Delivering Cognitive Processing Therapy in a Community Health Setting: The Influence of Latino Culture and Community Violence on Posttraumatic Cognitions

Abstract

Despite the applicability of Cognitive Processing Therapy (CPT) for Posttraumatic Stress Disorder (PTSD) to addressing sequelae of a range of traumatic events, few studies have evaluated whether the treatment itself is applicable across diverse populations. The present study examined differences and similarities amongst non-Latino, Latino Spanish-speaking, and Latino English-speaking clients in rigid beliefs – or “stuck points” – associated with PTSD symptoms in a sample of community mental health clients. We utilized the procedures of content analysis to analyze stuck point logs and impact statements of 29 participants enrolled in a larger implementation trial for CPT. Findings indicated that the content of stuck points was similar across Latino and non-Latino clients, although fewer total stuck points were identified for Latino clients compared to non-Latino clients. Given that identification of stuck points is central to implementing CPT, difficulty identifying stuck points could pose significant challenges for implementing CPT among Latino clients and warrants further examination. Thematic analysis of impact statements revealed the importance of family, religion, and the urban context (e.g., poverty, violence exposure) in understanding how clients organize beliefs and emotions associated with trauma. Clinical recommendations for implementing CPT in community settings and the identification of stuck points are provided.

Numerous epidemiological studies have found higher rates of PTSD among Latinos compared with non-Latino Whites in the United States, even after adjusting for demographic variables and trauma exposure (e.g., Hinton & Lewis-Fernández, 2011; Perilla, Norris, & Lavizzo, 2002). In a systematic review of 24 articles that reported on racial and ethnic differences in conditional risk for posttraumatic stress disorder (PTSD) prevalence (i.e., the probability of PTSD among those exposed to a trauma) and PTSD persistence (i.e., symptom onset, duration, and severity), Alcántara and colleagues (2013) found that Latinos were more likely to develop PTSD after trauma exposure and endorsed higher severity of symptoms compared to non-Latinos. Despite higher rates of trauma exposure related mental health problems, racial and ethnic minority individuals (vs. non-Latino Whites) have less access to adequate mental health treatment (Wang et al., 2005). In addition to limited access to adequate mental health care, ethnic minority clients actively seek mental health treatment less often than non-Latino Whites (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011), often citing medical mistrust as one of the primary reasons for poor engagement in treatment (Office of the Surgeon General, 2001). Further, racial and ethnic minority clients are less likely to have access to evidence-based treatments, relative to non-Latino White clients (e.g., Alegría et al., 2008). Thus, research on cultural adaptations of evidence-based treatments for PTSD in racially and ethnically diverse, under-resourced settings such as those serving predominantly Latino clients is critical to address barriers related to access, engagement, and treatment response.

Cognitive processing theories of PTSD (e.g., McCann & Pearlman, 1990; Resick & Schnicke, 1992) suggest that PTSD is the result of a person’s failed attempts to integrate their traumatic event into pre-existing psychological schema. Resick and Schnicke (1992) observed that traumatized individuals’ attempts to integrate their traumatic experiences can result in two types of cognitive distortions: assimilation and overaccommodation. Assimilation is defined as the incorporation or alteration of new information to fit existing schemas, whereas, overaccommodation occurs when the schema is altered or becomes over-generalized (Piaget, 1987). The central aim of Cognitive Processing Therapy (CPT) for PTSD is to identify and then address these cognitive distortions that maintain PTSD symptoms (Resick & Schnicke, 1992). Early sessions of CPT focus on assimilated beliefs, which are cognitive distortions in which the individual, in an attempt to make sense of the trauma and to protect themselves from future harm, makes sense of why and how the trauma occurred in a way that maintains prior beliefs and schema. This can confirm prior maladaptive beliefs or disconfirm prior positive beliefs (e.g., “When something bad happens, the victim must have done something to deserve it.”). In the second half of CPT, the therapy addresses overaccommodated beliefs or cognitive distortions in which the person changes their prior beliefs as a result of the traumatic event and does so in a way that is overly rigid or extreme (e.g., “I can’t trust anyone.”). CPT focuses on overaccommodated beliefs relevant to five key areas: safety, trust, power, esteem, and intimacy. Over the course of treatment, clients learn to modify assimilated and overaccommodated beliefs (called “stuck points”) to develop more accurate and flexible beliefs.

