Psychiatry & Psychotherapy Podcast - PTSD and Cognitive Processing Therapy with Patricia Resick

Episode Date: March 29, 2024

Learning how to approach patients with PTSD and severe trauma is necessary to help long term. Dr. Patricia Resick has plenty of experience in dealing with PTSD and is on the podcast today, sharing her wisdom so that we may better serve patients suffering from trauma.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Patricia Riesick. She is PhD, A, B, P, P, P, Professor Emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University. She has received many grants, including grants from the NIH, NIH, NIJ, CDC, SAMH, SAMH, SAMH, SAMH, SAMHSA, VA, DOD, for her innovative work in developing and testing cognitive processing therapy. She has written two books, one called Cognitive Processing Therapy for PTSD and getting unstuck from PTSD. She has another textbook on the way. She is recently retired, but very busy from what I hear giving grand rounds and writing and doing all the things. that would forward and further the work

that she has spent her life doing. She's published over nine books, 250 journal articles, and she has worked with countless PTSD patients. And so I thought I would start by asking her some questions about her journey into this important work. And then I really wanna focus in on what cognitive processing therapy is.

And kind of the, what I would say, say the pearls that we can glean from it, this will not replace, you know, a training in this or supervision, but maybe we'll give you a taste of, you know, what are some of the stuck points that people have when they have a traumatic event and how using more of a cognitive therapy approach can actually help get them out of that stuck point.

So welcome to the podcast. Thank you. Yes, part of your internship, you were part of the first cohort of, of rape crisis counselors in the mid-1970s, how did this impact you at the time and your future work with trauma patients? I was on internship in South Carolina

at the Medical University of South Carolina and the VA Hospital, and I was approached by a couple of people who were setting up one of the first, it wasn't the first, but it was one of the first rape crisis centers in the country. I had been working with children before that and that was my area of research and thought that was going to be my career.

And then when I started working with the rape victims, I realized, you know, I was asked to do a symposium for Southeast Psychological Association. And one of my fellow students and I did a complete review. And of course, we had no computers back then. So I was looking issue by issue of psychological abstracts. I think that's what it was called back then. I don't remember. But anyway, it was volume by volume looking through the indexes. And we could only find four articles on the topic of rape. And they were all like horrible. So we then got the word that the federal government, NIMH, was going to be funding research, $3 million, which back in 1970s money is pretty big to fund research on the effects of rape. So I was working as a rape crisis

counselor and getting called out in the middle of the night and learning a lot about kind of like how women were responding. Mostly they were numb, not saying much, but sometimes the family members were fairly outrageous. And the doctors took forever and were unturned. And the doctors took forever and were untrained at the time to do rape kits. Now they have the same program and nurses do that in most places or many places. But we started doing research and my whole field shifted because everything we learned was new. There was absolutely nothing in the field. So everything we learned was important, even if we didn't have a finding, it was important. So you were, yeah, you were really learning from observation. And what was some of the bad that you saw, like maybe the physicians, the bad

things physicians would do in interacting with patients? Well, typically it wouldn't be that, it would be some intern or a resident or something that would do the rape exam, and they were fairly rough. You know, the blame, they didn't under, I mean, literally people did not understand what rape was. I mean, I actually have. a psychiatrist actually asked me, what's the big deal about rape? Isn't that just sex? What? They didn't understand.

They literally did not understand that it was traumatic because it wasn't called traumatic. So, I mean... It's mind-blowing that, I mean, this is like 50 years later, but it's mind-blowing that that wasn't considered traumatic back then. That's just like, it's hard for me to conceptualize that. There was no field of traumatic stress. I mean, PTSD wasn't, post-traumatic stress disorder was not even put in the DSM until 1980. So when I started working in the 70s, people were just then starting to talk about rape trauma syndrome, child abuse syndrome, Vietnam Veterans Syndrome.

And they started realizing they were all talking about the same thing. and then when it got into the DSM, people started taking it more seriously and saying, and it was put with the anxiety disorders. It's like, okay, this is a real thing. And before that, usually with wars, as soon as the war was over, people would forget about it, and they wouldn't think about these diagnoses. And, of course, before that, it was things like shell shock and combat fatigue and things like that. They just didn't understand the nature of trauma and how lasting it could be.

Yeah, so you were in the midst of it. You submitted two grants and both were funded. Yeah. I wasn't since I was still a grad student, but I helped. Yeah. And yeah, what were some of the early findings that shaped your future trajectory? Well, we did lot. Both of these studies were longitudinal studies.

One looked at fear and anxiety. And the other one, when I went back to Georgia to finish my dissertation, we wrote a grant application looking at depression and seeing what happened with depression. And you could see that a fair number of people recovered, but there was a fair number who didn't recover over the period of time we were studying them over the year that we studied them. And we had some initial efforts in Charleston. Of course, this grant went on after I left and took an academic job up in South Dakota. But we were trying to treat them or have rape crisis counselors treat them.

didn't do a very good job. We didn't understand acute stress disorder. There was no such thing. Okay. And most people didn't want to get treated early on. That's still the case. Most people just like don't want to think about it, don't want to deal with it. I want to pretend it didn't happen. If I ignore it, it'll go away and stop bothering me. So getting people to even intervene now and get help early is still a problem, but it was even more so of a problem than we didn't have any idea what to do. And then, so initially, you had like an anxiety perspective on PTSD, if I, if I read that correctly. And then you looked at this one study where assertiveness training was one of the three arms.

Oh, yeah. And there was not much of a difference between them. Do you want to? Well, yeah, the very first study I did was I had some funding from the university I was at. And I looked at assertiveness training, and I looked at more of a psychodynamic condition and supportive treatment. And they were all the same. Of course, some of it had to do with the fact they were small studies.

But I was also hearing in the process of doing therapy with these women that they weren't always talking about fear and anxiety. Sometimes they said, I didn't think he was going to kill me. It was my husband or it was my ex-boyfriend. but what he did was so humiliating to me. He betrayed me. So they were describing horror and shame and guilt and saying, what did I do wrong? Why did he do this to me?

