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Cognitive Processing Therapy for Sexual Assault Victims

Journal of Consulting and Clinical Psychology
Authors:
Patricia A Resick at Duke University Medical Center
Patricia A Resick
Monica K. Schnicke
Monica K. Schnicke
Monica K. Schnicke
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Abstract

Cognitive processing therapy (CPT) was developed to treat the symptoms of posttraumatic stress disorder (PTSD) in rape victims. CPT is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Nineteen sexual assault survivors received CPT, which consists of 12 weekly sessions in a group format. They were assessed at pretreatment, posttreatment, and 3- and 6-month follow-up. CPT subjects were compared with a 20-subject comparison sample, drawn from the same pool who waited for group therapy for at least 12 weeks. CPT subjects improved significantly from pre- to posttreatment on both PTSD and depression measures and maintained their improvement for 6 months. The comparison sample did not change from the pre- to the posttreatment assessment sessions.
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... Although CPT was originally developed for survivors of sexual assault with chronic PTSD (Resick & Schnicke, 1992;Resick 1993), research shows that it significantly reduces PTSD symptoms, depression and anxiety across populations with different trauma types such as veterans (Chard et al., 2012), survivors of interpersonal violence (Resick et al., 2008) and refugees (Bernardi et al., 2019). Studies reveal that CPT produces better PTSD outcomes compared to inactive or wait-listed control groups (Asmundson et al., 2019;Tran et al., 2016) and is as equally effective (or superior) to alternative treatments (Lenz et al., 2014;Resick et al., 2015; see also Resick et al., 2024, for an updated review of CPT outcomes). ...
... Although initially developed and first evaluated in group format (Resick & Schnicke, 1992), for many subsequent years CPT was most commonly evaluated across multiple RCTs in an individually delivered format, with 60-minute sessions delivered once or twice a week over the course of 12 sessions (Asmundson et al., 2019;Nixon et al., 2016). Even though CPT has proven effective in addressing PTSD, as with other PTSD therapies, considerable barriers remain for those seeking treatment. ...
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... Negative posttraumatic thought plays a critical role in the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). Cognitive models of PTSD describe how trauma can contribute to negative thought that maintains PTSD symptoms (Ehlers & Clark, 2000;Foa et al., 2006;Resick & Schnicke, 1992). For example, difficulty assimilating one's trauma with preexisting "just world" Several trauma-focused treatments for PTSD, including first-line interventions, were founded on cognitive theories (e.g., Cognitive Processing Therapy [CPT], Resick et al., 2017; Cognitive Therapy for PTSD; Ehlers et al., 2005). ...
Uncovering the Temporal Dynamics of Negative Thought in Posttraumatic Stress Disorder
Article
Full-text available
  • Apr 2025
  • COGNITIVE THER RES
Purpose Cognitive theory posits that negative posttraumatic thoughts play a critical role in the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). Though negative thought in PTSD is often measured using static, between-subjects, and cross-sectional assessments via retrospective self-report, recent approaches have investigated negative thought as a dynamic process that unfolds within people over time. Here, we examine the temporal dynamics of negative thought in daily life (i.e., variability, inertia, and reactivity) and whether these dynamics are associated with PTSD severity in trauma-exposed adults. Methods Participants with (n = 39) and without (n = 41) a current PTSD diagnosis completed three days of ecological momentary assessment (n = 2158 observations; Mobs = 27) assessing four subdomains of negative thoughts. Results Participants reported variability in negative thought over time, and that variability was explained by both situational and dispositional factors. Higher PTSD severity was associated with higher mean levels, more variability, and more reactivity in negative thought over time, but not negative thought inertia. Conclusions Findings suggest that negative thought is a dynamic process that exhibits short-term fluctuations and that the temporal dynamics of negative thought help characterize the cognitive experience of PTSD. Future work should incorporate ambulatory assessment and interventions to better understand and intervene on negative thought in PTSD.
