Bob Boland 00:02
Welcome to the Mind Dive Podcast brought to you by the Menninger Clinic, a national leader in mental health care where your host, Dr. Bob Boland,
Kerry Horrell 00:11
and Dr. Kerry Horrell. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives in the minds of distinguished colleagues near and far. Let's dive in.
Bob Boland 00:43
We're delighted to have Dr. Patricia Resick, who is a professor of psychiatry Behavioral Sciences at Duke University Medical Center and adjunct professor at the Medical University of South Carolina. She's widely accredited for developing cognitive processing therapy for PTSD in 1988. Treatment manual for CPT has been formally disseminated throughout the VA, and other veterans services abroad. CPT is now considered a first line therapy for PTSD. You can also see her work in the newly published self help book, "Getting Unstuck from PTSD, Using Cognitive Processing Therapy to Guide Your Recovery." And disclaimer, we use that therapy here.
Kerry Horrell 01:20
Oh, yeah, we're just saying before we got going that we just had another round of people get trained in CPT. And I remember one of my very first like, full time practicum. I was at a community mental health clinic where there were certain evidence based practices that the government was specifically willing to pay for. And CPT was like one of the three of them it was like Seeking Safety CPT. And I actually don't remember the third one, but great. Yeah, like, I mean, just
Patricia Resick 01:45
probably prolonged exposure. Yeah.
Bob Boland 01:48
Well, welcome. Well, anyhow, welcome. Thank you. Thanks for doing this.
Kerry Horrell 01:52
Yeah, we again, I'm so excited. I feel really privileged, we get to talk to the the creator of CPT, again, it's having having learned about it so early in my career and knowing how effective it is. So you you developed this model, you know, as we said, in 1988, I wonder what got you interested in developing it. And specifically, I'm thinking about if you saw a need in the field to kind of do something a little bit different?
Patricia Resick 02:16
Well, when I started, there was no field. So anything you did was different. In 1974, I was an intern in Charleston, South Carolina. And one of the techs, who was working there, was talking about the being in the process of setting up one of the first rape crisis centers in the country. And she said, Would you like to be a rape crisis counselor? Sure. What's that? Being a good little grad student, I went to the library to see what was there and there was nothing. There were four articles on the topic of rape. And two of them were about victim precipitated, right meaning they were blaming the victim. One of them was past pastoral counseling, and one of them was the interruption of the psychoanalytic process by a rape.
Bob Boland 02:57
Oh, my god.
Patricia Resick 02:58
That was it. That was the total sum
Kerry Horrell 03:00
Doesn't seem like particularly useful resources.
Patricia Resick 03:03
Yes, yes.
03:04
But fortunately, when I got back, I did a year in London after I did some months in Charleston. When I got back, the government, NIH had funded $3 million, which in 1975 money, it was a lot to study rape. So while I was doing the second half of my internship in Charleston, I helped write a grant application where we were tracking rape victims longitudinally to see you know, how many of them had problems, what was the you know, in, particularly looking at fear and anxiety, because that was the logical thing to look at. It was considered to be a prominent symptom. Mind you is before there is a PTSD that was actually developed as a diagnosis in 1980. So we were pre diagnosis. And then in January, I went back to University of Georgia to finish my dissertation. And when they were just in the process, we were still working on that grant application. And one of my professors at Georgia asked me if I wanted to also write a grant. So we had two submissions, one doing longitudinal with fear and anxiety, one looking at depression. They both got funded,
Kerry Horrell 04:10
Understandably so.
Patricia Resick 04:12
In the in the meantime, I went to University of South Dakota because by the time I got back, all other jobs were taken in there was very few academic jobs left and I thought, Okay, I want an academic job. I'll go to South Dakota. Unfortunately, it was hard for me to study my topic, because there were a lot more cows than there were people. I stayed there for about four years and flew back and forth to Charleston in Atlanta, where we were doing the other research. And then finally, I ended up moving and I was looking for a city where a university was, which is hard to find a lot of state universities are out in the middle of nowhere. You know, like, that's true. Yeah. So I ended up going to the University of Missouri St. Louis, my two and a half million people in St. Louis. I figured okay, I can keep doing my research. And that's what we had started trying to do. Some treatment research when I was down in Charleston and didn't seem to work too well what we planned. So I started trying to do Stress Inoculation Training, and comparing it with just sort of, you know, psychodynamic Support Group Type groups, because I was working with rape victims from rape crisis centers at the time. And they both worked equally well, until I was not impressed. I was never into anxiety disorders. And by that time, I had worked with enough rape victims that I didn't think of, I didn't think of rape as an anxiety disorder. I mean, granted, that's where they put it, when it came out in 1980. But there were just too many rape victims that said to me, it wasn't that I thought I was gonna die, or that he was gonna really kill me, but because I, you know, had dated him or he was my husband. But what he did was so humiliating. So mortifying, I was so betrayed by this person. And I thought, okay, you get one exception to something you can't just say it's an anxiety disorder. It's got to be more than so I started looking at the work of Aaron Beck and the cognitive therapies. And he had done cognitive therapy for depression, he had done cognitive therapy for anxiety. And I thought that looks like a good approach to me. Except what I wanted was something that was a lot more specific. His true manual for depression was one of the first to come out but it was still, I thought he kind of vague to me, like, what do you actually do? So I set out and thought 12 sessions so that might be something that insurers would fund.
Bob Boland 06:29
Pracitcal way to choose.
Patricia Resick 06:32
I wanted something short, but that would cover all the territory that I wanted. So I experimented around, using some of the worksheets they had done. I also looked at the work of Laurie Perlman and, and some of the work that she was doing. And they were talking about themes that got disrupted as in response to rape, safety, trust, power and control the seeming them. And I thought those should be in there, too. I didn't have a big grand, I had a little grant from the university. So I had to do group treatment to start with, again, very practical, because I could collect more data. And so I wanted to cover all those bases. So I covered all those themes. But those came later in the therapy early on, we worked on the trauma itself. I think by the time I got my first randomized control trial to compare it with prolonged exposure, I had already done 84 pilot cases. Wow. So I knew the therapy work, my grad students got the same kind of results that I did. So then we did, you know, finally published the first trial in 2002. I think it got funded in 1994. So took a long time to collect the data. So that's what got me started. But anything we were publishing on assessment on, on case studies on anything we had was publishable because nobody knew anything. Wow. I mean, people were still at the point where they were saying, rape, is that a problem? What's wrong with that?
Kerry Horrell 07:53
If our audience could see me, I feel like my job has been a little bit on the floor, because for a few reasons, but I mean, yeah, how, how little there was, and then also how long it took to, I mean, just like some of the bureaucracy of developing a treatment protocol like that, gosh, that just what what impressively perseverant work that must have been just yeah, like, stick with it.
Patricia Resick 08:18
They funded that assessment study. But the second part of it was the treatment study, and they would not fund that. So I just kept going. Funding, I kept doing more pilot data until I condensed them. Wow.
