Cognitive processing therapy (CPT) is a type of cognitive behavior therapy (CBT) that is specially designed to treat post-traumatic stress disorder (PTSD) or other forms of trauma (Greene, 2022).
CBT is a type of psychotherapy in which negative thought patterns are challenged to change unwanted behavior or thinking, and it is often used to treat depression and anxiety.
CPT uses the tools of CBT. It helps patients evaluate and change the upsetting thoughts they’ve had since their trauma.
CPT generally consists of 12 sessions. Each lasts about 60 to 90 minutes. Patients can attend one-to-one with a provider, or in a group of about 6 to 10 people with one or two providers (Va.gov, 2018).
During these sessions, therapists guide patients through understanding their thoughts and feelings and changing their harmful beliefs. As beliefs change, so do the feelings that follow.
Patricia Resick and colleagues developed CPT in the 1980s, in a treatment program for rape survivors (Resick & Schnicke, 1992).
The U.S. Department of Veterans Affairs (VA) later offered it widely (VA.gov, 2018). The American Psychological Association (APA) now strongly recommends CPT for PTSD (American Psychological Association, 2017).
Key Takeaways
Definition: Cognitive Processing Therapy (CPT) is a specific type of cognitive behavioral therapy that helps patients deal with traumatic events and reduce symptoms of post-traumatic stress disorder (PTSD).
Focus: It focuses on altering maladaptive beliefs and thought patterns related to the trauma.
Method: In CPT, patients are taught to overcome negative thought patterns which contribute to their symptoms of PTSD and to replace them with more adaptive, realistic ways of thinking.
Format: CPT consists of about 12 sessions of 60 to 90 minutes each, spread over roughly three months. CPT also includes at-home worksheets and exercises to continue what one learned in the session.
Evidence: CPT is evidence-based and can be extremely effective for those with PTSD. This includes victims of sexual assault, childhood trauma, military personnel, first responders, and more.
Outcome: Successful completion of CPT therapy helps decrease negative emotions and become unstuck from their past trauma, freeing them to enjoy day-to-day life more.
CPT vs. Exposure Therapy
Prolonged exposure therapy is CPT’s closest rival among the strongly recommended treatments for PTSD. The two are related but different. Exposure therapy exposes patients to the source of their anxiety in a safe setting, showing no real danger.
In doing so, providers help patients overcome fears and anxieties. Repeated exposure weakens the memory’s power to distress.
Prolonged exposure therapy for PTSD helps people to gradually approach trauma-related memories, feelings, and situations they have been avoiding since their trauma.
Exposure therapy for PTSD asks people to recall and describe their traumatic experience repeatedly. They confront the trauma head-on.
In contrast, CPT focuses on helping people with PTSD evaluate upsetting thoughts that have existed since their trauma.
More specifically, CPT is interested in changing the way these patients look at themselves and the world and challenging their trauma-related beliefs through critical thinking (Richman, 2022).
The two treatments reach the same goal by different routes:
Feature
CPT
Prolonged exposure
Core idea
Beliefs formed after the trauma keep PTSD going
Repeated, structured engagement with the trauma memory reduces its distressing power
Main method
Worksheets and Socratic questioning to challenge stuck points
Repeated, structured exposure to the memory
What changes
The meaning the survivor gives the event
The memory’s power to distress
Head-to-head result
Both improved PTSD and depression far more than a waitlist (no treatment yet), with no significant difference on most primary measures (Resick et al., 2002)
Guideline status
Both are strongly recommended in the APA’s 2017 PTSD guideline (American Psychological Association, 2017)
PTSD is a disorder in which a person has difficulty recovering from a traumatic event for months or even years. “Triggers” can bring back physical and emotional memories of the trauma, and symptoms include nightmares, panic attacks, intrusive thoughts, anxiety, and depression (Greene, 2021).
PTSD is hard to treat partly because many people do not know they have it. Many also do not know treatment exists. People might also hear opinions from loved ones, such as “It will pass” or “You’ve just gotta tough it out.”
Negative self-talk is also very common in PTSD. Labeling oneself as damaged or weak for not being able to move on can be extremely damaging.
