 Well, thank you again so much for coming, and I'm so excited to invite our BORAC speaker for today, Dr. Patricia Riesig. Dr. Patricia Riesig is a professor at Duke University. She is a professor of psychiatry and behavioral sciences. Prior to moving to Duke, she was the director of the Women's Health Sciences Division at the National Center for PTSD, just down the road in Boston VA. To say that Dr. Riesig has made a contribution to the field of psychology and mental health treatment and research as an understatement of the year, Dr. Riesig has been very, very involved in the treatment and understanding of post-traumatic stress disorder, or PTSD. And she has credited with developing, evaluating, and disseminating cognitive processing therapy, or CPT, which is one of the best treatments we have for treating post-traumatic stress disorder. It is used internationally, it has been translated to seven languages. To put it bluntly, it just works. But as good scientists, you should know that you shouldn't just take someone's word for it that it works, and that is why Dr. Riesig is here to share with us some of the evidence as to why CPT is such an effective treatment. So please bring your hands together to welcome Dr. Patricia Riesig. My block in your view, if I stand here, I hate standing behind podium, podium, whatever. Hi. I don't just want to show that CPT works, I want to show that, one of the things I want to show that things don't just come out in whole cloth and then they just stay static for years, which is why I called it the evolution. I'm not the only person who's been involved in the development of CPT. I started it, but it's come a long way, we've changed it over time, we've learned things about it, dropped things, added things, modified things, so I'm going to walk you through some of that, so that you kind of see that we have to go with the times and we have to go with the population that we're working with and so forth. I think there are chairs if you want to sit, there's some over there, no? Okay. All right, so I'm going to talk about early CPT and revisions that we made when we started to roll it out in the VA. I was actually in academia in a department of psychology, first in the University of South Dakota, and then I was for 23 years at the University of Missouri-St. Louis and that is where I actually developed CPT and then moved to the VA and someone else actually did the research to find out that it worked with veterans and then the VA decided to roll it out and it was the first of many rollouts, meaning dissemination projects and what we learned over that interim period between the time I developed it, researched it and we started to roll it out is if you build it, they don't necessarily come. You really, really have to get people to try to do something and try something new and take the time to learn it. We had a new manual that just came out in 2017 and we've made, again, more changes based on research, based on clinical findings because one of the things we had found is that when you start to apply something, you have to take what you learn from your clients and adapt your therapy and you take your research findings and adapt it to your clients. So it's changed back and forth and our therapists and all the trainers that we've had have given us lots of feedback. So what looks like that first month or second, you see the bones of CPT but you'll see it's changed over time and I'll show you some of the new and future research, the stuff that's not out yet. So in the beginning, PTSD was conceptualized as an anxiety disorder. If you're out in the hallway, there are seats over here, over here, PTSD was conceptualized as an anxiety disorder and that was in 1980. I started working in the field before that and we were just working on this nameless disorder. It was called rape trauma syndrome or battered women syndrome or child abuse syndrome or combat syndrome or whatever and then lo and behold, they figured out we were all talking about the same thing. And so in 1980, with a pretty strong push so that it wouldn't die again after the Vietnam War, as often these things do tend to get pushed to the back burner again, it got reified and then of course, once you've got something in the DSM, whether you like it or not, it's going to get studied and sometimes the impetus for studying something. So it was classified with the anxiety disorders until 2013. I never liked it in the anxiety disorders. I was on the DSM-4 committee and the DSM-5 committee and we tried to get it out of the anxiety disorders in DSM-4 because there was a lot of research that there's a lot of people who don't have fear and anxiety. They have sadness, anger, guilt, shame, all sorts of other emotions and it didn't always fit and I think calling it an anxiety disorder gave everybody tunnel vision. So we were pushing and our whole committee had voted to move it out of the anxiety disorders. They went to the anxiety disorders committee and they agreed with us and then it went to the big little APA, the psychiatry organization and they didn't know what to do with it so they left it where it was. So it took until 2013 to get it moved and then by then, of course, we had seen a lot more research. So we knew that people with PTSD had lots of other emotions other than just fear and anxiety. Shame, guilt, anger, sadness, you name it, they're going to have lots of different negative effects and in fact fear and anxiety was not a good predictor of who is going to get PTSD and not recover from their trauma. Guilt and anger were much better predictors following the trauma and we think of it as a failure to recover not that you develop PTSD. People don't get worse, they just don't get better. The worst time is the moment of the trauma and so some people will start having flashbacks, nightmares immediately and some recover, takes a few months, some don't recover and they stall out. Usually it's about, it looks like it's about a month and when the avoidance really kicks in. Cognitions have been shown to precede change in PTSD in both exposure therapy and cognitive treatments. So we started thinking about it maybe not so much as a bottom up, a habituation model but maybe a top down cognitive model or maybe it's both, it could be a combination of both, maybe there's more than one mechanism of change, what a shocking idea. So even when I was doing cognitive therapy, people kept saying that I must be doing habituation fear response and so I did a dismailing study just to see if that was the case. So I'll show that in a little while. So this is what DSM-5 now looks like and those bars there are the actual changes in it so it's no longer an anxiety disorder. There's a different chapter that has PTSD, it has acute stress disorder. They even changed the criteria for adjustment disorder to expand it out so if you're sub-threshold PTSD you can get a diagnosis of adjustment disorder and there isn't that short time on window that used to be. We tightened up what fit under criterion A so finding out you have a cancer diagnosis is not a criterion A stressor. People dying of natural causes doesn't cause PTSD, it causes lots of other things but nothing to say that people aren't going to have disorders but they're not going to get PTSD from it so we tightened it up that it had to be an actual or threatened death, serious injury or sexual violation to you or a loved one. The intrusions symptoms, what we did there was get rid of the thinking part of it. There were a lot of different measures of PTSD and some of them say I think about it and that's not what we were intending by intrusions. Intrusions are something that come at you when you're trying not to think about it. So if somebody came into treatment say oh I think about it all the time and somebody gave them yes on that they were giving them probably a faulty diagnosis. So we got the thinking part out because now that's in a different category. So what we had