Cognitive Processing Therapy Versus Schema Therapy in the Treatment of PTSD among Military Veterans: Design of a Randomized Clinical Trial and Patient Preferences for Treatment

Amirpour, B., Badri, A., Aghayousefi, A., Alipour, A., & Zare, H. (2017). The effect of       cognitive processing therapy and schema therapy on marital satisfaction and avoidant coping in war veterans with chronic post-traumatic stress disorder. Journal of Nursing and Midwifery Sciences, 4(2), 1–10. http://jnms.mazums.ac.ir/article-1-121-en.html

Summary by: Alara Dogan

Introduction

Post-traumatic stress disorder (PTSD) does not impact only the internal state of the individual—it pervades the quality of their most intimate relationships, weakening emotional connections and instating patterns of avoidance. This pattern can especially be seen among veterans, whose combat-related trauma frequently presents as a disruptive subcurrent in their interpersonal lives. Amirpour et al. (2017) aimed to test whether two trauma-sensitive psychotherapies, Cognitive Processing Therapy (CPT) and Schema Therapy (ST)’ had a positive impact upon veterans with chronic PTSD, enhancing marital satisfaction and diminishing avoidant coping. While CPT is formalized and trauma-based, ST addresses more generalized early maladaptive schemas and overall psychological functioning. The central research question was clinically pertinent as much as it was humane in its scope: can we heal relational breaks by addressing the origins of trauma?

 

Methods

This semi-experiment involved 34 male Iran-Iraq war veterans from Kermanshah. Participants were initially screened with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, then required to have met criteria for PCL-M-PTSD (Post-Traumatic Stress Disorder Checklist—Military Version). Following exclusion, veterans were assigned randomly to three groups: CPT (n = 10), ST (n = 12), and a control (n = 12) group. The interventions involved group delivery, CPT in 12 sessions with a formal structure, ST being a modification of Young’s schema style. Outcomes were measured with GRIMS (Generalized Responsibility Inventory for Marital Satisfaction) for marital satisfaction, as well as with escape-avoidance subscale Coping Styles Questionnaire. Repeated-measures ANOVA was conducted in SPSS version 22, which monitored intra-group variance assumptions as well as group-time interactions.

 

Results

ST, as well as CPT, obviously surpassed the control group in both increasing marital satisfaction (p < .05) and decreasing avoidance coping strategies. Yet, CPT resulted in greater, more persistent decreases in avoidance symptoms, with post-test scores along with follow-up avoidance scores consistently showing improvement. ST, too, evidenced a short-term gain in marital satisfaction, but these gains faded over time. Demographic factors like age, wartime participation, as well as percentage of disability, remained evenly balanced, making findings more dependable.

 

Discussion

These findings align with clinical experience: directly engaging with the trauma, as CPT does, seems more to break up avoidance processes than more global interventions. The use of written exposure, along with cognitive reframing in CPT, perhaps allowed participants to engage with and reframe trauma memories, to decrease emotional numbing, and to bolster coping. Alternatively, ST’s overall emphasis upon schemas should increase short-term interpersonal understanding but should not adequately challenge avoidant behavior specific to trauma.

 

What I found most interesting in this research was its emphasis on relational outcomes, coping style, as well as marital satisfaction, over symptom severity. These are concerns that most often bring clients into treatment, but they have not been adequately represented in research. The conclusions indicate that CPT can lead to more stable relational gains by directly confronting avoidance, a fundamental aspect of PTSD.

 

Limitations

There are, naturally, some limitations to bear in mind. The all-male, combat exposed sample limits the generalizability. Group-based formats also might not generalize to comparable gains in individual contexts, and statistical significance found might not represent fully appreciable, clinically meaningful change for everyone. The research design didn't account for lifetime histories of trauma exposure or for prior psychiatric illness that can influence responsiveness to treatment.