As a result, CPT’s focus on changing how people think about a traumatic event can be extremely effective if one overcomes the stigma (Greene, 2022).
How Does CPT Therapy Work?
Stuck Points: Assimilation and Over-Accommodation
CPT rests on a schema-based theory of why some trauma survivors stay stuck. Most people recover naturally within weeks or months. Resick and Schnicke (1992) argued that PTSD persists when the way a survivor interprets the event reshapes their beliefs about themselves, others, and the world.
Most people hold unexamined “assumptive world” beliefs (Janoff-Bulman, 1989): that the world is meaningful, benevolent, and controllable, and that they are reasonably safe and worthy. A trauma clashes with those beliefs. CPT says survivors resolve the clash in one of three ways.
Assimilation: distorting the trauma’s meaning so it fits existing beliefs. Self-blame is the classic case: “I must have caused it” protects the belief that the world is just.
Over-accommodation: changing beliefs so drastically that they overshoot what happened. One betrayal becomes “no one can ever be trusted.”
Accommodation: the balanced middle path CPT works toward. Beliefs change just enough to fit the new information, without denying it or overgeneralizing.
CPT calls the unhelpful beliefs that result stuck points. Examples include “It was my fault” and “I can never let my guard down again.”
Because a stuck point is a specific sentence, a client can notice it, write it down, and test it. This turns a vague sense of being trapped into a workable list of targets.
Psychoeducation
Psychoeducation is the first phase of CPT. It refers to a broad range of interventions that combine educating a patient with counseling and support activities.
Many psychotherapeutic interventions are based on traditional models of treating pathology and illness. In contrast, the psychoeducation model is more holistic. It stresses collaboration, coping, and empowerment for the patient and their support system (Lukens & McFarlane, 2004).
In psychoeducational therapy, the patient and the patient’s support system are considered partners with the provider in treatment. The premise is simple. The more they know about the mental health condition, the better the patient’s outcomes tend to be.
To build this knowledge, providers focus on removing barriers to comprehending mental health conditions and developing strategies for the patients to be proactive in their treatment.
In CPT, this means teaching patients about PTSD. It also means tackling stigma and self-blame and assigning writing tasks that practice real-life skills (Va.gov, 2018).
Clients also write an impact statement, a short piece on why they think the trauma happened and how it has affected their beliefs. They write a new one at the end of treatment, which makes the shift in their thinking visible.
Understanding Your Thoughts and Feelings (Processing the Trauma)
At its base, CPT is built on the premise that what we think influences how we feel. For example, after a traumatic event, one’s thought patterns might change to cope and keep oneself safe in the future (Greene, 2022).
These thought patterns might lead to over-negativity, feelings of uncertainty, and even feelings of danger.
CPT teaches people to reprocess a traumatic event. In doing so, patients are encouraged to challenge their long-held assumptions about these events to progress emotionally.
For people with PTSD, it can be extremely difficult to talk or even think about the traumatic event(s) which changed their lives. Changing long-held beliefs about those events can be harder still.
CPT helps reshape patients’ long-held beliefs and destructive thought patterns by retraining their automatic tendency to think negatively. By learning to challenge initial thought processing, patients effectively “rewire” their brains over time.
B (belief): what the person tells themselves about it.
C (consequence): the emotions and behavior that follow.
Clients apply it to trauma-related situations. Working through the model shows them that the belief, not the event alone, generates the distress. Clients also keep a running stuck-point log. They add problematic beliefs as they notice them, and these become the material for later sessions.
Learning New Skills
Small changes in thinking can greatly impact how you feel. By helping you get “unstuck” from your past, CPT can free you to enjoy the parts of life you have been missing out on.
In CPT, the provider leads the client through exercises that help them to recognize and investigate unhelpful thought patterns. This includes regular out-of-session practice assignments to apply what has been discussed in therapy sessions.
The middle sessions use three structured worksheets.
Challenging Questions Worksheet: prompts such as “What is the evidence for and against this belief?” and “Am I thinking in all-or-nothing terms?”
Patterns of Problematic Thinking Worksheet: helps clients spot recurring cognitive distortions, such as jumping to conclusions, overgeneralizing, discounting the positive, and emotional reasoning.
