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FAQs for Cognitive Processing Therapy (CPT) and Cognitive Processing Therapy for Group (CPT-G)

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FAQs for CPT for Group
17:  I have taken the two-day individual training and want to start group CPT.  Is there anything to know before I start group?

18:  When I have done group treatment in the past, it always seems like one patient takes over.  Time management gets derailed!  Any suggestions?

19:  If we decide to use CPT+A (doing the written account) in group, what are some good ways to manage this?

20:  What about aftercare groups?

1:  Sometimes Active Duty members have to rotate or leave precipitously before an EBP protocol can be completed. Is it better under these circumstances to forego the EBP protocol (using CPT) and simply deliver supportive therapy? 
Answer:  There are a few issues to consider when deciding to start treatment with a Service member who will be leaving for a new duty station or deployment.  The first is to discuss it with the patient and let them decide.  Many times, there is much going on in their life and for their family members; they may not be able to focus time and energy on their PTSD treatment or complete the practice assignments.  
Remembering that CPT may be conducted twice per week in an outpatient setting, do you and the patient have time to meet twice weekly until they leave?  This may be a good option to consider.
A general guideline is for you and the patient to determine if there is time to provide treatment at least through Session 5 or 6 and to use the standard protocol of not having them write an account of the trauma.  Having a CPT therapist available at the new site is also key for a successful transition to ongoing care.
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2:  I have a female client that was molested in childhood. We are on session 6. She is not allowing herself to experience the natural feelings of the trauma. While she is very proactive with doing her homework, her PCL 5 scores have not gone down and recently increased.  She states “I would rather die than experience these feelings."  How can I help her experience her natural emotions?
Answer:  Fearing emotions may cause the patient to use avoidance to cope, maintaining and increasing PTSD severity over time, and this can lead to premature termination of treatment. 
You can use the stuck point of “I would rather die than experience these feelings” and do a worksheet on that.  Sometimes a simple “why?” question can elicit statements important to discuss.  Many times patients are fearful that if they allow themselves to feel, they will “never stop crying” or will become so angry they will alienate everyone around them. 
It may be helpful to talk about a less laden emotion, such as a time they felt mildly embarrassed and is not related to the traumatic event.  Ask them to name a time they felt embarrassed, and let themselves feel that emotion again.  Another approach, paradoxical in nature, is to ask if they are willing to try an experiment.  Ask them to name a place they would feel safe enough to feel an emotion.  Then ask that they set a timer for 5 minutes, let themselves feel for that period of time and, as soon as the timer goes off, turn the feeling off.  This works better than trying to convince a patient that they can control their emotions. Be sure to review the Identifying Emotions Handout with the patient to facilitate a discussion about the types and intensity of emotions.  It may also be helpful to ask the patient where they “hold” the emotion in their body as an intro to talking about their feelings.
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3:   There is a lot to do in Session 1. Can I split it into 2 sessions if I have a patient who has a lot to talk about and contribute?
Answer: Many clinicians use one or two pre-treatment sessions to begin educating clients on much of the material covered in Session 1. If you have already covered some of the material in pre-CPT sessions (such as the review of PTSD symptoms), then you may be able to provide a briefer review of this material in Session 1. 

Other general tips:
•    If the patient wants to discuss multiple traumas, explain that there will be time later in therapy, but for now you would like to focus on the index trauma. Review the rationale for this.
•    If the patient has difficulty understanding the content and asks a great deal of questions, you should make every attempt to finish Session 1 in a timely manner and assign the appropriate practice assignment.  Much of the material introduced in session 1 will be reviewed again later and it’s not uncommon for patients to better understand the material after it has been revisited.
•    If every attempt has been made and the session is running long, then make sure to cover every topic not covered in the first session at the second session.