Like, I must have done something wrong. And so it really got me heading in a whole different direction than the anxiety disorders. I started reading Aaron Beck's work on depression and the cognitive therapy that he was doing. And he was also working in, you know, he started with depression and then moved to anxiety. So I could see that perhaps looking at the cognitions would be a way to get to, I change in emotions and get rid of some of the guilt and the self-blame and the shame that they felt and that sort of thing. Yeah, so it sounds like you were seeing more than just anxiety and fear. It was like shame. It was disgust.

It was betrayal. Yeah. And it sounded like you shifted to Beck's CBT approach. or you shifted his approach by going back to the traumatic memory and to look at where the client's thinking developed. Tell me about this. Well, Beck's work mostly

because he was working with depression and more general anxiety, they were focused on the here and now. And it just seemed like we needed to go back and actually work on their beliefs about the trauma before you can work on the here and now. And I think that's probably the case. I mean, you do get some of the things,

effect by working on the here and now, but you're not going to really resolve it until you resolve their thinking and their emotions about the trauma itself. The other thing that was different is that the original manuals that I was seeing that were being produced were, I got done reading them and say, yeah, I get the approach, but I don't know what to do. I really wanted a protocol to kind of laid it out, especially because I was thinking at the time in the very beginning that I was going to be working with rape crisis counselors and victim assistance programs and things like that because that wasn't a field in psychology psychologists were not working with trauma victims so I wanted a therapy that would be like session one do this session two do this session three do this and we were doing group

treatment because that's how they were tending to be treated like in the rape prices and so forth they would be getting groups at least where I was so that's how I ended up developing CPT is like as a very specific protocol. Okay. And you stated you would work with like the index trauma, like the first time someone had some sort of type of trauma. And you would be looking for a type of belief, like a over-accommodated belief where it's like I always make bad decisions.

No one can be trusted. I must control everyone around me. Can you tell me about that? Am I getting that right? Those are the here and now and the future, and those are the result of what they said to themselves about the trauma. So if they say, I made a mistake, I must have done something wrong for this to happen to me,

then their logical conclusions is I can't trust my own judgment. Or if they say it happened because I was in a dangerous place, then they jump to the conclusion that the world is entirely dangerous. Like they take it too far. That's what we call it over-accommodated. accommodated would be this bad thing happened to me. Okay, okay, let me phrase this different. So you would not start with the over-accommodated belief.

Oh, that's what we finish with. That's what we finish with. Okay, okay, good. So, right, like, I am always, I always make bad decisions. So someone who's not taking a trauma approach may start with that belief and start to work on that. But what you would do is you would go back to the first trauma. Not necessarily.

Not necessarily the first trauma. the worst trauma, the one that causes the most PTSD symptoms. Okay, and you would define the worst trauma as the one that's like the most nightmares, the most flashbacks, is that correct? How do you define it? Well, we measured the PTSD. And so we asked them, I mean, we might do a trauma timeline because most of the people who come for treatment have had more than one trauma happened to them.

It's rare to see somebody come to treatment with only one trauma. Right. So you would do like a PCL or what would you do? due to kind of... Once we identify what we would call what their index event is, the one that causes the most PTSD symptoms. Okay. So they might have had, they might have been molested as a child or had a car accident before

that, but then they have something much worse happened to them, like a rape or domestic violence or something like that. And then even within domestic violence, we would pick out the worst of the incidents. Mm-hmm. focus in on, not just like domestic violence generally or child abuse generally, but pick out the one where they thought they were going to die, or they thought their children were going to get abused or killed, or something like that. I mean, you know, there's something that would be markedly different and more traumatic about, and that's where we would start as the one that causes

the most PTSD symptoms, if we can identify it. Yeah, I remember, I used to work in the VA back back when I was a resident, there was one patient in particular. It's like the events that I would find that would be that pinnacle event would often be tied to they felt they had done something really wrong. Like I did something that killed my friend or I did something that, this incredible guilt, this incredible shame around that event. You want to speak to that? Yeah, when I first started, as I said, I first started working with rape victims.

And then, you know, eventually we started opening up to any kind of interpersonal trauma. And then I moved to the VA in Boston. And same thing with the veterans. I mean, we already knew at that point then that other kinds of traumas were producing the same kind of thinking. That very often people would say, let me back up a step, they would say things like, I should have done this or I should have done that or I could have stopped it. If only I had done this or that, they go back and try. to redo the event. It's like trying to unring the bell. And a lot of that comes from having

the fact that we're all raised with the just world belief, the good things happen to good people and bad things happen to bad people. So if you've had a fairly nice life and bad things haven't happened to you when something bad happens to you, you want to keep that belief intact. So you say, I must have done something wrong or I'm being punished. So I've got to figure out what I did wrong so I don't do it again so bad things won't happen to me. Now it's also possible that you could start out if you've been abused your entire life like from from birth you know you've been emotionally abused physically abused sexually abused you might start out from that negative position than any other traumas that happened you would just be more confirmation of that set of beliefs that you have that I'm worthless

or bad things will happen to me because there's something wrong with me or you know all that negative kinds of beliefs. But they still say, why me? Why does this keep happening to me? Yeah. Yeah. So what do you do? How do you help someone through that? Well, yeah, I mean, it's the same process. You help them go through what is their thinking about it. So one of the first assignments we give them when they start CPT is to write an impact statement about the event that we've identified. We're starting with one so it isn't too vague because it's really hard to take. on somebody's whole life. So we pick out what we consider like the worst because you're going to get a domino effect. If you can start with the one that causes and the most nightmares, splashbacks

and so forth. And we have them write what we call an impact statement. Why do you think this event happened specifically? And then we have them right about and what are the effects of having that happened to you? And that's where we get to those over-accommodated statements. Well, because this happened, I don't trust anybody or I don't trust my own judgment or I stay home all the time because I'm in danger. Every place feels dangerous to me, that sort of thing. And, you know, so we've got these five themes that we have them right about safety, trust, power and control, esteem and intimacy. They're very hierarchical. That's the how this has impacted them in those five areas?

