Cognitive processing therapy

1. Introduction

Version followed: Resick, Monson & Chard, Cognitive Processing Therapy for PTSD: A Comprehensive Therapist Manual, 2nd edition (Guilford, 2024). Standard 12-session individual CPT without a written trauma account, with the written-account variant (CPT+A) and the other variations given in Section 4. Worksheet names follow the 2nd edition. Older names, from the 2014 VA Veteran/Military manual and the 2017 first edition, are given in brackets. Naming changed between versions: in the 2010 and 2014 VA manuals, "CPT" meant the version with the account and "CPT-C" the version without it. From the 2016/2017 manual on, "CPT" means the version without the account and "CPT+A" the version with it. [source: Deployment Psychology staff perspective; Guilford 2nd ed. table of contents]

CPT is a manualised, trauma-focused cognitive therapy for PTSD, developed by Patricia Resick from 1988. Its model treats PTSD as a disorder of non-recovery. After trauma, natural recovery stalls because of two things. The first is beliefs about why the event happened and what it means ("stuck points"), which generate strong secondary emotions. The second is avoidance of reminders, which blocks the processing that would otherwise correct those beliefs. Change comes when the client examines these stuck points through Socratic dialogue and structured worksheets practised between sessions. First the client looks at self-blaming or "undoing" beliefs about the index event (assimilation). Then the client looks at over-generalised beliefs about safety, trust, power/control, esteem and intimacy (overaccommodation). The aim is balanced, accurate beliefs (accommodation), which lets natural emotions run their course. The manual stresses that the client reaches new conclusions themselves rather than adopting the therapist's view. [source: Wikipedia CPT article; Guilford 2nd ed. TOC, ch. 4 and sessions 3–4]

2. Framework

Format. The individual format is 12 sessions of 50–60 minutes, once or twice weekly, with practice assignments between sessions. Group CPT is 12 sessions of 90–120 minutes, usually with two co-therapists and 8–10 clients. A mixed format adds individual sessions to the group. Intensive formats deliver daily sessions over about 3 weeks. Personalized-length CPT can end earlier or extend beyond 12 sessions (Section 4). [source: Wikipedia; Guilford 2nd ed. TOC ch. 18–19; Zalta et al. 2018 table]

Phases. The manual organises CPT session by session, not in named phases. The three-phase grouping below is the common secondary description, mapped onto the 2nd-edition session chapters. [source: Wikipedia phases; Guilford 2nd ed. TOC]

Phase 0: Pretreatment (before session 1).

Goals: confirm PTSD, identify the index trauma, screen for anything that must come first, build a cognitive case conceptualisation, and obtain informed agreement (treatment contract).
Content: diagnostic assessment; baseline self-report measures (the manual supplies a modified PCL-5 and the PHQ-9); history; likely treatment-interfering behaviours and cognitions; strengths and reasons to change; early hypotheses about assimilated versus overaccommodated stuck points. [source: Guilford 2nd ed. TOC ch. 3–5]
Moving on: the manual has a chapter on whether "pretreatment" (stabilisation) is needed and on when the protocol should begin. The authors' general position is that most clients can start CPT directly, once imminent danger, serious current suicidal or homicidal intent, and uncontrolled substance use or psychosis are managed. [uncertain: criteria are the usual CPT training guidance]

Phase 1: Education and identifying stuck points (sessions 1–3).

S1, Overview of PTSD and CPT: agenda; PTSD symptoms and functional model; scoring PCL-5/PHQ-9 with the client; PTSD and the brain; cognitive theory; the role of emotions; brief identification of the index trauma; description of the therapy; Impact Statement assigned.
S2, Impact Statement: client reads it aloud; stuck points identified and entered on the Stuck Point Log; nonadherence addressed; event–thought–feeling links; ABC Worksheet introduced.
S3, ABC Worksheets: review ABCs; begin Socratic work on assimilated ("why" and self-blame) stuck points about the index event.
Goals: understand the model, identify the core stuck points, separate thoughts from feelings, and start reducing avoidance.
Moving on: the client has an Impact Statement, a starter Stuck Point Log, and can complete an ABC linking an event, a thought and a feeling. [source: Guilford 2nd ed. TOC ch. 6–8; NCT01928732 protocol]

Phase 2: Processing the index event and learning cognitive skills (sessions 4–7).

S4, Processing the Index Event: Socratic dialogue on assimilated stuck points; distinguishing intention, responsibility and the unforeseeable (Levels of Responsibility handout); Exploring Questions Worksheet introduced.
S5, Exploring Questions: review; Thinking Patterns Worksheet introduced.
S6, Thinking Patterns: midprotocol assessment of treatment response; Alternative Thoughts Worksheet introduced with a trauma example.
S7, Alternative Thoughts: review; overview of the five themes; Safety introduced.
Goals: resolve self-blame and hindsight bias about the index event, and build independent skill in challenging stuck points.
Moving on: index-event (assimilated) stuck points have loosened, with lower belief ratings and more natural grief or sadness in place of guilt and shame, before the focus shifts mainly to themes. [source: Guilford 2nd ed. TOC ch. 9–12] [synthesis: the readiness criterion]

Phase 3: Trauma themes and consolidation (sessions 8–12).

