Beyond PTSD: The Transdiagnostic Potential of Cognitive Processing Therapy

Apr 20 / Dr. Candice Monson, C. Psych
For decades, Cognitive Processing Therapy (CPT; Resick, Monson & Chard, 2024) has stood as one of the most effective, well-researched treatments for posttraumatic stress disorder (PTSD). Its evidence base is robust. Its mechanisms have been documented. Its impact can be life-changing. What is becoming clear in clinical practice and research is that CPT is being administered for conditions beyond PTSD, including subthreshold PTSD, experiences that clients described as traumatic but don’t meet diagnostic criterion for a traumatic stressor, adjustment disorders, and PTSD comorbid with a range of conditions and problems (e.g., moral injury, addictions, pain, depression, general anxiety, anger, criminal recidivism).So, you might wonder: Why does CPT seem to have broader-range effects on mental health and psychosocial functioning? How might we use the theory underlying CPT and the structure of the protocol to treat conditions beyond PTSD?

Why does CPT Work Beyond PTSD?

One important place to start in understanding why CPT works for a range of problems is that trauma is a transtheoretical risk factor for all kinds of mental and physical health problems - substance misuse, depression, personality disorders, first episode psychosis….Although we think of PTSD as the mantlepiece disorder when it comes to traumatic experiences, many mental health conditions include trauma as predisposing or precipitating factor. Next, traumatic experiences can lead to or disrupt cognitions, emotions, and behaviors that drive or maintain many conditions. Take for example, the thought “I can’t trust anyone”. This thought can fuel chronic low mood, general anxiety, social isolation, avoidance, loneliness, and psychosis. It may also indirectly lead to or exacerbate addictions, physical pain, aggression against others, self-harm, and other problematic behaviors. You might think of CPT as a well-packaged, trauma-focused treatment protocol tailored originally for PTSD and solidly grounded in cognitive theory of psychopathology and interventions for a range of mental health problems. In the case of PTSD, the cognitions about why a trauma happened (aka. trauma appraisals) and the consequences of trauma on core beliefs about the self, others, and the world more generally are specifically targeted. These same cognitions underlie other problems. At its core, CPT is not simply about trauma—it is about how people make meaning of difficult experiences and overcoming avoidance that prevents new learning. These processes are not unique to PTSD. They are central across a wide range of psychological disorders. In other words: CPT works because it targets mechanisms, not just diagnoses.

How To Think About CPT Beyond Treating PTSD

Posttraumatic Stress Symptoms: For years clinicians have been using CPT in studies and practice without making a diagnosis of PTSD. We base the appropriateness of using CPT on having a traumatic event meeting diagnostic criteria and a score above a clinical cut score on a self-report measure and/or clinician interview (especially in jurisdictions where treaters may not have diagnostic privileges).

Adjustment to Stressful or Client-defined Traumatic Events: I personally have used CPT in cases where people are adjusting to stressful events or client-described traumas that might not meet diagnostic criteria as a traumatic event but are nonetheless very distressing. An example of this in my current practice is a client who inadvertently discovered her partner having an affair with another person for many years. Another example in my practice is a client suddenly diagnosed with late-stage cancer. The principles of CPT still hold - feel your natural feelings, avoid avoidance, and shift problematic thinking to come to a realistic and balanced narrative that allows for adaptive emotions and behavior. You might think of this application of CPT as CPT for Adjustment Disorders.

Trauma-informed Cognitive Therapy: A third application of CPT is to think of it as a trauma-informed therapy for conditions that have a well-established history of being treated with cognitive therapy - mood disorders, anxiety disorders, substance use disorders, grief disorders, functional disorders, and anger problems. For clients with a history of trauma (self- or diagnostically-defined) and diagnosed with disorders other than PTSD, taking into account their history of trauma and its impact on cognition and behavior may facilitate treatment engagement and tackling Stuck Points that fuel the problems. To illustrate this use case, many clients with Substance Use Disorders have histories of trauma and many treatment centers seek to be “trauma-informed” in their service delivery. A client’s learning history, including traumatic experiences, influences their thinking about themselves, others, and the word more generally. Substance misuse is an avoidant coping strategy that relieves distress in the short-term but ultimately can lead to physiological and/or psychological dependence and maintains problematic thinking and emotions. With CPT, the clinician and client can mutually determine and work on Stuck Points that directly target substance misuse (disorder-specific cognitions) - “I can’t tolerate my stress if I don’t use,” “I won’t have fun if I don’t use,” “I won’t be able to stay sober.” In addition, cognitions that are indirectly related to substance misuse and influenced by trauma can be targeted to decrease the likelihood of misuse - “I am a loser,” “I am a broken person,” “I need to please people,” “People are ultimately out for themselves.” The goal in this application is to help the client identify thoughts influenced by traumatic or stressful experiences that are conceptualized to indirectly cause or contribute to the disorder, as well as thoughts directly related to the specific condition being treated.

Well-packaged Cognitive Therapy. Finally, consistent with the movement toward transdiagnostic conceptualizations of problems and treatments, CPT might be thought of as a well-packaged cognitive therapy for a range of disorders whether or not the client has a history of trauma. The CPT protocol is well laid out in terms of providing psychoeducation, the building blocks of any good cognitive-behavioral therapy, and topics that are germane to all kinds of conditions and problems (e.g., sense of safety, trust, control, esteem, intimacy).

Final Thought

Thinking of CPT as a transdiagnostic treatment is the next frontier for conceptualizing the whole person sitting in front of you in order to offer true trauma-focused or trauma-informed treatment for a range of conditions or for sticking to a well-packaged cognitive-behavioral treatment for the range of problems that clients face in your practice. Learning CPT can elevate your practice for PTSD and beyond.

Join Us: Transdiagnostic CPT Training

We are excited to be offering an upcoming training focused specifically on the transdiagnostic application of CPT. This is not a basic CPT training. It is designed for clinicians who want to:
Deepen their understanding of CPT mechanisms
Apply CPT flexibly across diagnostic presentations