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

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When Prolonged Exposure Fails: Adding an Imagery-Based Cognitive Restructuring Component in the Treatment of Industrial

Accident Victims Suffering From PTSD

Brad K. Gruner t , Mervin R. Smucker , J o M. Weis, and Mark D. Rusch, Medica l College o f Wisconsin

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.

A CIDENTS WITHIN the workplace affect a large number of individuals each year. The residuals of such

accidents can range from a minor bruise or scratch to a major mutilating injury, such as amputation of arms, hands, legs, or feet. It is noteworthy that severity of injury, when the injury is mutilating, does not appear to place the victim at greater risk for developing PTSD (Grunert, De- vine, Matloub, et al., 1992; Grunert & Dzwierzynski, 1997). Clinical studies conducted thus far have focused primarily upon the nature of clinical symptoms experienced by traumatically injured workers. To date, relatively little research has examined the effects of clinical treatment with individual victims following exposure to a traumatic injury.

Industrial A c c i d e n t s and PTSD-Related S y m p t o m s

Although research on the aftereffects of job-related injuries is still in its infancy, a number of recent studies in- vestigating the psychological effect of industrial accidents have reported the presence of numerous clinical symptoms, including PTSD, among traumatically injured workers (Bear-Lehman, 1983; Burgess, Hibler, Keegan, & Everly, 1996; Cheng, 1997; Fukunishi, Sasaki, Chishima, Anze, & Saijo, 1996;Johnson, 1986; Lawson, 1987). In a sample of

Cognitive and Behavioral Practice 10, 333-346, 2003 1077-7229/03/333-34651.00/0 Copyright © 2003 by Association for Advancement of Behavior Therapy. All fights of reproduction in any form reserved.

21 victims of industrial accidents, 10 reportedly experienced full PTSD or multiple posttraumatic symptoms while 11 suffered from somatoform disorders (Schotten- feld & Cullen, 1986). Similarly, Grunert, Devine, Matloub, Sanger, and Yousif (1988) and Grunert, Devine, Matloub, et al. (1992) found evidence of significant short- and long-term maladjustment in individuals who had suffered severe work-related hand injuries. Specifically, a large percentage of these hand-injured patients continued to suffer from PTSD and other clinical symptoms related to their injuries at 18 months post-injury. Frequently reported symptoms included recurring visual flashbacks, anxiety, fear of reinjury, depression, disgust over physical appearance of their disfigured hands, irritability, social withdrawal secondary to disfigurement, and avoidance of stimuli associated with their accidents. Other researchers have reported significant correlations (following industrial accidents) between severity of PTSD and such variables as type, duration, and severity of exposure (Amir, Kaplan, & Kotler, 1996; Weiseath, 1989), extent of injury (Malt & Ugland, 1989), and poor premorbid adjustment (Fran- ulic, Gonzalez, Trucco, & Vallejos, 1996).

Treatment o f Work-Re la ted PTSD

The most frequently studied traumas thus far have involved victims of combat, violent crimes, physical and sexual assault, natural disasters, and motor vehicle accidents. Cognitive-behavioral therapies reported in the literature that have been used in the treatment of PTSD include

334 Gruner t e t al.

stress inoculation training (Kilpatrick, Veronen, & Resick, 1982; Meichenbaum, 1985, 1994), prolonged exposure (Foa & Kozak, 1986; Foa, Rothbaum, Riggs, & Murdock, 1991; Keane, Fairbank, Caddell, & Zimmering, 1989; Keane & Kaloupek, 1982), cognitive processing therapy (Resick & Schnlcke, 1992), imagery rescripting and reprocessing therapy (Dancu, Foa, & Smucker, 1993; Smucker, 1997; Smucker & Dancu, 1999; Smucker, Dancu, Foa, & Niederee, 1995; Smucker & Niederee, 1995), and cognitive restructuring within reliving (Grey, Young, & Holmes, 2002).

To date, however, only a few studies have investigated the treatment of clinical symptoms of industrial accident victims. Richards and Rose (1991) reported significant improvement using a combination of imaginat and in vivo exposure together with cognitive restructuring in their treatment of four patients suffering from PTSD symptoms, one of whom had been injured in an industrial set- ting. Grunert, Matloub, Sanger, and Yousif (1990) used imaginal and in vivo exposure procedures to treat reexperiencing and avoidance symptoms of 32 hand-injured patients, 80% of whom returned to work following treatment.

In a treatment study with 24 civilian trauma victims diagnosed with acute stress disorder--several of whom were industrial accident victims--Bryant, Harvey, Dang, Sackville, and Basten (1998) applied the following behavioral and cognitive treatment elements: education about trauma reactions, relaxation training, imaginal exposure to traumatic memories, in vivo exposure to avoided situations, and cognitive restructuring of fear-related beliefs. Bryant et al. found this CB treatment to be significantly more effective than supportive counseling in preventing the onset of PTSD and in reducing intrusive, avoidance, and depressive symptoms.

In their work with victims of traumatic industrial accidents since the mid-1980s, Grunert and colleagues (Grunert, Devine, Smith, et al., 1992; Grunert, Hargar- ten, et al., 1992; Grunert, Matloub, Sanger, & Yousif, 1990; Weis, Grunert, & Rusch, 2000) have noted that, while many industrial accident patients suffering from PTSD respond positively to exposure therapy (which may consist of some combination of in vivo and prolonged imaginal exposure), a significant percentage of such patients do not respond well to exposure treatment alone. Weis et al. (2000) hypothesized that for such patients, exposure therapy may need to be supplemented with a cognitive restructuring component to enhance treatment effects. Smucker, Grunert, and Weis (in press) have further elaborated on the benefits of adding a cognitive restructuring component to the treatment of PTSD, in particu- lar when fear is not the primary PTSD emotion.

The Present Study

The present study involved examining the efficacy of adding an imagery-based, cognitive restructuring compo-

nent to the treatment of two victims of work-related injuries suffering from PTSD who had failed to improve from prolonged exposure alone. Imagery rescripting and reprocessing therapy (IRRT) was employed as the cognitive restructuring treatment. Originally developed for treating adult survivors of childhood trauma (Dancu et al., 1993; Smucker & Dancu, 1999; Smucker et al., 1995; Smucker & Niederee, 1995), IRRT is essentially cognitive therapy applied in the context of imagery modification. The goal of IRRT is to alleviate PTSD and related clinical symptoms by eliminating intrusive traumatic flashbacks, al- tering maladaptive trauma-related beliefs and schemas (e.g., powerlessness, vulnerability), and enhancing the victim's ability to self-nurture and self-soothe while re- storing a sense of competence and self-assurance. The primary components of IRRT include: (a) imaginal exposure (accessing and reexperiencing the entire fear memory along with associated affect), (b) imaginal rescripting (replacing victimization/traumatic imagery with mastery/ adaptive imagery), (c) self-soothing/self-nurturing imagery (e.g., SURVIVOR-nurturing-VICTIM imagery, ADULT- nurturing-CHILD imagery), and (d) emotional-linguistic processing (transforming the traumatic imagery and accompanying emotions into narrative language while challenging and modifying maladaptive trauma-related beliefs).

