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MILITARYMEDICINE,179,10:1077,2014
Effects of Cognitive Processing Therapy on PTSD-Related
Negative Cognitions in Veterans With Military Sexual Trauma
´
RyanHolliday, MA*†; Jessica Link-Malcolm, PhD*; Elizabeth E. Morris, PhD*; Alina Surıs, PhD*†
ABSTRACT Treatingpost-traumatic stress disorder (PTSD) related to military sexual trauma (MST) continues to be
a priority in veteran populations. Because negative cognitions (NCs) contribute to PTSD severity and treatment, further
understanding of how PTSD and related NCs can be addressed and changed within an MST sample is important. Our
study analyzed 45 participants who received either cognitive processing therapy (n = 32) or present centered therapy Downloaded from https://academic.oup.com/milmed/article/179/10/1077/4159641 by guest on 28 September 2022
(n = 13). Participants who received cognitive processing therapy had significantly lower NCs scores post-treatment and
at follow-up sessions than participants in the present centered therapy condition (p < 0.05). In addition, NCs were
positively correlated with PTSD severity (p < 0.05). Implications for future research are discussed for both MST-related
and non-MST-related PTSD.
INTRODUCTION patient’s trauma(s). Over the course of CPT treatment, the
Military sexual trauma (MST) is defined by the Department therapist teaches the patient how to challenge negative cogni-
1
of Veteran Affairs as “sexual harassment that is threatening tions (NCs). The patient learns how irrational interpretations of
in character or physical assault of a sexual nature that the traumatic experience maintain PTSD symptoms and nega-
occurred while the victim was in the military, regardless of tively affects beliefs about self and the world. Through cogni-
geographic location of the trauma, gender of the victim, or 4
tive restructuring, reductions in PTSD symptoms will occur.
the relationship of the perpetrator.” It is important to note that NCs may inhibit a patient’s ability to fully engage in the
MST is not a clinical diagnosis, but rather, it is a traumatic treatment process. Furthermore, higher levels of NC’s are
8–12
event of a sexual nature that occurs while a person is on associated with greater severity of PTSD symptoms.
active duty, that often results in post-traumatic stress disorder Since its development, CPT has demonstrated effective-
2 13
(PTSD). Moreover, because of the prevalence of and negative ness in multiple populations, including survivors of MST.
3
consequences of MST in both returning military personnel Despite the wide breadth of knowledge regarding CPT’s effi-
and veterans, research related to clinical treatment of MST- cacy in treating PTSD,4,6,7,13–16 a review of the literature
related PTSD is critical. revealed only one published study which examined the
Specifically, MST-related PTSD has been shown to have effects of CPT on reducing the number of NCs.17 These
numerous negative health associations including comorbid researchers reported that CPT was effective at reducing NCs
psychiatric disorders (e.g., depression and substance use dis- in a sample of high school students who had experienced a
orders), cardiovascular health problems, and socioeconomic traumatic event.17 To date, no published studies have exam-
´ 3
difficulties (for a complete review see Surısetal). As such, ined the effects of CPT on NCs in patients diagnosed with
treatment of MST-related PTSD continues to be a priority in PTSDorinsurvivors of MST.
clinical treatment settings including Veteran Affairs Medical Several critical issues were investigated in this study; we
Centers (VAMCs). examinedtherelationship between NCs and symptom severity
One of the most commonly utilized treatments for PTSD among veterans diagnosed with PTSD related to MST and
at both VAMCs and non-VAMCs is cognitive processing assessed the effects of two interventions on clinical outcomes
therapy (CPT). CPT is an evidence-based treatment (EBT) in this population. We had three hypotheses: (1) Veterans
that has been found to be significantly more effective at treated with CPT would demonstrate a greater reduction in
treating PTSD than other forms of psychotherapy and phar- NCs compared to those treated with a nontrauma-focused
macotherapy.4 CPT is a form of cognitive behavioral therapy treatment (Present-centered therapy, PCT); (2) treatment with
that was originally developed for civilian survivors of rape5 CPT would result in sustained symptom reduction over the
that has been adapted by the Veterans Health Administration pre- and post-treatment (PT) evaluations; and (3) the number
to treat MST and combat-related PTSD.6,7 CPT effectively of reported NCs would be positively correlated with measures
treats PTSD by having the patient recognize cognitive “stuck of symptom severity among Veterans diagnosed with PTSD
points,” which are negative/distorted cognitions related to the related to MST.
