Draft:Cognitive Processing Treatment and Survivors: the relationship to SUD

Overview Cognitive Processing Therapy (CPT) is a highly recommended, evidence-based treatment for Post-Traumatic Stress Disorder (PTSD). Introduced in 1992, CPT offers a broad, cognitive-focused approach to trauma recovery, helping individuals reframe and process trauma-related beliefs, thoughts, and emotions. It can be administered in individual or group settings. Throughout the therapeutic process the therapist helps the identified client work though their cognitions and thought patterns. This process of reframing thoughts allows the client to process their emotions, assisting them to stay grounded by finding productive emotional regulation and interpersonal beliefs. This model of intervention is typically completed through a process of 12 to 18 sessions, which is contingent on the individual needs.

History and Endorsements • Developed to move beyond direct problem-focused approaches toward deeper cognitive restructuring. • Strongly recommended by: o American Psychological Association (APA, 2017) o International Society for Traumatic Stress Studies (ISTSS, 2018) o National Institute for Health and Clinical Practice (2018) o Phoenix Australia Centre for Posttraumatic Mental Health (2013) o Department of Veterans Affairs/Department of Defense (2023)

How CPT Works CPT presumes a collaborative relationship between equals rather than a hierarchical relationship. These factors are congruent with principles of cultural humility and collaboration (Foronda 2020). Although CPT is past and trauma-focused, it also facilitates generalization of skills to address present stressors and concerns, which may be particularly useful for groups that are experiencing current social stressors like discrimination and stigma. This form of treatment askes the survivor to be an active participant in the treatment process but first sets the stage for a collaborative relationship by first acknowledging the role of avoidance in treatment and being very transparent when addressing how this may hinder treatment. Other factors within CPT may be less congruent with culturally informed treatments, including an explicit focus on a more biomedical model of symptoms, rather than one based on the stigmas related to rape and/or mental health. The various phases of treatment include selecting an index trauma and acknowledgment of the avoidant behaviors. Addressing concerns about the treatment process and potentially escalating symptoms, dialogue that is targeting emotions and thoughts assimilated to the trauma. Later in the therapeutic relationship the therapist should be aware of any new trauma disclosures, even if they are new details about the identified trauma; by doing this the therapist works through cognitive blocks or “stuck points.” During the wrap up session the final impact statement should be written to describe how they view the trauma now and this will also be impactful since the client is able to compare where they were prior to treatment.

• Begins and ends with impact statements to help clients acknowledge causes and consequences of trauma. • Focuses on restructuring "stuck points" — maladaptive thoughts that maintain PTSD symptoms. • Applies across a wide range of settings: outpatient, residential, military, and civilian.

CPT and Co-occurring Substance Use • Substance Use Disorders (SUDs) are common in those with PTSD. • Research shows that CPT: o Does not worsen substance use. o Leads to improvements in PTSD and reductions in hazardous drinking (Straud et al., 2021). ° Is effective even without modifications for clients with comorbid PTSD/SUD. • CPT has been compared favorably to medications like sertraline and alternative treatments like Relapse Prevention therapy.

Special Populations and Cultural Adaptations Randomized controlled test show that baseline variables such as demographic variables, trauma history, presence of comorbid disorders, and PTSD and depression scores did not clearly discriminate between patients who had a delayed response to treatment (very little change in the first half or treatment but fully recovered by Session 12) and those who showed a partial response or no response. These results suggest that therapists should be cautious about terminating therapy too quickly with more complex patients lest they inadvertently deprive their patient of the opportunity to reap the full benefit of the protocol. • Race/Ethnicity: No major differences in CPT outcomes among White, African American, and Latino populations in the U.S. VA system. • Gender Identity and Sexual Orientation: CPT is effective among veterans of color who identify as LGBTQ+, with significant symptom improvement. • International Adaptations: o Minor cultural adjustments (language, examples) without altering core CPT structure. o Successfully implemented in countries like Egypt, Iraq, Tanzania, and the Democratic Republic of Congo. Statistics on Trauma and Substance Use • Survivors of childhood rape are twice as likely to develop alcohol abuse symptoms. • In 2022 4.7% of women and 3.5% of men reported unwanted sexual contact in the past year. • Substance use often serves as a maladaptive coping mechanism following trauma.

