Cognitive Process Theory in PTSD Treatment
People are diagnosed with psychological disorders for many reasons. For some it is a lack of care or event in their childhood that results in a disorder. Others simply appear to be born with an affliction. Post Traumatic Stress Disorder, however, is unique in that it is a disorder whose cause can be narrowed to a specific event, in most cases. Famously, the disorder has been tied to a variety of wars in which soldiers return from the front lines expressing signs of psychological disorder. In fact, famous pieces of post-war literature, such as Ernest Hemingway’s short story “Soldier’s Home,” may be describing such a disorder. Today, the disorder has been linked to events that some may consider even more traumatic, like rape. A discussion of the disorder, along with several experiments with implications for the future of the disorder will shed light on Post Traumatic Stress Disorder (PTSD) and its potential treatments.
According to Barlow (YEAR), symptoms of PTSD are “distressing and intrusive because the individual has no control over when or how they occur and because the elicit strong negative emotions associated with the initial trauma” (p.61). These symptoms include the intrusion of memories associated with the trauma into the sufferer’s every day life. Similarly, when a person with PTSD is faced with memories or other “cues associated with the traumatic event,” he or she may react in a strong way both psychologically and physiologically. For instance, the PTSD sufferer may react to the cue with intense fear, a psychological reaction, while similarly showing physical signs of fear such as an increased heart rate, a great deal of perspiration, and irregular breathing. The cues that bring about these disorders can be immediately associated with the trauma, or simply a set of factors that remind the sufferer about the trauma in some way. Other symptoms besides the most obvious and famous reactions include a heightened sense of awareness, suggesting that the patient is nearly always feeling the “fight or flight” response, in addition a numbness in which the sufferer attempts to forget the trauma, and sometimes succeeds (Barlow YEAR, p.61). In order to be diagnosed with PTSD, a victim must be experiencing all of these symptoms at such a degree that they interfere with normal tasks for at least a month (Barlow YEAR, p.62).
Although those who suffer from PTSD must exhibit all of the above symptoms within the given time range, this does not mean that few are actually found to be suffering from the disorder. On the contrary, the epidemiology of the disorder is quite widespread. According to Barlow (YEAR), “studies have determined high rates of trauma and PTSD in the population” (p.62). In fact, most people had experienced a traumatic event. Sixty-six percent of women in one study noted that they had experienced a traumatic even, and this trauma was primarily linked to rape and sexual assault. In fact, one study pointed to the fact that rape was the “trauma most likely to lead to PTSD” in both men and women (Barlow YEAR, p.62). Motor vehicle accidents and wartime combat were two other leading traumatic events that would likely lead to PTSD (Barlow YEAR, p.62).
Thus, the common contextual features suggest that the disorder is much more likely to occur in victims of some type of sexual assault for women. Environments involving child abuse, and combat situations are other climates that may produce the disorder. While many who suffer from a traumatic incident are able to re-enter society in a healthy way, even after experiencing the symptoms of PTSD for a short time, only some can be classified as having PTSD, and thus experiencing symptoms over a longer period of time.
Several theoretical models have been developed in order to deal with PTSD. Some of these models include Mowrer’s traditional theory of classical and operant conditioning, in which classical conditioning was called upon to explain the large amounts of fear and fearful symptoms in trauma victims while operant conditioning was used to explain the avoidance tactics used by victims. Other theoretical conceptualizations included anxiety and information-processing theories, which suggests a “fear network” that triggers the “information network” for memory intrusions (Barlow YEAR, p.63). Although each of these theories clearly suggests a well-thought-out explanation for the disorder, the theories that are most accurate are the social-cognitive theory. These theories dwell on how a trauma situation impact’s a person’s individual belief system. Furthermore, the theories focus on the addition of the trauma to that belief system and the changes on that belief system that the trauma requires. The theories encompassed by the social-cognitive genre are varied. Horowitz suggested that PTSD is caused by “a basic conflict between the need to resolve and integrate the event into the person’s history on the one hand, and the desire to avoid emotional pain on the other” (Barlow YEAR, p.63). Other constructivist theories suggest that a person has self-made ideas about their selves and worlds that are changed by the traumatic event. These theories focus on reconstructing the person’s self-made ideas as treatment. Further social-cognitive theories suggest a “dual-representation of both conscious memories and unconscious sensory memories” (Barlow YEAR, p.63-64).
