What is the purpose and process of Cognitive Processing Therapy?

Cognitive Processing Therapy (CPT) is a cognitive-behavioral therapy for posttraumatic stress disorder (PTSD) and related conditions. It is a manualized therapy that includes common elements from general cognitive-behavioral treatments. CPT typically consists of 12 sessions and has been shown to be effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats. The theory behind CPT conceptualizes PTSD as a disorder of “non-recovery” in which erroneous beliefs about the causes and consequences of traumatic events produce strong negative emotions and prevent accurate processing of the trauma memory and natural emotions emanating from the event. Although PTSD is classified currently as an anxiety disorder, most people with PTSD experience a range of emotions including horror, anger, shame, guilt and sadness as well as fear. A significant contributor to the interruption of natural recovery process is the ongoing use of avoidance as a coping strategy. By avoiding the trauma memory and situations that trigger reactions, people with PTSD limit their opportunities to process the traumatic experience and gain a more adaptive understanding. CPT incorporates trauma-specific cognitive techniques to help individuals with PTSD more accurately appraise these “stuck points” and progress toward recovery.

Overview of CPT Phases of Treatment

During the course of CPT, the primary focus is to help patients gain an understanding of, and modify the meaning attributed to, their traumatic event. In pursuit of this objective, an important goal of CPT is to decrease the pattern of avoiding the trauma memory so that beliefs and meanings can be further evaluated and understood within the original context. The initial phase of treatment consists of education regarding PTSD, thoughts, and emotions. The therapist develops rapport with patients by establishing a common understanding of the problems experienced by the patients (e.g., PTSD) and outlining the cognitive theory of PTSD development and maintenance. This information is essential to help patients understand the rationale and goals of therapy. Patients are asked to write an Impact Statement to identify how the patient understands why the event occurred and the impact that it has had on their beliefs about themselves, others, and the world. In this phase of treatment, a large focus is on the identification of automatic thoughts and increasing awareness of the relationship between a person’s thoughts and feelings. Specifically, patients are taught to identify ‘stuck points,’ which are problematic beliefs that interfere with recovery from traumatic experiences (e.g., “It is my fault. I should have known that he would attack me. I should have fought harder”).

The next phase of CPT involves formal processing of the trauma. Patients are asked to write a detailed account of their worst traumatic experience, which they read to the therapist in session. By writing the account of their worst traumatic experience, patients break the pattern of avoidance and increase the process of dissipating the strong emotions that have yet to “run the natural course of recovery.” Emotional processing continues throughout the course of CPT as patients discuss their traumatic experiences in efforts to clarify and modify their maladaptive beliefs. Clinicians use Socratic dialogue to discuss the details of the trauma, which helps patients gently challenge their thinking about their traumatic event and become increasingly able to consider the context in which the event occurred, with the goal of decreasing self-blame and guilt and increasing acceptance. The Socratic method is based on the understanding that patients need to engage in their own process of knowing. By asking questions, rather than providing interpretations or advice, patients are able to gradually unfold their own insights.

An alternative model of CPT that has been found to be equally effective, and perhaps more efficient, is to conduct the standard protocol without the written accounts. This method relies instead on Socratic dialogue between therapist and client to bring out the details of the trauma that might refute the client’s assumptions and appraisals about their worst traumatic experience.

The final phase of treatment focuses on teaching the patient the cognitive skills necessary to identify, evaluate, and modify their beliefs as necessary regarding any and all traumatic events they have experienced. Patients focus on the ‘stuck points’ identified and work to better understand and challenge habitual and unrealistic conclusions about their traumatic experience (e.g., “This means that no one can be trusted in any way”). The skills learned in this phase of treatment are helpful to empower patients to “become their own therapist” and to learn how to engage in adaptive coping post-treatment.

The final phase of treatment also focuses on five themes that have been identified as areas in which beliefs are commonly impacted by a traumatic experience. These themes include Safety, Trust, Power/Control, Esteem, and Intimacy. Patients learn to recognize how their beliefs may have become over-generalized based on their traumatic experiences, and how their current functioning and quality of life have been impacted as a result. They utilize their new cognitive skills to reevaluate these beliefs and develop alternate ways of viewing the world that are ultimately more balanced and adaptive.

Structure of CPT Individual Sessions

• Twelve 50-minute structured sessions
• Sessions typically conducted once or twice weekly
• Patients complete out-of-session practice assignments

2 Formats:

• CPT includes a brief written trauma account component, along with ongoing practice of cognitive techniques
• CPT-Cognitive (CPT-C) omits the written trauma account, and includes more practice of cognitive techniques

Structure of CPT Group Sessions

• Twelve 90-120 minute structured group sessions
• Typically conducted by two clinicians
• 8-10 patients per group
• Patients complete out-of-session practice assignments

3 Formats:

• CPT includes a brief written trauma account component, along with ongoing practice of cognitive techniques. The details of the written accounts are not shared during sessions, but the emotional and cognitive reactions identified while writing the account are processed by the group.
• CPT-Cognitive (CPT-C) omits the written trauma account, and includes more practice of cognitive techniques.
• Individual and Group Combined includes practice assignments and the written trauma account, which are processed in additional individual therapy sessions.

Patricia A. Resick is the author of Cognitive Processing Therapy for Rape Victims.