When prolonged exposure fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial accident victims suffering from PTSD Original Research Article

Prolonged exposure (PE) is a widely promulgated treatment modality for PTSD. While successful with many subjects, PE also has a significant failure rate (i.e., dropouts, nonimprovement, symptom exacerbation). To date, outcome research has not examined why PE at times appears to be the treatment of choice for PTSD and why it sometimes needs to be combined with cognitive restructuring interventions to be effective. This study presents a detailed cognitive-behavioral analysis of two industrial victims suffering from PTSD who failed to benefit from PE alone, but who subsequently made a quick and lasting recovery when an imagery-based, cognitive restructuring component was added to their exposure treatment. A comparative analysis is presented of the theoretical underpinnings and treatment components of the behavioral and cognitive treatments used with the subjects in this study—PE and imagery rescripting and reprocessing therapy (IRRT). PE is a behavioral treatment based upon theories of classical conditioning that relies on exposure, habituation, desensitization, and extinction to facilitate emotional processing of fear. By contrast, IRRT is cognitive therapy applied in the context of imagery modification. In IRRT, exposure is employed not for habituation, but for activating the trauma memory so that the distressing cognitions (i.e., the trauma-related images and beliefs) can be identified, challenged, modified, and processed.