Post-traumatic stress disorder (PTSD) can be a debilitating mental health issue, characterized by recurrent and disturbing memories of a traumatic event, frightening dreams, dissociative reactions, extreme avoidance, and prolonged psychological and physiological distress (American Psychiatric Association, 2013). PTSD exemplifies the discrepancy between the demand for and supply of available mental health resources and services. In fact, in their survey of almost 2,000 veterans from recent U.S. wars, Schell and Marshall (2008) found that only one quarter of those with diagnosable PTSD received minimally acceptable treatment over the previous year. What services are available are often criticized for their long wait times, inconsistent quality of care, and emotionally demanding methods (Austern, 2015). A need has emerged for a PTSD treatment with qualities neglected by other current and recommended practices including tolerability, uncomplicated implementation and dissemination, economical soundness, and accessibility. Written exposure therapy (WET) is a PTSD treatment developed with these criteria in mind that has been proven to have the same immediate and maintained effective PTSD symptom reduction as other empirically tested treatments (Sloan, Marx, Lee, & Resick, 2018). Through examining its methods, theoretical foundations, representation in current literature, and benefits, the recently developed therapeutic technique of WET can be expounded as a legitimate and attention-worthy treatment for PTSD.
Implications of PTSD and Recommended Treatments
PTSD is a pervasive issue with widespread impacts on society. Prevalence rates in the United States range between 6% and 9%, and rates among some trauma-exposed populations are much higher; prevalence of PTSD in soldiers who have been deployed, for example, increase linearly with their quantity of direct combat experiences, reaching almost 20% (Hoge et al., 2004). Similarly, populations frequently exposed to physical injury, peacekeeping, and disaster (e.g. first responders) have rates of PTSD from 10% to 40% (Sareen, 2014). The impact of the disorder touches many aspects in the lives of those affected, as well as those around them. People with PTSD often face interpersonal problems such as marital interferences and issues with parenting, which can have behavioral consequences in their children (Austern, 2015). Epidemiological studies have shown that over 80% of people with PTSD have at least one comorbid disorder, most frequently that of major depressive disorder, alcohol or substance use disorders, and other types of anxiety or stress disorders (Galatzer-Levy, Nickerson, & Marmar, 2013). Even when controlling for these comorbid disorders, however, research shows that PTSD is extremely highly correlated with suicidal behavior (Nepon, Belik, & Sareen, 2010). Studies with combat veterans uncovered various physical health conditions in connection with PTSD as well, including bone and metabolic diseases, chronic pain, and cardiovascular, respiratory and neurological conditions (Frayne et al., 2004). These combined impairments also impact society and the economy—Kessler (2000) found that the debilitating consequences of PTSD effect an annual productivity loss of about $3 billion; what is more, a recent study by the RAND Corporation found that veterans with PTSD are more likely to be unemployed, to miss days of work, and to be homeless than those without the disorder (Tanielian et al., 2008).
Due to these many considerations, much research and clinical attention has been paid to developing reliable, effective, and standardized treatments for PTSD. As members of the military are especially vulnerable to developing PTSD in addition to being a heavily studied population, the Department of Veterans Affairs (VA) has issued practice guidelines providing clear evidence-based practices (EBPs) recommended in the treatment of PTSD. These guidelines include trauma-focused psychotherapy interventions encompassing elements of exposure, stress inoculation training, and cognitive restructuring (Austern, 2015). Some of the most widely used interventions on this list, used not only with military clients but in the civilian population as well, include prolonged exposure (PE) and cognitive processing therapy (CPT). While these are well-validated treatments, barriers to their effectiveness still arise in the forms of accessing clinicians who are trained in these methods, tolerability, economic factors, and lengthy time commitments (Sloan et al., 2012). In fact, data show that around one-quarter of participants in exposure-based treatments drop-out before completion of the intervention (Hembree et al., 2003). Consequently, a need has arisen for an effective, accessible, acceptable (tolerable), and economical treatment for PTSD. Written exposure therapy (WET), an intervention involving confronting the traumatic memory through writing, may fulfill all of these conditions.
Written Exposure Therapy
Written Exposure Therapy is a brief, five-session treatment designed to facilitate clients’ processing and confronting of a traumatic memory through writing about it. There are two components involved, psychoeducation-rationale and written exposure. In the first session, the clinician informs the client about the symptoms of PTSD and the rationale for the treatment, specifically addressing avoidance reduction and habituation of detrimental conditioned emotional responses (Austern, 2015). Then the clinician gives specific writing instructions, namely to write down everything they can remember of the event that causes them the most distress and their thoughts and emotions during the event, and then leave the client to write. Clinician contact with the client is minimal in this intervention: 25 minutes in the first session and 10 minutes in the following four sessions. In the subsequent sessions the client is instructed to focus on different aspects of the trauma, including focusing on the part of it most afflicting to them (“hot spot”), and describing how the trauma has changed the way they live, view the world, or interact with others. Between sessions the client is encouraged not to avoid memories or thoughts about the event that come up but rather to simply experience them (Sloan et al., 2012).
