsey-Stirman, S. (2015, May 11). Delivering Cognitive Processing Therapy in a community health setting: The influence of Latino culture and community violence on posttraumatic cognitions. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000044.
Monson, C.M., Schnurr, P.P., Resick, P.A., Friedman, M.J., Young-Xu, Y., & Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898-907. doi: 10.1037/0022-006X.74.5.898.
esick, P.A., Galovski, T.E., Uhlmansick, M.O., Scher, C.D., Clum, G.A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76(2), 243-258. doi: 10.1037/0022-006X.76.2.243.
Resick, P.A., Nishith, P., Weaver, T.L., Astin, M.C., & Feuer, C.A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879. doi: 10.1037/0022-006X.70.4.867.
Resick, P. A., Suvak, M. K., & Wells, S. Y. (2014). The impact of childhood abuse among women with assault‐related PTSD receiving short‐term cognitive–behavioral therapy. Journal of Traumatic Stress, 27(5), 558-567. doi: 10.1002/jts.21951.
Resick, P.A., Williams, L.F., Suvak, M.K., Monson, C.M., & Gradus, J.L. (2012). Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80(2), 201-210. doi: 10.1037/a0026602.
Schulz, P. M., Huber, L. C., & Resick, P. A. (2006). Practical adaptations of cognitive processing therapy with Bosnian refugees: implications for adapting practice to a multicultural clientele. Cognitive and Behavioral Practice, 13(4), 310-321. doi: 10.1016/j.cbpra.2006.04.019.