Thus, instead of relying on learning and conditioning models, the social-cognitive theory of PTSD suggests that the traumatic event affects a person’s already established belief and value systems. This theory is superior to the other two because it gives the most accurate explanation for the disorder. Obviously, a traumatic event would profoundly impact a person’s belief system and understanding of who they are.
Formulated especially for those who have faced rape and sexual assault, Cognitive Process Therapy is the treatment that is best designed to intervene for those diagnosed with PTSD based on a sexual trauma based on the social-cognitive conceptualization of PTSD. The theory was designed in the 1990s, and focuses on addressing a person’s beliefs and cognitions based on the trauma event. According to Kaysen (2005), the intervention addresses “denial and self-blame, then over generalized trauma-related beliefs.” These beliefs are generally those that have been held to a certain degree by the patient, but are “modified” because of the trauma. An example that Kaysen (2005) suggests is, “the world is a dangerous place.” Testing has suggested that Cognitive Process Therapy is an effective treatment for PTSD. In tests, patients who experiences Cognitive Process Therapy for three months improved significantly. Furthermore, Cognitive Process Therapy performed slightly better than other PTSD therapies in some areas. It is especially affective for those who have dealt with a sexual assault or abuse case and those who have extraordinary amounts of guilt because of their trauma (Kaysen 2005).
Review of Current Scholarship
In recent years, three experiments regarding Cognitive Process Therapy as the treatment of PTSD in rape victims and others have stood out as important to the treatment’s evolution. The first study was designed to compare Cognitive Process Theory with Imaginal Exposure as a treatment of PTSD in those with PTSD from a variety of traumas. Unlike other experiments, this test was designed to test many PTSD patients’ response to treatment, not just those with PTSD from a specific cause, such as rape or combat. The methodology consisted of subjects that were referred to the researchers from a variety of health services throughout Northwestern England. The first stage of the experiment consisted of monitoring, while the second stage included an allocation to treatment. The patients were randomly assigned to either Cognitive Process Therapy or Imaginal Exposure Therapy. Each patient was given sixteen sessions of treatment, each treatment lasting one hour. Patients were asked to rate their impression of the treatment’s credibility in the second, session, while in the fifth session therapists were asked to rate the patient’s motivation. The demographics of the study included 90 patients who made it the whole way through the second assessment. Most of the patients were male, and the mean age was just over 38 years; most were working during the time of the trauma, through most were unemployed during treatment. A minority of the subjects had been diagnosed with or were being treated for other psychological maladies. While the study did not manage to establish a significant difference between the therapies, the researchers were able to discover some important information about PTSD sufferers. For instance, those patients who completed the treatment showed a significant improvement over those who did not. Furthermore, the authors suggested that the number of those who did not show up for the second session of treatment was astounding (Tarrier et al.).Al. 1999).