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4:  Is it possible to add an additional session when patients have a lot to discuss?
Answer: Depends on what they want to discuss! CPT has been validated as a structured treatment protocol. The more deviation from that protocol, the more likely your results may vary from proven randomized control trials. Consider if the patient’s need to discuss or control the flow of therapy is an act of avoidance. 
You can reinforce the pace of therapy by briefly reviewing the agenda at the start of each session. If the patient truly has additional needs that cannot be addressed in the context of CPT (and if your schedule allows), then you can offer a few additional “crisis” or “stressor sessions” to focus on the outstanding issues. This format allows you to address the patient’s needs while reinforcing the importance of following the CPT protocol.
Also, you may have clients who are “late completers,” and by Session 11 are still scoring above the threshold on objective measures (PCL) you can discuss with them, adding up to three additional sessions at the end of treatment. In this case, you would not assign the Final Impact Statement; instead, focus on those stuck points, using the Challenging Beliefs Worksheet, that may be preventing decreased PTSD symptoms.
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5:  If a patient is having difficulty understanding the concepts from the ABC Worksheet, can I add a few more of these sessions, or should I move forward anyway?
Answer: The ABC Worksheet at this point does NOT have to be done perfectly or completely. As with other things, with practice they will master the task. Ultimately, the goal is for the patient to obtain a basic understanding of the concepts of the ABC Worksheet within a few sessions so that you can continue with the CPT protocol without deviation. A great deal of confusion with the ABC Worksheet can be prevented with a thorough explanation, while eliciting the patient’s examples to complete the columns. Be sure to convey that the primary goal of the ABC Worksheet is to differentiate between thoughts and the emotions. It may also be helpful to first ask the patient to identify the emotion and then to list the thoughts that might be causing that emotion. Cognitive difficulties may need to be explored and addressed with the patient also. Infrequently, a client may not be able to understand the basic concepts of CPT and another trauma-focused treatment may be needed.  Ultimately, you should move forward and not add sessions. 
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6:  Should the patient write a trauma account about each traumatic event?
Answer: Writing accounts about every trauma is not necessary and should not come at the expense of cognitive restructuring. Selecting an index trauma does not mean that the other experiences do not matter. This is a good time to explain the concept of how addressing the worst trauma often resolves other traumas since traumas can share stuck points. Explain that the process of completing the full protocol often resolves multiple traumas, and that there will be time at the end to introduce other traumas that have not resolved. In addition, there will be time to discuss other traumas when the themes in sessions 4 and 5 are discussed. 
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7:  How do I handle patient refusal to complete homework?
Answer: Non-compliance of practice assignments is a common concern since successful completion of treatment is linked to positive treatment outcomes. You should emphasize the importance of practice assignments throughout the course of therapy and explain the rationale for each assignment. It is helpful to review the practice assignment with the patient at the end of each session to encourage continued progress in recovery at home and to problem-solve any foreseeable barriers to completion. Collaborate with the patient in reviewing the assignment, and clarify if they have a good understanding of the assignment through their own examples. Assignments can be used as a tool to demonstrate progress to the patient and elicit motivation. If the patient does not complete homework assignments across multiple sessions, then it will be important to have an open discussion about motivation for therapy, and whether or not the patient can commit to the therapy at this time. If the patient continues to not complete practice assignments over multiple sessions, they are less likely to make significant gains in treatment.
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8:  How do I know if it’s a good stuck point?
Answer: A good stuck point is an extreme, concise, specific, and/or unhelpful belief that can be challenged by Socratic questioning. If you are not sure that it is a “good” stuck point, imagine trying to challenge it using the Challenging Questions Worksheet. If you cannot challenge it, then it likely needs some fine-tuning. Other characteristics of stuck points include the following:
•    Can often be formed with “If…then” statements 
•    Evoke an emotion
•    Can be about self, others, the world, or the trauma
•    Tend to reflect “black or white” or “good or bad” dichotomous thinking 
•    Are thoughts, NOT behaviors or feelings