Those five areas, yeah. Okay. And so they start with writing like a paragraph or a, paper one page on why they think that this event happened. Yeah. And explain to me the thought process about why the why is so important. Well, that's where the therapy starts, is working on whatever beliefs they have about why that trauma happened, because the chances are if they were trying to keep their old belief system intact, then they've distorted the event to fit that belief system.

They're trying to figure out where to put it in their brain. and so they say, I must have done something wrong. It must be my fault. I should have been able to save that person. If only I had done this. And so that's where we take them back. That's where the therapy starts with Socratic questioning and like, okay, so how far away were you from that person?

Could you have gotten to them in time to save them? Well, if you were stationed behind the house and you didn't know anything was going wrong until you heard the shots, how could you have been up there saving him? you know those kinds of questions so you help them expand the picture of what happened to them out so they can see that their logic is not working and then when they change what they're saying to themselves it changes their emotion about it instead of feeling guilt and shame they may feel grief and sad which is not a bad outcome because if they need to be grieving somebody that's where they need to be all right sometimes with grave victims they're

they go from blaming themselves to suddenly feeling angry and outraged. And that's okay too. It's like, he did this to me. I can't believe he did this to me. But they're putting blame where it belongs. What if they said, like, you know, a common thing I'll hear is I froze and I didn't, you know, in the midst of this event, I froze and I just didn't, I didn't say anything. I should have screamed.

I should have kept telling them to stop. I should have. What do you? you say to someone in that? Well, you don't say anything. You ask questions. I mean, the only saying it would be some education. It's like there's, there's a fight, flight, and then there's a freeze response. And there's two kind of freeze responses. One is what you were just describing is like an orienting response. Like, what's going on here? Like the event is a surprise to them. Maybe not to the person who's committing the act, but it's a surprise to them. And they're like, what's happening

here. And so they freeze for a second. And then they blame themselves for having a normal physiological reaction. The other kind of freeze response is it happens later when the fight and fail and the event continues on. Then they might dissociate and they're kind of frozen in their dissociation. And that especially is true when people are abused a lot as children. They can't fight. They can't flee. So they dissociate. and, you know, it's a different physiological reaction. Instead of having the blood go out to their hands and feet to get them to fight and freeze, it goes back to the core so they don't bleed out.

The endorphins kick in to stop the pain. And then they have that sense of when you've got that kind of almost amorophine response, you know, that's the sensation of dissociating. And if somebody learns to do that a lot, then later that becomes what their automatic response is. It's not fight or flee, it's freeze and dissociate. Which, of course, as an adolescent would put you at greater risk for having something happened to you another time

because you're not stopping it. The event goes on without you. Okay, so you're using Socratic questioning. You're using a, you know, gentle questioning, trying to understand more about the situation. And so like, let's say they say something like, yeah, you know, I was like, I wasn't expecting this to happen. And then all of a sudden, like, I just kind of remember like I couldn't talk and I couldn't say anything.

So can we do a little roleplay here? Yeah, we do a little education there. We talk about the fight and flight and freeze response. but we also talk about when your amygdala lights up, which is what gets that fight-flight response going, the prefrontal cortex turns off. Broca's area, your speech area, is in your prefrontal cortex. So if they have speechless horror,

that's not surprising because that got shut down. You don't need to be thinking about your philosophy of life when you're supposed to be fighting or fleeing. So it is very hard to think. And normally with a normal fight, response, what happens is that when the danger is over with, then the brain comes back online and things calm down. Like if you have an almost car accident, everybody's had that kind of response.

It's sometime in their life or the other, but things calm down and goes back online. That circuit is closed again, and it says to the amygdala shut down, you're not in danger anymore. You don't have to be in a panic mode. And then it changes all the neurotransmitters that are going through and you calm back down again with somebody with PTSD and particularly if they've had a number of things happen to them it goes offline and you don't get that final closing of the loop because the prefrontal cortex actually goes so dark that they're they're just like frozen there so it takes them much longer it's

very easy to get them activated and very slow to get them to shut down okay yeah and what is there different sort of techniques with someone who heavily dissociates in your perspective. I read in one of your, in your manual here, you talk about how the writing portion of CPT was more helpful in people who have heavy dissociation. Correct me if I'm wrong. Yeah, we did a, we do what we call a dismantling study. The second study I did because people were saying back then this is just still fear and anxiety, and it's the written portion of the account that is actually habituating their fear, and this is still all about fear circuitry. And I kept thinking, no, it's about the cognitive therapy, I think, but we'll see. So I had one condition where we did the full protocol with

written accounts. We did that across two sessions, and they would read it to themselves every day after they wrote it. And then we had one condition that was the cognitive therapy only, no written accounts and then I had a written account only therapy where they would write their accounts for an hour in the session and read back to the therapist and read it between sessions. No cognitive therapy. So overall we found out that the doing it without the accounts had a faster recovery. I mean they were showing clinically significant improvement by session four and it took longer when they wrote the accounts to catch up. And then there was no value. you added from having written the accounts. The exception to that was the high dissociators.

Not low dissociators or medium dissociators, but in the high dissociation group, they seemed to need to write their accounts before you did the cognitive therapy. So that original protocol worked best with high dissociators. Probably because their memory, when it had been put into their storage, was very fragmented because when you're dissociating during an event, things are coming in in a very fragmented way. So by writing their account and getting everything, the beginning, the middle, of the end, you've got the whole story.

Now you can do the cognitive therapy and help them look at it. So that was the one group that really seemed to do better. Most other groups do better, or there's no difference if they do their account or not, written account or not. Okay. So normally, you know, the therapist will ask them,

do you want to write your account or not write your account? We had about a 15% lower dropout rate when they didn't write the account. So that's the main part of the manual is without the accounts. But sometimes people want to write. They'll say, I'd like to write. I'd like to have this document. Okay, we'll do it that way.

Okay. And when you think about cognitive processing therapy and prolonged exposure, and I know you've compared them in studies, like, what do you find the difference between those two approaches are? Well, the cognitive processing therapy is really focusing a lot more on the cognitions. You know, helping them think through what they've been saying to themselves, which they probably came up with at the time of the event or shortly thereafter. So it might have been very childlike or adolescent kind of thinking.

