Delivered as Described: A Successful Case of Cognitive Processing Therapy With an Older Woman Veteran With PTSD

Abstract

Cognitive processing therapy (CPT) is a first-line, evidence-based treatment for posttraumatic stress disorder (PTSD). Little is known, however, about the use of CPT for older adults. As the United States population continues to grow and age, an understanding of the utility of CPT for older adults is vital. We present a case study describing the assessment and cognitive treatment of a 74-year-old woman veteran with PTSD secondary to military sexual trauma. CPT was associated with decreased PTSD symptoms as measured before and after treatment. Factors contributing to the veteran’s response, as well as contextual and environmental factors, are discussed. The case demonstrates that CPT may be effective for older adults without major modification.

Individuals aged 65 and over represent the fastest growing cohort of the United States (U.S.) population. By 2050, the population aged 65 and over is projected to reach 83.7 million (Ortman et al., 2014). The increase is particularly pronounced among veterans: the proportion of veterans aged 65 and older has outpaced that of the civilian population (Pietrzak & Cook, 2013). The shift in the number of aging veterans is also accompanied by increasing diversity with regard to gender: by 2045, the proportion of women in the veteran population is projected to double (Bialik, 2017). Wilmoth and London (2011) noted a recent increase in the proportion of older veterans who are women, from 3% of the total U.S. veteran population in 2010 to 5% in 2020.

Given these trends in the veteran population, research regarding posttraumatic stress disorder (PTSD) and its treatment in older veterans is critical. Certain normative, developmental events related to older age (e.g., retirement, bereavement) may prompt reflection regarding past traumatic events, and delayed-onset PTSD in older adults has been documented (e.g., Horesh et al., 2011). Davison and colleagues (2016; 2020) propose that veterans may reengage with their military-related memories in an effort to find meaning and build coherence later in life. Considering the age-specific, developmental context of PTSD is therefore important.

In terms of PTSD treatment, older veterans are often disadvantaged, as they are less likely to be offered and to receive psychotherapy for mental health concerns and to be included in systematic research such as randomized controlled trials (RCTs) of trauma-focused psychotherapies (e.g., Dinnen et al., 2015; Pless Kaiser et al., 2018). Although explicit age cutoffs are uncommon, the mean age of women veterans in recent trials was 40–45 years old (with a standard deviation of approximately 10 years; e.g., Mouilso et al., 2016; Schnurr et al., 2007; Voelkel et al., 2015). Other studies that focus on a given era (e.g., OEF/OIF in Castillo et al. 2016; mean age = 35.9 years) render many older veterans ineligible.

Cognitive behavioral interventions such as Cognitive Processing Therapy (CPT; Resick et al., 2017) demonstrate promising outcomes for PTSD. CPT is a manualized therapy that was originally developed for women with PTSD resulting from rape. The therapy begins with psychoeducation about PTSD, and patients are tasked with writing an impact statement describing how their most distressing trauma has affected their life and impacted their views of themselves, other people, and the world. In keeping with its predominant cognitive component, CPT therapists use Socratic questioning to challenge their clients’ interpretations and conclusions about their traumatic events. Later sessions focus on specific topics of safety, trust, power/control, esteem, and intimacy in relation to PTSD. Scant empirical work, however, has examined the efficacy and effectiveness of psychotherapy for PTSD among older adults (see review by Dinnen et al., 2015). The use of CPT in older veterans has not been explicitly examined; however, two CPT outcome studies that included older veterans did report positive effects overall (Chard et al., 2010; Jeffreys et al., 2014).

In addition to considering age-related factors, extant evidence suggests that women veterans’ physical and mental health is complex (Creech et al., 2019) and worse than that of both male veterans and female non-veterans (e.g., Frayne et al., 2006; Lehavot et al., 2018). Women veterans often must navigate negative health consequences related to their military experiences, such as sexual assault sustained during military service (e.g., Murdoch et al., 2006; Suris & Lind, 2008). Military sexual trauma (MST) is prevalent among women veterans (Wilson, 2018) and may be associated with unique sequelae such as feelings of institutional betrayal that can interfere with mental health treatment-seeking, particularly VA care (Holliday & Monteith, 2019). Although MST is not specific to women veterans, women veterans face greater risk of MST by percentage (Wilson, 2018). Women veterans are less likely than male veterans to have a service-connected disability, which may further impede access to veteran’s Affairs (VA) health care services (Wilmoth & London, 2011). In light of the aforementioned information, aging women veterans likely require special consideration regarding their intersectional identities.