Bob Boland 08:28
Yeah. Can you take us through? I mean, so we keep talking about CPT. But we haven't really described it yet. Can you take us a little bit through the model? And, and how you kind of, in a brief summary, how it works in what you do? Yeah,
Patricia Resick 08:41
You heard me mention, Aaron Beck. So it follows under the big umbrella of cognitive behavioral treatment. But with the emphasis on the cognitive, which we were not studying a lot back then I wanted to develop it as, as I said, a session by session protocol, where we're actually teaching the clients that we work with, or patients, whatever you happen to call them in your setting, to learn themselves, how to rethink, in other words, to think about their trauma differently, and then to think about how it's affected their life differently. So it is almost exclusively a cognitive therapy, with the emphasis on Socratic dialogue and getting them to figure out the answers because if you tell somebody is not your fault, they're gonna say, Yeah, sure. People have said that, and they'll go, you weren't there. You don't know.
Kerry Horrell 09:29
Exactly, what what do you know?
Patricia Resick 09:31
So you have to ask them questions so that they can figure out for themselves. They were too small, they were too far away. They were too whatever it was, to be able to stop whatever the trauma was. So of course, we started with rape and then move to child sexual abuse and domestic violence and then any kind of interpersonal and then of course, then we started moving into veterans and in 2003, I moved to Boston and started working a lot with veterans, and we ended up launching the first rollout for CPT. Once Candice Munson had done her first study to show it worked with Vietnam veterans, and that PTSD was in fact treatable.
Kerry Horrell 10:08
A pioneer, I mean, my God, this is so cool to hear about it to dive a little bit more in, it seems like both from my experience with CPT. And also getting to read your new book, there's the clear emphasis within CPT is getting unstuck, like stuck points and like, and this... can you say a little bit more about that, and how, and why this is so important for people with trauma and what you've seen of this as a phenomenon that they just get so stuck, and how you tend to think about helping them through that.
Patricia Resick 10:41
Probably one of the best things I did when I developed the protocol was to start out with what we call the impact statement. Yes. And we had, if I had to get rid of anything else, that would be the last thing I would get rid of. Because they tell you in one session that you could spend six months trying to just listen for, you say, Why do you think this happened? And how has it affected you and they will write you down? Exactly, well, it's my fault, it happened, it happened because, you know, I had a drink, or I wasn't watching where I was going, or I should have run faster, or whatever it happens to be. What I realized, in working with all these pilot cases that I was doing is that they, they tended to have the same thought over and over and over again, it's like whatever they thought of it, the time of the trauma to explain is kind of where they stuck they. And because the symptoms are so strong, the arousal symptoms, the flashbacks and nightmares, these know the strong emotions they are going to avoid. And so in the process of avoiding all that, all those PTSD symptoms, they never rethink their first assumptions about the trauma. Sometimes their assumptions are very childlike, because the trauma happened when they were children. Sometimes it's just because they have this "just world" belief that we're all raised with the good things happen to good people and bad things happen to bad people. So they're assuming you always look to yourself, first, I must have made a mistake, what did I do, and that's where people get stuck. And that's why I thought of it, it was like something was interfering with their natural recovery, the vast majority of people will recover from a trauma, a trauma. Now most of the patients we see have multiple traumas, because you don't go to therapy, it could really help. So that that's usually their last resort. But so usually, you know, we see the people who've had the worst kind of trauma histories. But if they get stuck, it's because they haven't let themselves feel the feelings. They haven't let themselves think about it differently. They haven't, they've avoided instead of approached, and so they isolate themselves, they cut off activities with other people and and the way they're talking to themselves is just keeping them running in a circle. They're keeping themselves stuck. I used to use the term record. Actually, those are coming back. Yeah, I can go back to using the term record. Back
Kerry Horrell 12:59
I have a I have a record player and I love get out. I do I collect records. Well, I do find myself curious about and just what what you might think about this, of how the role of control how control plays a role, I should say in some of these stuck points. And I think just about the idea that, especially when you're a kid, like if it's a child trauma, and something bad happens to you, especially something bad happens to you by someone that you're supposed to trust. My sense is that a lot of people blame themselves because in like this kind of paradoxical way gives them a sense of control rather than like, the world is scary. And the people that I need are not reliable. But maybe if I'm bad, like if I'm just bad, and it was just something I must have done. It seems like a kind of seeking of control and certainty in this otherwise, completely unfair, unjust, uncertain experience.
Patricia Resick 13:49
Right? I mean, I mentioned the the "just world" myth, that that good things happen to good people and bad things happen to bad people. But also human beings really want prediction and control. Yes, they want to believe that you can predict what's going to happen in the future. If I just do this, this will happen. You know, if I'm a good person, this will happen. And they also want control. And so then, of course, people with PTSD may make their lives much narrower because they're trying to control their environments. They're trying to control themselves, their emotions, other people. So yeah, there's a great deal to do with control. Even some of the styles of avoidance they have are about control. I mean, even drinking, if I can't be in control, I'll be totally out of control. Or if I starve myself, that's control, isn't it? I mean, if I can, I can make myself really, really skinny.
Kerry Horrell 14:40
And that's why it feels like such a this work is so courageous for people to do a protocol like CPT because it's like in my mind, not only are you doing something terrifying by by moving past, avoidance and going to, in your mind, the place in which you were terrified and alone and harm, but then Also, again, like I think on this cognitive level, there's also this place of having to face like, if I am not to blame, or if I, you know, whatever the stuck point is that also going to have to do some grief and acceptance that like bad things happen and like, the world is not fair. And I feel like that's like, again, like this meta level of terror. And yeah, I'm just, that's what I'm just thinking about this moment of that this is such courageous work, because there's sort of there's multiple levels of how scary it is to do.
Patricia Resick 15:29
Well, it is. And that's why it takes I mean, it takes a therapist who has been trained to do it and do it well, so that they're reassuring that and I'm hoping that the self help book will do the same thing. I don't know if you've gotten a chance to look at it. But we've tried to lay it out very slowly. Very encouraging. Liana gentle way to help them face what they actually experienced. Unlike the exposure stuff, we don't go into the gory details, we don't look for the blood and guts, we look for where they're where they got stuck, what idea they got stuck on. And so sometimes we have to talk about the trauma just to say, you know, like, Okay, you couldn't get your brother out of that burning house. What happened when you tried to? Well, you know, I went there, and then the heat blew me back, and I couldn't go in the doors or whatever it happens to be. So they have to go through that amount of it. But we don't have to talk about the smells, and the sights and all that kind of stuff. That's not That's not why they have PTSD.
Bob Boland 16:22
So you're talking a bit about how it differs from some of the other treatments? Because like you said, there was nothing was available when you're starting. But there are some other treatments out there now, like at the institutions that last probably the concentration was on trauma focused therapy forum for PTSD and I kind of a different stuff or what's what's, what's the focus?
Patricia Resick 16:42
Usually, TFCBT is referring to a child therapy. Drill, I'm not sure what they're talking about their prolonged exposure, it's definitely going through the event over and over again, but also having people approach things in their environment and staying there until the anxiety decreases. But that prolonged exposure has focused much more on PTSD is an anxiety disorder. Right. And I think when I compared that first RCT, I did the randomized control trial I did was to compare CPT with prolonged exposure which had just come out. They were absolutely the same in terms of PTSD and depression, even over the long haul. We did a long term follow up five to 10 years later, and they were just the same. But guilt, hopelessness, more improvement in suicidal ideation. So some of the more cognitive things did better with CPT.