*Veteran Affairs North Texas Health Care System, 4500 South Lancaster METHOD
Road, Room 116A, Dallas, TX 75216. Participants
†Department of Psychiatry, University of Texas Southwestern Medical
Center, 5323 Harry Hines Boulevard, Dallas, TX 75390. The study was conducted at a large Southwestern VAMC.
doi: 10.7205/MILMED-D-13-00309 Participants were recruited via posted advertisements,
MILITARYMEDICINE,Vol.179,October2014 1077
Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST
recruitment letters, and clinician referral. Participants good internal consistency (PTCI total score, Cronbach’s a =
received monetary compensation for their participation. 0.97; NCs about self, Cronbach’s a = 0.97; NCs about the
Inclusion criteria were as follows: (1) veteran status with a world, Cronbach’s a = 0.88; self-blame, Cronbach’s a =
diagnosis of MST-related PTSD, (2) MST occurrence at least 0.86) and test–retest reliability (PTCI total score, p = 0.74;
3 months prior, (3) MST identified as the most distressing NCsaboutself, p = 0.75; NCs about the world, p = 0.89; self-
PTSD-related trauma, (4) at least one clear memory of the blame, p = 0.89).22 The PTCI subscales also have strong
MST, and (5) no changes to psychiatric medication in the convergent validity with similar NC measures on the Per-
past 6 weeks. Exclusion criteria were as follows: (1) sub- sonal Beliefs and Reactions Scale (PBRS).22,23 For example,
stance dependence/abuse in the past 3 months, (2) current the NCs about self subscale was significantly related to the
psychotic symptoms, (3) unstable bipolar disorder, (4) severe self-scale of the PBRS (p = 0.085), the NCs about the world
cognitive impairment, (5) concurrent enrollment in an EBT subscale was significantly related to the others (p = 0.64) Downloaded from https://academic.oup.com/milmed/article/179/10/1077/4159641 by guest on 28 September 2022
for PTSD, (6) involvement in a violent intimate partner rela- and safety (p = 0.65) scales of the PBRS, and the self-
tionship, and/or (7) significant suicidal/homicidal ideation. blame subscale was significantly related to the self-blame
The study was approved by the Institutional Review Board (p = 0.50) scale of the PBRS.22
of the Veteran Affairs North Texas Health Care System, and The PTSD Checklist-Military (PCL-M)24 was used to
all participants gave their written consent before taking part assess for PTSD severity. The PCL-M is a self-report mea-
in the study. sure that is commonly utilized to assess a patient’s PTSD
One-hundred twenty-one participants were randomized to symptom severity over the course of treatment. The PCL-M
receive either CPT or PCT. Four masters or doctoral level is a 17-item self-report measure of PTSD symptom severity,
female therapists (therapist A, B, C, and D) provided therapy with each item scored from 1 (Not at all) to 5 (Extremely).
