An Evaluation of Cognitive Processing Therapy for the Treatment of
Posttraumatic Stress Disorder Related to Childhood Sexual Abuse
Kathleen M. Chard
Cincinnati VA Medical Center and University of Cincinnati
This study compared the effectiveness of cognitive processing therapy for sexual abuse survivors
(CPT-SA) with that of the minimal attention (MA) given to a wait-listed control group. Seventy-one
women were randomly assigned to 1 of the 2 groups. Participants were assessed at pretreatment and 3
times during posttreatment: immediately after treatment and at 3-month and 1-year follow-up, using the
Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (D. Blake et al., 1995), the Beck
Depression Inventory (A. T. Beck, R. A. Steer, & G. K. Brown, 1996), the Structured Clinical Interview
for the DSM–IV (R. L. Spitzer, J. B. W. Williams, & M. Gibbon, 1995; M. B. First et al., 1995), the
Dissociative Experiences Scale-II (E. M. Bernstein & F. W. Putnam, 1986), and the Modified PTSD
Symptom Scale (S. A. Falsetti, H. S. Resnick, P. A. Resick, & D. G. Kilpatrick, 1993). Analyses
suggested that CPT-SA is more effective for reducing trauma-related symptoms than is MA, and the
results were maintained for at least 1 year.
Keywords: PTSD, child sexual abuse, cognitive therapy, trauma, treatment
Several therapies have been introduced over the past 20 years
for the treatment of psychological symptom responses to interper-
sonal violence, for example, cognitive processing therapy, stress
inoculation training, and prolonged exposure. Most of this research
has focused on rape survivors, demonstrating that cognitive–
behavioral interventions that include some type of reprocessing of
the traumatic event are highly effective in reducing symptoms of
posttraumatic stress disorder and other trauma related sequelae
(Foa, Keane, & Friedman, 2000). In addition, the significant
amount of research comparing the efficacy of different types of
cognitive–behavioral interventions for rape survivors has allowed
investigators to identify which personal or event-based character-
istics could make someone a better candidate for one treatment
over another (e.g., Resick, Nishith, Weaver, Astin, & Feuer, 2002;
Riggs, Rukstalis, Volpicelli, Kalmanson, & Foa, 2003). Unfortu-
nately, less attention has been given to the treatment of adult
survivors of childhood sexual abuse, perhaps due to the impact that
the abuse can have on the development and creation of enduring
schemas and personality characteristics that are more difficult to
address in therapy.
Initial studies on the treatment of childhood sexual abuse sur-
vivors often did not use treatment manuals, have a solid theoretical
paradigm, and typically did not examine the impact of treatment
interventions on the symptom responses most commonly associ-
ated with abuse, including posttraumatic stress disorder (PTSD)
(e.g., Alexander, Neimeyer, Follette, Moore & Harter, 1989). The
Diagnostic and Statistical Manual (4th ed, DSM–IV; American
Psychiatric Association, 1994) field trials (Roth, Newman, Pelco-
vitz, van der Kolk, & Mandel, 1997) reported that PTSD is the
most commonly prevalent lifetime Axis I disorder seen in child
abuse samples, with rates ranging from 20% (PTSD only) to 53%
(PTSD and complex PTSD). However, additional studies have
documented the cooccurrence of other disorders or symptoms that
can make treatment very difficult, including depression and dis-
sociation, not to mention personality disorders (Johnson, Pike, &
Chard, 2001; Zlotnick et al., 1994). In addition, child abuse sur-
vivors can have attachment, communication, sexual intimacy, and
social adjustment issues that may not be as prevalent in rape
survivors. These differences need to be accounted for in treatment
protocols under examination.
More recent forays into the treatment of abuse survivors have
used theoretically based manuals adapted from rape survivor stud-
ies, with some initial success (e.g., Skills Training in Affect and
Interpersonal Regulation/Prolonged Exposure, STAIR-PE; Cloitre,
Koenen, Cohen, & Han, 2002). Unfortunately, some of these
authors have reported high dropout rates in their treatment proto-
cols even with the addition of coping skills building exercises,
such as the Dialectical Behavioral Therapy affect regulation mod-
ule (Linehan, 1993). Thus, researchers are still trying to identify
efficacious treatment models for adult survivors that are associated
with statistically and clinically significant results, as well as high
levels of treatment completion.