S8: Safety reviewed; Trust introduced.
S9: Trust reviewed (Trust Star); Power/Control introduced.
S10: Power/Control reviewed; Esteem introduced; termination discussed; compliments and nice-things tracking assigned.
S11: Esteem reviewed; termination discussed; Intimacy introduced; new Impact Statement assigned.
S12, Intimacy and Facing the Future: compare original and new Impact Statements; review the course of treatment; set goals; plan aftercare.
Each theme is examined in its self-directed and other-directed form.
Goals: shift overaccommodated beliefs to balanced ones, and leave the client able to act as their own therapist.
Ending: in fixed-length CPT, after session 12. In personalized-length CPT, when symptom and clinical criteria are met (Section 4). [source: Guilford 2nd ed. TOC ch. 13–18; NCT01928732 protocol]

Every session has the same skeleton: review the self-report scores → review practice assignments, done first and always → Socratic work on stuck points arising from them → introduce the new skill or theme → assign practice → check the client's reactions to the session. [source: Guilford 2nd ed. TOC, recurring headings in ch. 6–17]

3. Guiding principles

[source: Guilford 2nd ed. TOC ch. 4–5 and session headings; Wikipedia; Deployment Psychology. Where a one-line meaning goes beyond those, it is marked.]

PTSD as non-recovery. Your job is to remove what is blocking natural recovery (stuck points and avoidance), not to add something new. In practice: frame symptoms as recovery that got interrupted.
Meaning over memory detail. Work on what the client concluded from the event, not on rehearsing it. Standard CPT therefore uses no written account. In practice: ask "what does it mean to you that it happened?" rather than asking for more sensory detail.
Assimilation before overaccommodation. Target self-blame, hindsight bias and "I should have…" beliefs about the index event first (sessions 2–6). Theme-wide beliefs come later. In practice: if guilt or shame about the event is still high, stay with the index event.
Accommodation is the goal, not positive thinking. The target is balanced, accurate beliefs ("some people can be trusted with some things"), not the opposite extreme. In practice: reject over-positive replacements as firmly as negative ones. [synthesis: the wording of the practice point]
Natural versus manufactured emotions. Natural emotions such as fear or grief that follow directly from the event are allowed to run their course. Emotions manufactured by stuck points, such as guilt from hindsight bias, change when the thought changes. In practice: help the client feel grief; question guilt. [uncertain: in the published manual]
Socratic dialogue, not persuasion. The client's own conclusions produce durable change. In practice: ask questions you do not know the answer to; never argue or lecture.
Stuck points are thoughts. They are concise, testable beliefs, not feelings, behaviours or questions. In practice: rephrase "I feel unsafe" into the belief beneath it ("If I go out at night, I will be attacked").
Practice assignments are the engine. Always review them first. Treat nonadherence as avoidance or a stuck point, never as something to skip. In practice: if the work was not done, complete it together in session.
Avoidance maintains PTSD. Gently and consistently counter avoidance of feelings, reminders, the work and sessions. In practice: name avoidance kindly, every time it appears.
Measurement-based care. Clients complete the PCL-5 and PHQ-9 regularly (each session in the manual's procedure), and scores are reviewed in session and formally at midprotocol (session 6). In practice: let the data drive decisions about pace and length.
Structure and protocol fidelity. Keep an agenda for every session and introduce new skills in the given sequence. In practice: deal with a crisis of the week briefly, then return to the protocol where safe.
Collaboration. A treatment contract (Handout 5.1) sets out shared commitments. In practice: refer back to it when commitment wavers.
Case conceptualisation guides the dialogue. History, treatment-interfering behaviours and cognitions, and strengths shape which stuck points to prioritise. In practice: keep a running hypothesis of the client's core stuck points.
Responsibility is not blame. Separate intention, responsibility, and what was unforeseeable or outside the client's control. In practice: test "fault" claims against what was actually knowable and intended.
Watch for therapist stuck points. Therapists hold their own stuck points, for example "this client is too fragile" or "they really were to blame". In practice: notice when you avoid a topic or agree with a stuck point, and take it to consultation.
Diversity and context. Adapt examples and themes to culture, religion and morality, gender and sexual identity, occupation (warrior ethos, first responders) and cognitive capacity, without changing the core mechanism. [source: Guilford 2nd ed. TOC ch. 20]

4. Intervention inventory

[source, unless stated otherwise: the Guilford 2nd ed. table of contents gives the names, order and session placement of every procedure and handout. The NCT01928732 protocol and the Zalta et al. 2018 intensive-CPT table give per-session content. All steps and wording are paraphrased. Handout and worksheet content is described, not reproduced.]