Kerry Horrell 17:35
It makes me wonder about, you know, we're talking about PTSD, which, you know, our listeners who are primarily mental health clinicians will know that PTSD, you have to fit that criteria and a trauma. But I wonder, when we think about trauma in general, you know, we also have things like attachment trauma, complex trauma, at times kind of sub threshold PTSD, where we're still seeing a lot of those symptoms is a is CPT, just for PTSD. And then kind of following up to however you answered that. Like, when do you know CPT is indicated for a person?
Patricia Resick 18:10
Well, I would include complex PTSD with PTSD. I mean, we don't have it, at least in the US using the DSM. We don't have complex PTSD. I hate it. I want it. Well, the problem is, is that they're doing that over with the ICD, but now nobody has PTSD. They all have complex PTSD.
Bob Boland 18:28
Yeah, it all seems pretty complex to me.
Patricia Resick 18:31
Yeah. And the whole content of complex PTSD is problems with affect regulation, which CPT treats beautifully. And they're not including things that I would think of as complex, like substance abuse. Yeah. And some of the other comorbid disorders like the sleeping disorders or eating disorders, those are complex, multiple traumas, I mean, so they kind of very narrow definition of complex PTSD. And we've always, I mean, all of our patients, we never ruled it back out. So they've always been included in all of our CPT studies. So I don't see too much added with the concept of complex PTSD, I don't think you have to do anything different. In fact, we found there's worse results, if you add stuff at the beginning of the therapy that quote, get people ready for therapy. We've always just launched right into CPT and all we've had 38 randomized controlled trials at this point around the world, not just me, but lots of people, they just launch right into therapy. And when they've looked at doing prep work, the dropout rate is higher. And in the in the VA, they they very, very commonly put people into prep groups, they actually do worse with the evidence based treatment they get, or they don't get it at all to get the prep group and then quit. So if they went straight into the therapy, they did better.
Bob Boland 19:51
You're better off going straight into it. Yeah. Interesting.
Patricia Resick 19:55
Well, I mean, the other I mean, think about it this way, if you do a lot of prep work What message are you giving the patient? You can't handle it. You're too fragile, you're too weak. And you might mean therapist is I'm not ready
Bob Boland 20:11
Let's take this slow.
Patricia Resick 20:12
Sometimes I think it's a therapist stuck point.
Bob Boland 20:16
Well, probably so.
Kerry Horrell 20:17
Well, I mean, it makes me think about a particular population, which is the population of folks with personality disorders, and how you know that that's so often related to trauma. And I wonder is, is there is that at all a rule out for CPT? I think I know the answer to this. But I am curious. I am curious how you think about this of like, people who do have some of those kind of character pathology traits where they might be more resistant to treatment, or they might be at a place where they're some of the again, that underlying personality features are coming up.
Patricia Resick 20:46
You know, we haven't really seen it with personality disorder so much. I mean, we've had people we never ruled out personality disorders, again, from right from the beginning, we had people in that first trial, who had borderline personality we looked at that was not a predictor of treatment outcome, they had higher PTSD to start with, but then they had a steeper slope and actually got better, because we can find them to doing this treatment, and it got them focused. And then when we looked over the long haul, there were a number of personality disorders that decreased over time, you know, as they got better with their PTSD. So it was mediated by the improvement of PTSD. I think severe dissociation might be a place where you might have to do something first, not mild or moderate dissociation, but only there really severe dissociation. Because if they can't sit in the room with you, and stay there long enough to even tell you what happened to them, you might have to spend a few sessions, doing some grounding work, helping them, you know, stand here and now and not dissociate, and so forth. So I think that's probably more important than a personality disorder, per se. That's helped. Yeah, and you know, and obviously, with imminent danger, suicidality, homicideality, if they have to go through, if they're gonna go through withdrawal, if they stopped doing their drugs, or alcohol, I mean, we have stopped in all the military studies we did, we have done a whole series with active duty military, we just stopped rolling out any kind of substance abuse, if they were really severe, they probably would have been out of the military. So we just stopped rolling it out. But when we when we did look at the hazardous drinkers and those, they tended to be binge drinkers, because they didn't, when they were on duty, they weren't drinking, but they would go home and to have a ton that night or on the weekends, they decreased with the CPT. And we have three different studies that shows the same thing they decrease with the PTSD. And and there was a big VA study that just looked at their records of people who got CPT and they also decrease in their substance use. So I think we don't need to worry about some of those other things as much as we thought they did everything we were hesitant about in the beginning and used to rule out or say we need to wait, now we don't wait anymore.
Kerry Horrell 22:57
I really liked that, because I do think that treatments, I do have a bit more structure to them, like like CPT where there is, you know, a certain amount of sessions, and there's a way that the sessions progress. In my mind, there is a tendency for that to correlate with, like, we're only treating, you know, like, this is only for people with just depression. And, you know, it's a lot of ruling out and ultimately, like a lot of our folks, especially with trauma, it is complex, there is you know, comorbid depression, eating disorders, substance use, like there is just so much and so the fact that the treatment, didn't like rule them out, and just like we're gonna focus in on this thing, and and we're seeing other things get better. I think that's very cool.
Patricia Resick 23:35
Yeah, we've had a couple of people in who had multiple personality disorder in that first trial. We didn't rule that out because it wasn't in our rollouts. It was helpful is still Yeah, I mean, we didn't measure their dissociative disorder, but we looked at their PTSD. And they got better on their PTSD. They just ignored the I didn't happen to be their therapist, but the person just sort of ignored it and treated the main drama.
Bob Boland 23:59
Can you say a bit of just about the general acceptance of this when it's posed to people as a treatment? Because they I mean, I don't know, just maybe just my own bias and stuff, I found that sometimes hard to get people with PTSD in the therapy usually been through a few that haven't helped. And then they end up instead on a lot of medications that definitely don't help. Yeah. So and you kind of get into this kind of cycle of that.
Patricia Resick 24:20
Yeah, I think how you explain the therapy. And, and, and that you're not going to ask them for all the gory details, you're not going to ask them to revisit because we've already done the research that shows that the doing the accounts is the way I had started it but then we did a dismantling study, and it actually delayed their improvement. They started improving faster if they didn't do the accounts, and we went straight into the Socratic questioning. Gotcha. If you explain what the therapy is, and that we're gonna hand the therapy over to them by about Session Four, and you know, like they're gonna be taking the lead on it. I mean, that's what led us into doing the self help book. Finally, it's like there's so many people who can't get a therapist, they can't afford it.
Bob Boland 25:03
They don't have access. Yeah,
Patricia Resick 25:05
waiting lists have gotten longer and longer. And so then we thought, well, this is what we're teaching them anyway. Maybe we could reach him just directly. Of course, sometimes you need somebody behind you pushing you and gently to stay with it. And we have places in the book where we say, if you're, if you're not doing this, if you just stuck it up on the shelf, then you need a therapist.
