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The Evidence BaseD Practitioner

The Official Publication of the Philadelphia Behavior Therapy Association

Written Exposure Therapy for Posttraumatic Stress Disorder: An Update

02/26/2022 9:26 AM | Anonymous

Denise M Sloan, PhD - National Center for PTSD at VA Boston Healthcare System & Boston University School of Medicine

Nearly 20 years ago, Dr. Brian Marx and I conducted our first study of expressive writing (Sloan & Marx, 2004). We were intrigued by the results from a systematic line of research by James Pennebaker and colleagues (e.g., Pennebaker and Beall, 1986) in which they had participants write about their most traumatic or stressful life event on three consecutive days for 20 minutes each time sessions. We were quite surprised, and skeptical to be honest, with the consistent, significant symptom improvements observed across Pennebaker and colleagues’ studies as well as the hundreds of expressive writing studies that followed in their wake (for a review see, Frattaroli, 2006).  As we read the details of these studies, we were struck by the similarity of the expressive writing protocol to exposure-based treatments for posttraumatic stress disorder (PTSD), such as Prolonged Exposure (PE; Foa et al., 2019). Yet, despite the procedural similarity of asking individuals to recount the details of traumatic experiences, we were not convinced that writing about one’s trauma for only 20 minutes during three consecutive sessions would be enough of a therapeutic dose to result in significant decreases in PTSD symptoms among individuals who had experienced a bona fide traumatic stressor and had at least moderately severe PTSD symptoms. However, this was exactly what we found (Sloan & Marx, 2004).

These initial findings made us question what was known about how to best treat PTSD and, more specifically, how many therapy sessions might be necessary for good clinical outcomes. Following our initial study, other researchers have demonstrated that PTSD can be successfully treated with fewer therapy sessions than was previously thought necessary (Galovski et al., 2012; Natsh et al., 2015; van Minnen & Foa, 2006). The results of our first study were so intriguing to us that we wanted to follow it up with a second study. The findings of that second study resulted in a series of studies examining the use of expressive writing to treat PTSD and comorbid disorders experienced by trauma survivors (see, Sloan & Marx for a summary, 2017). This work ultimately led to the development of the written exposure therapy (WET) protocol (Sloan & Marx, 2019), a five-session treatment for PTSD, with no between-session homework assignments.  

We have conducted several randomized clinical studies examining the efficacy and effectiveness of the WET protocol. The first study found WET to be efficacious in treating PTSD among individuals who had PTSD resulting from a motor vehicle accident (Sloan et al., 2012). Not only did we observe a large difference in PTSD symptoms at follow-up between individuals assigned to WET and those randomized to a wait-list condition, but we also found that, whereas 88% of individuals randomized to the wait-list condition continued to have PTSD at follow-up, only 9% of individuals randomized to WET still met criteria for PTSD at post-treatment assessment. We also found that only 8% of the participants assigned to WET prematurely dropped out of treatment. This dropout rate is much lower than to the usual dropout rate of approximately 36% for trauma-focused treatments (Imel et al., 2013).

The next study directly compared WET with a more time intensive (12 treatment sessions) evidence-based PTSD treatment, Cognitive Processing Therapy (CPT; Resick et al., 2017). Findings indicated that 126 adults randomized to both treatment conditions had a significant reduction in PTSD symptoms (Sloan et al., 2018). Notably, despite the shorter treatment, WET was found to be non-inferior to CPT in terms of PTSD treatment outcome. Again, the number of individuals dropping out of WET was very low compared to the number of those dropping out of CPT (6% vs. 39%).  We found no differences between the two treatments in terms of treatment expectancy ratings at the beginning of treatment, treatment satisfaction ratings at the end of treatment, or client and therapist ratings of therapeutic alliance at the end of treatment (Sloan et al., 2018). Moreover, treatment gains for both WET and CPT were maintained for a year (Thompson-Hollands et al., 2018).

These findings were replicated in a recently completed study that compared WET with the cognition only version of the CPT protocol, which does not include the written account component of the protocol (Resick et al., 2017), with 169 active duty service members with PTSD (Sloan et al., 2022). Service members randomized to both treatments displayed significant reductions in PTSD symptoms. Once again, treatment outcome for WET was non-inferior to CPT. Although the number of treatment dropouts for WET was notably higher than what we had seen previously (24%), the rate of dropout for CPT was significantly greater (45%).

We also have findings of WET delivered in routine care settings. The United States Veterans Health Administration (VHA) has been training mental health providers in the delivery of WET for the past several years. Patient outcome data from WET being used in routine clinical practice have been collected as part of this training initiative and these findings have been recently reported (LoSavio et al., in press).  Results of this WET implementation project show significant, large reductions in PTSD symptoms. Notably, these outcomes are similar to those observed from implementation efforts within VA for both PE and CPT (Eftekhari et al., 2013). These findings further demonstrate that WET produces treatment outcomes similar to more time intensive trauma-focused treatments, even in routine care settings. In addition, WET delivered by mental health providers working in a college counseling center has also been shown to be effective in treating PTSD symptoms (Morissette et al., in press).