then was we had much more of the sensory intrusions that are kind of against your will. You're starting to fall asleep at night and all of a sudden you're remembering it again or you're not feeling well. We see people who retire and suddenly they have too much time on their hands. High functioning people with PTSD are the busiest people on earth. They'll have two jobs, they'll go back to school, they'll do all sorts of things. And then when they retire all of a sudden they've got this time and it's now back. It never went away. They just managed to avoid by busyness. And speaking of avoidance, we used to have seven items under avoidance. Now we have two, avoiding internally or avoiding externally. There's some chairs over there, folks. There's a couple down here in the front. That doesn't mean there are only two kinds of avoidance, internal or external. Internal would be avoiding your thoughts or pushing away and doing something to stop the intrusions. Or the strong emotions from happening. It might be drinking. It might be cutting. It might be doing all sorts of other behavioral things to stop and suppress. But the external avoidance would be avoiding anything that reminds you of the trauma. But there's 1,000 ways that people can avoid. Maybe 1,000, 1,000. There's probably as many ways as avoided as there are people. So one of the things therapists have to learn is like, how are you avoiding? Do you avoid? Because that's the absence of behavior. You're not doing something. It's sometimes harder to pick out. But if they're always coming in late for the session, or they don't do their practice assignments, or they miss sessions, they're avoiding. I've had people who tell jokes to get me off topic. That's avoiding. It's like, ooh, it got me again. So you have to kind of figure out in what ways they're avoiding. So telling me a joke is one way to get me to avoid and right along with them. And you don't want to collude with their avoidance because that's what actually keeps the PTSD going. I don't think of it as one of the primary symptoms. I think of it as a secondary bad coping. It works in the short run, but not in the long run. Sometimes being angry is a form of avoidance. And if you can get angry at the therapist and push them away, or get angry at other people and push them away, it's a form of avoidance. All right, so it says two, they have to do two, and you've got to figure out, are they avoiding in some way or another? So the question is, in what ways are you avoiding? What are the things you don't do now that you used to do? It's always a reasonable question to ask. The new category is negative alterations in cognition and mood, and that came from an abundance. By the way, everything had to have multiple studies if you were going to ask. Multiple studies, if you were going to add an item, we had to have multiple studies to support it. The default was to leave something in unless you had multiple studies to get rid of it. So there's a few things that we got rid of or changed the wording on. But mostly, I mean sleep is still in there, and I don't think of that as a PTSD symptom. But anyway, negative alterations in cognition and mood are things like blaming yourself for the trauma, erroneously, falsely blaming someone else instead of the actual perpetrator. It could be thinking that the world is a dangerous place now and now the probability of bad things happening to you has gone up because now it's happened to you. So we have all sorts of cognitions that we look at and we look at cognitions about self, cognitions about others, thoughts about the world. And then we have the full range of emotions that I've already mentioned, guilt, shame, sadness, and those kinds of things. And sometimes people will really avoid sadness. I think I'll talk about grief later. People would rather be angry at themselves than actually accept the fact that a friend or a loved one died, and so they'd rather blame themselves and be angry at themselves or feel guilty than actually accept it and feel grief. We see that a lot with soldiers who say, I'll forget them if I don't keep my PTSD flashbacks. And that becomes one of the things that we would work on. Marked alterations in arousal and reactivity is pretty much the same as it used to be startle response and hypervigilance, but we did add some reactivity, which is not anger as a mood but aggressive behavior. Our prisons are filled to the brim with people with PTSD. Some people, stone cold, don't care they killed, they don't have PTSD. But there's a lot of people who have killed or have acted out because they had PTSD and now they're in prison because they got aggressive with somebody and they assaulted someone or something like that. So actually the Federal Bureau of Prisons now requires the therapist to all learn CPT and they're using it in federal prisons. And then those are the criteria. Nothing changed. You have to have the symptoms in each of those categories for at least a month. It's got to be clinically distressing or what's the point. You wouldn't call it a disorder if it doesn't distress you or impair your functioning in some way. And it can't be attributed to something else like a traumatic brain injury or from a car accident or substance abuse or some other something like that. There is now also a subtype which I won't get into that has prominent dissociative aspects and we've seen that in both epidemiology research. They've seen it in treatment outcome research. We've seen it in some other kinds of studies that we've done. They've seen it in physiological and fMRI studies that there's this small group of people who are very dissociative and they seem to respond quite differently both biologically and even in terms of treatment. They're the one group that we do the accounts with because they have a fragmented memory and we need to put it back together. Okay, so cognitive processing therapy, CPT, the therapy I'm going to be talking about today is a short-term evidence-based treatment. It's a very specific protocol. It's going to, if it's done as a set 12 sessions, it'd be session one, do this, session two, do this, session three, do this, and so on. And people always say, isn't that a cognitive behavior therapy? Yeah, it is with the emphasis on the cognitive. So it may or may not include a written account and I'll talk about why it's mostly not these days. It's a treatment that can be conducted in groups or individually or in combination. In some of the residential programs in the VA and particularly they do it in a combination. So if they have a residential program for substance abuse, they might do individual and group sessions or they might do it if they have a PTSD-intensive outpatient program. They might do a combination of individual and group. So it's kind of the best of both worlds if you can do both of those. There's, of course, much more time consuming. So I developed CPT in 1988. That was not my first research. I had already done a treatment outcome study. I wasn't too happy with. And instead of, because I was hearing, I was working a lot with rape victims then. You can see from the title of the book, Cognitive Processing Therapy for Rape Victims. They were often telling me things like, no, I didn't think I was going to die. I was just so shamed and humiliated. So I never thought of it as an anxiety disorder. I wanted to get into arguments with people regularly over that. But so I didn't look at the exposure therapies. What I did was I looked over at the cognitive therapies and I had a choice of Beck or Albert Ellis at the time. And Albert Ellis had a really rough form of therapy. He was trying to convince people they were thinking wrong. They had thinking stinking and all that stuff. And I just didn't think that was going to play in St. Louis. So I went for the softer Becky inversion, where he does more Socratic questioning. I think Ellis's therapy softened up quite a bit. But what plays in New York