4.1 Pretreatment assessment and cognitive case conceptualisation

Purpose / when: before session 1. Confirms that CPT fits and sets up the stuck-point hypotheses.
Steps:
1. Assess PTSD diagnostically, and identify the event that is most distressing now (often the one causing the most intrusions or shame).
2. Give baseline measures: the PCL-5 (the manual's modified version) and the PHQ-9.
3. Screen for imminent risk to self or others, current danger (for example ongoing domestic violence), uncontrolled substance use, psychosis or mania.
4. Fill in the manual's Case Conceptualization Form (Appendix A.1). It covers relevant history; likely treatment-interfering behaviours (missed sessions, lateness, substance use, crises) and cognitions ("talking about it will make me worse"); strengths and reasons to change; and draft stuck points sorted into assimilated (about the event: blame, undoing) and overaccommodated (about the world now).
Example language (illustrative): "Of everything that's happened, which memory comes back most often or bothers you the most now?"
Watch for: clients who name a "lesser" event to avoid the worst one. Probe gently which memory intrudes most. Where several traumas are similar (for example repeated childhood abuse), the worst or most representative episode can serve as the index event, and the others are addressed later. [synthesis: the handling of multiple traumas]

4.2 Introducing CPT and the treatment contract

Purpose / when: pretreatment or the start of session 1. Builds informed commitment and anticipates avoidance.
Steps:
1. Describe CPT: about 12 sessions, structured, with daily practice assignments, focused on how the trauma changed beliefs.
2. Go through the contract (Handout 5.1): attend regularly, do the practice, tell the therapist about urges to quit, and limit avoidance behaviours such as substance use.
3. Ask about past treatment experiences and worries about the treatment.
Example language (illustrative): "This is a short, focused therapy. Most of the change happens in the practice you do between sessions, so I'll ask about it every time we meet."
Watch for: agreement that sounds hollow. Ask what might get in the way, and plan for it now.

4.3 Psychoeducation: PTSD symptoms, the functional model, and PTSD and the brain (session 1)

Purpose: normalise symptoms and give the rationale that avoidance and stuck points block recovery.
Steps:
1. Set the agenda.
2. Score the PCL-5 and PHQ-9 with the client and link the items to symptom clusters.
3. Walk through Handout 6.1, Recovery or Nonrecovery from PTSD Symptoms. Most people have symptoms after trauma that fade naturally. For some they do not fade, because avoidance and particular beliefs interrupt processing.
4. Give a brief, plain-language explanation of the brain's threat (alarm) system and of how the thinking brain can help regulate it.
5. Ask the client how avoidance has shown up for them.
Example language (illustrative): "Recovery after trauma is the natural course. PTSD is what happens when something gets in the way of that. We're going to find what's in the way."
Watch for: clients who hear "my brain is damaged". Stress that these are learned, changeable patterns.

4.4 Cognitive theory: assimilation, accommodation, overaccommodation, and natural versus manufactured emotions (session 1, revisited throughout)

Purpose: gives the client the map for every later step.
Steps:
1. Explain that people hold prior beliefs. A trauma that does not fit them is either altered to fit (assimilation, for example "it must have been my fault" or "it wasn't really assault"), or the beliefs are over-corrected (overaccommodation, for example "no one can be trusted"). The goal is accommodation: beliefs updated just enough to be accurate.
2. Explain that natural emotions (fear in danger, sadness at loss, anger at an intentional harm) fade if they are felt, while manufactured emotions are produced by what the client tells themselves and change when the thinking changes. [uncertain: from the published manual]
3. Introduce stuck points: thoughts that keep the client stuck.
Example language (illustrative): "Feelings that come straight from what happened, like grief, need to be felt so they can run their course. Feelings fuelled by the story we tell ourselves about it, like 'I should have stopped it', can shift if we look at that story."
Watch for: clients who conclude that feeling anything is bad. The message is "feel natural emotions; examine manufactured ones".

4.5 Reviewing the index trauma briefly (session 1)

Purpose: agree on the target event without a detailed retelling.
Steps:
1. Ask for a brief, few-minute outline of the worst event.
2. Do not probe for details. Note emotions and early stuck points.
3. Confirm that this is the index event for the Impact Statement.
Example language (illustrative): "Just give me the headline version for now, a few sentences. We won't go into detail today."
Watch for: flooding, which you contain by pacing and grounding. Also watch for detachment, and note it as possible emotional avoidance.

4.6 Impact Statement (assigned after session 1, read in session 2)

Purpose: baseline record of the client's beliefs about why the trauma happened, and how it changed beliefs about self, others and the world in the five themes. It is the richest early source of stuck points.
Steps:
1. Assign at least a one-page statement, written at home, about why the event happened and how it affected beliefs about safety, trust, power/control, esteem and intimacy, for self and others (Handout 6.2).
2. Stress that it is about meaning, not a description of the event.
3. In session 2 the client reads it aloud.
4. Listen for "why" beliefs (self-blame, undoing) and over-generalisations, and write the stuck points on the Stuck Point Log together.
5. If it was not done, explore what got in the way (often avoidance or a stuck point such as "it won't help"). Have the client say aloud, in session, what the event means to them, then reassign it. [source: TOC session 2 "Addressing Nonadherence"; NCT01928732]
Example language (illustrative): "Write about why you think this happened and how it has changed the way you see yourself, other people and the world. It isn't about what happened; it's about what it has come to mean."
Watch for: the client reading in a flat, rushed voice (slow them down). Watch also for only describing events; steer them back to meaning.

4.7 Stuck Point Log and the Stuck Point Help Guide (session 2 onwards)

Purpose: a running, client-owned list of target beliefs, used throughout.
Steps:
1. Explain the criteria: a stuck point is a concise thought or belief, not a feeling, behaviour or question, and it can be examined.
2. Turn feelings and questions into beliefs ("Why me?" becomes something like "I must have done something to deserve it").
3. Add stuck points as they surface in any session.
4. Cross off or re-rate them as they change.
5. Use the Stuck Point Help Guide (Handout 7.4) to help word them.
Example language (illustrative): "That 'If I had gone home earlier, he'd be alive' sounds like a stuck point. Let's put it on the log."
Watch for: stuck points phrased as facts the client will defend. Keep them as beliefs to be examined, not attacked.

