Program Profile: Cognitive-Processing Therapy for Female Victims of Sexual Assault

This is a cognitive therapeutic program that is intended to assist female victims of sexual assault with posttraumatic stress disorder (PTSD). The overall goal is to restructure unbalanced thoughts directly related to the trauma. The program is rated Effective. Women in the treatment group demonstrated reduced symptoms of both PTSD and depression, compared with women in the control group. These differences were statistically significant.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Cognitive-Processing Therapy (CPT) was designed to treat posttraumatic stress disorder (PTSD) in victims of sexual assault. The overall goal of CPT is to restructure unbalanced thoughts directly related to the trauma. The therapy sessions focus on distorted beliefs (such as denial and self-blame), as well as over-generalized beliefs about oneself and the world. Clients are also exposed to their traumatic experience through writing detailed accounts of the incident, which they read aloud to their therapists. Therapists encourage clients to experience emotions while writing and reading the account in an effort to better determine areas of conflicting beliefs, logic, or assumptions that the client has in relation to the trauma.

Program Components

The therapeutic technique is a manualized, 12-session therapy developed by Resick and Schnicke (1993), which includes cognitive therapy and a writing/reading exercise to recall the traumatic event. Session one begins with an overview of PTSD and cognitive therapy. Clients are also assigned to write a statement about the impact the trauma had on their lives. During session two, the client and therapist discuss the meaning of trauma, and clients are taught how events, thoughts, and emotions are intertwined.

Following session three, clients are again asked to write about their trauma, but this time instructed to write a detailed account of the event, including emotions and thoughts. Clients are asked to experience their emotions when writing their statement, as well as read it back to themselves. This statement is read aloud to the therapist during session four, where the therapist begins incorporating cognitive therapy, through Socratic questioning, to challenge the client’s self-blame and distortions surrounding the event. In session five, clients write another account of their traumatic event and read it aloud to their therapist.

Beginning with session six and continuing for the remainder of the therapy, the therapist focuses on teaching clients to challenge and change their beliefs about the meaning of the event, as well as the impact of the trauma on their lives. Clients are first taught to challenge a single thought by asking themselves a series of questions. Clients then learn to identify problematic patterns of thinking that have come to represent their style of responding.

During sessions 7–12, clients use worksheets that incorporate their earlier responses and are asked to develop more balanced self-statements. Clients are asked to focus on a theme each week (e.g., safety, trust, esteem) and correct any over-generalized beliefs related to the themes for that week. To wrap up the therapy, during session eleven, clients are asked to rewrite their impact statements using their new beliefs. These new statements are then evaluated during session 12 to determine progress made during treatment, as well as areas where the clients should continue working. 

Program Theory

CPT is based on a social cognitive theory and information processing theory of PTSD. The social cognitive theory focuses on how the traumatic event is constructed and handled by a person who is trying to regain a sense of mastery and control in their life (Resick, Monson, and Chard 2006). This theory centers on the content of cognitions and the impact that distorted cognitions have on emotional responses and behavior.

Alternatively, the information processing theory indicates that PTSD emerges as a result of the development of a fear network in memory that provokes avoidance behavior (Resick, Monson, and Chard 2006). It is believed that repetitive exposure to the traumatic memory in a safe environment can result in subsequent change in the fear structure.

Using these two theories as its framework, CPT aims to understand how the traumatic event has affected the individual, and to challenge distorted beliefs that develop as a result.

Study

Resick and colleagues (2002) evaluated a cohort of women who had experienced a rape incident and were at least 3 months posttrauma. Participants were excluded if they had a current psychosis, developmental disability, suicidal intent, current parasuicidal behavior, current dependence on drugs or alcohol, or were illiterate. Participants were also excluded if they were in an abusive relationship or were being stalked. Women who had a history of incest were also excluded unless there was another separate incidence of rape. Finally, women who had experienced marital rape were eligible as long as they had been out of the relationship for at least 6 months.

A total of 171 women were randomized to Cognitive-Processing Therapy (CPT; treatment group), Prolonged Exposure (PE; comparison group), or minimal attention condition (MA; waitlist control). Of the 171 participants, 13 women never returned after the first session, and 37 dropped out during the treatment, leaving a total of 121 women who completed the entire treatment and posttreatment assessments. The CPT group included 41 women, the PE group included 40 women, and the MA group included 40 women.