Although the previous study suggested that Cognitive Process Therapy did not produce any better results than Imaginal Exposure Therapy, Cognitive Process Theory has not been discounted as an effective theory for dealing with PTSD. Instead, Bryant et al. (2008) suggested combining Cognitive Process Theory with others in order to maximize PTSD treatment effectiveness. In their recent study, the researchers began by questioning earlier studies like Tarrier et al.’s 1999 report that suggested Cognitive Process Theory was no more effective than other theories. In this study, patients were adults suffering from PTSD that had been referred after three months of PTSD symptoms. These patients were not combat soldiers, and had been referred after either a non-sexual assault or a motor vehicle accident. The patients were between 17 and 60 years old and did not have other psychological problems. Eighty-four individuals made it through the primary assessment through the follow-up meeting. Individuals were randomly assigned to a treatment, although an equilibrium in regards to gender and trauma was maintained. The patients’ progress was measured through the CAPS assessment, an interview that assesses the PTSD symptoms according to the DSM — IV regulations. Secondary measures, including the Beck Depression Inventory, Impact of Event Scale, Catastrophic Cognitions Questionnaire, and State-Trait Anxiety inventory were used. Patients were exposed to either Imaginal Exposure, in Vivo Exposure, Imaginal Exposure with in Vivo Exposure, or Imaginal Exposure with in Vivo Exposure and Cognitive Process Therapies. The researchers found that combining the two treatments with Cognitive Process “resulted in greater treatment effects for both PTSD and depressive symptoms than did exposure alone” (Bryant et. Al. 2008, p. 701). The authors conclude that they may have received these results because Cognitive Process Therapy is intended to correct “maladaptive thoughts.” If the researchers had a way to measure simply the correcting of such thoughts, they contend the experiment would be more adequate.
In the third piece of scholarship, researchers intended to dismantle the view that Cognitive Process Therapy was better than other therapies for PTSD sufferers. In this study, the researchers chose only women who had been involved in interpersonal violence situations to participate. The women were not only referred from assistance agencies, but were also recruited via flyers and other forms of advertisement. One hundred and sixty-two women were chosen from a total of 526 assessed. Of those 162, 13 would be unable to complete the first steps. The intent to treat population for the study included 150 women. The researchers were able to gather a rather accurate random sample — consisting of women who had no “significant differences” in demographic groups other than income (Resick et al. 2008, p.245). Patients were measured using both standardized interviews and self-report scales. The interviews and scales were determined to assess, among other things, symptoms of trauma, depression, a person’s shame, and “trauma-related beliefs” (Resick et al. 2008, p. 248). Patients were randomly assigned into groups using Cognitive Process Theory including its accessories of other types of therapies, Cognitive Therapy Only, and Written Accounts Therapy. The researchers found that those in all three groups improved in PTSD symptoms and depression, while those in the Cognitive Therapy Only group improved to a greater extent then those in the Written Accounts treatment (Resick et al. 2008).
The wealth of information regarding PTSD and its various treatments is varied if not conclusive. A variety of treatments exist, and scholarship has not yet proven Cognitive Process Theory to be any better than many other traditional therapies. Similarly, scholarship has not proven the theory to be any worse. In some cases, however. Cognitive Process Theory was shown to better certain specific groups of people, or to be an asset when other types of treatment were also given. This research suggests that Cognitive Process Theory, while not the ultimate solution to PTSD, is still beneficial in reconciling the disease.
Although the current scholarship on the issue seems to suggest that Cognitive Process Theory is, indeed, a legitimate theory for dealing with PTSD, further research must be done to determine exactly how Cognitive Process Theory helps. It has been stipulated that this type of therapy be most adept at dealing with restructuring belief systems to a positive, pre-trauma state. In order to best assess the treatment, one must find a way of testing it against other theories that attempt to deal with the personal belief systems of patients. Further more, increased testing regarding the disorder and certain types of trauma groups, along with other disorders, will help to determine just what situations call for this therapy.
Barlow, David H. (YEAR). Clinical Handbook of Psychological Disorders Third Edition.
Bryant, Richard a. et al. (2008). A Randomized Controlled Trial of Exposure
Therapy and Cognitive Restructuring for Posttraumatic Stress Disorder. 76(4), p. 695-703.
Kaysen, Debra. (2005). Cognitive Process Therapy for Acute Stress Disorder
Resulting From Anti-Gay Assault. 12(3), p. 278-289.
Resick, Patricia a. et al. (2008). Randomized Clinical Trial to Dismantle Components of Cognitive Processing Therapy for Posttraumatic Stress Disorder in Victims of nterpersonal Violence. 76(2), p.243-258.
Tarrier, N. et al. (1999). A Randomized Trial of Cognitive Therapy and Imaginal Exposre
Treatment of Chronic Posttraumatic Stress Disorder. 67(1), p. 13-18.
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