4.8 Identifying emotions (session 2)

Purpose: build emotional vocabulary so the client can complete column C of the ABC and separate emotions from thoughts.
Steps:
1. Introduce the Identifying Emotions handout (Handout 7.2), which covers basic emotions and their variants.
2. Practise naming the emotion behind a recent event.
3. Show that "I feel that…" usually introduces a thought, not an emotion.
Example language (illustrative): "'I feel that I'm worthless' is really a thought. What's the feeling that goes with it: shame, sadness, anger?"
Watch for: clients who can only report "stressed" or "numb". Use body cues and the basic emotion families.

4.9 ABC Worksheet (introduced in session 2, reviewed in session 3)

Purpose: links an Activating event, a Belief or stuck point, and the Consequence (feelings and behaviour). Builds awareness that thoughts shape feelings.
Steps:
1. Complete one ABC together in session on a recent everyday event (the manual provides three worked examples, Handouts 7.3a–c).
2. Assign one ABC per day, with at least one about the index trauma (Handout 7.5).
3. In session 3, review the ABCs. Check that the emotion matches the thought, and ask whether the thought is realistic. Use trauma-related ABCs to start Socratic work on assimilated beliefs.
4. Simplified option: the Visual ABC Worksheet (Appendix B.1) for clients with literacy or cognitive limits.
Example language (illustrative): "When your boss raised his voice (A), what went through your mind (B)? And then what did you feel and do (C)?"
Watch for: thoughts entered in the emotion column, or worksheets that avoid the trauma. Praise the effort and correct gently. [source: NCT01928732, "gentle correction"]

4.10 Socratic dialogue (the core method, every session)

Purpose: help the client examine and revise stuck points by their own reasoning.
Steps:
1. Pick a stuck point that matters, starting with assimilated ones about the index event.
2. Ask clarifying questions to understand what the client means and the exact facts.
3. Ask questions that examine the belief: the evidence, alternatives, and what was knowable at the time.
4. Ask the client to summarise and draw conclusions in their own words, and have them write down the new conclusion.
5. Stop when the client reaches a more balanced view or the session's natural end; do not chase every stuck point at once.
6. The manual frames the stance as curious and collaborative, not adversarial. [source: Wikipedia; TOC ch. 5 "Socratic Dialogue"] [uncertain: this exact staging of question types is from CPT training materials]
Example language (illustrative): "Walk me through what you knew at the moment you made that choice." … "Given what you knew then, what were your options?" … "So when you put that together, what do you make of it now?"
Watch for: you talking more than the client; the client agreeing too fast ("yes, I know it wasn't my fault, but…"); arguing. Signs that it is working: the client spontaneously offers counter-evidence, belief ratings drop, and guilt gives way to sadness.

4.11 Processing the index event: addressing assimilated stuck points (sessions 3–6)

Purpose: resolve self-blame, hindsight bias, "undoing" ("if only…") and just-world beliefs about the index event.
Steps:
1. Choose the assimilated stuck point with the most emotional charge.
2. Reconstruct the moment: what the client knew, felt and could do then, not what is known now. This counters hindsight bias.
3. Explore the outcome-based reasoning ("because it ended badly, I must have chosen wrongly").
4. Look at the role of the perpetrator or the circumstances.
5. Help the client notice natural emotions (grief, sadness, anger at the perpetrator) as they emerge, and allow them.
Example language (illustrative): "You're judging the decision you made in three seconds using what you've known for three years. What did you actually know in those three seconds?"
Watch for: the switch from guilt to sadness, which is a good sign: stay with it. Watch also for the client moving blame to another innocent party, which is still assimilation.

4.12 Levels of Responsibility: intention, responsibility and the unforeseeable (session 4)

Purpose: separate blame from responsibility and accident.
Steps:
1. Introduce the Levels of Responsibility handout (Handout 9.1).
2. Define the distinctions in the client's words. Blame requires intent to cause harm. Responsibility means causing harm without intending it. Unforeseeable or no fault means the outcome could not reasonably have been known.
3. Place the client's role in the index event on this continuum, and place the perpetrator's role too.
4. Also separate guilt (wrongdoing) from regret (wishing it had been different).
Example language (illustrative): "Did you intend for this to happen? Could you have known it would? Then where does that put you: blame, responsibility, or something you couldn't have foreseen?"
Watch for: genuine perpetration or moral injury, where the client did intend or did cause harm. Do not talk them out of real responsibility. Explore the context, proportionality, and what amends or values-based action is possible. [synthesis]

4.13 Exploring Questions Worksheet [2014/2017: Challenging Questions Worksheet] (introduced in session 4, reviewed in session 5)

Purpose: a self-administered set of questions for examining one stuck point at a time.
Steps:
1. Write one stuck point at the top.
2. Work through each question on the sheet. The question topics include: evidence for and against; habit versus fact; whether the interpretation is accurate; all-or-none thinking; extreme words (always, never, should); taking things out of context; reliability of the source; confusing low and high probability; feelings versus facts; and focusing on irrelevant factors. [uncertain: the list of topics is from the published worksheet]
3. Do one together in session using an assimilated stuck point.
4. Assign one per day, using stuck points from the log (Handout 9.4). Two worked examples and a guide accompany the sheet (Handouts 9.2a–b, 9.3).
Example language (illustrative): "Let's take 'I should have fought back' and run it through these questions. Start with the evidence. What supports it, and what doesn't?"
Watch for: answers that only restate the stuck point, and questions skipped because they "don't apply". Review a few questions in depth rather than all of them superficially.

