Cognitive Processing Therapy for Sexual Assault Victims

Reviewed by
Priscilla Schulz, LCSW

from an article of the same title by:
Patricia A. Resick and Monica K. Schnicke, University of Missouri-St. Louis

Journal of Consulting and Clinical Psychology,
V. 60 (5), 748-756, 1992

Why is this article important to providers serving sexual assault survivors?

Cognitive Processing Therapy (CPT) is a treatment specifically designed to address posttraumatic stress disorder (PTSD) in sexual assault survivors. This article describes the theoretical basis behind a cognitive processing approach, and presents data from a preliminary outcome study. Certain aspects of PTSD are common among rape survivors. CPT is designed to treat these specific aspects of PTSD. The study presented looks at the effectiveness of CPT when used in a group format with rape survivors suffering with chronic PTSD.

  What is the origin of cognitive processing therapy for sexual assault survivors?
Cognitive Processing Therapy (CPT) combines information processing theory and knowledge gleaned from prolonged exposure treatments that have been effective in alleviating PTSD in survivors of other traumas. In particular, CPT draws upon an information processing theory of PTSD that proposes that information about a traumatic event is stored in the brain in "fear networks." These networks consist of memories of traumatic stimuli and responses along with their meanings. The entire network is designed to stimulate avoidance behavior in the trauma survivor to prevent future threat to survival. Unfortunately, as researchers have discovered, these "fear networks" seem to be responsible for a set of beliefs or expectations (schemata) of trauma survivors that causes them to have an attentional bias toward evidence of threat, ambiguous or otherwise, and to disregard evidence to the contrary. Such attention to cues of threat serves to trigger typical fear responses of escape and avoidance, and seems to account for the re-experiencing phenomena of PTSD.

How rape survivors interpret the trauma (the meaning or cognitive appraisal of the event) effects subsequent reactions to the experience. Studies have found that rape survivors who experience conflict between their prior beliefs and the rape experience are more likely to have more severe reactions to the rape and to have more difficulty recovering. Examples of schema conflicts are "Rape doesn't happen to nice women", a prior belief that the situation in which an assault occurred had been safe, or that the victim was somehow particularly invulnerable to crime. As a result of such schema conflicts, feelings of shame, guilt, humiliation, anger, betrayal, anxiety and especially confusion are commonly seen in sexual assault survivors with PTSD.

Information processing theory explains that in an attempt to resolve schema conflicts caused by a traumatic event such as a rape, survivors respond by:

    1. Assimilating the new, albeit horrific, information into their existing belief system by altering the event (e.g., "Maybe it wasn't a rape" or "I must have done something bad that brought this on, because good people don't get raped"), or
    2. Accommodating their prior beliefs to the traumatic experience. The statement "Sometimes bad things happen to good people" exemplifies a healthy accommodation. Oftentimes rape survivors in situations without good social support or guidance make accommodations that are maladaptive and extreme, such as "No one can be trusted" or "I can never be safe".
How does Cognitive Processing Therapy address the treatment needs of sexual assault survivors with PTSD?
Cognitive Processing Therapy consists of three components:
    1. Education about PTSD symptoms and information processing theory Exposure to the traumatic experience by directing clients to write about and read their accounts of the event. This exercise elicits the feared memories of sexual assault survivors and encourages processing of emotions. Ultimately it enables survivors' fears to habituate, similar to how other exposure therapies treat PTSD.
    2. Cognitive therapy which addresses rape survivors' intense feelings of anger, betrayal, disgust, shame, guilt, humiliation, anxiety and confusion by identifying and modifying schema conflicts ("stuck points"). Whereas CPT believes that many of the problems of rape survivors result from schema conflicts, at times therapy reveals previously existing distorted or dysfunctional thinking patterns and ways of coping with emotions which are activated by the assault. In such cases CPT addresses these problems by teaching clients how to recognize and challenge faulty thinking patterns and how to cope with distressing emotions. These methods of CPT are similar to the established Beckian method of cognitive therapy for depression.
Cognitive Processing Therapy for sexual assault survivors consists of 12 weekly group sessions of 1.5 hours in duration each. In the latter sessions, CPT explores and helps survivors modify "stuck points" in the five major areas of functioning that are usually affected by victimization: safety, trust, power and control, esteem, and intimacy. What is the purpose of this study?

The purpose of the study presented in this article is twofold:
    1. To examine the effectiveness of CPT in a group format in the treatment of chronic, rape-induced PTSD.
    2. To examine the effectiveness of CPT in also reducing symptoms of depression among study participants.
Note: Of the 19 study participants who completed the study, 16 had received treatment for symptoms of PTSD and depression at some time before the study, but all participants had PTSD at the time they entered the study. True random assignment of subjects to either the treatment or control groups was not achieved, so the investigators present the study as "quasi-experimental". What are the study's findings?

Group Cognitive Processing Therapy was effective in reducing symptoms of chronic PTSD.
    CPT resulted in significant improvements in both PTSD and depression among study participants:
      • When treatment ended, none of the study participants met full criteria for PTSD and this was maintained at the 6-month follow-up
      • At the end of treatment 42% (5 subjects) met criteria for depression compared to 99% at pretreatment, but by the six-month follow-up, only 1 study participant still met criteria for depression.

    Many study participants reported substantial improvements in the quality of their lives as a result of participating in the treatment.

Reviewed by Priscilla Schulz, September 1999
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