Cognitive processing therapy (CPT)

A frightening or terrible event can change how you see yourself and the world. You might come to believe it was your fault, that no one can be trusted, or that danger is everywhere. These beliefs can feel like plain facts. But they can keep PTSD (post-traumatic stress disorder) going long after the danger has passed.^1,3

Cognitive processing therapy, often called CPT, is a talk therapy that helps you look closely at those beliefs. With a trained therapist, you check whether they fit the facts, and you build fairer, more balanced ways of thinking about what happened. Many people feel better after a few sessions, and the gains often last.¹

How CPT works

After trauma, most people try to make sense of what happened. Sometimes the mind lands on an explanation that is harsh or extreme. CPT calls these explanations stuck points, because they keep you stuck in PTSD.³

Stuck points tend to come in two kinds:³

• Bending the event to fit old beliefs. If you always believed that bad things only happen to people who deserve them, you might decide the trauma was your own fault. Thoughts like "I should have seen it coming" belong here. Looking back, things often seem clearer than they were at the time.
• Swinging too far the other way. After being hurt by one person, you might decide that everyone is dangerous, or that you can never feel safe again.

The goal is not to talk yourself into "everything is fine." It is to reach a balanced view. For example: "Some people are dangerous, but most are not, and I can learn to tell the difference."³

The treatment's authors are psychologists Patricia Resick, Kathleen Chard and Candice Monson.¹¹ Therapists follow a written manual, so trained providers deliver it in a similar way.³

What happens in CPT

CPT moves through three broad phases: learning about PTSD and writing an impact statement, working through the trauma's meaning, and then using the skills on your own.²

1. Learning about PTSD. Your therapist explains common trauma reactions and why recovery can stall. You learn how thoughts, feelings and actions affect one another.^2,11
2. Writing an impact statement. Early on, you write a short piece at home about why you think the trauma happened. You also write about how it changed what you believe about yourself, other people and the world. You read it in the next session. It helps you and your therapist find your stuck points.²
3. Checking stuck points. Your therapist asks gentle, curious questions. This is called Socratic questioning (questions that help you look at the evidence yourself, rather than being told what to think). Early sessions often focus on self-blame, guilt and shame.^2,3
4. Practice between sessions. You fill out short worksheets at home to catch and test stuck points. People who put effort into this practice tend to get more out of CPT.¹
5. Working on five themes. Later sessions look at how the trauma affected your sense of safety, trust, power and control, self-esteem, and closeness with others.^1,3
6. Looking ahead. Near the end, you look back at how your thinking has changed. You plan how to keep using the skills on your own after therapy ends.²

The written account is optional

The original version of CPT included writing a detailed account of the worst trauma, then reading it aloud in session. Today, the standard version focuses on thinking skills, and the written account is a choice. The version with the account is often called CPT+A.^2,3

Both versions work well for most people, and dropout rates are similar.³ If you choose the written account, you usually start it around the third session. You write it at home, read it to yourself, and then read it to your therapist.¹

Formats

• One-on-one. This is the most common format and seems to work best. In a trial of 268 active-duty service members, individual CPT reduced PTSD symptoms more than group CPT by the end of treatment.^3,7
• Group. One or two therapists lead a group of about 6 to 10 people with PTSD. Group sessions last about 90 minutes.¹ Groups still helped in the trial above, and by six months later the two formats had similar results.⁷
• Video visits. Studies show CPT works when delivered by secure video, which helps people who live far away or have trouble getting around.³
• Intensive. Some programs pack CPT into about a week, with daily sessions. This may help people who cannot commit to 12 weeks. Early results are encouraging, and larger studies are under way.³

How well does CPT work?

CPT is one of the best-studied therapies for PTSD. About 34 randomized trials (studies where people are assigned to treatments by chance) have tested it. Reviews of these trials show large drops in PTSD symptoms.³

• Guidelines. The 2023 VA/DoD guideline gives CPT, prolonged exposure (PE) and EMDR its strongest recommendation. It also prefers these therapies over medicines as a first choice for PTSD.⁴ The American Psychological Association rates CPT as strongly recommended.²
• Real-world numbers. Across trauma-focused talk therapies like CPT, PE and EMDR, about 57 out of 100 people improve in a way they can feel, after about 3 months. That compares with about 36 out of 100 on medicine alone and about 8 out of 100 with no treatment.⁵
• Losing the diagnosis. In the first large CPT study in U.S. veterans, about 4 in 10 people no longer had PTSD by the end of treatment.³
• Other benefits. CPT has also been linked with less depression, fewer thoughts of suicide, better sleep and better daily functioning.³

CPT compared with PE. The largest head-to-head study included 916 veterans aged 21 to 80. Both therapies helped a lot. PE lowered symptoms a little more, but the researchers judged the gap too small to matter much in daily life. Fewer people dropped out of CPT (about 47%) than PE (about 56%).⁶

What this means for you. CPT does not work for everyone. In the service member trial, about half of the people in individual CPT still had PTSD at the end.⁷ But many people feel better, and the gains often last after therapy ends.¹

Is CPT hard?

