Cognitive Processing Therapy (CPT)

If you’re considering adding cognitive processing therapy (CPT) as a therapeutic intervention to your practice, you may be wondering who it’s best for and how it works. This article walks you through this structured, evidence-based therapeutic approach. 

Research supports the effectiveness of cognitive processing therapy for PTSD, or post-traumatic stress disorder. As shown in a randomized controlled trial involving 60 veterans with chronic PTSD, CPT helps those who’ve experienced trauma to change their dysfunctional beliefs and learn adaptive ways to cope with and process their trauma. 

Learn more about the history and background of cognitive processing therapy, its roots in cognitive behavioral therapy (CBT), what kind of cognitive processing therapy training you’ll need before offering CPT, and how this type of therapy is practiced. 

This article also addresses when techniques from one therapeutic treatment should be used over the other—for example, when to  use cognitive processing therapy for PTSD vs. when to use cognitive behavioral therapy for anxiety.

What is cognitive processing therapy for PTSD? 

Developed by Duke Professor of Psychiatry and Behavioral Sciences, Patricia A. Resick, PhD, and her colleagues in the late 1980s, CPT is a form of therapy that focuses on treating post-traumatic stress disorder (PTSD). 

Individuals who have gone through trauma—including war, natural disaster, childhood abuse, sexual assault, loss, violence, and other life-threatening situations—often struggle with negative thoughts. 

The goal of CPT is to teach clients to recognize these thoughts and beliefs, which are referred to as “stuck points.” These stuck points are the reason why clients with trauma continue to feel emotionally distressed long after the traumatic event has ended. 

Examples of thinking errors that come up for  people with trauma: 

• “What happened is all my fault.”

• “This wouldn’t have happened if I did something to prevent it.”

• “Everyone is out to hurt me.”

• “I might not be able to move on from this experience.”
• “I deserve to suffer.”

Since these thoughts can become deeply ingrained, they can affect the client’s behaviors, relationships, and ability to perform at work or school. 

CPT is a well-recognized therapy for PTSD that can offer benefits lasting beyond the completion of the therapy. 

One study, involving 171 adult women who were diagnosed with sexual assault related PTSD, found that those who received CPT treatment had greater reductions in their feelings of hopelessness. 

CPT vs cognitive behavioral therapy (CBT)

One thing to note about CPT is that it is a specific type of CBT. 

CBT is broader in the sense that it helps with a wide range of mental health issues, such as anxiety, depression, and eating disorders, while CPT is trauma-focused. 

However, one way that CPT and CBT are similar is that they both target unhelpful thoughts. Both approaches are also supported by research and have been used in various populations. 

Cognitive processing therapy techniques and cognitive behavioral therapy techniques can also be modified depending on the client’s age (children versus adults) and background. 

Cognitive processing therapy techniques

You can provide CPT in individual  or group therapy settings—typically held over the course of 12 consecutive weekly sessions divided into three phases. 

Each session lasts approximately 60 to 90 minutes, but the time frame may vary depending on your client’s progress and the activities being conducted in a session. It is also possible to offer CPT virtually as part of teletherapy, in cases where clients have conflicting schedules or other concerns that prevent them from attending in-person sessions. 

What to expect in the three phases of CPT

First phase

During the first few sessions, or “initial phase,” you’re going to thoroughly assess your client—learn their history, trauma exposure, and the symptoms they’re having. They may share intrusive flashbacks of the traumatic event and the current beliefs they hold about themselves and the world. 

Your assessment will help establish their PTSD diagnosis, which will then serve as a basis for their treatment plan. It’s important that your client knows how CPT helps them and what they can expect. Ask them if they have questions about cognitive processing therapy for PTSD and provide clear answers. 

In my therapy practice, I often emphasize to my clients that I’ll be here to support them every step of the way. Individuals with PTSD usually have difficulty trusting others, especially if their traumatic experience involved harm being inflicted on them. Consequently, reassurance from a therapist can be very helpful. 

Second phase

The second phase of CPT is when your client gains a deeper awareness of their feelings and thoughts related to their trauma. With your guidance, they’ll be able to identify their “stuck points” or beliefs that are making their PTSD symptoms worse, and holding them back from healing. 