Evidence Base Resick et. Al. (2024). Completed a literature review which sums up much of the historical research and currently accepted applications of CPT/ Substance use disorders (SUD) commonly co-occur with PTSD, especially in treatment-seeking samples (Brady et al., 2021). Some providers have concerns about whether trauma-focused treatments might lead to increases in use (Back et al., 2009, Cook et al., 2014). However, neither current nor past SUD, hazardous drinking, or cannabis use predict poorer PTSD outcomes or higher dropout from CPT among active-duty service members or veterans (Dondanville et al., 2019, Hale et al., 2021, Held et al., 2021, Kaysen et al., 2014, LoSavio et al., 2023, Straud et al., 2021). Those with comorbid PTSD and substance use do tend to have higher PTSD symptoms prior to starting treatment than individuals without SUD but experience similar rates of improvement on PTSD as those without substance use comorbidity.

Within studies reporting substance use outcomes, CPT without adaptation has reduced substance use and associated risk factors like trauma-cued cravings (e.g., ElBarazi et al., 2022, Peck et al., 2018, Simpson et al., 2022, Straud et al., 2021). In a secondary analysis of a clinical trial of active-duty military, individuals who received individual or group CPT experienced medium to large improvements in hazardous drinking, with two thirds of those who originally met hazardous drinking criteria no longer meeting criteria following CPT (Straud et al., 2021). Two studies explicitly recruited individuals with PTSD/SUD. In a trial conducted in Egypt, CPT was compared to sertraline and placebo (substance use was most commonly cannabis; Elbarazi et al, 2022). Both CPT and sertraline had large effects on PTSD and substance use, and both were superior to placebo medication. CPT was also significantly better at reducing PTSD than sertraline, although there were no significant differences between the two on substance use. CPT was also compared to Relapse Prevention and symptom monitoring for individuals with comorbid PTSD and alcohol use disorder. CPT demonstrated superior improvements in PTSD symptoms posttreatment compared to symptom monitoring whereas Relapse Prevention did not, and both CPT and Relapse Prevention were superior to symptom monitoring in reducing drinking(Simpson et al., 2022). PTSD and drinking outcomes were monitored out to 1 year following treatment. At the 1-year follow-up, Relapse Prevention was superior to CPT in reducing days of heavy drinking, but 27% of those who received CPT maintained PTSD remission, 41% achieved abstinence, and 52% were drinking in low-risk ways.

Challenges and Research Gaps

More research needed on survivors outside of military setting however there a need for more standardized approaches for non-military, diverse civilian populations. Underreporting of gender and sexual orientation demographics in clinical trials impacts the data so controlling for underreporting is a consideration for future researchers.

Resources for Clients and Clinicians

For Clients: • National Center for PTSD - CPT Overview • APA Division 56 Trauma Psychology Resources • Sidran Institute for Trauma Survivors

For Clinicians: • CPT Training and Certification (Medical University of South Carolina) • VA PTSD Consultation Program for Providers • Recommended Reading: o "Cognitive Processing Therapy for PTSD: A Comprehensive Manual" by Patricia Resick, Candice Monson, and Kathleen Chard. o Peer-reviewed research articles referenced (Brady et al., 2021; Dondanville et al., 2019; Straud et al., 2021; Bass et al., 2022).

References

References: Cowan, A., Ashai, A., & Gentile, J. P. (2020). Psychotherapy with Survivors of Sexual Abuse and Assault. Innovations in Clinical Neuroscience, 17(1–3), 22–26. Ford, J. D., & Courtois, C. A. (Eds.). (2020). Treating complex traumatic stress disorders in adults:Scientific foundations and therapeutic models (2nd ed.). The Guilford Press. Keefe, J. R., Wiltsey Stirman, S., Cohen, Z. D., DeRubeis, R. J., Smith, B. N., & Resick, P. A. (2018). In rape trauma PTSD, patient characteristics indicate which trauma‐focused treatment they are most likely to complete. Depression and Anxiety, 35(4), 330–338. https://doi.org/10.1002/da.22731 Lomax, J., & Meyrick, J. (2022). Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault. Journal of Health Psychology, 27(2), 305–331. https://doi.org/10.1177/1359105320950799 Resick, P. A., LoSavio, S. T., Monson, C. M., Kaysen, D. L., Wachen, J. S., Galovski, T. E., Wiltsey Stirman, S., Nixon, R. D. V., & Chard, K. M. (2024). State of the Science of Cognitive Processing Therapy. Behavior Therapy, 55(6), 1205–1221.