Bob Boland 25:27
Yeah. And what's your sense of how I mean, along those lines? How available is I mean, obviously, we're the center where we do it. And so it's kind of an you know, we're lucky here, but is it in major centers and academic or in outside, I mean, outside of the VA?
Patricia Resick 25:43
Well, yeah, we've trained 11,000 People in the VA, but a lot of them have left the VA. So when they go into other practices, they take it with them, I can't remember how many 1000 people we have, we have a website where the providers are listed for every state. And so if they go to CPT for ptsd.com, they can go into the provider list and see if there's somebody in their state, or in their city or whatever they want to do it in person, they would look for somebody in town, but with telehealth, you can get anybody who's licensed in your state. And now with licensure starting to cut across states, we need we need to get something in there. We don't have that yet. Because sometimes people are licensed in many states.
26:28
So CPTforPTSD.com Yes,
26:31
just small letters, CBTforPTSD.com. For providers, we have all sorts of resources in terms of, you know, handouts, and stuff and, and, and lists of when there's workshops and things like that, but I think for for the for potential patients and clients there. We now because of the self help book, have a whole list of whiteboard videos that show you how to fill out all the forms and everything. And there's video examples and all that kind of stuff. We have an online course for therapists that helps where they can week, I think we have 36 videos in that course, that shows various aspects of doing CPT. So I think it's becoming more available. Strong star, the consortium that I was working with, with the active duty military has a training division now. Katie dondon, and Bill is leading. And they started by getting foundation money, I think it was just from one source to begin with. But now they have three or four different sources of funding. And they used to just do training in Texas for people who were treating, or possibly treating veterans, like even community mental health centers, because sometimes people don't want to go to a VA or it's too far away, especially in a big state like Texas. So they were doing it there. But now they've done it in I think 20 states. So there's lots of people being trained.
Kerry Horrell 27:51
I'm almost positive they're the folks who train Menninger, the ones who just even did our most recent training.
Patricia Resick 27:56
Yeah. Oh, that was that was through that. Training Initiative. Okay.
Kerry Horrell 28:02
You know, you've alluded to this. So this might feel like a silly question. But I am curious if, you know, let's say people are listening at this point, and they still haven't. They're like, I'm not I still not sure about the CPT thing. I wonder if you want to speak a little bit to the efficacy and the benefits that I know, again, there's probably so much research out there on this, but there is a general trends we've seen with with how beneficial it is.
Patricia Resick 28:23
Well, I mean, just as an overall it works better. It tends to work better with civilians than it does with military. We know that having some cognitive flexibility in the patient helps. In other words, they're able to change their mind. They're not just like, rigidly adhering to something. Sometimes I think people in the military have been trained to have PTSD. They they get trained in stuck points. Like, if y'all do your jobs, y'all come home. Yikes. Point. Yeah, you are responsible for your men. You know, they're just a number of things that people are, you know, like, stay alert, stay alive, like, well, let's teach people to be hyper vigilant. Exactly. So I think I think sometimes it's a setup that they train people to go into combat, but they don't train them when they come out of combat, undo some of those beliefs. And so I think sometimes they get stuck on the very things they've been trained in things that were absolutely impossible for them to have foreseen or prevented. But anyway, we do tend to see civilians do better. We now usually do variable lengths. Some people don't even need to have sessions. That wasn't something in some magic number. among civilians, it tends to be 910 sessions, typically. We've seen people do it as a texting, piloting a texting format for the therapy, or people who do it in a week or two, and they get, you know, daily sessions for a week or two and they're done with it in a couple of weeks. So they can do it, take a vacation or take sick leave and and get the therapy all done quickly. And it works, lower dropout rates and it works just as well. Yeah, we know lots about who it's going to work for, first of all they have to do To practice assignments, yeah, there are some therapist variables. But in terms of the patient's themselves, they, it's really well, it's really important for the therapist to emphasize doing the worksheets, but they didn't have to have the competence to actually work with them and do the good Socratic questioning. And that's where the training comes in. Because if you haven't been trained to, to be able to not just ask rhetorical questions, or try to convince them to change their minds. And I think that that makes a difference.
Bob Boland 30:28
Yeah. And how do you define success there? Is the goal just to not be stuck and to be more functional? Or how do you see it?
Patricia Resick 30:34
Oh, it's several things. I mean, we usually in our research, we measure, you know, loss of PTSD diagnosis that they've they've had a clinically significant drop in their symptoms on these variable length studies we've done where where they can have, you know, they stopped when they get to what we call a low end states, which would be like a BDI, below 10. And at low PCL score, like below 20, on the PCL, and then you talk to them about Are you done? Or do you want to keep going, and if if they're really stuck, you might say, I think we need a few more sessions, you've got a core belief here that started in early childhood, like, I'm always a failure, because your mom always said, You're a failure, you're a failure, you're a failure. And so maybe they have to sand that out because it's fixed. And so, you know, really keeping an eye on where they are, and whether they're doing the self help book, and they're monitoring their own scores, or whether it's the therapist really keeping an eye on good and state, not just a loss of diagnosis, but really good functioning, not having PTSD anymore, getting on with your life, being able to set new goals and get back on your developmental track.
Kerry Horrell 31:44
Yes, I mean, and again, just want to highlight this book, getting unstuck from PTSD, using cognitive processing therapy to guide your recovery. What a cool resource again, that people would be able to do some of this work on their own, that makes it so accessible. And, again, just so appreciative of your other work.
Bob Boland 32:02
I do want to Yeah, thank you for everything you've done. I mean, I certainly being older, I trained at a time when PTSD was considered largely untreatable.
Patricia Resick 32:02
Yeah, isn't that amazing. That's where I started, too.
Bob Boland 32:06
But you did something about it. So we've been listening again to Dr. Resick. And we're gonna give you the last word, what do you want to leave our, with our listeners with?
Patricia Resick 32:25
Well, I was glad glad you brought up the self help book that as I said, there's a lot of people who either are put on long waiting lists now or, and I'd rather them not get parked in some kind of a prep group. They might as well start the work themselves. I mean, even if they're going to see a therapist eventually. So the therapists could work with them as far as they've gotten in the book, and it might shorten the course of therapy. But you know, there's people who just don't have access to even a tablet to do the the telehealth. By the way, telehealth works just as well as in person.
Bob Boland 32:57
I think you implied that but I'm glad you said that. Yeah,
Patricia Resick 33:00
It's amazing. And we've even done group telehealth so you can get, you know, 8 or 10 people on a screen like on a zoom screen and you're all talking to each other and you could be all over the state.
Bob Boland 33:12
That's so optimistic. I'm so glad to hear. So. We've been your hosts. This is the Mind Dive Podcast. I'm Bob Boland.
Kerry Horrell 33:18
I'm Kerry Horrell and thanks for diving in! the Mind Dive Podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.
Bob Boland 33:31
For more episodes like this, visit www.MenningerClinic.org.
