The theoretical basis of CPT is cognitive theory, one of the most prominent theories explaining the onset and maintenance of PTSD. A predominant notion underlying cognitive theory of PTSD is that PTSD is a disorder of non-recovery from a traumatic event (Resick et al. 2008b). Thus, PTSD is not a condition with a prodromal phase or one in which early signs and symptoms are observed. Rather, in the majority of cases, the widest variety and most severe symptoms of PTSD are experienced in the early days and weeks after exposure to the traumatic event has ended. With time, the majority of individuals who have been exposed to a traumatic event(s) will experience an abatement of PTSD symptoms, or a natural recovery from the trauma. In a substantial minority of cases, individuals will continue to experience symptoms consistent with a diagnosis of PTSD. In other words, for this minority of all trauma survivors, natural recovery from the trauma has been impeded.

According to cognitive trauma theory of PTSD, avoidance of thinking about the traumatic event, as well as problematic appraisals of the traumatic event when memories are faced, contributes to this non-recovery. More specifically, individuals who do not recover are believed to try to assimilate the traumatic event into previously held core beliefs that are comprised of positive or negative beliefs about the self, others, and the world. Assimilation serves as an attempt to construe the traumatic event in a way that makes it fit, or to be consistent, with these preexisting beliefs. A common example of assimilation in those with PTSD is just-world thinking, or the belief that good things happen to good people and bad things happen to bad people. In the case of traumatic events (i.e., bad things), the individual assumes that he/she did something bad that may have led to the event or that the event is punishment for something he/she may have done in the past. An example of this type of thinking by a sexual assault survivor: “If I just hadn’t been drunk that night (i.e., bad behavior), then I wouldn’t have been assaulted (i.e., bad consequence).” Another common type of assimilative thinking is hindsight bias, or evaluating the event based on information that is only known after the fact (Fischhoff 1975). We will see an example of hindsight bias later in our clinical case description. At its essence, assimilation is an effort to exert predictability and control over the traumatic event after the fact that paradoxically leaves the traumatized individual with unprocessed traumatic material that is perpetually reexperienced.

Another tenant of cognitive trauma theory is that problematic historical appraisals about traumatic events (i.e., assimilation) lead to, or seemingly confirm, overgeneralized maladaptive schemas and core beliefs about the self, others, and the world after traumatization. In other words, individuals over-accommodate their beliefs based on the traumatic experience. Over-accommodation involves the modification of existing schemas based on appraisals about the trauma, but these modifications in schemas are too severe and overgeneralized. A common example of over-accommodation is when a traumatized individual comes to believe, based on his/her appraisals of his/her trauma, that the world is a completely unsafe and unpredictable place when he/she previously believed that the world was relatively benign or at least that bad things would not happen to him/her. Alternatively, traumatized individuals may have preexisting negative schemas, usually a result of a history of prior traumatization or other negative life events, that others cannot be trusted or that they have no control over bad things happening to them. In these cases, traumatic experiences are construed as proof for the preexisting negative schemas. Borrowing from earlier work by McCann and Pearlman (1990), cognitive trauma theory identifies beliefs related to the self and others that are often over-accommodated and contribute to non-recovery. These beliefs are related to safety, trust, power/control, esteem, and intimacy. A strength of cognitive trauma theory of PTSD is that it accounts for varying preexisting beliefs in each area that may have been positive or negative based on the client’s prior trauma history. In CPT, assimilated and over-accommodated beliefs are labeled “stuck points,” describing thinking that interferes with natural recovery thereby keeping people “stuck” in PTSD. Stuck points are targeted in therapy.

According to cognitive trauma theory, clients must allow themselves to experience the natural emotions associated with the event that are typically avoided in the case of PTSD. Natural emotions are emotions that are considered to be hardwired and emanate directly from the traumatic event (perhaps sadness of loss of loved one during trauma, fear of the danger associated with the trauma, etc.). Natural emotions that have been suppressed or avoided contribute to ongoing PTSD symptoms. According to cognitive trauma theory, natural emotions do not perpetuate themselves and thereby, contrary to behavioral theories of PTSD (Foa and Kozak 1986), do not require systematic exposure to achieve habituation to them. The client is encouraged to approach and feel these natural emotions, which have a self-limiting course once they are allowed to be experienced.

In contrast, maladaptive misappraisals about the trauma in retrospect (i.e., assimilation), as well as current-day cognitions that have been disrupted (i.e., over-accommodation), are postulated to result in manufactured emotions. Manufactured emotions are the product of conscious appraisals about why the trauma occurred and the implications of those appraisals on here-and-now cognitions. In the case of a natural disaster survivor who believed that the outcomes of the disaster occurred because he/she or others did not do enough to protect himself/herself and his/her family (self or other blame), he/she is likely to feel ongoing guilt and/or anger and be distrustful of himself/herself or others. In this way, trauma-related appraisals are manufacturing ongoing negative emotions that will be maintained as long as he/she continues to think in this manner. The key to recovery with regard to manufactured emotions is to foster accommodation of the information about the traumatic event. In other words, clients are encouraged to change their minds enough to account for the event in a realistic manner without changing their minds too much resulting in overgeneralized and maladaptive beliefs.