Theoretical background
In 2008, the Institute of Medicine conducted a review of the available treatments for PTSD and their efficacies. They found the strongest evidence for successful treatment of PTSD in exposure therapy and recommended it as the first line of treatment for the disorder. Exposure involves a continued confrontation with frightening stimuli until the anxiety around it is reduced (in a process called habituation). The goal is to extinguish the conditioned emotional response that has been created to the traumatic memory in order to reduce symptoms of avoidance and distress (Institute of Medicine, 2008). However, much research has shown that while exposure therapy is more effective than other PTSD treatments, nonresponse and dropout rates have been an issue in its usage (Schottenbauer, Glass, Arnkoff, & Gray, 2008). As such, researchers have explored alternative means of applying this intervention such as using virtual reality technology, pharmacotherapeutics to aid in the extinction learning process, and finally, writing-based interventions (Austern, 2015).
Writing about emotional traumas has been shown to increase physical and mental health. Studies from the mid 1980’s illustrated this concept in a model called the Expressive Writing paradigm, where students randomly assigned to write about emotional and personal topics received autonomic health benefits, had less subsequent health center visits, and had reduced subjective distress compared to students assigned to write on trivial topics (Pennebaker & Beall, 1986; Pennebaker, Kiecolt-Glaser, & Glaser, 1988). Although no concrete research has been generated around the specific mechanisms that contribute to the efficacy of expressive writing, hypotheses have been generated based on results of the clinical interventions it has been used in.
As far as its applicability to trauma, Sloan, Marx, and Greenberg (2011) tested Pennebaker and Beall’s (1986) written disclosure procedure on PTSD severity. They used their three, twenty-minute session written-exposure treatment, and when testing it on individuals with the disorder they found reductions in PTSD symptoms but no significant differences from the control group. They found that habituation did not occur, leading them to the hypothesis that habituation takes more than three writing sessions to develop. In extending the treatment in the creation of WET, researchers found more effective results. Thus, it is hypothesized that WET works by obstructing avoidance of the traumatic memory through repeated exposure to it, both promoting habituation to the feared stimulus and encouraging new learning about the stimulus association (Sloan et al., 2012). While this is probably WET’s main mechanism of action, there are other potential factors influencing its effectiveness. For example, writing about the event may help individuals integrate and organize their traumatic memories. Another mechanism may be the potential of WET to encourage the disclosure of the traumatic memory to others, thus strengthening their social bonds which, in turn, reduces their symptoms (Sloan et al., 2012).
Empirical Evidence of the Effectiveness of WET
In response to the findings of Sloan, Marx, and Greenberg (2011), Sloan et al. (2012) developed the updated treatment protocol with five, 30-minute sessions, and added components of psychoeducation and a revised treatment rationale. They named this new protocol written exposure therapy (WET) to distinguish it from its forerunners. Its rationale highlighted the importance of confronting traumatic memories rather than avoiding them and used writing as the means of this confrontation. They tested their program of WET against a control group assigned to a waitlist (WL) with 46 individuals diagnosed with PTSD related to a motor vehicle accident. The sample was applicably ethnically diverse and was also consistent with dual diagnoses and substance usage in the population of PTSD-diagnosed individuals. Measures included PTSD symptom severity, self-reported emotion in response to sessions, and perceived treatment credibility and satisfaction. Treatment dropout rate was extremely low (9%, n = 2), which compares quite favorably to retention rates in other PTSD treatments, indicating tolerability in addition to effective participant retention strategies (Foa et al., 2005). Results showed that participants randomly assigned to the WET condition exhibited significantly reduced PTSD symptom severity at each follow up session (6-, 18-, and 30-week post-baseline) as compared to WL participants. The resulting effect size was quite large (g = 3.49), and is comparable with that of other EBPs for treating PTSD (exposure therapy: g = 1.91; cognitive processing therapy: g = 1.13) (Sloan et al., 2012). Finally, there were also significant reductions in negative affect and arousal over the course of treatment as well as high perceived credibility and satisfaction.
While this study revealed promising heuristic results, there were a few limitations that should be addressed. For one, participant demographics were limited to motor vehicle accident survivors, so it is unclear if the results would generalize to other traumas (military, sexual assault, etc.). The highly significant results may also have been artificially inflated by the control group of a WL versus another treatment (EBP or neutral writing condition). The study did address this, however, citing the appropriateness of such a technique when initially testing a recently developed treatment. As this was the first study introducing WET, subsequent research attempts to address these points.
