ART vs cognitive processing therapy (CPT): images versus beliefs

Cognitive processing therapy (CPT) is a structured talking-and-writing therapy that helps you examine and change the beliefs a trauma left behind, such as “it was my fault” or “nowhere is safe.” Accelerated Resolution Therapy (ART) uses eye movements and image replacement to reduce the distress a memory carries, without requiring you to discuss it. CPT has among the strongest evidence of any PTSD treatment and is rated “Strong for” by the 2023 VA/DoD guideline; ART is rated as having insufficient evidence to recommend for or against.

I am trained in ART and EMDR, not in CPT. If CPT is the better fit for you, that means a clinician trained in it, and I will say so if I think that is the case.

What CPT involves

CPT was developed by Patricia Resick and colleagues; its first published trial, with sexual assault survivors, appeared in 1992. The VA describes a course of about 12 weekly sessions of about 60 minutes (the CPT developers’ site says 50 minutes), although it is acceptable to adjust the number to the person.

The core of CPT is looking at how the trauma changed the way you think about yourself, other people and the world. You identify “stuck points,” the beliefs that keep the distress going, and work through them with worksheets and discussion. Common themes are safety, trust, power and control, esteem and intimacy.

At around the third session you have the option, with your therapist, of writing a detailed account of the trauma. The current protocol lets you choose whether to include it. Between sessions you complete writing and worksheets, so homework is a real part of CPT.

What ART involves

ART was developed in 2008 by Laney Rosenzweig, LMFT. It works less on beliefs and more on the sensory side of a memory. You briefly bring a scene to mind while following sets of about 40 side-to-side eye movements, with further sets to settle the physical sensations. Then, through Voluntary Image Replacement, you replace the distressing images with ones you choose. The narrative memory stays; what changes is the picture your mind goes to.

You don’t have to tell the therapist the details, and there is no homework. That doesn’t mean ART avoids the memory: brief deliberate recall is a core step. More in ART without talking about it.

Side by side

The evidence, plainly

CPT is about as well supported as a PTSD treatment gets. The VA’s professional guide notes 34 randomized trials in its PTSD Repository and says CPT “has the strongest recommendation as a treatment for PTSD in every clinical practice guideline.” The VA estimates that 57 out of every 100 people who receive CPT, PE or EMDR have meaningful improvement at about three months, against 8 out of 100 with no treatment.

ART has two randomized trials with published results. One (Kip and colleagues, 2013) compared ART with a non-therapy attention control in 57 service members and veterans, using self-reported symptoms. The other compared ART with a wait-list for complicated grief in 54 older caregivers. Both involved researchers connected to ART’s development. The VA/DoD guideline’s stated reason for its rating is that “No RCTs of ART included the critical outcome of clinician-rated PTSD.” A 2024 systematic review concluded ART “shows some promise” but “more high-quality studies are needed.”

Some practitioners have written side-by-side descriptions of ART, EMDR and CPT with case examples (Hernandez and colleagues, 2016). That paper states it was “not part of a formal study,” and one author is an ART trainer, so it describes the methods rather than testing them.

When CPT may be the better choice

• You want a treatment with top-tier guideline support.
• Guilt, self-blame, shame or a changed sense of trust or safety are at the center of what you are struggling with. Working directly on those beliefs is what CPT is built for.
• You like structure, writing and working things through between sessions.
• You have access to a clinician trained in CPT.

When ART may be worth considering

• What bothers you most is intrusive images and the physical jolt of the memory, more than particular thoughts about it.
• You would find worksheets or writing about the trauma hard to sustain.
• You have tried CPT and it stalled or you stopped, and you want a different procedure.
• You understand the evidence gap and are choosing ART knowingly.

On trying ART after CPT: an uncontrolled study of 148 veterans (Pang and colleagues, 2023) included 33 who had previously had CPT or PE. Among those who completed ART, the proportion with meaningful improvement was similar to that of veterans with no prior treatment. With no comparison group, completers-only figures and a research team connected to ART, this is a reason to consider it, not a prediction.

They aren’t mutually exclusive

Beliefs and images both matter after trauma, and people sometimes use more than one approach over time. What matters is that someone is keeping track of what is changing and what isn’t. The full comparison table shows CPT alongside the other options, and ART vs EMDR covers the other eye-movement therapy. If you would like to talk about whether ART suits your situation, you can get started here.