One feature that distinguishes the rescripting/restructuring component of IRRT from other exposure and imagery-focused therapies is its emphasis on Socratic imagery (i.e., Socratic dialogue applied in the context of imagery modification). Since many trauma victims con- tinue to struggle with pervasive feelings of inner helplessness and disempowerment, employing a Socratic approach that promotes a sense of intrinsic mastery and control (i.e., empowering victims to empower themselves as they process their traumatic experiences) is viewed as a critical treatment component of IRRT. Trauma victims are thus encouraged to develop their own mastery/adaptive imagery while challenging and modifying their maladaptive trauma-related beliefs.

Methodology

The two subjects in this study were referred by their treating physicians to the Medical College of Wisconsin's Department of Plastic and Reconstructive Surgery following accidents they experienced in the workplace. Both subjects met DSM-IV (American Psychiatric Association, 1994) criteria for PTSD based upon a structured clinical interview at the beginning of treatment. Both subjects were treated by the senior author (B.K.G.), a licensed psychologist who has treated more than 800 PTSD patients over the past 20 years using exposure therapy. The first subject was traumatized by injuries sustained at work

Imagery-Based Cognitive Restructuring for PTSD 335

when his arm was caught in a conveyor bel t and became mang led in a set of gears. The second subject was t raumatized by an explosion he witnessed at his workplace that resul ted in severe bu rn injuries to two of his coworkers.

P r o c e d u r e

Instruments The Impact of Event Scale (IES) is a 15-item, self-report

ques t ionnaire that measures the f requency of psychological responses to stressflfl life events occurr ing within 7 days pr ior to administrat ion (Horowitz, Wilnm, & Alvarez, 1979). The IES yields three scores: an Intrusion subscale score, an Avoidance subscale score, and a total score. The IES can be a useful ins t rument for the initial assessment of acc ident victims and for the mon i to r ing o f progress t h roughou t t r ea tment (Best & Ribbe, 1995).

The Beck Depress ion Inventory (BDI) is a 21-item self- r epor t inventory that assesses the presence and intensity of depressive symptoms and at t i tudes within the past week (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The BDI can be used to assess depress ion in accident victims at pre- and pos t t r ea tment as well as over the course of t r ea tment (Best & Ribbe, 1995).

The State-Trait Anxiety Inventory (STAI) is a self-report scale that measures state (S) and trait (T) anxiety (Spiel- berger, 1982). On the S-Anxiety scale subjects rate how they feel "right now," whereas on the T-Anxiety scale subjects rate how they "generally" feel. Each scale consists of 20 items.

Subjective Units of Distress (SUDS) is a self-report measure indicat ing the degree of d iscomfor t or distress that a subject is current ly exper ienc ing (Wolpe & Laz- arus, 1966). A rat ing of 0 indicates the cl ient is feel ing no discomfor t whatsoever. By contrast, a ra t ing of 10 indicates the cl ient is feel ing ext remely uncomfor table . Com- pa red with most o ther instrumentat ion, obta ining SUDS levels is relatively nondisruptive and informs the clinician of the subject's discomfort level at various points throughout the imaginal exposure and restructuring session.

The Digit Span subtest of the Wechsler Adult Intelli- gence Scale-Revised (WAIS-R) measures a subject's suscep- tibility to anxiety, distractibility, and lack of concentrat ion (Kaufinan, 1990). In the first section of the subtest, the sub-

j ec t repeats digits in the same order in which they are spo- ken by the examiner, while in the second section the sub- j ec t repeats a series of digits in reverse order.

Schedule o f Assessment The BDI, IES, State-Trait Anxiety Scale, and the WMS-

R Digit Span Subtest were admin i s te red at pre- and post- t rea tment , and again at 1-month, 3-month, and &month follow-ups. SUDS ratings were r eco rded t h roughou t each t r ea tment session as well as at intake, pos t t rea tment , and each of the follow-ups.

PE The t rea tment for bo th subjects consisted of pro-

longed imaginal exposure sessions lasting approximate ly 90 minutes. The first several minutes of each exposure session were spent he lp ing the subject to relax via a focused- brea th ing technique. The subject was then asked to close his eyes, recall the day of the accident, and begin to visualize and verbalize a loud the entire traumatic event in detail and in the presen t tense, as though it were h a p p e n i n g now. T h r o u g h o u t exposure, subjects were asked to describe how they felt emotionally, what they were thinking, what they smelled, saw, felt and heard , and how others re- sponded . The t rauma memorywas p resen ted 3 to 5 t imes dur ing each exposure session. SUDS levels were ob ta ined f rom both subjects at four discreet points dur ing imaginal exposure: (1) while p repa r ing for going to work the morn ing of the accident; (2) while at work up to the t ime jus t p reced ing the t raumatic event; (3) dur ing the traumatic event itself; and (4) dur ing the "rescue" by coworkers and medical personnel .

For Subject 1, p ro longed exposure was t e rmina ted after 14 sessions when his persistently high SUDS ratings r ema ined unchanged and no improvemen t was no ted with his PTSD and re la ted clinical symptoms. A clinical decis ion was made at that po in t to add a cognitive re- s t ructur ing c o m p o n e n t to the exposure.

Subject 2 fai led to exper ience any degree of desensitization following two sessions of p r o l o n g e d imaginal exposure. Because of an exacerbat ion of PTSD symptoms ( increased f requency and severity of flashbacks) dur ing the two exposure sessions, Subject 2 refused to cont inue with PE. Despite extensive discussion of the ra t ionale of exposure treatment, Subject 2 failed to a t tend (no show, no call) his next scheduled appointment . When contacted by phone , he indicated that the t rea tment was "too intense emotionally" and that he i n t ended to '~just try and block it out of my mind." After fur ther lengthy discussion, the clinician suggested they try add ing a cognitive res t ruc tur ing componen t to exposure. The subject re lented and agreed to come in for "your last chance to help me with this."

IRRT A critical role of the cognitive therapis t employing

IRRT is to provide a supportive, safe env i ronment in which the subject can visualize and verbalize the traumatic imagery while reprocessing the associated painful affect. The therapis t assists the subject in staying with the affectively charged imagery throughout . Socratic imagery is an essential c o m p o n e n t of the cognitive res t ructur ing session. Socratic d ia logue (Beck, Rush, Shaw, & Emery, 1979; Overholser, 1993) app l ied in the context of imagery modif icat ion involves pat ients developing their own mas te ry /adap t ive imagery, a process that is t hough t to p romote a sense of greater se l f -empowerment than if the

336 Grunert e t al.

mastery/adapt ive imagery is suggested, directed, or dic- tated by the therapist (Smucker & Dancu, 1999). After the t rea tment rat ionale is presented and the subject's questions or concerns are addressed, the following instructions are given pr ior to the initial exposure phase of IRRT:

"I 'm going to ask you to recall the traumatic memory. It is best if you close your eyes so you won' t be distracted. I will ask you to recall the painful memory as vividly as possible. It is impor tan t that you describe the traumatic event in the p r e s e n t - - a s if it were happen ing now. If you start to feel uncomfor table and want to leave the image, let me know and I will help you to stay with it. Every so often, I ' l l ask you to rate your discomfort level on a scale from 1 to 10. It's best if you answer quickly and do not leave the image. Do you have any questions before we start? . . . When you are ready you may close your eyes and visualize a poin t in t ime earl ier in the day pr ior to the traumatic event, and describe what you see and feel as well as the thoughts you have about what is h a p p e n i n g . . . " (paraphrased from Smucker & Dancu, 1999, p. 46)

At this point , the imaginal exposure phase begins. The therapist ' s p r imary role dur ing exposure is to facilitate the activation of the ent i re t r auma memory network (visual, verbal, emot ional , kinesthetic, olfactory). The therapist does not in tervene o the r than to ask for more details of the event or to e labora te on thoughts and feelings about what is h a p p e n i n g in the imagery. Exposure is con- t inued until the verbal ized account o f the ent i re traumatic m e m o r y appears to have ended , at which po in t the therapis t asks: "Is there anything more that happens in the imagery?" When the subject confirms that the traumatic imagery has ended, the imaginal exposure phase is b rough t to a close and the master,/- imagery phase begins.