Talking and writing about trauma and the beliefs tied to it can be uncomfortable. This discomfort is usually mild to moderate and short-lived, and it tends to ease as treatment goes on.¹

Dropping out early is common in all trauma therapies. In the big veterans' study, close to half of the people in the CPT group did not finish.⁶ If you feel like quitting, tell your therapist so you can talk it through together. The more you put into CPT, the more you tend to get out of it.¹

How CPT compares with other PTSD therapies

Sources for the table: VA and VA/DoD.^1,4,9,13 For more on choosing among them, see trauma-focused therapies.

CPT may suit you if you would rather work with thoughts than relive details, if guilt or self-blame is a big part of your PTSD, or if you like structured, written practice.

CPT in later life

Many older adults carry trauma from war, abuse, accidents, disasters or medical crises. Symptoms can return or grow stronger in later life, for example after retirement, the loss of a spouse or friends, or new health problems. PTSD can also start for the first time in later life.¹⁴ See PTSD in older adults and veterans.

What the research shows so far:⁸

• Trauma-focused therapy, including CPT, is usually well tolerated by older adults. Symptoms improve, and dropout in studies has been low.
• In one study, both older and younger adults benefited from CPT. Younger adults improved a bit more and needed fewer sessions on average.
• Nothing in the research suggests that older adults should be steered away from first-choice therapies like CPT.
• Mild or moderate memory problems are not, by themselves, a reason to avoid PTSD treatment. If memory or thinking is a concern, your therapist may suggest a short memory screening or a fuller evaluation first.

Small changes can make CPT easier:⁸

• Worksheets printed in larger, bold type.
• Plain words instead of therapy jargon.
• Video visits if driving or transportation is hard.
• A family member or caregiver can help with reminders, while the therapist still speaks to you first.

The research has limits. Few studies have included people over 75, or people with serious illness or dementia.⁸ For more on later life, see older adults.

How to find CPT

• Veterans. Almost all VA medical centers offer CPT in their PTSD programs. Smaller sites may offer it by video. Vet Centers can also help.^1,10
• Everyone. The CPT developers keep an online roster of trained providers at cptforptsd.com.^10,11 When you call a therapist, ask: "Are you trained in CPT, PE or EMDR?" and "Do you have experience with trauma?"¹⁰
• Cost. Check which therapists your insurance covers. If you have no insurance, state-funded clinics may help.¹⁰ See how to find a therapist and paying for therapy, including Medicare coverage.
• CPT Coach app. This free app from the VA, for Apple and Android phones, holds CPT worksheets, tracks symptoms and sends homework reminders. It is meant to be used with a CPT-trained therapist, not instead of one.¹²

Common questions

Do I have to tell my therapist everything that happened?

No. In standard CPT, you focus on what you believe about the trauma, not on every detail. You can choose to add a written account, and you decide with your therapist what feels right.^1,3

Can I do CPT on my own with a book or app?

CPT is designed to be done with a trained therapist. The CPT Coach app supports therapy but does not replace it.¹² For general thought skills you can practice alone, see the thought check tool, but trauma work is best done with support.

My trauma was a long time ago. Can CPT still help?

Yes. CPT is about how the event affects your thinking and life now. Older adults, including veterans with trauma from decades ago, can benefit.⁸

Can I do CPT if I take medicine for PTSD or depression?

Many people do. Guidelines prefer trauma-focused therapy as a first choice, and some people use both.⁴ See medicines for PTSD. Talk with your doctor or pharmacist before changing anything.

How is CPT different from regular CBT?

CPT is a form of CBT built only for PTSD. It follows a set plan aimed at trauma beliefs and the five themes of safety, trust, power and control, esteem and closeness.^2,3 General CBT is used for many problems, like depression and anxiety.

How can I support a loved one in CPT?

Be patient on hard days, respect their privacy about what they share in therapy, and encourage them to keep going. See supporting someone with PTSD.

When to get help right away

Also reach out to a doctor or therapist soon if trauma memories, nightmares, anger, drinking or numbness are getting in the way of sleep, work or relationships. PTSD can be treated at any age, even decades after the event.^1,8

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.