Despite the adaptability of CPT to a wide range of traumatic events, only a few studies have evaluated whether cognitive processing theory and the treatment itself is applicable across racially- and ethnically-diverse populations. CPT has been evaluated among torture victims in Iraq, trauma-exposed (primarily Bosnian) refugees in the U.S., and sexual assault victims in the Democratic Republic of Congo (Bass et al., 2013; Kaysen et al., 2013; Schulz, Huber, & Resick, 2006; Schulz, Resick, Huber, & Griffin, 2006). Moreover, only one study has evaluated outcomes comparing African American to non-Latino White women in a community sample (Lester et al., 2010). These studies describe several adaptations to standard CPT based on feedback from clients and providers, including translation of the manual into the primary language, simplification of language (e.g., omission of jargon), modifications to training for paraprofessionals and/or clinicians with little or no experience in cognitive behavioral or manualized interventions, use of interpreters, and the provision of alternative but theoretically consistent strategies for illiterate clients. Cultural considerations and modifications to the content, such as the need to understand clients’ experiences and beliefs around mental health and mental health treatment, including stigma, occurred across these studies (Schulz et al., 2006). This preliminary evidence for the effectiveness for CPT across diverse populations suggests that the therapy may translate well to other diverse populations (Bass et al., 2013; Kaysen et al., 2013; Schulz, Huber, & Resick, 2006; Schulz, Resick, Huber & Griffin, 2006). One previous CPT study found that African American women were more likely to discontinue treatment than non-Latino White women (Lester et al., 2010)—thus, examining cross-cultural differences in treatment adherence and acceptability may be warranted. Given that drop-out is only one proxy for client acceptability, the current literature does not capture the complexity of this construct.

Provision of culturally-responsive and competent therapy includes attention to clients’ culture and values (e.g., Aguilera, Garza, & Muñoz, 2010; Chapman, DeLapp, & Williams, 2013). Although there is a dearth of research on cultural considerations for administering CPT in community settings, there is relevant preliminary research on cultural adaptations of other evidence-based treatments to diverse populations. For example, relevant aspects of Latino culture include consideration of family values and structure, religion, and gender role expectations, all of which may be affected by trauma exposure and may affect how individuals make sense of traumatic events (Sue & Sue, 2008). In addition, systemic inequities in U.S. society and experiences with racism and discrimination may also impact the beliefs one develops following trauma exposure (Kaysen et al., 2006; Organista, 2006; Sue & Sue, 2008). Given these factors, it is important to examine to what extent stuck points typically seen and targeted for change in CPT are present among Latinos and non-Latino Whites in a community sample. We were particularly interested in the influence of both Latino culture and community exposure to violence on posttraumatic cognitions. Our study consisted of two primary aims. First, we aimed to establish whether the content of stuck points differ across groups (Latinos v. non-Latinos; Spanish- v. English-speaking Latinos). Second, we aimed to provide a nuanced understanding of how the experiences of individuals living in a diverse low-income urban community with high trauma exposure inform posttraumatic cognitions.

Methods

Participants and Procedures

The current study is a cross-sectional qualitative analysis from a larger study examining the implementation of CPT for PTSD (Resick & Schnicke, 1992) in a diverse community mental health center outside of Boston, MA where 62% of the patients identify as Latino/Hispanic. The hospital Institutional Review Board approved all study procedures. This community health center is located in the zip code with the highest poverty and violent crime rate in the state.

Clients were eligible to participate in the study if they were over the age of 18, were a new or active client at the health care center, and had a current primary diagnosis of PTSD (per medical record and/or Posttraumatic Symptom Checklist-Specific Version [PCL-S] score >36 [Weathers, Litz, Herman, Huska, & Keane, 1993 ]). Clients who were acutely at risk for suicide, homicide, or required hospitalization (as assessed by their provider) were excluded. All providers received a 3-day, one time CPT training delivered by a designated national trainer and the study principal investigator. Providers also participated in weekly consultation meetings with the study principal investigator. Providers identified eligible clinic participants (n = 51), and these prospective clients were invited to meet with a member of the study staff to review the informed consent. A total of 37 (of 51) clients consented to study participation. Clients who did not complete an impact statement or stuck point log (n = 8) were excluded from the current analysis. Our analytic sample thus consisted of 29 clients. Clients completed a demographics measure which assessed for gender, age, race, ethnicity, language, marital status, education level, household income, and religion. Providers (n = 11) also completed a demographic questionnaire.

Cognitive Processing Therapy

CPT begins with psychoeducation on PTSD and treatment rationale, and then proceeds to a written impact statement. Sample impact statement instructions for a rape victim are presented below:

Please write at least one page on what it means to you that you were raped. Please consider the effects the rape has had on your beliefs about yourself, your beliefs about others, and your beliefs about the world. Also consider the following topics while writing your answer: safety, trust, power/control, esteem, and intimacy.

