The two therapies were found to be equally effective, and only 12.5 percent of subjects in the written exposure group dropped out before completing a course of treatment, compared to 35.6 percent in the prolonged exposure group. In 2018, a study by the same team found that written exposure therapy was as effective as cognitive processing therapy, another first-line, or most recommended, PTSD treatment.
Writing down traumatic memories can be easier for some people, if they feel shame or embarrassment about what happened to them, says Denise Sloan, a psychologist who helped develop the treatment and an author of student He said patients were asked to write by hand, which took longer and allowed them to engage in memory.
“It’s a slower process, which allows them to better think about ‘what happened next, and who was there, and what they said,’ because they’re writing about it, said Dr. Sloan, associate director of the Behavioral Science Division of the National Center for PTSD. “It slows everything down, as opposed to just saying it out loud.”
The therapy was inspired by the work of James Pennebaker, a Texas psychologist who, in the 1980s, began experimenting with what he called “expressive writing,” and found that people who regularly wrote about negative life experiences had stronger immune systems and paid fewer doctor visits.
The first study of written exposure therapy as a treatment for PTSD appeared in 2012. It works, says Dr. Sloan, as other trauma-focused treatments do: by allowing the client to confront the traumatic memory, reducing their fear and avoidance, and allowing them to recognize misconceptions such as blame to oneself.
Why It Matters
Cognitive processing therapy and prolonged exposure therapy, the two treatments highly recommended by the Departments of Veterans Affairs and Defense, has been widely used since the 1980s and is backed up by abundant research. A newer method, eye movement desensitization and reprocessing, is rapidly growing in popularity.
But all three are time-intensive, requiring sessions of 60 to 90 minutes for three months or more. A large number of patients – an average of 20 percent, and sometimes as high as 50 percentstudies have shown — stop before completing a course of treatment.
Written exposure therapy, said Dr. Sloan, seems to achieve similar effects with fewer sessions.
“We have a lot of people who need mental health treatment, and we can’t accommodate the demand,” he said. “We have to go back to what we are doing and how much is needed for good results. Because most people cannot go to treatment for 12 to 16 sessions.
what next
Data on the effectiveness of written exposure therapy are still emerging.
The studies comparing it with cognitive processing therapy and prolonged exposure therapy were non-inferiority trials – designed to show that a newer treatment was no worse than an established one – and “not as scientifically rigorous as ” as tests done to determine superiority, said Dr. Barbara Rothbaum, one of the developers of prolonged exposure therapy. He added that dropout rates at his clinic, at Emory University, are about 10 percent.
There’s a reason, he said, that talk therapy has such a strong record of success in treating PTSD.
“There’s something inherently healing about saying out loud the worst, scariest, most embarrassing, most humiliating moment of your life to someone else who’s trying to be supportive,” she says. “Is that necessary? No.”
Written exposure therapy is not endorsed as a first-line intervention by the Departments of Veterans Affairs and Defense in its latest clinical practice guidelines, largely, Dr. Sloan, due to the small number of published studies examining it.
That is likely to change in the next two years, he said, as several larger tests are completed. Clinicians, too, need to get used to the idea of using writing, in addition to speaking, to communicate with patients on painful topics.
“Some people, they feel threatened by it, because it’s kind of a challenge to the tree of what they normally do,” he said. “It flies in the face of what they think is important in treatment.”