Dur ing mastery imagery, subjects are asked to visualize themselves as a survivor today en te r ing into the t raumatic scene to he lp thei r " t raumatized self" cope more effectively with the t raumatic event and to process the event more adaptively. The therapis t facilitates this th rough such quest ions as:

Can you visualize yourself, the survivor today, en te r ing into the scene?

Where are you, the survivor, and what do you see? Is there anything that you, the survivor, would like to

do or say to the t raumat ized you? Can you see yourself do ing / say ing that? How does the t raumat ized you respond? How are others a round you responding? How does the t raumat ized you feel about you the sur-

vivor today be ing there? What 's h a p p e n i n g now in the imagery between the

t raumat ized you and the survivor you?

The therapis t records the subject 's SUDS levels at various points t h roughou t the imagery. This gives the therapis t direct feedback on the subject 's distress level as well as how affectively involved the subject is, how much emo- t ional processing may be occurr ing, and whether any dis- sociating or n u m b i n g is present . If the subject 's SUDS level remains low th roughou t exposure or rescripting, the imagery session is no t likely to be effective.

Once it appears that the "survivor self" has offered suf- ficient support , assistance, and nur turance to the "traumatized self," and a sense of mastery has been accomplished in the rescr ipted imagery, the subject is asked if there is anything more that needs to h a p p e n in the imagery before the imagery is b rough t to a close. When the subject indicates a readiness to te rminate the imagery session, the therapis t says, "You may now let the imagery fade away, and when you are ready you may open your eyes."

Daily l i s tening to an aud io t ape of the ent i re , just- comple t ed imagery session is assigned as homework. This is des igned to facilitate fur ther cognitive and emot iona l processing between sessions. IRRT is general ly discontin- ued when SUDS ratings are consistently at 20% or less and the intrusive, recur r ing t raumatic memor ies (e.g., flashbacks, n ightmares) have ceased.

Case Example 1

Carlos, a 27-year-old, single, Hispanic male was in jured at work when his arm became caught in a conveyer bel t and was pul led into a set of gears. The acc ident resul ted in the amputa t ion of his left a rm jus t distal to the shoul- der. Carlos a p p e a r e d for the initial clinical evaluation approximate ly 3 months after the accident . Referred for t r ea tment of PTSD, he r epor t ed exper ienc ing 10 to 15 recur r ing flashbacks daily of the t raumatic event, each of which tended to last f rom 5 to 15 minutes. He also suffered from significant sleep disturbance, repor t ing that he was unable to sleep for more than 1 hour at any time. When asleep, he frequently exper ienced startle responses with ab rup t awakening as a result of n ightmares that he repor tedly exper ienced every night. He had been started on 20 mg of paxil and 75 mg of imipramine shortly after the accident , a l though the medicat ions had had virtually no effect on his m o o d or clinical symptoms. He com- p la ined of hypervigilance and startle responses whenever hear ing any sound similar to that of the conveyor bel t in which he had been t rapped. He also r epo r t ed pers is tent feelings of depression, worthlessness, and hopelessness, a long with concerns regard ing his physical appea rance since the accident. Embarrassed to be seen and ques- t ioned by others about his arm, he rarely left h o m e o ther than to a t tend his medical t reatment .

At the time of his initial evaluation, Carlos was notice- ably fat igued and ext remely re t icent about discussing the


accident in any manner . Carlos had to be coaxed th rough this pa r t of the interview, a l though he was eventually able to reveal details of the accident . P ro longed imaginal exposure was begun the following week at the nex t session. Carlos was asked to visualize and verbalize, in the presen t tense, what he expe r i enced pr io r to, dur ing, and following his be ing caught in the conveyor bel t and to focus especially on his emot iona l and behavioral responses to the event. Dur ing exposure, Carlos initially recal led having had a s t rong p r e m o n i t i o n on the day of his acc ident that he should no t go to work. This was followed by vivid recollections of the t r auma itself accompan ied by intense emot iona l reactions. Carlos cr ied uncont ro l lab ly as he re- e x p e r i e n c e d the acc ident . His h e i g h t e n e d e m o t i o n a l react ions dur ing exposure suggested that Carlos was reliving the horror, the fear, and the pain associated with the event. He also r eexpe r i enced the fr ight he felt in two emergency depar tmen t s when medical pe rsonne l were unable to conceal thei r own horr i f ied react ions to his severe and grotesque injury and how he prayed to God to save his arm.

Over the next 2 months Carlos comple t ed a total of 14 p r o l o n g e d imaginal exposure sessions. Except for a slight decrease in SUDS ratings (from 10 to 8) in Scene 1 (i.e., visualizing events p r io r to arrival at work on the day of the accident) , Carlos consistently r epo r t ed max imum distress t h roughou t all of the 14 exposure sessions. He also r epo r t ed no change in his s leep dis turbance or in the frequency and intensity of his repeti t ive nightmares, recur- r ing flashbacks, hypervigilance, and start led responses. Not surprisingly, Carlos began to feel increasingly hopeless a b o u t his recovery as well as the t r e a t m e n t he was receiving. Finally, after 14 unsuccessful sessions of prolonged imaginal exposure (which inc luded comple t ion of between-session assigned homework) , a clinical deci- sion was made to add a cognitive res t ructur ing componen t to t rea tment . At this point , IRRT was in t roduced. As par t of the exposure phase o f IRRT, Carlos was asked to again visualize and verbalize the t raumatic event. This time, however, at the po in t of injury Carlos was asked to visualize h imself as a survivor today in teract ing with his in jured, t raumat ized self. The following are excerpts f rom that imagery session.

THERAPIST: The bel t has caught your clothes. It 's taken your clothes. [pause] Can you now pic ture yourself as you are today going into the plant , walking up to the Carlos of last February whose c lothing is caught in the belt. Wha t would you, Carlos today, like to do or say to your in jured self?.

CLIENT: I see my body. I want to take it off f rom the belt .

T: You 'd like to take yourself f rom the belt, even though in reality you know you cannot do that.

C: I see Carlos r ight there. T: Wha t do you want to say to yoursel f while this is

happening? C: I d o n ' t have to pu t more a t ten t ion to my job . I

d o n ' t care if my j o b is bad.

Carlos has now left the imagery and is ref lect ing on how ha rd he had worked for his employer and how he is now suffering, a theme that he had raised repea ted ly during the previous 14 exposure sessions. Before con t inu ing with the imagery, the therapis t spends a few minutes processing these cognitions with Carlos (secondary cognitive processing 1) so that they will be less likely to interfere with the subsequent imagery (primary cognitive processing2). The therapis t then facilitates a re turn to the imagery by asking Carlos to visualize h imself back in the factory on the day o f the accident .