The impact statement is reviewed in the subsequent session, and collaboratively, the client and provider identify conflicting beliefs or strong negative beliefs (“stuck points”) that create unpleasant emotions and problematic or unhealthy behaviors for the client (Resick & Schnicke, 1992). These stuck points are the central targets of treatment and were recorded on a tracking log; if patients were illiterate or marginally literate, they were given the option to audio record their impact statement (one patient elected to in this study).

Data Analysis

Stuck point logs and impact statements were transcribed from hand-written documents and then imported into QSR’s NVivo 10 Software Program for qualitative data management. Transcripts were translated from Spanish to English by bilingual, bicultural members of the study staff. Codes were generated based on mixed inductive and deductive approaches. First, the qualitative method of directed content analysis was employed (Hsieh & Shannon, 2005). This approach was selected since there is existing literature and theory on common CPT stuck points (McCann, Sakheim, & Abrahamson, 1988). Coding procedures employed were similar to those reported in a previous qualitative study of the impact statements of female rape survivors engaged in CPT (Sobel, Resick, & Rabalais, 2009). All stuck point logs were coded using established themes from the CPT literature.

Codebook development and coding

The coding team was comprised of five researchers. A doctoral-level expert in CPT provided consultation to the coding team at the beginning of the project, and a qualitative researcher supervised codebook development and coding. Three coders were responsible for coding stuck points logs based on established themes from CPT. Stuck point logs were coded independently by two coders and entered into NVivo 10. Next, 20% of these codes were audited by a third coder (Hill et al., 2005). In the end, the rate of agreement between codes assigned through consensus (i.e., between the two original coders), and the codes assigned by the auditor was 85%.

A second pair of coders were responsible for developing a codebook based on emergent themes from the impact statements. While coding the data, some additional categories emerged that did not fit into existing categories. Thus, new codes were created and added to the codebook. Then, previously coded transcripts were re-coded to ensure that codes were not missed. This process was repeated until no new codes emerged from the data (i.e., saturation). After saturation had been achieved, the codebook was finalized. A final code book with definitions for all codes was developed and used to re-code all transcripts. All impact statement transcripts were double-coded, with inter-coder reliability (% agreement) of 82%.

Results

Full client demographics are presented in Table 1. Available data for qualitative analysis consisted of 35 impact statements and 23 stuck point logs from 29 clients. For clients who wrote more than one first impact statement, both were used for analyses. In general, clients were asked to re-write their first impact statement if it did not fully address all five focus areas (safety, trust, power/control, esteem, and intimacy) of CPT, or if they wrote a trauma account (a detailed description of the event). In the impact statement, clients were asked to write about the trauma that bothers them the most (i.e., index event). Clients reported a wide array of traumatic experiences that did not vary based on ethnicity; the most common traumas were childhood sexual abuse, domestic violence, physical assault, witnessing death, and rape. However, Latinos were more likely to report trauma related to immigration than non-Latinos.

Table 1.

Demographic Characteristics of the Sample

Characteristic	n (%)
Age (N = 27)	M = 40.44, SD = 14.03
Gender (N = 29)
Male	9 (31.0)
Female	20 (69.0)
Race/Ethnicity (N = 29)
Latino	18 (62.1)
White	9 (31.0)
Black	1 (3.4)
Multiracial	1 (3.4)
Sub-Ethnicity of Latinos (N = 18)
South or Central American	10 (55.6)
Puerto Rican	5 (27.8)
Cuban	2 (11.1)
Other	1 (5.6)
Latinos who received treatment in Spanish (N =18)	10 (55.6)
Marital Status (N = 28)
Single	10 (35.7)
Married	8 (28.6)
Divorced	4 (14.3)
Separated	4 (14.3)
Living with a partner	2 (7.1)
Religion (N = 27)
Catholic	15 (55.6)
Other Christian	3 (11.1)
Evangelical	2 (7.4)
Protestant	2 (7.4)
Other	5 (18.5)
	Latinos	Non-Latinos
Education (N = 27)
Less than high school degree	4 (25.0)	0 (0.0)
High school degree	7 (43.8)	2 (18.2)
Partial college	3 (18.8)	5 (45.5)
College or Graduate degree	2 (12.5)	4 (36.4)
Household Income (N = 25)
$0 – $9,999	12 (80.0)	3 (30.0)
$10,000 – $24,999	2 (16.7)	0 (0.0)
$25,000 – $49,999	1 (6.3)	3 (30.0)
$50.000–74,999	0 (0.0)	3 (30.0)
Greater than $75,000	0 (0.0)	1 (10.0)

Marginally literate or illiterate clients did not generate as long or robust impact statements as fully literate clients. As such, some clients may be overrepresented in the analyses. The majority of the participants in our sample identified their ethnicity as Latino (62.1%); of this group, 55.6% (10) received treatment in Spanish. The majority of providers were female (81.8%), and White (90.9%), with 18.2% identifying as Latino. Providers were social workers (54.5%), psychologists (18.2%), psychiatrists (9.1%), nurses (9.1%), or psychology/social work trainees (9.1%). Providers had worked an average of 13.8 years (SD = 12.69) at the study clinic.

