Discerning Trauma

Today, many are enduring the constraints and hardship of trauma. The U.S. Department of Veteran Affairs (2019) state that about 8 million people in the United States have Posttraumatic stress disorder (PTSD) any given year and claim this is a small section of the overall number affected by trauma. Additionally, they state women have been found to be more vulnerable to developing PTSD than men. However, there is hope in a treatment that can help process traumatic events and return to a more balanced life. Cognitive Processing Therapy (CPT) is an evidence-based treatment that has been shown in numerous studies to help reduce PTSD symptoms (Resick et al., 2017). Christian counselors can adopt CPT into faith-based Christian counseling due to its technique’s compatibility with a Christian worldview. CPT can be adapted for use in diverse populations, making it a safe and effective treatment for many (Resick et al., 2017). Drawing heavily on the CPT comprehensive manual by its developer, Patricia Resick, I will explain the basic tenets of CPT so therapists considering adopting its use have a short overview. For further information, I recommend reading Cognitive Processing Therapy for PTSD: A Comprehensive Manual  by Resick, Monson, and Chard (2017). 

Central Constructs

CPT is highly dependent upon Cognitive theory. Cognitive theory states that people’s interpretations of events cause their reactions to events. These interpretations, especially of erroneous thoughts, can cause intense emotional reactions. CPT’s emphasis on identifying erroneous thoughts, using Socratic questions and worksheets demonstrates its emphasis on cognitive therapy (Galovski et al., 2020). A major difference is that CPT has as its primary focus cognitions specific to a past trauma.

In CPT, the therapist emphasizes discovering the thought that is driving the distress in the client. However, there is still a strong emotional component as the client has a chance to tell their story and engage in a real conversation in which they can feel their feelings and lay down the burden of the trauma they experienced as they realize some of the things they thought and considered absolute truth are re-evaluated and “he/she realizes she is not at fault for the worse thing that ever happened, starts living again, is able to cry, and then to stop crying” (Galovski et al., 2020, p. 32). 

Causes of Dysfunction

Cognitive theory states that reactions to events are caused by the way an event is interpreted (Galovski et al., 2020). Those erroneous, or unhelpful thoughts can lead to impairment in everyday life. In the case of PTSD, according to cognitive theory, the interpretation of a traumatic event can cause a lack of a natural recovery. More specifically, it is believed that those who develop PTSD get “stuck” believing erroneous thoughts. These stuck points are a key understanding for the proper dissemination of CPT.

In CPT, there is an important distinction between assimilated and over accommodated stuck points. Assimilated stuck points involve thoughts that reveal the client has altered the information related to the trauma in order to match the information to an already existing belief system. Discovering these stuck points requires discussion about the trauma during which the client overcomes avoidance and is allowed and encouraged to explore feelings. 

Over accommodated stuck points occur when the client has instead changed an entire belief system in order to integrate the information from the trauma. Galovski et al. (2020) state that assimilated stuck points are at the heart of PTSD and must be found and tackled first. They also state that addressing these stuck points will reveal any over accommodated stuck points the client may have. This is evidenced in the structure of CPT, which emphasizes assimilation before accommodation, since the assimilated stuck points have been found to be used by clients to support their over accommodated stuck points (Resick et al., 2017).

Identifying Stuck Points

Resick et al. (2017) explain that stuck points are not statements of feelings, behaviors, or events. Rather, they are concise statements that reflect thoughts. For example, “I am nervous when I go on a date” is not a stuck point, however, there may be an underlying stuck point of, “If I go on a date, I may get hurt” (Resick et al., 2017). Stuck points are often but not always phrased in an “if, then” format.

Another example of a possible stuck point regarding the statement ”I am nervous when I go on a date” may be “people always take advantage of me”. When the stuck point is not stated, Socratic dialogue can be used to identify the stuck point (Resick et al., 2017). For example, the client can be asked what they are telling themselves about the date. Notice the term “Socratic dialogue” rather than Socratic questioning is used to emphasize a collaborative relationship between the therapist and client (Resick et al., 2017). 