may not play in the Midwest, as we might notice from time to time. So I did one open trial. I published it in 1992 and did the first manual while I was trying to get a grant funded from NIH, and it took me a while. So in the meantime, I got the manual published and kept collecting data. And it took me a while before I could actually get my first NIH grant funded to do the therapy. Here's what the therapy, the basic therapy look like. It still does for the most part. You start out with education. Here's why you have PTSD. You've been avoiding. There's something about your thoughts that we're going to have to examine and look at because you've been saying something that's gotten you stuck in your PTSD. Anybody here know what a record is? A couple of you? The older people in the room. So you have a thought that keeps coming back to you and you can't get off of it. You're stuck on that thought. So we talked to them about there's something about this trauma that you're stuck on. And we've got to figure out what that is so we can get you unstuck so you can get back to normal recovery. So the client's going to learn about the connections between events, thoughts and feelings. We use an ABC sheet for that. And actually we have to teach people the difference between a fact and a thought because they think their thoughts are facts. It's my fault. That's fact. No, that's your thought. The fact that you were assaulted is the fact. Now, your thought is it's all my fault. That starts to plant seeds already. Maybe there's another way to look at it. So we name the thoughts as we hear them. So sometimes we have to actually help them understand the difference between an event and a thought. And that's gotten very difficult in the last couple of years as you might have noticed. Because sometimes there's false facts being thrown out there and it's hard to tell what's a fact. So we talk about needing evidence for facts. And then there's thoughts and then there's feelings. And then we have, in the old version, we had them write a detailed account of the incident including sensory details, thoughts, feelings and so forth. I thought we needed at least an exposure piece in that regard. We only did it for two sessions. But we thought, you know, I was assuming we needed some kind of habituation and we needed to hear all those details. As it turns out I was wrong. But that sometimes happens. We did processing then. They would read us the account. We would do socratic questioning. We'd figure out what their worst stuck points were. And then we started to turn the therapy over to them. And one of the goals of CPT is for the client to become their own therapist. So we're trying to teach them, maybe you have to have balanced thinking 101 in school. Right. Nobody gets it. You didn't get it in elementary school. You didn't get it in college. And so we have to normalize it with them and say, nobody gets taught balanced thinking 101. So you learn to think the way your parents probably thought or the way people thought around you. Like if good things happen to good people and bad things happen to bad people, which everybody tends to believe when they're small because we don't tell children if you misbehaved or might or might not get caught and punished. So we tend to assume that if we behave, things are going to work out. And if we misbehave, things are going to be bad. Now, if something bad happens, we've got a problem here, don't we? Because it's now violated our just world. And so what we do is we have them stop and say, what have you been saying to yourself? Well, it must have been my fault. I must have done something wrong. And that's why I have... That's why this event happened. If it was wrong, then it won't happen again. They're trying to keep that sense of control, that sense of just world intact. And so we will challenge questions. There is a way that people also go overboard and they'll just say, I don't trust anybody anymore. In other words, instead of going into balance, they go straight from one extreme to another extreme. No one's to be trusted. I can't... I'm never safe. I have bad judgments, so I'll never make decisions again. They'll just have all sorts of things. I'm a worthless person. So there's all sorts of things that people will say to themselves that we went from one extreme to the other because of the trauma, as well as trying to distort it to get that just world back. So we have the learning about challenging questions for a single belief. We have them make up a stuck point log of all the thoughts they have. And they might say, that's not a stuck point. That's a fact. That thought is real. That's true. And I'll say, well, let's put it down there, humor me. And let's take a look at that. We will examine that. And if it's true, no problem. If it's not true, we'll find the evidence and figure out what else you can say instead. So they're going to start learning about halfway through the therapy to start doing this therapy for themselves. So they put one stuck point on a page and they ask themselves a series of questions about it. Then they start looking for patterns of problematic thinking, meaning, do you have a tendency to jump to conclusions? Do you have a tendency to mind read? An emotional reason or somebody says, I feel fear so I must be in danger. I better get out of here. Dodge that bullet. A bad thing was just about to happen and I stopped it. So they've got that tendency to jump from their emotions to as proof of their thought. So they're still convinced that they're in danger because they felt fear. I feel guilty so I must have done something wrong. Otherwise why would I feel guilty? So they're going backwards from how they feel as proof to how they think. So we teach them how to notice what their tendencies are, not just about the trauma but or traumas, which is most of our clients have multiple traumas, to actually thinking about is that a tendency I have in my general life too? Do I tend to mind read? Do I tend to jump to conclusions? Do I tend to have black and white thinking? There's only two buckets, trust or not trust, that kind of thing. And then we move them to the final worksheet which incorporates all the other worksheets and that is the challenging beliefs worksheet. And the challenging beliefs worksheet has all the other worksheets in it. It's got the ABC sheet in it. It's got the challenging questions. It's got the patterns of problematic thinking and then the only thing we add after that is what else could you say to yourself now that you've asked yourself all these questions and looked at your patterns? What's more balanced? What's more factual? And we'll have them look at the evidence against as the place to look for an alternative thought. And then they'll rate how much do you believe that? Now how much do you believe the old thought? Now what do you feel? It might be less of the first feeling or it might be actually an entirely different feeling. Before I was blaming myself now I'm blaming the rapist. Now I'm angry. I used to feel guilty. So it might be a completely different shift in emotion. And we differentiate with our clients the difference between a natural emotion which we're all hardwired for. If I got you up on the top of the building and pushed on your back I understand it's kind of rickety on some of these buildings up there. You wouldn't have to think, oh I should be scared now. You would automatically be scared. And if I jumped back and said, kidding, you'd turn around and what would you feel? Angry? Yeah. You don't have to think about that either. Why do you do that? But if you switched around and said I should have known not to go up on the roof of that Resick woman. She's got BDIs. Now I'm feeling guilty because I went up on the roof with that woman who wasn't to be trusted. That's a manufactured emotion. Alright? So we help differentiate the natural emotions we want them just to feel and the manufactured emotions are the