THERAPIST: Can you picture your survivor self today, dressed in blue j eans and a burgundy-co lored shirt with the sleeve tucked in where your arm used to be, s tanding nex t to your in ju red self when the acc ident happened? Wha t would you today like to do or say to Carlos in February?

CLIENT" The past Carlos, he is stupid. T: So you want to tell yoursel f that you are stupid? C: Yeah. T: And why are you stupid? Because you tr ied to do a

good job? C: Yes. All the time I like to make a good job. All the

time I like to be a credit to my manager because if my manager has problems that means that I don ' t make a good job. Right now I am thinking I am mixed up.

Again Carlos leaves the imagery and begins to talk about his observations that the t ra ining he received in the oper- a t ion of the machines was inadequate . The therapis t en- gages Carlos in several addi t ional minutes of secondary cognitive processing, he lp ing h im to express and process his feelings of anger and betrayal about the inadequa te t ra ining he received. The therapis t then invites Carlos to r een te r the imagery. (The therapis t is careful to r ema in Socratic with Carlos t h roughou t the imagery rescr ipt ing phase so that the new mas te ry /adap t ive images are developed by Carlos h imself and no t by the therapist .)

THERAPIST: Wha t else would you like to do o r say? CLIENT: I want to destroy this machine . T: You want to destroy the machine? Can you picture

yourself do ing that?

1 Secondary cognitive processing refers to the activation of the individual's verbal cognitions as a means of linguistically processing thoughts and feelings about an event.

2The activation of imagery is viewed as a primary cognitive process (i.e., mental activity that is primarily- iconic in nature and lacking in temporal dimension).

3 3 8 Grunert et al.

C: Yeah. T: How are you doing that? C: It is too dangerous, this machine. T: So what are you doing to the machine at this

moment? C: I want to cut it up. It's too dangerous, this machine.

This machine is no t safe anywhere. Even right now. T: So what are you doing? Can you picture it in your

mind? C: I am destroying it. T: You're tearing it apart? C: I 'm making it into junk . T: You're making it into junk? C: Yeah. T: So you are tearing that machine apart. Can you

picture it all smashed and being junk? C: Yeah. T: So that nobody can ever get hur t on it again?

[ Carlos had earlier expressed concern that others could also be injured by this machine.]

C: Yeah. Even that. This machine is really dangerous. T: It was the machine that jus t tore your arm off?. C: Yeah. Even if I destroy this machine I never get my

arm back. T: No, you can ' t ever get your arm back.

Visualizing himself destroying the machine demon- strates a significant step forward for Carlos in moving beyond the victimization imagery and gaining mastery over the previously recurr ing painful memories and images of the traumatic experience. Although Carlos cannot change what actually happened to him on the day of the accident, he can change the thoughts and images he has about the event. The cognitive restructuring-within-reliving also enables Carlos to emotionally process (visually and

Table 1 Case Example 1

Post-PE/ 1-Month 3-Month 6-Month Measures Pre-PE Pre-IRRT Post-IRRT Follow-up Follow-up Follow-up

WAIS-R Digit Span 4 4 8 9 10 IES Avoid 27 27 13 10 5 IES Intrude 25 25 8 7 3 BDI 22 22 9 5 2 State 80 80 52 43 37 Trait 71 71 46 39 36 SUDS 1 10 10 1 1 1 SUDS 2 10 10 2 1 1 SUDS 3 10 10 1 1 1 SUDS 4 10 10 1 1 1

verbally) his PTSD-related anger and perceived powerlessness. A noticeable change in his affect occurs at this point in the imagery,, as Carlos appears significantly more relaxed and self-assured. In the imagery that follows, he talks about the poor design of some machines at work and prays that God will help the engineers and mainte- nance workers to improve the safety of these machines so that no one else will be injured. Carlos also begins to eval- uate and process his distressing, trauma-related beliefs and assumptions (e.g., his percept ion that his employer took advantage of his willingness to work hard and failed to protect him from injury). Carlos further reexamines his belief that he has been abandoned by God since the accident, and concludes that to some extent he is respon- sible for this separation because he allowed himself to become bitter and isolated (he stopped at tending all church- related activities shortly after his injury). He then pro- ceeds to carry out an imaginal dialogue with God dur ing which Carlos, after initially expressing his feelings of estrangement, begins to feel a sense of reconnectedness and reconciliation with God along with a renewed sense of optimism about his life and future.

Following complet ion of the imagery session, Carlos was given an audiotape of the session to listen to as daily homework. At his next office visit a week later, his clinical symptoms had improved dramatically. Most notably, Car- los reported that (a) his flashbacks had stopped alto- gether, decreasing in frequency" from 10 to 15 per day to 0 per day; (b) his sleep had dramatically improved such that he was now able to sustain 6 or more hours of un in- terrupted sleep without nightmares; (c) his overall concentration had improved markedly; and (d) his hypervigilance had decreased, although he cont inued to experience occa- sional mild startle reactions. Three weeks later, Carlos was again funct ioning in public without anxiety about be ing

seen by others, he had enrol led in classes at the local technical college, and he had begun an active job search.

As can be seen from Table 1, Carlos's PTSD, depression, and related clinical symptoms - - w h i c h had remained unchanged dur ing the previous 14 p ro longed

10 imaginat exposure sess ions - - improved sig- 2 nificantly on all clinical assessment mea- 3 sures and SUDS ratings immediate ly fol- 2 lowing the one cognitive res t ructur ing

34 session, and con t inued to improve at 1- 33

1 month , 3-month, and 6-month follow-ups. 1 At his 6-month follow-up session, Carlos re- 1 por ted a complete absence of any PTSD or 1 other clinical symptoms. He had also ob-

ta ined part-time employment and was at- t end ing two classes per week at the local technical college.

Note. PE = prolonged exposure; IRRT = imagery rescripting and reprocessing therapy; WAIS-R = Wechsler Adult Intelligence Scale-Revised; IES = Impact of Events Scale; BDI = Beck Depression Inventory; SUDS = Subjective Units of Distress.


C a s e Example 2

Charles is a 42-year-old, single, Caucasian male who witnessed an accident that occurred when a cutt ing torch, used by two coworkers, came into contact with a flamma- ble lubricant, causing an explosion benea th the train car where they were working. Charles had jus t ben t over to look u n d e r the train car to speak to his two coworkers when the explosion occurred, the force of which threw him backwards some 10 feet. Al though Charles ma na ge d to escape without physical injury, his two coworkers u n d e r the train car were badly burned . Charles reac ted quickly and effectively by ext inguishing the flames on one of his coworkers and providing first-aid to bo th of the burn victims. Dur ing the 2 weeks following the acc ident and his re turn to work, Charles deve loped a n u m b e r of PTSD-like symptoms, inc luding recur r ing nightmares, flashbacks, impa i red concent ra t ion , irritability, hypervig- i lance, and social withdrawal. By the third week, he s topped going to work pr imar i ly because of his growing fear of be ing in jured himself or causing injury to some- one else. At that point , Charles was refer red by his company's workers ' compensa t ion carr ier for evaluation and t reatment .

