Evidence-Based Trauma Treatment: What is Cognitive Processing Therapy?

Trauma is incredibly common, with 60% of men and 50% of women experiencing a trauma at some point. On average, 6% of all people will go on to develop post-traumatic stress disorder (PTSD), with women more likely (8%) than men (4%) to have PTSD. Additionally, women are more likely to have traumatic experiences related to child sexual abuse or sexual assault while men are more likely to experience accidents, combat, disasters, or witness a death/serious injury ^[1].

As providers working in the mental health field, we tend to see much higher rates of trauma and PTSD in our patients than one would see in the general population. This makes it essential for all mental health providers to be skilled and knowledgeable regarding evidence-based treatments for PTSD.

Developing a trauma-informed approach

Since half of women and most men have trauma histories, clinicians are wise to integrate a trauma-informed approach with all patients. A trauma-informed approach consists of:

• Being aware of how trauma has impacted your patients
• Knowing how to spot the signs and symptoms of PTSD
• Understanding the difficulties people face following a trauma
• Integrating trauma information in all aspects of clinical practice
• Having an intentional focus to avoid retraumatizing patients

Effective trauma-informed treatment favors psychotherapy over pharmacotherapy, with individual therapy being more effective than group therapy (although group therapy can also be effective). 

When providing therapy to patients showing signs of PTSD, consider a manualized trauma-focused therapy like cognitive processing therapy (CPT), one of the most effective approaches for treating PTSD ^[2]. Other effective trauma-focused therapies include:

• Prolonged exposure
• Trauma-focused cognitive behavioral therapy (CBT)
• Narrative exposure therapy

CPT: An evidence-based trauma treatment

CPT is one of the leading trauma treatments used today. It is often well tolerated, which can increase treatment adherence, attendance and symptom reduction. Typically, 12 sessions of CPT are recommended, although 16 sessions are recommended for those with a history of childhood sexual abuse. Sessions address the following and more:

• Assessment and education of how trauma impacts people
• Challenging unhealthy/harmful thought patterns related to the trauma
• Working through issues related to safety, trust, power, control, self-esteem and intimacy
• Processing painful trauma memories
• Working through stuck points
• Developing cognitive skills
• Challenging beliefs

Some of the many benefits of CPT include:

• Strong empirical support
• Structured and time-limited treatment
• Emphasis on cognitive modification
• Grounded in cognitive behavioral therapy (CBT)
• Compatible with other CBT-type therapies
• Can be done with or without written accounts of the trauma
• An active and collaborative format

If you are unfamiliar with CPT and are interested in learning more, we encourage you to seek training or supervision on how to apply CPT with patients. At the bottom of this article, we also offer you a link to our clinician-led webinar that walks you step by step through the process of getting started with CPT.

Is your patient ready for CPT?

Some providers may worry that a patient may be too unstable to begin trauma therapy. However, we find that most patients are ready to begin and that the benefits of using an evidence-based trauma treatment outweigh the risks. If you see the following signs of readiness, is it likely that CPT is appropriate:

• Your patient is ready and willing to talk about/work on their trauma.
• Your patient has PTSD or symptoms of PTSD.
• You feel ready to begin trauma work with that patient.

However, there are some signs that your patient is NOT ready to work on their trauma. If these signs are present, we would not recommend that you start intensive trauma therapy at this time:

• Patient is in danger of hurting themselves or others.
• Patient has mania or psychosis and is unmedicated.
• Patient has substance use issues requiring detox.
• Patient experiences extreme dissociation.
• Patient lacks motivation for treatment.

If you’re still not sure if you should proceed with trauma treatment, we encourage you to think twice, look at relevant research and review CPT recommendations from the manual. You may also want to consult with trauma experts or a supervisor/colleague.

Getting started with CPT

If you are a new therapy practitioner or new to CPT, we encourage you to thoroughly read the manual, take a training or seek supervision/consultation before you begin. Through in-session work, homework and worksheets, your patient will have the opportunity to process their experiences, beliefs and emotions -- reducing strong feelings of distress that are commonly associated with a trauma history. Examples of the types of beliefs addressed with CPT include:

• Safety: Patient avoids people, social gatherings and new experiences because they feel unsafe.
• Trust: Patient is distrustful of others.
• Self-esteem:  Patient feels worthless, bad or damaged in some way.
• Power and control:  Patient tries to control events, emotions and people, because deep down they want to prevent bad things from happening.
• Intimacy:  Patient believes that connecting with others is risky and possibly dangerous.

Along with ensuring competence in applying this new treatment in therapy sessions, we encourage you to work on your own issues and stuck points related to your own trauma history, if any. Additionally, it can be helpful to prepare for each session by reviewing handouts, worksheets and educational materials ahead of time.

Signs of complex PTSD -- A type of PTSD

As an additional note, we want to mention complex PTSD (C-PTSD), a form of PTSD that occurs following repeated, prolonged trauma. C-PTSD is a diagnosis that may be given to people who have experienced trauma for months or years (war refugees, domestic violence or child abuse survivors, etc.).

Both people with PTSD and people with C-PTSD may experience flashbacks, nightmares, avoidance and hypervigilance. But people with C-PTSD are more likely to experience the following symptoms:

• Problems with emotional regulation, particularly anger and feeling hurt
• A negative self-concept, feelings of worthlessness or guilt
• Interpersonal problems, having few close friends or feeling disconnected from others

Some clinicians wonder how to distinguish C-PTSD from borderline personality disorder (BPD), since some of the systems overlap. While people with C-PTSD and BPD may have difficulty controlling their emotions:

• Fear of abandonment is more common with BPD than C-PTSD.
• With C-PTSD, one’s self-concept is consistently negative (feeling helpless, guilty, ashamed or different from everybody else); with BPD, one’s identity tends to shift.
• With BPD, one is more likely to engage with others in a chaotic manner; people with C-PTSD tend to avoid relationship conflict.
• A person with BPD is more likely to self-injure or attempt suicide.

Final words on treating trauma

With trauma being as common as it is, we encourage all mental health professionals to educate themselves on trauma, PTSD, C-PTSD and the manualized, evidence-based treatments that are most effective for healing trauma. By becoming a competent, trauma-informed therapist, you can help people regain their lives from their traumatic past. To watch someone heal before your eyes is incredibly powerful and we are so grateful to all of you for doing this essential work.

Learn more about Pathlight's specialty trauma track.

Get access to our full library of continuing education webinars

To get an even more in-depth look at getting started with CPT, we encourage you to watch our continuing education course, “Treating Trauma,” presented by Kim Anderson, PhD, CEDS and Al Tsai, MD. Dr. Anderson shows you the basics of getting started with CPT. If you’d like to view this webinar along with many other behavioral health topics, we invite you to learn more about our accredited continuing education program and get free access to our entire continuing education library.

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Related Reading

• The Danger of Downplaying Trauma With PTSD
• Treating Patients With PTSD
• Trauma and Comorbid Binge Eating Disorder: A Clinical Approach to Treatment
   

Sources

1. PTSD: National Center for PTSD. How Common Is PTSD in Adults? Accessed July 19, 2022
2. PTSD: National Center for PTSD. Cognitive Processing Therapy (CPT) for PTSD. Accessed July 19, 2022