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... CPT aims to identify and address cognitive distortions that are hypothesized to maintain PTSD symptoms. Treatment consists of 12 sessions focused on helping patients modify or challenge unhelpful trauma-related beliefs (Resick et al., 2017;Resick & Schnicke, 1992). For a full description of CPT, see Resick et al. (2002). ...
Assessing Implementation and Health Equity Determinants to Develop a Facilitation Plan for Varied Intensity Posttraumatic Stress Disorder (PTSD) Treatments in Minority-Serving Institutions
Article
Full-text available
  • Mar 2025
Though the implementation of science frameworks has recently been expanded to understand determinants of health equity (Woodward et al., 2021), the application of these frameworks in safety net hospital settings is new. We applied the health equity implementation framework to (a) understand the determinants of implementation and equity and (b) develop an institution-wide implementation facilitation plan for three evidence-based practices (EBPs) for posttraumatic stress disorder. We utilized researcher field notes from clinical case consultation gathered during posttraumatic stress disorder treatment implementation initiatives (cognitive processing therapy, written exposure therapy, brief skills training in affective and interpersonal regulation) at the same safety net hospital (N = 94 meetings total, from 2020 to 2023) to assess determinants of implementation and equity. We developed a qualitative codebook based on the health equity implementation framework to specify determinants and then built an implementation facilitation toolkit for multi-EBP implementation. Similar determinants were found across clinics and EBPs (e.g., provider training gaps and misperceptions about manualized treatments; inefficiencies in identification, triage, and referral pathways; patient engagement barriers related to stigma, literacy, and mistrust) with additional nuance per clinic and EBP. Institution-wide facilitation strategies were then utilized to enhance implementation and equity and focused on enhancing both access and quality of services (e.g., training and consultation, refining referral pathways) and patient engagement (e.g., culturally responsive training, consultation, and treatment delivery). Implementation science has an important role to play in enhancing health equity. Our findings illustrate how pooling determinants across clinics and treatments can help implementation scientists engage with hospital leadership and advocate for system-level implementation facilitation strategies.
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... 34 Additionally, one study found that schema therapy outperformed cognitive behavioral therapy for posttraumatic stress disorder (PTSD) and that changes in maladaptive schemas accounted for 26.3% of the variance in symptom reduction. 35 Notably, sexual trauma histories are associated with maladaptive self and sexuality schemas, 5,29,36 which have been associated with a range of psychosexual decrements. [37][38][39] As such, interventions that target improvement in maladaptive schemas (eg, schema-focused writing) may be particularly fruitful in leveraging improvement in psychological and sexual wellbeing. ...
Online expressive writing intervention for the psychosexual well-being of women with a history of childhood sexual abuse: a randomized clinical trial
Article
  • Mar 2025
  • J SEX MED
Background Sexual schema expressive writing that addresses nonconsensual sexual experiences has demonstrated initial support for improving psychosexual well-being for women with childhood sexual abuse (CSA) histories and is easily modifiable to an online modality for accessibility and scalability. Aim The current study aimed to assess the online efficacy of a 5-session sexual schema expressive writing intervention against a daily events writing condition and an assessment-only condition for women with CSA histories. Methods Women were initially randomized to 1 of the 2 active writing conditions (sexual schema, n = 73; daily events, n = 71); then, to minimize awareness of anticipated results, an assessment-only condition was recruited (n = 22). Outcomes were measured at baseline (T1), 3 weeks after baseline/posttreatment (T2), and at 1-month follow-up (T3). Additionally, participant-perceived change in sexual and psychological functioning across the course of the study was assessed at T2 and T3. Outcomes Outcomes included posttraumatic stress symptoms, sexual functioning, global self-esteem, and sexual self-concept. Results Mixed effects linear regression models controlling for participant age demonstrated significantly greater rates of change in sexual functioning and sexual self-concept for both active writing conditions (sexual schema and daily events) in comparison with the assessment-only condition, with no differences across conditions in posttraumatic stress symptoms or self-esteem. Furthermore, analyses of variance controlling for age indicated that women in the sexual schema writing condition reported significantly greater perceived change in sexual well-being and psychological well-being than the assessment-only condition, though the daily events writing condition reported significantly greater perceived change only in psychological well-being as compared with the assessment-only condition. Clinical Implications The current study provides evidence for the use of online modalities for expressive writing for women with CSA histories and supports the use of sexual schema writing paradigms for improving sexual well-being in this population. Strengths and Limitations The study is strengthened by its ecologically valid and diverse community sample and its rigorous multisession treatment protocol. The study is limited by being underpowered for some of its analyses. Additional research is needed on the daily events writing condition and ways to target more psychological outcomes in combination with sexual outcomes in online writing treatments. Conclusions Online expressive writing paradigms that allow for guided reflection and space on how individuals’ nonconsensual sexual experiences have affected their sexuality may be a fruitful strategy for many women to begin to achieve sexual recovery following sexual trauma.