Despite strong evidence for the effectiveness of CPT, practitioners may harbor specific concerns about using a cognitive therapy with older adults given the cognitive emphasis and the cognitive decline that may accompany aging. Further, combat history and aging has been frequently studied, but less work has been done regarding other trauma types such as sexual trauma. The goal of this article is to present a clinical example of a successful course of CPT to treat PTSD secondary to military sexual trauma (MST) in a 74-year-old female Army veteran to demonstrate that CPT can be appropriate for older adults with few to no modifications.

Demographics and Presenting Problem

Mrs. Z is a 74-year-old Army veteran who was evaluated and treated for PTSD at a northeastern U.S. VA medical center. Mrs. Z served stateside during the Vietnam War for 12 months; she did not deploy to Vietnam. Approximately 10 months into her service, she was sexually assaulted by a superior. She reports being drugged, violently raped, and subsequently threatened to remain silent about the incident. After the trauma, she began drinking alcohol heavily and abusing prescription medication in an attempt to self-medicate, was psychiatrically hospitalized, and ultimately received an early administrative honorable discharge from the military. Upon returning home from service, she continued to use alcohol and other substances heavily, and she engaged in multiple transient sexual relationships. She became pregnant and chose adoption for her baby at her religious parents’ urging. She had five additional children across two subsequent marriages, both of which ended in divorce. She was employed part-time throughout her life up until her early retirement at age 55.

Initial Contact With VA and Referral to Specialty Trauma Program

In the fall of 2017, Mrs. Z connected with VA for the first time, in order to obtain prescriptions and immunizations through VA primary care. During her routine initial visit, her primary care provider completed a health screen regarding military sexual trauma (MST) exposure, to which Mrs. Z responded affirmatively. She was then offered and accepted a meeting with a psychologist embedded within primary care. The primary care psychologist provided support and psychoeducation regarding MST, PTSD symptoms, and trauma recovery services available in mental health at VA. Mrs. Z declined referral at that time.

Mrs. Z later reported, however, that her discussion with the primary care psychologist was “like opening a can of worms,” and she contacted her VA’s mental health department approximately 1 year later, at the encouragement of a town veterans’ Agent. She was referred to a specialty women’s trauma recovery outpatient program where she attended an initial intake appointment with the second author (EHD), a clinical psychologist with expertise in geropsychology and trauma. She completed the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) and the Patient Health Questionnaire (PHQ-9; Kroenke & Spitzer, 2002). The PCL-5 is a 20-item self-report measure of PTSD symptoms with strong psychometric properties. Scores range from 0 to 80. Scores above 24 are suggestive of possible PTSD among elderly VA outpatients, which is considerably lower than the cut score of 33+ for middle-aged and younger veterans (Yeager & Magruder, 2014). Mrs. Z anchored her responses on the PCL-5 to “rape, violent” at age 18 and scored a 53 with symptoms endorsed in all four distinct PTSD symptom clusters: reexperiencing, avoidance, negative cognitions and mood, and arousal. Her PCL-5 responses, taken together with her description of her symptoms during an intake interview, indicated that she was significantly affected by symptoms of PTSD. She was referred for individual psychotherapy with the recommendation that initial sessions be devoted to further assessment for diagnostic clarification and treatment planning. She denied any cognitive concerns at intake (and throughout treatment).

Initial PTSD Evaluation

The first author (LR), a predoctoral psychology intern at the time, served as Mrs. Z’s psychotherapist under the supervision of the second author (EHD). Over the course of three hour-long sessions, the first author (LR) completed a structured assessment of PTSD using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013). The CAPS-5 is the gold-standard, structured interview for assessing the presence and severity of PTSD. Results of Mrs. Z’s CAPS-5 indicated the presence of PTSD per DSM-5 criteria (American Psychiatric Association, 2013). Again, Mrs. Z anchored her responses to the Criterion A event of directly experiencing MST at age 18, indicating that this was the traumatic event that caused her the most distress. Of note, she also endorsed having experienced childhood physical abuse and a single instance of childhood sexual abuse (CSA; molestation by a stranger), as well as intimate partner violence (IPV). The veteran denied that the single instance of CSA caused her current distress and very clearly indicated that the violent MST experienced at age 18 was, subjectively, the most distressing trauma. She described that she reported the CSA to her father, and that her father believed her and directly addressed the perpetrator. The veteran experienced physical abuse by her father yet described this as normative for her generational and cultural (Irish Catholic) background. The veteran experienced IPV in both of her marriages, which began following her military service (and after the MST).