It's my fault. I should have done something wrong or I'm being punished or whatever it happens to be. And then you help them think through that that's probably not the case. case. You know, the event happened in spite of them, not because of them. And exposure therapy is having them go through the event in detail, feeling their emotions, habituating to the emotions, and then they start thinking about things differently. And in fact, they found that even with prolonged exposure, cognitions change before the PTSD symptoms go down. So it seems to have the same effect that you're keeping them online by talking through their event.

In both cases, if you want to use that biological model, you're keeping their prefrontal cortex online by making them use their words and talking, whether it's the prolonged exposure. You're not having them do it just in their imagination. You're having them tell the story to the therapist out loud. So they have to use their words. They have to keep their prefrontal cortex online. Yeah. that helps them start thinking through. Now, some people who are doing, I think more recently, people are adding a fair amount of cognitive therapy after they do the exposures.

Oh, okay. So they're not sticking to just doing exposures. And what do you think of that you'll have to forgive me? I went to this conference when I was a resident and there was so much hurrah around. you know, other types of trauma therapies, like you have to get into the brainstem, you have to do EMDR. And I was almost surprised when I read recently this meta-analysis that compared, like, more of a cognitive approach like yours to EMDR. I wonder if you could speak to kind of like what you've seen in your career as like new approaches have come up and how you might advocate for years compared to other approaches.

There's a lot of debate about EMDR. It does have a cognitive component to it, and it does have an exposure component to it. And there have been some studies that said it doesn't matter what you do. And in fact, I was at a conference this year that said, yeah, the tapping actually doesn't make any difference. They were trying to do tapping instead of the eye movements and saying that doesn't help any. Some of the studies haven't been the same quality. So it depends on which meta-analysis you read and which of the treatment guidelines you read. If you read the BAs, I think it's the DOD treatment guidelines, they don't list EMDR is one of the preferred treatments.

It's either CPT or P.E. Over in Europe, they use EMDR a lot, and that's in their treatment guidelines. I think we would need more research. But think about it this way. If you've got therapists who were never treating the trauma by actually talking about the trauma, they're treating PTSD by saying, what would you like to talk about today? They wouldn't get too far. And so any therapy that you have that gets them to focus on their trauma and not avoid

and gives them some support is going to have an effect. I mean, the fact that they're taking three hours out of their day to drive to the therapist office, go have an hour therapy session, drive home, pay for the parking, they're already invested in getting better. They're thinking about what happened to. So almost anything you do is going to have some effect. And those are what I think of is the nonspecific effects of treatment. And so anything we do has got to be better than the nonspecific effects of treatment. And so anything we do has got to be better than the nonspecific. specific effects of treatment. In other words, you've got to have something that's going to add to that and do better than that. There have not been studies that have compared CPT with EMDR. They've compared it to PE, or they've just done various studies about EMDR. There is one study that I know of that is comparing CPT with EMDR right now, and I don't know what the results of it are. But sometimes, I mean, the problem is getting the funding for it, getting a large enough sample, you know, all those things, having all the bells and whistles that you have to do with a randomized control trial

to show that you've really controlled for all these other variables. But I'd say therapists who say, oh, I do this and it works. I'd say, sure, yeah, anything you do is going to have some effect. The question is, is it going to have the best effect? Or is there value added by what you're doing? Yeah, I think as a psychiatrist who's actively practicing both psychotherapy and med management. So some of my patients are just med management. I've referred people to EMDR therapists. They come back. Some of them get better.

Some haven't. And then I refer them to CPT or some prolonged exposure. Some it works. Some need something else. Sometimes it's the therapist isn't a good fit. So I'm constantly in this kind of like. searching for the best therapists or the best people to help a particular person, you know? Well, and that's where our research with CPT has been going, is to like, how do you make it

more accessible and more acceptable to people? I mean, we've found, we've been looking for predictors of treatment outcome. One is, do they do their practice assignments? If they go to CPT or PE and don't do their practice assignments, they're not going to do as well. So they can say that's CBT and they may not have really gotten a sufficient dose. It's possible that therapists didn't do a good job because they went after the over-accommodated stuck points first and didn't actually go back and really treat the trauma itself. And so, of course, they're going to go back and still be stuck on the traumatic event and feel shame and blame about that. So being very Socratic has turned out to be a factor that matters, putting the assimilated stuck points before the over-

accommodated, has we've shown in research that matters. Okay. You don't have to have them feeling their big emotions in the therapy session. That doesn't matter. The other thing we've been doing is trying to make it faster. There was one study that we did after my, I've always done twice a week for six weeks on all of my studies all the way back since 1994. Okay.

That doesn't mean other people do that. But even with that, we were, after we did, the first two studies, my study comparing it with prolonged exposure, and then the dismantling study, somebody came in and did a couple of things. We've done a couple of things with those combined samples. One was to look at length of the number of days between sessions, and the faster the therapy happened, the better. So, you know, like even if they're coming in twice a week, if they miss a week, you know, then, you know, like if you're only seeing them once a week, and they don't, and they miss a session or two, then now you've got a real problem because now you're

playing catch up like what's happened. They haven't been doing their practice assignments at home. So they're, they're staying where they are. They're stuck. Yeah. But that led us to doing faster and faster therapies. I'm curious. So like when you say we're doing faster and faster therapy, so you're doing like two week long, every day a session, yeah? Yeah, two weeks now. The only randomized control that's been done with really fast therapy did it in a week. And that one hasn't been published yet. But the dropout is so low when you do it fast. And that's the other thing I was going to say is that much lower dropout rates when you do it quickly.

