What is Written Exposure Therapy?

What is Written Exposure Therapy (WET)?

Written Exposure Therapy (WET) is a concise, five-session intervention designed to alleviate symptoms of post-traumatic stress disorder (PTSD). Rooted in extensive research on expressive writing by Dr. James Pennebaker, WET encourages individuals to confront their traumatic experiences through structured writing exercises. The therapeutic process involves recounting specific traumas, focusing on emotional and sensory details, over multiple sessions.

As discussed in the article of Thompson-Hollands et al. (2019), mechanistic studies suggest that WET operates through processes such as the extinction of conditioned fear responses. By activating cognitive structures related to fear during writing sessions, individuals experience reduced arousal levels over time, contributing to symptom improvement. Continued investigation into these mechanisms enhances our understanding of how WET produces therapeutic effects.

What makes this different from other exposure therapies?

Written Exposure Therapy stands out from other exposure therapies, such as prolonged exposure therapy (PE), due to its efficiency and effectiveness, particularly in addressing the needs of veterans with posttraumatic stress disorder. While PE and cognitive processing therapy (CPT) are recognized as effective PTSD treatments, barriers such as treatment intensity and high dropout rates among veterans remain significant challenges. WET offers a compelling alternative by providing a structured, exposure-based intervention that is notably briefer than traditional approaches.

In a non-inferiority randomized design study comparing WET to PE in a veteran sample, Sloan et al. (2021) aim to demonstrate that WET is as effective as PE in reducing PTSD symptoms. By investigating whether WET can achieve comparable outcomes with fewer treatment sessions, this study addresses the critical need for more efficient and accessible PTSD treatment options for veterans. With its focus on assessing PTSD symptom severity using validated measures like the Clinician-Administered PTSD Scale for DSM-5, this research contributes to advancing evidence-based care for veterans.

WET's streamlined format, characterized by five sessions without between-session assignments, offers several advantages over traditional exposure therapies. Its brevity makes it more feasible for both veterans seeking treatment and providers delivering care. Additionally, the absence of between-session assignments simplifies the treatment process and reduces patient burden.

Furthermore, WET's effectiveness has been demonstrated in previous research, showing non-inferiority to more time-intensive trauma-focused treatments. By leveraging expressive writing techniques, WET facilitates the processing of traumatic experiences while minimizing the time commitment required from both patients and mental health professionals. This efficiency is particularly appealing in the context of addressing the unique needs of veterans with PTSD.

How long do WET programs usually last?

WET programs are structured, concise treatments for PTSD, consisting of five sessions lasting approximately 40 minutes each. The first brief exposure-based treatment session, lasting about an hour, provides psychoeducation about PTSD and the use of expressive writing as a therapeutic tool.

The next session involves 30 minutes of structured writing about the same traumatic event identified in the first session. After each session, brief check-ins with the therapist are conducted to gauge the patient's response.

WET differs from traditional exposure therapies by not including between-session assignments, making it more manageable for patients and mental health professionals. This structured yet concise format makes WET an efficient and effective treatment option for PTSD.

Core competencies and skills of WET therapists

Core competencies and skills of therapists practicing WET are essential for effectively treating anxiety disorders, including PTSD. While the discussion in the book of Abramowitz (2019) primarily focuses on EP for Anxiety, the principles and practices discussed are highly relevant to WET due to their shared emphasis on exposure-based interventions.

• Transdiagnostic approach: WET therapists must understand the underlying conceptual framework of anxiety disorders, recognizing that objectively safe stimuli are often misperceived as dangerous.
• Application of therapeutic exposure: Therapists proficient in WET apply exposure techniques to promote fear tolerance and inhibitory learning, which are effective mechanisms of change.
• Functional assessment and treatment planning: Competent WET therapists conduct thorough functional assessments to identify specific fear cues, feared consequences, and safety behaviors unique to each patient.
• Implementation strategies: WET therapists employ evidence-based implementation strategies to facilitate exposure sessions effectively.
• Case formulation and intervention flexibility: Competent WET therapists demonstrate proficiency in case formulation, synthesizing assessment data to develop a comprehensive understanding of each patient's anxiety symptoms and treatment needs.
• Ethical considerations and treatment integration: WET therapists navigate ethical considerations related to EP, including risk-benefit analyses and ensuring informed consent.

What are their goals?

While the therapy can help by developing a more balanced view of themselves and others moving forward; The goals of WET therapists are to:

• Provide education: They educate individuals about PTSD and WET, explaining how the therapy works and discussing treatment goals.
• Facilitate trauma processing: Therapists guide individuals in writing about their traumatic experiences, focusing on their thoughts and feelings. They help process difficult memories and emotions to reduce distress.
• Encourage reflection: Therapists assist individuals in reflecting on how the trauma has affected their self-perception, relationships, and worldview. They provide feedback to promote continued reflection and growth.
• Support emotional processing: Therapists help individuals process their writing experiences during sessions, facilitating shifts in their perspectives and emotional responses.

What code of ethics do they abide by?

