PTSD: National Center for PTSD

Written Exposure Therapy

Denise M. Sloan, Ph.D. and Brian P. Marx, Ph.D.

Written Exposure Therapy (WET; 1) is a manualized exposure-based psychotherapy for PTSD that is recommended by the VA/DoD Clinical Practice Guideline. A growing number of studies indicate that WET is effective for PTSD, even among patients with complicated presentations and other comorbid disorders (2,3). In addition, compared with other trauma-focused treatments, a low number of those who receive WET drop out of treatments (e.g., less than 10%; 1).

Continuing Education

Written Exposure Therapy

Explains the theoretical model and session content of Written Exposure Therapy (WET), including a review of effectiveness research and studies.

Theoretical Model

The WET treatment protocol was developed through a series of systematic studies. Based upon a fear extinction/emotional processing treatment model, these studies examined the extent to which trauma survivors with PTSD symptoms experienced symptomatic relief from writing about their experiences. The amount of writing necessary to bring about clinically significant symptom change was also evaluated (1).

This work indicated that five, 30-minute writing sessions in which patients are directed to write about a traumatic experience in detail, paying particular attention to their thoughts and emotions that occurred at the time of the event, resulted in reduction of pathological fear and subsequent significant PTSD symptom reduction. Using an empirically derived set of instructions for repeatedly writing about their traumatic experience, the patient learns that:

• The trauma memory is not dangerous and can be experienced without significant distress.
• Distress associated with remembering the trauma is transient.
• Emotional distress gradually reduces with time, even without doing anything.
• Physiological responses, such as rapid heart rate and sweating, are not dangerous.
• High negative affect can be tolerated.
• It is possible to develop new ways of thinking about the trauma event and its meaning.

Although patients are not required to conduct in vivo exposures outside of sessions, research has found that confronting previously avoided people, situations and places related to the trauma occurs spontaneously in WET (4).

Although evidence supports the hypothesis that fear extinction is an underlying mechanism of WET, it is possible that other mechanisms are also responsible for the clinically significant symptom reductions observed among those who receive WET. Work investigating other possible mechanisms is underway.

Session Content

The WET treatment protocol consists of five sessions, with each session lasting approximately 50 minutes. During each session, patients write narratives about their traumas in response to specific writing instructions. There are no between-session assignments.

The first treatment session starts by providing the patient with psychoeducation about PTSD and a treatment rationale. This is followed by the patient completing the first, 30-minute trauma narrative. Following the 30 minutes of writing, the therapist checks in with the patient about their experience while completing the written narrative. In the remaining four sessions, clinicians provide feedback to patients on the previous session's writing, specifically on how well the client followed the writing instructions, deliver instructions for the writing to be done during that day's session, allow the patient to complete the day's 30-minute writing assignment, and check in with the patient about the session's writing assignment after it is completed. At the end of the session, patients are instructed to allow themselves to have whatever trauma-related feelings, thoughts or memories that they may experience during the course of the week without trying to push them away. Treatment sessions are highly scripted, ensuring standardization of treatment delivery and increasing provider adherence to the protocol.

Overall and Relative Effectiveness

To date, findings from two published randomized controlled trials (RCTs; 4,5) support the effectiveness of WET. Patients who receive WET show significant reductions in PTSD symptoms, with large within-group effects observed in each of the studies. Moreover, most of those who receive WET no longer meet diagnostic criteria for PTSD after treatment (4,5) and maintain their treatment gains a year after treatment (3). The most recently published RCT found that WET was non-inferior to Cognitive Processing Therapy (CPT + written account) in terms of PTSD symptom reduction, despite having more than half as many therapy sessions in the treatment protocol (5). Moreover, this study found significantly fewer participants dropped out of the WET condition than during the first 5 sessions of CPT. An initial investigation of potential moderators (e.g., severity of PTSD, comorbid psychiatric disorders, baseline depression, race, sex) of WET treatment outcome revealed no significant moderators of PTSD symptom change (2). Additional research is needed to examine other potential moderators.

To date, the RCTs that have provided the evidence of efficacy for WET have been conducted by the treatment developers. Several other studies examining the efficacy and effectiveness of WET led by other investigators are now underway.

WET in Clinical Practice Guidelines

WET is recommended as a first-line treatment for PTSD in the VA/DoD Clinical Practice Guideline for Managing PTSD and it is listed as an emerging recommended treatment in the International Society for the Study of Traumatic Stress (ISTSS) guideline. It is not mentioned in American Psychological Association, National Institute for Health and Care Excellence (NICE), or Australian guidelines (6).

Research With Military Personnel and Veterans

Sloan and colleagues (2013) conducted a small open trial of Veterans with chronic PTSD to examine the feasibility and acceptability of the WET protocol and obtain some pilot findings (7). Five of the seven Veterans reported a clinically meaningful reduction of their PTSD symptoms following treatment, and these treatment gains were maintained three months later. In addition, all the Veterans who reported clinically significant symptom improvements no longer met diagnostic criteria for PTSD. Treatment satisfaction ratings were high and only one Veteran dropped out of treatment. A more recently published RCT of WET (5) included both civilians (n = 92) and Veterans (n = 34). This study found that the Veterans and civilians had a significant reduction in PTSD symptom severity and treatment dropout was low (6%; 5). A study of Service members found that WET was non-inferior to the more time intensive CPT in terms of PTSD treatment outcome. WET also had significantly less dropout in this study (8).