One such study tested the treatment in an uncontrolled trial with PTSD-diagnosed veterans (Sloan et al., 2013). Participants were seven white male veterans (average age = 54.29) who had all experienced a military-related trauma an average of 30.85 years prior. Outcome measures included the Clinician-Administered PTSD Scale for PTSD diagnosis and symptom severity, a Structured Clinical Interview to assess for other DSM diagnoses, and the Client Satisfaction Questionnaire. The procedure followed the guidelines for WET with five treatment sessions, and participants’ PTSD severity was assessed pretreatment, posttreatment, and at a 3-month follow-up. One participant dropped out after attending three sessions, reporting that he believed the treatment would not work for him; however, he did complete all of the assessments. Clinically significant reductions in PTSD symptom severity were found for four of the seven participants at posttreatment. By the 3-month follow-up, six out of the seven showed significant symptom reduction and five participants no longer met the criteria for PTSD. Participants reported high satisfaction with the treatment and did not report needing supplemental therapist support between sessions for increased distress.
These results may indicate that WET is an appropriate treatment to apply to PTSD from military trauma however this study too has its limitations. The small sample size, lack of a control group, and dearth of diversity in the sample greatly limit the generalizability of the study.
In 2018, Sloan, Marx, Lee, and Resick attempted to further analyze the effectiveness of WET in recognition of the earlier limitations. They randomly assigned 126 participants diagnosed with PTSD to receive either WET or CPT in order to assess WET against a widely disseminated and empirically supported treatment. Participants were 52% male, mostly White, Hispanic/Latino, and African American, with an average age of 43.9. They were given an initial clinical interview for PTSD diagnosis and comorbid disorders and assessed for treatment expectancy in the first session, and assessed at baseline, 6-, 12-, 24-, and 36-weeks post-treatment for PTSD symptom severity. Treatment satisfaction was measured in the last treatment session; all assessors were blind to the assigned conditions. The WET condition used the same five, 30-minute session paradigm, and the CPT treatment involved a 12-sesion trauma-focused intervention of challenging distorted cognitions about the traumatic event and their own self-concept, as well as two trauma accounts to be written at home. In addition to these accounts, homework was assigned between each session of CPT. Results showed that participants were significantly more likely to drop out of the CPT treatment prematurely (31.7% in CPT, 6.3% in WET). Both groups showed significant reductions in PTSD severity but did not significantly differ from each other. These results were also not biased by treatment expectancy or satisfaction, as those measures did not differ based on condition. A follow-up study was even conducted by Thompson-Hollands, Marx, Lee, Resick, and Sloan (2018) to see if these results were maintained in a 60-week follow-up with the original participants. Their analysis proved that WET remained noninferior to CPT even approximately a year after the start of treatment.
These findings may challenge the previous understandings of the necessary doses of therapy for successful outcomes of PTSD. This study shows that PTSD symptoms can be reduced with both less therapeutic exposure and fewer number of sessions than some current and well-recommended EBPs. While the study’s mixed-trauma sample may not have provided specific results that could be applied to veterans on their own, for example, it still speaks to the retention abilities and effectiveness of a shorter, less emotionally and temporally demanding treatment.
Benefits of WET
These identified benefits are consistent with those recognized throughout the literature on WET. In each study mentioned, dropout rate was low and favorably comparable to other EBPs. This indication of tolerability may be directly connected to the complementary advantages of the treatment’s acceptability and efficiency. Although none of the studies mention cost, cost effectiveness may be extrapolated from required clinician time and training. As compared to CPT’s or PE’s 500 minutes or more of face-to-face therapist contact, WET involves no more than 75 minutes of face-to-face clinician contact. Simultaneously, while clinician contact in WET is low, client perceived treatment credibility and satisfaction are high (Sloan et al., 2012). Due to these factors of reduced face-time and number of sessions, WET also lends itself to potential use in telehealth care settings (Sloan et al., 2013; Austern, 2015).
Conclusions and Future Directions
Written exposure therapy has its roots in the beneficial health outcomes tied to writing about one’s emotions and troubling thoughts. The brief, nonintrusively therapist-led treatment may operate through facilitating habituation to feared stimuli, education of the conditioned-stimulus response, strengthening of social bonds, and integration of problematic memories. This is still a relatively recent development in PTSD treatment, and as such necessitates further research with varied samples, methodologies, and replications. Especially pertinent is to conduct a larger WET study with veterans or current military service members, as there is some research suggesting lower efficacy of trauma-focused PTSD treatments in those populations (Sloan et al., 2018). Nevertheless, there have been empirically supported benefits of disseminating trauma-focused, exposure-based treatments to those struggling with PTSD, and WET with its high tolerability, efficiency, and perceived credibility appears an effective treatment to be considered among these best-practices.