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Combined imaginal exposure and cognitive restructuring therapy is more effective than supportive counselling for treating post-traumatic stress disorder
  1. Steven Taylor, PhD
  1. Department of Psychiatry, University of British Columbia, Vancouver, Canada

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Q For people with post-traumatic stress disorder (PTSD), does cognitive restructuring with prolonged imaginal exposure lead to greater symptom relief than imaginal exposure alone?


Embedded Image  Design:

Randomised controlled trial.

Embedded Image  Allocation:


Embedded Image  Blinding:

Assessors blinded to treatment.

Embedded Image  Follow up period:

Six months.

Embedded Image  Setting:

Hospital PTSD unit, Sydney, Australia.

Embedded Image  Patients:

58 people referred to PTSD unit after non-sexual assault or traffic accident, displaying PTSD (DSM-IV criteria) ≥ 3 months. Exclusions: history of psychosis, substance dependence, childhood sexual abuse, current suicidal ideation, or aged <17 or >60 years.

Embedded Image  Intervention:

Imaginal exposure; imaginal exposure plus cognitive restructuring; or supportive counselling for 8 weekly 90 minute sessions with daily homework.

Embedded Image  Outcomes:

PTSD symptoms assessed using clinician administered PTSD scale.

Embedded Image  Patient follow up:



Imaginal exposure with cognitive restructuring significantly reduced PTSD symptoms compared with supportive counselling (p<0.05 at post-treatment and 6 months follow up; see web extra table 1). Imaginal exposure did not significantly reduce PTSD symptoms compared with supportive counselling alone.

Table 1

Absolute risk of post-traumatic stress disorder after treatment.


Imaginal exposure with cognitive restructuring was more effective than supportive counselling for the treatment of PTSD.


Randomised controlled trials have shown that cognitive behaviour therapy is an effective treatment for PTSD. This treatment contains several interventions, including (a) cognitive restructuring (CR) for correcting distorted, self defeating patterns of thinking; (b) live exposure (LE) to distressing but harmless trauma related stimuli; and (c) imaginal exposure (IE) to traumatic memories in order to reduce (habituate) the distress evoked by these memories.

Component studies have sought to determine whether each of these cognitive behavioural interventions contributes to treatment efficacy. If some components are ineffective, then treatment outcome may be improved by concentrating on the more effective interventions. Several studies have sought to determine whether CR contributes to the outcome of cognitive behaviour therapy for PTSD.1–,3 So far the results have been mixed. Some research suggests that CR improves outcomes,3 while other research indicates that outcomes are no better, or possibly worse, when CR is included.1,2

This study is the latest component study comparing IE, CR+IE, and a supportive counselling control condition. On a number of measures, IE and CR+IE were both more effective than counselling, and CR+IE was somewhat more effective than IE alone, suggesting that CR makes a useful contribution to treatment outcome.

Although this study had a number of methodological strengths, it also has several important limitations that make it difficult to determine generalisability to clinical practice. First, the sample was not representative of treatment-seeking populations because people with sexual abuse were excluded. PTSD commonly arises from sexual abuse. In our recent study of people seeking treatment for PTSD, almost half (45%) of the sample had PTSD associated with sexual abuse.4 Similarly, other common forms of PTSD, such as combat related PTSD, were not included in the Bryant study.

Bryant’s exposure therapy was IE only, which is less effective than LE.5 Participants did not receive an audiotape for IE homework, making it more difficult to practice IE homework exercises. With a modestly effective intervention like IE, it would be relatively easy to show that an additional intervention (CR) improves outcome. It is unclear whether a more potent intervention, such as LE, would have been enhanced by the addition of CR. Bryant et al also failed to report whether participants had additional treatment (eg pharmacotherapy) during their pre-to-post-treatment phase or during follow up.

In summary, this study does little to clarify the role of CR in the treatment of PTSD because of their atypical sample and unrepresentative exposure protocol. Indeed, the authors conclude that more research is needed. Although Bryant’s study provides further evidence that supportive counselling is not a treatment of choice for PTSD, it provides little other guidance for clinical practice with exposure therapy as it is typically used.



  • For correspondence: Dr R A Bryant, School of Psychology, University of New South Wales, Sydney, New South Wales, Australia.

  • Sources of funding: The National Health and Medical Research Council.

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