Good Stuck Point Structure

Resick et al. (2017) state the following regarding best structure for stuck points:

• If a client states multiple stuck points together, they need to be broken down into individual stuck points.

• An “if/then” format can be useful in properly identifying the underlying stuck point.

• Stuck points tend to be very black and white statements with extreme language.

• When the stuck point is specific it facilitates challenging it.

• A stuck point can be made more specific by asking what is meant by words that can have multiple interpretations. 

Stuck Point Examples

(Resick et al., 2017)

The Nature of Therapy

CPT is highly structured with the therapist functioning as a collaborator and educator (Resick et al., 2017). Clients are allowed and provided time for processing thoughts and emotions but discouraged from going on any kind of tangent that can possibly represent avoidance (Resick et al., 2017). Avoidance is highly discouraged so that goals related to each session and overall treatment can be properly achieved. This therefore makes CPT a very focused treatment with a specific order for interventions and assessments (Resick et al., 2017).

Understanding PTSD and CPT

In the very first session of CPT, therapists thoroughly explain the nature of PTSD and the process of CPT (Resick et al., 2017). 

PTSD education involves understanding the difference between recovery versus nonrecovery of PTSD symptoms following trauma (Resick et al., 2017). One of the major roles a therapist has in this stage is helping clients understand the role of avoidance behaviors in maintaining PTSD symptoms. 

Just as important is understanding CPT and its underlying theory: Cognitive theory. The therapist discusses the role of thoughts in perpetuating the trauma, including a description of stuck points. The role of emotions are expanded upon in differentiating between natural emotions emanating directly from the trauma experience versus the manufactured emotions that fuel the fire of emotions resulting in PTSD (Resick et al., 2017).

Additionally, the client is encouraged to give a brief description of the index trauma. When multiple traumas are present, the one that causes the most dysfunction is selected as the index trauma (Resick et al., 2017). 

Lastly, clients are thoroughly briefed on the process and content of CPT before making the decision to proceed with therapy. It has been found that the first most determinant for beginning CPT is client readiness (Resick et al., 2017).

Finding Stuck Points

Next, therapy proceeds with an emphasis on finding stuck points. The client is asked to write an impact statement that delineates the feelings and thoughts that have resulted as a result of the trauma (Resick et al., 2017). 

Psychoeducation on stuck points is important in helping the client eventually become his/her own counselor in the future. The client needs to come to an understanding that a stuck point is a thought that keeps them stuck from recovering rather than behaviors, feelings, facts, questions, or moral statements (Resick et al., 2017). 

The ABC worksheet helps clients understand the differences between an event, a thought, and the resulting feeling (Resick et al., 2017). A stands for Activating event, B stands for a Belief or a stuck point, and C stands for the consequence (a feeling). This is the first worksheet the client is taught for the purposes of identifying thoughts (Resick et al., 2017).

It is here the therapist begins to challenge by the use of Socratic dialogue any assimilated stuck points the client has revealed. Care must be taken to ask questions rather than try to convince clients of inaccurate thoughts. Socratic dialogue allows the client to come to their own conclusion regarding the thought (Resick et al., 2017). 

Processing the Index Event 

As the client becomes more aware of the differences between actions, thoughts, and feelings, it is time for the therapist to begin processing stuck points related to the index trauma (Resick et al., 2017). 

The challenging questions worksheet asks the client to provide evidence for and against the stuck point as well as other questions that allow the client to go more in depth into the stuck point to reveal its inaccuracies (Resick et al., 2017). 

More psychoeducation is provided in the patterns of problematic thinking worksheet. It provides insight into what stuck points may fit these patterns. The seven patterns are jumping to conclusions, exaggerating or minimizing a situation, ignoring important parts of a situation, oversimplifying things, overgeneralizing, mind reading, and emotional reasoning (Resick et al., 2017). 