Challenging Beliefs Worksheet: asks clients to write a more balanced alternative belief and re-rate how strongly they hold both versions.
Consistent completion of these practice assignments is one of the strongest predictors of how much a client benefits.
Therapists use Socratic questioning throughout. They ask guided, open questions that let clients re-examine their own beliefs, rather than simply telling them a belief is wrong. Through this and other techniques, patients learn to challenge unhelpful trauma-related beliefs and build new thinking skills.
Changing Your Beliefs
People diagnosed with PTSD often struggle in one or more of five areas (My Clients Plus; Resick et al., 2016). Each can become a stuck point:
Safety: beliefs about danger and vulnerability, from “I am never safe anywhere” to constant over-vigilance that no one can truly guarantee.
Trust: beliefs about other people, and sometimes one’s own judgment, from “no one can be trusted” to “I can’t trust my judgment about people anymore.”
Power and control: beliefs about agency versus helplessness, such as feeling permanently powerless or needing to control everything to prevent a repeat.
Esteem: beliefs about one’s own worth, such as shame, self-blame, or feeling permanently damaged by what happened.
Intimacy: beliefs about closeness, such as difficulty tolerating vulnerability or touch, and withdrawing from relationships that once felt safe.
In the final sessions of CPT, clients apply the adaptive strategies they have learned to everyday situations in each area.
In doing so, providers aim to replace their client’s faultier interpretations with healthier cognitions. CPT emphasizes how negative or incorrect thoughts of past trauma can increase symptoms of PTSD and fuel powerful emotions.
These emotions make healthy processing harder. CPT therefore offers a framework for challenging negative thoughts and replacing them with new, productive ones (My Clients Plus).
Finally, CPT provides clients with coping skills they can use on their own to continue to process past trauma. These coping strategies can also be used in the future if clients experience additional trauma, helping them to stop negative thoughts in their wake.
Cognitive-Only CPT (CPT-C) vs. the Full Protocol
The original CPT included a written account of the trauma, which clients read aloud and re-read as homework. This full version is now called CPT+A (“with account”). A randomized trial tested whether the account was needed.
Aim: Resick et al. (2008) tested whether the written trauma account adds anything beyond CPT’s cognitive work.
Method: Female victims of interpersonal violence with chronic PTSD were randomly assigned to full CPT, cognitive-only CPT, or written accounts alone.
Results: All three conditions improved substantially. Cognitive-only CPT matched the full protocol on the main PTSD measures, and its symptoms may have fallen somewhat faster.
Conclusion: The cognitive work of identifying and challenging stuck points appears to drive recovery. The written account is not necessary.
As a result, cognitive-only CPT (CPT-C) is now the more widely used version, especially in large systems such as the VA. It is shorter to teach and less distressing for some clients.
The finding applies to CPT specifically. It does not show that confronting the trauma memory is never useful, since prolonged exposure also has strong evidence.
What Is the Role of Self-Blame in PTSD?
Self-blame plays a strong role in keeping people stuck in the memory of their trauma. Therefore, reducing self-blame is a key focus of CPT.
Self-blame is a cognitive process in which an individual attributes the occurrence of a stressful event to oneself. To those who experienced a traumatic event, self-blame might feel useful as a way to make one feel control over what happened.
However, self-blame can be a corrosive and dangerous coping mechanism. If one blames oneself for a traumatic event, the result can be an increase in symptoms of PTSD. Therefore, self-blame blocks one’s natural capacity for healing after a traumatic event (Greene, 2022).
As CPT’s developer Patricia Resick explains, reassurance alone rarely works. Telling survivors the trauma was not their fault tends to be met with disbelief.
On the Menninger Clinic’s Mind Dive podcast, she said therapists “have to ask them questions so that they can figure out for themselves” (Resick, 2023).
Some events cause more self-blame than others. For instance, survivors of sexual assault often blame themselves because of the personal nature of the crime and societal judgment.
Furthermore, childhood abuse can lead to self-blame as children are likely to assume the trauma they experience is a result of something they did. Even as these children become adults, they typically do not re-examine these memories.
