Addiction A-Z

Cognitive processing therapy (CPT)

Cognitive processing therapy – often referred to as CPT for short – is a short term therapy that was originally developed to treat rape survivors with posttraumatic stress disorder (PTSD) or symptoms associated with the disorder. Studies have found it to be one of the most beneficial treatments for individuals who suffer from PTSD.

Designed as a structured, short-term therapy, CPT helps trauma survivors learn to identify and challenge distorted beliefs and perceptions created by the traumatic event. This process enables them to break free from paralyzing feelings such as helplessness, fear, and distrust, and finally regain a sense of control over their lives.

Potential Impact of Trauma

If you’ve ever experienced a traumatic experience, such as a violent assault, life-threatening motor vehicle accident, the horrors of combat, or childhood sexual abuse, you know that the negative impact it has on your life can be significant. At the very least, it can take quite some time to feel safe again after life as you once knew it has been completely turned upside down.

The more serious outcome of trauma, however, is that you begin to experience troubling symptoms such as nightmares of the event, anxiety, irritability, guilt, sadness, anger, emotional numbness, or even thoughts of suicide that you can’t seem to shake. These symptoms can interfere with your relationships, your job performance, and your ability to function as well as you used to.   You feel stuck; unable to recover and move on with your life no matter what you do or how hard you try.

Trauma can trigger the development of several serious mental health disorders. One of the most common, of course, is PTSD. Other disorders that may develop (sometimes in addition to PTSD) include acute stress disorder (similar to PTSD, but the symptoms develop and resolves within 30 days of the incident), major depressive disorder, substance use disorder, and other anxiety disorders such as social phobia, OCD, or panic disorder.

For those who develop PTSD, the symptoms usually begin to appear within 3 months of the trauma. However, some individuals don’t exhibit any symptoms for several months or even years after the event.   Without treatment, PTSD symptoms can – and in many cases do – endure for the rest of their life.

Brief History of CPT

As mentioned above, cognitive processing therapy was originally designed specifically to treat survivors of sexual assault. However, it has gained recognition as a very successful treatment for veterans, military personnel who will be returning to combat, refugees, and individuals who have experienced trauma in other situations.

Due to its strong evidence base and proven effectiveness as a treatment for PTSD, the Veteran Association’s Office of Mental Health Services has established a training program for VA therapists. Research on the use and effectiveness of CPT with specific populations is ongoing.

How CPT Works

Many individuals who experience trauma have a hard time making sense of what happened. This can cause them to get “stuck”, as they grasp for meaning and reason that constantly seems to elude them. Distressing thoughts, faulty beliefs, and a plethora of painful emotions make it impossible to feel normal or safe.

In CPT, the therapist guides clients through a process of examining the troubling thoughts, emotions, and beliefs that stem from the trauma. For some individuals, trauma severely shatters their prior beliefs (e.g. that bad things don’t happen to good people, or that the world is a safe place). For others, it confirms beliefs they had prior to the event (e.g. the world is dangerous place, or people can’t be trusted). The therapist helps them challenge the flaws in their reasoning with Socratic questioning.

This process helps clients identify their “stuck points”. Stuck points refer to irrational thoughts that make it impossible for the client to recover from PTSD symptoms. For example, a common stuck point for survivors of trauma is self-blame – the belief that if only they had done something different (e.g. paid closer attention, cancelled a date, or booked a later flight) then the traumatic event (e.g. a sexual assault or rush-hour car accident on the way to the airport) wouldn’t have happened. , clients are able to look at themselves, others, and the world in a more balanced, healthy, and rational manner – one that is no longer driven by the trauma. This change has a direct and positive impact on how they act and feel.

CPT consists of several phases:

  • Clients are assessed to determine if cognitive processing therapy is a good fit for them, based on factors such as whether or not they have PTSD or related symptoms, their ability to participate in this type of treatment, and treatment goals and priorities.
  • Early in treatment, the focus of CPT is on educating clients about 1) the impact of trauma and the symptoms they’re experiencing, 2) how CPT can help and the various aspects of the process, 3) treatment goals, and 4) what to expect in terms of recovering from the trauma. Clients can ask questions about the process.
  • The next phase focuses on making clients more aware of how the way they think about the trauma directly impacts their feelings and behaviors. This phase involves identifying stuck points, faulty beliefs and reasoning, and the impact the trauma is currently having on their life. This helps clients start to think about the trauma in a new, more balanced and less extreme, way. Clients may discuss the trauma in therapy or write about it in between sessions and read it out loud during sessions.
  • As clients’ self-awareness increases, they can start learning how to challenge their thoughts themselves. The therapist will give them worksheets to use to guide them through the process. Developing these skills is very empowering, because it enables clients to choose how to think and feel about the traumatic event, rather than continuing to feel victimized by it. Clients can use the skills they learn in this phase to more effectively handle other problems in their life as well. Essentially, clients learn how to become their own therapist as the therapist takes on the role of consultant.
  • During the final phase of therapy, clients learn about common reactions to trauma – specifically how it alters a person’s beliefs about themselves, others, and the world in general. Their sense of safety, their ability to trust themselves and others, their self-esteem, and their sense of control over their life can be significantly disrupted by a traumatic event. Understanding how their beliefs have been impacted enables them to balance their pre-trauma and post-trauma beliefs. This balance enables clients to feel that they are capable of managing life and moving forward.
  • Therapy concludes as the client and therapist review the client’s journey and talk about what’s next for the client – including measures the client can take to prevent a relapse down the road.

