2016 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
(DCoE) Summit
September 13 - 15, 2016
“Medically Ready Force…Ready Medical Force”
Presenter(s) Biography
Dr. Joseph Maio is the Chief
of the Trauma Intensive
Outpatient Program at
Landstuhl Regional Medical
Center. His doctorate is in
Clinical Psychology from the
University of Alabama. He
leads the team of clinicians
and military personnel
specializing in the
treatment of combat
trauma as well as sexual trauma. He has
served as the Chief of the Trauma Intensive
Outpatient Program for the past 3 years. His
area of interest is the application of Cognitive
Processing Therapy in group modalities.
Dr. Jorgensen-Wagers is a
Licensed Clinical Mental Health
Counselor and Rehabilitation
Counselor. Her doctorate is in
Rehabilitation Counseling from the
University of Texas at Austin. She
is a former therapist in the Trauma
Intensive Outpatient Program and
has served formerly as the
Rehabilitation Psychologist for the
Traumatic Brain Injury Clinic at
Landstuhl Regional Medical Center. She presently serves as
the Senior Clinical Research Director for the Defense
Veterans Brain Injury Center at Landstuhl. Her areas of
interest are in goal attainment scaling and functional
rehabilitation outcomes for individuals with psychiatric
disabilities and traumatic brain injury. She is certified in
Cognitive Processing Therapy.
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Learning Objectives
∎ At the conclusion of this presentation the participants will be
able to:
o Illustrate the process of group CPT in the intensive outpatient program
at Landstuhl.
o Distinguish the utility of group cognitive processing therapy for their
patients with PTS and mTBI.
o Formulate strategies to implement group cognitive processing therapy.
o Evaluate the clinical utility of cognitive processing therapy.
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Efficacy of Cognitive Processing Therapy for
Comorbid PTS mTBI Patients in Group Therapy
Joseph E. Maio, Ph.D.
Chief, Trauma Intensive Outpatient Program
Kendra L. Jorgensen-Wagers Ph.D
Senior Clinical Research Director
Landstuhl Regional Medical Center
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Disclosure
The views expressed in this presentation are those of the
presenters and do not reflect the official policy of the
Department of Defense, The United States Army, or the United
States Government.
 The presenters have no relevant financial relationships to disclose.
 We do not intend to discuss devices, products, or procedures which
are off-label, unlabeled, experimental, and/or investigation (not FDA
approved).
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Acknowledgements
This work is the result of the combined clinical
expertise of a number of outstanding personnel at
Landstuhl Regional Medical Center. We wish to thank
the following additional team members:
Cynthia Brooks, Ph.D.
Kelly Meade, LCSW
Bob Maradei, RN
SGT Melissa Bates
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Learning Objective #1
History of the TRIOP Program at Landstuhl Program started in March 2009 for combat and
deployment related trauma as an 8 week program (now
6 weeks).
 Sexual trauma track launched in 2014. 4 cohorts since
then.
 Generally try to run 2 concurrent cohorts, but staffing
has often limited us to one cohort at a time.
 Combat tracks take precedence.
 Staffing has included clinical psychologists, social
workers, licensed counselors, and nurse case managers.
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Learning Objective #1
The foundation of clinical treatment is the Evidence based
therapy: cognitive processing therapy (Chard et.al. 1999,2010,2011,2012)
The process of group CPT in the intensive outpatient program at
Landstuhl is:
- 6 week long program- 3x a week. 90 minute sessions
- Co-facilitated sessions
- Group membership 4-8 combat trauma or sexual
trauma patients
-Active duty. Mixed gender (combat). Single gender
(sexual trauma).
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Learning Objective #1
Cognitive Processing Therapy is only one component of the
TRIOP Program.
 Other groups include: social communication,
relationships, grief and loss, process groups.
 Altogether about 30 hours of face to face treatment per
patient including group and individual therapy sessions.
 Integrated group schedule allows for connection between all groups of the material discussed.
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Learning Objective #2
The typical outcome measure in treatment programs is the PCL.
The PCL is useful but has significant limitations:
 It has face validity and may be subject to a patient’s
conscious or unconscious inflation of scores related to
other considerations.
 In our program we often see PCL scores that are not
consistent with observed changes in patient
presentation and behavior.
 It also is not consistent with the self-described changes
that patients have seen in each other and themselves.
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Learning Objective #2
Another complication of the PCL is that different versions use
different scoring protocols.
To address this, we transformed the PCL-C, PCL-M, and PCL-5
scores into percentages of possible scores.
Our data show significant improvement from admission to
discharge.
Furthermore the improvement seems to be sustained over time.
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Learning Objective #2
Percentage of Possible PCL Score
(Follow-Up Data)
75
70
65
60
55
50
Admission
Discharge
Follow-Up
73
59
55
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Learning Objective #2
Because of concerns that the PCL was not fully representing the
clinical changes our patients were demonstrating, we looked for
another way to measure outcomes.
We wanted a measure that would be specific to the cognitive
elements of recovery that we were promoting with CPT as our
primary treatment model.
Our solution?
- THE STUCK POINT INVENTORY
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Objective #2
The Stuck Point Inventory measures 99 common stuck points.
 Patients rate each 0-100 based on how accurate they believe these
statements to be to themselves.
 Ratings are obtained at the beginning of treatment and the end of
treatment.