Is CPT a “Cure” for PTSD?
For some, CPT can effectively treat PTSD. Of course, they do not forget the traumatic event, but the trauma no longer perpetuates the same PTSD symptoms that existed before treatment.
Research has shown that most people who complete CPT treatment experience significantly reduced symptoms. Some overcome all symptoms of PTSD entirely. For others, they might continue to experience symptoms of PTSD but to a lesser degree than before (Greene, 2022).
In a Veterans Health Administration feature, U.S. Army veteran Christopher Tyler described drifting for years after service, feeling emotionally numb and disconnected (U.S. Department of Veterans Affairs, 2016).
He doubted therapy would help, expecting little more than a superficial exercise. Working through the stuck-point worksheets with his therapist changed that: “the stuff actually works. It’s very real” (U.S. Department of Veterans Affairs, 2016).
CPT’s effectiveness depends strongly on client commitment. Some patients find it especially difficult to complete the take-home homework assignments or to do the difficult job of confronting and analyzing their trauma.
CPT will unlikely be helpful without the client completing these important tasks of following through with all sessions. Through these important exercises and sessions, clients examine their thoughts and emotions in a way that reduces PTSD symptoms.
CPT Outcomes Across Trauma Populations
Trials have tested CPT with several groups of survivors, mostly against a waitlist (a control group that receives treatment later).
Sexual assault survivors: in women with chronic PTSD after rape, CPT and prolonged exposure both improved symptoms far more than a waitlist. They did not differ significantly on most primary measures (Resick et al., 2002).
Childhood sexual abuse survivors: in 71 women, group CPT reduced PTSD symptoms more than a waitlist, and the gains held at one-year follow-up (Chard, 2005).
Combat veterans: in 60 veterans with chronic military-related PTSD, CPT beat a waitlist. About 40% of those who completed treatment no longer met PTSD criteria (Monson et al., 2006).
Active-duty military: in a large trial, individual CPT produced greater improvement than group CPT (Resick et al., 2017).
Long-term follow-up: gains in the original rape-survivor trial held five to ten years later. About 22% of the CPT group still met PTSD criteria (Resick et al., 2012).
Most of these trials compared CPT with a waitlist rather than another treatment. They show that CPT works better than no treatment, not that it beats other therapies.
Critical Evaluation of CPT
CPT is among the more rigorously tested psychotherapies, but its evidence has limits. Recent work has pooled the trial evidence and tested briefer ways to deliver treatment.
Contemporary Research
How Large Are CPT’s Effects?
A meta-analysis pools many trials into one estimate, and Hedges’ g expresses the size of the difference between groups.
Aim: Asmundson et al. (2019) pooled the randomized trial evidence on CPT for adults with PTSD to estimate its overall effect.
Method: The meta-analysis combined 11 randomized controlled trials with 1,130 participants. It compared CPT with inactive controls, such as waitlists, after treatment and at follow-up.
Results: CPT’s effect was large after treatment (Hedges’ g ≈ 1.24) and still large at follow-up (g ≈ 0.90). The average treated participant fared better than roughly 89% of controls after treatment, and 82% at follow-up.
Conclusion: CPT produces large, lasting improvements compared with no active treatment, with some shrinkage between the end of treatment and follow-up.
Most included trials used passive controls. The result shows that CPT beats doing nothing. It says less about how CPT compares with other active treatments.
Can a Briefer Treatment Match CPT?
In a randomized noninferiority trial, active-duty service members with PTSD received either CPT or written exposure therapy (Sloan et al., 2022). A noninferiority design tests whether a new treatment is not meaningfully worse than an established one. The comparison treatment was a five-session course built around written trauma narratives.
Written exposure therapy was noninferior to CPT. It needed far fewer sessions, and significantly fewer people dropped out. The wider trend is toward shorter, more efficient trauma-focused protocols, which CPT-C already anticipated.
Criticisms and Limitations
CPT draws several well-founded criticisms, distinct from those aimed at CBT or PTSD treatment in general:
Engagement and dropout: benefit depends on completing homework and sessions. Dropout has been reported as high as 29% across CPT trials (Kline et al., 2018).
