Dissertations, Theses, and Capstone Projects

Date of Degree


Document Type


Degree Name





Denise Hien

Committee Members

Steven Tuber

Lesia Ruglass

Benjamin Harris

Diana Punales

Subject Categories

Clinical Psychology | Counseling Psychology | Developmental Psychology | Psycholinguistics and Neurolinguistics


PTSD, Substance Abuse, Exposure Therapy, Referential Process, Linguistic Analysis


Exposure therapy is currently considered the “gold standard” in treating posttraumatic stress disorder (PTSD). Though exposure therapy has been increasingly used and studied as an intervention for PTSD in recent years, little is known about the mechanisms of change in this type of treatment. The Trauma and Addiction Project at the City College of New York ran a clinical research trial for individuals with co-morbid PTSD and Substance Use Disorders (SUDs). Participants randomized into the experimental group, Concurrent Treatment with Prolonged Exposure (COPE), participated in a twelve-session therapeutic intervention that combined exposure therapy focused on the participant’s primary trauma with relapse prevention techniques. This dissertation extends the research on the mechanisms of change in exposure therapy for PTSD by applying a computerized linguistic analysis program (DAAP), which measures components of the referential process (Bucci, 1997), to the COPE Imaginal Exposures of two demographically matched participants, one treatment responder and one treatment non-responder.

This investigation set out to examine the relationship between Bucci’s referential process theory, the language participants use in their Imaginal Exposure narratives, and treatment outcome in an exposure therapy for co-morbid PTSD and SUD. The predictions included: 1) referential activity in the participants’ Imaginal Exposures will increase over the course of the intervention; 2) an increase in referential activity scores will be associated with a decrease in substance use and cravings, posttraumatic stress, and dissociative symptomatology; and 3) the COPE treatment responder will have higher referential activity scores in his Imaginal Exposure narratives than the treatment non-responder.

Results showed: 1) an increase in narrative immersion over the course of the Imaginal Exposures for the treatment responder; 2) that the increase in narrative immersion occurred alongside improvements in posttraumatic stress and substance use symptom severity in the treatment responder; and 3) the mean referential activity scores in the Imaginal Exposures for the treatment responder were significantly higher (at a 95% Confidence Interval) than those of the treatment non-responder.

These findings have implications with regard to the nature of exposure therapy for co-morbid PTSD and SUD, and the relationship between the language a participant uses to describe their primary traumas and their progression towards health.


A revised version was uploaded on October 27, 2021 with the approval of the dissertation committee chair and the Graduate Center.