Mechanisms of change during exposure therapy for persistent post-concussion symptoms: insights from session-level process data

Background Persistent post-concussion symptoms affect a substantial subgroup of individuals following mild traumatic brain injury. Intensive exposure therapy may be an effective intervention by directly targeting psychological mechanisms underlying symptom maintenance. This study provides insight into the clinical processes of this therapy.Materials and methods Therapy session-level data from two single-case experimental design studies with a total of eight participants was analyzed using mixed-methods.Results The most frequently targeted feared expectations included: cognitive failure, task breakdown, catastrophic consequences of physical symptoms; and exposure tasks: cognitive challenges, sensory rich environments, social interaction. Quantitative analyses demonstrated a significant within-session reduction in belief strength about expected outcomes (mean decrease = 38.49, p < 0.001), with notable individual differences. Belief reduction was consistent across the exposure sessions. Despite observed reductions, participants often retained some concerns after therapy, most commonly due to generalization doubts or uncertainty under higher task demands.Conclusions Findings highlight the multidimensional and personalized nature of feared beliefs in persistent symptoms and underscores the clinical value of individualized behavioral experiments. The study provides process-level insights that may inform more confident and targeted implementation of (intensive) exposure therapy in mild traumatic brain injury treatment.