Part 1: Content Analysis of CPT Themes

In total, we examined 202 qualitative data points that were identified through the coding process. We conducted group comparisons of frequency of stuck points that mapped onto CPT themes (safety, trust, power/control, esteem, intimacy, assimilation [blame]); frequencies are presented in Table 2. T-tests revealed significantly fewer identified stuck points for English-speaking Latino clients (t = 4.07, df = 16.97, p < .001) and Spanish-speaking Latino clients (t = 5.65, df = 11.61, p < .001), relative to non-Latino clients.

Table 2.

Frequency of CPT Themes by Group (N = 29)

	Non-Latino (n = 11)	Latino-Spanish (n = 10)	Latino-English (n= 8)
	n (%)	n (%)	n (%)
Safety	6 (55) “The world isn’t safe” “I am unable to protect myself against predators, authority figures, and angry people” “If I’m not on guard I will be taken advantage of”.	5 (50) “I am not safe anywhere”, “It has affected me, because now I feel like I always have to be alert, that anything can happen to me or my kids” “I have never felt safe and am always alert and nervous.”	3 (38) “If I go out in the street, I will get stabbed by someone.” “Babysitter will kidnap [my child]”
Trust	10 (91) “I am not trustworthy” “I don’t trust my own judgment” “I do not trust anyone”	5 (50) “I don’t trust anyone or anything” “All men are liars” “I don’t trust anyone. I don’t believe anything”	4 (50) “I don’t trust anyone” “I have no trust in anyone nor the system.” “I feel like if I ever trust anyone I will get hurt again”.
Power and Control	6 (55) “I have no power or control” “I don’t have any control over my life” “If I can’t control the situation something bad will happen.”	0 (0)	5 (63) “I am an angry person, and I have no [self- ]control” “I have to be in control of everything so I know I won’t ever get hurt again nor will my children”
Esteem	7 (64) “I’m unlovable because of this experience” “I am damaged goods because of the incest”	2 (20) “Love is not for me.” [undeserving of love] “I am never going to be happy.” [because I am damaged]	5 (63) “If my own mother does not [love me] then nobody else is really ever going to love me” “I am useless to others and myself” “I am a failure” “I feel like a waste of a human being.”
Intimacy	5 (45) “If I get close to others I will get hurt” “If I get involved with a partner they will leave” “Getting close to someone is very frightening and I just don’t do it”.	2 (20) “If I fall for someone again I think they will hurt me” “Anyone who falls in love loses, and I don’t want to lose again”	1 (13) “I can’t be close to people.”
Assimilation (Blame)	7 (64) “The attack is my fault for putting myself in a dangerous area/situation” “Because I was drunk it was my fault I was attacked (I provoked it)” “I could have prevented this.”	4 (40) “It was my fault because I made an effort that I didn’t have to make” “As far as guilt goes, personally, I have blamed myself for everything”.	5 (63) “If I had listened, my mom wouldn’t have hit me” “I blame myself for putting my step dad through it.”
	Non-Latino (n = 9) M (SD)	Latino-Spanish (n = 7) M (SD)	Latino-English (n = 6) M (SD)
Stuck points identified (per participant)	11.56 (5.15)	2.43(1.40)	3.17(3.82)

Safety stuck points were endorsed similarly by non-Latino, Latino Spanish-speaking, and Latino English-speaking clients (55%, 50%, & 38% respectively). Non-Latino clients endorsed stuck points related to trust of self and trust of others, whereas Latino clients exclusively endorsed stuck points related to not being able to trust others. Latino clients (Spanish- & English-speaking) described more stuck points related to their own self-worth, compared to very few related to the worth or value of other people. In contrast, non-Latino clients endorsed esteem stuck points about themselves and others at similar rates. Stuck point logs for Latino clients revealed very few stuck points related to intimacy or power and control (intimacy: 17%; power/control: 28%). In fact, there were no power and control stuck points identified for Spanish-speaking Latino clients. Assimilation (blame) stuck points were identified somewhat more often among Latino versus non-Latino groups (64% of Latinos v. 50% of non-Latinos). Despite observed differences in the overall frequency of stuck points identified by clients and provider, there were few qualitative differences in the types of stuck points.

