By Holly N. O'Reilly, Ph.D.
May 6, 2020

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Written exposure therapy, also called written narrative exposure therapy, is a brief trauma-focused treatment for PTSD which may readily be adapted for use during the current telehealth environment.

What is written exposure therapy (WET)?

The WET protocol is an evidence-based, trauma-focused treatment which may lead to a clinically significant reduction in PTSD symptoms in five treatment sessions. WET was adapted by Sloan and colleagues from the Pennebaker & Beal (1986) version. The first treatment session is 60 minutes in length and provides psychoeducation about reactions to trauma, PTSD and WET followed by a 30-minute written trauma narrative session. The clinician provides guidance and allows the patient to complete the trauma narrative during the treatment session. During the following four 30-minute sessions, the patient completed the narrative alone, later the provider gives feedback on the prior session's trauma narrative. Sessions may occur weekly or more often as indicated by clinical presentation, severity of PTSD symptoms, and patient availability. For more specifics, see Sloan and Marx (2019).

How does WET differ from prolonged exposure (PE) and cognitive processing therapy (CPT)?

• There is no "homework" in WET therapy
• Research suggests that there are lower attrition rates than PE or CPT
• The provider does not engage the patient in cognitive restructuring

Does WET work for military populations?

Research suggests that WET is best suited for adult populations and is strongly recommended in the 2017 VA/DOD Management of Posttraumatic Stress Disorder and Acute Stress Reaction Clinical Practice Guideline.

A recent study compared WET to CPT, including a subsample of veterans and, found that WET was non-inferior to CPT (Sloan et al, 2018).

How do I get smart on WET and implement it quickly?

For providers who are already trained in exposure-based trauma-focused treatments, no additional training is required and the WET protocol allows clinicians to pivot the trauma-treatment skill set to a telehealth format.

It is important to start with a firm grasp of the theoretical framework underlying imaginal exposure. Without being too reductionist, repeated exposure to trauma-related memories allows habituation and eventually extinction to take place over time, leading to reduced anxiety in response to trauma-related stimuli. To this end, it is critical to conduct a detailed trauma history interview prior to treatment, selecting the trauma memory which is most salient, elicits the most symptoms or is most representative of repeated trauma exposure.

When conducting sessions, it is important to read the instructions for the written narrative verbatim, without improvising or rewording (Sloan & Marx, 2019). Clinicians should also measure PTSD symptoms (e.g., using the PTSD Checklist or other measure) at baseline and regularly throughout treatment. As the patient completes the written narrative in session, the patient should fully engage in the narrative without breaks or distractions (e.g., listening to music). Following each session, the patient allows the clinician to review the written trauma narrative and provide specific guidance and redirect as needed. At the beginning of sessions two through five, the provider should open the session with a "check-in" to review changes in trauma memory or changes in their reaction to the trauma memory. The clinician will share feedback regarding the written trauma narrative, help the patient to focus on the most salient traumatic memory, and encourage inclusion of thoughts and emotions as part of the narrative.

I encourage clinicians to read the manual in its entirety and to consider supervision when first implementing this treatment protocol.

How can I translate WET to telehealth?

The WET sessions may be easily conducted via Adobe Connect or a similar platform. Depending on the platform capabilities, you may be able use the file transfer or chat function to share the directions with the patient. Likewise, the patient may scan or take a picture of their trauma narrative to share with the provider through the file transfer function.

Resources

1. Pennebaker, J. W., & Beall, S. K. (1986). Confronting a traumatic event: toward an understanding of inhibition and disease. Journal of abnormal psychology, 95(3), 274.
2. 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 clinical trial with motor vehicle accident survivors. Behaviour research and therapy, 50(10), 627-635.
3. 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.
4. Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. Washington, DC: American Psychological Press.

Dr. O'Reilly is a clinical psychologist and sexual assault/sexual harassment SME at the Psychological Health Center of Excellence. She specializes in the consequences of psychological trauma and women's mental health.