Putting it into Words: A Clinical and Linguistic Analysis of Trauma Narratives in Two Short-Term Exposure Therapies for Co-Morbid PTSD and SUD


Nearly half of the individuals who experience Posttraumatic Stress Disorder (PTSD) will also have a Substance Use Disorder (SUD) in their lifetimes. Prolonged Exposure Therapy (PE), considered the “gold standard” in treating PTSD, has been increasingly used and studied as an intervention for PTSD, yet little is known about the mechanisms of change in this type of treatment. In PE for PTSD, participants tell and re-tell the story of their primary trauma many times over. This re-telling is called an “Imaginal Exposure.” When efficacious, this type of treatment allows for habituation, and PTSD symptom severity begins to dissipate. This paper seeks to better understand the psychological and linguistic processes that occur in such a treatment in order to contemplate for whom such a treatment might be beneficial, and why, (This article is a distillation of the doctoral dissertation by Zachary Kahn, “Words of Change: How Linguistic Shifts Over the Course of a Short-Term Exposure Therapy Represent Movement Towards Psychological Health” (2017).) by exploring the clinical and linguistic differences in the narratives of a treatment responder (decreased PTSD and SUD severity) and a treatment non-responder. A qualitative analysis of portions of the narratives (which were recorded and transcribed) demonstrated that there were clear clinical differences between the responder and non-responder. A linguistic analysis of the narratives using measures of the referential process showed that the treatment responder increasingly engaged in the referential process during exposures over the course of treatment, whereas the non-responder engaged in the referential process less frequently over the course of the treatment and less consistently throughout.

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Fig. 1


  1. 1.

    Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (2000). The Trauma and Addiction Project’s Clinical Trial began prior to publication of the DSM-V, so for purposes of this research, the DSM-IV-TR was used to define the criteria of mental illnesses.

  2. 2.

    The project was led by Dr. Denise Hien and her team of clinician-researchers at the Trauma and Addiction Project (TAP) at the City College of New York, in New York City Prior to beginning treatment, all participants had to consent to being willing to be randomized into either the COPE or RPT intervention. Overall, 39 participants were randomized into the COPE condition. Eight participants completed all twelve sessions of the COPE intervention. Due to that small number, a single case design was used to hone in on the linguistic and symptomatic impact of the COPE intervention as a case study with two individual participants.

  3. 3.

    Per DAAP instructions, each / symbol represents a one second pause.

  4. 4.

    For a more detailed account of the qualitative changes that occurred for these two participants see Kahn (2017, pp. 79–105).

  5. 5.

    Participant 521 and Participant 1017 had different therapists, as well as different therapeutic alliances with their respective therapists. For scholarship on the impact of the therapeutic alliance with regard to treatment outcomes in this research study, see Pedersen (2017).

  6. 6.

    Unlike Participant 521′s trauma, which was an acute incident, the day that Participant 1017 focuses on as his primary trauma is an incident that represents the culmination of long-endured interfamilial losses, violence, and discord. In addition, Participant 521 suffered his trauma during childhood, whereas, Participant 1017 the primary trauma was experienced during adolescence.


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This work was made possible by Dr. Denise Hien’s immense support and mentorship. In playing with the nuances and complexities of language, Dr. Sean Murphy has been a critically important translator. The secondary research was supported by a grant from the Far Fund, and the initial TAP study was supported by a grant from the National Institute on Drug Abuse (NIDA; R01DA10843; PI: Denise Hien, Ph.D.).

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Correspondence to Leon Hoffman.

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Kahn, Z., Hoffman, L. Putting it into Words: A Clinical and Linguistic Analysis of Trauma Narratives in Two Short-Term Exposure Therapies for Co-Morbid PTSD and SUD. J Psycholinguist Res (2021). https://doi.org/10.1007/s10936-021-09770-7

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  • PTSD
  • Substance use disorder
  • Prolonged exposure therapy
  • COPE treatment
  • Linguistic analysis
  • Referential process