She endorsed two out of five intrusion symptoms (Criterion B), two out of two avoidance symptoms (Criterion C), five out of seven negative alterations in cognitions and mood (Criterion D), and two out of six marked alterations in arousal and reactivity (Criterion E). The duration of these symptoms was more than 1 month (Criterion F), and she reported the symptoms were causing significant distress and impairment in functioning (Criterion G). She denied any depersonalization or derealization experiences in the past month. Further, Mrs. Z reported having experienced increased posttraumatic symptoms over the past 5 years in the context of multiple medical issues: surgeries, high levels of pain, and weight gain following each surgery.

Although Mrs. Z initiated mental health treatment in her 70s, her PTSD evaluation revealed a long history of posttraumatic stress symptoms and associated impairment. Mrs. Z stated that her initial visit a year prior with the psychologist in primary care prompted an “epiphany.” She reported realizing that her rape at age 18 “was like a snowball in my life.” She reported feeling as though she had been reacting to the rape her entire life, and that now with hindsight she could see how her life course had been profoundly affected by the MST. For example, Mrs. Z noted that she repeatedly chose to date men who were “below” her and reported believing she had tolerated poor treatment in relationships (e.g., intimate partner violence) due to low self-esteem associated with the rape. She reported that she self-medicated with drugs and alcohol for many years prior to finding support through Alcoholic Anonymous and achieving and maintaining sobriety for the past 30 years. She described specifically opting for part-time jobs to try to minimize daily stress. She avoided reminders of the military, avoided discussing her service with her children, and discouraged her children from enlisting in the military. Notably, she had not disclosed the rape to anyone prior to seeking mental health treatment in VA.

Overview of Treatment: CPT Session by Session

Based upon the above assessment by the first author (LR), the treatment team offered Mrs. Z a course of CPT with or without the optional written account. Mrs. Z elected to complete CPT without the optional written account. This decision, which collaboratively incorporated the two authors and the veteran, was also consistent with research findings. Specifically, Resick and colleagues (2008) suggested that CPT without an account—in comparison to CPT with a written account—yielded a faster decline in PTSD symptoms and had a lower rate of dropout. Given additional research evidence suggesting that honoring patient treatment preferences can positively affect retention and outcome (Swift & Callahan, 2009), the authors supported the veteran’s choice. Mrs. Z completed thirteen 60-minute CPT sessions (with the content from CPT Session 10 taking place over the course of two sessions) over the course of 3 months. Throughout the course of CPT, Mrs. Z was administered the PCL-5 prior to each session. At times, she noted that her responses on the PCL-5 reflected more general distress in the past week (e.g., from medical illness or family stressors). Despite occasional re-explanation of the PTSD-specific nature of the measure, Mrs. Z continued to rate some items with regard to past-week general distress.

CPT Session 1

In line with the standard CPT protocol, the therapist provided psychoeducation about symptoms of PTSD, cognitive theory, natural versus manufactured emotions, and “stuck points.” A stuck point in CPT is a concise statement that reflects a thought that inhibits recovery from trauma. Mrs. Z demonstrated good insight, began to identify some stuck points relating to the MST such as the belief that “it was all my fault,” and began to construct her stuck point log. Upon the therapist’s introduction and assignment of the Impact Statement—a written document that describes the meaning of the traumatic event and how it has affected one’s view of themselves, other people, and the world—Mrs. Z discussed her worry that writing would be difficult due to the “Irish Catholic belief” of not wanting to write down “anything you wouldn’t want to see on the cover of the newspaper.” The therapist validated Mrs. Z’s worry and provided reassurance regarding confidential storage of documentation and therapy materials. Last, the therapist assessed any perceived barriers to attending therapy sessions and completing between-session assignments and assisted Mrs. Z in problem-solving these barriers. Mrs. Z anticipated that caring for her grandchildren for extended periods of time might make homework completion difficult.