ones we want to change by what they're saying to themselves by looking at the evidence. So that's where we focus a lot of the therapy on is their manufactured emotions. We don't work on their emotions. We work on their thoughts. And if they're in natural emotions as you all know from having had emotions. So over accommodation is that jumping to big conclusions that are way beyond real going from one extreme to the other and so we've got safety, trust, power and control, esteem and intimacy and we'll have a module on each one. I started doing that when I was doing group treatment but we found it quite helpful. They can be self-referent or other referent meaning I, self-safety I don't trust myself, other safety would be I don't trust, other people are dangerous or self-safety is I can't protect myself self-trust is, you know, I don't trust my judgment, other trust is people aren't to be trusted. Power and control, if I don't control everything bad things will happen to me or people are trying to control me. There's self-esteem, there's other esteem in other words the regard to which you hold other people and you can see how people get prejudices against entire groups of people who would remind them of somebody who assaulted them or remind them of the parent abused them or whoever and then intimacy is also self-animacy and that's beyond self- esteem, that is who am I your sense of self, your sense of worth and then what are my tastes, what are my values being alone without being lonely, being able to say I don't need everybody's approval, I mean Maslow would really like me and then other intimacy of course is the full range of other relationships and then we finalize it with having them write their impact statement again and then we compare the two from where they started therapy to where they ended therapy and usually it's wow, wow did I really think that? Which is always a fun session so after conducting 84 pilot cases my graduate student and I I finally after doing the first open trial and back in that day I was actually able to publish it in Journal of Consulting and Clinical Psychology which would never be published there today because it didn't have a randomized control group, it was just an open trial but I was finally awarded a grant in 1994 to compare cognitive processing therapy to prolonged exposure I had to change it over to being an individual therapy so I could compare it to prolonged exposure and that's an exposure therapy that includes going over and over again the account of what happened to them they do that verbally and then they do behavioral exposures out in the environment usually that's after again an education session and then usually some breathing just I think it's just to kill it sometimes so they don't get to the exposures until session three but anyway they had that in there and then I had a delayed treatment wait list and then they got either randomized to CPT or P.E. so this is how it looked we started out if you go down to who was randomized into the study it was 181 were randomized into the study 10 were terminated because they met the exclusion criteria at some point in the trial so we had 171 in our intent to treat for those of you who have not gotten intent to treat that means everybody re-randomized in we're going to do data analysis on whether you stayed in the study or not and back then we didn't have the fancy statistics that we have today so we used to have to take their pre-score and carry it all the way forward to post I had one woman had all 12 sessions and didn't come in for the post-treatment I knew she got better but I had to use her pre-treatment score as her post-treatment score we have much fancier statistics now that we can manage with missing data and looking at session data and all that kind of good stuff we had a number that never returned for the first session and that's common they say I want to be in your study and then they go ooh I'm feeling better I'm feeling worse I think I won't 86% of these people who are hypothetically rape victims had other traumas in addition to and that is typical so I kept saying can't I do a study with PTSD and they say no you're a rape researcher so my second study when I was trying to get it in there I finally got them to let me I did a battered women's study so then they let me do women but then they wouldn't let me do men because I hadn't done a study with men yet I was like can't we just study PTSD does it matter to NIH at the time it did anyway you can see 86% had other traumas 41% had child sexual abuse history and on average they had six other types of adult traumas happen to them not numbers but types of traumas happen to them so at least one other rape physical assaults I was surprised more than a quarter of them had homicide or alcohol vehicular death of a close friend or family member so I mean there was just a range of things and I was just looking at crimes I was not looking at accidents or natural disasters so I'm sure the rate was even higher this is the intent to treat SAML this is in everybody including all those people I carried over their pretreatment scores we had about a 26% dropout rate you can see my little thing up here this is the waiting list group the one that doesn't change here this is across the six weeks we are on all of my studies we always did a week for six weeks and because we didn't want to leave people on a waiting list too long so you see they don't change then they get randomized and you can see there is really not much difference between CPT and PE they both in the intent to treat SAML they both dropped about 50% in their scores and there was just a very small effect size difference between the two treatments on PTSD the picture is a little bit different not between PE and CPT but the picture is a little bit different when we look at the people who actually completed treatment we had a 75% drop in their scores if they completed treatment there was again a small effect size difference favoring CPT but nothing to get too excited about and what happened there we go that's diagnosis 80% lost their PTSD diagnosis now I was at a university that gave part of the indirect money back to the department who then gave part of the money back to the PI and so I was able when this study was done to do a follow up so I started doing a follow up study to look at the long term effectiveness most of the studies at most had gone out a year and I was curious as to how people were still doing and so I had enough money we went back and tried to contact all 171 now we had fancier statistics so I went back and tried to get all 171 who were in the intent to treat SAML whether they had therapy or not and had to get a survey research firm to help us because they were all women and sometimes women changed their names and moved to other states strangely enough so we weren't able to positively locate 27 of them they didn't contact them or anything they just helped us try to track them three had died we had a large age range I don't think it had anything to do with their treatment two of them were not appropriate we had very few exclusion criteria if people had had schizophrenia diagnosis we let them in as long as they were stable bipolar we let them in we let them in substance abuse if they weren't abusing in the last few months we let them in so we had two people that we could tell from the phone screen one was completely drunk and the other one sounded quite manic so we just decided they probably were not going to give us valid data so we considered them inappropriate for the follow up 11% refused out of the 171 we attempted to locate we did get caps on 126 of those in fact located so we located 126 that was 87% of the original sample and in total it was no, that's of the ones we found and it was 70% of the original 171 I was so excited to get that kind of response that I almost didn't care what the results were so there's the results and again as I said now we