Trauma & recovery

What Actually Happens in Cognitive Processing Therapy

CPT is one of the most studied treatments for PTSD. Here is what the twelve sessions actually consist of, and what the trials found.

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The idea behind it

Cognitive Processing Therapy starts from the observation that what keeps people stuck after a trauma is often not the memory itself but the conclusions they drew from it. Conclusions about why it happened, what it says about them, and what the world is now like. In CPT these are called stuck points, and they are the target of the work.

The treatment was first described by Resick and Schnicke (1992), who delivered it in a group format to sexual assault survivors and reported significant reductions in both PTSD and depression symptoms that held at follow-up.

What the sessions look like

CPT is a structured protocol, usually twelve sessions, and it is unusually transparent about its own mechanics. Broadly it moves through three phases.

• Understanding the model. Early sessions cover how PTSD is thought to work and ask you to write an account of what you believe the trauma means about you and about the world. This is not a narrative of events. It is a statement of conclusions.
• Learning to examine a thought. The middle of the protocol teaches a specific skill: taking a belief, finding the evidence for and against it, and noticing the habits of thinking that keep it in place. This is done on paper, with worksheets, deliberately.
• Applying it to the themes that matter. The final sessions work through five areas that trauma commonly damages: safety, trust, power and control, esteem, and intimacy.

There is homework every week, and the homework is the treatment as much as the session is.

What the evidence shows

In a randomised trial of 171 women with chronic PTSD following rape, Resick and colleagues (2002) compared CPT with prolonged exposure and a minimal attention condition. Both active treatments produced large improvements and both were clearly superior to the control condition, with gains maintained at follow-up.

The treatment also holds up outside that population. Monson and colleagues (2006) tested CPT with sixty veterans carrying chronic military-related PTSD in a wait-list controlled trial and found significant improvements in PTSD and comorbid symptoms relative to the wait-list, with a dropout rate of around twenty percent in the treatment arm.

Who tends to find it a fit

People who like knowing the plan, who are willing to write things down between sessions, and whose distress is bound up in questions of blame, fairness, or what the event proved about them, often take to CPT quickly. It is demanding in a specific way: it asks for consistency more than it asks for courage in any single moment.

It is also worth saying plainly that CPT does not require you to give a detailed account of the trauma to anyone. That surprises people who have been putting off treatment for exactly that reason.

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