4.14 Thinking Patterns Worksheet [2014/2017: Patterns of Problematic Thinking Worksheet] (introduced in session 5, reviewed in session 6)

Purpose: helps the client spot habitual thinking styles that keep stuck points alive, across many situations.
Steps:
1. Introduce the patterns. Those confirmed in the sources are jumping to conclusions, mind-reading, emotional reasoning and all-or-none thinking. [source: NCT01928732] The published sheet also lists exaggerating or minimising, ignoring important parts of a situation, oversimplifying, and overgeneralising from a single incident. [uncertain]
2. For each pattern, the client writes examples from their own life and how the pattern affects them (Handout 10.1; worked example 10.1a).
3. Assign completion over the week (Handout 10.2).
Example language (illustrative): "Which of these patterns do you catch yourself in most? Can you think of a time this week when it showed up?"
Watch for: clients turning the list into self-criticism ("I do all of these, I'm hopeless"). Treat that as a stuck point in its own right.

4.15 Midprotocol assessment of treatment response (session 6)

Purpose: a formal check on progress, used to adjust focus or plan the length of treatment.
Steps:
1. Compare current PCL-5 and PHQ-9 scores with baseline.
2. Review which stuck points have changed and which have not.
3. If change is minimal, check for avoidance, missed practice, assimilated stuck points not yet resolved, and outside factors.
4. Agree on adjustments.
Example language (illustrative): "We're halfway. Your scores have dropped from X to Y. Let's look at what's helped and what's still stuck."
Watch for: little change at midprotocol. It usually means the core assimilated stuck point has not been addressed. Return to it before moving to the themes. [synthesis]

4.16 Alternative Thoughts Worksheet [2014/2017: Challenging Beliefs Worksheet] (introduced in session 6, used through session 12)

Purpose: the main integrating tool. It brings the ABC, the Exploring Questions and the Thinking Patterns together on one page to produce and rate a balanced alternative thought.
Steps: the sequence of columns (paraphrased from an older Challenging Beliefs Worksheet copy; the 2nd edition layout may differ [uncertain]):
1. Situation.
2. Thought or stuck point. Rate belief 0–100%.
3. Emotions. Name and rate each 0–100%.
4. Exploring Questions applied to the stuck point.
5. Thinking Patterns identified.
6. Alternative thought. Rate belief 0–100%.
7. Outcome. Re-rate belief in the original stuck point and the emotions, noting any new emotions.
8. The older version also included a "decatastrophising" prompt about the realistic worst case and how the client would cope. [source: UW CPT Challenging Beliefs Worksheet copy]
9. Introduce it with a trauma example in session 6 (worked examples in Handouts 11.1a–e).
10. Assign daily worksheets on stuck points from the log, and from session 7 onwards on the theme of the week.
11. Simplified alternatives: the Outline Alternative Thoughts Worksheet and the Simplified Alternative Thoughts Worksheet (Appendices B.2–B.3).
Example language (illustrative): "Your new thought doesn't have to be positive. It needs to be accurate. How much do you believe it, 0 to 100?"
Watch for: alternative thoughts that are just negations ("I'm not to blame") with low belief, or over-positive. Aim for balanced statements the client actually believes. Signs that it is working: belief in the original stuck point drops and the intensity of manufactured emotion falls.

4.17 Overview of the five themes (session 7)

Purpose: organises overaccommodated beliefs into safety, trust, power/control, esteem and intimacy. Each is examined as beliefs about self and about others.
Steps:
1. Explain that trauma can disrupt beliefs in these areas. A belief may have been negative before the trauma and been "confirmed" by it, or positive before and "shattered" by it.
2. Over sessions 7–11, introduce one theme module per session (Handouts 12.1, 13.1, 14.2, 15.1, 16.1).
3. For each theme, the client reads the module, identifies their stuck points in that area, and completes Alternative Thoughts Worksheets on them. [source: TOC; NCT01928732; Zalta et al. 2018]
Example language (illustrative): "Each week we'll take one area where trauma often changes beliefs. This week is safety. Read the module and see which stuck points fit you."
Watch for: themes already resolved for this client. Spend less time there and more on live themes.