In the past, treatments for survivors of interpersonal violence
have used either a group or an individual treatment modality (Foa
et al., 2000). Recently, more focus has been on individual inter-
ventions that allow recapitulation of the traumatic event and re-
Kathleen M. Chard, PTSD Division, Cincinnati VA Medical Center and
Department of Psychiatry, University of Cincinnati.
The data for this study was collected as part of a treatment outcome
study funded by the National Institute of Mental Health Grant
1R21MH56633-01. I thank Patricia Resick, Terri Weaver, Gina Owens,
Dawn Johnson, Rich Gilman, Rebecca Kayo, Julie Pike, Andrea Blount,
Danielle Oakley, Rebecca Elliot, and Jan Wertz for their assistance with
Correspondence concerning this article should be addressed to Kathleen
M. Chard, Cincinnati VA Medical Center, PTSD Division, 3200 Vine
Street, Cincinnati, OH, 45220. E-mail: firstname.lastname@example.org
Journal of Consulting and Clinical Psychology
2005, Vol. 73, No. 5, 965–971
Copyright 2005 by the American Psychological Association
0022-006X/05/$12.00 DOI: 10.1037/0022-006X.73.5.965
move the risk of secondary traumatization caused by hearing the
detailed histories of other trauma survivors in a group setting.
Although individual therapy can provide ample opportunity for
processing and challenging cognitions, it cannot provide the same
normalizing, universalizing, and useful social dynamics as group
therapy. The combination of group and individual therapy may
help to decrease the number of dropouts by providing clients with
individual time to process, as well as cohesion, normalizing, and
universalizing with other women in the group milieu. In individual
therapy, clients are able to talk at length about the abuse while
building a therapeutic relationship with one of the group coleaders.
Individual therapy also offers the survivor the opportunity to more
fully integrate group materials, through the process of repetition.
Thus, in group therapy, clients may talk about homework assign-
ments, current important issues, and symptom experiences and
practice new tools to aid in their recovery. I was unable to identify
any literature evaluating a combined group and individual treat-
ment model for abuse survivors that addressed PTSD, depression,
dissociation, and related symptom disturbances in the format of a
brief manual. The following randomized controlled study was
conducted to examine the utility of a combined group and indi-
vidual cognitive–behavioral intervention that was specifically de-
signed to address issues salient for abuse survivors.
Participants were recruited through community advertising, letters to
physical and mental health professionals, and presentations at local mental
health facilities. Eighty-seven women were formally assessed for inclusion
in the study. Sixteen of these individuals were judged inappropriate or
changed their minds about participating in the study. Inclusion criteria for
entry into the study included a diagnosis of PTSD, at least one incident of
child sexual abuse as defined by state law, and at least one memory of the
abuse. Exclusionary criteria included current trauma, substance depen-
dence, suicidal intent, or other impeding medical conditions (e.g., undiag-
nosed seizure disorder). Individuals taking prescription medication were
accepted into the study if they were stable on the medication for at least 3
months before treatment. Participants with a history of substance depen-
dence were included in the study if they maintained sobriety for 3 months
following a detoxification treatment. Seventy-one women entered into the
study (36 in the active treatment group and 35 in the minimal attention
(MA) wait-listed control group). Ten individuals who completed MA chose
to enroll in active treatment after completion of the MA condition. Eight
individuals (6 with treatment only and 2 with treatment after MA) dropped
out of the treatment condition (18%), and 7 dropped out of the MA
No differences were found between individuals assigned to treatment
and the wait-listed control group, so aggregate data were reported. The
mean age of the women at treatment was 32.77 years (SD ? 8.87) with a
range from 18 to 56 years. The educational level ranged from 8 to 20 years,
with a mean of 13.83 years (SD ? 2.39). Forty-one percent reported an
income below $10,000, 52% below $30,000, and 3.5% above $50,000.
Ethnicity of this sample was as follows: 14% were African American (n ?
12), 81.4% were White (n ? 70), 3.5% were Hispanic, Latin, or Mexican
American (n ? 3), and 1% identified as “other” (n ? 1). The following
abuse characteristics were found in the sample. The participants reported
the average age at onset of abuse was 6.4 years (SD ? 2.78); and 21%
indicated that there were between 1 and 5 incidents of abuse, 12% reported
between 6 and 10 incidents, and 10% reported between 11 and 30 inci-
dents; 57% reported more than 100 abuse incidents. Thirty-five percent of
the sample indicated having had only 1 abuser, 63% more than 2 abusers,
and 2% innumerable perpetrators. Forty-eight percent indicated they were
abused by a relative, 16% by a nonrelative, and 36% by a relative and a
nonrelative. Finally, 94% reported kissing and fondling, 58% indicated oral
sexual contact, and 57% reported penetration. Also of note was the finding
that 40% of the participants met criteria for current major depression.
