Seattle Anxiety Specialists - Psychiatry, Psychology, and Psychotherapy

Cognitive Processing Therapy 

Overview

Cognitive processing therapy (CPT) is a specific type of cognitive behavioral therapy designed to help patients learn how to change and adapt to symptoms related to traumatic events.[1,2] Specifically, CPT helps people focus on maladaptive beliefs and thoughts that stem from a traumatic event and assists them in overcoming and replacing them with a more healthy, realistic way of thinking.[3] CPT has been deemed one of the most effective treatments for dealing with PTSD and is now used to assist sexual assault survivors, child abuse victims, first responders, military veterans, and anyone else dealing with PTSD-related symptoms.[4] Additionally, CPT has been endorsed by the U.S. Department of Veterans Affairs and Defense, the International Society of Traumatic Stress Studies, and the U.K. Institute of Health and Care Excellence as the best practice for PTSD.[5] 

History & Development 

Clinical Psychologist Patricia A. Resick first developed CPT in the late 1980s to treat patients suffering from PTSD related to sexual assault, since therapies at the time did not fully meet patients’ specific needs.[6] Resick developed this type of therapy from the ideas of social cognitive theory and aimed to focus on repairing the negative thoughts and experiences stemming from one’s traumatic events. Today, her therapy is used not only for victims of sexual assault but also for anyone suffering from PTSD symptoms.[7]

Foundation

The main focus of CPT is to challenge the negative thought patterns and symptoms created by traumatic events using different therapeutic tools to create a more healthy and realistic thinking pattern.[8] The therapist’s main role includes guiding the patient through the challenge of remembering these events and pushing them to rethink the event through critical thinking and Socratic questioning.[9,10] 

Since self-blame and guilt can be quite common in trauma-related symptoms, it is imperative the therapist creates a safe and welcoming environment to allow the patient to describe their trauma in the most detailed way possible. The bond between the patient and their therapist is imperative to create a safe space for them to open up about their trauma and experiences following the incident; it is also key in predicting how engaged the patient will be in therapy.[11,12] 

PTSD victims tend to suffer most in areas of safety, trust, power, control, esteem and intimacy.[13] Therefore, more emphasis tends to be placed on these areas to help the client apply the adaptive strategies learned during therapy to everyday life situations as well as continue to use them in the future. Additionally, it’s important for the patient to understand how our thoughts influence our behavior and can leave us painfully stuck in the past.[14] 

Procedure 

CPT is typically delivered over 12 sessions, each 60 to 90 minutes, once or twice a week with a focus being to help the patient understand and reconceptualize their trauma.[15] The first phase of treatment includes psychoeducation where the therapist and patient work together to ensure the patient understands how CPT is meant to work and aid them in their recovery.[16] This phase may include discussions on how people can become unstuck from their past, how their thoughts influence their perception of emotions, as well as how challenging unhelpful beliefs can lead to the adaptation of more advantageous skills. 

Next, the individual will write an impact statement detailing their current understanding and thoughts on the traumatic event, and how it impacted themselves, those around them, and the world. These statements are used to document changes in thinking that occur over the course of therapy. Once an account of the traumatic event is given, “stuck points'' are identified to assist in challenging unhelpful thinking using open-ended questions, initial thoughts about self-blame, and attempts by the patient to revisit the event.[17] Specifically, most negative cognitions related to trauma involve safety, trust, power, control, esteem, or intimacy so the focus is mainly placed on these themes. 

Once the patient has developed the skills to identify and dress unhelpful thinking, they then apply these skills to modify their beliefs related to their trauma. The therapist will then introduce Socratic questioning to help the patient question their maladaptive thoughts and to introduce them to shift their attitudes towards their trauma. Thus, the focus then shifts to allow the therapist and patient to develop these adaptive strategies outside of treatment.[18] 

Another critical component of CPT includes out-of-session practice assignments, which may include an impact statement, challenging question sheets, written trauma accounts, and patterns of problematic thinking sheets. However, it is up to the therapist to implement trauma accounts or not. If not used, more emphasis is given to cognitive techniques.[19] These assignments are essential to developing out-of-session skills, however, some may find it difficult to control or analyze their trauma on their own,[20,21] particularly in the beginning of their therapy. It is essential that the therapist explains the importance of these assignments as they can pose as a predictor of response to treatment, as well as create the out-of-session skills vital to improving overall quality of life. 