4.18 Safety module (introduced in session 7, reviewed in session 8)

Purpose: beliefs about one's own ability to stay safe, and about the danger posed by other people and the world.
Steps:
1. Read the module.
2. Identify safety stuck points (for example "I can't protect myself" or "Everyone is dangerous").
3. Complete Alternative Thoughts Worksheets that weigh realistic probability against possibility.
4. Discuss reasonable precautions as distinct from hypervigilance.
Example language (illustrative): "How many people have you passed on the street this month? How many hurt you? What does that say about 'everyone is dangerous'?"
Watch for: genuinely unsafe circumstances. Here, beliefs about danger may be accurate, and the work becomes realistic safety planning, not challenging the belief. [synthesis]

4.19 Trust module and the Trust Star (introduced in session 8, reviewed in session 9)

Purpose: trust in one's own judgment (self-trust), and trust in others as graded and domain-specific rather than all-or-none.
Steps:
1. Read the module.
2. Identify trust stuck points. Self-blame often shows up as "I can't trust my judgment".
3. Use the Trust Star Worksheet (Handout 14.1, example 14.1a). With a specific person in mind, the client separates different kinds of trust (for example trusting someone with secrets, with money, to be on time, to be emotionally supportive), showing that trust varies by area and is earned over time.
4. Discuss how to extend trust gradually and test it. [uncertain: the Trust Star's exact layout is not given; the description follows CPT training materials]
Example language (illustrative): "Your friend is late for everything. Would you still trust her with something private? So trust isn't one switch, is it?"
Watch for: betrayal trauma where the person really was untrustworthy. Validate that, and work on generalisation to everyone else.

4.20 Power/Control module (introduced in session 9, reviewed in session 10)

Purpose: beliefs about control over oneself (emotions, outcomes) and over others or events. These often swing between helplessness and over-control.
Steps:
1. Read the module.
2. Identify stuck points (for example "If I'm not in control of everything, something terrible will happen" or "I have no control over my life").
3. Complete Alternative Thoughts Worksheets that separate what can be influenced from what cannot.
4. Discuss anger, and assertiveness as opposed to aggression or passivity, where relevant. [uncertain: the module's specific subtopics]
Example language (illustrative): "What parts of that situation could you actually influence, and which were never in anyone's control?"
Watch for: an over-controlling style showing up in therapy itself, such as rigid scheduling or refusing assignments. Explore it as a theme stuck point.

4.21 Esteem module and giving/receiving compliments and doing something nice for oneself (introduced in session 10, reviewed in session 11)

Purpose: beliefs about one's own worth ("I'm damaged, broken, worthless") and about others' worth (cynicism, contempt). Behavioural assignments test these beliefs.
Steps:
1. Read the module.
2. Identify esteem stuck points and complete worksheets on them.
3. Assign the Tracking Sheet (Handout 15.2). Each day, the client gives and receives at least one compliment (accepting it with a simple thanks rather than deflecting) and does one nice thing for themselves without having to earn it.
4. In session 11, review the experience and the stuck points it triggered.
Example language (illustrative): "When someone compliments you this week, the only job is to say 'thank you' and notice what goes through your mind."
Watch for: "I don't deserve it." That is an esteem stuck point; put it on a worksheet. Watch also for clients picking "nice things" that are really chores.

4.22 Intimacy module (introduced in session 11, reviewed in session 12)

Purpose: self-intimacy (the ability to soothe and comfort oneself and to be alone without distress) and intimacy with others (emotional and physical closeness).
Steps:
1. Read the module.
2. Identify stuck points (for example "If I let anyone close, I'll be hurt", or reliance on food, alcohol or work to self-soothe).
3. Complete Alternative Thoughts Worksheets.
4. Where relevant, discuss sexual intimacy after sexual trauma.
Example language (illustrative): "When you're upset and alone, what do you do to comfort yourself? What does that tell you about what you believe you can handle?"
Watch for: self-soothing through substances or self-harm. Address it directly and add safety planning (Section 5).

4.23 Final Impact Statement and comparison (assigned in session 11, reviewed in session 12)

Purpose: shows the change in beliefs and consolidates it.
Steps:
1. Assign a new statement on what the client now thinks about why the trauma happened, and about the five themes.
2. In session 12, the client reads the new statement aloud.
3. The therapist then reads the original Impact Statement aloud (or the client does).
4. Discuss the differences, and identify stuck points that remain.
Example language (illustrative): "Listen to what you wrote twelve weeks ago. What's different about how you see it now?"
Watch for: stuck points that still remain. Name them as the targets for ongoing self-practice.

4.24 Reviewing progress, future goals and aftercare (session 12; termination discussed from session 10)

Purpose: consolidation and relapse prevention, with the client acting as their own therapist.
Steps:
1. Review the symptom score trajectory.
2. Review the skills learned and which worksheets helped most.
3. Set goals for the future, including behavioural ones such as re-engaging with avoided activities and relationships.
4. Plan to keep using Alternative Thoughts Worksheets when stuck points flare, for example around anniversaries.
5. Arrange aftercare or booster sessions as needed. [source: TOC ch. 17 "A Note on Aftercare"]
Example language (illustrative): "If you notice the old thought 'it was my fault' creeping back next year, what will you do?"
Watch for: fear of ending. Treat it as a stuck point (for example "I can't cope without therapy").

4.25 Practice assignments and the end-of-session reaction check (every session)

Purpose: ensures between-session practice and catches avoidance or rupture early.
Steps:
1. Give a written practice assignment sheet each session (Handouts 6.2, 7.5, 8.1, 9.4, 10.2, 11.2, 12.2, 13.2, 14.3, 15.3, 16.2).
2. Agree when and where the client will do it.
3. At the end, ask how the session felt, what was hard, and whether anything might get in the way.
Example language (illustrative): "What was it like to talk about that today? Is there anything that might make it hard to do the worksheets this week?"
Watch for: a vague plan ("I'll try"). Get specifics.