Participants were initially screened using a phone survey designed to
rule out individuals who met the exclusionary criteria. After the phone
screen, eligible women were asked to take part in a 3–5 hr assessment
session including both interviews and self-report scales. All participants
who attended the assessment session gave informed consent to be in the
study using institutional review board–approved measures and procedures.
All therapy and assessments were conducted at the Center for Traumatic
Stress Research, a university-based clinic focusing on the research and
treatment of PTSD. Research assistants blind to the assigned condition of
the subject conducted all interviews, and treatment completers were asked
not to mention having been in therapy at posttreatment assessments.
Participants were paid $50 for each assessment session. The following
measures were included in analyses for this article.
PTSD Scale for DSM–IV: One-Week Symptom Status Version (CAPS-SX;
Blake et al., 1995) is a 30-item interview measure used to assess the
frequency and intensity of specific PTSD symptoms during the past week
and the impact these symptoms have had on social and occupational
functioning and to provide a global scale score of PTSD severity for
diagnostic purposes (Blake et al., 1990). Symptom frequency is rated on a
5-point continuum that ranges from never (0) to daily or almost every day
(4). Intensity is similarly measured and ranges from no experiencing of the
symptom (0) to extreme experiencing of the symptom (4) (Blake et al.,
1995). The test was found to have excellent psychometric properties and
has been used extensively in PTSD treatment outcome studies.
Structured Clinical Interview for DSM–IV Non-Patient Versions-I and II
(SCID-I; Spitzer, Williams, & Gibbon, 1995; SCID-II, First et al. 1995).
The SCID is a diagnostic interview developed to assess DSM–IV disorders.
The SCID has been used in multiple studies of PTSD and victimization and
when used by a trained staff has adequate interrater reliability and test–
retest reliability (Maffei et al., 1997).
Standardized Trauma Interview (Resick, Jordon, Girelli, Hutter, &
This standardized structured interview was
adapted from the version previously used by its creators in a cognitive
processing therapy study involving rape victims. The measure included the
following topics: information about the sexual abuse, information on PTSD
Criterion A events and/or potentially stressful events, within-crime reac-
tions, social support, and treatment history. At the follow-up assessment,
the modified version of the interview included questions regarding any
treatment received since the posttreatment assessment and any other sig-
nificant life events.
Sexual Abuse Exposure Questionnaire, Part 1 (SAEQ; Rowan, Foy,
Rodriguez, & Ryan, 1994).
The SAEQ Part 1 is a 10-item self-report
measure designed to assess sexual acts experienced before the age of 16.
Researchers have found that individual items exhibit moderate to high
test–retest reliability (from .73 to .94) with an overall kappa coefficient of
Modified PTSD Symptom Scale (MPSS; Falsetti, Resnick, Resick, &
The MPSS is a 17-item self-report measure of post-
traumatic stress disorder used to assess PTSD levels every other session
during therapy as well as at all other assessment points. In accordance with
the DSM–III, the 17 test questions are clustered into reexperiencing,
avoidance, and arousal symptoms. Foa, Cashman, and Jaycox (1997) found
the measure to have an internal consistency of .91, and test–retest reliabil-
ity of .74. Good concurrent validity has been shown with the following
measures: Impact of Event Scale (IES; Horwitz, Wilner, Alvarez, 1979)
avoidance subscale, .53, IES intrusion subscale, .81; Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), .80;
Reduced Array Selection Test (RAST; Margolis, 2000), .81; State Trait
Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970) trait,
.56; STAI state anxiety, .52. They also reported good convergent validity,
with sensitivity reaching 62% and specificity reaching 100%.
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996).
The BDI-II is a 21-item self-report test measuring severity of depression.
Test questions are intended to correspond with criteria in the DSM–IV for
depression. Beck et al. (1996) report internal consistency for outpatient
populations at .92 and test–retest reliability for outpatients to be .93. This
measure has been frequently used in treatment outcome studies for survi-
vors of interpersonal violence.
Dissociative Experiences Scale-II (DES-II; Bernstein & Putnam, 1986).