So if you can have people come in and do it every day for two weeks. Or even they set aside, they did this study at Fort Belvoir, one of my colleagues, Jen Watchin was the PI on this study, the principal investigator, and they did it in a week compared to the six-week version. And no differences in outcomes, but there was only a 5% dropout rate. It was tiny compared to regular. And at Ohio State, Craig Bryan did a study where he was looking at it across a couple of weeks, but he compared the mass treatment to doing it. weekly and 33% dropout rate if you do it weekly and almost no dropout rate if you do it daily. And if you're doing it, like what percentage of people compared to waitlist or compared to no

therapy are getting better? Because I read this big meta-analysis on CBT for depression and recently came out this last year. It was like 10,000. thousand plus people, you know. It was like 20% out of the group got better, like got into remission for depression. Depression? Depression, yeah. And with doing what was this medication therapy? No, CBT, CBT 12, 12 session. We don't do that for depression. We use it for PTSD. It could be a problem. Right. No, no, no, not CBT, sorry, CBT. Cognitive behavioral therapy, just basic cognitive behavioral therapy. Yeah. So I'm curious, like, what... Well, we do better than that. Yeah. There is a difference. I mean, we, uh, it depends on the study, but we know that civilians tend to do better than, um,

veterans in active duty, but we're at least 50 percent. Um, some studies have had up to 75 percent. And if we do it variable length, it's closer to 80 percent are losing their PTSD diagnosis and, and getting not just to their scores down, but getting to a good end state where you'd say they don't have PTSD at all. And variable length means that you're not doing a set 12 sessions, that they may get done sooner, it may take them a few sessions longer,

but you base it on their scores on their PCL is how long you should go, which is I think often what happens in a therapy setting anyway. The set 12 sessions is often because you're doing research and you're comparing two things so they have to be the same. Yeah. So, wow, and that seems very short. And 50%, it's impressive.

Even if it's 50, just 50%, like that's an impressive amount of people getting out of PTSD. Yeah. Well, losing your diagnosis is one thing, but I mean, we always measure it in multiple ways. how many people lost their diagnosis, how many people had a clinically significant improvement, and then ultimately how many people have a good end state, which means their scores are really low. Their depression score, like on the BDI, the Beck Depression inventory would be below 10, and their PCL would be below 19. I mean, you're in a pretty good shape if you've got those things. So you're saying really good end state.

And that's where the variable length seems to do better. Well, I feel like a lot of trauma-oriented therapy is like somatic experiencing or body therapy. Actually, in your manual, I was reading, you will ask people what they're feeling in their body. You want to talk about that at all? Absolutely. It's like some of those people say like, oh, the cognitive people, all they do is talk about thoughts, you know, but I'm like reading in your manual like, no, you ask people what they're feeling in their body. So you are.

We have a whole emotion wheel. We teach them how to identify their emotions and, yes, how it feels in their body and that kind of stuff, where we're not laying hands on. And the cognitive therapy is to get them to reason through. They have to figure out how to think about it differently. So we're teaching them a set of skills. We're teaching them to think in a more balanced way. We're teaching them to take all the factors that were about that trauma into account when they think about the trauma, not just their flashback or their guilt or whatever it happens to be. So we put all the rest of the picture together by asking lots of questions.

And then we see if that changes that, you know, what else could you say to yourself and how do you feel when you say that? If you say it wasn't my fault or I did the best I could or I didn't see it coming and I froze. and that's okay it wasn't me it was the event there's no way I could have saved that person how does that feel so yeah we do we do talk about

especially we talk about how does it feel in your body when they're having trouble identifying emotions how does fear feel different than anger how does sadness feel different than those other two when you're feeling shame how do you feel You know, so, yeah, sometimes we focus on that more when they have trouble identifying emotions. Some people are, you know, like, specialize in anger or some people feel nothing but shame and guilt. Yeah, what would you say, how might you help a patient who has a hard time experiencing anger at all?

Maybe because developmentally anger was not a helpful emotion to experience in their family unit, you know, and now you're in the trauma. And it's like dissociations there a lot, but it's really hard to get to any anger. Well, I mean, you don't push the anger. You just say, you know, if you thought it was their fault instead of your fault, how would you feel? You know, like we reason to prove that it isn't their fault by asking lots of questions. It's like, what was your, what were you thinking was going to happen that day? What was your intent for that day to turn out? and so it turned out this way.

So who actually has the blame? So how do you feel that this person did this to you? I mean, they might feel sad. They might feel angry. We don't push anger. But if they feel it, say, yeah, that's righteous anger. That's okay to feel that. And then help them differentiate.

I mean, we have lots of people who have too much anger and they get aggressive. Our prisons are filled with people with PTSD. Yeah. Because they lash out in anger and they harm somebody, and then they're in the criminal justice system. Mm-hmm. And CPT is being used in prisons. It's being used across the correction system now.

That's cool. Yeah. So, okay, how do you teach practitioners to use Socratic questioning? Well, that comes through doing the workshop, and then comes through doing case consultation, because that, I think that's the only thing that's really difficult. Everything else is like do this session one, do this session two, make sure they're doing their practice assignments. Don't let them get away with not doing the practice

because their life is out there in the world. And they bring their worksheets in, and that's the meat of the session. That's what they're going to be working within the session. So if they're not doing that, that's a problem. But then the only other hard thing is like getting them to, helping them to to think about it differently

and learn the skill of thinking about it differently. And that you have to do with by asking questions, not trying to convince them. You can't say to somebody, this isn't your fault. They'll just go, yeah, you weren't there, you don't know. Because other people have said that to them. Okay. So we teach them these skills one by one.