Learning to Self-Challenge

By the time the clients have reached this point in therapy, they are able to understand the way their thoughts influence their feelings. The challenging beliefs worksheet brings together all of the concepts learned so far (Resick et al., 2017). In addition to the ABC (situation, belief, and emotional consequence), it also incorporates the challenging questions and patterns of problematic thinking. Lastly, it considers an alternative thought and emotion. Ratings of how much the client believes the thought and feels the emotion before an after can produce an immediate sense of understanding how the worksheet helps develop healthier ways of thinking (Resick et al., 2017). This is the worksheet that in an ideal situation the client can turn to rather than to old patterns. 

The five themes are introduced briefly at this point in therapy to give an overview of the rest of the sessions and set the stage for discovering over accommodated stuck points.

Trauma Themes

The trauma themes of Safety, Trust, Power/Control, Esteem, and Intimacy are all explored to identify stuck points related to the trauma in the context of self and others (Resick et al., 2017).

Preparing for Termination

Discussing therapy termination should begin several sessions before the termination. Clients may have strong feelings or concerns regarding therapy ending, therefore it is important for therapists to ask and challenge any stuck points that may arise (Resick et al., 2017). Additionally, clients can rest assured that should they need it, they are able to return for booster sessions.

Comparing a new impact statement with the first written at the beginning of therapy allows clients to realize the changes in their thought patterns since the beginning of therapy. Clients are asked to read out loud their new impact statements, followed by the therapist reading out loud the old impact statement (Resick et al., 2017).

Identifying goals for the future includes encouraging clients to begin rebuilding their lives and allowing themselves to grieve what they have lost (Resick et al., 2017). Ideally, clients are able to differentiate between natural and manufactured emotions, as well as challenge their stuck points.

Role of Assessment

The PTSD Checklist – 5, Patient Health Questionnaire – 9, and Impact Statement are all used as forms of assessment (Resick, Monson, & Chard, 2017). Assessment holds a constant role throughout treatment. Therapists are expected to assess every session for changes in PTSD symptoms using the PTSD Checklist – 5 (Resick et al., 2017). Additionally, the Patient Health Questionnaire – 9 can be used, if needed, to assess for depressive symptoms (Resick et al., 2017). The Impact Statement provides a qualitative assessment of the client’s thoughts and feelings regarding the trauma.

The role counselor is encouraging and collaborative, while keeping on task and resisting avoidance (Resick et al., 2017). Socratic dialogue is employed by the counselor for the purpose of guiding the client to reach their own conclusions (Resick et al., 2017). The client’s role is one of dedication to be willing to sit with their feelings and trust the process. Additionally, commitment to attending sessions and completing out-of-session assignments is paramount (Resick et al., 2017).

Goals of Therapy

Goals of CPT include improving PTSD and associated symptoms the client presents by identifying maladaptive thought patterns, feelings, and behaviors in order to improve everyday life (Resick et al., 2017).

Examples of Techniques Used

Socratic dialogue is a key technique used by CPT therapists (Resick et al., 2017). Therapists must learn to listen for stuck points and when therapeutically appropriate, begin to challenge them through Socratic dialogue. A therapist must always ask in the spirit of wanting to understand and be careful to avoid telling clients what they should see (Resick et al., 2017).

Psychoeducation is also a major component of CPT. From the first session (heavy in psychoeducation) though the last session, therapists are encouraging teachers, disseminators of information (Resick et al., 2017). Psychoeducation often is established with the use of worksheets which the client keeps together and ideally refers to often in between sessions (Resick et al., 2017).

Therapy Process

Therapy proceeds for an average of 12 sessions that progressively increase the ability of the client to eventually become his/her own counselor as they learn how to identify stuck points, psychoeducation on PTSD and Cognitive theory, challenging their own stuck points, and developing healthier thoughts and emotions within the context of the major themes of Safety, Trust, Power/Control, Esteem, and Intimacy (Resick et al., 2017).

