Cognitive Processing Therapy (CPT) is a form of cognitive-behavioral therapy which focuses on teaching a set of skills that will help clients identify and challenge negative thoughts and emotions such as fear, anxiety, anger, and guilt, and gain control over the impact they have on their lives. CPT has been shown to be particularly effective in confronting traumatic experiences, especially in those who have a diagnosis of post-traumatic stress disorder (PTSD). Based on the social cognitive theory of PTSD, Cognitive Processing Therapy focuses on repairing damage that has been done to one’s beliefs about themself and the world caused by a traumatic event. In other words, cognitive restructuring skills are used to help people more effectively manage distressing thoughts by understanding how their experiences may have a lasting influence on them. Although CPT was designed to treat PTSD in survivors of sexual assault, it has also demonstrated efficacy in treating a variety of other issues such as military trauma. CPT may be particularly beneficial for individuals who are likely to experience additional subsequent traumatic events, such as those in the military or emergency workers, because it aims to change the way these individuals interpret and process trauma in the long-term.

CPT may be conducted using either individual or group therapy sessions, and more often than not includes a combination of the two. A course of CPT generally includes 12 weekly sessions, during which the client works with their therapist to identify and explore any ways their traumatic experience has affected their thoughts and/or beliefs, and how these thoughts and beliefs affect the way they feel and act. A therapist may help their client pinpoint specific thoughts that keep them fixated on their trauma, and those that create barriers to their recovery. These maladaptive thoughts are then challenged, and modified using specific strategies which are practiced with worksheets and exercises, such as writing about the trauma. Ideally, the client finishes therapy with a healthier perspective about the trauma (i.e. although the perpetrator harmed them, they know that not all people will harm them), and an increased capability to cope with future trauma.

CPT for Trauma

Cognitive Processing Therapy was created to treat symptoms associated with trauma. Consequently, there is an overwhelming amount of evidence pointing to CPT as efficacious treatments for PTSD and for comorbid health concerns such as traumatic brain injury.31 Although other trauma-focused treatments have also been supported(larsen), CPT has been shown to decrease the severity of PTSD symptoms above and beyond decreases seen with waitlist conditions and/or alternative treatments.18 Patients who have received CPT have demonstrated greater improvements in their perspective on their trauma and their future,23 their guilt cognitions,21 and declines in symptoms of anxiety, depression, intrusion, avoidance and numbing associated with their trauma.1 CPT has also been associated with significant reductions in hopelessness, which has been suggested to predict changes in symptoms of PTSD,8 as well as with improvements in sleep disturbance,11 which may then correspond with improvements in PTSD and depressive symptoms.10 It has been suggested that CPT is especially effective for women with high levels of dissociation and depersonalization related to their trauma27 and that high therapist competence in socratic questioning and prioritizing assimilation before over-accomodation in CPT were associated with greater improvement in PTSD severity.6

CPT for Military-Related Trauma

Trauma is often discussed within the context of military veterans. Both veterans and civilians who have experienced war/conflict-related trauma also seem to benefit from CPT when coping with their PTSD symptoms.5,4 Veterans who have received CPT demonstrate greater improvements in depression12,34 as well as in anxiety and interpersonal relationships than those who received treatment as usual (TAU).7 Not only do CPT recipients demonstrate more significant symptom improvement than those who receive TAU, but significantly more patients treated with CPT are classified as being recovered at the time of discharge in clinical settings.2

Although some literature suggests that other trauma-focused treatments such as Prolonged Exposure may be more effective in reducing PTSD symptoms in military veterans,24 others suggest that a combination of group CBT and CPT is effective for veterans with trauma history12 and that individual CPT may be more effective than group CPT in reducing PTSD and depressive symptoms in veterans.16 Additional factors may influence the efficacy of CPT for veterans. For example, veterans with high anger scores demonstrated less of a decrease in PTSD severity when receiving CPT than those with lower anger scores, suggesting that these individuals may benefit from anger reduction strategies to increase the effectiveness of CPT for treating their PTSD.19

One significant concern when treating veterans with PTSD is military sexual trauma (MST). Evident in the literature, veterans who receive CPT demonstrate significantly greater reductions in both self-reported PTSD symptom severity20,32 and depressive symptoms who have experienced MST20 in both men and women.33 Further, treatment gains associated with CPT seem to be maintained over a 6-month follow-up period.20 It has been suggested that improvements in symptoms for military sexual trauma-related PTSD are influenced by improvements in self-blame.13 Overall, individuals treated with CPT report significantly higher psychosocial functioning than those who have received alternative treatments.14