How do I, what's the difference between an event and your thought? In other words, a fact and an opinion. And then when you say this to yourself and you feel this, you think this, how do you feel? And if you said something else to yourself, how would you feel? So we might use an everyday example to help them see that if they said something else to themselves, they'd feel differently. So we're doing all this stuff and teaching questions. So we show during the workshops, we show lots of videos, we have that role play. we have a new that you held up the treatment manual we have a new manual coming out in april and we've

gotten rid of the word challenge completely because we used to call it challenging questions and challenging beliefs worksheets and faulty thinking patterns i've taken all of that out of there because that's even though we're trying to think about them challenging their thinking that sounds aggressive that sounds um adversarial so we've just got rid of that. Now we say exploring questions and alternative thoughts worksheet and thinking patterns. And we just like totally wiped out the word challenge out of that whole manual because sometimes people make, therapists make this mistake by trying to be too convincing. But don't you think you could have done this or you couldn't have done that or, you know, like they, they're so eager to get

them better that they get pushy. And that's, that's one of the main mistakes that people do instead of being quietly Socratic and gently asking questions, because the answer is inside that person, and they're going to have to convince themselves. The therapists can't convince them. Okay. So how do you

what are some other issues that you see that are common mistakes when people are trying to learn this approach? Well, I mean, one of the main ones is not sticking to the protocol, you know, having poor fidelity. They just, they'll say, oh, I think I'll add this in the middle of the therapy. And, you know, the therapy has been tested with many, many randomized controlled trials.

We have, you know, we have changed it over time, but we've changed it and tested it over time. And so if somebody just, like, goes off on a tangent and starts adding other things, they're not doing CPT anymore. And so that could be a mistake, is not having good fidelity to the manual. they're jumping over things and not doing it in the sequence it was intended because we're systematically trying to teach them how to think in a more balanced, more factual way, and that'll change their thinking. And then the PTSD symptoms go away. I mean, even their arousal and startle responses go away if they're successful at doing CPT. It really does change not just their thinking and their emotions, but even their physiological reactions.

Okay, yeah, what are some other common stuck points that we haven't discussed? Because I feel like that's like so essential in this approach is to find those stuck points, those erroneous beliefs that date back to the time of the trauma. Well, I mean, it depends on, it depends on, I mean, I mentioned that just world. That's the go-to is I must have made a mistake or I must have done something wrong or I'm being punished. but people often try to go back and kind of like try to undo the event in some way. If only I had done this or if only I had done that, I could have saved them or I could have prevented it or I should have known.

We call it hindsight when somebody says I should have known, maybe I really did know. You know, I shouldn't have been there. I should have known that it was a dangerous place to be. So they're trying to undo the event after the fact, which you can't do. so it's it's not just that they're feeling shame and guilt about what happened to them but they also try to like undo it by by the statements they make themselves if only i had done this or that that kind of thing or even real simple just outcome based reasoning something bad happened to me therefore it must be my fault and it depends on how they were raised but if they were raised in an emotionally abusive home they probably were taught that everything was their fault. That's their, that's going to be their go-to. Okay.

So something, it seems like once those beliefs are there, it's like that trauma is not resolving until you, you know, put those beliefs, let's see, adjust those beliefs, put them on trial. I like to say put them on trial, but maybe that's too. You could say that. But also putting, getting them to put it back on the context of what actually happened, as opposed to the way they think about the trauma. So they leave out the important facts,

like how big they were. How big they were? Yeah, well, you know, like if you're abused by somebody who's much bigger than you, I've seen people who left out the fact that there was three people holding them down or the gun at their head. You know, I should have fought harder.

Well, tell me how you could have fought harder. I should have punched him. Where were your arms? I was being held down. Well, how could you punch them if your arms were being held down? So, you know, like just helping them think through what actually happened and that they can't make those assumptions given what actually happened. And now this, as you can hear, theocratic questioning is not getting into the blood and the guts and the gore and the terror.

It's talking about the facts of the event. So you're right. In a sense, you're helping them put it on trial. But by putting in all the stuff they've left out, all the stuff that made it happen the way it happened. and what their intent was and what the other people's intent was. Or maybe there's no intent if it's an accident, but they didn't have the intent for the trauma. Right.

Okay. So one thing that you talk about is that as providers, we need to not be afraid of asking really maybe taboo questions. So specifically around sexual abuse or rape, what are some of the taboo questions that you have found helpful? Well, taboo, yeah, I think if you ask in a gentle way and you're asking Socratic questions, you can ask anything. So in terms of sexual abuse, especially with boys,

they almost always have had arousal as part of the abuse. And so they think they're a pervert because they felt arousal. I've seen rapists who intentionally caused arousal with the victim. and so then they feel like they can't be a rape because they were aroused during the event and having them understand the difference between pleasure and arousal that's two different things entirely you can torture people with arousal oh i think i think that's so helpful so there's it's like you can feel disgust while you're aroused you can feel something is very unwanted while you're aroused exactly so you're saying was that pleasurable

No, okay. So that person made you feel aroused, but that wasn't pleasurable and you didn't choose it. So that's very different than lovemaking, isn't it? So we're helping them kind of see the difference between. But if you don't ask those questions, you can't even talk about that. So it's fine to, you know, if they're feeling guilt or if they're stuck, I mean, sometimes people are afraid to bring that up, but sometimes they will bring it up.

But like with a boy who's been sexually abused now as a grown-up, it almost ought to be a standard question. Were you sexually aroused during the event? Did they do this to you? Because their conclusion is going to be, I was a participant. Therefore, that makes me a pervert. Right. or a monster or whatever it happens to be. Now, that isn't always the case with women who were abused as children,

but sometimes with, you know, like with child sexual abuse, there's a grooming process. There's a good, yeah, yeah. And they're giving them pleasure and hugging them. Attention. And giving them attention and being very loving. And then they just kind of slowly go along. And then she thinks she's a participant.

Sometimes the most traumatic event for them is when they finally say no, and it happens anyway. Oh. That may be their index event. Oh. So, yeah, the grooming aspect seems very, I don't know, it's just disturbing for me. Like, read recently about this kind of religious figure that groomed this young 14-year-old girl. And just reading the full account of it just left me with this, like, bad taste in my mouth.

and just awful. Yeah. And that's why as a therapist, you can't shy away from that stuff, but we may need to talk to somebody else about it when we're hearing it because we're hearing it secondhand. But we have a reaction too. So I think that's why sometimes getting consultation can be helpful if you haven't been working with trauma victims before and you're hearing these stories.