The DES-II is a 28-item self-report scale that quantifies the frequency and
intensity of a wide range of experiences that are indicative of absorption,
dissociation, derealization, amnesia, and depersonalization. Factor analyses
(Carlson & Putnam, 1993) supported only factors representing general
dissociative tendencies. Subjects respond on a scale from 0 to 100, with
increments of 10. The DES-II score is an index of the average frequency
of dissociative experiences (range 0–100).
Design and Treatment Overview
The study was conducted over a 3-year period to allow time for 3-month
and 1-year follow-up data to be collected. Eligible participants were
randomly assigned to the CPT-SA (active treatment condition) group or the
MA (control condition) group after completion of the assessment proce-
dures. Both conditions lasted 17 weeks and after completion of the post-
assessment, individuals in the MA condition were offered inclusion in the
active treatment protocol. Six groups were conducted, each by two female
therapists, with group members randomly assigned to one of the group
therapists for completion of the individual therapy sessions at the same
CPT-SA is an adaptation of Resick and Schnicke’s (1993)
cognitive processing therapy for rape victims and was designed to focus on
the areas of trauma symptom response that appear to be commonly found
in child abuse survivors. CPT-SA is based on a broad treatment model
combining information processing (Lang, 1977), developmental (Cole &
Putnam, 1992: Finkelhor, 1988), and self-trauma theories (Briere, 2002),
thereby addressing the roles that fear processing, attachment, cognitions,
and development play in the creation and maintenance of symptoms.
The CPT-SA treatment consisted of 17 weeks of manual-based group
and individual therapy, with participants attending a 90-min group each
week and a 60-min individual therapy session for the first 9 weeks and the
17th week. This format has a couple of advantages. First, clients can
process their traumatic events with the sole attention of the individual
therapist. This focus increases the amount of time given to working through
the traumatic memory and finding the clients disruptive cognitions, while
decreasing the likelihood of vicarious traumatization by removing event
recounting from the group sessions. Second, when the individual sessions
stop at Week 9, the group members are forced to rely less on the therapists
and more on the group to work through their reactions to the homework.
This allows for a more approximate recreation of social interactions, giving
the clients a better opportunity to process their thoughts and feelings with
someone other than their therapist.
The following is a brief review of the treatment sessions. During Week
1, the clients are educated about PTSD, given the rationale for the treat-
ment, begin establishing rapport with the other group members, and are
introduced to the concept of “rules” or beliefs. For homework, they are
asked to write down rules that they use to organize their life. In Week 2,
clients discuss their developmental history and examine rules that devel-
oped within the context of their childhood. For homework, they are asked
to write an impact of event statement identifying ways in which the abuse
has affected their beliefs about self-other and the world. In Week 3, the
clients review the impact statement for rules and begin to discuss the
relationship among events, thoughts, and feelings. During Week 4, the
clients further examine the impact of thoughts on feelings and for home-
work, they begin the exposure portion of the treatment by writing an
account of the most traumatic incident of childhood sexual abuse. During
Weeks 5–8, the exposure component is continued by having the client read
additional written narratives to the therapist in the individual sessions and
process the experience of doing the homework in the group sessions.
