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Cognitive processing therapy (CPT)

Reviewed by Susan Radzilowski, MSW, LMSW, ACSW

Cognitive processing therapy (CPT) helps people with PTSD identify and resolve the unhelpful trauma-driven beliefs that shape how they see the world.

What is cognitive processing therapy?

Cognitive processing therapy (CPT) is a type of cognitive behavioral therapy (CBT) developed to treat posttraumatic stress disorder (PTSD).

CPT helps people identify, address, and challenge negative or unhelpful thoughts, feelings, and behaviors following a traumatic event. It also helps people evaluate and understand the beliefs that motivate their feelings and behaviors. CPT’s two main goals are reducing PTSD symptoms and getting “unstuck.”

Reducing PTSD symptoms

CPT can help reduce PTSD symptoms, which generally fall into four categories1:

  1. Intrusive memories: Unwillingly remembering or reliving a trauma through memories, flashbacks, or nightmares
  2. Avoidance: Adjusting your life to avoid any triggers (including people, places, thoughts, situations, and memories) associated with the trauma
  3. Changes in mood or thinking: Having feelings of hopelessness, numbness, or detachment; struggling to remember either the trauma or other unrelated information
  4. Reactivity: Constantly feeling on guard (or “hypervigilant”) or struggling to manage your reactions to stress (such as irritability, angry outbursts, or intense guilt and shame)

Getting unstuck

In CPT, “stuck points” are the beliefs a person develops about a trauma that prevent their recovery. They may be beliefs about themselves, others, or how the world works.

Stuck points are often rooted in shame, guilt, or fear. They involve extreme beliefs, exaggerations, negativity, and black-and-white thinking, meaning they don’t always reflect reality. An example of a stuck point would be a car accident survivor believing it’s their fault that other people died.

It’s difficult to move forward without addressing stuck points, especially if a person is also experiencing intrusive memories or other PTSD symptoms. With cognitive processing therapy, people can identify their stuck points, learn to challenge them, and discover how these extreme beliefs affect their self-esteem, intimate relationships, and ability to trust.

Benefits of CPT

In addition to reducing PTSD symptoms and helping you get unstuck, CPT can help you:

  • Put words to what you’ve been through: It can be cathartic to express what happened to you in your own words while in a safe place. It can also help you identify any unhelpful beliefs you may have developed in response to trauma.
  • Learn to challenge unhelpful thoughts: Even if you know your thoughts aren’t helpful, it can be difficult to push back on them. CPT gives you tools to identify and overcome these thoughts in a productive way.
  • Apply what you’ve learned: You can apply the skills you develop in CPT (like identifying unhelpful thoughts and challenging your own beliefs) in a variety of contexts, including applying them to parts of your life that aren’t related to your trauma. CPT skills can also help if you go through a stressful or traumatic situation in the future.

Is CPT effective?

Cognitive processing therapy has proven effective in treating PTSD.2 It’s especially helpful for people with complex PTSD (in which someone experiences multiple forms of trauma, chronic trauma, or some combination of both).

CPT is effective for both military veterans and the general public. However, it may be not be a good fit for people who struggle to complete weekly assignments or express themselves through writing, which is a key component of treatment.

How does CPT work?

Before starting treatment, the therapist assesses the client’s emotional stability and potential risk factors, such as suicidal ideation, thoughts of harming themselves or others, substance abuse requiring medical intervention, or psychosis.3 If the client is found to be at high risk, those issues may need to be addressed before trauma processing begins.

Even if there’s no immediate threat of danger, it’s common for clinicians to recommend preparatory therapeutic work before beginning CPT. Unfortunately, there’s limited research supporting the benefits of this preparation.4

CPT can take place as individual or group therapy. It follows a 12-week program divided into four phases.

Phase one: Education

In the first session, your therapist will explain PTSD symptoms and the body’s trauma response. They’ll also give you a brief overview of what to expect during treatment.

First disclosure

You’ll briefly discuss your trauma with your therapist. This first discussion isn’t meant to be detailed—it just gives your therapist an idea of what you’ll be exploring together. If you’ve experienced multiple traumas in your life, you may choose to focus on the one you feel has impacted you the most.

Impact statement

At the end of your first session, your therapist will ask you to write about how the traumatic event has affected you. This is called an “impact statement.” Keep in mind that you will not be asked to relive the trauma through writing. Instead the focus is on the thoughts, feelings, behaviors, and beliefs that the traumatic event has caused you to carry.