Sometimes therapists, I think that's a therapist mistake, is to stay away from the trauma. And there's an awful lot of people that say, what would you like to talk about today and they're afraid to go there or they think we've got to spend a long time getting ready for therapy that's talking about stage-based therapy we got to get them ready I think that's the therapist getting themselves ready oh um wow you know they're procrastinating yeah yeah I was I was talking to a new client I'm going to change some variables but they basically said you know it's interesting like you're asking me questions about the actual trauma where I've been in therapy for years and no one is asking me actually what happened.

Yeah. And I was like struck by like, what? Like how does that? But I think you're right. Like we have, it's like, yeah, especially if you're traumatized by hearing someone's trauma story. It's like, I don't know if I want to go back into someone's trauma. That was an awful experience.

But I think that's where you're supervision. That's where the training and the supervision and case consultation come in. It's so important. And if you can't handle that stuff, you shouldn't be doing this kind of therapy, which is fine. Go work in another area of psychopathology. Don't work with trauma victims. There's nothing wrong with not doing trauma work. But you've got to be able to do it.

Okay, so I've heard from other new providers like, oh, I don't think I could do this work. You know, like, I don't think I could ever be trained because I'm a sensitive person. what might you say to that person to maybe give them some confidence that yeah i i tend to remind them that it isn't their trauma and you're feeling feelings for them isn't and putting yourself in their shoes is not going to help them they've got to feel their own feelings that's their event you've got your own events in life that you need to deal with they've got their events in life you can't feel their feelings for them so if they're reading an account if they're doing the version with the account. They're sitting there listening in the account. I'll actually give them advice on what

to think about. Instead of putting themselves in their shoes and feeling their feelings, you said you felt sick to your stomach. But if you were listening to somebody's account directly, I'd be saying to you, okay, what are their stuck points? What are the parts that they've left out before when they wrote their impact statement? Where are you going to start your Socratic questioning? Okay. So it's like sometimes grounding yourself in a model, in a way of asking things can be soothing to your own internal distress. It's like, okay, it's like the same thing if I was in a code. Okay, what's their blood pressure? What's their heart rate? What's their, you know, it's like I may ground myself in some of the basics to kind of like

move through that. Yes. Life and death situation. Yeah, exactly. So, yeah, I would help, you know, obviously that's where the supervision comes in. Like, what am I supposed to? be doing. And the best cure for feeling horrible is to see it through the outcome and see them get better. I mean, PTSD is treatable. It's very treatable, and we don't see relapse. We've tracked people for five to ten years later and don't see relapse. That's thrilling as a therapist. Yep. So even though you're hearing a horrible story, you do accommodate to those horrible stories after you've heard of you, but getting your mind focused on what are you going to do to help them get past that and fill out the story and be thinking about like, okay, so they're

blaming themselves, but why are they blaming themselves? Like what happened here that would be their fault? What was their intent? Did they have any options? What options did they have? and that's where you want to have you you want to be actively thinking while they're giving you their story and that active thinking activates your your frontal lobe right because you're planning and so it keeps you from dissociating and keeping the emotions in check now that doesn't mean you shouldn't go talk to somebody else it's like a game of telephone if you go talk to a therapist you know like a colleague or something and tell them that story it's not going to affect them as much as it affected you hearing it which isn't as the person who experienced it.

Exactly. You know, I find having good friends who are therapists and colleagues that I discuss things with. I tell my residents I teach at psychotherapy, I say, if there's ever a story that you're up in the middle of night thinking about, that's the one to bring to supervision. Yeah, good suggestion. Yeah. Okay, any like, as we kind of wrap up our time, any final things that we didn't hit that you definitely wanted to mention and then and then maybe we'll mention like next steps for people who are thinking about learning more.

Okay. No, I think we've kind of talked about the kind of the overview. I mean, the therapy, as I said, is very systematic. If you've been trained in cognitive behavioral therapy, I think, and especially if you've been training cognitive therapy, it's pretty easy to pick up the manual and do it, but I do strongly recommend if you want to get on the provider roster so that you get referrals, go through the two-day training and get the case consultation, make sure you're doing it with fidelity and with competence. And then we put you on the provider roster, not until you've completed

at least two cases. And, you know, this is being done all over the world. So this isn't just like an American therapy. It's been done in at least six low resource countries successfully. I mean, sometimes you have to, and Western countries like Germany and Australia and Canada, of course, it's easily translated, although in German, getting them big words onto that little worksheet is sometimes a little tough, or translating something like Stuck Point. But other than that, they've been able to stick to the protocol and do it very well. In some of the low resource countries, they've had to adapt because the clients or the patients were illiterate, and so they had to make it verbal or use pictures. pictures. And so they kept the bones of the therapy, but they've had to modify it to fit the culture that they're working in. The other thing we've done recently is that there is a huge shortage of qualified therapists in this country and everywhere else. So recently, this last

April almost a year ago, we published a self-help book. And we're getting good reviews on that. People are using it. And therapists are actually using it with their patients. You know, for a good handout, you know. This one? Getting unstuck, yeah. Getting unstuck from PTSD. But for somebody who doesn't have access to a therapist, can't afford a therapist. I mean, therapy's gotten easier to do with telehealth. It works just as well with telehealth as it does because we have we have an app where it has all the worksheets on it and so forth. Yep. And they can email, and they can email, you know, through a safe server, the worksheets ahead

of time or their PCL, the PTSD checklist to their therapist before the session starts. They've even done group therapy with telehealth, which means that the distance might not matter as long as they have access to a tablet and have Wi-Fi that's sufficient. But if you can't get a therapist at all, or if somebody's on a long waiting list, instead of putting them into some kind of holding group, I mean, we're starting to look at, there's some studies that are starting to look at, instead of getting them something else, have them do the self-help book first and start on the therapy. Yeah, or I would say, you know, get the self-help book, and then when you get to one of these stuck points in your memory, like bring that into your therapist. and say, hey, this is what I want to work on. I feel a lot of guilt about this specific thing. And you could be a proactive patient in that way.