During Weeks 8 and 9, the clients are taught the Challenging Questions and
the Disruptive Thinking Patterns (Chard, 1997) as a way to examine their
unhealthy cognitions that may have resulted from the abuse or other
subsequent traumatic events. The core challenging of cognitions is com-
pleted in Weeks 10–16 when the clients use the Challenging Beliefs
Worksheet (Chard, 1997) to examine their rules about safety, trust, power/
control, self-esteem, communication, intimacy, and social support. Finally,
in Week 17, the clients meet with the individual therapist again to review
their new impact of event statement and to plan for possible problems in
Although many of the central tenets of CPT-SA are borrowed from CPT,
several significant changes make CPT-SA more appropriate for child
sexual abuse survivors (see Chard, Weaver, & Resick, 1997). Unlike
CPT’s focus on schema-discrepant beliefs, CPT-SA focuses on schema-
discrepant and schema-congruent beliefs, because many of these beliefs are
created during childhood and the abuse context. The addition of the
Developmental Session 2 allows the clients time to discuss their family of
origin, developmental interruptions, and the ways in which their schemas
were established and reinforced during childhood. Second, in CPT-SA,
sessions on assertiveness/communication, sexual intimacy, and social sup-
port have been added. All three of these areas seem to present relevant
topics that many sexual abuse survivors struggle with and need to address
Individuals in the MA wait-listed control group received a 5–10
min telephone call once a week during the 17 weeks. Clients were assessed
for their current emotional state and were given supportive, nondirective,
brief counseling if they were experiencing a crisis. Clients who called in
distress during the 17 weeks were offered the same supportive counseling
unless the symptom severity was so high that they needed to be referred for
immediate therapy (these individuals are included in the MA dropout
The therapy groups were run by seven therapists, including the principal
investigator and six graduate students in psychology with a background in
cognitive–behavioral interventions. All sessions were videotaped, and the
principal investigator provided weekly adherence supervision. In addition,
all staff members were required to attend at least one of the 2-day
supervisory workshops performed by Patricia Resick during the first and
second years of the study. Before running a group, each therapist watched
two training tapes and conducted individual CPT-SA with two pilot study
clients. An independent rater trained in cognitive–behavioral interventions
as well as in CPT-SA rated the therapists on adherence and competence for
the study. This rater had no affiliation with this study other than to
complete the ratings. Ratings were performed using checklist forms
adapted from Patricia Resick’s prior CPT study (Resick, 2002) that in-
cluded unique requirements for each session (Chard, 1997). A random
selection of participant videotapes and sessions was made so that the
reviewer could code 10% of the sessions conducted. The therapists were all
judged to be competent at performing CPT-SA, and the mean adherence
rating was 98%.
Initial Treatment Effects
Before outcome analyses were conducted, the six treatment
groups were compared for differences pre- and posttreatment to
rule out group differences or therapist effects. The six groups did
not differ significantly on any of the demographic or outcome
measures. Subsequently, the treatment completers (N ? 28) were
compared to the minimal attention wait-listed controls (n ? 27) on
symptom changes from pretreatment to posttreatment. The results
of four ANCOVAs revealed significant main effects for PTSD,
depression, and dissociation. With the pretreatment scores on the
same measures partitioned out as control variables, the treatment
group showed significantly greater improvement than the MA
group on the CAPS-SX, F(1, 54) ? 95.96, p ? .001; MPSS, F(1,
54) ? 121.35, p ? .001; BDI-II, F(1, 54) ? 71.18, p ? .001; and
DES-II, F(1, 52) ? 68.76, p ? .001. Paired t tests showed that the
MA group had no significant changes from pretreatment to post-
treatment on any of the assessment measures. Means and standard
deviations for both groups are presented in Table 1.
Two separate effect sizes were computed. The Cohen’s d sta-
tistic (1992) was first computed to compare differences between
treatment participants and wait-listed participants at posttreatment,
without controlling for pretreatment scores. The CAPS-SX (d ?
1.52), MPSS (d ? 1.55), BDI-II (d ? 1.42), and DES-II (d ? .91)
all revealed effect sizes that were considered to be “large” (see
Cohen, 1988). Eta-square was subsequently computed after the
pretreatment scores were controlled. The CAPS-SX (?2? .65),
MPSS (?2? .70), BDI-II (?2? .58), and DES-II (?2? .32) again
indicated strong effect sizes.
Pairwise t tests were conducted to assess maintenance of treat-
ment gains at 3-month and 1-year follow-ups. Assessment data
were obtained for 28 of the 36 treatment participants at 3-month
follow-up and for 27 of the participants at 1-year follow-up. This
sample included participants who after completing the MA condi-
tion chose to enter treatment. Comparisons were made between
scores at posttreatment and 3-month follow-up and between scores
at 3-month follow-up and 1-year follow-up. There was a signifi-
cant difference between scores on the CAPS-SX at posttreatment
and at 3-month follow-up (t ? 2.43, p ? .02), suggesting that
participants continued to show improvement of PTSD symptoms 3
months posttreatment. No other measures showed significant
change from posttreatment to 3-month follow-up, indicating that
the positive effects of treatment remained stable for other symp-
toms as well. No significant difference on CAPS scores was seen
from 3-month to 1-year follow-up, indicating that treatment im-
provements made from posttreatment to 3-month follow-up were
maintained through 1-year follow-up. There were no significant
differences between all other measures from 3-month follow-up to
1-year follow-up, suggesting that treatment gains measured at
posttreatment were maintained for other symptoms as well. Means
and standard deviations are presented in Table 2.
