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Staff Perspective: CPT Group for Military-Connected Patients: Applying Research to Clinical Practice

Staff Perspective: CPT Group for Military-Connected Patients: Applying Research to Clinical Practice

Carin Lefkowitz, Psy.D.

Cognitive Processing Therapy (CPT) is one of the gold-standard treatments available to adults with posttraumatic stress disorder (PTSD) and remains a first-line recommended treatment in the latest VA/DoD Clinical Practice Guideline for the Management of PTSD and Acute Stress Disorder (DVA & DoD, 2017).  CPT is a robust and flexible treatment in that it can be delivered with or without a written trauma account, in person or via tele-health, and individually or in group format.  Dozens of randomized control trials and effectiveness trials demonstrate that CPT is one of the most effective treatments for PTSD in both civilian and military-connected populations.

Large health systems such as the Veterans Health Administration and the Military Health System are committed to delivering high-quality behavioral health care to the patients they serve.  But the combination of high demand (large number of patients) and low supply (low number of providers delivering evidence-based psychotherapies) can limit access to treatments such as CPT.  Therefore, delivering CPT via group format (CPT-G) is an attractive option for the efficient provision of treatment to a large population.  However, until recently, the effectiveness of individual CPT vs CPT-G had not been compared in military-connected patients.  Two studies shed light on this issue.

Resick and colleagues (2017) compared the effectiveness of individual CPT and CPT-G for an active duty population.  In their clinical trial, 268 Service members seeking outpatient treatment in an Army medical center were randomized to receive either individual or group CPT.  All participants had served in Afghanistan or Iraq and presented with deployment-related traumas.  Results demonstrated that both modalities led to significant improvement in PTSD and depressive symptoms.  However, faster and greater improvements in PTSD symptoms (about twice as much) were made by Service members receiving individual CPT.  Depressive symptoms and suicidal ideation were addressed equally well by both formats.  So while both modalities were effective for active duty Service members, the individual format demonstrated an advantage over CPT-G for this population.

More recently, Lamp and colleagues (2018) sought to understand how effective CPT-G is for military Veterans.  They compared outcomes of CPT+A (CPT with the written trauma account) in individual vs. group formats in two VA PTSD clinics. The population included 465 Veterans of mixed service eras, age, gender, and ethnic backgrounds.  This was not a randomized or controlled study and Veterans self-selected what type of treatment they received. Once again, symptoms of PTSD and depression decreased in both conditions, though individual CPT+A outperformed group CPT+A.  In fact, PTSD symptomatology decreased nearly twice as much for Veterans who received individual CPT+A.

Taken together, these studies offer strong evidence that individual CPT can offer greater gains for military-connected patients seeking treatment for PTSD in an outpatient setting.  While we cannot definitively explain WHY individual CPT outperforms CPT-G in this population, several hypotheses exist:

  • Individual CPT allows for more focused attention on each patient’s symptoms, needs, and progress with assignments.  One-on-one attention may allow for more thorough Socratic dialogue and challenging of personal stuck points.  Additionally, patients may receive more individualized instruction and feedback, especially on skills with which they struggle.  It’s easy to imagine greater guidance and instruction can result in greater improvement.
  • CPT-G may be prone to the effects of social loafing; that is, each participant might contribute or participate less in a group setting because responsibility for contributions is diffused amongst all group members.  In a group setting there is less time available to review every patient’s unique stuck points and practice assignments, which also leads to less individual accountability.  Individual CPT holds the patient more accountable for discussion, homework review, and practice, and this may ultimately lead to better outcomes.
  • Missed sessions become problematic in CPT-G.  If a patient misses a session of individual CPT, they can simply reschedule the session and continue to move through the protocol in its proper order.  In a group setting, treatment proceeds regardless of whether an individual patient has missed a session.  So if a patient misses one or more sessions, they also miss the skill development that accompanies it and may not receive a full dose of treatment.

Looking at the data from these studies, it’s natural to conclude that we should only offer individual CPT to military-connected patients, or at least decrease the number of groups offered and increase the availability of individual CPT.  However, it’s important to also consider the unique benefits that CPT-G can offer, such as:

  • Social Support.  Particularly for socially isolated patients, increasing social support can be very helpful.  CPT-G allows peers to bear witness to each other’s experience, offer encouragement, and instill hope.  Participants may also learn from each other ways to successfully negotiate challenges and setbacks within the treatment through a modeling approach.  Having support from other military-connected individuals with similar backgrounds and values may be especially powerful for this population.
  • Exposure to more perspectives. A crucial element of CPT is brainstorming more objective ways to view the traumatic event, the patients’ responses to it, and the assumptions they make about the future.  Having the input of multiple people when challenging assumptions, interpretations, and stuck points can help each patient develop a broader perspective.
  • Managing supply and demand.  As noted previously, CPT-G may enable overwhelmed clinics to more efficiently deliver high-quality treatment to their patients.

In summary, these two studies strongly suggest that individual CPT leads to faster and greater improvement in PTSD severity for Service members and Veterans receiving treatment in an outpatient setting.  However, CPT-G may offer some unique benefits that should not be automatically discounted.  If your clinical judgment or clinic needs lead you to offer CPT-G, consider how you might address or mitigate the potential challenges noted above.  As always, our CPT Subject Matter Experts are available to consult with you about these questions.  Visit our consultation page to get in touch.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Carin Lefkowitz, Psy.D., is a clinical psychologist and Cognitive Behavioral Therapy Trainer at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, MD.

REFERENCES

Department of Veterans Affairs and Department of Defense.  (2017 June). VA/DoD Clinical Practice Guideline for the Management of PTSD and Acute Stress Disorder.  Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/

Lamp, K. E., Avallone, K. M., Maieritsch, K. P., Buchholz, K. R., & Rauch, S. A. M. (2018, May 14).  Individual and group cognitive processing therapy: Effectiveness across two Veterans Affairs posttraumatic stress disorder treatment clinics. Psychological Trauma: Theory, Research, Practice, and Policy.  Advance online publication. DOI: http://dx.doi.org/10.1037/tra0000370

Resick, P., Wachen, J., Dondanville, K., Pruisma, K., Yarvis, J., Peterson, A., Mintz, J., & the STRONG STAR Consortium.  (2017).  Effect of group vs. individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: a randomized clinical trial.  JAMA Psychiatry, 47(1), 28-36.

Staff Perspective: CPT Group for Military-Connected Patients: Applying Research to Clinical Practice | Center for Deployment Psychology

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