Kerry Horrell 33:36
To submit a topic for discussion, send us an email at podcast@menninger.edu
Welcome to the Mind Dive Podcast brought to you by the Menninger Clinic, a national leader in mental health care where your host, Dr. Bob Boland,
Kerry Horrell 00:11
and Dr. Kerry Horrell. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives in the minds of distinguished colleagues near and far. Let's dive in.
Bob Boland 00:43
We're delighted to have Dr. Patricia Resick, who is a professor of psychiatry Behavioral Sciences at Duke University Medical Center and adjunct professor at the Medical University of South Carolina. She's widely accredited for developing cognitive processing therapy for PTSD in 1988. Treatment manual for CPT has been formally disseminated throughout the VA, and other veterans services abroad. CPT is now considered a first line therapy for PTSD. You can also see her work in the newly published self help book, "Getting Unstuck from PTSD, Using Cognitive Processing Therapy to Guide Your Recovery." And disclaimer, we use that therapy here.
Kerry Horrell 01:20
Oh, yeah, we're just saying before we got going that we just had another round of people get trained in CPT. And I remember one of my very first like, full time practicum. I was at a community mental health clinic where there were certain evidence based practices that the government was specifically willing to pay for. And CPT was like one of the three of them it was like Seeking Safety CPT. And I actually don't remember the third one, but great. Yeah, like, I mean, just
Patricia Resick 01:45
probably prolonged exposure. Yeah.
Bob Boland 01:48
Well, welcome. Well, anyhow, welcome. Thank you. Thanks for doing this.
Kerry Horrell 01:52
Yeah, we again, I'm so excited. I feel really privileged, we get to talk to the the creator of CPT, again, it's having having learned about it so early in my career and knowing how effective it is. So you you developed this model, you know, as we said, in 1988, I wonder what got you interested in developing it. And specifically, I'm thinking about if you saw a need in the field to kind of do something a little bit different?
Patricia Resick 02:16
Well, when I started, there was no field. So anything you did was different. In 1974, I was an intern in Charleston, South Carolina. And one of the techs, who was working there, was talking about the being in the process of setting up one of the first rape crisis centers in the country. And she said, Would you like to be a rape crisis counselor? Sure. What's that? Being a good little grad student, I went to the library to see what was there and there was nothing. There were four articles on the topic of rape. And two of them were about victim precipitated, right meaning they were blaming the victim. One of them was past pastoral counseling, and one of them was the interruption of the psychoanalytic process by a rape.
Bob Boland 02:57
Oh, my god.
Patricia Resick 02:58
That was it. That was the total sum
Kerry Horrell 03:00
Doesn't seem like particularly useful resources.
Patricia Resick 03:03
Yes, yes.
03:04
But fortunately, when I got back, I did a year in London after I did some months in Charleston. When I got back, the government, NIH had funded $3 million, which in 1975 money, it was a lot to study rape. So while I was doing the second half of my internship in Charleston, I helped write a grant application where we were tracking rape victims longitudinally to see you know, how many of them had problems, what was the you know, in, particularly looking at fear and anxiety, because that was the logical thing to look at. It was considered to be a prominent symptom. Mind you is before there is a PTSD that was actually developed as a diagnosis in 1980. So we were pre diagnosis. And then in January, I went back to University of Georgia to finish my dissertation. And when they were just in the process, we were still working on that grant application. And one of my professors at Georgia asked me if I wanted to also write a grant. So we had two submissions, one doing longitudinal with fear and anxiety, one looking at depression. They both got funded,
Kerry Horrell 04:10
Understandably so.
Patricia Resick 04:12
In the in the meantime, I went to University of South Dakota because by the time I got back, all other jobs were taken in there was very few academic jobs left and I thought, Okay, I want an academic job. I'll go to South Dakota. Unfortunately, it was hard for me to study my topic, because there were a lot more cows than there were people. I stayed there for about four years and flew back and forth to Charleston in Atlanta, where we were doing the other research. And then finally, I ended up moving and I was looking for a city where a university was, which is hard to find a lot of state universities are out in the middle of nowhere. You know, like, that's true. Yeah. So I ended up going to the University of Missouri St. Louis, my two and a half million people in St. Louis. I figured okay, I can keep doing my research. And that's what we had started trying to do. Some treatment research when I was down in Charleston and didn't seem to work too well what we planned. So I started trying to do Stress Inoculation Training, and comparing it with just sort of, you know, psychodynamic Support Group Type groups, because I was working with rape victims from rape crisis centers at the time. And they both worked equally well, until I was not impressed. I was never into anxiety disorders. And by that time, I had worked with enough rape victims that I didn't think of, I didn't think of rape as an anxiety disorder. I mean, granted, that's where they put it, when it came out in 1980. But there were just too many rape victims that said to me, it wasn't that I thought I was gonna die, or that he was gonna really kill me, but because I, you know, had dated him or he was my husband. But what he did was so humiliating. So mortifying, I was so betrayed by this person. And I thought, okay, you get one exception to something you can't just say it's an anxiety disorder. It's got to be more than so I started looking at the work of Aaron Beck and the cognitive therapies. And he had done cognitive therapy for depression, he had done cognitive therapy for anxiety. And I thought that looks like a good approach to me. Except what I wanted was something that was a lot more specific. His true manual for depression was one of the first to come out but it was still, I thought he kind of vague to me, like, what do you actually do? So I set out and thought 12 sessions so that might be something that insurers would fund.
Bob Boland 06:29
Pracitcal way to choose.
Patricia Resick 06:32
I wanted something short, but that would cover all the territory that I wanted. So I experimented around, using some of the worksheets they had done. I also looked at the work of Laurie Perlman and, and some of the work that she was doing. And they were talking about themes that got disrupted as in response to rape, safety, trust, power and control the seeming them. And I thought those should be in there, too. I didn't have a big grand, I had a little grant from the university. So I had to do group treatment to start with, again, very practical, because I could collect more data. And so I wanted to cover all those bases. So I covered all those themes. But those came later in the therapy early on, we worked on the trauma itself. I think by the time I got my first randomized control trial to compare it with prolonged exposure, I had already done 84 pilot cases. Wow. So I knew the therapy work, my grad students got the same kind of results that I did. So then we did, you know, finally published the first trial in 2002. I think it got funded in 1994. So took a long time to collect the data. So that's what got me started. But anything we were publishing on assessment on, on case studies on anything we had was publishable because nobody knew anything. Wow. I mean, people were still at the point where they were saying, rape, is that a problem? What's wrong with that?
Kerry Horrell 07:53
If our audience could see me, I feel like my job has been a little bit on the floor, because for a few reasons, but I mean, yeah, how, how little there was, and then also how long it took to, I mean, just like some of the bureaucracy of developing a treatment protocol like that, gosh, that just what what impressively perseverant work that must have been just yeah, like, stick with it.
Patricia Resick 08:18
They funded that assessment study. But the second part of it was the treatment study, and they would not fund that. So I just kept going. Funding, I kept doing more pilot data until I condensed them. Wow.