4.26 Variant: written trauma account (CPT+A)

Purpose / when: an optional addition for clients who prefer it, or whose memory is fragmented or highly avoided. The 2nd edition gives separate practice assignments for it (Handout 18.1). Research comparing the versions found similar outcomes, with faster symptom reduction without the account. [source: Deployment Psychology; TOC ch. 18]
Steps (as in the trial protocol; the 2nd edition's timing may differ [uncertain]):
1. After session 3, the client handwrites a full account of the worst event at home. It is written in the first person, as if happening now, with sensory details, thoughts and feelings. The client stops and draws a line if overwhelmed, then resumes, and reads the account to themselves daily. [uncertain: the past- versus present-tense instruction differs between sources; the NCT protocol excerpt states past tense]
2. In session 4, the client reads it aloud while the therapist does not interrupt.
3. The therapist then asks about emotions felt during writing and reading, missing details, and "stuck" places, and challenges blame and hindsight bias.
4. The client rewrites the account, adding detail and the current thoughts and feelings in brackets, and reads it in session 5. A different trauma may be written next if needed.
5. Thereafter, follow the standard sequence. [source: NCT01928732; Zalta et al. 2018]
Consent and safety: explain the rationale, that distress is expected and temporary, and that the client can pace the writing. Make sure there is support available. Check for dissociation and substance use as ways of coping.
Example language (illustrative): "When you read it, I'll just listen. Afterwards we'll talk about what you felt and which spots feel most stuck."
Watch for: writing an account like a police report with no feelings, or skipping the worst moment (the "hot spot"). Ask what was left out.

4.27 Variant: personalized-length CPT

Purpose / when: tailor the number of sessions to response instead of using a fixed 12.
Steps:
1. Track the PCL-5 and PHQ-9 at every session.
2. If a good end state is reached early, the client may finish early: symptoms below the criteria, therapist and client agree, and the final Impact Statement is completed. If progress is slow, add sessions on the remaining stuck points. Trials used up to about 18 sessions. Trial protocols have also allowed 10–14 sessions. [source: NCT01928732 allows 10–14] [uncertain: the exact 2nd-edition score thresholds]
3. When finishing early, compress the remaining themes into fewer sessions, and still do the final Impact Statement and review.
Example language (illustrative): "Your scores have been in the low range for two weeks and you're handling stuck points on your own. Shall we plan to wrap up with the final impact statement next time?"
Watch for: early ending driven by avoidance rather than recovery. Check that scores and functioning agree.

4.28 Variant: group CPT (and CPT for sexual abuse)

Purpose / when: efficient delivery, and peer normalisation.
Steps:
1. Prescreen, and hold information sessions.
2. Set group rules, especially that no trauma details are shared in group.
3. Use 90–120-minute sessions with two co-leaders, following the same 12-session sequence.
4. Teach the group to do Socratic questioning of each other's stuck points.
5. In CPT+A groups, accounts are written but not read in group; emotions and stuck points from writing are processed together, or accounts are read in added individual sessions.
6. Aftercare groups are an option.
7. The manual also covers CPT for sexual abuse, a variant for adult survivors of childhood sexual abuse.
Example language (illustrative): "Let's help Sam with this one. What question could we ask about 'I should have known'?"
Watch for: members comparing traumas ("mine wasn't as bad"), and one member dominating. Watch also for vicarious distress from details that slip out. [source: Wikipedia; TOC ch. 19; Zalta et al. 2018 table]

4.29 Variants: intensive CPT, telehealth, and acute stress disorder

Intensive: daily individual CPT, often with group CPT and other components, over about 3 weeks. The example given is 15 daily individual sessions with parallel group sessions and three worksheets per day as practice. Plan coordination with community aftercare from week 3. [source: Zalta et al. 2018 table]
Telehealth: same protocol by video. Plan how worksheets are shared (screen share or photographed worksheets), and have a local emergency plan and the client's location confirmed each session. [source: TOC ch. 18] [synthesis: the logistics]
Acute stress disorder: the manual includes a chapter on CPT for ASD. [uncertain: the adaptations]

5. Handling problems

[The manual covers nonadherence (session 2), treatment-interfering behaviours and cognitions (ch. 4), therapist stuck points (ch. 5), midprotocol non-response (session 6) and special populations (ch. 20); source: Guilford 2nd ed. TOC. The chapter texts are not drawn on, so the concrete responses below are [synthesis] consistent with the CPT model unless a source is cited.]

