CPT is one of the most-used and effective therapies for post-traumatic stress disorder (PTSD). Learn why.
Many types of therapy strive to heal post-traumatic stress disorder (PTSD). One of them works particularly well, taking a targeted yet gradual approach.
Cognitive processing therapy (CPT) is one of the most tested and proven therapies used to treat PTSD. It targets and treats harmful thoughts that fuel the condition, allowing survivors to gain confidence so they can feel safe in the world again.
This helps relieve the symptoms caused by past trauma.
(CPT is not to be confused with CBT, which is a related therapy. We’ll get more into that below.)
Looking for resources for yourself or your clients right away? Check out our tools for anxiety, PTSD, and self-care.
Ready to learn more about this groundbreaking treatment? Below is a look at CPT, and how it might help you or those you work with.
Article Highlights
How CPT Was Developed
CPT was developed in 1988 by Dr. Patricia Resick when she was at the University of Missouri in St. Louis. She worked with rape victims at the time, and was looking for a cognitive therapy to help her clients who were suffering from PTSD.
Over time, she developed an approach that built on the ideas from cognitive behavioral therapy (CBT). She adapted the basics of CBT to help her clients work through the unhelpful thoughts relating to their trauma (Resick, 2019).
An early study of CPT showed that this method indeed helped decrease symptoms of PTSD and depression among survivors. Over time, the therapy has been modified and refined, as more was learned about CPT and how to best use it with clients (Resick & Schnicke, 1992; Resick, 2019).
The main difference at the time between Resick’s approach and other PTSD treatments was that it worked from the “top-down,” meaning it targeted the thoughts about the trauma first, rather than targeting the resulting symptoms (Resick, 2019).
CPT is now applied to post-traumatic stress disorder (PTSD) in many settings. It’s used with those who’ve survived all types of trauma, including sexual assault, physical assault, accidents, combat exposure, and much more.
Since the initial development of CPT, repeated studies have shown it to be effective across a range of traumas, age groups, and backgrounds (Asmundson, et al., 2019).
How it Works
CPT targets negative thoughts that make people feel unsafe following a trauma. In my experience, these thoughts typically fall within just a few broad categories. They include:
Guilt and self-blame. It seems a natural trait for many people to blame themselves after something bad happens. Thoughts such as, “I shouldn’t have done that,” “I should have handled it differently,” or “I didn’t fight back hard enough,” are common beliefs I hear.
Beliefs about poor self-worth. Sometimes trauma triggers underlying negative beliefs. Examples include, “I deserve bad things to happen to me,” or “I’m a person unworthy of love or a happy life.”
Fear-based thoughts about safety in the world. Following a trauma, humans instinctively try to figure out what’s safe and what’s not. Those who develop PTSD haven’t yet returned to that feeling of safety.
A person with PTSD may think, “Everywhere in the world is unsafe,” or “I will feel out of control in certain situations.” They may also believe people who resemble or are similar to someone who harmed them will be unsafe, ie: “All tall men will harm me.”
These aren’t all of the possible negative beliefs people with PTSD experience, however these categories cover the majority of the thoughts my clients have experienced.
Such thoughts continue to send signals to the survival part of the brain that the world is unsafe. Even months or years following a trauma, someone with PTSD may still feel instinctively in danger.
This often happens even when the individual is in an obviously safe, harmless environment. They may know on the surface-level that nothing bad is likely to happen, but their body still reacts in defensive, self-protective ways. This leads to problems like hypervigilance in public settings, and frequent anxiety.
CPT targets the underlying thoughts, like those above, that are fueling the PTSD. Within this particular therapy, these thoughts are called “stuck points.”
For example, a CPT therapist may guide their client to reconsider thoughts of self-blame. This is often done through the Socratic method.
Rather than “telling” someone what they should believe, the therapist guides them to challenge their own thoughts about the trauma. A set of worksheets are often used to teach this method, which were created for CPT.
I’ve also developed a user-friendly set of PTSD worksheets consistent with treatments like CPT. You can check them out here.
The CPT worksheets, which clients complete both inside and outside of sessions, cover specific skills that help people challenge their negative beliefs.
During CPT, a client might make a breakthrough in one session, and begin to see their role in their trauma in a more balanced way. Other times it takes several sessions to work through one particular thought that’s blocking their recovery.