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... Furthermore, evidence-based treatments for alcohol use, such as motivational interviewing (W. R. Miller & Rollnick, 2012), and PTSD, such as cognitive processing therapy (Resick & Schnicke, 1992) or prolonged exposure (Foa et al., 2008), do not specifically address anger despite high endorsement of anger in these treatment settings (Barrett et al., 2013;Orth & Wieland, 2006;Van Voorhees et al., 2021). Our results suggest that interventions to reduce anger difficulties may be beneficial for reducing the risk of violence. ...
Anger Mediates the Relationship Between Changes in Alcohol Use and Violence: A Longitudinal Examination Among Iraq/Afghanistan-Era Veterans
Article
Full-text available
  • Feb 2025
Objective: Interpersonal violence is a common barrier to reintegration into civilian life in post-9/11 veterans. Alcohol use and anger, also common among veterans, are both risk factors for violence. The present study used longitudinal data to examine relationships between these factors. Method: Post-9/11-era veterans (N = 302) were assessed via clinical interviews and self-report questionnaires at baseline, 6 months, and 12 months on alcohol use, anger, violence, and posttraumatic stress disorder (PTSD) symptom severity. Multilevel structural modeling was used to compare two different mediation models across the three waves of data. Results: The indirect effect of changes in alcohol use on violence via changes in anger was significant (p = .046). When covarying for PTSD symptom severity, the effects of Path A and Path B were consistent; however, the indirect effect between alcohol use and violence was no longer significant (p = .076). The indirect effect of changes in anger on violence via changes in alcohol use was not significant (p = .074). Conclusions: Alcohol use, anger, and violence are variables closely influencing one another. The association between changes in anger and subsequent violence was not mediated by changes in alcohol use. The association between changes in alcohol use and subsequent violence was mediated by changes in anger; however, this mediating effect disappeared when controlling for PTSD severity. These findings shed light on the importance of anger and PTSD as contributors to the relationship between alcohol use and violence. They suggest that assessing and treating anger may reduce violence among veterans with problematic alcohol use.
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... CPT is an evidenced-based, manualized 12-session therapy for the treatment of PTSD (Resick et al., 2017). Building on established cognitive theory, the authors of CPT suggest that when an individual experiences a traumatic event, they may struggle to reconcile the event with their preexisting beliefs about the world (e.g., "If I do the right thing, nothing bad will happen to me") (Resick & Schnicke, 1992, 1993Resick et al., 2017). When this occurs, two subsequent cognitive processes may take place: assimilation and accommodation. ...
The intersection of trauma and eating disorders: evaluating cognitive processing therapy through qualitative analysis
Article
  • Feb 2025
  • Eat Disord
Quantitative research has demonstrated that many individuals with eating disorders (EDs) present with PTSD (ED-PTSD). Cognitive processing therapy (CPT) has been integrated into the overall treatment for ED-PTSD, but qualitative data on the effectiveness of this approach is lacking. Ten patients with ED-PTSD completed 12 sessions of CPT during residential treatment (RT). After sessions 1 and 11, patients wrote an "impact statement" clarifying their beliefs about why their trauma occurred and how it has impacted their life. Two coders using MAXQDA2020 software evaluated these statements using a structured coding protocol to assess changes in trauma-related cognitions over time. Analyses of these cognitive changes demonstrated shifts in the appraisal process regarding why trauma occurred from stances of self-blame to external fault. Exploratory analyses also indicated that perceptions of control and safety were associated with a greater frequency of reference to EDs and body image. Qualitative findings demonstrated that trauma-related cognitions became more realistic and adaptive following CPT as evidenced by a significant reduction in assimilated and overaccommodated cognitions, and an increase in accommodated cognitions. Last, there was a notable shift in perceived responsibility for trauma and improvements in control and safety in relation to EDs.