CPT Session 2

Mrs. Z arrived to session with a brief, bulleted Impact Statement. The therapist praised Mrs. Z for her homework completion and assisted her in expanding upon her answers verbally, in session. The therapist then introduced the connections between activating events (A), beliefs/stuck points (B), and consequences or feelings (C) and the accompanying A-B-C worksheet. Overall, Mrs. Z demonstrated engagement and understanding of the concepts and assignments. She readily identified additional stuck points and completed an A-B-C worksheet related to thoughts and feelings associated with hearing sexual assault-related testimony on television in session.

Relatedly, a consistent theme resurfaced in the second session whereby Mrs. Z’s experiences in CPT were profoundly affected by daily experiences outside of session. For example, Mrs. Z shared at the outset of Session 2 that she had been feeling overwhelmed given ongoing stress related to an ill relative who had recently been moved to hospice care and to watching ongoing testimony related to sexual assault during the appointment hearings for a Supreme Court nominee (Jacobs, 2018; Rittenberg, 2018). Throughout the course of CPT, the therapist and Mrs. Z worked together to incorporate these current experiences into the worksheets and practice assignments while also continuing to directly address the MST.

CPT Session 3

Mrs. Z began this session by stating that she had “failed,” as she had not done her assigned A-B-C worksheets. She stated, “I can’t do this,” and articulated beliefs related to her performance as a student in grade school (e.g., “I was never good at homework”). Using these beliefs as example stuck points, the therapist and Mrs. Z collaboratively completed several A-B-C worksheets in session, drawing connections between Mrs. Z’s recent feelings of failure and her stuck points related to the MST (for example, “I made bad choices in men”) that also elicited feelings of failure. Following this review of the concepts involved, Mrs. Z expressed an improved understanding of the assignment and a willingness to complete additional A-B-C worksheets for homework.

CPT Session 4

Mrs. Z arrived to session with completed homework. During this session, the therapist provided psychoeducation regarding differences between responsibility and blame. Mrs. Z expressed understanding, noting that this distinction was interesting to her and helped her to adopt a new perspective. The therapist then introduced the Challenging Questions Worksheet and used Socratic questioning to address Mrs. Z’s assimilated self-blaming belief, “It’s my fault that I was in the wrong place at the wrong time.” In considering the psychoeducation about responsibility and the skills offered via the worksheet, Mrs. Z modified her belief to, “I was socializing appropriately, and someone took advantage of me.” She also acknowledged that she had no evidence that the location was the “wrong place.”

CPT Session 5

Upon arriving to this session, Mrs. Z reported that she had been sleeping better and attributed this improvement to changes in her thinking. Although Mrs. Z had not completed her homework due to not remembering which stuck points she had planned to challenge, she was amenable to challenging beliefs in session. She and the therapist jointly practiced a Challenging Questions Worksheet regarding the belief, “I need to be in control or something bad will happen.” Following the therapist’s Socratic questioning, Mrs. Z modified her belief to reflect that it is not always possible to prevent bad things from happening, and “bad things can happen even if you do seem to have control” (e.g., car accidents). The therapist then introduced the Patterns of Problematic Thinking Worksheet, and Mrs. Z accurately identified personal examples of these patterns related to thinking negatively. Prior to leaving this session, Mrs. Z shared that she spontaneously told three people about her MST despite initially stating she would never share this history with anyone other than her VA providers.