Practice assignment not done.
1. Review it first anyway.
2. Ask what got in the way, and listen for avoidance or a stuck point ("it won't help", "I'll do it wrong").
3. Complete the assignment together in session. For an Impact Statement, have the client say aloud what the event means to them.
4. Reassign it, with a specific when and where. [source: TOC session 2 heading] [synthesis: the steps]
Chronic avoidance (cancellations, lateness, "nothing to talk about").
1. Name avoidance as the symptom that keeps PTSD going, and revisit the contract.
2. Map the costs of avoidance on an ABC.
3. Consider twice-weekly sessions to keep momentum. [synthesis]
Stuck on the index event (self-blame will not move).
1. Check that you are working on an assimilated stuck point, not an overaccommodated one.
2. Slow down and reconstruct the timeline: what was known, what options existed, how much time there was.
3. Use the Levels of Responsibility handout.
4. Ask what holding on to blame gives the client. It often preserves a sense of control ("if it was my fault, I can stop it happening again"). Treat that as a stuck point.
5. If you are arguing, stop and go back to clarifying questions. [synthesis]
Real perpetration or moral injury. Do not challenge accurate responsibility. Separate intention from outcome and context. Address over-generalised conclusions ("I'm a monster"), and allow natural guilt or grief. Explore values-based amends. [synthesis; the manual has a "Religion and Morality" section]
No change by midprotocol.
1. Re-examine the conceptualisation: is the core stuck point still unaddressed?
2. Is there ongoing avoidance or substance use?
3. Is the index trauma the right one?
4. Are worksheets being done mechanically?
5. Adjust, and consider personalized length. [source: TOC session 6 midprotocol assessment] [synthesis: the checklist]
Overwhelm, dissociation or very high distress in session.
1. Ground the client: orient to the room and the present, use feet on the floor, describe objects.
2. Shorten the stretch of dialogue, then resume. Treat distress as expected and temporary rather than a sign to stop.
3. Teach brief grounding before practice. Lower the demand (for example the Simplified worksheets) rather than dropping trauma focus. [synthesis]
Ruptures (client feels blamed, challenged or misunderstood).
1. Notice withdrawal or irritation, and ask about it directly.
2. Own your part, for example a question that sounded like an accusation.
3. Repair, and go back to a curious, collaborative tone.
4. Check whether your own stuck point ("they really are to blame", "they're too fragile") drove the moment, and take it to consultation. [source: TOC ch. 5 therapist stuck points] [synthesis: the steps]
Suicidal thoughts or self-harm.
1. Assess current risk with standard structured practice: ideation, intent, plan, preparatory behaviour, history, protective factors.
2. Write a safety plan with warning signs, coping steps, contacts and crisis lines.
3. Do lethal-means counselling (secure storage or removal, with family or a trusted person holding means).
4. If risk is imminent, pause the protocol for crisis management. Otherwise continue CPT, because PTSD-related stuck points ("I don't deserve to live") are themselves targets.
5. Review risk at each session. [synthesis, following standard risk-assessment practice]
Ongoing danger (for example a current abusive relationship) or ongoing threat at work. A belief about danger may be accurate. Shift to safety planning and appropriate referrals. Focus CPT on beliefs that are inaccurate (for example self-blame for the past assault), and judge each belief on its accuracy, not its emotional comfort. [synthesis]
Substance use. Discuss it as avoidance. Agree not to come to sessions intoxicated. Track use, and treat co-occurring substance use alongside CPT rather than requiring abstinence first, unless use prevents meaningful participation. [uncertain: the manual's position on pretreatment] [synthesis]
Literacy, cognitive impairment or brain injury. Use the Visual ABC and the Outline or Simplified Alternative Thoughts Worksheets. Add memory aids (phone reminders, completing the first one together), slow the pace, and consider extra sessions. [source: TOC Appendix B; ch. 20 "Clients with Cognitive Impairments and Disabilities"] [synthesis: the aids]
Multiple or childhood traumas. Start with the worst or most representative index event. Stuck points often generalise across events, so later worksheets can address other traumas. CPT for sexual abuse is the specific group variant. [source: TOC ch. 19–20] [synthesis: the sequencing]
PTSD complicated by grief. Separate natural grief (to be felt) from manufactured guilt (for example survivor guilt or "I should have saved them"). Use worksheets on undoing beliefs. [source: TOC ch. 20 heading] [synthesis: the approach]
Client wants to tell the whole story in detail (in standard CPT). Allow a brief account where needed. Explain that change comes from examining meaning, and offer CPT+A if the client strongly prefers a written account. [synthesis]
Over-positive or "right answer" alternative thoughts. Ask how much they believe it (0–100). Low belief means the stuck point has not been examined yet, so go back to the Exploring Questions. [synthesis]
Group-specific problems. Redirect trauma details to individual time. Name comparison ("my trauma isn't as bad") as a stuck point. Have co-leaders split roles between leading the content and monitoring the group process. [synthesis]
Early improvement and a wish to stop. Check scores against functioning. If criteria are met, finish with the final Impact Statement (personalized length). If not, explore whether the wish to stop is avoidance. [synthesis]

Sources

Sources:

Attempted but not readable: the CPT+A session summaries for the 2nd edition (cptforptsd.com, .docx, binary), and the cptforptsd.com resources page and impactce.com course page (access not granted).

Books and manuals cited (not drawn on in full):

Resick, P. A., Monson, C. M., & Chard, K. M. (2024). Cognitive Processing Therapy for PTSD: A Comprehensive Therapist Manual (2nd ed.). Guilford Press. This is the version followed.
Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Press.
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive Processing Therapy: Veteran/Military Version: Therapist's Manual. Department of Veterans Affairs.
Resick, P. A., & Schnicke, M. K. (1993). Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Sage.
Resick, P. A., Galovski, T. E., et al. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 76, 243–258. Cited via Deployment Psychology.
Resick, P. A., Stirman, S. W., & LoSavio, S. T. (2023). Getting Unstuck from PTSD. Guilford Press. A client workbook, not drawn on.

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