have other statistics so instead of looking at the caps what we looked at was the NFO as PTSD symptom scale because we were giving that every week to people so they had two sessions a week we gave it to them once a week so here's their pre-treatment excuse me so we gave it to them at pre-treatment session 2, 4, 6, 8, 10 12, here's post-treatment 3 months, 9 months and 5 to 10 years follow up which would be around the room if I did it proportionally they didn't relapse that was the exciting news and both P.E. and CPT worked on their PTSD and nice slope and we did see a number of them did go to get more treatment but they got treatment for other things my son was diagnosed with ADHD marital therapy weight loss programs other things not going back to get treated for the rape that they came in with as their index event we did a lot of secondary papers comparing P.E. and CPT in some cases there's no difference there was no difference in depression in guilt there was a difference because it's a cognitive therapy CPT did better on the guilt cognitions it did better on the reported health symptoms they just did reported things like headaches, stomach aches, stuff like that we weren't doing health diagnoses then anger was interesting if they stayed in they did the same but they were more likely to drop out of prolonged exposure if they were really angry we had an interaction with age which you'll see shortly when it comes up again younger clients did better with CPT older clients did better with P.E now maybe that's they get more rigid in their thinking it's harder to change their mind they need those repetitions so that they can remember I don't know there may be something about that because again it's going to show up even within my military sample with a smaller age group hopelessness they did better with CPT suicidal ideation they improved in both cases but did better with CPT and did the same on social and work functioning we did a bunch of papers where we collapsed P.E and CPT because we wanted to look at two other things so we wanted to look at how they did if they had borderline personality characteristics and so we looked at them at pre-treatment whether they had higher low borderline characteristics and in fact there was no difference at the outcome on their PTSD but they started the people with borderline personality started higher they actually had a steeper slope and they ended up in the same spot that the people who didn't have borderline personality and then later on you'll see we followed up with them to see how they looked at the 5 to 10 year follow up on the borderline personality that's not yet Mike Griffin one of my colleagues and I were interested in doing psychophysiological assessment we found that responders had lower startle to loud tones even though we weren't treating we're doing a cognitive therapy or exposure therapy there was nothing to do with loud tones but and they didn't get any loud tone exposure in the meantime all they did was get either CPT or PE but they had less startle response at post-treatment compared to the non-responders so we compared people who did better and responded to the CPT compared to the non-responders there was no difference in outcomes based on whether they had a child sexual abuse history which I said was 41% or a child physical abuse history sometimes there's people out there arguing you gotta do a lot of other therapy first we didn't do a lot of other therapy first we went right into CPT or PE change in PTSD symptoms now this is where we get to we looked at them at the long term follow up and change in PTSD symptoms mediates in other words it was related to changes in personality severity on paranoid, schizotypal anti-social, borderline avoidant and dependent personalities I don't like to think in terms of personality disorders I'd rather start to think like over generalized patterns of behavior or over generalized patterns of thinking so if they've been doing a lot of these things acting in certain ways that may be just an expansion on their PTSD and when you treat their PTSD these other things tend to go away Cassidy Guttner what was curious about even though they're supposed to come in twice a week for six weeks she was curious about frequency of sessions because just because you want them to come in doesn't mean they're going to sometimes they would just no show on you or cancel or be sick or something and what she found was frequency how fast they did the therapy made a difference the faster you do the therapy the better the outcome more important than being consistent consistently coming once a week you didn't do as well as if you did faster so we've got a lot of studies you'll see coming up that we're doing faster and faster CPTs we're getting down to a week now with it change in PTA Sefranski looked at the dropouts from two studies this study and another study and found that just because they dropped out of therapy was a bad thing so I argue with people when they get all bent out of shape about what's the dropout rate 37% of the dropouts had a good end state and I found the same thing with the military sample 27% of my military sample lost their PTSD diagnosis they just don't care we're doing research you know they're done bye see ya so we also looked at practice assignments this one we've been sending back and forth and actually this one is impressed doing their practice assignments matter if they do a lousy job or they don't bring them in it makes a difference doing a worksheet a day you see a lot more improvement than if they don't do their practice assignments we actually in the clinic will fire them if they don't do their homework after a few sessions come back when you're ready to do the treatment because the treatment is dependent on you doing your practice assignments okay so then I went and moved to the VA and in the meantime I'm doing the dismailing study which I'll show you in a minute I moved right in the middle of it Candace Munson did a study with mostly Vietnam vets 78% were Vietnam vets they had been in treatment for years and found that 40% of them had PTSD diagnosis in those 12 sessions and the dropout rate was only 20% down in Australia David Forbes replicated it found the same kinds of findings and then the VA in the US decided to disseminate CPT probably helped that I knew who Tony Zeiss was and she was now in charge of mental health and the VA and I kept saying Tony I'm being invited to do these workshops in various places this seems very unsystematic and she said well in our planning that we're going to start doing rollouts you want to start okay so she gave me a whole lot of money and we started the first rollout I didn't get to do what I wanted to do because then they started all these other rollouts but anyway the phase one was it started in 2006 I moved to the VA in 2003 we had to write the treatment manual so we had to update it make it appropriate for military veteran examples we had to come up with a group manual and an individual manual and the materials manual they need we revised some of those changed some of the worksheets and so forth we had to come up with a trainers manual and a power point presentation and I had to put in all the notes and we all had to put in all the notes so the trainers would know what to say because I'm used to just like as you see standing here and talking with slides but I had to put everything down that I would think to say so that took a while and writing the manuals took a while we had a consultants manual because the part of training the workshop is the beginning of training and then they had to do six months of getting weekly case consultation and then they could be put on a roster if they completed at least two cases and had attended the case consultation and then we did our first train conference and I didn't have enough people in the VA who now got to do CPT so I recruited some of my cronies from St. Louis that I had trained and