to study participants. Two doctoral-level therapists adminis- 25
The PCL-M has strong test–retest reliability (r = 0.96) and
tered the study measures and were blinded to the patient’s concurrent validity to measures of PTSD including the
25,26
therapy condition. Before analyzing data, therapist fidelity Mississippi Scale for Combat PTSD (r = 0.93) and the
was assessed for both conditions.18 Clinician Administered PTSD Scale (CAPS; r = 0.93).25,27
Toensure accurate administration of the manualized ther- The CAPSisclinician administered instrument that is one
apies, a random selection of session videos from each thera- of the “gold-standard” measures used to diagnose PTSD as
pist was rated by an independent reviewer from 1 (poor) to well as to measure PTSD symptom severity.27,28 The CAPS
´ 13
7(excellent). As previously discussed (see Surısetal ), ther- is a 30-item semi-structured interview used to assess the
apist D demonstrated poor fidelity (M = 3.30, SD = 0.87) in the frequency and intensity of PTSD symptoms. The CAPS has
CPT condition and was removed from analysis. However, strong inter-rater reliability (k = 0.95–1.00) and strong con-
upon further analysis of therapist fidelity, therapist C was current validity to other measures of PTSD including the
found to have significantly lower fidelity (M = 4.44, SD = PCL-M (r = 0.93) and Mississippi Scale for Combat-related
0.77) in the CPT condition than therapists A (M = 5.04, SD = PTSD(r=0.70,r=0.81).27,28
0.52) or B (M = 5.26, SD = 0.60). Similar results were found Although the PCL-M and the CAPS correlate highly, we
in terms of PCT fidelity, with therapist D (M = 4.25, SD = administered both measures because patients sometimes
0.67) having significantly lower ratings than therapist A (M = differ in their level of disclosure during self-report compared
29
5.09, SD = 0.85), B (M = 5.53, SD = 0.37), and C (M = 4.86, to clinician administered interviews. This method ensures
SD=0.79).However, no significant difference was observed that both patient and clinician perceptions of PTSD symptoms
between therapists A, B, and C in terms of PCT fidelity. are assessed. In addition, measurement of PTSD severity with
Because the accuracy of psychotherapeutic administration is both the PCL-M and the CAPS is commonly utilized in clini-
19–21 ´ 13 30
strongly related to the effectiveness of EBTs, it was cal PTSD research (see Surısetal and Monson et al ).
decided that only the data from therapists with average fidelity Strong internal consistency was observed at baseline within
ratings of 5 (good) or better would be included in data analy- our sample for all administered measures (PTCI, Cronbach’s
ses. Therefore, therapists C and D’s data were excluded, a=0.94;PTCIsubscaleNCsaboutself,Cronbach’sa = 0.94;
leaving 45 participants (n = 32 for CPT and n = 13 for PCT). PTCI subscale NCs about the world, Cronbach’s a = 0.91;
PTCI subscale self-blame, Cronbach’s a = 0.78; PCL-M,
Cronbach’s a = 0.91; CAPS, Cronbach’s a = 0.85).
Measures
The Post-traumatic Cognitions Inventory (PTCI)22 was used
to assess for trauma-related NCs. The PTCI is a self-report Procedure
instrument with 36 items that assess how much the partici- Following informed consent, participants underwent a base-
pant agrees with each statement from 1 (totally disagree) to line assessment that included administration of the PTCI,
7 (totally agree). The PTCI generates a general NCs score as CAPS, PCL-M, and a demographics form. Participants then
well as scores on three subscales: (1) NCs about self, (2) NCs received 12 weekly 1-hour sessions of either CPT or PCT (a
about the world, and (3) NCs about self-blame. The PTCI has comparison condition that did not address NCs and instead
1078 MILITARYMEDICINE,Vol.179,October2014
Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST
focused on general support and psychoeducation31). After wasassociated with the PTSD symptom severity, a Pearson’s
psychotherapy completion, participants were readministered correlation was calculated.