Unclear mechanism: CPT-C matches the full protocol, but why cognitive restructuring alone works is less well understood (Resick et al., 2008).
Parity, not superiority: the strongest head-to-head trial found CPT and prolonged exposure about equal (Resick et al., 2002). They are comparable options, not a contest with a winner.
Focus on individual thinking: stuck points often involve self-blame, so therapy can seem to locate the problem in the survivor’s thinking. A skilled therapist separates distorted beliefs from accurate appraisals of real danger or injustice.
Limited population coverage: evidence is strongest for sexual assault, childhood abuse, and combat trauma. Dedicated CPT trials in refugees, disaster survivors, and first responders are largely absent.
How to Get Started (Where to go for Help)
To find a therapist in your area, use the find-a-therapist directory from the Association for Behavioral and Cognitive Therapies (ABCT). Try this clinical directory of CPT providers too (Greene, 2022).
Veterans can also go through the VA. Almost all VA Medical Centers offer CPT in their specialized PTSD programs, and more than 2,000 VA providers are trained in CPT (VA.gov, 2018).
Finally, CPT Coach is a mobile app that you can use with a provider during CPT. It can help you learn more about CPT and PTSD symptoms.
It also helps you keep track of homework and assignments. The app is free and can be downloaded on most mobile devices (VA.gov, 2018).
FAQs
How long does cognitive processing therapy take?
CPT generally consists of 12 sessions. Each lasts about 60 to 90 minutes, so the therapy takes about three months to complete.
Patients may feel better after a few sessions. The benefits can last long past the final session: in one follow-up of rape survivors, gains held five to ten years later (Resick et al., 2012). The effectiveness of CPT therapy is also strongly influenced by engagement.
Is cognitive processing therapy evidence-based?
CPT is evidence-based. Multiple research studies have shown that it works. For instance, one study tested CPT in veterans with co-occurring PTSD and alcohol use disorders (Kaysen et al., 2014).
Participants attended an average of nine sessions. There was a significant reduction in the symptoms of PTSD across all groups who received a course of CPT therapy.
Another study published in the Journal of Consulting and Clinical Psychology compared CPT’s effectiveness against prolonged exposure therapy for victims of sexual assault.
The study concluded that both treatments were highly effective. They did not differ significantly on most primary outcome measures. CPT did score slightly better on some secondary measures, such as guilt-related thoughts (Resick et al., 2002).
Who benefits from CPT?
CPT is an effective form of therapy for people diagnosed with PTSD or coping with past trauma.
It was first developed for survivors of sexual assault. Trials have since supported its use with survivors of childhood sexual abuse and with military veterans (Chard, 2005; Monson et al., 2006).
CPT aims to reshape how a traumatic experience is interpreted and processed. For that reason, it may also help people who face future trauma, such as active military personnel or first responders (My Clients Plus).
What are the goals of CPT therapy?
CPT therapy has several goals. These include understanding how PTSD affects life, feeling the emotions of a traumatic event, and reducing avoidance of it.
It also aims to develop more realistic beliefs about the world and to decrease negative emotions created by maladaptive thought patterns. Above all, it aims to improve the day-to-day living of people stuck in their trauma (CEBC).
Who developed cognitive processing therapy?
CPT was developed in the 1980s by Patricia Resick.
Resick, a clinical psychologist, and her colleagues first designed it for survivors of sexual assault, in a rape-crisis treatment program (Resick & Schnicke, 1992). It has since been expanded to address other types of trauma, such as combat-related trauma and PTSD resulting from other traumatic events.
A later trial found that the written trauma account could be dropped without losing effectiveness (Resick et al., 2008). The cognitive-only version, CPT-C, is now widely used.
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BSc (Hons) Psychology, MRes, PhD, University of Manchester
Chartered Psychologist (CPsychol)
Saul McLeod, PhD, is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Erin Heaning is a Princeton University psychology graduate and Licensed Associate Counselor specialising in maternal mental health and early child development. At Princeton she worked at the Baby Lab, researching mother-infant interaction, and completed a senior thesis on the effects of maternal mental health on cognitive and brain development in infants.