Part 2: Thematic Analysis of Cultural Considerations

Although stuck points identified across groups appear qualitatively similar (see Table 2 for exemplars), several important themes emerged from the data that may inform implementation of CPT in a diverse community setting (i.e., an urban, predominately Latino community with high rates of trauma). These themes provide a context by which clients attempt to explain or find meaning from their traumatic experiences, or the larger context of their lives. We have attempted to highlight ways in which personal history and environmental context present among community mental health clients. The impact statements of clients in this study revealed the importance of the following in understanding their lived experience: a) value of family and relationships, b) role of religion, and c) exposure to community violence and experiences with discrimination. To protect the confidentiality of these clients, we have changed potentially-identifying details of the quoted impact statements.

Family and relationships

Disrupted family structure

Some clients described how a disrupted family structure affected their framework for understanding trauma. For example, one client described how her mother left the family (and the client) to escape domestic violence. In her mother’s absence, violence directed at the client increased. She wrote:

I think that that man was very bad, because he hit my mother a lot…She left me sleeping, and when I woke up, she had gone very far away from that man and left me with my aunt. …And since my mom wasn’t there anymore, [he] would hit me every day. [Female, Latino, Spanish-speaking]

Perpetration of abuse by family members and family response

Many clients made attempts to explain, and sometime dismiss, the behavior of family perpetrators. They cited family members’ mental illness, substance use, and intergenerational violence as causes of perpetration. For example, one client described the following:

It all began when I was 6 yrs., young. My mom was very abusive to both my brother and I, but mostly me because I was older. Mom always looked for an excuse to beat me. I didn’t understand why the person I looked up to the most physically abused me. Now I know it was because she was also physically abused growing up, by her family members. Let me not forget she was in two violent relationships as well. [Male, Latino, English-speaking]

Clients also described how family member (perpetrator) loneliness, negative emotions, and mental health caused violence. For example, one client wrote the following:

Now that I am older and I look back at how I was treated growing up, I think it was because my mother was alone most of the time. She was down south and came up north to live with my father. Who was a truck driver he would be home three days and gone ten days. She had no friends; her only contact would be a neighbor and her husband. … It could be the cause for her action and I was the only one there for her to take out her anger. [Female, non-Latino, English-speaking]

A few clients expressed beliefs that familial abuse was with the intention of helping or protecting the client. For example, one woman wrote:

How my mother’s pulling knife on me affected: because I was not listening to her and when I got with men older than me I just think that she wanted to choose the men she wanted for me. I think I was a bad daughter or that other people did not understand what I been through. [Female, Latino, English-speaking]

Many clients described challenges navigating ongoing relationships with perpetrators, especially when perpetrators were family members or partners. Some clients described finding themselves in additional abusive relationships. One client described pressure (i.e., religion, family) to “fix” her marriage, “I kept quiet and didn’t defend myself because I was trying to stay with my husband and save our relationship [Female, Latino, Spanish-speaking].”

Belief that disclosure caused family suffering

Some clients reported distress associated with disclosure of abuse, stating that the act of disclosure caused the client’s family suffering. For example, one client wrote about his perception of the pain disclosure caused his family:

The event has [led] me to believe that I caused pain and suffering that night. I felt worse and worse about seeing my stepdad mistreated. I kept thinking that my actions had been a mistake. I thought that the misery that we all went through that night had been brought down because I made the choice of having him arrested, these thoughts normally come up during an argument. [Male, Latino, English-speaking]

Family role obligations

In addition to disrupted family structure, some clients wrote about family obligations in their impact statements. For example, one client wrote about the pressure to stay at home with her mother:

I don’t feel like I’m living or going to live in the future I want to live, like in college to dorm or get my own place, because I have to stay here for my Mom. My Mom and I don’t get along anymore and we argue a lot more. [Female, Latino, English-speaking]

One client, who reported guilt associated with her sister’s death from cancer, described how she now tries to please everyone since she feels unworthy of love and fears abandonment:

When I think about the day my sister died I remember how guilty I felt. Have felt that way since then. Maybe if I had taken care of her a lot more she would still be alive. Now I have this need to always take care of others. When I say no to someone I feel so miserable and anxious. Feel like if I don’t please everyone then they will leave me like my sister. [I] don’t like being [complimented] or being told I love you. How can someone tell me they love me? I was a bad sister, I don’t deserve being loved. [Female, Latino, English-speaking]