had been part of my research and so we had a few non-VA trainers to begin with so from 2007 to 2012 we had 66 funded workshops we had 62 where the VA's asked us to come back and do another workshop part of the roll out so we did a whole lot of workshops did them for the VA, the vet centers the department of defense asked us to come out and do them in military bases we did refresher workshops for people who came to the first workshop and then didn't attend the case consultation and then they said can I do it now so we had a refresher workshop we didn't let them just start case consultation they had to go through a like why didn't you pick it up and begin with so they had to confess again anyway so we had those available and then we had more trained the trainer workshops because we needed more trainers at this point we now have 100 trainers inside and outside the VA consultation phone calls were available 48 hours a week so no excuses we can find a time where you can fit into a group and the groups usually had about 8 people in them and you talk about your cases and you hear about other people's cases we did a lot of top down work getting the support of people at various levels of the VA vision means region basically so we had people who that we had them make sure that we were getting the support of the mental health community who were the supervisors because you can't just count on the therapist saying I want to do this their supervisor has to give them a workload release to be able to be on those phone calls to go to the workshops and so forth so we had to work at every level of the VA to get this thing rolling and I wanted to bring everybody back for a second workshop and they said no we're starting the PE roll out you can't bring everybody back for a second workshop so we started doing advanced lectures the nice thing about being in the VA is you can take over everybody's computer and you can turn on the computer and plug in and you are advancing the slides you can mute everyone and go through your lecture and then leave time for questions we recorded every one of those lectures I don't know how many lectures there are 50 or 60 of them advanced lectures on various topics and then we recorded them and then posted them and they could get CE credits for attending but we were able to give them a lot of advanced work through the teleconferences and then we would open up the lines or they could put questions in the little chat box and so forth we started in the beginning sometimes there would be 30 or 40 people I think in the end there were sometimes 200 or 300 people on the line at once obviously that's why you have to mute otherwise you're hearing a lot of stuff in the background then we had to decentralize because the VA central office is not going to pay for this forever so they said okay you need to train the local trainers in each of these 22 regions these visions and they're going to have to start paying for it so they're going to have to take over if they want CPT done and we are mandating it and your boss gets his bonus based on whether you're doing CPT so there was a carrot and stick involved in there and sometimes people would get bonuses for doing CPT or they would get a lighter workload I mean there was all sorts of things that they were doing if they did the evidence based treatments we came up with computerized session note templates to make it easy to drop out which thing are you doing are you doing group you're doing CPT with or without the accounts what are you doing here and then there was even things like if you didn't do X component of this session why didn't you do it and when are you going to do it we did program evaluation and then we've done a couple since then or at least they have I've left so the national rollout from 2007 to 2015 that's when we were mostly there's you can see there's an overlap because we started the regional ones in 2010 and those are still going on and that's where the funding tended to shift but we tried to get one to seven trainers per region per vision and we had coordinators and so forth and so forth and all together this is people who are currently in the VA now that's there's been a lot of people have left the VA they're now in the community and some of them are on our our civilian roster because we have a CPT website where people can get rostered in mental health centers and so forth but currently there are seven forty seven hundred people who are on the CPT provider roster which is really nice when somebody says I'm moving to California and you want to know who to refer them to you know who's on the roster and who's been trained to do CPT especially if they leave in the middle or whatever we can do the same thing I don't have to answer all those questions about do you know somebody in Philadelphia who can do CPT we can just go into the roster and look and the answer to the question about Vermont zero if you're wondering you have no rostered clinicians outside the VA in Vermont this is how the number of workshops look we started out doing all the nationally funded ones and then you can see how the regional ones took over and here's the results these are brand new clinicians that were training so we're monitoring and I don't think you need to know whether they're Vietnam or OEFOIF or Persian Gulf or something else but you can see the scores were coming down that's the old PCL and then when they switch to the DSM-5 it was different scoring but you can see same kind of slope when they're giving us the weekly measures on them sometimes there's a little blip when they're going through some of the tough part about the trauma itself the socratic questioning and stuff and then as you move on with the protocol the scores drop quite dramatically so they were doing quite well then there was a Candace moved from the VA in Boston where she was had been my deputy director and moved up to Ryerson University in Toronto the VA in Canada wanted to they were interested in dissemination but unlike the VA who wouldn't let us do research in the US they only would let her do a dissemination project if she did a research project which I thought was just fascinating so they compared different kinds of therapist consultation to determine the best way to train and help them implement and adopt CPT so they had a no consultation group although they knew they were watching their scores so I wouldn't say that they're probably the same as somebody who's really let loose on the community they got regular phone calls like the ones I just described many of these people on the call they're talking about and then they had a tech where they'd listen to sections of the sessions to see if that really helped if they can listen part of the session does that help your consultation do they do better therapy and the answer was no strangely enough I'm saying the no consultation group I think probably did better when they looked at their outcomes they were turning in the scores they probably more attentive because they knew they were being monitored and they weren't getting consultation I don't think they would have done that well but the one that was a surprise was the tech enhanced didn't do much better than the no consultation at all and I think it was because it would take up too much of the time of the consultation or they'd get a breakdown and couldn't get find the place in the clip or it wasn't a good clip burdened them they did a much better job when they just did the standard consultation what I'm encouraging is don't try to get it fancy just just do your consultation okay so we changed the name I mentioned I was doing a dismantling study part of the reason maybe more than part of the reason people kept saying it's habituation you're having them write their accounts that's the mechanism of change and I said okay let's figure that out if I just do cognitive therapy without the written accounts will it be as good now I put the written accounts