CPT Session 6

Despite reporting that she could not complete her homework during the past week due to feeling anxious upon attempting to open her CPT folder, Mrs. Z had completed one Challenging Questions Worksheet. In session, Mrs. Z and her therapist jointly practiced two additional Challenging Questions Worksheets targeting stuck points such as, “I can’t trust anyone,” and again reviewed the Patterns of Problematic Thinking worksheet. Upon collaboratively completing one of these worksheets in session, Mrs. Z remarked, “I feel like I can trust myself more; I’m understanding things better.” Next, the therapist introduced the final cognitive worksheet, the Challenging Beliefs Worksheet, which brings together the previous worksheets and introduces the development of alternative thoughts and feelings. Together, Mrs. Z and the therapist completed a Challenging Beliefs Worksheet related to the thought, “I can’t change.” Upon selecting this belief, Mrs. Z expressed disbelief that she had identified this stuck point from her initial impact statement, stating that she realized she had already changed significantly through therapy. After completing the worksheet, Mrs. Z’s modified belief read, “I can change with help from counseling,” and she endorsed experiencing emotions such as “happy and proud” at “85–90%.” She referenced her ability to modify her thinking in CPT and her 30 years of sobriety as evidence that she could change. Although she expressed some continued skepticism regarding her ability to complete worksheets for daily practice, she agreed to try at least one additional Challenging Beliefs Worksheet for homework.

CPT Sessions 7–9

During subsequent sessions, Mrs. Z continued to modify beliefs using the Challenging Beliefs Worksheet. For example, she challenged the stuck point, “I don’t deserve healthy relationships,” a thought that initially led her to feel sad and anxious. Upon modifying the belief “As I become healthier, I can seek healthier relationships,” Mrs. Z reported feeling “good.” The therapist oriented the veteran to the five themes—Safety, Trust, Power/Control, Esteem, and Intimacy—to be consecutively discussed during the remaining sessions of CPT, and assigned a thematic handout at each session. During the ninth session, the veteran also completed the “Trust Star” handout. Mrs. Z identified five people that she could trust in varying ways and degrees (e.g., lending money, honoring last wishes, keeping secrets, making medical decisions). Accordingly, she modified her stuck points regarding trust to acknowledge that there are people she can trust in different ways. She also expressed an interest in learning additional skills for identifying who she can trust.

CPT Session 10, Part One

Upon arriving to session, Mrs. Z described feeling frustrated with her recent VA compensation and pension disability examination, which had taken place shortly prior to this session. She reported feeling worried about her responses during the exam, and felt that she did not adequately convey how the MST had “wreaked havoc” in her life. The therapist validated her concerns and provided information regarding the function of compensation and pension examinations and how these exams differ from therapy. Next, Mrs. Z and the therapist turned to the Power/Control module of CPT. However, Mrs. Z had forgotten her folder in session the previous week and thus had not completed any practice assignments; additionally, she continued to voice distress surrounding her recent disability examination. Mrs. Z and therapist jointly reviewed the Power/Control handout and collaboratively challenged her stuck point, “I need to be in control,” using a Challenging Beliefs Worksheet, and discussed benefits and disadvantages of having control. At the end of the session, the therapist introduced the Esteem module and assigned associated reading for practice. The therapist also assigned homework practice of giving and accepting compliments and doing one kind thing for herself daily.

CPT Session 10, Part Two

Upon arriving at the next session, Mrs. Z continued to articulate ruminative worry regarding her recent VA compensation and pension disability examination. Accordingly, the therapist provided support and validation, offered information regarding the estimated timeline for receiving a decision, and told her how she might obtain a copy of her medical records. Given the small amount of time remaining in session after this discussion, the therapist elected to review material from the previous session. This included a review of Mrs. Z’s stuck point log and remaining points to tackle. Jointly, Mrs. Z and the therapist reflected upon her progress with regard to changes in her thinking. The therapist reviewed the Power/Control module and assigned homework to continue challenging the few remaining stuck points as well as to read handouts regarding Esteem.

CPT Session 11

Mrs. Z completed all her homework prior to session and reviewed said work in session. Regarding her overaccommodated stuck point, “I don’t feel safe,” Mrs. Z identified that she did indeed feel safe in many situations but that previous traumatic experiences with men continued to affect her general sense of safety. The therapist introduced the topic of Intimacy (self-intimacy and intimacy with others), and Mrs. Z reflected that the concept of self-intimacy was new to her. Indicative of her adept ability to grasp this novel concept, she readily identified many ways in which she is intimate with herself (for example, knowing her preferences and owning her decisions). The therapist introduced the final homework assignments: to write a new/final impact statement and complete a worksheet related to intimacy.