And you could tell your therapist, like, hey, I want to talk. I think this is the seminal event, and I want to talk about it, and this is my stuck point. And can you help me? Yeah. I mean, ultimately, when I develop CPTN, I tell everybody that my goal is always to have them not need a therapist, you know, that they're they're going to learn enough skills. And that's why we don't see a lot of relapse, because once people have learned the skills of thinking more factually,

taking their thoughts to trial, as you would say, and checking them out. Once they learn how to do that, they manage, we've had people who go back to war and get deployed again. They said, I didn't get PTSD this time. You know,

they'll call their, email their therapist and said, you know, like it really worked. I had another trauma and nothing. I dealt with it totally differently. So that's why we ended up. thinking like if our goal is to have them not need a therapist, why shouldn't we be able to

do a self-help book and get them to the point where they don't need a therapist anyway? Now, some people definitely need a therapist. I mean, when I look at the reviews on Amazon, somebody said, this really was good, but I do it with therapist or do it with someone. I don't think anything's going to replace a therapist, because if there's something about the human-to-human connection, that is so powerful. Well, and I think also the avoidance is one of the big problems with PTSD. I'll be interested to see how well the book the book works without a therapist. And there's some studies that are starting to look at that because the avoidance is the

biggest end of mean. If you just stick it on the shelf and don't do the practice assignments, it's not going to work. And that's where the therapist who's checking on, did you do your practice assignments, did you do enough worksheets this week? Let's go through those worksheets. So moving it along can be very helpful. What do you think? So there was this book called The Great Psychotherapy Debate,

and it was talking about the kind of like therapist effect, right? That there's these common factors, these factors that are not necessarily modality that make the biggest difference. And it seems like in some of the studies that you've done where you're comparing, you know, different types of therapy, they're all, there seems, they seem to be pretty similar, right? And so recently I came upon this study that looked at therapist effect, and it looked at specifically reflective function, which is measured by the adult attachment interview.

And it found that this had 70.5% to do with what made the best therapist. Okay. So, you know, reflective function. So people, the therapists, you know, had a bunch of patients. they measured the OQ-45, and they looked at some therapists had better, faster outcomes on their group of patients than other ones. And they took every therapist and they had them do the adult attachment interview. And then based off of the transcript of the therapists, adult attachment interview, they did a measure called the reflective function, which is like, I don't know if you're

familiar with this, but I wasn't a couple weeks ago either, so it's okay. It's, it's, it's basically like how well they were able to reflect upon their own internal state and their parents' internal state in the adult attachment interview. And it scored from like negative one to nine. And if you were below average, none of your patients got better. If you were average to a little bit below seven, then your patients got better at kind of an average rate. But if you were a seven, eight, or a nine, which are the three highest scores, your patients got better quite a bit faster

on the OQ45. So I'm curious if you have any reflections over the years on this idea of therapist effects. And specifically, like, as I'm reading your manual and I'm with this understanding of therapist effect, I mean, some of what the therapists are naturally doing with your approach is actually very high, it's a higher reflective function ability

to be able to look at some. someone's experience and do the Socratic questioning. Anyways, I'm curious. I'll let you share what you thoughts are. I can see that because there's some people who, you can tell immediately they're going to do CPT really well. And they gravitate to it. It makes perfect sense to them.

And they love doing the Socratic resting with the clients. And there's other therapists who really struggle with it. I mean, you know, when we do training, it's not that everybody finishes the training. Some people just don't do it. So I can see that there'd be differences in therapists. And it'd be interesting using that to test people when they come into graduate school or residency or whatever, just to see if they've got what it takes, especially with trauma.

Yeah, absolutely. I think without knowing about it, when we would interview people, if they had lower ability to talk about their life, lower ability, like to reflect upon, you know, as they, if their answers seemed very rehearsed in the interview, we rated them lower. But if they had a higher ability to talk and conversate and introspect, but also like read the interviewer, right, that's part of reflective function, then we were more interested in getting them into our program. So I think it's probably taking place to some degree. Like one study was that prisoners had a three on the reflective function,

which is pretty low. Whereas inpatient, psychiatric patients had an average of like four. So anyway, anyways, okay, so you had some thoughts there. Okay, to wrap this up, any final thoughts before we wrap it up? Where people could go?

That's interesting. Hopefully when we do training, we're teaching some, I don't know if that's a factor that can be modified in therapists. But hopefully when we're teaching CPT, we would be teaching some of those things. I think that it can

And I think this is where Like there are studies where people Like borderline precise order They go through transference focus therapy And through that they go from a three to a four Through therapy So I think that there is this idea Of doing your own work in psychotherapy

Like for example I imagine if you had Someone who goes through your program And they're like I have a lot of traumas I haven't worked through Maybe I should work through those because they're getting triggered by this patient's traumas. Like, you'd probably say, yeah, you should probably do some of your own work. Yeah, before you start doing it with somebody else, yeah. Yeah, so I imagine.

But also just teaching them when you're teaching somebody to do Socratic questioning, you're really teaching them to tune in to somebody else and how they think and stop thinking about yourself. Right. The neighbors who get into trouble or you're sitting there thinking, what am I going to ask next and they're not listening to the answer, that they just asked, as opposed to if you're really listening to the patient, they would be telling you the next question to ask by what they just said.

So you're really learning, you're having to learn how to tune in and really listen to what they're saying and get outside yourself. Yeah, absolutely. And I think any good supervision that has longevity will increase that ability, you know, over time. Yeah, so great. Well, wonderful to have you on. Thank you. I want to just plug your, so how would, if someone wanted to take one of your trainings, where would they go? We have a website that's called CPT for PTSD. That's all like one word, small letters.com.

Okay. In there, we have information about, you know, purchasing the books. We've got a discount there. There's a, if somebody's looking for a therapist, you can look under the provider. roster and you can go by country, state, city, zip code. If you're looking for a therapist, who knows how to do CPT and it's gone through the training. They don't get on the roster until I've completed the training. And then there's also a place where people can look for trainings. Or they can, if they want to set up a group training, like for a whole program, they could contact through the website. Great. Okay. Well, I'm excited to see how people are going to

going to sort of dig into this. And I imagine, I mean, some of the, many of the things you said were just so helpful. And I think it's going to be an amazing podcast to put out there. So thank you so much for your time. Thank you.