What is Written Exposure Therapy for PTSD?

Summary: Written exposure therapy for PTSD, a.k.a. posttraumatic stress disorder, is a variation one of the most effective, evidence-based approaches to PTSD available, called progressive exposure therapy, or more simply, exposure therapy.

Key Points:

• Cognitive-behavioral exposure therapies focus on gradual exposure to traumatic memories in an emotionally safe environment.
• Facilitated by therapists trained in trauma-informed principles, patients gradually learn to detach negative emotions from memories of their initial traumatic experience.
• This process can significantly reduce disruptive PTSD symptoms and allow patients to return to full and productive function across life domains, such as family, peer relationships, work, and school.

The Need for Effective PTSD Treatment: PTSD Definition and Symptoms

The American Psychological Association (APA) provides this definition of PTSD:

“PTSD is a mental health condition that some people develop after experiencing or witnessing traumatic events. These events pose significant physical, emotional or psychological threat to the victim or to loved ones, and are overwhelming, shocking or dangerous.”

Events and experiences that may trigger subsequent PTSD include, but aren’t limited to:

• Witnessing or experiencing war firsthand and/or living in a war zone
• Sexual abuse, assault, rape
• Emotional abuse
• Physical assault
• Emotional, sexual, or physical abuse during childhood
• Witnessing or experiencing domestic violence
• Serious accident, illness, disease, or injury
• Natural disasters including fires, floods, hurricanes, tornadoes, earthquakes
• Witnessing serious injury and/or death of another person

When a person experiences those events, the emotions they feel are often too powerful, painful, and confusing to understand, discuss, or process effectively. Therefore, over time, people with a history of trauma develop strategies to avoid those emotions. These strategies may be effective for a short time, but in most cases result in the appearance of disruptive symptoms.

PTSD: Common Symptoms

• Flashbacks to the event, which may include:
  • Negative emotions such as fear and anger
  • Include physical responses such as elevated heart rate, sweat, chills, nausea
• Avoidance of anything that may evoke memories of the event or trigger flashbacks, including:
  • People and places associated with the event
  • Talking about the event
• Deteriorating mental health, which may include:
  • Self-isolation
  • Persistent negative emotion
  • Chronic fatigue
  • Decreasing self-esteem
  • Self-medication with alcohol or drugs
• Hypervigilance/hyperarousal:
  • Persistent anxiety and worry
  • Always feeling on edge, irritable, jumpy
  • Tantrums, i.e. anger that seems mismatched to the proximate cause
  • Insomnia, caused by anxiety, thoughts of the event, current anxiety

Those symptoms can make daily life difficult, and for some patients, make participating in or fulfilling daily responsibilities impossible. Although facing and processing thoughts and emotions related to past trauma is difficult, the consequences of deferring treatment can be severe.

The Consequences of Untreated PTSD

PTSD affects millions of people in the U.S. The latest data shows that at any given time, around 13 million people in the U.S. have a recent PTSD diagnosis, with around 20 million people having received a PTSD diagnosis during their lives.

Without professional support, those people face significant distress and difficulty. When left untreated, untreated symptoms of PTSD can escalate and appear as:

• Depressive disorders
• Aggressive behavior
• Anger/problems managing anger
• Withdrawal from friends, family, social interaction
• Suicidal ideation and attempts
• Alcohol and/or drug addiction
• Unstable relationships
• Risky behavior

In addition, PTSD is associated with an increase in chronic and acute physical problems, including, but not limited to:

• Changes in brain structure and function
• Problems with the heart and circulatory system
• Disorders affecting muscles, bones, and joints
• Digestive problems
• Metabolic disorders

That’s why effective, evidence-based treatment for PTSD is important. To learn more about PTSD, please read the following articles on our blog:

PTSD Treatment: How Do I Find It and What Does It Involve?

Do You Need a Psychiatrist for Complex PTSD?

Are There Psychiatrists Who Specialize in Trauma? What Does That Entail?

For the rest of this article, we’ll focus on a new approach to PTSD treatment, which is really a restructuring of specific elements of a common, and now traditional approach.

Written Exposure Therapy: Writing to Process Past Trauma and Emotion

The U.S. Department of Veterans Affairs funds and maintains the National Center for PTSD, which includes an analysis and review of written exposure for PTSD in the online resource “Written Exposure Therapy (WET) for PTSD.”

We’ll use that as a resource for this information that follows, as well as a meta-analysis called “State of the Science: Written Exposure Therapy for the Treatment of Posttraumatic Stress Disorder,” which provides the evidence base for the WET protocol developed for veterans with mild, moderate, and severe PTSD. Here’s how the study authors describe the need for expanding PTSD treatment options:

“Although there are effective psychotherapies available for posttraumatic stress disorder (PTSD), brief treatments for PTSD are needed to expand the reach of treatment. Written exposure therapy (WET) is a brief treatment that has the potential to fill an important need in PTSD treatment and has a rapidly expanding evidence base to support its use.”