Phase two: Processing trauma

The second phase of treatment focuses on helping you process your trauma. Your therapist will review your impact statement with you and look for stuck points. You’ll learn to identify your emotions and make connections between your everyday behaviors and your thoughts and feelings about the trauma.

First trauma account

During this time, your therapist will ask you to write a trauma account. Instead of writing about how the trauma affected you, this account will be about the trauma itself: what happened, who was involved, how you felt in the moment, and other details. This can be a difficult exercise, and it may take a few tries to write everything down.

It’s normal to feel uncomfortable while writing or talking about traumatic memories, but these feelings are often temporary and should improve through the CPT process. The long-term benefits tend to outweigh any short-term discomfort.5 Your therapist is there to offer support and help you feel as safe as possible in each phase of treatment.

You’ll be asked to reread your account to yourself in the days leading up to your next session. Then you’ll read the account to your therapist.

Writing, reading, and sharing your account is important because it allows you to address intense emotions that may have been stopping you from processing what happened. Your therapist can also help you identify stuck points more effectively if they hear your story from your point of view.

Second trauma account

After talking with your therapist, you’ll write a second trauma account, this time applying what you’ve learned.

In this account, you may find that some of your stuck points have been resolved. For example, instead of writing “I should have done something to prevent this,” you might write something like, “I wish I could have done something to prevent this.”

Some stuck points will likely still be present, but now you’ll be able to recognize them as you write them down. Being able to identify these unhelpful beliefs is key to the next stage of treatment.

It’s worth noting that while a written trauma account can be helpful, it isn’t strictly required for everyone who undergoes CPT. Evidence suggests that people can still find relief from PTSD symptoms without this part of treatment.

Phase three: Challenging unhelpful thought patterns

In the third phase of treatment, you’ll learn to question and challenge unhelpful thought patterns. Now that you’ve identified your stuck points, your therapist can help you question them in a meaningful way.

Some trauma survivors already know some of their beliefs are unhelpful, but they don’t know what to do about them. A person may understand logically that their assault wasn’t their fault, for example, but they still feel and behave as if it were. Questioning and challenging during CPT sessions can help bridge the gap between what you know and what you truly believe.

Cognitive distortions

A person usually arrives at stuck points because of “cognitive distortions”—flawed shortcuts in thinking that rely on extremes, stereotypes, or biases to provide an answer. Cognitive distortions offer people simple narratives that make them feel safe and in control, even if that narrative paints a negative picture of themselves or others.

Common cognitive distortions include:

  • Magnification: Exaggerating the importance of a shortcoming or failure
  • Minimization: Discounting the value of a success or achievement
  • Overgeneralization: Making broad assumptions based on an isolated event
  • Mind reading: Assuming you know what other people are thinking and feeling
  • Catastrophizing: Assuming the worst will happen, and that more disasters are sure to follow
  • Labeling: Applying descriptions of events (“I failed my math test”) to yourself (“I’m a failure”), typically in negative ways

Phase four: Trauma themes

In your final sessions, your therapist will help you identify how the unhelpful beliefs you developed in response to trauma affect you in five areas of life:

  1. Safety
  2. Trust
  3. Power and control
  4. Esteem
  5. Intimacy

You’ll discuss each area in terms of yourself, others, and the world. For example, your therapist will help you explore your ability to trust yourself; your ability to trust friends, family, and others; and your ability to trust that most people in most circumstances aren’t intent on hurting you.

Second impact statement

At the end of your eleventh session, you’ll write a new impact statement. This is an opportunity to rethink what your trauma means and how it affects you in light of what you’ve learned during therapy.

During your last session, you’ll share your new impact statement with your therapist. You’ll then go over your first impact statement together and see the progress you’ve made during treatment. Together, you’ll identify any further treatment you may need and any goals you want to work toward in the future.

Other treatments for PTSD

CPT is a form of cognitive behavioral therapy that specifically targets PTSD. Other types of therapy can also help treat the effects of trauma, including:

  • Cognitive behavioral therapy (CBT) can help people identify and change unhelpful thoughts that impact their behavior.
  • Eye movement desensitization and reprocessing (EMDR) helps trauma survivors to reprocess memories and make new connections in their brains.
  • Prolonged exposure therapy enables people to confront traumatic memories in a safe, controlled environment.
  • Somatic therapies help heal the mind-body connection that trauma often damages.

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