the PTCI, CAPS, and PCL-M 4 subsequent times (1 week,
2 months, 4 months, and 6 months PT). RESULTS
At baseline, there were no significant differences between
DATAANALYSES treatment condition for any demographic variables except
Statistical analyses were conducted using SPSS, version 19.32 for age and education (see Table I). No significant differences
Baseline characteristics were compared via independent sam- were found between the two treatment conditions on the
ple t tests for continuous measures (e.g., age and education) PTCI total score or on any of the subscale scores at the
andc2analysesfor qualitative measures (e.g., gender, ethnic- baseline evaluation (see Table II). There were also no signif-
ity, and attrition). To examine treatment efficacy, a 2 (treat- icant baseline differences between the two groups on measures Downloaded from https://academic.oup.com/milmed/article/179/10/1077/4159641 by guest on 28 September 2022
ment) + 5 (assessment session) repeated measure ANOVA of PTSD severity (CAPS and PCL-M total Score). No signifi-
was calculated on scores from the PTCI (total score and cant differences were found based on gender or ethnicity for
subscale scores). Post hoc independent sample t tests were CAPS, PCL-M, PTCI total score, or PTCI subscale scores at
used to assess for any differences between the treatment any session. However, participants in the CPT condition were
conditions at specific time points. Within-condition PTCI significantly younger and more educated than participants in
differences over the course of treatment were tested via the PCT condition. Because the two treatment groups differed
dependent sample t tests. To determine if the number of NCs significantly in age and educational level, both variables were
TABLE I. Demographic Information
Total (N = 45) CPT(n=32) PCT(n=13)
Variable M SD M SD M SD
Age 44.91 9.72 42.69* 10.15 50.38* 5.88
Years of Education 14.18 2.09 14.59* 1.98 13.15* 2.08
% n % n % n
Gender (Female) 75.60 34 71.90 23 84.60 11
Ethnicity
White, Nonhispanic 46.70 21 40.60 13 61.50 8
Black, Nonhispanic 33.30 15 34.40 11 30.80 4
White, Hispanic 4.40 2 6.30 2 0.00 0
American Indian 2.20 1 3.10 1 0.00 0
Pacific Islander 2.20 1 3.10 1 0.00 0
Other 8.90 4 9.40 3 7.70 1
CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy. *p < 0.05.
TABLE II. Comparison of PTCI Scores Between Treatment Conditions Over the Course of Treatment
PTCITotal Score NCsAboutSelf NCsAbouttheWorld Self-Blame
M SD M SD M SD M SD
Baseline
CPT 153.88 32.90 4.40 1.12 5.79 0.99 4.19 1.47
PCT 162.62 32.25 4.82 1.25 5.87 1.10 4.05 1.45
1 Week PT
CPT 121.14* 39.51 3.35* 1.33 4.96* 1.24 3.20 1.33
PCT 155.55* 35.25 4.58* 1.31 5.92* 0.95 3.60 1.91
2 Months PT
† †
CPT 114.32*** 37.59 3.10*** 1.17 4.90 1.57 2.97 1.38
† †
PCT 167.89*** 38.62 5.05*** 1.41 6.00 1.00 3.96 1.61
4 Months PT
CPT 116.86** 40.91 3.23** 1.34 4.81** 1.55 3.10 1.22
PCT 159.91** 26.17 4.67** 1.15 6.14** 0.70 3.78 1.64
6 Months PT
CPT 114.86** 42.20 3.14** 1.38 4.91† 1.45 2.91 1.31
†
PCT 157.82** 42.07 4.59** 1.42 5.87 1.40 4.05 2.18
PTCI, Post-traumatic Cognitions Inventory; NCs, Negative cognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post-
treatment. †p < 0.10, *p < 0.05, **p < 0.01, ***p < 0.001.
MILITARYMEDICINE,Vol.179,October2014 1079
Effects of CPT on PTSD-Related Negative Cognitions in Veterans With MST
used as covariates when examining treatment effects. The scores at 1 week, 2 months, 4 months, and 6 months PT
repeated -measure ANCOVA revealed that neither variable compared to participants in the PCT condition. In addition,
had any effect on the PCTI total or subscale scores. participants in the CPT condition showed significant within-
No significant differences were found for PTCI scores or condition decreases from baseline to 6 months PT, while
its subscales between participants who withdrew from or participants in the PCT condition did not.