CPT Session 12

Mrs. Z completed the PCL-5 prior to session and scored a 39. She arrived to session without having completed her final Impact Statement. She agreed to do so verbally in session, and the therapist transcribed her statement verbatim on the computer and provided Mrs. Z with a printed copy. The therapist then read Mrs. Z’s initial Impact Statement aloud. Mrs. Z reflected on the pronounced changes in her thinking patterns and beliefs over the course of CPT. She described sentiments reflecting the core CPT themes of Trust—“There are good people in the world and people I can trust in this world; I’ve learned that”—and Control—“I have let go of control; I don’t try to fix everything all the time anymore. I realize at this point I need to let it go.” Additionally, her final Impact Statement evinced shifts in beliefs about self-blame as well: “Now I know I was taken advantage of; before, I used to think that it was my own fault for not being sharp enough.” More broadly, Mrs. Z demonstrated posttraumatic healing: “Until now, I really thought I had something crazy going on in my head, and I did. But now it’s gone. And I feel like I can start to heal now. I have inner peace now—not 100% but pretty close to it.” Of note, Mrs. Z had received notification of her service connection rating for PTSD a few days prior to this final session.

In consolidating gains, Mrs. Z identified several components of CPT that had been helpful to her, such as learning to distinguish between blame and responsibility for the MST. She and her therapist discussed her ongoing therapy goals, such as challenging beliefs about whether she is truly a veteran (e.g., in comparison to a paraplegic combat veteran whose wounds are visible). Mrs. Z expressed gratitude for the intervention and an enthusiasm to continue therapy in order to maintain her gains and continue working on enriching her time in retirement and developing an improved sense of self-esteem.

Aftercare

Following CPT completion, Mrs. Z met with the first author for nine additional individual therapy sessions. Session topics included identifying future goals (e.g., broadening her social network, moving to a new residence), skills practice, case management (e.g., pursuing a disability appeal if necessary; assistance with housing), further psychoeducation about service connection, and support. One of the nine sessions was a family session to which Mrs. Z invited one of her adult children in order to share about her MST, PTSD diagnosis, service connection, and course of treatment with her therapist’s support. Following this conjoint visit, it was recommended that Mrs. Z take a break from individual therapy in order to independently consolidate therapeutic gains, as well as to allow for more time to focus on increasing external social support and addressing medical issues such as weight management and Type II diabetes. To this end, Mrs. Z was referred to a stress management psychotherapy group in another program for continued skills practice and opportunities to socialize with fellow veterans. The veteran attended nine group sessions. Simultaneously, she reengaged with a psychiatrist to address lingering sleep concerns and connected with a VA health coach.

Approximately 1 month after concluding individual therapy with the first author, Mrs. Z contacted the therapist’s supervisor and clinic director (EHD) with a request to resume individual therapy to address new treatment goals. She reported having benefitted greatly from CPT and subsequent sessions yet articulated a desire to disclose, with the support of a therapist, her experience of MST to another adult child in order to enhance and improve their relationship. Further, the considerable financial compensation awarded in the context of Mrs. Z’s service connection afforded her funds to be able to move, and she was now contending with the stress of identifying a new living situation and moving after several decades in the same apartment. She also identified several developmentally normative relational and later-life tasks that she wished to address in therapy. The supervisor (EHD) began meeting with Mrs. Z at a significantly reduced frequency (i.e., biweekly, and then triweekly) for individual psychotherapy sessions in order to address these new treatment goals. Mrs. Z was also offered a conjoint session with her other adult child; however, she ended up independently disclosing her MST to this child outside of session.

The veteran shared with her current provider (18 months after concluding CPT) that “A lot of mental hard work is starting to pay off, and it’s really nice!” The veteran added, “I’m a true testimony to therapy.” Mrs. Z later met with the first author via phone to review the case report. Upon reviewing the case report, the veteran shared, “It was a walk down memory lane. I forgot all the hard work I did—I’m a different person. … There are no words to explain what working with you did to my life.”

Considerations

Mrs. Z’s course of Cognitive Processing Therapy took place in the midst of numerous contextual factors, some of which were specific to Mrs. Z’s phase of life and to developmentally normative aging and unique intersections of identity (i.e., older woman veteran), and others that pertained to the current political climate and national events. These factors—including medical illness and conditions, inclement winter weather, family involvement, and homework completion—are worth mentioning, as they affected aspects of her treatment.