Participants in the CPT group received therapy twice a week for a total of 13 hours. CPT typically consists of 12 hours of therapy; however, for the purposes of this analysis, 1 hour was added to ensure the therapy aligned with PE. PE, which is another form of cognitive–behavioral treatment used to reduce the symptoms of posttraumatic stress disorder (PTSD), was used as another comparison group in this analysis. Similar to CPT, participants in the PE group received therapy twice a week for a total of 13 hours. PE includes four components in the following order: education-rationale, breathing retrainings, behavioral exposures, and imaginal exposures. PE involves more time-intensive homework assignments than CPT. There is an average of approximately 22.6 hours of homework in CPT, while PE averages about 44.8 hours of homework. Finally, the MA women served as the waitlist control group. The CrimeSolutions review of this study focused on the differences between the CPT treatment group participants and the MA waitlist control group participants.

There were no statistically significant differences in demographic characteristics among the three groups (CPT, PE, and MA). Additionally, there were no significant differences between women who dropped out of the therapy versus those who completed it. Women were assessed using both interviews and self-report scales. Interviews included the Clinician-Administered PTSD Scale (CAPS), the Structured Interview for DSM-IV-Patient Version (SCID), and the standardized trauma interview. The primary outcomes of interest were PTSD, measured through the self-report PTSD Symptom Scale (PSS), and depression, measured by the Beck Depression Inventory (BDI). A simple repeated measures multivariate analysis of variance was conducted for each group to determine the impact of CPT on PTSD and depression symptoms. The authors conducted additional analyses to examine the differences in outcomes between the CPT and the PE treatment groups.

Comparative Research

Resick and colleagues (2002) conducted additional analyses to examine the difference between participants in the Cognitive-Processing Therapy (CPT) treatment group and the prolonged exposure (PE) treatment group. They found no statistically significant differences between the two treatment groups in posttraumatic stress disorder (PTSD) symptoms or in major depressive symptoms at the posttreatment follow-up.

Resick and colleagues (2008) conducted a dismantling study, comparing Cognitive-Processing Therapy (CPT) with its components: cognitive therapy only (CPT-C) and written accounts (WA).

The CPT-C protocol is very similar to the CPT protocol, except for the exclusion of the WA component. In CPT-C, participants are assigned to complete event–thought–emotion worksheets in session 3 for homework, rather than the writing assignment that is assigned in CPT. Following this assignment, therapists begin to challenge the participants’ beliefs about the meaning of the event. In WA, the written component of CPT, participants spend almost all of the last five therapy sessions writing about their worst traumatic experience.

The results showed that both components of CPT (CPT-C and WA) and the full protocol (CPT) were successful in treating PTSD and depression. There were no significant differences between participants in the CPT and CPT-C groups on measures of PTSD or depression as a result of either treatment. However, measures of PTSD were significantly lower for the CPT-C group compared with the WC group. This suggests that CPT-C was more effective at reducing measures of PTSD than repeatedly writing and reading accounts of traumatic experiences.

The authors suggests these findings support the idea that altering the meaning of a traumatic event may be an active mechanism of change for clients, but that systematic and extensive exposure to the trauma (as the WA component requires) may not be a

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Following are CrimeSolutions-rated programs that are related to this practice:

Psychotherapies for Victims of Sexual Assault

This practice examines interventions for adult sexual assault victims that reduce psychological distress, symptoms of post-traumatic stress disorder (PTSD), and rape trauma through counseling, structured or unstructured interaction, training programs, or predetermined treatment plans. The practice is rated Effective in reducing symptoms of trauma and PTSD in victims of sexual assault and rape.

Evidence Ratings for Outcomes

Mental Health & Behavioral Health - Trauma/PTSD

Psychotherapy with Adults Sexually Abused in Childhood

This practice comprises therapeutic approaches for adults who were sexually abused in childhood, and is designed to improve psychological distress, reduce maladaptive behavior, or enhance adaptive behavior through counseling, structured or unstructured interaction, or a predetermined treatment plan. The practice is rated Promising for decreasing posttraumatic stress disorder, trauma, and internalizing and externalizing symptoms.

Evidence Ratings for Outcomes

	Mental Health & Behavioral Health - Trauma/PTSD
	Mental Health & Behavioral Health - Internalizing behavior
	Mental Health & Behavioral Health - Externalizing behavior

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?