CPT +A is available for those who want to write a trauma narrative and recommended for those with dissociative PTSD (Resick et al., 2017). Writing and reading the trauma narrative can help clients piece together the puzzle of the trauma and aid in the examination of the facts of the trauma that may have been forgotten (Resick et al., 2017).

Case Example

(About Face, 2020) Tyler chooses to enter into CPT treatment and writes his impact statement.

(About Face, 2020) Tyler writes his trauma narrative.

(About Face, 2020) Tyler started feeling some relief as his thoughts became more flexible.

(About Face, 2020) Tyler experiences the ability to lead a more balanced life.

Critique

Empirical support from 14 randomized controlled trials have demonstrated CPT to be highly efficient and effective in the treatment of PTSD (Galovski et al., 2020; Resick et al., 2017). Therefore it is considered an evidence-based treatment for PTSD (Resick et al., 2017). Additionally, it was determined that even with the presence of severe co-occurring depression, CPT was effective in reducing symptoms in 75% of participants (Resick et al., 2017). It has been found through nonrandomized studies that CPT is also effective for treating clients without PTSD and helps to reduce issues with broader life concerns (Galovski et al., 2020). Improvements were reported in general well-being, interpersonal relationships, dissociations, health and somatic complaints, sexual functioning, and suicidal ideation (Galovski et al., 2020).

Additionally, the APA (2017) strongly recommends CPT for the treatment of PTSD.

Emphasis for further research should be on engagement and retention during therapy due to high drop out rates (Resick et al., 2017).  

Variations of CPT accommodate for different situations. In addition to CPT +A, there exists protocols for Group CPT and CPT for sexual abuse (Resick et al., 2017). Modified and simplified worksheets are also available (Resick et al., 2017). Cultural considerations with regards to stuck points is important to keep in mind for clients of cultures different from the therapist (Resick et al., 2017). Multicultural considerations such as reading ability, beliefs within the culture, religion and morality should be considered but a therapist should not avoid discussing topics that they do not know about and need to instead employ Socratic dialogue to understand more (Resick et al., 2017).

Compatibility with Christian Worldview

Viewing PTSD as a normal reaction to an abnormal situation removes the shame and stigma associated to this diagnosis (Resick et al., 2017). In a fallen world filled with abnormal events, we are prone to experience hardship. Recent research points to PTSD having a strong biological component in its effect on the brain (Resick et al., 2017).

Romiyim (Romans) 12:2 states “And do not be conformed to this world, but be transformed by the renewing of your mind, so that you prove what is that good and well-pleasing and perfect desire of Elohim” (The Scriptures, 2018). This verse is relevant to those enduring with PTSD as they work towards transforming their minds through the process of CPT. CPT and Cognitive theory in general are highly compatible with a Scriptural worldview in the emphasis on thoughts. The challenging questions worksheet asks for evidence for and against a thought. This can be adapted to a Christian worldview by asking clients to imagine what evidence Yeshua would provide for and against each thought. Yeshua states, “Of Myself I am unable to do any matter. As I hear, I judge, and My judgment is righteous, because I do not seek My own desire, but the desire of the Father who sent Me” (Yohanan (John) 5:30, The Scriptures, 2018). Through the help of the Set-Apart Spirit and our righteous judge, Yeshua, clients can reach an understanding of truth regarding themselves and their thoughts.