At the initial evaluation 1 m o n t h after the explosion, Charles appea red ext remely fatigued. He r epo r t ed developing a fear of falling asleep because of the recurr ing nightmares he was having about the accident. He expressed feelings of remorse that his coworkers had suffered serious burn injuries while he had survived unharmed. He repor ted exper iencing vivid, recurring, intrusive images of his coworkers ' b u r n e d bodies and thei r skin looking like " rubber gloves." Charles stated repeatedly that there should have been someth ing he could have done to prevent the acc ident f rom happen ing . It became clear during the interview that Charles had deve loped a significant mistrust of his own work capabilities, despi te his 20 years of emp loymen t as a successful welder. He now feared that his coworkers would be unwilling to work with h im again because he had escaped physical ha rm and had not pre- vented the acc ident f rom occurring. Pr ior to this incident , Charles had repor ted ly been a very sociable individual with no history of psychiatric difficulties, and no history o f a lcohol or d rug abuse.

PE During the initial phase of Charles 's t rea tment , pro-

longed imaginal exposure was employed by the t reat ing psychologist. The p rocedu re involved asking Charles to visualize and verbalize (in the present) what he experienced immedia te ly p r io r to, dur ing, and after the explosion, and to describe in detail his emot iona l and behavioral responses to the situation. Two sessions of PE were employed over a 2-week per iod, with no not iceable or

r epo r t ed decrease in his anxiety level or PTSD symptom- atology. Charles con t inued to exper ience recurr ing, intrusive flashbacks and n ightmares that con ta ined vivid images of his coworkers ' char red skin and smells of their b u r n e d flesh. His perceived helplessness vis-/t-vis his recurr ing flashbacks, toge ther with his con t inued cognitions of culpabil i ty and self-blame for his coworkers ' injuries and an exacerbat ion of his emot iona l and physical discomfort dur ing the exposure sessions, suggested that little if any habi tuat ion or emot ional processing of the traumatic event was occurring. Charles did not show up for his next therapy appoin tment . When contacted by the clinician, Charles stated that he was discontinuing t rea tment and would '~just try and block it out" of his mind.

IRRT After considerable discussion with Charles, the clini-

cian p roposed add ing a cognitive res t ructur ing componen t to the exposure t rea tment , to which Charles reluc- tantly agreed. The initial phase of the p r o c e d u r e began with imaginal exposure , which involved asking Charles to visualize and verbalize a loud the ent i re event, beg inn ing with a br ie f descr ip t ion of the industr ial scene jus t p r io r to the explosion. SUDS ratings were taken t h roughou t all phases of the imagery session. The following are excerpts of the only IRRT cognitive res t ructur ing session con- duc ted with Charles.

THERAPIST: Are you able to get a pic ture of the work env i ronment in your mind?

CLIENT: Yes, I am. I can see the two guys, J o h n and Sam. They are u n d e r n e a t h the train car working on gett ing this large uni t taken out. They have thei r torches and they ' re cut t ing on it. I can also see Sam spraying some lubr icant up into one o f the areas. I am s tanding r ight next to the car b e n d i n g down looking at them.

T: So no th ing has h a p p e n e d yet and everything is alright, and you ' re observing these two individuals whom you are working with as they ' re cut t ing with the torch. Is that correct?

C: Yes, it is. T: Okay, so what happens next? Can you descr ibe

what you are exper iencing? C: I 'm leaning down and actnally going u n d e r n e a t h

the train car now and all of a sudden there is a big explosion. There ' s all this big flame, it 's all over. I r e m e m b e r d r o p p i n g down and rol l ing ou t f rom unde rne a th the car. I can hear the two o the r guys screaming. When I get out f rom unde rnea th the car I look a round and I can ' t see ei ther one of them, so I am runn ing a round to the o ther end of the car.

T: You are now runn ing a r o u n d to the o the r end of the car? Are you hurO


C: No, I 'm not hurt. I can ' t believe it! I 'm not hurt! I should have been hurt!

T: On a 1-to-10 scale, how uncomfortable do you feel right now?

C: 10+. I can ' t believe I 'm not hurt. I should have been hurt!

Charles's guilt-ridden cognit ion and belief, "I should have been hurt," may offer some clues as to why prolonged exposure alone was no t effective, since exposure does no t directly address or challenge his trauma-related cognitions of guilt.

THERAPIST: You're going a round the end of the car now? What do you see on the other side?

CLIENT: When I come around, I can see John standing there totally engulfed in flames. He is on fire everywhere. He is u n d e r the car too. How come I 'm not b u r n e d when he is just on fire everywhere?

T: And what do you do now, Charles? C: I grab the fire extinguisher, and I am r u n n i n g after

him trying to put h im out. I can ' t believe that I can carry that fire extinguisher and run that fast. I am able to catch up with him and spray the fire extinguisher on him and put him out. His skin looks like, kind of like those rubber gloves. It's just there and it doesn ' t look like the fight color. He's bu rned all over. I had to put him out, bu t I know that Sam is still not here. I don ' t know where he went.

T: You just put the fire out on the one guy who was on fire, but the other one you haven't been able to find yet? What is your level of discomfort at this moment?

C: Still a 10+. I have to go out and find him. I am r u n n i n g from one end of the railroad car to the other looking for him. All of a sudden I can hear him yelling from outside. So I run out the door and I can see him. He is about 40 yards out rolling in the snow. I r un out there and he is in shock. He has burns too. I take my shirt off and wrap it a round him to try and keep him warm because I know that it is dangerous for him to be out in the cold after he has had a burn. He can walk, so I have him get up and we walk back into the plant. I still can ' t believe that I d idn ' t get hurt! I can look at both of these guys and they look jus t terrible, and I don ' t even have a scratch on me!

T: What is your level of discomfort at this moment? C: It's still a 10 [on a 14o-10 scale]. In fact, maybe it's

like a 15. It jus t seems to be getting worse, because both of these guys have been badly bu rned and no th ing happened to me.

Despite the very intense emotional reaction accompanying the imaginal flooding, Charles was no t habi tuat ing or desensitizing. This followed the course of the previous

two PE sessions, which only served to escalate his emotional discomfort. Charles remained visibly upset over the fact that his coworkers had been so badly injured while he had managed to escape unharmed. Charles's "survivor guilt" had become a major obstacle in his recovery and thus needed to be directly addressed and challenged.

THERAPIST: Okay, have you gotten back into the plant yet with Sam?

CLIENT: Yes, I have. He's down by J o h n now. One of my friends that I work with is hold ing Sam. And I 'm trying to comfort John. They don ' t have any fire blankets and they don ' t have any sterile water and there is no oxygen. Both of these guys are screaming. There is no th ing that we can do for them except to try and be there to comfort them. The vice pres ident of the company is coming now. He says he has called 911. It seems to take forever before the ambulance comes. It is about 15 or 20 minutes already and these guys are jus t screaming. I jus t can ' t believe that I 'm okay. I 'm upset because the chances of this happen ing at this company are way higher than anywhere else I have worked. I told them before that they should have sterile water and b u r n blankets and oxygen. They haven ' t done anything. I can jus t smell what that b u r n e d flesh is like on them. I wish there is something I Call do .

Charles cont inues to struggle with his own sense of powerlessness, though he is beg inn ing to experience some anger for the first time toward the company for not having on hand the first-aid materials necessary for him to assist his coworkers in this emergency situation. As the imaginal exposure continues, his discomfort levels in- crease and he expresses his fear that he will never be able to leave these horrible images behind.

THERAPIST: So you find it really hard to think about the entire incident, and yet it seems so real when you talk about it?