Intent-to-treat (ITT) analyses were
conducted using the last observation carried forward procedure (or
LOCF) to account for drop outs from the study. Repeated measures
MANOVAs performed across the four assessment points indicated
that changes in treatment scores were still significant over time on
the CAPS-SX (Pillai’s Trace, F(3, 39) ? 26.72, p ? .001; MPSS
(Pillai’s Trace, F(3, 39) ? 23.68, p ? .001; BDI-II (Pillai’s Trace,
F(3, 39) ? 21.60, p ? .001; and DES-II (Pillai’s Trace, F(3, 39) ?
9.72, p ? .001.
Kendall and Grove (1988) recom-
mended evaluating clinical improvement as well as statistical
change in treatment groups. One way to show clinical improve-
ment is by reporting the diagnostic status of both groups at post-
treatment. In the CPT-SA group, 7% met criteria for PTSD as
assessed by the CAPS-SX compared with 74% of the MA group,
?2(1, N ? 55) ? 25.7, p ? .001. This trend continued, with 3%
meeting criteria at 3-month and 6% meeting criteria at 1-year
follow-up. In addition, to examine good end-state functioning, I
computed an index that combined scores on the MPSS and BDI-II
using the same cutoffs as Foa et al. (1999) and Resick et al. (2002).
Good end-state functioning was defined as an MPSS score of 20 or
less and a BDI score of 10 or less. At the postassessment, 79% of
the CPT-SA participants achieved good end-state functioning,
compared with 4% of the wait-listed control group, ?2(1, N ?
55) ? 31.7, p ? .001. At 3-month follow-up, 73% of the treatment
group met criteria for good end-state functioning, and at 1-year
follow-up, this trend continued with 75% meeting criteria. This
analysis was also performed using the LOCF treatment sample,
which showed that at postassessment, 60% of the treatment group
met criteria for good end-state functioning; 62.8% met such crite-
ria at 3-month follow-up and 60.5% at 1-year follow up.
To account for those individuals who
may have had an adverse reaction to the therapy experience, I
compared the posttreatment CAPS-SX total severity score with
baseline scores. No participants reported that their symptoms had
become worse from pre- to posttreatment.
Further analyses of participants revealed
that the treatment dropouts had significantly higher pretreatment
PTSD scores (CAPS-SX; p ? .047) than individuals who com-
Scores of CPT-SA Treatment Group versus MA Group at Pre-
Measure and group
M SDM SD
MA ? minimal attention (n?27); CAPS-SX?Clinician-Administered
Post-Traumatic Stress Disorder (PTSD) Scale, 1-Week Symptom Status
Version; MPSS ? Modified PTSD Symptom Scale; BDI-II ? Beck
Depression Inventory-II; DES-II ? Dissociative Experiences Scale-II.
CPT-SA ? cognitive processing therapy for sexual abuse (n?28);
pleted the study, although none of the other symptom and event
characteristics differed between these two groups.
The purpose of this study was to evaluate the efficacy of Resick
and Schnicke’s (1993) cognitive processing therapy in an adapted
format for survivors of childhood sexual abuse. These initial
findings suggest that CPT-SA shows promise as an alternative
form of treatment for this population, with clients reporting sig-
nificant statistical and clinical gains on symptom measures of
PTSD, depression, and dissociation from pretreatment to posttreat-
ment. The treatment gains and effect sizes are as strong as those
seen in other treatment studies of women who have suffered from
interpersonal violence. For example, Cloitre et al. (2002) reported
Cohen’s d effect sizes for clients treated with STAIR-PE compared
to clients who were wait-listed controls on the CAPS (1.30), BDI
(1.24), and DES-II (.73). In addition, the CPT-SA treatment gains
were maintained at 3-month and 1-year follow-ups, with some
continued improvement on PTSD scores from immediately after
treatment to 3-month follow-up. Also important is the fact that no
clients who completed the treatment reported that their symptoms
had gotten worse, and intent-to-treat analyses performed to ac-
count for treatment dropouts indicated that results were still sta-
tistically significant across all variables.