CPT for Assault

Literature also explores the efficacy of CPT for victims of assault. For patients experiencing acute stress disorder following an assault, CPT has been associated with a greater proportion of participants not meeting criteria for PTSD, treatment gains maintained at 6-month follow-up, and a reduction in depressive symptoms.22 Similar improvements and improvements in general mental health, social functioning, and quality of life and health perceptions have also been found in victims of interpersonal violence.9 Changes specific to psychosocial functioning in these individuals have been suggested to occur as a function of improvements in emotional numbing and hyperarousal symptoms targeted by CPT.30

More specifically for victims of sexual assault, CPT has further been associated with improvements in anxiety, guilt and dissociation25 as well as reductions in cognitive distortions (iverson) and improvements on depression measures.26 It has been suggested that many of the improvements associated with CPT in sexual assault victims are maintained. 28,26 Similar outcomes and maintenance have also been observed in victims of childhood sexual abuse.3 Some studies suggest that the greatest improvements and overall outcomes from CPT were seen in those who had higher levels of depression and guilt at the beginning of treatment, and in younger women.29

Cognitive Processing Therapy is already considered a first-line treatment for PTSD. Not only has it been found to be effective for victims of military-related trauma, but it has also demonstrated efficacy for victims of sexual assault and interpersonal violence as it targets similar mechanisms in the recovery process in each of these groups. CPT may be effective on its own or in combination with other treatment plans and it may be that different strategies are beneficial for different individuals and different types of trauma.

1. Ahrens, J., & Rexford, L. (2002). Cognitive Processing Therapy for incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6(1), 201-216.

2. Alvarez, Jennifer, McLean, Caitlin, Harris, Alex H. S., Rosen, Craig S., Ruzek, Josef I., & Kimerling, Rachel. (2011). The Comparative Effectiveness of Cognitive Processing Therapy for Male Veterans Treated in a VHA Posttraumatic Stress Disorder Residential Rehabilitation Program. Journal of Consulting and Clinical Psychology, 79(5), 590-599.

3. Chard, K., & La Greca, Annette 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.

4. Dickstein, B., Walter, K., Schumm, J., & Chard, K. (2013). Comparing Response to Cognitive Processing Therapy in Military Veterans With Subthreshold and Threshold Posttraumatic Stress Disorder. Journal of Traumatic Stress, 26(6), 703-709.

5. N. Inès Dossa, & Marie Hatem. (2012). Cognitive-Behavioral Therapy versus Other PTSD Psychotherapies as Treatment for Women Victims of War-Related Violence: A Systematic Review. The Scientific World Journal, 2012, The Scientific World Journal, 01 January 2012, Vol.2012.

6. Farmer, Mitchell, Parker-Guilbert, & Galovski. (2017). Fidelity to the Cognitive Processing Therapy protocol: Evaluation of critical elements. Behavior Therapy, 48(2), 195-206.

7. Forbes, Lloyd, Nixon, Elliott, Varker, Perry, . . . Creamer. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26(3), 442-452.

8. Gallagher, M., & Resick, W. (2012). Mechanisms of change in Cognitive Processing Therapy and Prolonged Exposure Therapy for PTSD: Preliminary evidence for the differential effects of hopelessness and habituation. Cognitive Therapy and Research, 36(6), 750-755.

9. Galovski, Tara E., Blain, Leah M., Mott, Juliette M., Elwood, Lisa, & Houle, Timothy. (2012). Manualized Therapy for PTSD: Flexing the Structure of Cognitive Processing Therapy. Journal of Consulting and Clinical Psychology, 80(6), 968-981.

10. Galovski, T., Harik, J., Blain, L., Elwood, L., Gloth, C., Fletcher, T., . . . Davila, Joanne. (2016). Augmenting Cognitive Processing Therapy to improve sleep impairment in PTSD: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(2), 167-177.

11. Gutner, Casement, Stavitsky Gilbert, & Resick. (2013). Change in sleep symptoms across Cognitive Processing Therapy and Prolonged Exposure: A longitudinal perspective. Behaviour Research and Therapy, 51(12), 817-822.

12. Haller, M., Norman, S., Cummins, K., Trim, R., Xu, X., Cui, R., . . . Tate, S. (2016). Integrated Cognitive Behavioral Therapy Versus Cognitive Processing Therapy for Adults With Depression, Substance Use Disorder, and Trauma. Journal of Substance Abuse Treatment, 62, 38.

13. Holliday, Holder, & Surís. (2018). Reductions in self-blame cognitions predict PTSD improvements with cognitive processing therapy for military sexual trauma-related PTSD. Psychiatry Research, 263, 181-184.

14. Holliday, R., Williams, R., Bird, J., Mullen, K., Surís, A., Deleon, Patrick H., . . . Sbrocco, Tracy. (2015). The Role of Cognitive Processing Therapy in Improving Psychosocial Functioning, Health, and Quality of Life in Veterans With Military Sexual Trauma-Related Posttraumatic Stress Disorder. Psychological Services, 12(4), 428-434.