CLIENT: That 's fight. Whenever I start to think about it, I can ' t stop myself. It [the imagery] jus t keeps coming over and over, and I can see how the skin is jus t like surgical gloves and how the smell of the bu rn is so bad I don ' t know if I 'm ever going to be able to eat any meat again. They just look so terrible and they're screaming! It's just a horrible thing. There's noth ing I can do to help them. There's no th ing that happened to me. I can ' t believe that no th ing happened to me! I am the one who was telling them how to do this j ob and we did everything right, bu t no th ing happened to me and they're both b u r n e d forever.

This last comment suggests that his own escape from


injury has left h im feel ing t r emendous guilt and that this guilt has thwarted habi tua t ion and successful emot iona l processing of the trauma. Charles remains deeply trou- b led over having survived the inc iden t u n h a r m e d and worr ied that his coworkers will no t want to work with h im again because of his failure to prevent the accident. Charles 's t rauma-re la ted "survivor guilt" appears to have rep laced his pre-accident cognitive schemas of compe- tency and dependabil i ty .

When the imaginal exposure phase of IRRT ended , the therapis t i n t roduced the "mastery imagery" phase, which involved asking Charles to visualize h imself as a survivor "today" (i.e., 8 weeks after the accident) en te r ing the acc ident scene and speaking to his " t raumat ized self" as he was at the t ime o f the accident . As Charles contin- u e d to feel helpless as a result of his recur r ing thoughts and t raumatic images abou t the accident , the pervasive sense of helplessness and guilt he felt dur ing the inc iden t r e m a i n e d a "stuck" po in t in his recovery, and thus became the therapeut ic target for cognitive res t ructur ing dur ing the imagery rescr ipt ing phase:

THERAVlST: I ' d like us now to go back th rough the accident again. This time, however, when we get to a cer tain point , we will change the imagery in a way that will he lp you to feel more in control o f the thoughts, images, and feelings you have been having about the accident. Are you ready to p roceed with this?

CLIENT: Yes, it 's k ind of scary to th ink abou t it again, bu t I would do anything to stop th inking about it over and over and over.

T: Okay, when you ' re ready you may go back to the beg inn ing of the scene, which I believe is when you are in the shop working with J o h n and Sam. W h e n you ' re ready you may close your eyes, visualize the beg inn ing of the scene jus t before the explosion, and verbalize out l oud what you exper ience . Are you able to do that?

C: Yes, bu t it [the imagery] seems to want to go racing ahead on me.

T: Wha t does it race ahead to? C: It races r ight ahead to the explosion. T: Can you try and slow that whole process down and

go back to be ing in the shop where you see Sam and John u n d e r n e a t h the train car? They've got their torches and they ' re working on removing that unit. Can you picture that? John and Sam are u n d e r n e a t h the train car and they've got their torches. They spray some lubricant up a round the unit. I ' m bend ing over to start to go u n d e r n e a t h the car to he lp them. All of a sudden there is this big explosion. There ' s jus t a big ball of flame.

C:

T: Wha t is your level of d iscomfor t r ight now, Charles? C: It 's 10. It 's definitely a 10. T: Wha t do you see h a p p e n i n g now? C: I ' m d r o p p i n g down and I ' m rol l ing out f rom

u n d e r the car. I can feel how ho t it is r ight by me. I jus t r e m e m b e r I have to stop, drop, and roll in o rde r to keep from catching fire.

T: Are you saying that you are now doing the things that you 've been t ra ined to do in o rde r to keep yourself f rom catching on fire? Is that what you ' r e doing?

C: Yes, that 's right.

The above Socratic ques t ioning (by the therapist) appears to elicit a more deta i led descr ip t ion of Charles 's actions at the m o m e n t of the explosion. For Charles, re- m e m b e r i n g that he reac ted to the explos ion exactly as he had been t ra ined to do was critical. At this point , Charles is asked to visualize h imself as a survivor today en te r ing into the imagery, which he is able to do with relative ease. His "survivor self" in the imagery immediate ly becomes the "rational voice" (which he had previously been unable to access and activate) and points out to his " traumatized self" that he is doing "the right thing," which in turn appears to p r o m p t an immedia te cognitive and affective shift. Charles is then able to appraise more rat ionally and accurately bo th the t raumat ic event and his response to it, that is, by do ing the r ight th ing to save himself, he is able to provide life-saving assistance to his critically in- j u r e d coworkers.

THERAPIST: Carl you now pic ture yourself coming into that scene as you are today?

CLIENT: Yes, I can. T: Wha t would you like to do or say at this point? C: I can see myself rolling, and I guess I tell myself

that I ' m do ing the th ing that I was tanght to do. I am doing the r ight thing.

T: You are watching yoursel f roll ing, and you say to yourself that you are do ing the r ight thing? How is that the r ight thing?

C: Well, that 's what I 've always been taught, to make sure that I d o n ' t catch fire if someth ing happens . A n d now because I ' m not on fire I might be able to he lp the o the r guys.

T: You're r emind ing yourself that because you d id the r ight thing, you are now going to be able to he lp the o the r two men?

C: Yeah, you know I 've never though t about that before. If I had caught on fire, then maybe all of us would have died.

I t is not at all unusual for skillfully app l i ed Socratic ques t ioning dur ing imagery to lead to such critical thera-


peutic insights by the pat ient that, in turn, can prompt significant cognitive-affective shifts.

THERAPIST: So what do you want to tell yourself now? CLIENT: [ can tell myself that I need to go and help

the other guys. I can tell myself to run a round the end of the car and look for John.

T: Are you able to do that now? C: Yes, I am, and I can tell myself that I have to get the

fire extinguisher because we don ' t have any fire blankets. I r emember looking for fire blankets first before I r emembered that we d idn ' t have any, so I need to get the fire extinguisher to put John out.

T: You are now telling yourself to pick up the fire extinguisher and go after John to put him out?

C: Yes, that's right. And I r emember when I tried to do that before, I d idn ' t know if I 'd be able to catch up with J o h n because he was runn ing , there were flames blowing from him, and he was screaming.

T: So, what can you say to yourself now; Charles? C: This is kind of crazy because it's the worst part, but

I only feel about a 3 now [on a 14o-10 scale].

In the post-explosion mastery imagery, Charles began to see himself as a capable individual who had made good decisions at the time of the accident that enabled his coworkers to receive critical assistance from him, which they could not have received from him had he also been in jured by the explosion. Charles's reframing of the acci- den t dur ing the above imagery rescripting segment appears to have prompted an immediate cognitive-affective shift that led to feelings of competence and self-efficacy, which, in turn, resulted in a significant reduct ion in his SUDS (from a 10 to a 3). The realization that he escaped injury by "doing the right thing" changed the at tr ibution from guilt to competence, and the effect on his mood was striking.

Table 2 Case Example 2

Post-PE/ 1-Month 3-Month 6-Month Measures Pre-PE Pre-IRRT Post-IRRT Follow-up Follow-up Follow-up

WAIS-R Digit Span 6 6 7 11 13 IES Avoid 26 24 15 12 11 IES Intrude 27 27 14 13 10 BDI 32 31 23 10 9 State 74 75 58 50 37 Trait 58 58 53 44 31 SUDS 1 10 8 1 1 1 SUDS 2 10 10 1 1 1 SUDS 3 10 10 2 1 1 SUDS 4 10 10 1 1 1

THERAPIST: Do you think maybe that's because you decided you did the right thing when everything caught on fire?