Mrs. Z had several chronic medical conditions that are relatively common among older adults, including Type II diabetes and associated retinopathy. She also had diagnoses of gastroesophageal reflux disease (GERD) and diverticulosis. As a result, Mrs. Z had numerous medical appointments each week, some of which would occasionally interfere with her ability to attend therapy sessions with regularity (at times due to exhaustion from or confusion about her numerous appointments). Mrs. Z’s medical appointments—and associated distress—led the therapist to offer additional flexibility with rescheduling (e.g., next-day rescheduling following a same-day cancellation). The therapist also provided basic psychoeducation about the possible connections between anxiety and somatic symptoms.

Further, Mrs. Z expressed the belief that the early stress associated with undergoing the CAPS-5 interview and initiating CPT may have aggravated her gastrointestinal concerns. Also, Mrs. Z’s course of CPT took place during snowy winter months, and she would occasionally cancel sessions the morning of an appointment due to cold temperatures or to concerns about slipping and falling on ice. On one occasion, Mrs. Z cancelled an appointment 3 days after a snowstorm as she had not yet found help in shoveling her car out.

Throughout the course of therapy, Mrs. Z would often articulate self-deprecating statements related to her past (e.g., multiple “failed relationships” and the belief that she “made bad choices in men”), her education level (e.g., “I was a poor student”), her socioeconomic status (“I live in the projects”), and her weight, among other physical characteristics. Although some beliefs could be addressed through cognitive restructuring (and the veteran attempted to address other concerns, such as weight gain, through behavioral changes), the veteran often followed said statements with comments suggesting a comparison to the first author, who is also a White woman but differs in multiple aspects of identity (e.g., age, religion, marital status). For example, Mrs. Z would comment on known or visible differences, such as the first author’s higher level of educational attainment, lower weight, and current marital status (indicated by a wedding band). At times, Mrs. Z would also express regret for not having addressed her MST earlier and a hope that she could live a life similar to what she perceived the first author lived. The author often acknowledged the valid aspects of the veteran’s sentiments and repeatedly encouraged the veteran to use her skills (e.g., Challenging Questions worksheets) to address said beliefs.

As a mother, grandmother, and involved caretaker for an elderly relative, Mrs. Z also had numerous family obligations throughout the course of treatment. During this course of therapy, a relative similar in age to herself grew ill and passed away; as such, Mrs. Z experienced increased stress due to hospice visits, and she missed a therapy appointment in order to attend the funeral. Mrs. Z also would, at times, cancel on the day of an appointment in order to take care of a sick grandchild. An ex-husband also passed away during her course of CPT. Despite her anger towards her ex-husband, Mrs. Z reported distress related to her children losing their father. Somewhat relatedly, Mrs. Z embraced her role as the matriarch of her large Catholic family and firmly believed in keeping her personal matters (e.g., medical and therapy appointments; past traumas and other struggles) private from her children; consequently, she often would accept caregiving and other requests from family and would not disclose that this caregiving conflicted with her own care. Above all, her role as the matriarch—intersecting with her Irish Catholic upbringing— contributed to her concealing from her children that she was seeking care for her mental health and MST.

Mrs. Z frequently expressed difficulty with CPT homework completion, despite not evidencing any cognitive difficulties or comprehension problems. Although Mrs. Z did not have any cognitive concerns, she self-identified as a historically “poor student” and, accordingly, held the belief that she was not able to complete homework independently. On more than one occasion, Mrs. Z arrived to session without having completed her homework with the explanation that she “forgot how to do it” or “did not understand it.” However, with a simple reminder and review in session, Mrs. Z was able to complete examples in session, and for practice assignments that were given over multiple weeks (for example, the Challenging Beliefs Worksheet), she demonstrated increased competence and confidence over time.