WET therapists abide by the following ethical considerations as discussed in the article by Davidson (2016); WET therapists prioritize the use of empirically-supported treatments, such as EP, for anxiety disorders, recognizing it as the gold standard for various psychopathologies. They obtain informed consent from patients on an ongoing basis, following ethical mandates from the American Psychological Association (APA). Risk management strategies include scheduling adequate length of sessions, preparing for negative outcomes, and conducting exposures both inside and outside traditional office settings. Competence and training are crucial in delivering exposure-based treatments, with increased training opportunities and dissemination of expert guidelines. Integrating scientific thinking in clinical practice is also emphasized, ensuring treatment decisions are guided by empirical evidence and expert consensus guidelines. This bridging the gap between research and practice improves the utilization of empirically-supported treatments.

General prompts for WET sessions

In this therapy, therapists play a crucial role in guiding patients through the process of confronting and processing traumatic memories. Utilizing a structured approach can enhance the therapeutic journey and aid in symptom reduction.

Here are 10 guiding questions and discussion points commonly used by WET therapists to support patients in their recovery journey:

1. Exploring traumatic memories: Begin by gently exploring the patient's traumatic memories. Ask open-ended questions like, "Can you describe the event that led to your PTSD symptoms?" or "What thoughts come to mind when you think about that experience?"
2. Identifying triggers: Help the patient identify triggers associated with their trauma. Discuss situations, thoughts, or emotions that tend to evoke distressing memories. For instance, ask, "What situations or thoughts make you feel most anxious or overwhelmed?"
3. Understanding avoidance behaviors: Explore any avoidance behaviors the patient may engage in to cope with their PTSD symptoms. Encourage them to reflect on how avoidance affects their daily life and relationships. Ask, "How do you typically respond when faced with reminders of the traumatic event?"
4. Challenging negative beliefs: Assist the patient in challenging negative beliefs stemming from their trauma. Encourage them to examine the validity of these beliefs and consider alternative perspectives. Prompt with questions like, "What evidence supports or contradicts your belief about yourself or the world?"
5. Writing the trauma narrative: Guide the patient through the process of writing their trauma narrative. Discuss the importance of detailing their thoughts, emotions, and sensory experiences during the event. Ask, "Can you describe the sequence of events leading up to, during, and after the traumatic experience?"
6. Reflecting on emotional responses: After writing the trauma narrative, facilitate reflection on the emotional responses it evokes. Encourage the patient to explore any shifts in their emotional intensity or clarity. Inquire, "How do you feel after writing about the traumatic experience? Are there any changes in your emotional state?"
7. Examining cognitive distortions: Explore any cognitive distortions present in the patient's perception of the traumatic event. Help them identify and challenge distorted thoughts or beliefs. Use prompts like, "Do you notice any patterns of thinking that might be influencing how you perceive the trauma?"
8. Practicing exposure between sessions: Emphasize the importance of practicing exposure exercises between sessions, especially in the first treatment session. Discuss strategies for gradually confronting triggers and tolerating distress. Ask, "What exposure exercises do you feel comfortable trying between our sessions?"
9. Tracking symptom progress: Encourage the patient to track changes in their PTSD symptoms over time. Use assessment tools or self-monitoring logs to monitor symptom severity and frequency. Inquire, "Have you noticed any changes in your PTSD symptoms since starting therapy? How do you rate your distress levels compared to before?"
10. Setting treatment goals: Collaboratively establish treatment goals that align with the patient's recovery journey. Discuss realistic and achievable outcomes, considering both short-term and long-term objectives. Prompt with questions like, "What specific changes would you like to see in your life as a result of therapy?"

Isn't exposure therapy potentially dangerous?

EP is often perceived as potentially dangerous due to the nature of deliberately confronting feared stimuli, which can evoke intense emotional responses in individuals with anxiety disorders like PTSD. However, it's essential to address this concern by examining the available evidence and ethical considerations surrounding EP.

According to Davidson (2016), EP is recognized as a gold standard treatment for various psychopathologies, including anxiety disorders. Despite its efficacy, concerns about potential harm may deter practitioners from utilizing this treatment modality. However, empirical evidence suggests that EP is not inherently harmful. Treatment dropout rates for exposure therapies are comparable to other interventions, and exposure is safer than psychotropic medications alone for anxiety disorders (Cahill & Foa, 2004).

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References

Abramowitz, J. S. (2019). EXPOSURE THERAPY FOR ANXIETY: principles and practice. Guilford Publications.

Cahil, S.P. & Foa, E.B. (2004). A glass half empty or half full? Where we are and directions for future research in the treatment of PTSD. In S. Taylor, (Ed.). Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (pp 267-313). New York: Springer.

Davidson, J. (2016, November 6). Ethical considerations of exposure therapy. Portland Anxiety Clinic. https://portlandanxietyclinic.com/ethical-considerations-of-exposure-therapy/

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, 100764. https://doi.org/10.1016/j.conctc.2021.100764

Thompson-Hollands, J., Marx, B. P., & Sloan, D. M. (2019). Brief novel therapies for PTSD: Written exposure therapy. Current Treatment Options in Psychiatry, 6(2), 99–106. https://doi.org/10.1007/s40501-019-00168-w