Bob Boland 08:28
Yeah. Can you take us through? I mean, so we keep talking about CPT. But we haven't really described it yet. Can you take us a little bit through the model? And, and how you kind of, in a brief summary, how it works in what you do? Yeah,
Patricia Resick 08:41
You heard me mention, Aaron Beck. So it follows under the big umbrella of cognitive behavioral treatment. But with the emphasis on the cognitive, which we were not studying a lot back then I wanted to develop it as, as I said, a session by session protocol, where we're actually teaching the clients that we work with, or patients, whatever you happen to call them in your setting, to learn themselves, how to rethink, in other words, to think about their trauma differently, and then to think about how it's affected their life differently. So it is almost exclusively a cognitive therapy, with the emphasis on Socratic dialogue and getting them to figure out the answers because if you tell somebody is not your fault, they're gonna say, Yeah, sure. People have said that, and they'll go, you weren't there. You don't know.
Kerry Horrell 09:29
Exactly, what what do you know?
Patricia Resick 09:31
So you have to ask them questions so that they can figure out for themselves. They were too small, they were too far away. They were too whatever it was, to be able to stop whatever the trauma was. So of course, we started with rape and then move to child sexual abuse and domestic violence and then any kind of interpersonal and then of course, then we started moving into veterans and in 2003, I moved to Boston and started working a lot with veterans, and we ended up launching the first rollout for CPT. Once Candice Munson had done her first study to show it worked with Vietnam veterans, and that PTSD was in fact treatable.
Kerry Horrell 10:08
A pioneer, I mean, my God, this is so cool to hear about it to dive a little bit more in, it seems like both from my experience with CPT. And also getting to read your new book, there's the clear emphasis within CPT is getting unstuck, like stuck points and like, and this... can you say a little bit more about that, and how, and why this is so important for people with trauma and what you've seen of this as a phenomenon that they just get so stuck, and how you tend to think about helping them through that.
Patricia Resick 10:41
Probably one of the best things I did when I developed the protocol was to start out with what we call the impact statement. Yes. And we had, if I had to get rid of anything else, that would be the last thing I would get rid of. Because they tell you in one session that you could spend six months trying to just listen for, you say, Why do you think this happened? And how has it affected you and they will write you down? Exactly, well, it's my fault, it happened, it happened because, you know, I had a drink, or I wasn't watching where I was going, or I should have run faster, or whatever it happens to be. What I realized, in working with all these pilot cases that I was doing is that they, they tended to have the same thought over and over and over again, it's like whatever they thought of it, the time of the trauma to explain is kind of where they stuck they. And because the symptoms are so strong, the arousal symptoms, the flashbacks and nightmares, these know the strong emotions they are going to avoid. And so in the process of avoiding all that, all those PTSD symptoms, they never rethink their first assumptions about the trauma. Sometimes their assumptions are very childlike, because the trauma happened when they were children. Sometimes it's just because they have this "just world" belief that we're all raised with the good things happen to good people and bad things happen to bad people. So they're assuming you always look to yourself, first, I must have made a mistake, what did I do, and that's where people get stuck. And that's why I thought of it, it was like something was interfering with their natural recovery, the vast majority of people will recover from a trauma, a trauma. Now most of the patients we see have multiple traumas, because you don't go to therapy, it could really help. So that that's usually their last resort. But so usually, you know, we see the people who've had the worst kind of trauma histories. But if they get stuck, it's because they haven't let themselves feel the feelings. They haven't let themselves think about it differently. They haven't, they've avoided instead of approached, and so they isolate themselves, they cut off activities with other people and and the way they're talking to themselves is just keeping them running in a circle. They're keeping themselves stuck. I used to use the term record. Actually, those are coming back. Yeah, I can go back to using the term record. Back
Kerry Horrell 12:59
I have a I have a record player and I love get out. I do I collect records. Well, I do find myself curious about and just what what you might think about this, of how the role of control how control plays a role, I should say in some of these stuck points. And I think just about the idea that, especially when you're a kid, like if it's a child trauma, and something bad happens to you, especially something bad happens to you by someone that you're supposed to trust. My sense is that a lot of people blame themselves because in like this kind of paradoxical way gives them a sense of control rather than like, the world is scary. And the people that I need are not reliable. But maybe if I'm bad, like if I'm just bad, and it was just something I must have done. It seems like a kind of seeking of control and certainty in this otherwise, completely unfair, unjust, uncertain experience.
Patricia Resick 13:49
Right? I mean, I mentioned the the "just world" myth, that that good things happen to good people and bad things happen to bad people. But also human beings really want prediction and control. Yes, they want to believe that you can predict what's going to happen in the future. If I just do this, this will happen. You know, if I'm a good person, this will happen. And they also want control. And so then, of course, people with PTSD may make their lives much narrower because they're trying to control their environments. They're trying to control themselves, their emotions, other people. So yeah, there's a great deal to do with control. Even some of the styles of avoidance they have are about control. I mean, even drinking, if I can't be in control, I'll be totally out of control. Or if I starve myself, that's control, isn't it? I mean, if I can, I can make myself really, really skinny.
Kerry Horrell 14:40
And that's why it feels like such a this work is so courageous for people to do a protocol like CPT because it's like in my mind, not only are you doing something terrifying by by moving past, avoidance and going to, in your mind, the place in which you were terrified and alone and harm, but then Also, again, like I think on this cognitive level, there's also this place of having to face like, if I am not to blame, or if I, you know, whatever the stuck point is that also going to have to do some grief and acceptance that like bad things happen and like, the world is not fair. And I feel like that's like, again, like this meta level of terror. And yeah, I'm just, that's what I'm just thinking about this moment of that this is such courageous work, because there's sort of there's multiple levels of how scary it is to do.
Patricia Resick 15:29
Well, it is. And that's why it takes I mean, it takes a therapist who has been trained to do it and do it well, so that they're reassuring that and I'm hoping that the self help book will do the same thing. I don't know if you've gotten a chance to look at it. But we've tried to lay it out very slowly. Very encouraging. Liana gentle way to help them face what they actually experienced. Unlike the exposure stuff, we don't go into the gory details, we don't look for the blood and guts, we look for where they're where they got stuck, what idea they got stuck on. And so sometimes we have to talk about the trauma just to say, you know, like, Okay, you couldn't get your brother out of that burning house. What happened when you tried to? Well, you know, I went there, and then the heat blew me back, and I couldn't go in the doors or whatever it happens to be. So they have to go through that amount of it. But we don't have to talk about the smells, and the sights and all that kind of stuff. That's not That's not why they have PTSD.
Bob Boland 16:22
So you're talking a bit about how it differs from some of the other treatments? Because like you said, there was nothing was available when you're starting. But there are some other treatments out there now, like at the institutions that last probably the concentration was on trauma focused therapy forum for PTSD and I kind of a different stuff or what's what's, what's the focus?
Patricia Resick 16:42
Usually, TFCBT is referring to a child therapy. Drill, I'm not sure what they're talking about their prolonged exposure, it's definitely going through the event over and over again, but also having people approach things in their environment and staying there until the anxiety decreases. But that prolonged exposure has focused much more on PTSD is an anxiety disorder. Right. And I think when I compared that first RCT, I did the randomized control trial I did was to compare CPT with prolonged exposure which had just come out. They were absolutely the same in terms of PTSD and depression, even over the long haul. We did a long term follow up five to 10 years later, and they were just the same. But guilt, hopelessness, more improvement in suicidal ideation. So some of the more cognitive things did better with CPT.