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... In our study, sessions 1-4 include client history, problem behaviors, and emergency procedures (Bohus et al., 2019). Sessions 5-16 include the original core CPT sessions using the cognitive-only version described by Resick and Schnicke (1992). In subsequent sessions, the client writes a statement about why the worst event happened and how it has affected her life, as well as beliefs about safety, trust, control/ power, self-esteem, and intimacy. ...
Is dissociation predicting the efficacy of psychological therapies for PTSD? Results from a randomized controlled trial comparing Dialectical Behavior Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT)
Article
Full-text available
  • Feb 2025
  • PSYCHOL MED
Background Neuropsychological evidence suggests that dissociation might disturb emotional learning, which is a fundamental mechanism of psychotherapy. However, a recent meta-analysis on the impact of dissociation on treatment outcomes in psychotherapy trials for posttraumatic stress disorder (PTSD) reported inconsistent results and concluded that further high-quality clinical trials are needed to test whether dissociation affects the efficacy of psychotherapies. We had two main aims: First, to test whether the efficacy of two evidence-based psychotherapies for individuals with trauma-related PTSD is affected by the level of pretreatment dissociation. Second, we investigated whether a significant reduction in dissociation at an early stage of treatment is beneficial for subsequent efficacy. Methods The potential impact of dissociation on efficacy was studied in 193 women with PTSD related to childhood abuse who were randomized to dialectical behavior therapy for PTSD (DBT-PTSD) or cognitive processing therapy (CPT). Efficacy was operationalized as a change in the Clinician-Administered PTSD Scale (CAPS). Dissociation was assessed with the Dissociation Tension Scale (DSS). The analyses accounted for major confounders (in particular initial PTSD severity). Results Two main findings emerged from this study. First, baseline dissociation was a negative predictor for treatment efficacy. Second, a significant drop in dissociation at the initial stages of treatment was beneficial for subsequent efficacy. Conclusions Dissociation likely reduces the efficacy of trauma-focused therapies. Accordingly, successful reduction of dissociation at an early stage of treatment assists the efficacy of trauma-focused psychotherapies.
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Twenty-Five Years of Empirical Research on Treatment Following Sexual Assault
Article
  • Jul 2007
In the United States, rape is a frequent and devastating occurrence. Survivors experience numerous social, medical, and psychological difficulties, including post-traumatic stress disorder. This article reviews the empirical research on interventions following sexual assault, identifies gaps in the research, and considers future directions for research and practice. Searches of PsycINFO and Social Work Abstracts were conducted for peer-reviewed articles published between 1980 and summer 2005. Keywords used were “rape” or “sexual assault,” and “treatment,” “intervention,” or “therapy.” Reference lists were searched for additional articles. Most of the published articles presented here report positive results. However, the strength, quality, and relative efficacy of the research beg further analysis. Given the strength of accumulated evidence, rape crisis centers and social workers would be well advised to consider exposure and cognitive behavioral interventions when presented with a rape survivor.