in so my hypothesis was that you needed the written accounts and so what we did is we came up with three groups to compare we had 150 participants this time they let me actually put in other kinds of traumas you can see over there on the left is their index events on this far left column 31% said an adult sexual assault was their worst trauma their index event that they're going to start therapy with child sexual assault 38% adult physical assault very rarely did you see a childhood physical assault be their index event but if you look at that middle column that's all in the 70s and 80s they had that in their histories anyway a lot of them had big time trauma histories in fact they came in with higher average PTSD scores from the first time it's like there was enough people in the community in St. Louis I'll send you that one they were referring to some of their worst cases 5 minutes oh boy chronicity was about 14 years later they had other stuff on average usually you see about 50% have major depressive disorder so we had three conditions we had the old version of CPT with the written accounts we had a version without where they'd spend more time doing the ABC sheets and then we broke up one session and turned it into two and then we had a written account thing which is kind of artificial because we only had two sessions of written accounts we made it look like PE where they would have seven sessions they had two weekly sessions and then they had we put them in a room to write for an hour and then they would read it back to the therapist and process it but they couldn't do any cognitive therapy and the surprise to me was that the cognitive only group had a clinically significant drop here there was an overall group difference between the written account group and the cognitive therapy group but this is a clinically significant drop between sessions two and four and it wasn't until they got in CPT it wasn't until they got done writing the accounts that they had their clinically significant drop and they had a 15% higher dropout rate and in the end they caught up but there was no value added from having written in the account so if they're more likely to drop out and there's nothing value added why do it so every study I've done since then that I've had control over has been without the accounts Kate chart also looked in the VA and looked at people who had one or the other versions and found out there's no difference between CPT and getting CPT with the accounts she let them choose which they wanted to do so we changed the names that we looked at CPT and somebody in a workshop rightly said cognitive processing therapy cognitive that doesn't make any sense so we said okay let's make it CPT plus accounts and now we're calling CPT the version without the accounts in the meantime as soon as we finished that variable length study my colleague who helped finish up the study in St. Louis came to me and said I really think right even before that because she had to submit the grant application she said a couple more sessions I think I could have gotten them around the corner so she redefined what a treatment completer was and said okay a treatment completer is somebody who gets a low score who has a good end state not somebody who has just 12 sessions you know raise that go so they could stop early if they had a low score and this was using again the updated PDS this is another PTSD self-report measure the BDI had to be below a 10 they could go up to 18 sessions because again this was a research project you couldn't go on endlessly but if they needed more time they just didn't do the final impact statement they just kept doing more of the worksheets and using the stuck points logs and what she found was that of these civilians these were men and women hey they finally let us study men so she found that 58% were early responders and they I think they averaged about 7 or 8 sessions so I made up 12 it sounded like a good number at the time I'm wrong you know and I really love the idea of treating people until they're better as opposed to saying you've only got 12 sessions there was a group that needed more 26% needed more therapy until they got to a good end state there were like one or two people who stopped right at 12 and there were one or two people who were non-responders this is how it looks compared to my first two studies you can see that this is positive diagnostic status on the cap so on my first study comparing that's just the CPT part of it the blue bars post treatment and follow up you can see 80% more than 80% lost their PTSD diagnosis and then didn't do quite as well but we're still below 30% so 70% lost their PTSD diagnosis but hers are the green bars she at the three month follow-up she only had one person with PTSD out of the 50 she treated so that won me over and I've been doing a study where we're looking up to 24 sessions with active military they're tougher to treat we can talk about that in the reception if anybody's interested time for treatment I won't let them go up to 24 we didn't have anybody who got better and past like 20 anyway so we were trying to look and see how they looked they had anywhere from 4 to 23 sessions and I said 20 I think one person did get better and hit a low PCL 5 by session 23 we had one person who's a dropout that we're going to move he just left and he had a score of 5 at his last assessment but he didn't tell us he was dropping he wasn't coming back but we're putting him we're going to move him up to the completers these are just first look of the data there were 20 people who had all 24 sessions we had to stop them at 18 weeks I'm going to put those two together because it's like 24 sessions or 18 weeks whichever comes first because we were trying to treat them twice a week sometimes the military pulled them out and sent them to a training sent them to another base sent them somewhere else deployed them whatever and here we go here's the number who were remitted at one month follow up and I'm sorry I gave a one month follow up because I wanted to do a full diagnosis we lost a lot of people particularly the military people because they were often gone and some of those we could get in you can see 45% who were discontinued by the army and there were only 5 of them didn't have had lost their PTSD diagnosis 27% who ran out of time I'm sorry 27% of the dropouts lost their PTSD diagnosis I already mentioned that but you can see the people who actually got to the low end state most of them had remitted and then we got the new book and that just came out in 2017 I'm going to do this really fast eh, read the book we've got lots of research findings with active military that's who I've mostly been working with I've been doing DOD grants working with the strong star consortium and the consortium to alleviate PTSD we had in my first study we did group treatment comparing group CPT with group PCT we got some interesting biological findings on fMRI that I don't have time to talk about and aren't on the slide doing doing PCT present center therapy has been shown to be an effective treatment and that means just focusing on current PTSD symptoms, current problems and so forth but fortunately the CPT did better not as much as I wanted I wanted a larger effect size than a 0.4 I was hoping for more of a medium effect size the way it was powered then I did a second study that still I wanted to do for decades which was to compare individual and group treatment and that definitely we had a bigger effect size individual did better than group but the interesting thing is that there's reasons for that 70% of these people have traumatic brain injury so what we found so far is that they don't do as well in individual this is just showing the effect sizes on individual versus group from pre to post skip that one here's what shows up is age I remember I mentioned age before the youngest people 75% lost their diagnosis especially if they got