- The best-tested treatments for PTSD are highly effective but require intensive therapist involvement.
- A new study found that writing about one's trauma could be just as helpful as recounting it to a therapist.
- The study also found that shorter sessions and fewer sessions could be highly effective.
- The written exposure therapy treatment had fewer dropouts than the traditional approach.
A major trauma can have devastating effects on a person's life. Many of the men and women I've treated in my therapy practice told me that their lives changed dramatically after the traumatic event. Post-traumatic reactions can include changes in how a person sees the world and themselves, as well as major shifts in emotion and behavior.
Fortunately, there are effective treatments for post-traumatic stress disorder (PTSD). I have used one of these treatments for many years. It's called prolonged exposure treatment (PE), a form of cognitive behavioral therapy (CBT). The name comes from the central part of PE, which involves retelling the story of one's trauma with their therapist (exposure) for 30 minutes or longer (prolonged).
Not surprisingly, most people find it hard to confront their painful memory, especially at first. But with repeated retellings, the incident loses its emotional charge. By the end of treatment, many people say they're starting to feel bored by the memory.
It's not a pleasant thing to think about, but it no longer triggers the strong emotions that it did before treatment. They haven't grown numb to it. The emotional numbness that often follows trauma tends to fade with effective treatment. Instead, they describe being able to make peace with the memory and no longer feeling controlled by it.
Limitations of Prolonged Exposure
However, prolonged exposure therapy is very intensive. It requires a person to commit not only to attending 8 to 15 sessions, but each session can last 90 minutes. These long treatment sessions are often hard for therapists to accommodate since typical sessions are 45-50 minutes long, and longer sessions would be more expensive for their clients (and are often denied by health insurance companies).
PE also includes a lot of "homework" for clients between sessions, including listening to an audio recording of themselves recounting their trauma memory in their session and facing things they've been avoiding because of the trauma (e.g., being in a car for those whose trauma was a motor vehicle accident).
Many of the people I treated were understandably hesitant to revisit the story of their trauma, given the distress it caused. Not surprisingly, a fairly high percentage of people drop out of prolonged exposure. One study of veterans found that nearly 45 percent dropped out of the treatment, which was higher than for a comparison CBT program called cognitive processing therapy (33 percent).
Written Exposure Therapy
A new study addresses these limitations. Psychologist Denise Sloan, Ph.D., a professor at the National Center for PTSD in Boston, along with several of her colleagues, completed a large-scale study among veterans that directly compared prolonged exposure to written exposure therapy (WET). The researchers randomly assigned 178 participants to receive one of these treatments and tracked participants' symptoms over the following seven months.
The written exposure treatment was significantly shorter—those in the WET condition had about half as many sessions (6.2) as those with prolonged exposure (12.5). Each WET session was also shorter—45 to 60 minutes versus 90 for PE—and did not include any between-session assignments that are part of PE.
In five of the WET sessions, the person wrote about their trauma for 30 minutes. They focused on the feelings and thoughts they had during the trauma for the first three writing sessions; the last two focused on how the event had affected their lives.
A Highly Promising New Approach
Results showed that those in the written exposure therapy condition did just as well as those who got PE. For both groups, 40 percent no longer met the criteria for PTSD at the 7-month assessment point. The groups were also very similar in their reduction of symptoms—23 percent for WET and 25 percent for PE.
But a significant difference between treatment groups emerged for dropout: The rate for the PE group (35.6 percent) was nearly triple that of the WET group (12.5 percent). The vast majority of those who dropped out of PE (30 of 32) did so by the seventh session, showing that higher dropout cannot be blamed on the fact that PE was a longer treatment compared to WET.
The authors note that additional research is needed, given the many studies showing PE and similar treatments to be effective. However, Sloan and her collaborators have added important findings to many studies showing that writing about a trauma can take the sting out.
Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 107.
Sloan, D. M., Marx, B. P., Acierno, R., Messina, M., Muzzy, W., Gallagher, M. W., ... & Sloan, C. (2023). Written exposure therapy vs prolonged exposure therapy in the treatment of posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry.
Sloan, D. M., Marx, B. P., Resick, P. A., Young-McCaughan, S., Dondanville, K. A., Straud, C. L., ... & STRONG STAR Consortium. (2022). Effect of written exposure therapy vs cognitive processing therapy on increasing treatment efficiency among military service members with posttraumatic stress disorder: A randomized noninferiority trial. JAMA Network Open, 5, e2140911-e2140911.