Cognitive Processing Therapy
Encyclopedia
Cognitive processing therapy (CPT) is an adaptation of the evidence-based therapy known as cognitive behavioral therapy (CBT) used by clinicians to help consumers explore recovery from 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.
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.
Patricia A. Resick is the author of Cognitive Processing Therapy for Rape Victims.
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
Sexual assault
Sexual assault is an assault of a sexual nature on another person, or any sexual act committed without consent. Although sexual assaults most frequently are by a man on a woman, it may involve any combination of two or more men, women and children....
victims, and refugees.
CPT can be provided in individual
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
and group
Group therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a 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
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
, most people with PTSD experience a range of emotions including horror, anger
Anger
Anger is an automatic response to ill treatment. It is the way a person indicates he or she will not tolerate certain types of behaviour. It is a feedback mechanism in which an unpleasant stimulus is met with an unpleasant response....
, shame
Shame
Shame is, variously, an affect, emotion, cognition, state, or condition. The roots of the word shame are thought to derive from an older word meaning to cover; as such, covering oneself, literally or figuratively, is a natural expression of shame....
, guilt
Guilt
Guilt is the state of being responsible for the commission of an offense. It is also a cognitive or an emotional experience that occurs when a person realizes or believes—accurately or not—that he or she has violated a moral standard, and bears significant responsibility for that...
and sadness
Sadness
Sadness is emotional pain associated with, or characterized by feelings of disadvantage, loss, despair, helplessness, sorrow, and rage. When sad, people often become outspoken, less energetic, and emotional...
as well as fear
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
. A significant contributor to the interruption of natural recovery process is the ongoing use of avoidance
Avoidance coping
Avoidance coping, or escape coping, is a kind of generally maladaptive coping, characterized by the effort to escape from having to deal with a stressor.Post Traumatic Stress Disorder symptoms are thought to be the precursor to avoidance coping...
as a coping
Coping (psychology)
Coping has been defined in psychological terms by Susan Folkman and Richard Lazarus as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing" or "exceeding the resources of the person".Coping is thus expending...
strategy. By avoiding the trauma memory and situations that trigger
Trauma trigger
A trauma trigger is an experience that triggers a traumatic memory in someone who has experienced trauma. A trigger is thus a troubling reminder of a traumatic event, although the trigger itself need not be frightening or traumatic....
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 educationPsychoeducation
Psychoeducation refers to the education offered to people who live with a psychological disturbance. Frequently psychoeducational training involves patients with schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, and personality disorders, as well as...
regarding PTSD, thoughts, and emotions. The therapist develops rapport
Rapport
Rapport is a term used to describe, in common terms, the relationship of two or more people who are in sync or on the same wavelength because they feel similar and/or relate well to each other....
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
Socratic dialogue
Socratic dialogue is a genre of prose literary works developed in Greece at the turn of the fourth century BC, preserved today in the dialogues of Plato and the Socratic works of Xenophon - either dramatic or narrative - in which characters discuss moral and philosophical problems, illustrating a...
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
Cognitive Appraisal
Personal interpretation of a situation . "Appraisals refer to direct, immediate, and intuitive evaluations made on the environment in reference to personal well-being." They are "evaluative frameworks that people utilize to make sense of events." Cognitive appraisal is regarded by some sport...
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
Coping (psychology)
Coping has been defined in psychological terms by Susan Folkman and Richard Lazarus as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing" or "exceeding the resources of the person".Coping is thus expending...
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
Safety
Safety is the state of being "safe" , the condition of being protected against physical, social, spiritual, financial, political, emotional, occupational, psychological, educational or other types or consequences of failure, damage, error, accidents, harm or any other event which could be...
, trust, power/control, esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
, 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
Quality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...
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 sessionsGroup therapyGroup psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...
- 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.