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The compilation of an educational package to improve the psychological status of kids of Shahed and veterans’ families and compare its efficacy with cognitive processing therapy on distress tolerance and cognitive regulation of their emotions
Article
Full-text available
  • Sep 2021
Aim: This study aimed at compiling an educational package to improve the psychological status of kids of families of shahed and veterans and compare its efficacy with cognitive processing therapy on distress tolerance and cognitive regulation of their emotions. Method: The research method was a combinative type of exploratory-sequential approach design and contained two qualitative and quantitative dimensions. The qualitative part aimed to determine the content, structure, and final form of the educational package to enhance the psychological status of the kids of families of shahed and veterans based on their life experiences. The qualitative approach has been used to compile an educational package to improve the psychological status of the kids of shahed and veterans, and the quantitative approach has been used to compare its efficacy with cognitive processing therapy. And a quasi-experimental method with a pre-test-post-test design and a control group and two months of follow-up was used in this study. In addition to scientific texts, the statistical population of the qualitative part of the research included all the kids of families of shahed and veterans of Yasuj city that were studying in Shahid high schools and Yasuj University during the academic year 2018-2019. The statistical population of the quantitative part consisted of all the kids of the shahed and veterans’ families of Yasuj city. The sampling of the qualitative part was conducted purposefully, and 15 people were interviewed with a semi-structured interview to achieve theoretical saturation. In the quantitative part, the purposive sampling method was used to select 45 kids of shahed and veterans’ families of Yasuj city, and they were randomly assigned to three groups of the first experimental group (15 people), the second experimental group (15 people), and control group (15 people). The first experimental group received a researcher-made educational package to improve the psychological state at eight weeks, and the second experimental group was treated with the cognitive processing therapy of Resick et al. (2007) in twelve weeks of 90 minutes. The research instruments included the Cognitive Emotion Regulation Questionnaire of Garnefski et al. (2002) and the Distress Tolerance Scale of Simons & Gaher (2005). The qualitative data were analyzed by the Phenomenology method and the approach highlighted by Colaizzi, and quantitative data were analyzed by repeated-measures analysis of variance and Tukey post hoc test. Results: The content of the package to improve the psychological status of the kids of families of shahed and veterans includes four main concepts: training to cope with grief and loss, coping and overcoming suffering, expanding social support, purposeful adaptation to circumstances, and situations. Also, the validity of the educational package was reported at 0.87. The results of the quantitative part indicated that the two groups of the educational package to improve the psychological status of kids of the shahed and veterans and cognitive processing therapy were effective on cognitive emotion regulation (F = 3.64, P = 0.035), and distress tolerance (F = 8.70, P = 0.001), and this effect was constant in the follow-up stage. Furthermore, according to the results of the Tukey post hoc test, there was no significant difference between the two experimental groups (P < 0.05). Conclusion: as the educational package of improving the psychological status and the treatment of cognitive processing promote distress tolerance and cognitive regulation of emotion, therefore it is concluded that they can be used to improve distress tolerance and cognitive emotion regulation among kids of the shahed and veterans’ families.
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Attributional Style and Combat-Related Posttraumatic Stress Disorder
Article
Full-text available
  • Aug 1988
This study examined the relations of attributions for good and bad events on the one hand and combat-related posttraumatic stress disorder (PTSD) on the other. The sample consisted of 262 Israeli soldiers who suffered a combat stress reaction episode during the 1982 Lebanon War and were followed 2 and 3 years after their participation in combat. Cross-sectional analyses revealed significant relations between attributions and PTSD at the two points of assessment. Changes in PTSD from Time 1 to Time 2 were also associated with changes in attribution. Theoretical and clinical implications of the findings are discussed.
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Psychophysiologic Responses to Combat Imagery of Vietnam Veterans With Posttraumatic Stress Disorder Versus Other Anxiety Disorders
Article
Full-text available
  • Feb 1990
We used psychophysiologic techniques to assess responses to imagery of psychologically stressful past experiences in medication-free Vietnam combat veterans classified, on the basis of DSM-III-R criteria into posttraumatic stress disorder (PTSD; n = 7) or non-PTSD anxiety disorder (anxious; n = 7) groups. Scripts describing each individual's combat experiences were recorded and played back in the laboratory. Ss were instructed to imagine the events the scripts portrayed while heart rate, skin conductance, and frontalis electromyogram were recorded. PTSD Ss' physiologic responses were higher than those of anxious Ss. A discriminant function derived from a previous study of PTSD and mentally healthy combat veterans identified 5 of the 7 current PTSD Ss as physiologic responders and all 7 of the anxious Ss as nonresponders. Results of this study replicate and extend results of the previous study and support the validity of PTSD as a separate diagnostic entity.
