Introduction to Cognitive Processing Therapy for PTSD: An Evidence-Based Treatment

UT Health Science Center, San Antonio

Key Points

  1. Cognitive processing therapy offers a more approachable alternative to prolonged exposure for treating PTSD to patients who have high levels of avoidance and are reluctant to disclose their trauma in detail.
  2. CPT focuses on differentiating between natural and manufactured emotions, identifying and addressing stuck points— maladaptive thoughts contributing to PTSD.
  3. Psychoeducation in CPT involves understanding the four PTSD symptom clusters and recognizing the importance of therapy attendance in reducing avoidance behaviors.
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Education on Cognitive Processing Therapy

The client was educated on cognitive processing therapy (CPT) for PTSD, highlighting its evidence-based nature and cognitive-behavioral framework. The focus was on its distinction from other therapies, such as prolonged exposure (PE), and its suitability for patients with avoidance tendencies and a need for control.

Cognitive Processing Therapy vs. Prolonged Exposure

CPT is distinguished from prolonged exposure (PE) therapy. While PE is potent, it can be distressing in the short term, particularly for patients with high avoidance and control levels. In contrast, CPT is more approachable, centering on patients’ thoughts and interpretations of events, rather than reliving them. However, in practice, PE may follow CPT to address residual symptoms.

The Nature of Emotions in CPT

CPT involves differentiating natural emotions (such as sadness and anger) from manufactured ones, identifying stuck points— maladaptive thoughts that fuel PTSD and sustain manufactured emotions over time. Part of the therapy involves allowing the patient to experience and process natural emotions they may have previously ignored or suppressed.

Identifying Stuck Points

Stuck points are identified through conversation and guided handouts. Clinicians listen for self-critical thoughts or overgeneralizations that maintain fear. Emotional aspects, particularly guilt, responsibility, shame, and regret, are focal points for exploring these stuck thoughts. The approach involves inquiring into the patient’s interpretation of events.

For instance, if a patient expresses guilt, the clinician probes further by asking, “Why do you feel guilty? What thought is driving this feeling?” or “In what way do you perceive yourself as guilty in this context? Please, help me understand your perspective.”

The Role of Socratic Questioning in Cognitive Processing Therapy

Socratic Questioning Techniques

Cognitive processing therapy incorporates Socratic questioning, a method characterized by deep inquiry and curiosity. This technique involves asking precise questions to gather essential information and guide the patient toward self-realization and understanding.

For instance, when identifying stuck points, the clinician might express uncertainty to encourage the patient’s explanation, such as, “I’m not entirely sure I understand. Can you explain why you feel responsible for what happened?” This prompts the patient to explore their thoughts and emotions deeper, providing more specific details crucial for effective treatment.

Unveiling the Patient’s Trauma History

The patient disclosed the details of the trauma in one of these deep conversations. She disclosed enduring sexual abuse by her stepfather from ages eight to fourteen. Despite informing her biological mother, the mother failed to act, choosing to protect the stepfather instead. This neglect represents an additional layer of trauma, often creating a deeper psychological wound than the original trauma.

In exploring these traumas, the clinician asks targeted questions like:

  • Do you feel guilty?
  • Why do you feel guilty?
  • Who do you blame for this?
  • If you feel guilty, what aspect do you feel guilty for?
  • Why do you feel so shameful?

Such inquiries are instrumental in encouraging patients to articulate their stuck points, fostering a deeper understanding of their trauma and its impact.

Psychoeducation on PTSD: Four-Symptom Clusters

Educating patients about PTSD involves outlining the four symptom clusters defined in the DSM-5:

  1. Intrusions: Re-experiencing symptoms, including memories and nightmares.
  2. Hyperarousal: Physiological reactions to reminders of the event, manifesting as anxiety, panic symptoms, and sleep disturbances.
  3. Negative changes in mood and cognition: Altered perceptions about oneself, others, and the world, often leading to depression.
  4. Avoidance: Evading thoughts, feelings, people, or places associated with the trauma, which perpetuates symptoms.

Addressing Avoidance in Therapy

By attending therapy, patients are actively reducing their avoidance, a fact that clinicians often emphasize to underscore their participation in the healing process. The discomfort associated with therapy appointments is a common experience; many patients feel an urge to avoid or cancel them. Clinicians normalize these feelings, reassuring patients that their presence in therapy signifies a decrease in avoidance behaviors. It’s important for patients to understand that an increase in other symptoms resulting from confronting rather than avoiding is a normal part of recovery and indicative of progress in the therapeutic work.

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Introduction to Cognitive Processing Therapy for PTSD: An Evidence-Based Treatment