This study examined both demographic and event-based char-
acteristics that could have affected a client’s participation or re-
sponse to treatment. The dropout rate for CPT-SA has been lower
than the rates that have been reported in other outcome studies on
child abuse survivors, (e.g., Cloitre et al. in 2002 reported a 29%
dropout rate) and rape survivors (e.g., Resick et al. in 2002
reported a 26.8% dropout rate for CPT and 27.3% for PE), sug-
gesting that CPT-SA may offer an acceptable alternative treatment
for sexual abuse clients who are typically already in a great deal of
distress. In addition, no differences were found between treatment
dropouts and treatment completers on any demographic or symp-
tom measures. Because it appears that this is the first study to use
a combined group and individual format, the extent of the role that
the group process played in the treatment results is unknown, but
anecdotal oral and written statements from the clients received at
the completion of therapy suggest that the group component may
have played a key role in reducing dropouts from the treatment.
Future research should include a dismantling study that examines
the effects of combined CPT-SA with an individual therapy–only
treatment protocol, in addition to examining the role of higher
levels of PTSD in treatment dropouts.
In keeping with prior research results on CPT (Resick et al.,
2002)), no differences were found in this sample for treatment
outcome response related to the age at onset of abuse, chronicity of
abuse, time between last abuse and treatment, and relationship to
the perpetrator (see Johnson et al., 2001). This is significant
information in that these variables are often used by therapists to
judge the type of therapy and readiness for therapy on behalf of the
client. Instead, therapists may want to consider severity of PTSD
or other variables reported in the literature, such as peritraumatic
dissociation, when making treatment decisions. In addition, the
findings that CPT-SA worked equally well for reducing PTSD and
depression symptoms. Although current studies (e.g., Resick et al.,
2002) of survivors of interpersonal violence have not reported high
rates of depression diagnoses alone, some evidence seems to
suggest that depression is one of the most frequent comorbid
diagnoses with PTSD (Breslau, Davis, Peterson, & Schultz, 2000;
Shalev et al., 1998). CPT-SA shows promise as a treatment that
can alleviate symptoms in both of these symptom domains, per-
haps because of the inclusion of cognitive techniques that have
been shown to work well with depressed clients in other studies
(DeRubeis, Gelfand, Tang, & Simons, 1999; Strunk & DeRubeis,
2001). Although CPT-SA also reduced the symptoms of dissoci-
ation, this effect was not as strong. In part, this may be due to the
fact that fewer participants presented with elevated dissociation
scores than with PTSD or depression, so the sample was smaller.
However, there may also be treatment issues that a larger study
could examine regarding individuals with high levels of pretreat-
ment dissociation. Prior research has suggested that dissociation is
one of the more persistent symptoms clusters (Roth et al., 1997;
Zlotnick et al., 1994), calling for a need to investigate the efficacy
of CPT on dissociation in a future study.
This study has several strengths: First and foremost is the
adherence to the guidelines for gold standards of methodologically
sound treatment outcome research outlined by Foa and Meadows
(1997). There was a broad list of inclusionary criteria that allowed
clients to enter the study even if they were on medication, met
criteria for substance abuse or personality disorders, had experi-
enced multiple traumas throughout their lifetime, had suicidal
ideation, or were committing self-injurious behaviors that were not
imminently fatal. Allowing clients such as these to participate
resulted in the population in this study more closely approximating
the type of clients that practitioners may see in a community
mental health setting, thus, increasing the likelihood of generaliz-
able results. Other strengths included the randomized design, the
blind assessments, and the comprehensive assessment package.
The small sample size is one limitation of the study, thus
reducing the generalizability of the sample. This concern also
extends to the small number of minorities recruited for the study,
which further limits any conclusions regarding the efficacy of this
treatment with non-White populations. Because this study was
conducted with a control group design, it is impossible to judge the
efficacy of CPT-SA in relation to other brief treatments for survi-
vors of child sexual abuse. Future studies might include direct
treatment comparisons of therapies with the same time duration
that use a different agent of change in their protocol, for example,
prolonged exposure or personal construct therapy. Finally, future
Scores of Treatment Group at 3-Month and 1-Year Follow-Up
3 months1 year
M SDM SD
SX ? Clinician-Administered Post-Traumatic Stress Disorder (PTSD)
Scale, 1-Week Symptom Status Version; MPSS ? Modified PTSD Symp-
tom Scale; BDI-II ? Beck Depression Inventory-II; DES-II ? Dissociative
At 3-month follow-up, n ? 28; 1-year follow-up, n ? 27. CAPS-
studies using CPT-SA need to use updated assessments that more
thoroughly evaluate guilt, anger, sexual intimacy, severity of
abuse, and the possibility of complex PTSD because these have all
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Received April 25, 2004
Revision received May 2, 2005
Accepted May 3, 2005 ?