CPT has historically been administered over 12 sessions in individual, group, or combined formats. The administration of CPT can be most briefly explained in terms of phases of treatment. During the pretreatment phase (Phase 1), the clinician will assess the presence of PTSD as well as consider the host of usual treatment priorities (suicidality, homicidality) and the presence of potentially interfering comorbid conditions such as current mania, psychosis, and substance dependence. Special challenges to treatment will be discussed later in this chapter. The next phase (Phase 2; sessions 1–3) consists of education regarding PTSD and the role of thoughts and emotions in accordance with cognitive theory described above. Phase 3 (sessions 4–5) consists of processing the actual traumatic event and allowing the client to engage with the trauma memory. The goals are the discovery of stuck points preventing the client’s recovery and the expression of natural affect associated with the trauma memory. In Phase 4 of treatment (sessions 6 and 7), the clinician uses Socratic questions to begin to aid the client in challenging stuck points. This process is complemented by clinical tools (a series of worksheets) that aid the client in implementing formal challenging of stuck points between sessions at home. Phase 5 (sessions 8–12) often marks the transition to a more specific focus on over-accommodated stuck points with individual sessions dedicated to the trauma themes of safety, trust, power and control, esteem, and intimacy. Phase 5 also includes “facing the future” and focuses on relapse prevention, specifically targeting stuck points that might interfere with the maintenance of therapeutic gains. The following provides an overview of a recent case in our clinic of a young woman treated for PTSD secondary to a home invasion. Although, with this client’s permission, this case depiction is based on true events, details have been altered to protect the identity of the client and those involved in the traumatic event.

Molly is a young woman who appeared in our clinic seeking assistance for distress she was experiencing following exposure to a traumatic event. She had recently moved to town to begin graduate training at a nearby university. She reported that she was trying to start a new life for herself and leave the past behind but, after a couple of months, realized that her distress actually seemed to be getting worse. We began the assessment process, typically a 2-h interview in which we take the time to hear the client’s story, conduct a thorough clinical interview, and assess any psychopathology. Molly described a difficult childhood history in which she was raised primarily by her grandfather, who was physically and emotionally abusive to her and her siblings. During the interview, Molly demonstrated pride at her life accomplishments, getting herself out of a very bad neighborhood (while some of her siblings succumbed to drug addiction, engaged in criminal activity, and suffered from other types of psychopathology) and eventually graduating from the police academy and taking a job on the force in a major city on the East coast. She served as a police officer for 4 years with excellent reviews and even an early recommendation for promotion.

Approximately 3 years into her job as a police officer, she left work one night and headed over to visit an old friend (Jack) who was in town visiting his grandmother and mother. When she arrived, Molly was delighted that Jack’s sister, Beth, had also come into town with her three kids to visit their uncle. The grandmother, mother, Beth, and kids went to bed and eventually Jack walked Molly to her car. At the curb, two hooded gunmen approached and demanded money. Molly and Jack did not have anything of value, so the gunmen forced them back into the home. They woke Jack’s mother, the grandmother, and Beth. The tension escalated and eventually Molly made the decision to physically charge at the gunman. Multiple shots were fired with Molly taking five bullets directly in the chest and upper body, Jack getting shot multiple times, and Beth being fatally wounded. During the interview, Molly sobbed, repeating over and over that if only she had not made her move, this would not have happened and Beth would be alive. Molly met full criteria for PTSD and major depression. The event had occurred 2 years ago.

We began a course of CPT. During session 1, the results of Molly’s diagnostic assessment were discussed with an emphasis on explaining the disorder of PTSD. In general, the goals of session 1 include gaining a thorough understanding of PTSD and why we believe (from a cognitive theory perspective) that some people develop the disorder. Our job in therapy was described as taking Molly’s trauma memory and “airing it out,” looking for places where interpretations about the actual event may not be entirely accurate (assimilation) and places where one might have drastically (and inaccurately) altered worldviews (over-accommodation). These inaccurate beliefs likely played a role in keeping Molly “stuck” in the recovery process. So we labeled such inaccurate beliefs as “stuck points.” Throughout the assessment and into session 1, the therapist offered the example of a possible trauma-related stuck point that she had heard Molly repeat several times, “If I had not attacked the gunman, Beth would be alive today.” In other words, Molly believed that Beth’s death had been her fault. The role of emotion was also discussed in session 1, and Molly was clearly able to assert that she avoided memories of this event and any feelings associated with the memory whenever possible, even to the extent of cutting off old relationships and moving out of town. Molly agreed that it would be helpful to spend some time thinking about the beliefs around why that night happened and the influence of those events on her current beliefs by writing an impact statement (CPT assignment 1) for session 2.

Through the course of reading her impact statement and expanding on the information therein, we accumulated more examples of assimilated stuck points and present-focused stuck points (over-accommodated beliefs). Molly blamed herself for nearly every aspect of the events that unfolded during the home invasion. Specifically, stuck points such as, “I should have given the gunmen the keys to my car and they never would have gone in the house,” “I should have fought them outside the house and never let them in,” “I should have gone to the back of the house with them and they would have left,” and “I never should have attacked them.” We also identified a number of over-accommodated stuck points demonstrating substantial shifts in the way Molly viewed herself, others, and the world since the traumatic event. “I am a failure,” “I am incompetent,” “The world is a dangerous place and I am unsafe in it,” “I cannot trust myself or my abilities,” and “I am not the person I thought I was.” We collected and recorded these on Molly’s stuck point log and talked through the relationship between these types of thoughts and the significant distress that they were causing her. She agreed to continue this process outside of session by recording events, thoughts, and feelings on ABC sheets (a worksheet used in CPT to aid clients in identifying thoughts that might lead to emotion as well as help the client to understand the relationship between thoughts and emotions) for session 3.

The use of Socratic dialogue to challenge stuck points is termed the “cornerstone of CPT practice” in the training workshops and manual. Session 3 most typically begins the start of this Socratic process by gently challenging the stuck points that most likely lie at the heart of PTSD. Although the extent of the challenging can differ across clients in session 3 (depending on how tightly they are holding onto the beliefs, defensiveness, emotional arousal, etc.), Molly responded very well to this process from the start despite significant distress and the firmly held conviction that she was at fault. She made significant advances on several assimilated stuck points during this session. The following discourse is an example of a section of this dialogue, starting about a third of the way into the session.