Kerry Horrell 17:35
It makes me wonder about, you know, we're talking about PTSD, which, you know, our listeners who are primarily mental health clinicians will know that PTSD, you have to fit that criteria and a trauma. But I wonder, when we think about trauma in general, you know, we also have things like attachment trauma, complex trauma, at times kind of sub threshold PTSD, where we're still seeing a lot of those symptoms is a is CPT, just for PTSD. And then kind of following up to however you answered that. Like, when do you know CPT is indicated for a person?
Patricia Resick 18:10
Well, I would include complex PTSD with PTSD. I mean, we don't have it, at least in the US using the DSM. We don't have complex PTSD. I hate it. I want it. Well, the problem is, is that they're doing that over with the ICD, but now nobody has PTSD. They all have complex PTSD.
Bob Boland 18:28
Yeah, it all seems pretty complex to me.
Patricia Resick 18:31
Yeah. And the whole content of complex PTSD is problems with affect regulation, which CPT treats beautifully. And they're not including things that I would think of as complex, like substance abuse. Yeah. And some of the other comorbid disorders like the sleeping disorders or eating disorders, those are complex, multiple traumas, I mean, so they kind of very narrow definition of complex PTSD. And we've always, I mean, all of our patients, we never ruled it back out. So they've always been included in all of our CPT studies. So I don't see too much added with the concept of complex PTSD, I don't think you have to do anything different. In fact, we found there's worse results, if you add stuff at the beginning of the therapy that quote, get people ready for therapy. We've always just launched right into CPT and all we've had 38 randomized controlled trials at this point around the world, not just me, but lots of people, they just launch right into therapy. And when they've looked at doing prep work, the dropout rate is higher. And in the in the VA, they they very, very commonly put people into prep groups, they actually do worse with the evidence based treatment they get, or they don't get it at all to get the prep group and then quit. So if they went straight into the therapy, they did better.
Bob Boland 19:51
You're better off going straight into it. Yeah. Interesting.
Patricia Resick 19:55
Well, I mean, the other I mean, think about it this way, if you do a lot of prep work What message are you giving the patient? You can't handle it. You're too fragile, you're too weak. And you might mean therapist is I'm not ready
Bob Boland 20:11
Let's take this slow.
Patricia Resick 20:12
Sometimes I think it's a therapist stuck point.
Bob Boland 20:16
Well, probably so.
Kerry Horrell 20:17
Well, I mean, it makes me think about a particular population, which is the population of folks with personality disorders, and how you know that that's so often related to trauma. And I wonder is, is there is that at all a rule out for CPT? I think I know the answer to this. But I am curious. I am curious how you think about this of like, people who do have some of those kind of character pathology traits where they might be more resistant to treatment, or they might be at a place where they're some of the again, that underlying personality features are coming up.
Patricia Resick 20:46
You know, we haven't really seen it with personality disorder so much. I mean, we've had people we never ruled out personality disorders, again, from right from the beginning, we had people in that first trial, who had borderline personality we looked at that was not a predictor of treatment outcome, they had higher PTSD to start with, but then they had a steeper slope and actually got better, because we can find them to doing this treatment, and it got them focused. And then when we looked over the long haul, there were a number of personality disorders that decreased over time, you know, as they got better with their PTSD. So it was mediated by the improvement of PTSD. I think severe dissociation might be a place where you might have to do something first, not mild or moderate dissociation, but only there really severe dissociation. Because if they can't sit in the room with you, and stay there long enough to even tell you what happened to them, you might have to spend a few sessions, doing some grounding work, helping them, you know, stand here and now and not dissociate, and so forth. So I think that's probably more important than a personality disorder, per se. That's helped. Yeah, and you know, and obviously, with imminent danger, suicidality, homicideality, if they have to go through, if they're gonna go through withdrawal, if they stopped doing their drugs, or alcohol, I mean, we have stopped in all the military studies we did, we have done a whole series with active duty military, we just stopped rolling out any kind of substance abuse, if they were really severe, they probably would have been out of the military. So we just stopped rolling it out. But when we when we did look at the hazardous drinkers and those, they tended to be binge drinkers, because they didn't, when they were on duty, they weren't drinking, but they would go home and to have a ton that night or on the weekends, they decreased with the CPT. And we have three different studies that shows the same thing they decrease with the PTSD. And and there was a big VA study that just looked at their records of people who got CPT and they also decrease in their substance use. So I think we don't need to worry about some of those other things as much as we thought they did everything we were hesitant about in the beginning and used to rule out or say we need to wait, now we don't wait anymore.
Kerry Horrell 22:57
I really liked that, because I do think that treatments, I do have a bit more structure to them, like like CPT where there is, you know, a certain amount of sessions, and there's a way that the sessions progress. In my mind, there is a tendency for that to correlate with, like, we're only treating, you know, like, this is only for people with just depression. And, you know, it's a lot of ruling out and ultimately, like a lot of our folks, especially with trauma, it is complex, there is you know, comorbid depression, eating disorders, substance use, like there is just so much and so the fact that the treatment, didn't like rule them out, and just like we're gonna focus in on this thing, and and we're seeing other things get better. I think that's very cool.
Patricia Resick 23:35
Yeah, we've had a couple of people in who had multiple personality disorder in that first trial. We didn't rule that out because it wasn't in our rollouts. It was helpful is still Yeah, I mean, we didn't measure their dissociative disorder, but we looked at their PTSD. And they got better on their PTSD. They just ignored the I didn't happen to be their therapist, but the person just sort of ignored it and treated the main drama.
Bob Boland 23:59
Can you say a bit of just about the general acceptance of this when it's posed to people as a treatment? Because they I mean, I don't know, just maybe just my own bias and stuff, I found that sometimes hard to get people with PTSD in the therapy usually been through a few that haven't helped. And then they end up instead on a lot of medications that definitely don't help. Yeah. So and you kind of get into this kind of cycle of that.
Patricia Resick 24:20
Yeah, I think how you explain the therapy. And, and, and that you're not going to ask them for all the gory details, you're not going to ask them to revisit because we've already done the research that shows that the doing the accounts is the way I had started it but then we did a dismantling study, and it actually delayed their improvement. They started improving faster if they didn't do the accounts, and we went straight into the Socratic questioning. Gotcha. If you explain what the therapy is, and that we're gonna hand the therapy over to them by about Session Four, and you know, like they're gonna be taking the lead on it. I mean, that's what led us into doing the self help book. Finally, it's like there's so many people who can't get a therapist, they can't afford it.
Bob Boland 25:03
They don't have access. Yeah,
Patricia Resick 25:05
waiting lists have gotten longer and longer. And so then we thought, well, this is what we're teaching them anyway. Maybe we could reach him just directly. Of course, sometimes you need somebody behind you pushing you and gently to stay with it. And we have places in the book where we say, if you're, if you're not doing this, if you just stuck it up on the shelf, then you need a therapist.