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9:  What if my client doesn't have many assimilated stuck points? What if all of my client's stuck points are over-accommodated?
Answer:  It is possible to use OA stuck points to generate and then investigate hypotheses about possible assimilated stuck points. For example, “if I trust someone, I will be raped again” may be related to self-blame that hasn’t been acknowledged. Asking when the person started to believe that stuck point and how they came to that conclusion could lead to discovering an assimilated stuck point like “I was raped because I trusted my attacker.” 
Resources: VIDEO: Identifying Stuck Points
What Are Stuck Points?
Stuck Point Help Sheet for Therapists
Stuck Point Help Sheet for Patients
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10:  My client has multiple concerns (PTSD + comorbid depression/grief/moral injury/substance use).  How do I decide to focus on PTSD vs. other concerns?
Answer:  The primary issue here is one of behavioral stability and deciding if any of the co-morbidities will significantly affect PTSD treatment. While CPT is focused on the reduction of PTSD symptoms, it has also been shown that depressive symptoms are many times reduced as well during treatment.  Moral injurious thoughts are handled as stuck points, using Socratic questioning to shift the maladaptive thought to an alternative and more accurate assessment of the event.  Substance abuse issues must be determined to not need an inpatient detox or to begin a PTSD treatment immediately after detox.  If the patient uses substances, discuss what, how much, and if they can contract with you to reduce the amount and/or not use during sessions or while working on practice assignments.  Explaining the rationale around avoidance can be helpful in this discussion.  Finally, explain the full structure of CPT, including the important work outside of sessions, and determine with the patient if they have the energy, motivation, and desire to begin a focus on the PTSD issues.  Explaining to them that, many times, depression and other comorbid diagnoses remit or show symptom reduction during treatment can help them feel not as overwhelmed or believe they must deal with each issue in a linear way.
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11:  There is a concern that manualized, structured treatments are “cookie-cutter,” and there is little or no room for clinician creativity and rapport.
Answer:  Rapport comes naturally with the clinician’s attention, interest and unbiased concern, and ability to listen to traumatic events.  With the clinician’s focus on how the patient uniquely thinks and feels comes a natural dialogue and therapeutic bond.  Warmth, empathy, and rapport-building are crucial to all therapy outcomes, including in CPT.
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12:  Why is there such an emphasis on using Socratic dialogue?
Answer:  One of the most common errors is for clinicians to try and convince patients to change their minds about their stuck points, rather than using Socratic dialogue to draw out information and let the patient realize their assumptions are in conflict with evidence.  Asking questions in a gentle, clarifying way allows a patient to articulate the assumptions behind their stuck points and come to conclusions on their own.  Being curious is a good way to help a patient realize that their stuck point may not be entirely accurate or accurate at all.  A clinician risks being seen as argumentative by a patient without this approach and may cause a defensive stance in the patient.
Resource: VIDEO: Socratic Questioning: The Art of Guided Self-Discovery
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13:  At times it feels like nothing I ask is making any difference in the way a patient is thinking about their stuck point.  Should I hang in there and just keep using Socratic dialogue in the hope that something will finally click?
Answer:  There are generally easily identifiable “hardest” or “stickiest” stuck points.  If a patient has difficulty determining evidence against the stuck point, you can ask if they would work on it during the week.  You can also ask that they choose one they believe may be easier for them to challenge.  In this way, they gain the experience of how it feels to have a long-held belief proven to be untrue.  For those patients who may be avoiding challenging what may be the harder stuck points, it’s a good idea to have them choose one of those and work on challenging them in session.  For additional tips, please refer to Figure 6.1: Therapist Stuck Point Guide in your CPT manual.
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14:  What if I think my client needs coping skills to deal with trauma-focused treatment?
Answer:  There is much research indicating that patients do better if coping techniques are integrated into treatment at the appropriate points.  Delaying treatment sends a message that they cannot handle the work, are “fragile,” or that it is “dangerous.” It is important to remember that patients have been living with their memories of the trauma for a long time, and providing trauma-focused treatment allows them to take control of when and how they think about the trauma.   If you do not have concerns about a patient’s imminent safety, it is preferable to not delay evidence-based treatment.
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15:  What if my patient’s PCL scores are not decreasing?
Answer:  The most prevalent reason for this is that the patient has forgotten the initial instructions on answering the items on the PCL and is responding to them with the impact of how their day or week has gone -- a fight with a spouse, trouble at work, etc. Review the instructions to complete each item based on the index traumatic event.  Other possible reasons for a lack of decrease in PCL scores may be that the patient is not completing practice assignments, frequently cancelled sessions or, in the case of multiple traumatic events, may not be working on the trauma that is causing the most PTSD symptoms or leaving out important components.
Resources: VIDEO: Working With Guilt in CPT
VIDEO: Utilizing the PCL in CPT - The Unidentified Stuck Point
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16:  I’m worried I won’t know what to ask about a patient’s stuck point!
Answer:  This is a common worry for clinicians new to CPT and for whom Socratic dialogue may not yet have been mastered.  Listen to what the patient is saying, notice what doesn’t make sense (e.g. ,“How could they have known that would happen next?” or “Could such a young child have stopped what happened?”).  Consider the patient’s intention in the situation versus a partial responsibility for the outcome, and what real options were available to the patient under the circumstances, not wishful thinking.  Focusing on what the patient was thinking, feeling, and doing during the index trauma will result in knowing what to ask next.
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FAQs for CPT for Group
17:  I have taken the two-day individual training and want to start group CPT.  Is there anything to know before I start group?
Answer:  Yes, there is a separate one-day training specific to doing CPT group treatment.  CDP offers this training online approximately once or twice per year.  The prerequisite for this training is to have already taken the two-day standard workshop for individual treatment. While a separate manual has been provided in the past, the new manual includes both individual and group treatment guidelines.
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18:  When I have done group treatment in the past, it always seems like one patient takes over.  Time management gets derailed!  Any suggestions?
Answer:  Many times, excessive shyness and excessive dominance issues come up in group treatment.  Dominant patients may silence other group members and create hidden animosities affecting future dynamics.  The first step for therapists is to identify the dominant and shy patients as early as possible.  The therapists can then begin to loosely monitor and control the amount of time each patient has to talk.  One technique is to propose to the members that those who are quick to respond should count to 10 before giving an answer, thus giving clients who are slower to respond time to voice their thoughts and feelings.  Asking the group members to help ensure everyone gets a chance to be heard can be a powerful and helpful tool.
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19:  If we decide to use CPT+A (doing the written account) in group, what are some good ways to manage this?
Answer:  The first thing to remember is that the written accounts are not read within the group!  The reasons for this are multiple, including time management issues, general distress, or comparing index traumas e.g., “mine wasn’t as bad as the others.”  When possible, individual sessions should be scheduled for each patient to read their account, capture stuck points, and return to challenge the stuck points in group.  A good group discussion can be to have group members explore and discuss their reactions to writing about their event, with therapists listening to normalize emotions and determine whether the accounts are detailed and as complete as possible.
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20:  What about aftercare groups?
Answer:  As in individual CPT, it is recommended that therapists schedule a group check-in session meeting 2-3 months after the completion of treatment.  Some clinics offer CPT aftercare groups approximately twice a month to continue addressing stuck points from completed worksheets that patients will bring into each aftercare meeting. Limit aftercare to a specific end date, and focus on review of the worksheets using a whiteboard so all group members have input.
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FAQs for Cognitive Processing Therapy (CPT) and Cognitive Processing Therapy for Group (CPT-G) | Center for Deployment Psychology

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