 The Stuck Points are grouped into the five key schema of the CPT
framework: Safety, Trust, Power/Control, Esteem, Intimacy
 In addition we added a sixth schema based on our clinical experience
with our patients: Responsibility and Blame.
 We can then look at changes in endorsement of Stuck Points from
Admission to Discharge.
 These data gave a more direct assessment of the changes we expect to
see as a result of patients using CPT.
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Objective #2
Sample statements from the Stuck Point Inventory
include:
Schema
Sample Item
Responsibility and Blame
I am to blame for what happened.
Safety
I have to be hypervigilant all the time in order to stay safe.
Trust
I can’t trust anyone.
Power/Control
I have no influence over what other people do to me.
Esteem
I am a bad person.
Intimacy
If I let other people get close to me, they’ll hurt me.
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Objective #2
Our data strongly support that patients dysfunctional beliefs shift
significantly as a result of CPT.
Schema (Average Ratings)
Responsibility and Blame
Safety
Trust
Power and Control
Esteem
Intimacy
Combined
Pretreatment Posttreatment Difference
32.48
25.63
6.87
56.96
40.58
16.25
48.71
33.10
15.47
58.16
40.94
16.98
50.58
33.17
17.30
63.53
42.44
21.04
52.85
36.47
16.25
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Learning Objective #2- Utility of CPT in
Group
We also see changes in the patients’ overall
endorsement of Stuck Points.
Highly Rated Items on 0-100 Scale
Pretreatment Posttreatment Difference
Number Rated >= 75
40.25
19.21
21.04
Number Rated >= 50
59.61
40.88
18.73
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Learning Objective #2- Utility of CPT in
Group
Another aspect of assessing outcome deals with the
patient’s openness to change.
To the degree that groups are open to CPT process (as
seen on the following slide) there appears to be an
overall synergy of effort where everyone benefits in
part from the openness of the process—or conversely
is limited by the resistance.
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Learning Objective #2- Utility of CPT in
Group
Our data validate what we already know as clinicians—that openness to
change is critical to the patient’s success in treatment.
65.00
60.00
55.00
Comparison of Resistent vs. Open Teams (PCL-5 Scores)
57.67
54.75
50.00
49.88
Resistant
Open
45.00
40.00
40.00
35.00
Pretreatment
Posttreatment
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Learning Objective #2
Another way to look at the impact of CPT on recovery is to look at long-term
use of CPT and patient outcomes.
The more often patients use CPT the lower their symptoms and the more
positive experiences they have!
CPT Use and Negative Sx
(lower is better)
25.00
20.00
15.00
10.00
5.00
0.00
Negative Sx
None
Occasional
Often
Very Often
21.00
18.57
20.43
13.25
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Learning Objective #2
This graph also shows that the more often patients use CPT the
more positive experiences they have!
CPT Use and Positive Experiences
(higher is better)
35.00
30.00
25.00
20.00
15.00
Pos Experiences
None
21.00
Occasional
24.29
Often
20.71
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Very Often
32.25
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Learning Objective #3- Strategies to
Implement Group CPT
o Develop strong co-facilitation team
o Develop effective tool for appreciating base-line
stuck points
o Build closed group model that allows for
considerable process and group interaction time.
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Learning Objective #4- Strategies for Future
Implementation and Evaluation of Group
CPT effectiveness
o We are constantly seeking ways to enhance our understanding
of the group CPT process and variables that affect patient
outcomes:
-Consideration and inclusion of intragroup evaluation
process throughout the program.
-Inclusion of Group Facilitators’ Group Rating Scales or
other tools for rating participant engagement.
-Utilization of feedback for individual use and effectiveness
of CPT.
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References
Chard, K. M., Resick, P. A., & Wertz, J. J. (1999). Group treatment of sexual assault survivors. In B. H. Young & D.
D. Blake (Eds.), Group treatments for post-traumatic stress disorders: Conceptualization, themes,
and processes (pp. 35–50). Philadelphia:Brunner/Mazel.
Chard, K.M., Schumm, J.A., Owens, G.P., & Cottingham, S.M. (2010). A comparison of OEF and OIF Veterans and
Vietnam Veterans receiving cognitive processing therapy. Journal of Traumatic Stress. 23, 25–32.
Chard, K.M., Schumm, J.A., McIlvain, S. M., Bailey, G.W., & Parkinson, R. B. (2011). Exploring the efficacy of a
residential treatment program incorporating cognitive processing therapy – cognitive for Veterans
with PTSD and traumatic brain injury. Journal of Traumatic Stress, 24, 347–351.
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References
Chard KM, Schumm JA, McIlvain SM, Bailey GW, Parkinson RB. (2011) Exploring the efficacy of a residential
treatment program incorporating cognitive processing therapy-cognitive for veterans with PTSD
and traumatic brain injury. Journal of Trauma Stress. 24(3):347–51. [PMID:21626573]
http://dx.doi.org/10.1002/jts.20644
Chard, K. M., Ricksecker, E. G., Healy, E. T., Karlin, B. E., & Resick, P. A. (2012). Dissemination and experience
with cognitive processing therapy. Journal of Rehabilitation Research & Development, 49, 667– 678.
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Post-Test and CE Evaluation for
CE Credit
 To qualify to receive continuing education (CE) credit(s), you
must have registered for the summit before 11:59 p.m. (PT)
on September 15, 2016.
 To obtain CE(s), you must complete the post-test and CE
evaluation after the conclusion of the session at
http://dcoe.cds.pesgce.com.
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