CPT can be conducted both individually or in a group session. Individual sessions allow patients to discuss their trauma at length and build a one-on-one trusting relationship with their therapist. It also provides a better opportunity to integrate out-of-session materials into sessions. Conversely, in group sessions, individuals can create a cohesive group with people who have experienced similar trauma to theirs.[22] The created sense of normalcy and universality can allow clients to feel less alone in their struggles, allowing them to talk more openly about their experience and symptoms as well as aid them in their recovery and completion of out-of-session assignments.[23] 

Efficacy

CPT has been backed by compelling evidence of its effectiveness including a meta-analysis conducted by Asmundson et al. (2018). In this study, researchers analyzed how CPT fared in 11 different studies in comparison to different active treatments (e.g., exposure therapy, memory-specific training, and written exposure) as well as inactive treatments (e.g., waitlist groups).[24] 

In comparison to inactive groups, CPT fared significantly better on both non-PTSD-related conditions, at 84%, and PTSD-related symptoms at 89%. However, at follow-up, CPT fared similarly to other active treatment groups.[25] Additionally, when looking at negative cognition in relation to oneself, others, and self-blame, CPT was found to significantly reduce these thoughts from pre-treatment to post-treatment.[26] 

The effectiveness of this modality can also be seen in the transformation made in the impact statements written by patients. In a study done by Price et al. (2014), they compared initial impact statements with final statements of military veterans specifically analyzing their emotions towards power/control, esteem, safety, trust, intimacy, perspective on life, and the effect of therapy.[27] For almost every theme, participants all reported feeling significant improvement in each area. Many patients felt they achieved an entirely new perspective on life and could move past their trauma to create a better future.[28] The same positive results were found in a study done by Chard, (2005) when looking at survivors of sexual abuse. Following 12 sessions of combined individual and group therapy sessions, over 70% of the group achieved significant improvement. Additionally, the positive results of CPT held up at both the 3-month and 1-year follow-ups.[29] 

If you or someone you know is struggling with trauma and/or PTSD, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Heaning, E. (2023). What is cognitive processing therapy? Simply Psychology. https://www.simplypsychology.org/cognitive-processing-therapy.html

2 Cognitive Processing Therapy (CPT). (2017, May 25). https://www.apa.org. https://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy

3 Heaning (2023) 

4 Godfrey, K., & Albright, D. (2021). Cognitive Processing Therapy. Oxford Bibliographies. https://www.oxfordbibliographies.com/display/document/obo-9780195389678/obo-9780195389678-0297.xml#obo-9780195389678-0297-div1-0004 

5 Jobes, D. A. (n.d.). Featured Authors - Patricia A. Resick. Guilford Press. https://www.guilford.com/featured-author/december-2022-resick 

6 Godfrey & Albright (2021)

7 Jobes (n.d.) 

8 Heaning (2023) 

9 Ibid. 

10 Cognitive Processing Therapy (CPT) 

11 Heaning (2023)

12 Price, J. L., MacDonald, H. Z., Adair, K. C., Koerner, N., & Monson, C. M. (2014). Changing Beliefs about Trauma: A Qualitative Study of Cognitive Processing Therapy. Behavioral and Cognitive Psychotherapy, 44(2), 156–167. https://doi.org/10.1017/s1352465814000526

13 Asmundson, G. J., Thorisdottir, A. S., Roden-Foreman, J. W., Baird, S. O., Witcraft, S. M., Stein, A. T., Smits, J. A., & Powers, M. B. (2018). 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

14 Heaning (2023) 

15 Asmundson et al., (2018) 

16 Cognitive Processing Therapy (CPT) 

17 Holliday, R., Holder, N., & Surís, A. (2018). A Single-Arm Meta-Analysis of Cognitive Processing Therapy in addressing Trauma-Related Negative Cognitions. Journal of Aggression, Maltreatment & Trauma, 27(10), 1145–1153. https://doi.org/10.1080/10926771.2018.1429511 

18 Cognitive Processing Therapy (CPT)

19 Ibid.

20 Ibid. 

21 Heaning (2023)

22 Price et al., (2014) 

23 Ibid. 

24 Asmundson et al., (2018) 

25 Ibid. 

26 Holliday et al., (2018) 

27 Price et al., (2014) 

28 Ibid. 

29  Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965–971. https://doi.org/10.1037/0022-006x.73.5.965