Benefits of CPT

Clients who participate in cognitive processing therapy, and complete all the sessions, often experience the following benefits:

  • Significant decrease in the amount of distress caused by memories of the trauma
  • Decrease in avoidant behavior related to aspects of the trauma (e.g. avoiding people, places, things, thoughts, or events that commemorate the event (e.g. 9/11 memorial services)
  • The ability to feel a wide range of emotions more fully
  • Increase in healthy coping behaviors
  • Greater sense of control and mastery over one’s life
  • Improvements in self-esteem
  • Reduction of negative emotions, such as sadness, irritability, anger, guilt or shame, depression, and anxiety
  • Improvement in overall functioning and ability to enjoy life again
  • Reduction in feelings of edginess and tension / greater sense of calm

Indications and Contraindications for CPT

Cognitive processing therapy is generally appropriate for the following individuals (although exceptions may be made depending on various factors):

  • individuals who have been diagnosed with PTSD, or who are struggling with mood and / or other symptoms directly related to a traumatic event
  • Individuals with PTSD or related symptoms who also have a substance use disorder, have already gone through the detox process, are stable, and are able to tolerate this particular type of therapy
  • Individuals who have experienced a traumatic event and are struggling with depression

CPT may not be appropriate for anyone who is:

  • Actively having thoughts of suicide or self-harm
  • A danger to others
  • Unable to talk about the traumatic event without dissociating or having severe panic attacks
  • Actively abusing alcohol or drugs
  • In imminent danger of being harmed by a stalker or abusive relationship partner

For the individuals listed above, other types of treatment or therapy may be necessary before they are ready to CPT. Exceptions can be made on a case-by-case basis.

What to Expect

CPT is a manualized treatment protocol. This means that therapists follow the procedures for therapy that are outlined in the treatment manual, as opposed to devising their own process that may be only loosely based on the standard protocol.

The course of treatment is typically set up as 12 sessions. These may occur once or twice per week. Some versions of CPT go as long as 17 weekly sessions. The latter was developed for particular groups of trauma survivors, including combat veterans, adults who were sexually abused as children, and individuals who have been traumatized by domestic violence. If needed, the number of sessions can be modified or extended in order to meet a client’s particular or unique treatment needs. Therapists may offer additional sessions for individuals with severe or complex cases if needed.

CPT sessions are often conducted on a one-to-one basis. However, CPT may also be conducted in small group settings. Group sessions are usually co-led by two therapists, and consist of no more than 8 to 10 clients. It’s not uncommon for CPT to be conducted as a combination of individual and group sessions.

Homework assignments are an important part of CPT. Therapists typically assign homework each week. Each week’s homework helps clients develop a greater understanding of whatever was talked about in that session. Homework includes:

  • Stuck point log
  • ABC sheets – ABC stands for activating event, belief (about the event), and consequence (feelings triggered by the event)
  • Challenging questions worksheet (e.g. “Is your belief based on facts or habit?”
  • Patterns of problematic thinking worksheet (cognitive distortions, such as all-or-nothing thinking, jumping to conclusions, emotional reasoning, and over-generalizing)
  • Challenging beliefs worksheet
  • Trauma impact statement (at the beginning and conclusion of therapy only)

Clients do the homework assignments outside of therapy. Completing each homework assignment is crucial the clients’ success, because it allows them to actively review, apply, and practice what is learned in therapy.

In CPT, clients write down a brief account of the traumatic event or memory. They are instructed to read this out loud during their individual therapy sessions. In group treatment, the accounts are not shared with the group. Instead, the clients talk within the group about the thoughts and feelings they experienced while writing about the trauma.

Writing about the trauma and reading it aloud is preferable for many clients and therapists. This is because the degree of exposure – facing the trauma – is less threatening and uncomfortable than other types of treatment that focus specifically on exposure, such as in vivo exposure (confronting aspects of the trauma in real life), imaginal exposure (vividly imagining the trauma), or graded exposure (confronting the least terrifying aspects of the trauma and working up to the most terrifying).

Cognitive processing therapy can be conducted in a variety of settings, in addition to a therapist’s private office. These include VA and psychiatric hospitals, residential treatment facilities, community mental health clinics, and outpatient treatment clinics.

Finding a CPT Practitioner

The vast majority of clinicians who provide cognitive processing therapy are licensed mental health professions, including psychologists, psychiatrists, clinical social workers, and professional counselors. Non-licensed mental health professionals (e.g. a resident psychologist) may provide the therapy under the supervision of a qualified mental health professional. In some settings, trained nurses may also provide CPT.

If you can’t find a therapist by searching online, you might consider contacting your local VA hospital. Some hospitals have part-time therapists who also have private practices outside of the hospital. They may be able to give you a name of a practitioner.

Cognitive processing therapy is definitely worth considering if you’ve experienced a trauma – whether recently or long ago – and the negative thoughts, feelings, and memories are interfering with your life. It’s also worth considering if you’ve already been diagnosed with PTSD and have had treatment, but its effectiveness has been limited. CPT may be exactly what you need in order to finally break free from the chains of old trauma and find the peace, emotional freedom, and happiness you deserve.

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