Similarly, clients described feeling obligated to protect family members, particularly children. For example, one client, who had been abused by a cousin, described concerns about her children’s safety, and her need to protect them:

When it comes to my safety or my children’s safety, I will always put my children first. I never want any of my children to go [through] anything like my trauma. I don’t give my trust to anyone and [sentence cut off] that I trust them I don’t. I do feel that my trauma [affected] me in this because I wasn’t kept safe. I was harmed by a family member. My cousin betrayed my trust and I feel like if I ever trust anyone I will get hurt again. [Female, Latino, English-speaking]

Some clients described experiencing narrowed empathy, only to immediate family members, including partners and children. For example, one client described feeling close only to his wife, son, and other people close to him:

I’ve been through more loss at 35 yrs. old than most people experience in a 90 yr. life. Other people don’t mean much to me and not much that happens to others shocks me, (except for my wife, son and some close to me) [Male, non-Latino, English-speaking]

Religion

The role of religion in adaptation following trauma varied widely across participants. For instance, some clients referenced religion in their impact statements as a stabilizing factor after the trauma, whereas other clients described feeling confused about why the trauma had happened to them, or feeling punished or let down by God or their religion. Some clients discussed God or religion when trying to explain why the trauma occurred. As one woman who identified as Latino (Spanish-speaking) wrote, “I often thought why did God let this [rape] happen?” Other clients believed that trauma was punishment from God. For example, one client described her thoughts on why the trauma happened:

I think I offended God and that’s why he let this happen to me. Today, I ask him for forgiveness even though I was mad at him for a while; but then I thought, ‘who am I to judge anyone?’ So that’s where I am at. The loss of our baby affected me a lot at the beginning, but six months later, it really affected me strongly, very strongly. Today, after consultations with the priest of the church, I am calming down. [Female, Latino, Spanish-speaking]

Overall, most clients who mentioned religion in their impact statements described their religious beliefs as a source of support and strength after trauma. For example, one woman who identified as White, non-Latino, wrote about not being able to trust the world or other people, but being able to still trust in God, stating, “[I] Cannot trust world, [so I] trust God.” Another man who identified as White, non-Latino, wrote about God taking care of him, when he felt he had no one else to take care of him, and God saving him after being kidnapped, “I am sorry that I cannot shed tears anymore because I only have God to take care of me… It’s God that saved because I’m good.” Another woman who identified as Latino (Spanish-speaking) wrote about God as a source of strength in coping with daily psychosocial stressors, explaining “The boss said something rude – not supportive. I ask God to give me strength to keep going.”

Repeated exposure to violence

Another theme that emerged from clients’ impact statements was repeated exposure to violence across various contexts including the client’s current neighborhood, workplace, or school. Some clients also described exposure to violence prior to immigration to the U.S. or during military service. Client impact statements describe how repeated exposure to violence has reinforced negative beliefs about others and the world.

Neighborhood violence

Many clients described repeated exposure to violence in their neighborhoods. For example, one client described a global belief that her city is not safe:

Having my boyfriend stabbed, and almost dying changed my life. I try so hard to not live in the past, but it’s difficult when your past is still your present. When the area I’m in, all the negative and bad things have happened….This occurred because the world is not a safe place and things like that happen. [Female, non-Latino, English-speaking]

Some clients described experiences where they were directly targeted for violence. In turn some of these clients used their vulnerability as evidence for self-blame. These clients also described a sense of powerlessness that cut across their lives, with some clients referring specifically to socio-cultural disadvantage. As one client wrote:

He (boss) was insinuating that he would accuse me of robbery – he didn’t take anything. Every day they gave me more work. They didn’t care about us. They humiliated my coworker. We couldn’t do anything. These people are bad. The union doesn’t do anything. I wanted justice but we felt incapable. We had no one to talk to… I am nervous and insecure, but not vengeful. I wish there were someone who could listen and stop everything…The first thing that happened was they robbed [someone] and wanted to blame me (us). … Once someone was hit by my boss, I felt that he could hurt me too. [Male, Latino, Spanish-speaking]

Another client wrote about experiencing violence at school:

All she (mother) did was beat us, punish us, spit on us, ruin our day because she was having a bad day. [There] was never a good day with mother. I went to school and it felt like I was at home, there wasn’t any safe place. I was bullied, beaten… it would be the same routine all over again for many years. I tried talking to my teachers and counselors but they would call my mother and it was over. I couldn’t trust anyone, anytime I did say a word for protection I’d pay the consequences later. [Female, Latino, English-speaking]

Some clients described experiences with discrimination based on immigration status, ethnicity, and sexual orientation. Clients described not being treated fairly by police, lawyers, and the court system. Interestingly, most clients did not label these experiences as discrimination per se, but explained these events as normative experiences that were part of being a racial or ethnic minority individual living in a low-income urban community.