Over the course of our work on WET, we have examined whether WET works better for some patients than others. Notably, we have not found any patient characteristics that impact WET treatment outcomes. More specifically, baseline PTSD symptom severity, presence of comorbid depression, substance use or other mental disorders, time since trauma exposure, number of traumas, trauma type, patient gender, age, ethnicity, race, estimated intelligence, and educational level (e.g., Marx, Thompson-Hollands, et al., 2021; LoSavio et al., in press) do not affect client outcomes for WET.  In addition, there is no treatment outcome differences found when WET is delivered in person versus remotely (LoSavio et al., in press).

There are a number of studies in progress that are examining the utility of WET in various settings such as primary care, residential substance use programs, and inpatient psychiatry (Marx, et al., 2021). Some of these studies are also examining the spacing of treatment sessions (e.g., sessions delivered on consecutive days, multiple sessions in a day). There is a continuing effort to better understand the most efficient and effective methods to disseminate the treatment so that a greater number of providers can deliver WET (e.g., Worley et al., 2020). Lastly, the WET treatment protocol has been translated into Spanish and early results of this version of the protocol are promising (Andrews et al., in press). One area that needs greater attention is the application of WET with children and adolescents with PTSD. We have heard anecdotal reports from providers that WET can yield good outcomes with adolescents but there has yet to be an empirical study in this area.

We have come a long way in the past 20 years in terms of both developing a more efficient treatment for PTSD and establishing that WET is an effective treatment for a variety of individuals and can be used in a variety of settings. We are pleased to hear from providers that they appreciate having another treatment approach to offer their clients.  We are excited by the number of investigators who are conducting treatment studies with WET, and we look forward to findings that will be produced by these studies.

Andrews, A.R., Acosta, L., Acosta Canchila, M.N., Haws, J.K., Holt, N.R., Holland, K.J., & Ralston, A.L. (in press). Perceived barriers and preliminary PTSD outcomes in an open pilot trial of Written Exposure Therapy with Latinx immigrants. Cognitive and Behavioral Practice.  https://doi.org/10.1016/j.cbpra.2021.05.004

Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949–955. https://doi.org/10.1001/jamapsychiatry.2013.36

Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press. https://doi.org/10.1093/med-psych/9780190926939.001.0001

Frattaroli, J. (2006). Experimental disclosure and its moderators: a meta-analysis. Psychological Bulletin, 132, 823-865. https://doi.org/10.1037/0033-2909.132.6.823

Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968–981. https://doi.org/10.1037/a0030600

Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 394-404. https://doi.org/10.1037/a0031474

LoSavio, S. T., Worley, C. B., Aajmain, S., Rosen, C., Stirman, S. W., & Sloan, D. M. (in press). Effectiveness of Written Exposure Therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. _Psychological Trauma: Theory, Research, Practice, and Policy. _http://doi.org/10.1037/tra0001148

Marx, B. P., Fina, B. A., Sloan, D. M., Young-McCaughan, S., Dondanville, K. A., Tyler, H. C., Blankenship, A. E., Schrader, C. C., Kaplan, A. M., Greene, V. R., Bryan, C. J., Hale, W. J., Mintz, J., & Peterson, A. L., for the STRONG STAR Consortium. (2021). 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

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(1), 162-169. http://doi.org/10.1016/j.beth.2020.03.008

Morissette, S. B., Ryan-Gonzalez, C., Blessing, A., Judkins, J., Crabtree, M., Hernandez, M., Wiltsey-Stirman, S., & Sloan, D. M. (in press). Delivery of Written Exposure Therapy for PTSD in a university counseling center. Psychological Services.  https://doi.org/10.1037/ser0000608

Nacasch, N., Huppert, J. D., Yi-Jen, S., Kivity, Y., Dinshtein, Y., Yeh, R., & Foa, E. B. (2015). Are 60-minute prolonged exposure sessions with 20-minute imaginal exposure to traumatic memories sufficient to successfully treat PTSD? A randomized noninferiority clinical trial. Behavior Therapy, 46, 328-341. https://doi.org/10.1016/j.beth.2014.12.002

Pennebaker, J. W., & Beall, S. K. (1986). Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281. https://doi.org/10.1037/0021-843X.95.3.274

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press.

Sloan, D. M., & Marx, B. P. (2004).  A closer examination of the structured written disclosure procedure.  Journal of Consulting and Clinical Psychology, 72, 165-175. https://doi.org/10.1037/0022-006x.72.2.165

Sloan, D. M. & Marx, B. P. (2017). Commentary on the implementation of Written Exposure Therapy WET) for veterans diagnosed with PTSD. Pragmatic Case Studies in Psychotherapy, 13, 154-164.

Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. American Psychological Press. http://doi.org/10.1037/0000139-001

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, 627-635. https://doi.org/10.1016/j.brat.2012.07.001

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, _233-239. https://doi.org/10.1001/jamapsychiatry.2017.4249

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., and 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

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- 985-991. https://doi.org/10.1002/da.22825  

van Minnen, A., & Foa, E. B. (2006). The effect of imaginal exposure length on outcome of treatment for PTSD. Journal of Traumatic Stress, 19, 427–438. https://doi.org/10.1002/jts.20146

Worley, C.B., Losavio, S.T., Aajmain, S.A., Rosen, C., Wiltsey Stirman, S., Sloan, D.M.  (2020). Training during a pandemic: Successes, Challenges, and Practical Guidance during a virtual facilitated learning collaborative for Written Exposure Therapy. Journal of Traumatic Stress, 33(5), 634-642. https://doi.org/10.1002/jts.22589

Published February 26, 2022

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