completed the study. In addition, a c2 analysis revealed that
there was no differential withdrawal between the two treat- NCsAbouttheWorld
ment conditions, c2 (1, N = 45) = 1.19, p = 0.275. A repeated measure ANCOVA of NCs about the world
revealed a significant main effect of treatment condition,
PTCITotalScore F(1,25) = 4.69, p = 0.04, partial m2 = 0.16, indicating that
A repeated measure ANCOVA of the PTCI total score participants in the CPT condition reported significantly fewer Downloaded from https://academic.oup.com/milmed/article/179/10/1077/4159641 by guest on 28 September 2022
revealed a significant main effect of treatment condition, NCs about the world. However, there was no main effect of
2 2
F(1,25) = 6.40, p = 0.018, partial m = 0.20. Results indicated time, F(4,22) = 0.66, p = 0.63, partial m = 0.11, and no
that participants in the CPT condition showed greater reduc- significant interaction between treatment condition and time,
2
tions of their PTCI total score compared to participants in the F(4,22) = 1.42, p = 0.26, partial m = 0.21. Follow-up t tests
PCT condition. However, there was no main effect of time, (Table II) revealed that participants in the CPT condition had
F(4,22) = 0.67, p = 0.62, partial m2 = 0.11, and no significant significantly lower scores at 1 week and 4 months PT, and
interaction between treatment condition and time, F(4,22) = nonsignificant trends at 2 months and 6 months when
2
1.17, p = 0.35, partial m = 0.18. Follow-up t tests (see compared to participants in the PCT condition. In addi-
Table II) revealed that participants in the CPT condition had tion, participants in the CPT condition showed significant
significantly lower scores at 1 week, 2 months, 4 months, and within-condition decreases from baseline to 6 months PT,
6 months PT compared to the PCT condition. In addition, while participants in the PCT condition did not.
participants in the CPT condition showed significant within-
condition decreases from baseline to 6 months PT, while Self-Blame
participants in the PCT condition did not. Arepeated measure ANCOVA of self-blame did not reveal a
significant main effect of treatment condition, F(1,25) = 2.00,
NCsAboutSelf p = 0.17, partial m2 = 0.07, indicating that participants in the
Arepeated measure ANCOVA of NCs about self revealed a CPTcondition did not differ from those in the PCT condition
significant main effect of treatment condition, F(1,25) = 5.93, in levels of self-blame. Moreover, there was no main effect of
2 2
p = 0.022, partial m = 0.19, indicating that participants in the time, F(4,22) = 0.71, p = 0.60, partial m = 0.11, and no
CPT condition reported significantly fewer NCs about self. significant interaction between treatment condition and time,
2
However, there was no main effect of time, F(4,22) = 0.29, F(4,22) = 0.95, p = 0.45, partial m = 0.15. Follow-up t tests
p = 0.88, partial m2 = 0.05, and no significant interaction (Table II) revealed a nonsignificant trend with participants in
between treatment condition and time, F(4,22) = 1.67, p = the CPT condition reporting lower scores than participants in
2
0.19, partial m = 0.23. Follow-up t tests (Table II) revealed the PCTconditionat2months.Inaddition,participants in the
that participants in the CPT condition had significantly lower CPTcondition showed significant within-condition decreases
TABLE III. Correlations Between the PTCI and PTCI Subscales to the CAPS and PCL Over the Course of Treatment
PTSDOutcomeMeasure PTCITotal Score NCsAboutSelf NCsAbouttheWorld Self-Blame
Baseline
CAPS 0.40** 0.43** 0.31* 0.06
PCL 0.61*** 0.63*** 0.54*** 0.09
1 Week PT
CAPS 0.62*** 0.58** 0.57** 0.45*
PCL 0.61*** 0.56** 0.67*** 0.35
2 Months PT
CAPS 0.82*** 0.80*** 0.71*** 0.50**
PCL 0.86*** 0.83*** 0.73*** 0.61***
4 Months PT
CAPS 0.67*** 0.65*** 0.64*** 0.22
PCL 0.74*** 0.72*** 0.75*** 0.23
6 Months PT
CAPS 0.73*** 0.75*** 0.60*** 0.38*
PCL 0.79*** 0.79*** 0.71*** 0.48**
PTCI, Post-traumatic Cognitions Inventory; CAPS, Clinician Administered PTSD Scale; PCL, PTSD Checklist; PTSD, Post-traumatic stress disorder;
NCs,Negativecognitions; CPT, Cognitive Processing Therapy; PCT, Present Centered Therapy; PT, Post-treatment. *p < 0.05, **p < 0.01, ***p < 0.001.
1080 MILITARYMEDICINE,Vol.179,October2014
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