Trauma Therapy Options: CPT vs. Prolonged Exposure

Understand two evidence‑based trauma therapies, how they differ, and how to choose what fits your situation.

When it comes to trauma, there is not one typical, expected, or appropriate response. Due to the unique nature of every human being, two people can experience the exact same event and may emerge very differently from one another. This attests to the unique process by which some people develop PTSD while others do not. There are a host of factors that beget this diagnosis in approximately 4% of the worldwide population. Conversely a plethora of reasons may explain why the majority of people who undergo a traumatic event do not go on to carry this diagnosis, again highlighting the individualized response to traumatic events. There are a variety of evidence-based treatment modalities used by therapists to treat clients with PTSD, and treatment success is highly dependent on the fit of a treatment for the case at hand. Being equipped with the knowledge to understand the differences between various evidence-based trauma therapies in order to choose what fits best is imperative. For the purpose of this post, we will dive more deeply into Cognitive Processing Therapy and Prolonged Exposure, both of which fall under the wide umbrella of cognitive behavioral therapies. These interventions, though slightly different in their approach, have been researched heavily in a variety of populations, and are demonstrably effective.

Cognitive Processing Therapy (CPT) has been demonstrated to be effective in treating PTSD symptoms following trauma exposure. It is typically delivered over the course of 12 sessions by assisting clients in challenging and adapting unhelpful beliefs about the trauma they endured. The goal of this treatment is for the client to reprocess their trauma by identifying immediate thoughts that lead to the formation of unhelpful beliefs, also called “Stuck Points”, and to reprocess experiences to form more adaptive and helpful beliefs. CPT starts with psychoeducation around PTSD, thoughts, and emotions in order for the client to begin to be more aware of their automatic thoughts that perpetuate the symptoms of PTSD that they experience. Clients focus first on their beliefs about why the trauma happened and how it influenced their beliefs about themselves, others, and the world at large. From there, the client will begin to process their trauma in a structured way. They will be tasked with physically writing down their account of the worst traumatic experience they have had and subsequently will read it to the therapist who will utilize socratic questioning to identify and challenge their unhelpful thoughts and beliefs. They will take the skills they have developed throughout this process and be able to apply their newly developed beliefs in a variety of contexts throughout their life.  

Prolonged Exposure (PE) is another evidence-based trauma therapy, and has also been researched specifically in conjunction with Dialectic Behavior Therapy (DBT). In PE, therapists gradually introduce clients to their trauma memories, feelings, and situations and reframe the way they think about them and respond to them. Rather than continuing to avoid reminders of the trauma, which people with PTSD often do, therapists using PE work with clients to face their fear head-on with the objective of decreasing PTSD symptoms by way of relearning that cues which were connected to trauma are not dangerous. PE unfolds over the course of 8-15 sessions that can run from 60-120 minutes. This modality of treatment begins with psychoeducation and learning breathing techniques designed to combat anxiety that arises with exposures. Therapists cultivate a warm, safe environment in which clients can feel comfortable encountering their most feared stimuli. The exposures occur in two ways: imaginal exposure and in vivo exposure. Imaginal exposures occur within the therapeutic setting when the client details their traumatic event and, together with the therapist, processes their reaction to reliving their trauma. This sequence is recorded so that the client can listen to it outside of sessions and continue to process their emotions and utilize the breathing techniques. In vivo exposure, on the other hand, can also happen outside of therapy. Clients and therapists collaborate to create a treatment hierarchy, a list of potentially triggering places and people and rank them in order of least distressing to most. The client then works their way up the fear hierarchy between sessions with the ultimate goal of encountering their most feared situation with the ability to endure and employ breathing techniques when necessary. 

Both CPT and PE are “gold standard”, first line treatments for PTSD. The idea of directly bringing up our thoughts and feelings may sound overwhelming, and these treatments are intended to unfold gradually, at a pace that feels comfortable and manageable for the client. These are short term interventions, designed to move clients forward rather than keeping them in treatment long term. Both of these treatments have been researched thoroughly, and there is significant evidence that they are effective both in the short-term and in the long-term. Whichever treatment you choose, taking the time to look closer and figure out which makes sense for you is an important step in getting the best possible evidence-based treatment.