individual therapy once they got to a certain age it didn't matter whether they got to individual or group so that's one of the things we're going to want to look at in my in my variable length study if age makes a difference I'm interested in looking at cognitive flexibility and if people get less flexible over time ongoing post concussive symptoms do better if they get individual then group treatment we've looked at traumatic loss that just got accepted for publication it's mediated by depression if we don't treat their depression successfully they're not going to do as well this next study we're going to use a grief measure and look at that and see how that looks there are perceptions of social support change I don't know if it's that they actually change or if the result decreases in their PTSD and they get people in their life differently and I hear there's going to be some study of that here hazardous drinking can be decreased by treatment of PTSD they didn't drop out at a bigger rate their PTSD scores were not higher and they did just as well with treatment we don't rule out people with hazardous drinking anymore and their hazardous drinking dropped but they were not down to the level of being non-hazardous drinkers so they still need more work on their substance abuse either within the CPT part of it but they did well it's been translated into 12 languages this is the latest version of that new book it just came out in Japan it says in English there the cognitive processing therapy there have been studies published from research in the Democratic Republic of Congo one of my favorite studies of all time it was published in the New England Journal on medicine it was so amazing they did it during a war with no paper no literacy and they did CPT anyway they just did it verbally and the therapist had a junior high school education so the person who was the PI of the study said to the New York Times if you can do this there you can do it anywhere it's been done in Australia, Canada Iraq, Cambodia and Germany and those are published articles and there's four CPT studies going on currently in Japan I mentioned we're going to look at other versions of CPT we're combining with that one person is combining it with other activities particularly for people who are like special services and they don't want the military to know they're getting treated so they go up to Utah and they take their families on vacation and they get CPT sessions in the morning and then take their family hiking or skiing in the afternoons and it's all stealth there's a five day intensive outpatient that's just started compared to regular outpatient Kate Charter is testing a seven session version in my lab my postdoc Stephanie is looking at a modular version of PTSD and we're also looking, we've also just finished a pilot with a text, it is a texting study, the therapist and the the clients are texting back and forth and doing CPT that way we're looking at all sorts of different comorbidities insomnia, eating disorders smoking, borderline personality sorry that one's out and it's going to be published soon that one's finished that was a big multi site study in Germany and looking at effects of headaches and we're also looking at the effects of CPT on cardiac functioning at Duke and the big study that's going to be coming out we're going to see the results the first results in August in a meeting 916 patients treated at 17 sites in the VA I mean we're going to do a lot of predictor stuff with that study and that's the end and I'm sorry I'm late we could take a couple questions or we could just move out and go into the reception area and if you want to ask questions you could do it there we'll take a few questions save some food for us, those of you are leaving right here is there any research on CPT or similar techniques being used for youth or particularly children? not children adolescents in fact it's just been accepted by the JAMA psychiatry I just got an email and got the copy of it it works very well with adolescents and we've done it with a learning collaborative and they did they had a lower drop out rate than the adults but they had to be 14 or older I've seen in clinical practice people do it down to age 12 so I think an interesting question is going to be TFCBT versus CPT for adolescents where's the cut line when does TFCBT start seeming too young for them and when are they old enough to do but we do have modified worksheets that could be used we've got ones with pictures on them we have simplified worksheets so I think it would be possible to use it with younger than we have yes I was wondering if you think there's going to be more of a dropout rate in the texting study just because of the written assessment part of it the pilot that we did we only used the PCL and so they did that online because this was just a simple pilot we had almost no funding for it I think there's going to be a bimodal distribution either they're going to take it and run with it and they're running faster than the therapist would run with it they're just zooming through the therapy and doing great or they quit almost immediately I think that's the way it's going to we've got a DOD grant in now to look at it cause I think that would be a nice thing for the DOD when they can't reach out we've got the patient manual more like a manual now than just a set of materials so they've got stuff to read they can look at stuff online but the problem of course you've got with any kind of telehealth we've done three telehealth studies that I didn't mention the problem with anything to do with telehealth or texting is that right now you have to be in the same state that you're licensed in as your client and I think eventually they may move to having a more universal licensure but we're not there yet we've got a lot of CBOX the community based out patient clinics you say in Vermont and you say there's no therapists no I didn't say there's no therapists I said there's no therapists in the civilian we have nobody we have people who definitely we have people who are listed on the roster in the CBOX and VA's in both Vermont and New Hampshire but those are VA's veterans what we need is more people who are civilian I mean there's some states that have really gone gangbusters on getting civilians trained because the mental health system in that state Texas has a ton Oklahoma has a ton we've done several in North Carolina if you look at our roster you can just see there's certain states that just have a ton of people who are rostered there's other states you can't find the state and Vermont was one of those when I went into our civilian that's that cpt for ptsd.com we keep our civilian roster they don't even list Vermont so need to get more people doing it and getting rostered yes we typically on most of our studies we didn't we didn't look at it frankly they had to be either stably on or stably off of their medications so we asked them just don't make any changes in it so we've never parsed it out because we didn't have good enough reliable reporting on because even if you go into their records and see what they were prescribed that doesn't mean they're taking it as prescribed so sometimes people will get prescribed a depression medication and they'll take it like whenever they feel like it as opposed to like taking it every day at a certain time and so forth so we have not been able to do that there he has been a study with eversus sertraline and it worked for some people worked for other people but the problem is medications don't fix the problem and the idea of doing one of these therapies is that you not only get rid of their ptsd permanently you're teaching them a set of skills that they can carry for life and we've had people email back their therapist and say I had another trauma happen and I handled it totally differently so I like a therapy where it would put us out of business I haven't gotten there yet thank you