Once someone with PTSD is able to work through most of their negative thoughts about themselves and the world, as they relate to the trauma, their symptoms typically start to subside.
How Long Does it Take?
In the field (meaning in everyday therapy) CPT is often used however long it takes for symptoms to subside. The official protocol was created for 12 sessions, which may be offered weekly, or more times per week. Sessions are often worked around the participant’s needs and schedule.
Sometimes the therapy is provided in marathon sessions for those who don’t live close to a provider. They may spend two to three weeks attending multiple sessions during this timeframe, to speed up the therapy.
CPT Techniques
There are many elements to CPT. To get a full idea of each technique used, I’d recommend reading the most updated manual. However, I will review some of the standout techniques here, including those similar and different to other trauma therapies.
Impact Statement
In the impact statement, clients write about how they felt the trauma affected their lives. The event may have changed how they thought about themselves and the world, or how they interacted with others. This is a first step to identifying the “stuck points” relating to the trauma.
Education about PTSD
It’s helpful to understand the symptoms of PTSD and what causes it to develop. In the educational portion of CBT, these areas are reviewed. Clients begin to get an understanding of how PTSD forms, and why they are experiencing it.
Learning CBT Basics
CPT teaches the basics of CBT (the approach it’s based on) like connecting thoughts, behaviors and feelings.
A unique aspect of CPT is that it differentiates between “automatic” and “manufactured” emotions.
Automatic emotions are common and instinctual. If someone punches you, you are very likely to feel angry. That’s an automatic emotion.
However, if you begin to feel guilty for spending time with the person before they punched you, that is a manufactured emotion. Rather than being based on instinct, it required a bit of effort in your mind to come to that conclusion. It also involves self-blame and faulty reasoning.
In CPT, you learn to identify such manufactured emotions that aren’t based in fact. These make up the stuck points that fuel PTSD.
Identifying Stuck Points
The idea of stuck points is similar to that of cognitive distortions, identified originally by Aaron Beck who developed CBT therapy. In CPT, the term stuck points refers specifically to negative thoughts, most often relating to self-blame and guilt, relating to the trauma.
Stuck points may also relate to beliefs about safety in the world. Many of my clients with PTSD are very fearful of public places like grocery stores. However, their fears are not based on any actual evidence of danger.
Instead, they may simply feel that any crowded place will be unsafe, or that people in general just can’t be trusted. In most cases, my clients have never experienced a dangerous event at the grocery store. This is a stuck point about the likelihood of danger around them.
The earlier example also relates to a stuck point. The emotion of guilt likely connects to a thought such as, “I should have known that guy was dangerous.”
Challenging Questions
The name cognitive processing therapy may give this one away. CPT gets down to working through the stuck points and other thoughts about the trauma. Most people with PTSD have been avoiding thinking about their trauma, so stuck points continue to linger without being questioned.
In this portion of the treatment, the therapist, along with guiding worksheets, helps clients challenge their beliefs about the trauma. For example, if they believe they were to blame for being abused, this idea is brought into the light.
Questions considered might include:
Why do you believe this is true?
What is the evidence against this belief?
Would you blame someone if they were abused in this way? If not, then why not?
The therapist doesn’t simply tell the client what they should believe. If this was going to work, the person wouldn’t have ended up needing PTSD treatment.
Instead, client learns how to challenge their own thoughts, so they can ultimately become their own therapist.
In the end, those with PTSD will ideally see their trauma and the world in a more balanced way:
Are there dangerous people in the world? Sure, but that doesn’t mean I’m in constant danger.
Could another car accident happen? Of course, but the statistics of that are extremely low, and in many accidents no one is seriously injured.
Once these assumptions about danger are rebalanced, the messages in the brain change. The body’s instincts convert back to how they were before the trauma. Symptoms of hypervigilance, anxiety, and depression subside.
Writing about the Trauma
Sometimes, those participating in CPT will write about their experience during the trauma. In the CPT model, this is called the written account of the trauma. (Other similar therapies refer to this as the trauma narrative.)
In this case, the participants also read their story out loud in therapy. This portion of the therapy is largely meant to overcome avoidance, which is one of the common symptoms of PTSD.
Often avoidance is keeping people from facing the negative thoughts about the trauma, which may feel frightening and overwhelming. However, by writing and talking about the details of the trauma, the avoidance begins to break down, which allows the therapist and clients to get down to the stuck points.