Discussion

The purpose of this study was to improve upon the current understanding of the impact of client’s environmental context on the implementation of CPT in a diverse low-income urban community mental health setting. Qualitative analysis of stuck point logs and impact statements suggests that community mental health clients report similar stuck points seen in other populations, across the domains of safety, trust, power/control, esteem, intimacy, and assimilation (blame). We also found that some CPT themes were identified less frequently for Latino clients (v. non-Latino); this was especially true for Spanish-speaking Latinos. For example, impact statements and stuck point logs yielded substantially more esteem and power/control related stuck points for English-speaking Latino clients relative to Spanish-speaking Latino clients. This may suggest that Latinos are less likely to possess stuck points surrounding power and control— or, this finding may suggest that providers experience more challenges extracting stuck points from the impact statements of Latino clients, especially for Spanish-speaking Latinos, than they do for non-Latino Whites. Additionally, we would like to note that it is possible that non-native Spanish-speaking therapists may have not been as successful at eliciting stuck points as native Spanish-speaking therapists may have been; we cannot test this as most of our therapists were non-native Spanish speakers.

Thematic analysis of impact statements provided insight into the nuanced ways that living in an urban high-crime area informs belief systems around trauma, and how these translate into stuck points. Although stuck points were consistent across ethnic groups, our findings suggest that the ways by which clients arrive at stuck points may differ in a diverse community setting. This cultural lens that frames cognitive processing of events was most notable in the clients’ impact statements. Emergent themes from impact statements included family relationships, religion, and repeated experiences of violence. Clients discussed how prior experiences, including family culture and dynamics, repeated exposure to violence, and living in poverty influenced their beliefs about self, others, and the world following their index trauma.

As is common in other traumatized groups, community mental health clients wrote about family obligations and the need to protect their family, particularly their children. If family is a salient value for an individual client, experiences such as disruption of family structure, absence of caregiver(s), and negotiating future interactions or lack thereof with perpetrators within the family may be particularly challenging due to a difference between these experiences and traditional family structure and roles. References to religion emerged as another theme in our results. Core religious beliefs are not challenged directly in CPT, but our results suggest that traditional CPT stuck points, which can be identified and targeted in treatment by the client and provider, are often related to religious beliefs associated with trauma symptoms. For example, if a client expresses thinking that God is punishing them, there may be an underlying stuck point related to esteem and a just-world belief (i.e., “Something bad happened to me, therefore, I am a bad person.”). This underlying stuck point can then be targeted during treatment. This process allows both the client and the provider to uncover stuck points that are amenable to restructuring and are not inherently bound in religious values or beliefs.

Other clients described religion and God as a part of the client’s life. In this case, religion can be discussed as a coping resource, and, in fact, providers could use the client’s trust in God as a launching point to more flexible thinking around trust in people. For example, rigid beliefs about trust can be challenged by asking the client if there are members of the church or religious figures that could be trusted, thus demonstrating that some people can be trusted in some ways. In this case, the clinician validates the importance of religion in coping and organizing beliefs, while also challenging the client to think more flexibly within that schema. Our findings regarding the importance of incorporating religion into treatment are consistent with current recommendations from CPT experts in this area (Resick, Monson, & Chard, 2014). These findings further highlight that understanding belief systems, including those that are organized by religion, is critical in understanding and treating cognitive symptoms of PTSD.

In terms of intergenerational violence, clients often described their perpetrators own history of abuse victimization. Given the importance of family and family structure in traditional Latino culture, experiences with abuse by family members likely challenge family values in addition to other domains. In our sample, we found that Latinos (v. non-Latinos) were more likely to self-blame when abuse was perpetrated by family members; this may be just one example of how centrality of family may inadvertently reinforce stuck points. Similarly, impact statements revealed attempts by the clients to dismiss or explain the behavior of the perpetrator, especially when the perpetrator was a family member; however, this did not vary across groups.

Results from the National Latino and Asian American Study found that 30% of Latinos reported experiencing everyday discrimination, but percentages varied based on Latino subgroups (Pérez, Fortuna, & Alegría, 2008). Our findings are consistent with the literature in this area and collectively suggest that experiences with discrimination (general) as well as trauma are important areas to discuss in treatment when working in a diverse community mental health center. Interestingly, participant experiences of discrimination did not lead to identification of stuck points related to power/control, as we would predict. It is possible that clients or providers failed to make this connection upon review of the impact statements in session and that additional exploration may have resulted in identification of power/control stuck points.