Written exposure therapy (WET) as developed by therapists at the VA, is a short intervention consisting of five one-on-one therapy/counseling sessions that last 45 minutes to an hour each. During these sessions, patients provide – in written form – the following information:

• Details about the traumatic event
• How they think and feel about the event
• How the event has and continues to affect their lives

We’ll break down the stepwise flow of the sessions now.

First Session

• One hour long
• Therapist offers education on the science of PTSD and the theory supporting exposure therapy and written exposure therapy
• Therapist introduces the first writing prompt, patient follows prompt and writes of 30 minutes
• After 30 minutes, therapist ends the exercise and asks patient for feedback on the experience of encountering their traumatic memory through writing

Remaining Sessions

• 45 minutes long
• Begin with check-in/debrief, update on how things are going with patient
• Therapist offers feedback on writing from previous session
• Therapist provides next prompt, patient writes for 30 minutes
• After 30 minutes, therapist ends the exercise and asks about the writing experience.

Sessions Three and Four

• 45 minutes long
• Begin with check-in/debrief, update on how things are going with patient
• Therapist prompts the patient to write about how their traumatic experience has affected their life
• Post-writing check in focuses on that topic

Session Five

• 45 minutes long
• Begin with check-in/debrief, update on how things are going with patient
• Therapist prompts patient to write about what they learned by writing about their traumatic experience and memories, and how they can take what they learned and apply it to managing their symptoms in daily life, today, tomorrow, and in the future.

One major difference between WET and other forms of exposure therapy is that therapists do not assign between-session tasks or therapy homework. Therapists encourage patients not to avoid their traumatic memories, however, and checks in on the experience of encountering those memories at the beginning of the next session.

How Effective is Written Exposure Therapy for PTSD?

The VA therapists who developed WET solidified their protocols over a 20 year period of direct, hands-on work with patients. The study we cite above is a summary of the research conducted on WET after this phase, when WET was ready for more widespread dissemination and use among populations outside of combat veterans.

The VA team analyzed data from a total of 17 sources that examined the effectiveness of WET for various treatment populations, including:

• Survivors of severe accidents
• Survivors of childhood sexual assault/abuse
• Adolescents who survived a terrorist attack

Studies occurred in a variety of settings, including:

• Outpatient clinics
• Inpatient hospitalization units
• Residential addiction treatment programs

Studies also involved various treatment contexts, including:

• Individual therapy
• Group therapy
• Telehealth/virtual therapy

We’ll report the big picture results from those studies by their effect size, which is a measure of the difference between outcomes from a control group and an experimental group in a given study.

For reference, an effect size of ≤ 0.2 is considered small, an effect size of 0.5 is considered medium, and an effect size 0.8 is considered large.

Results of Recent Studies on WET for PTSD

1. Ahmadi, 2022:
   • Large, strong effect size: 1.19
2. Andrews, 2022:
   • Large, strong effect size: 1.28
3. Ellis, 2023:
   • Large, strong effect size: 1.26
4. LoSavio, 2023:
   • Large, strong effect size: 0.84
5. Morissette, 2023:
   • Large, strong effect size: 1.47
6. Nillni, 2023:
   • Large, strong effect size: 1.24
7. Park, 2021:
   • Large, strong effect size: 1.75
8. Schacht, 2023:
   • Large, strong effect size: 0.91
9. Sloan, 2012:
   • Large, strong effect size: 3.18
10. Sloan, 2018:
    • Large, strong effect size: 0.51
11. Sloan, 2022:
    • Small, weak effect size: 0.48
12. Sloan, 2023:
    • Medium, moderate effect size: 0.70
13. Zolfa, 2023:
    • Large, strong effect size: 5.02
14. Schumacher, 2023:
    • no difference
15. Sloan, 2013:
    • no difference
16. Tyler, 2022:
    • no difference
17. Yun, 2022:
    • no difference

After a thorough analysis of the initial data and extensive statistical review to account for confounding factors and determine the effect sizes listed above, the VA researchers concluded:

“Overall, these findings indicate that WET results in substantial PTSD symptom reductions, and the reported effect sizes are consistent with other more time-intensive evidence-based PTSD psychotherapies.”

The overall results are good: WET can work for a diverse range of patients across various treatment milieu. Another important outcome is its effectiveness in a relatively short time. Patients report real gains in just over a month, which means this approach expands access to treatment options for people with challenges related to time, money, and transportation.