Initially, the written account of the trauma was included in all CPT sessions. However, Resick completed later studies that showed that those who didn’t complete the written account benefited just as much as those who did (Resick, et al., 2008).
There was also the added benefit of a lower dropout rate among those who didn’t have to write about their trauma (Resick et al., 2008).
These days, the written account is often left as optional for clients. In my experience, many of my clients who’ve completed CPT say writing their trauma story was the most helpful part of the therapy. I believe people may feel a sense of completion and satisfaction when they face and complete this process.
I also personally believe that in the traditional model, the written account came too early in the process. In a similar therapy offered for children (see below), exposure to the memory of trauma is done very gradually over the entire course of the therapy.
With the more gradual method, it becomes much easier to work through the memories as a whole. By the time the children get to the part where they talk about the trauma details, the story is much less overwhelming.
Similar Therapies
While it’s one of the most popular therapies, CPT is not the only cognitive-based treatment shown to be effective for PTSD. Here’s a look at other popular options:
TF-CBT
One of the most similar therapies similar to CPT is called trauma-focused CBT (TF-CBT). This therapy includes many of the same concepts, however was developed specifically for children and teens.
In TF-CBT, many of the same cognitive techniques are used in a child-friendly way. In the children’s therapy, a caregiver is also involved throughout the process. And rather than a straightforward written account of the trauma, kids and teens develop a creative way to tell their story.
For example, they might write a comic book or a play about what happened. As they create the project, usually over several sessions, they are also working through their internal thoughts and beliefs relating to the traumatic event.
Prolonged Exposure (PE)
Prolonged exposure (PE) is another common treatment for PTSD. However, PE is a less cognitively directed approach. More exposure techniques are used, in an effort to prompt the client to begin processing more naturally for themselves, as they would have ideally done right after the trauma.
In my experience, prolonged exposure is the most intense PTSD therapy, and it’s certainly effective. It can also be more overwhelming for the therapists who provide it. I find more gradual therapies like CPT and TF-CBT are more manageable and even work a bit faster for my clients.
Despite my own preference for other therapies, I’ve found that many people who complete PE rave about the benefits and are glad they completed it.
Find a CPT Therapist
If you’d like to participate in CPT, you would ideally find a fully certified therapist who uses this approach. You can search for such a counselor through the CPT provider roster. Local therapists may also list this specialty through their website or on national therapy listings, such as Psychology Today.
If you’re interested in CPT but can’t find a fully trained provider, you may also look for therapists trained in other types of cognitive behavioral (CBT) therapies. For example, a TF-CBT therapist who also works with adults may use a similar approach.
Other therapists who provide CBT may also be willing to research this therapy to provide you with the best possible treatment. They can consult with a registered provider to learn more.
Ideally your therapist would be highly trained and experienced in CPT, however I believe the realities of therapist shortages require some flexibility. In my opinion, just about any therapy process that works is the right one.
Become a CPT Therapist
If you’re a licensed therapist interested in adding this specialty, I’d recommend you begin by learning about the basics of CBT, the broader approach CPT is based on.
If you find you like this approach, and are interested in treating PTSD, then you can continue with CPT training.
You can visit cptforptsd.com to get the training manual, and to check out upcoming training in person or online.
Tools and Worksheets
The materials I provide are not the same as the formal worksheets used in the formal CPT therapy, which you can access through the official website.
However, our user-friendly materials that use the CBT approach, which overlap with many of the techniques used in such trauma-focused therapies as CPT.
You can check out these tools here.
Sources
Asmundson, G., Thorisdottir, A. S., Roden-Foreman, J. W., Baird, S. O., Witcraft, S. M., Stein, A. T., Smits, J., & Powers, M. B. (2019). A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder. Cognitive behaviour therapy, 48(1), 1–14. https://doi.org/10.1080/16506073.2018.1522371
Resick, P. A. (2019). Dr. Patricia Resick on PTSD and the Evolution of Cognitive Processing Therapy, Presented at University of Vermont. Accessed at https://youtu.be/omKP0fYqOLM
Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of consulting and clinical psychology, 76(2), 243–258. https://doi.org/10.1037/0022-006X.76.2.243
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of consulting and clinical psychology, 60(5), 748–756. https://doi.org/10.1037//0022-006x.60.5.748