In addition to these studies, there are currently 3 studies underway that are investigating the effectiveness of WET with Veterans and Service members (9,10,11).

Research With Comorbidities and Special Populations

Findings to date indicate WET is effective for patients that have severe and chronic PTSD symptoms, and psychiatric comorbidity, such as depression (2). Moreover, WET is effective at reducing co-morbid depression symptoms among individuals with PTSD (3). WET has been found to be comparably effective at significantly reducing depression symptoms as CPT (12).

Emerging Issues

As previously described, there are a number of studies underway examining the effectiveness of WET with Veterans and Service members, as well as in primary care and acute inpatient settings. WET has been delivered using video telehealth platforms (i.e. VA Video Connect) with the narratives collected electronically (e.g. secure messaging). Phone only delivery of WET is not recommended at this time. An implementation program of WET conducted within VA is examining if different training formats are needed to disseminate WET, as well as examining the effectiveness of using different training models (11).

Although the treatment protocol is typically delivered as 5 weekly, 50-minute sessions (1), some research supports the notion that treatment can be delivered more frequently (i.e., in a massed format; treatment sessions occurring on consecutive days; see reference 1). One of the studies underway is investigating the efficacy of WET delivered in a massed-format (9), and another study underway is investigating a 6, 30-minute per session version of the protocol delivered in a primary care setting.

References

1. Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A brief treatment approach for mental health professionals. American Psychological Press. http://dx.doi.org/10.1037/0000139-001
2. Marx, B. P., Thompson-Hollands, J., Lee., D. J., Resick, P. A., & Sloan, D. M. (2021). Estimated intelligence moderates Cognitive Processing Therapy outcome for posttraumatic stress symptoms. Behavior Therapy, 52, 162-169. http://dx.doi.org/10.1016/j.beth.2020.03.008
3. Thompson-Hollands, J., Marx, B. P., Lee, D. J., Resick, P. A., & Sloan, D. S. (2018). Long-term treatment gains of a brief exposure-based treatment for PTSD. Depression and Anxiety, 3(10), 985-991. https://doi.org/10.1002/da.22825
4. Sloan, D. M., Marx, B. P., Bovin, M. J., Feinstein, B. A., & Gallagher, M. W. (2012). Written exposure as an intervention for PTSD: A randomized controlled trial with motor vehicle accident survivors. Behaviour Research and Therapy, 50(10), 627-635. https://doi.org/10.1016/j.brat.2012.07.001
5. Sloan, D. M., Marx, B. P., Lee, D. J., & Resick, P. A. (2018). A brief exposure based treatment for PTSD versus Cognitive Processing Therapy: A randomized non-inferiority clinical trial. JAMA Psychiatry, 75(3), 233-239. https://doi.org/10.1001/jamapsychiatry.2017.4249
6. Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., Megnin-Viggars, O., Forbes, D., Riggs, D. S., & Schnurr. P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56(3), 359-373. https://doi.org/10.1037/pst0000231
7. Sloan, D. M., Lee, D., Litwack, S., Sawyer, A. T., & Marx, B. P. (2013). Written Exposure Therapy for Veterans diagnosed with PTSD: A pilot study. Journal of Traumatic Stress, 26(6), 776-779. https://doi.org/10.1002/jts.21858
8. Sloan, D. M., Marx, B. P., Resick, P. A., Young-McCaughan, S., Dondaville, K. A., Straud, C. L., Mintz, J., Litz, B., & Peterson, A. L., for the STRONG STAR Consortium (2022). Effect of Written Exposure Therapy versus Cognitive Processing Therapy on increasing treatment efficiency among military Service members: A randomized noninferiority trial. JAMA Network Open, 5(1), e2140911. https://doi.org/10.1001/jamanetworkopen.2021.40911
9. Marx, B. P., Fina, B. A., Sloan, D. M., Bryan, C. S., Young-McCaughan, S., Dondanville, K. A., Tyler, H. C., Blankenship, A. E., Schrader, C. C., Kaplan, A. M., Bryan, C. J., Hale, W.J., Mintz, J., & Peterson, A. L. for the STRONG STAR Consortium (2020). Written Exposure Therapy for posttraumatic stress symptoms and suicide risk: Design and methodology of a randomized controlled trial with patients on a military psychiatric inpatient unit. Contemporary Clinical Trials, 110, 106564. https://doi.org/10.1016/j.cct.2021.106564
10. Sloan, D. M., Marx, B. P., Acierno, R., Messina, M. & Cole, T. A. (2021). Comparing Written Exposure Therapy to Prolonged Exposure for the treatment of PTSD in a Veteran sample: A non-inferiority randomized design. Contemporary Clinical Trials Communications, 22, 100764. https://doi.org/10.1016/j.conctc.2021.100764
11. LoSavio, S. T., Worley, C. B., Aajmain, S., Rosen, C., Stirman, S. W., & Sloan, D. M. (2021). Effectiveness of Written Exposure Therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://dx.doi.org/10.1037/tra0001148
12. Thompson-Hollands, J., Marx, B. P., Lee, D. J., Resick, P. A., & Sloan, D. M. (2018). Long-term treatment gains of a brief exposure-based treatment for PTSD. Depression and Anxiety, 35(10), 985-991. https://doi.org/10.1002/da.22825