Bob Boland 25:27
Yeah. And what's your sense of how I mean, along those lines? How available is I mean, obviously, we're the center where we do it. And so it's kind of an you know, we're lucky here, but is it in major centers and academic or in outside, I mean, outside of the VA?
Patricia Resick 25:43
Well, yeah, we've trained 11,000 People in the VA, but a lot of them have left the VA. So when they go into other practices, they take it with them, I can't remember how many 1000 people we have, we have a website where the providers are listed for every state. And so if they go to CPT for ptsd.com, they can go into the provider list and see if there's somebody in their state, or in their city or whatever they want to do it in person, they would look for somebody in town, but with telehealth, you can get anybody who's licensed in your state. And now with licensure starting to cut across states, we need we need to get something in there. We don't have that yet. Because sometimes people are licensed in many states.
26:28
So CPTforPTSD.com Yes,
26:31
just small letters, CBTforPTSD.com. For providers, we have all sorts of resources in terms of, you know, handouts, and stuff and, and, and lists of when there's workshops and things like that, but I think for for the for potential patients and clients there. We now because of the self help book, have a whole list of whiteboard videos that show you how to fill out all the forms and everything. And there's video examples and all that kind of stuff. We have an online course for therapists that helps where they can week, I think we have 36 videos in that course, that shows various aspects of doing CPT. So I think it's becoming more available. Strong star, the consortium that I was working with, with the active duty military has a training division now. Katie dondon, and Bill is leading. And they started by getting foundation money, I think it was just from one source to begin with. But now they have three or four different sources of funding. And they used to just do training in Texas for people who were treating, or possibly treating veterans, like even community mental health centers, because sometimes people don't want to go to a VA or it's too far away, especially in a big state like Texas. So they were doing it there. But now they've done it in I think 20 states. So there's lots of people being trained.
Kerry Horrell 27:51
I'm almost positive they're the folks who train Menninger, the ones who just even did our most recent training.
Patricia Resick 27:56
Yeah. Oh, that was that was through that. Training Initiative. Okay.
Kerry Horrell 28:02
You know, you've alluded to this. So this might feel like a silly question. But I am curious if, you know, let's say people are listening at this point, and they still haven't. They're like, I'm not I still not sure about the CPT thing. I wonder if you want to speak a little bit to the efficacy and the benefits that I know, again, there's probably so much research out there on this, but there is a general trends we've seen with with how beneficial it is.
Patricia Resick 28:23
Well, I mean, just as an overall it works better. It tends to work better with civilians than it does with military. We know that having some cognitive flexibility in the patient helps. In other words, they're able to change their mind. They're not just like, rigidly adhering to something. Sometimes I think people in the military have been trained to have PTSD. They they get trained in stuck points. Like, if y'all do your jobs, y'all come home. Yikes. Point. Yeah, you are responsible for your men. You know, they're just a number of things that people are, you know, like, stay alert, stay alive, like, well, let's teach people to be hyper vigilant. Exactly. So I think I think sometimes it's a setup that they train people to go into combat, but they don't train them when they come out of combat, undo some of those beliefs. And so I think sometimes they get stuck on the very things they've been trained in things that were absolutely impossible for them to have foreseen or prevented. But anyway, we do tend to see civilians do better. We now usually do variable lengths. Some people don't even need to have sessions. That wasn't something in some magic number. among civilians, it tends to be 910 sessions, typically. We've seen people do it as a texting, piloting a texting format for the therapy, or people who do it in a week or two, and they get, you know, daily sessions for a week or two and they're done with it in a couple of weeks. So they can do it, take a vacation or take sick leave and and get the therapy all done quickly. And it works, lower dropout rates and it works just as well. Yeah, we know lots about who it's going to work for, first of all they have to do To practice assignments, yeah, there are some therapist variables. But in terms of the patient's themselves, they, it's really well, it's really important for the therapist to emphasize doing the worksheets, but they didn't have to have the competence to actually work with them and do the good Socratic questioning. And that's where the training comes in. Because if you haven't been trained to, to be able to not just ask rhetorical questions, or try to convince them to change their minds. And I think that that makes a difference.
Bob Boland 30:28
Yeah. And how do you define success there? Is the goal just to not be stuck and to be more functional? Or how do you see it?
Patricia Resick 30:34
Oh, it's several things. I mean, we usually in our research, we measure, you know, loss of PTSD diagnosis that they've they've had a clinically significant drop in their symptoms on these variable length studies we've done where where they can have, you know, they stopped when they get to what we call a low end states, which would be like a BDI, below 10. And at low PCL score, like below 20, on the PCL, and then you talk to them about Are you done? Or do you want to keep going, and if if they're really stuck, you might say, I think we need a few more sessions, you've got a core belief here that started in early childhood, like, I'm always a failure, because your mom always said, You're a failure, you're a failure, you're a failure. And so maybe they have to sand that out because it's fixed. And so, you know, really keeping an eye on where they are, and whether they're doing the self help book, and they're monitoring their own scores, or whether it's the therapist really keeping an eye on good and state, not just a loss of diagnosis, but really good functioning, not having PTSD anymore, getting on with your life, being able to set new goals and get back on your developmental track.
Kerry Horrell 31:44
Yes, I mean, and again, just want to highlight this book, getting unstuck from PTSD, using cognitive processing therapy to guide your recovery. What a cool resource again, that people would be able to do some of this work on their own, that makes it so accessible. And, again, just so appreciative of your other work.
Bob Boland 32:02
I do want to Yeah, thank you for everything you've done. I mean, I certainly being older, I trained at a time when PTSD was considered largely untreatable.
Patricia Resick 32:02
Yeah, isn't that amazing. That's where I started, too.
Bob Boland 32:06
But you did something about it. So we've been listening again to Dr. Resick. And we're gonna give you the last word, what do you want to leave our, with our listeners with?
Patricia Resick 32:25
Well, I was glad glad you brought up the self help book that as I said, there's a lot of people who either are put on long waiting lists now or, and I'd rather them not get parked in some kind of a prep group. They might as well start the work themselves. I mean, even if they're going to see a therapist eventually. So the therapists could work with them as far as they've gotten in the book, and it might shorten the course of therapy. But you know, there's people who just don't have access to even a tablet to do the the telehealth. By the way, telehealth works just as well as in person.
Bob Boland 32:57
I think you implied that but I'm glad you said that. Yeah,
Patricia Resick 33:00
It's amazing. And we've even done group telehealth so you can get, you know, 8 or 10 people on a screen like on a zoom screen and you're all talking to each other and you could be all over the state.
Bob Boland 33:12
That's so optimistic. I'm so glad to hear. So. We've been your hosts. This is the Mind Dive Podcast. I'm Bob Boland.
Kerry Horrell 33:18
I'm Kerry Horrell and thanks for diving in! the Mind Dive Podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.
Bob Boland 33:31
For more episodes like this, visit www.MenningerClinic.org.
Kerry Horrell 33:36
To submit a topic for discussion, send us an email at podcast@menninger.edu