Mrs. Z articulated difficulties seeking treatment at the VA. As an older woman who served in the Vietnam era but who did not deploy overseas, Mrs. Z felt as though she were not deserving of VA care. Further, she compared her service to that of combat veterans with visible wounds (i.e., an amputated leg) and often minimized her mental pain in this context. It was not until Mrs. Z was awarded service connection for PTSD that she began to acknowledge—and experience pride regarding—her identity as a veteran. Mrs. Z also articulated that she delayed seeking care because she did not want to be around male veterans who reminded her of her MST. Throughout treatment, she indicated a hesitancy to ride the elevator with older male veterans and to sit in the waiting room with men. She was also hesitant to join co-educational group therapy offerings, such as a “Healthy Thinking” group or a weight management group due to the presence of male veterans (however, it is important to note that following CPT completion, she joined a co-educational stress management group).

In addition to the factors described above, two main “external” circumstances warrant highlighting. First, Mrs. Z completed a VA compensation and pension disability examination following her ninth session of CPT, and she was notified of the result (and considerable monetary award and back payment lump sum) immediately prior to her final session of CPT. Second, Mrs. Z’s course of CPT coincided with the confirmation hearings for Supreme Court Justice Brett Kavanaugh and the associated media coverage of allegations of sexual assault. Mrs. Z described increased stress, confusion, and intrusive memories associated with both of these proceedings; the impact of each is discussed below.

Mrs. Z noted increased distress surrounding the disability examination. Mrs. Z voiced surprise regarding the tone of the examination, as she had expected that it might be more “therapy-like” given that it was conducted by a psychologist. She questioned whether her answers had been accurate, and she also described feeling distressed by pieces of information obtained from her earlier hospital records and read aloud to her during the examination. Following her disability examination, Mrs. Z obtained a copy of her medical records dating back to her time in the military and reviewed them herself. In the weeks following her examination, Mrs. Z voiced a great deal of worry regarding the outcome and whether she would be believed. Upon notification of her 70% disability award, Mrs. Z articulated feeling validated—not simply in terms of the damage caused by her MST, but with regard to her status as a woman veteran, an identity that she had often discounted given her brief period of service and the fact that she never deployed. With regard to the disability examination, she commented, “I can add that therapy has given me a 70% and that is one of the most—if not the most—powerful things anyone has done for me. That has healed me internally.” It is important to consider the timing of this disability award in the context of her course of CPT (i.e., within 2 days of the final session).

Last but not least, Mrs. Z sought trauma therapy in the midst of the widely publicized #MeToo movement (Ohlheiser, 2017). Furthermore, her course of CPT coincided with highly televised and politicized events, including the confirmation hearing for Supreme Court nominee Brett Kavanaugh. Despite her political allegiance, Mrs. Z voiced feeling conflicted, as she believed the testimony of the woman accusing Mr. Kavanaugh of sexual misconduct. Specifically, Mrs. Z was bothered by questions she heard such as, “If it really happened, why did she wait so long to tell anyone?” as she herself had kept her experience of MST a secret for over 50 years. Mrs. Z was able to identify and challenge these beliefs using a Challenging Beliefs Worksheet; however, the environmental angst was distressing nonetheless.

Conclusion

This case study of a woman veteran in her 70s demonstrates that older adults can benefit from cognitively-based trauma-focused therapy for PTSD. To the authors’ knowledge, no single case study of CPT with an older adult woman veteran exists to date, and more generally no case reports have described the effects and potential benefits of cognitive trauma-focused therapy in this population. This case report offers many strengths, including novelty and the routine administration of clinical assessments. Further, the current case includes objective assessment information (e.g., the gold-standard CAPS-5 diagnostic interview as well as weekly self-report assessments). Case reports, however, are not without inherent methodological limitations (Kazdin, 1981). Further, it is impossible to rule out that the changes Mrs. Z evidenced are due to factors other than or in addition to therapy, such as the results of her VA disability examination and subsequent award. Taken together, however, this case illustrates the utility of Cognitive Processing Therapy for older, therapy-naive women veterans with PTSD. Collectively, the authors hope that this case study provides inspiration for cognitive behavioral therapists considering whether to offer trauma processing therapy to an older adult. Given the demand for effective PTSD treatment for older adults—a vulnerable, growing cohort with unique needs—future research should systematically examine the effectiveness of CPT in an older veteran population.

Highlights.

• Cognitive Processing Therapy (CPT) is a first-line treatment for PTSD.

• Special consideration for aging women veterans’ unique identities is warranted.

• The case example details a course of CPT with an older woman veteran.

• The case example addresses factors related to aging, VA, and current events.