CLIENT: Yes, I know I did the right thing because I wouldn' t have been able to help John ifI had caught on fire. I would have needed somebody to help me. I don ' t need that now, and I am able to help them.

T: So what would you now like to say to yourself about what happened, Charles?

C: I guess I have to tell myself that even though I thought I couldn ' t do anything, I did the right thing and that what I did may have made a big difference for these people.

T: So you feel like you really did make a difference and you weren ' t helpless the way that you thought you were?

C: Yes, that's right. I don ' t think I 'm ever going to think about being helpless like that again. I really did make a difference!

T: Is there anything else you might want to tell yourself about the accident?

C: Well, I guess I have to tell myself that I can ' t blame myself for not being on fire because I knew the right thing to do, and maybe those other guys got hur t too bad to do the right thing initially.

T: Is there anything else you 'd like to say to yourself? C: No, no t right now. This is pretty amazing! I can ' t

believe I feel so much better already! T: Pretty amazing, huh? . . . You may now allow the

imagery to gradually fade away, and when you're ready you may open your eyes.

Note. PE = prolonged exposure; IRRT = imagery rescripting and reprocessing therapy; WAIS-R = Wechsler Adult Intelligence Scale-Revised; IES = Impact of Events Scale; BDI = Beck Depression Inventory; SUDS = Subjective Units of Distress.

Dur ing the imagery restructuring session, Charles was able to transform his pervasive feelings of powerlessness and guilt into feelings of empowerment , competence,

and efficacy. By visually interjecting himself, the survivor today, into the traumatic scene, he was able to "see" things from a more rational and objective perspective. He was able to recognize and feel, for the first time, that his actions at the time of the accident made a significant difference and probably saved

13 the lives of his injured coworkers, some- 11 thing that he had not been able to "see" and 9 "feel" prior to the imagery rescripting ses- 9 sion. This insight enabled Charles to exon-

33 erate himself from guilt and self-blame and 27

1 begin to shift his anger toward his company 1 for no t having obtained the medical sup- 1 plies that Charles had requested prior to 1 the accident.

At the end of the session, Charles was given an audiotape of the entire imagery session for daily listening as homework. At


his next therapy appointment a week later, Charles repor ted a dramatic improvement in his overall function- ing. As can be seen from Table 2, there was a significant reduct ion in PTSD and related clinical symptoms imme- diately following the cognitive restructuring imagery session. In addition to experiencing no further flashbacks or nightmares, Charles's overall levels of depression and anxiety were significantly reduced, his concentration and sleep improved significantly, and he reported increased levels of energy, confidence, and social activity. One week later, Charles re turned to work and was able to effectively express his thoughts and feelings to the workers' compensation carrier, who, in turn, intervened to help the employer establish a safer work environment. No further exposure or cognitive restructuring sessions were conducted, as Charles's positive gains were maintained at post treatment and cont inued to improve at 1-month, 3- month , and 6-month follow-ups (see Table 2).

D i s c u s s i o n

The reported ineffectiveness (i.e., dropouts, nonim~ provement, symptom exacerbation) o f PE in the treat- men t of some PTSD patients is no t unique to our study (e.g., Bryant, 2002; Grunert, Weis, & Rusch, 2000; Van Minnen, Arntz, & Keijsers, 2002; Weis, 1999). A number of writers and clinicians have recently noted that because exposure t reatment is so poorly tolerated by a substantial number of PTSD patients, the utilization of exposure therapy has remained limited in clinical practice (Becker & Zayfert, 2001; Foy, Kagan, McDe/cmott, Leskin, Sip- prelle, & Paz, 1996; Foy & Meadows, 1998; Tarrier et al., 1999; Zayfert & Becker, 2000). Especially- troubling has been the reportedly high d ropout rate of PTSD subjects who undergo exposure treatment. A recent t reatment outcome study reported a d ropout rate o f over 40% of all PTSD subjects in the study treated with exposure (Zay- left, Becker, Gillock, & Schnurr, 2001). In another recent study of 45 patients diagnosed with chronic PTSD who were treated with pro longed exposure, 24% were dropouts, 36% were nonimproved, and only 40% improved whereby they no longer met PTSD criteria at posttreat- men t (Van Minnen & Hagenaars, 2002). A recently pub- lished clinician survey revealed that a high percentage of CBT-trained clinicians are either reluctant to use, or re- frain f rom using, exposure-based treatments with PTSD patients because o f concerns about, and experience with, exposure leading to symptom exacerbation a n d / o r re- traumatization (Becket, Anderson, & Love, 2001).

The critical PTSD-related emotions experienced by the two subjects in our case studies were not fear, but a sense of victimization with varying degrees of guilt, anger, hopelessness, and powerlessness. PE appeared to resensi- tize, rather than desensitize, the subjects to the loss of

control they had felt during their respective traumatic events. During the exposure sessions, the subjects were unable to access cognitions that would assist in reappraising their traumatic experiences more adaptively and moving beyond their victimization. Instead of habituating, both subjects experienced an exacerbation of symptoms as they became increasingly serf-blaming, angry, guilt-ridden, and hopeless during their exposure treatments. En t renched in their victimization, this symptom exacerbation appeared to further limit any possibility for adaptive reap- praisal or reprocessing. By contrast, a single session of cognitive restructuring (IRRT) appeared to facilitate and foster a significant cognitive shift, which resulted in successful emotional processing and an immediate allevia- tion of PTSD symptoms. The use of Socratic imagery appeared to further enhance the sense of self-efficacy for both subjects as they were able to generate their own mastery and adaptive images.

The findings of our study raise a number of broader questions with regards to the clinical utility of exposure and cognitive restructuring in the t reatment of PTSD:

1. What is the role of exposure in PTSD treatment? 2. When is pro longed exposure by itself likely to be an

effective t reatment for PTSD and when is it not? 3. When is exposure best applied as the core o f PTSD

treatment and when is it most effectively used as a componen t of PTSD treatment designed to enhance cognitive restructuring?

4. What role do imagery interventions have in PTSD treatment?

5. How can exposure (behavior therapy) and cognitive restructuring (cognitive therapy) interventions be combined to produce the best PTSD treatment results, what are the specific treatment components of an optimal cognitive-behavioral treatment, and how can such a hybridized cognitive-behavioral treatment be understood conceptually and theoretically?

Within the context o f this discussion, questions relat- ing to the relative efficacy of exposure and cognitive restructuring may be further explored through a comparative analysis of the theoretical underpinnings and specific t reatment components of PE (a behavioral treatment) and IRRT (a cognitive treatment). Although PE and IRRT do share some c o m m o n characteristics, they also differ in a number o f critical ways.

Specifically, PE is an exposure-based, behavioral treat- men t embedded in the theories of classical condit ioning and relies primarily on the processes of exposure, habituation, desensitization, and extinction to reduce fear and anxiety. A primary goal of PE in the treatment of PTSD is for patients to learn that they can tolerate the trauma memories and associated negative arousal without being over- whelmed. More specifically, patients are taught that avoid-

344 Grunert et al.

ance does not lead to long-term symptom relief, that traumatic memories are manageable and tolerable, and that the fear and anxiety provoked by these memories will eventually subside and extinguish as exposure continues. This process of habituation and desensitization is thought to enhance emotional processing of traumatic memories by providing "corrective information" (e.g., that the traumatic event is in the past, that the trauma- related t~ar and anxiety are manageable and not harm- ful). When successful, PE leads to a substantial reduction in the frequency and severity of posttraumatic stress symptoms (e.g., intrusive recollections, avoidance, anxious arousal).