One purpose of qualitative analysis is to inform theories that can later be tested through subsequent quantitative investigation; as such, this study points to constructs that are potentially important when delivering CPT in a community setting. There are several limitations of the current study that should be noted. First, qualitative analysis precludes us from drawing broad generalizations that extend beyond this group. It is possible that findings would present differently in other samples, thus larger diverse samples are needed to investigate these variables. Additionally, our data also suggests that the CPT Spanish manual is difficult to understand, and may not be applicable to low-income community populations. It is also possible that provider fluency in Spanish may have influenced the number or the types of stuck points gathered.

Culture, Posttraumatic Cognitions, and the Therapy Process

Our findings suggest that one difficulty in implementing CPT in a community setting may be providers’ and clients’ ability to identify clear stuck points. This difficulty is most pronounced in the stuck points logs and impact statements of Spanish-speaking Latinos. This was apparent upon cross-comparison of impact statements and stuck point logs, where some providers had listed descriptive statements rather than stuck points (Resick & Schnicke, 1992). Although, many of these statements were similar in content to stuck points, these statements were in need of refinement to extract the underlying stuck point. For example, “Being in the street, seeing other people grouped together, I feel as if they are going to attack me”, and “Perhaps I did bad things in the past and now I am paying for them?” While these statements closely resemble stuck points, they would need to be modified to fit the format of stuck points in the manual. For example, these may result in the stuck points, “If I leave my home, I will be attacked,” or “I am being punished.” It is important to note that the study providers were new to CPT and likely needed further consultation and practice to refine the skill of identifying stuck points which is arguably one of the most challenging components of the intervention.

Given the presence of power and control themes in impact statements, but the absence of these on stuck point logs, providers working with racial and ethnic minority clients should be careful not to overlook these stuck points when processing impact statements in session. It is likely that some clients may not feel comfortable initiating conversations around experiences with racism and discrimination with providers, particularly across areas of difference. In addition, providers may also feel uncomfortable having these types of discussions. This is an area that clinicians needs to pay special attention to, as previous studies have found that clients who identify with traditional Latino culture may defer to the provider to identify relevant topics and may not feel comfortable bringing up additional topics (Organista, 2006).

We observed some differences within the Latino group based on the language clients received therapy in (Spanish or English). Some of these differences in implementation may be due to the adaptability of the current CPT Spanish language manual. Further, some of the limitation of the Spanish manual may be related to aspects of acculturation—defined as a process in which exposure to the values and beliefs of another group impacts an individual’s own beliefs or values (Berry, Trimble, & Olmedo, 1986). The current literature is mixed on the relation between acculturation and treatment response in U.S. Latinos (Arroyo, Miller, & Tonigan, 2003; Villalobos, 2011), thus, future research should assess for acculturation.

Implications and Clinical Recommendations

One overarching clinical recommendation from our results is for CPT providers to be curious about their clients’ values and beliefs. As part of CPT, providers aim to understand the client’s unique belief system, especially in the sense that this belief system informed responses to trauma. Also, with an open-mind, the provider can learn about the client without making assumptions about how closely a client’s belief system adheres to traditional beliefs of a particular group. Overall, this strategy allows clients to define beliefs and values in their own words. However, given that clients may not readily discuss some topics, particularly with a provider from a majority group, these topics are important for providers to bring up in session.

While topics such as discrimination and religion can be challenging to discuss with clients, the information gained during these conversations can help providers and clients work together to identify underlying stuck points, which may never be identified without discussion of related aspects of the environmental and cultural content. In addition, these discussions work to build a bridge across cultural and environmental differences between the provider and the client, and are essential to practicing with cultural competency. Given that so many of our clients described the role of religion in recovery from trauma, not discussing religion in therapy would do a significant disservice to some clients. Further, although data to support that community mental health center clients experience higher rates of community violence than clients in other settings, clinicians should be cautious not to reinforce global statements about safety.

We recognize that it can be challenging to talk with clients about their values and experiences with contextual factors including marginalization and discrimination. Nonetheless, talking with clients about these aspects of identity may help clients and clinicians identify and challenge stuck points, the central goal in CPT. Further, taking time to understand clients’ thoughts and beliefs about themselves, others, and the world can serve to a) validate the lived experience of the client, and b) build rapport and foster client trust and engagement. We believe these discussions are important across clinical settings, but they may be particularly important in diverse community mental health settings, where clients may be more likely to experience marginalization based on one or more aspects of their identity.