15. Iverson, K., King, M., Cunningham, K., & Resick, P. (2015). Rape survivors’ trauma-related beliefs before and after Cognitive processing therapy: Associations with PTSD and depression symptoms. Behaviour Research and Therapy, 66, 49.

16. Lamp, K., Avallone, K., Maieritsch, K., Buchholz, K., & Rauch, S. (2018). Individual and Group Cognitive Processing Therapy: Effectiveness Across Two Veterans Affairs Posttraumatic Stress Disorder Treatment Clinics. Psychological Trauma: Theory, Research, Practice, and Policy, Psychological Trauma: Theory, Research, Practice, and Policy, 2018.

17. Larsen, Wiltsey Stirman, Smith, & Resick. (2016). Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion. Behaviour Research and Therapy, 77, 68-77.

18. Lenz, Stephen, Bruijn, Brian, Serman, Nina S., & Bailey, Laura. (2014). Effectiveness of cognitive processing therapy for treating posttraumatic stress disorder. Journal of Mental Health Counseling, 36(4), 360-376.

19. Lloyd, Nixon, Varker, Elliott, Perry, Bryant, . . . Forbes. (2014). Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder. Journal of Anxiety Disorders, 28(2), 237-240.

20. Mullen, Holliday, Morris, Raja, & Surís. (2014). Cognitive processing therapy for male veterans with military sexual trauma-related posttraumatic stress disorder. Journal of Anxiety Disorders, 28(8), 761-764.

21. Nishith, Nixon, & Resick. (2005). Resolution of trauma-related guilt following treatment of PTSD in female rape victims: A result of cognitive processing therapy targeting comorbid depression? Journal of Affective Disorders, 86(2), 259-265.

22. Nixon, R. (2012). Cognitive Processing Therapy Versus Supportive Counseling for Acute Stress Disorder Following Assault: A Randomized Pilot Trial. Behavior Therapy, 43(4), 825-836.

23. Price, J., MacDonald, H., Adair, K., Koerner, N., & Monson, C. (2016). Changing beliefs about trauma: A qualitative study of Cognitive Processing Therapy. 44(2), 156-167.

24. Ragsdale, K., & Voss Horrell, S. (2016). Effectiveness of Prolonged Exposure and Cognitive Processing Therapy for U.S. Veterans With a History of Traumatic Brain Injury. Journal of Traumatic Stress, 29(5), 474-477.

25. Regehr, C., Alaggia, R., Dennis, J., Pitts, A., & Saini, M. (2013). Interventions to Reduce Distress in Adult Victims of Sexual Violence and Rape: A Systematic Review. Campbell Systematic Reviews, 9(3)

26. Resick, P., Schnicke, M., & Beutler, Larry E. (1992). Cognitive Processing Therapy for Sexual Assault Victims. Journal of Consulting and Clinical Psychology, 60(5), 748-756.

27. Resick, P., Suvak, M., Johnides, B., Mitchell, K., & Iverson, K. (2012). The impact of dissociation on PTSD treatment with cognitive processing therapy. Depression and Anxiety, 29(8), 718-30.

28. Resick, Patricia A., Williams, Lauren F., Suvak, Michael K., Monson, Candice M., & Gradus, Jaimie L. (2012). Long-Term Outcomes of Cognitive-Behavioral Treatments for Posttraumatic Stress Disorder among Female Rape Survivors. Journal of Consulting and Clinical Psychology, 80(2), 201-210.

29. Rizvi, Vogt, & Resick. (2009). Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behaviour Research and Therapy, 47(9), 737-743.

30. Shnaider, P., Vorstenbosch, V., Macdonald, A., Wells, S., Monson, C., & Resick, P. (2014). Associations Between Functioning and PTSD Symptom Clusters in a Dismantling Trial of Cognitive Processing Therapy in Female Interpersonal Violence Survivors. Journal of Traumatic Stress, 27(5), 526-534.

31. Turner, Smith, Jones, & Harrison. (2018). Adapting Cognitive Processing Therapy to treat co-occurring posttraumatic stress disorder and mild traumatic brain injury: A case study. Cognitive and Behavioral Practice, 25(2), 261-274.

32. Surís, A., Link‐Malcolm, J., Chard, K., Ahn, C., & North, C. (2013). A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma. Journal of Traumatic Stress, 26(1), 28-37.

33. Voelkel, E., Pukay‐Martin, N., Walter, K., & Chard, K. (2015). Effectiveness of Cognitive Processing Therapy for Male and Female U.S. Veterans With and Without Military Sexual Trauma. Journal of Traumatic Stress, 28(3), 174-182.

34. Walter, K., Dickstein, B., Barnes, S., & Chard, K. (2014). Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program. Journal of Traumatic Stress, 27(4), 438-445.

by Callie Patterson

Callie Patterson is a graduate student pursuing a degree in psychological sciences at Northern Arizona University.

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