By contrast, IRRT is an imagery-based, cognitive treat- men t that employs exposure, no t for habituation, but for activating the images, emotions, and beliefs associated with the traumatic memories. In IRRT, exposure is used as a means to an end (i.e., activating the t rauma memory as a means of enhancing cognitive restructuring) rather than as an end in itself: Thus, the intended effect of IRRT involves activation and modification of the traumatic images and related maladaptive attributions, beliefs, and schemas (e.g., guilt, shame, self-blame, anger, powerlessness). The trauma-related "corrective information" in IRRT is processed both visually" and verbally during high states of affective arousal within the context of a Socratic- facilitated, intrapersonal dialogue between the patient's "traumatized self" and "survivor self."

Although IRRT interventions begin with the activation and modification of the traumatic imagery itself, cognitive restructuring of trauma-related beliefs and schemas is an essential componen t of IRRT. (Characteristically, cognitive therapy applications that do not employ imagery interventions--e.g. , cognitive processing the rapy- - promote linguistic processing of trauma-related thoughts and feelings, but fail to alter the recurring traumatic imagery.) In short, IRRT follows the Beckian cognitive therapy approach of beginning with the identification and modification of the patient 's most distressing cognitions. With PTSD sufferers, the "hot" cognitions tend to be intrusive, traumatic images. Reexperiencing the distressing t rauma images typically activates the individual's real- adaptive trauma-related beliefs (including misinterpreta- tions of the PTSD symptoms themselves), thus making them amenable to examination, modification, and cognitive processing within the context of heightened affective arousal.

The similarities and differences between IRRT and PE vis-/t-vis their specific t reatment components may thus be summarized as follows.

IRRT is similar to PE in:

• the use of imaginal exposure and narrative language; • the activation and reexperiencing of distressing

traumatic memories and accompanying affect;

• exposure to the trauma-related memories, images, and emotions over relatively long time intervals within each treatment session.

IRRT differs f rom PE in:

• the ~ n d of "corrective information" experienced during treatment (In contrast to PE, which attempts to provide corrective information via imaginal exposure and habituation, IRRT seeks to provide corrective information via active cognitive restructuring that involves both exposure to and modification of the traumatic imagery.);

• IRRT's emphasis on t ransforming the t raumat ic / victimization imagery into mastery/adaptive imagery (Transforming traumatic imagery into adaptive imagery is not part of PE.);

• IRRT's use of Socratic dialogue to facilitate the de- velopment and processing of adaptive imagery and corrective information (Socratic dialogue is no t part of PE.);

• IRRT's emphasis on exploring the symbolic mean- ing of the traumatic images (Symbolic meanings are not methodically explored in PE.);

• IRRT's emphasis on identifying and modifying maladaptive trauma-related attributions, beliefs, and schemas (PE offers no methodical approach for identifying, challenging, or actively modifying real- adaptive trauma-related cognitions.) 3

While exposure has been shown to be effective with trauma victims whose primary posttrauma emotion is fear and primary behavioral coping strategy is avoidance, nonfear emotions (e.g., anger, guilt) habituating through exposure has not been demonstrated. In the present study, where nonfear emotions of guilt, self-blame, anger, and powerlessness were the critical PTSD-related emotions, PE was not an effective PTSD treatment. By contrast, a single cognitive restructuring session may have been successful because it effectively blended visual and verbal interventions to directly activate, challenge, modify, and process the subjects' distressing cognitions of guilt, self- blame, anger, and powerlessness to significantly alter their underlying belief structures.

Future Directions for Research There has been much discussion in recent years on

the relative efficacy of compet ing cognitive and behavioral treatments for PTSD. Yet, relatively little is known about exactly when, why, and u n d e r what condi t ions

3Foa (personal communication, 2001) noted that spontaneous cognitive restructuring sometimes occurs during prolonged exposure sessions with PTSD patients. However, little is known about when, why, and how spontaneous cognitive restructuring occurs and why it often does not occur during exposure.

image ry -Based Cogni t ive Restructuring for PTSD 345

empir ica l ly s u p p o r t e d t r e a t m e n t i n t e rven t ions for PTSD

are l ikely to be effect ive o r ineffect ive. Perhaps o u r con-

ceptual izat ions , descr ipt ions , and empi r i ca l evaluat ions o f

PTSD t rea tments have n o t b e e n t h o r o u g h e n o u g h in (a)

e x a m i n i n g the specific t r e a t m e n t c o m p o n e n t s o f the vari-

ous approaches , (b) i d e n t i t ~ n g w h i c h PTSD-re la ted cogni-

t ions and e m o t i o n s are p r imary (e.g., fear, anger , self-

b l ame , guilt , shame) , and (c) d e l i n e a t i n g the specific

types o f t r a u m a tha t PTSD sufferers have e x p e r i e n c e d

(e.g., Type I vs. Type II t raumas, h u m a n - p e r p e t r a t e d vs.

n o n h u m a n - p e r p e t r a t e d t raumas) . It is o u r c o n t e n t i o n

tha t the t r e a t m e n t o f PTSD w o u l d be s ignif icant ly en-

h a n c e d by the d e v e l o p m e n t o f an a l g o r i t h m tha t m a t c h e s

t r e a t m e n t i n t e rven t ions with (a) type a n d n a t u r e o f

t r auma , and (b) specif ic t r auma- re l a t ed character is t ics

a n d symptoms, i n c l u d i n g iden t i f i ca t ion o f p r ima ry and

seconda ry t r auma- re l a t ed e m o t i o n s a n d cogni t ions .

T h e results o f o u r study, in c o n j u n c t i o n with o t h e r re-

p o r t e d f indings, have l ed us to advance the fo l lowing hy-

p o t h e s e s wi th r ega rds to t he a p p l i c a t i o n a n d uti l i ty o f

e x p o s u r e a n d cogn i t ive - res t ruc tu r ing t rea tments :

1. PE is m o r e likely to be an effect ive PTSD t r e a t m e n t

w h e n fear is the p r ima ry e m o t i o n and avo idance is

the p r ima ry c o p i n g strategy.

2. PE is less likely to be an effect ive PTSD t r e a t m e n t

w h e n n o n f e a r e m o t i o n s are p r imary (e.g., guilt,

self-blame, anger , shame , he lp lessness) .

3. An imagery-based, cogn i t ive - res t ruc tu r ing treat-

m e n t (e.g., IRRT) is l ikely to be an effect ive PTSD

t r e a t m e n t w h e n n o n f e a r e m o t i o n s are pr imary, p ro-

v ided that such t r ea tmen t (a) employs exposure not

for hab i tua t ion bu t for activating a n d r eexpe r i enc ing

the t raumat ic memory, and (b) actively employs bo th

visual and verbal in tervent ions to t ransform trau-

mat ic imagery into mas te ry /adap t ive imagery and mod i fy t r auma- re l a t ed bel iefs and schemas.

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Address correspondence to Brad I~ Grunert, Ph.D., Hand Rehabilitation Center, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Ave., Milwaukee, WI 53226.

Received: January 10, 2001 Accepted: February 9, 2003

Documents

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