Staff Voices: To PE or CPT…that is the question

Staff Voices: To PE or CPT…that is the question

By Dr. Holly O'Reilly

As I work with clinicians who are trained in evidence-based treatments for PTSD, one query is raised repeatedly…Should I use Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) to treat patient X?

PTSD is one of the signature disorders of the OIF/OEF conflict. PTSD is characterized by symptoms of re-experiencing, avoidance/numbing and hyperarousal. As many as 20% of the US service members returning from Iraq or Afghanistan since 2001 may have PTSD ( We may safely assume that a significant number of veterans from the current conflict and other eras will need effective treatment to alleviate PTSD symptoms. Let’s review…

The past few decades of intense scrutiny of post-traumatic response has lead us to several conclusions.  First, several cognitive-behavioral treatments for PTSD have been developed and empirically examined. Second, we know that any of the cognitive-behavioral treatments for PTSD are more likely to alleviate PTSD symptoms than purely supportive psychotherapy. Third, as we review the PTSD treatment research, two treatments in particular stand out as they have been researched extensively, have utilized gold-standard practices and have demonstrated efficacy in long-term outcome studies. PE and CPT are the most studied cognitive-behavioral treatments for PTSD, but clinicians struggle with the decision to use one over the other. Today I would like to briefly summarize each and review some factors to consider when choosing to treat patients.

CPT is a 12-session manualized treatment for PTSD focused on using cognitive-restructuring techniques to identify and correct erroneous beliefs (i.e., assimilated and over-accommodated self-statements) called “stuck points.” CPT uses socratic methods to challenge these beliefs and focuses on themes of safety, trust, power and control, esteem and intimacy. CPT also uses homework assignments to allow the patient to practice these new skills which are reflective of new, adaptive beliefs.  CPT includes a written trauma account allowing for some exposure component within CPT whereas CPT-C does not include a written account and has comparable efficacy to CPT and PE.

PE is a 10-session manualized treatment which focuses on both in-vivo and imaginal exposure to the trauma memory and subsequent habituation. This treatment notes that repeated activation of the trauma memory allows the patient to incorporate new, corrective information about the self and world. Additionally, homework assignments allow the patient to face safe situations which were previously determined to be dangerous based upon erroneous post-traumatic beliefs.

As cognitive-behavioral treatments, PE and CPT share some common ground. Both treatments incorporate symptom assessment throughout treatment and have detailed agendas to guide therapy session by session through a relatively brief protocol. Each protocol provides psychoeducation on trauma reactions, provides a treatment rationale, and requires homework following each session to practice new skills. In fact, many would argue that there is some cognitive restructuring in PE and some exposure in CPT. However it should be noted, that CPT-C (without written trauma account) has been shown to be comparably effective.

As research has yet to determine guidelines for choosing CPT vs. PE, let’s consider some of the factors clinicians may consider which choosing to use CPT or PE with patients…

  • Long term efficacy – Both treatments have demonstrated significant PTSD symptom reduction five years post-treatment.
  • Trauma type – Some clinicians note a preference based on whether the trauma is a community trauma (i.e., natural disaster) or an individual trauma. Others consider whether the individual trauma is intentional (i.e., assault or abuse) vs. unintentional (i.e., motor vehicle accident). Both treatments have demonstrated efficacy across trauma types and efficacy with individuals reporting repeated trauma exposure. For example, some clinicians prefer PE for those reporting combat exposure.
  • Patient symptoms – Some clinicians will consider individual symptoms such as guilt, anger or flashbacks when choosing a treatment.  For example, some evidence supports the notion that individuals with high levels of guilt may benefit more from CPT than PE.
  • Level of symptoms – As most patients will benefit from cognitive-behavioral treatments, some clinicians will consider the level of PTSD symptoms. For example, choosing to use CPT for patients who are sub-clinical or just above threshold as they may benefit from cognitive restructuring focus of CPT.
  • Trauma recall – In some instances, patients will not recall the trauma due to injury, influence of substances, etc. For patients who do not recall their trauma exposure, it may be better to use CPT – C.
  • Patient preference – Some clinicians provide information regarding all treatment options to patients and allow the patient to choose which treatment is likely to work for them.
  • Patient treatment history – If a patient has previously had a treatment failure, many clinicians would explore reasons for treatment failure and allow that information to inform their decision.
  • Scheduling issues – Both protocols can be modified to allow 2 sessions weekly with excellent results. In the case of PE, twice weekly sessions may reduce the total number of sessions as well.
  • Time allotted for appointment – Some clinicians may consider scheduling issues but it should be noted that PE exposure sessions can be abbreviated to accommodate a 60-65 minute session with good results.
  • Available supervision – Some clinicians must choose one treatment over the other due to availability of appropriate clinical supervision

What other factors do you consider when making this choice? Do you weight some factors more heavily than others?

To learn more about PE or CPT:

On the web:

DOD PTSD guidelines:

Recent study

Treatment manuals:

Reclaiming Your Life from a Traumatic Experience by Edna Foa Ph.D., Elizabeth Hembree, Ph.D. & Barbara Rothbaum, Ph.D.

Cognitive Processing Therapy for Rape Victims by Patricia Resick, Ph.D. & Monica K. Schnicke