Kathleen M. Chard

Dissemination of Evidence-Based Psychological Treatments for Posttraumatic Stress Disorder in the Veterans Health Administration

Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VAs national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed.

An Evaluation of Cognitive Processing Therapy for the Treatment of Posttraumatic Stress Disorder Related to Childhood Sexual Abuse.

This study compared the effectiveness of cognitive processing therapy for sexual abuse survivors (CPT-SA) with that of the minimal attention (MA) given to a wait-listed control group. Seventy-one women were randomly assigned to 1 of the 2 groups. Participants were assessed at pretreatment and 3 times during posttreatment: immediately after treatment and at 3-month and 1-year follow-up, using the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (D. Blake et al., 1995), the Beck Depression Inventory (A. T. Beck, R. A. Steer, & G. K. Brown, 1996), the Structured Clinical Interview for the DSM-IV (R. L. Spitzer, J. B. W. Williams, & M. Gibbon, 1995; M. B. First et al., 1995), the Dissociative Experiences Scale-II (E. M. Bernstein & F. W. Putnam, 1986), and the Modified PTSD Symptom Scale (S. A. Falsetti, H. S. Resnick, P. A. Resick, & D. G. Kilpatrick, 1993). Analyses suggested that CPT-SA is more effective for reducing trauma-related symptoms than is MA, and the results were maintained for at least 1 year.

A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy.

The current wars in Iraq and Afghanistan are producing large numbers of veterans who have experienced a variety of combat stressors. The potential impact of combat exposure has been established, including significant rates of posttraumatic stress disorder (PTSD). Limited research has examined potential differences between veteran groups and one study to date has examined differences between eras in terms of treatment response. The present study seeks to examine cohort differences between Operation Enduring Freedom and Operation Iraqi Freedom veterans and Vietnam veterans (N = 101) before and after completing treatment for PTSD using cognitive processing therapy. Findings suggest that veterans from these eras responded differently to treatment and there are multiple variables that should be considered in future cohort studies.

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self-reported and clinician-assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty-six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present-centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed-effects model analysis revealed a significant interaction between groups (p = .05, d = -0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self-reported, but not clinician-assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre- and posttreatment effect sizes were mostly moderate to large (d = 0.30-1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self-reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.

Exploring the efficacy of a residential treatment program incorporating cognitive processing therapy-cognitive for veterans with PTSD and traumatic brain injury†‡

As the numbers of military personnel participating in the wars in Afghanistan and Iraq continue to grow, the percentage of individuals who return with both a traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) also increases. Although there appears to be significant overlap in the symptoms resulting from PTSD and TBI, the best course of treatment remains an area of controversy. The authors present initial findings from a Veterans Administration residential program for comorbid PTSD and TBI. Forty-two participants completed a program comprising psychoeducational groups and cognitive skill building that was augmented with a modification of standard cognitive processing therapy. The results suggest that residential programs that incorporate this form of cognitive therapy can anticipate meaningful participation from patients, and that it may be an effective approach to treat PTSD in individuals with a history of TBI.

Group cognitive processing therapy delivered to veterans via telehealth: A pilot cohort†

The authors report clinical findings from the pilot cohort of the first prospective, noninferiority-designed randomized clinical trial evaluating the clinical outcomes of delivering a cognitive-behavioral group intervention for posttraumatic stress disorder (PTSD), cognitive processing therapy (CPT), via video teleconferencing (VT) compared to the in-person modality. The treatment was delivered to 13 veterans with PTSD residing on the Hawaiian Islands. Results support the general feasibility and safety of using VT. Both groups showed clinically meaningful reductions in PTSD symptoms and no significant between-group differences on clinical or process outcome variables. In keeping with treatment manual recommendations, a few changes were made to the CPT protocol to accommodate this population. Novel aspects of this trial and lessons learned are discussed.

The Relationship Between Maladaptive Cognitions, Anger Expression, and Posttraumatic Stress Disorder Among Veterans in Residential Treatment

ABSTRACT Ninety-nine veterans receiving treatment in a residential program for posttraumatic stress disorder (PTSD) were assessed to determine changes in maladaptive cognitions, anger expression, PTSD, and depression after receiving cognitive therapy. Veterans completed the Cognitive Distortions Scale (CDS), Trauma-Related Guilt Inventory, Beck Depression Inventory-II, State-Trait Anger Expression Inventory-2, and PTSD Checklist-Military. Paired samples t tests indicated significant differences from pre- to posttreatment for PTSD, depression, and CDS subscales. A hierarchical linear regression was conducted to determine predictors of posttreatment PTSD severity. Significant predictors were pretreatment cognitions related to wrongdoing and hopelessness and the interaction between anger expression and pretreatment PTSD severity. The interaction indicated that low pretreatment anger was associated with lower levels of posttreatment PTSD as baseline levels of PTSD severity increased.

Adapting cognitive processing therapy for child sexual abuse survivors

With the advent of managed care, there is an increasing need for short-term, empirically based treatments. This article presents a cognitive behavioral therapy protocol for the treatment of adult survivors of childhood sexual abuse, Cognitive Processing Therapy for Sexual Abuse (CPT-SA). Based on information processing, developmental and self-trauma theories, this 26-session model combines group and individual therapy over a 17-week period. Clients are asked to write about the trauma, and explore adaptive, schema congruent, and discrepant beliefs that developed during and after the abuse. Focus is placed on beliefs related to safety, trust, power/control, self-esteem, and intimacy, with individual modules for each of these areas. Initial pilot data (N = 15), clinical implications, and two client case studies are also discussed.

Personality Disorders, Coping Strategies, and Posttraumatic Stress Disorder in Women with Histories of Childhood Sexual Abuse

ABSTRACT Using a treatment-seeking sample of adult female survivors of childhood sexual abuse, the relationships between coping strategies, personality disorders (PD) and Posttraumatic Stress Disorder (PTSD) were explored. A variety of PDs were found to exist in this population, with avoidant, antisocial, dependent PDs having higher frequencies than borderline PD. Avoidant coping and PTSD severity significantly correlated with many of these PDs. PTSD severity and avoidant coping were also significantly correlated. Additionally, women with PTSD displayed higher rates of avoidant and dependent PDs, as well as more avoidant coping, than did women without PTSD. Results support a more complex conceptualization of the trauma-related symptoms that occur in adult survivors of childhood sexual abuse that incorporate the relationships between avoidant coping, personality disorders, and PTSD.

Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD

OBJECTIVE Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. DESIGN The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. RESULTS Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. CONCLUSION This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.