Overcoming avoidance is a substantially important aspect of CPT. This concept is also compatible with a Christian worldview as we take a look at what the apostle Paul states in Eph’siyim (Ephesians 5:11-14): ” And have no fellowship with the fruitless works of darkness, but rather convict them.12 For it is a shame even to speak of what is done by them in secret.13 But all matters being convicted are manifested by the light, for whatever is manifested is light.14 That is why He says, “Wake up, you who sleep, and arise from the dead, and Messiah shall shine on you” (The Scriptures, 2018). We are to expose the works of darkness through the light of Messiah. Trauma is a direct effect of the works of darkness in this fallen world. Avoiding the processing of natural grief and emotions lead to manufactured emotions which cause greater dysfunction (Resick et al., 2017). Christian clients have the added benefit of exposing the works of darkness to Yeshua, the Righteous Judge, who is Truth and can bring wholeness (shalom) to a person. (Resick et al. (2017) explain that a “just-world” theory is at the heart of many client’s dysfunction. Clients who hold to this theory essentially believe that “good things happen to good people, and bad things happen to bad people” (p. 89). The authors claim that this belief is promulgated by religion, parents, schools, and those in authority. Even if this belief is not essential to a client in the face of trauma, clients may revert to it (Resick et al., 2017). I contend that from a Christian worldview, if any client holds this belief they are misinterpreting Scripture. In My Utmost for His Highest, Chambers (n.d.) explains this best:

In addressing faith, Resick et al. (2017) refer to the concept of free will as a helpful way to help clients get past stuck points related to a higher power. However, they also state “… it could also be the case that God does not intervene in day-to-day lives and that the concept of God should be used for comfort, community, and moral guidance” (p. 286). I believe Christian counselors must emphasize the love, care, and devotion that Yahweh God has for every single one of his children. Yahweh is not only a comforting God but also a just God, who will one day judge the living and the dead for their trespasses, and only those found in Messiah will inherit His righteousness (Kepha Aleph (1 Peter) 4:5, The Scriptures, 2018).

Regarding forgiveness, Resick et al. (2017) state that it would be problematic to force forgiveness upon the victim of a traumatic event. They explain that bringing peace of mind to the client is foremost and “not a requirement for recovery from PTSD” (p. 287). Although I agree that everyone has a choice on whether to forgive those who have harmed them, Scripture is clear on the role of forgiveness as evidenced by the following Scriptures (The Scriptures, 2018):  

“And be kind towards one another, tenderhearted, forgiving one another, as Elohim also forgave you in Messiah.”

Eph`siyim (Ephesians) 4:32

“For if you forgive men their trespasses, your heavenly Father shall also forgive you.”

Mattithyahu (Matthew) 6: 14

“Then Kĕpha came to Him and said, “Master, how often shall my brother sin against me, and I forgive him? Up to seven times?”22יהושע said to him, “I do not say to you, up to seven times, but up to seventy times seven.”

Mattithyahu (Matthew) 18: 21-22

“And whenever you stand praying, if you hold whatever against anyone, forgive, so that your Father in the heavens shall also forgive you your trespasses.”

Marqos (Mark) 11: 25

Therefore, CPT stands out as an effective treatment for those enduring through maladaptive cognitions related to having experienced trauma. Christian counselors can utilize this therapy from a Christian worldview which does not pathologize clients, but instead seeks to normalize natural emotions while submitting manufactured emotions to the judgement of Messiah.

Key Resources

Cognitive Processing Therapy for PTSD: A Comprehensive Manual  by Resick, Monson, and Chard. 

Flexible Applications of Cognitive Processing Therapy by Galovski, Nixon, and Kaysen. 

American Psychological Association: Cognitive Processing Therapy

References

About Face. (2020, January 21). PTSD Therapies. CPT Cognitive Processing Therapy. https://www.ptsd.va.gov/apps/aboutface/therapies/cpt.html

American Psychological Association. (2017, July 31). Cognitive processing therapy (CPT). Clinical practice guideline for the treatment of Posttraumatic Stress Disorder. https://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy

Chambers, O. (n.d.). God’s purpose or mine? My Utmost for His Highest. https://utmost.org/god’s-purpose-or-mine/

Galovski, T. E., Nixon, R. D. V., Kaysen, D. (2020). Flexible Applications of Cognitive Processing Therapy. Academic Press.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. The Guilford Press.

The Scriptures. (2018). Institute for Scripture Research.

U.S. Department of Veterans Affairs. (2019, October 17). How common is PTSD in adults? PTSD: National center for PTSD. https://www.ptsd.va.gov/understand/common/common_adults.asp