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Treating Symptoms in Adult Victims of Sexual Assault
Article
Full-text available
This article reviews the prevalent theories and treatments regarding symptoms which may follow in the wake of sexual assault. Crisis theory and intervention are addressed first, followed by a description and discussion of cognitive and behavioral treatments for PTSD, depression, and sexual dysfunctions. Among the treatments considered are exposure techniques, coping skills packages, and cognitive therapy. The article concludes with a description of information processing theory and a discussion of future directions in the field.
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Concurrent Validity of a Crime-Related Post-Traumatic Stress Disorder Scale for Women within the Symptom Checklist-90-Revised
Article
  • Jan 1991
  • Violence Vict
Using a structured interview to obtain a lifetime history of criminal victimization, a community sample of 266 adult women who had experienced at least one incident of victimization was identified. These women were administered the Symptom Checklist-90-Revised, the Impact of Event Scale, and a structured clinical interview was used to identify Crime-Related Post-Traumatic Stress Disorder (CR-PTSD). A recently derived scale based on responses to items on the SCL-90-R was compared to the IES for predicting current diagnosis of Crime-Related Post-Traumatic Disorder. Both the scale and the IES were found to improve prediction of CR-PTSD above base rates and to perform in a similar manner. The utility of each of these scales as a screening measure is discussed.
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Criminal Victimization: Lifetime Prevalence, Reporting to Police, and Psychological Impact
Article
  • Oct 1987
  • CRIME DELINQUENCY
A sample of 391 adult females were interviewed about lifetime criminal victimization experiences, crime reporting, and psychological impact. In total, 75% of the sample (n = 295) had been victimized by crime, and 41.4% of all crimes were reported to the police. Reporting rates differed by crime type. Burglary had the highest reporting rate (82.4%); and sexual assault the lowest (7.1%). Of all crime victims, 27.8% subsequently developed posttraumatic stress disorder (PTSD). Major implications are the following: Prevalence rates are extremely high and reporting rates are low. The prevalence of PTSD indicates that crime has both an immediate and long-term psychological impact. Suggestions for improved victim services are discussed.
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Perceptions of Vulnerability to Victimization
Article
  • Jul 1983
  • J SOC ISSUES
Individuals who have not been victimized by negative life events, such as serious illness, accidents, or crime, tend to perceive themselves as “uniquely invulnerable,” as less vulnerable to victimization than others. The actual experience of victimization, however, appears to shatter this illusion of invulnerability, creating in victims a new and unfamiliar sense of vulnerability often accompanied by psychological distress. This article reviews literature documenting nonvictims' perceptions of unique invulnerability and victims' heightened perceptions of vulnerability, and addresses the potentially adaptive versus maladaptive consequences of these perceptions. It is argued that victims who have the most difficulty coping with their misfortune may be precisely those individuals who initially felt least vulnerable prior to being victimized. Therefore, how victims cope may depend in part on their prior beliefs about risk. In addition, a distinction is made between victims who feel “uniquely vulnerable” (more vulnerable than others) and those who feel “universally vulnerable” (equally vulnerable as others) to future misfortune. It is proposed that perceptions of universal vulnerability may be a more adaptive reaction to victimization than are perceptions of unique vulnerability.
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Trauma and Victimization: A Model of Psychological Adaptation
Article
  • Oct 1988
  • COUNS PSYCHOL
The topics of victimization and traumatic stress have become focal issues within the last two decades. This article synthesizes theoretical and empirical findings about psychological responses to traumatization across survivors of rape, childhood sexual or physical abuse, domestic violence, crime, disasters, and the Vietnam war. Five major categories of response, emotional, cognitive, biological, behavioral, and interpersonal, are described. Based on these findings, the authors present a new theoretical model for understanding individual variations in victim responses. In this model, they propose a complex relation among traumatic experiences, cognitive schemas within the areas of safety, trust, power, esteem, and intimacy, and psychological adaptation. Implications for assessment, treatment intervention, and further research within the area of traumatic stress are discussed.
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