Let’s take, for example, a fictional client named Evelyn, whose stuck points reflect feelings of being unworthy of respect, and regret for “not knowing better.” Her PTSD symptoms are due to a sexual assault by a co-worker. 

Your goal in phase two would be to help Evelyn recognize these stuck points and challenge them with more realistic and balanced perspectives. 

Clients may find this process uncomfortable, since they need to revisit these painful memories. Some might worry they’ll be misjudged or invalidated as they open up. Despite the discomfort, challenging their beliefs is an important step towards healing. 

Speaking of doing the work, in this phase, you should encourage your client to write an impact statement. In this statement, they’re going to describe the traumatic event, including the place, time, and people involved. They also need to express the effects the trauma had on their lives—their behaviors, relationships, work, and activities. 

Third phase

An important part of cognitive processing therapy for PTSD is teaching clients cognitive restructuring skills. These skills involve identifying automatic negative thoughts that arise when your client is triggered, finding evidence to support their thought, and then considering alternative interpretations of the event.

As therapists, we will be using Socratic questioning—asking open-ended, thought-provoking questions to help clarify their thoughts and prompt them to consider the downsides of holding onto their beliefs. 

Here are some examples of Socratic questions when exploring and challenging a client’s negative thoughts:

• What does it mean to you when you say you are undeserving?

• What factors might have been outside of your control?
• What would be the possible outcomes of viewing it from this perspective? 

Outside therapy sessions, you may assign clients homework to keep them actively working to change their unhelpful thoughts. Research shows that these practice assignments between sessions, help to reinforce the skills clients learn—reducing their PTSD symptoms. 

What are the five themes of cognitive processing therapy ?

The five themes of cognitive processing therapy are safety, trust, power, control, esteem, and intimacy. These are the aspects that most trauma survivors struggle with. 

For example, someone who has been in an accident may fear for their safety and worry about being in a certain location that reminds them of the accident. Meanwhile, those who experienced relational trauma (they’ve been abused, neglected, or betrayed) may find it difficult to maintain their relationships or avoid social interactions altogether. 

The final sessions of CPT are focused on addressing these concerns, which can involve answering worksheets corresponding to each theme. 

Who is a good candidate for CPT?

The appropriate candidate for CPT would be someone who has experienced trauma. Before starting CPT, therapists should have individuals complete a PTSD assessment. 

Moreover, since CPT uses cognitive restructuring techniques and involves completing homework assignments, a client would need to have adequate cognitive functioning to be able to participate. 

Can CPT benefit adolescents? 

While cognitive processing therapy for PTSD is designed for adults, it can be adapted for use with adolescents and young adults ages 14 and above. 

It’s helpful to introduce CPT to younger clients by first explaining the cognitive model or cognitive triangle, which helps them understand the connection between their thoughts, feelings, and behaviors. 

Teens also benefit from practicing coping skills in their daily lives, which are effective in calming them down when they feel triggered by a memory, object, or person. Helping young people through trauma involves a combination of techniques—and the social support they receive can provide validation for their healing journey. 

Who isn’t a candidate for CPT?

Although cognitive processing therapy is effective, unfortunately, it’s not suitable for some people—even if they’ve experienced trauma. 

Clients who are not candidates for CPT include individuals with:

• Literacy difficulties: Problems with reading, writing, and understanding both written and spoken language.
• Dementia: Memory deficits can make it difficult to recall past events and express their thoughts. 
• Self-harm behaviors and suicide attempts: When someone is at risk of harming themselves, they cannot effectively engage in this therapeutic process. 

Here is a list of alternative therapeutic interventions that you might consider for clients who may not be good candidates for CPT.

Closing thoughts 

Cognitive processing therapy acknowledges a person’s traumatic experience and its impact on their beliefs. With a clinician’s  guidance, clients make sense of what happened, recognize their distorted thoughts, and develop healthier perspectives as they do the work. 

Since clients need to revisit painful memories, CPT can be an emotional experience, which means they’re likely to feel a mixture of sadness, anger, fear, and shame. However, clients also gain a sense of clarity as they realize that their symptoms are normal responses to negative events. 

As they progress through therapy, they can become more self-aware, learn coping skills, have fewer symptoms, and best of all, experience personal growth. 

Note: Specialized cognitive processing therapy training is needed to get certification before offering it to clients with PTSD. 

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