Post-Traumatic Stress Disorder (PTSD) is a serious mental illness affecting approximately 7% of the population (Goldstein et al., 2016). It is more common in women, military veterans, and individuals from historically marginalized identities (Lehavot et al., 2018; Goldberg et al., 2019). Many people are exposed to trauma in their lifetime and will have symptoms similar to PTSD in the immediate aftermath of the event. However, many people have a natural recovery, and these symptoms fade out quickly. When the symptoms do not remit, individuals that continue to have symptoms related to the trauma. These include intrusion symptoms, negative alterations in cognitions and mood, arousal symptoms, and avoidance (APA, 2022).
Evidence based psychotherapies (EBPs) for PTSD including Cognitive Processing Therapy, Prolonged Exposure Therapy, and Eye Movement Desensitization and Reprocessing have been shown to be effective interventions (VA/DOD, 2023). However, we know that drop out rates are high from these treatments (Goetter et al., 2015), and not everyone can commit to 8-15 sessions of treatment. In the 2000s, Drs. Sloan and Marx began exploring therapeutic writing originally developed by James Pennebaker as another treatment option for PTSD. With care and rigorous experimentation, they developed a protocol for Written Exposure Therapy (WET). Their State of the Science article published in 2024 provides an overview of this work (Sloan & Marx, 2024)
Written Exposure Therapy for PTSD is a brief, 5-session, evidence-based intervention (Sloan & Marx, 2012; Sloan and Marx, 2025). Since its inception, the empirical literature supports the effectiveness of this intervention including a non-inferiority study with CPT and non-inferiority study with PE. It has been recommended by PTSD clinical practice guidelines from APA , the U.S. VA/DoD, and the International Society for Traumatic Stress Studies. The support for Written Exposure Therapy continues to grow including internationally (DeJesus et al, 2024). Therapeutic writing is not a new concept.
Written Exposure Therapy built from James Pennebaker’s work on (1997) expressive writing. However, Written Exposure is not just “journaling” or expressive writing. Sloan and Marx built upon the expressive writing framework with modifications to tailor the writing for patients with PTSD. The protocol was developed and tested in multiple iterations to address the trauma symptoms specifically. This structured protocol provides a framework for the patient to approach their traumatic experience including details, thoughts, and feelings. Importantly, because the patient provides the content, it allows for tailoring to the individual including opportunities for clients to explore individual and cultural diversity factors related to the trauma.
Written Exposure Therapy is unique in its brevity compared to other Evidence Based Psychotherapies for PTSD. WET is not necessarily a new treatment, but a repackaging of existing exposure therapy for PTSD. The exposure happens across five sessions with detailed instructions to write about a single index trauma. The first several sessions focus on approach of the trauma and latter sessions include exploration of the impact. The research support demonstrates the effectiveness of this intervention across different trauma types, populations, and languages (DeJesus, et al., 2024). Regardless of a clinician’s background in exposure therapy and/or treating PTSD, attending to avoidance in all forms is key. While this is a treatment that can appear deceptively easy, there is skill in finding the avoidance within narratives and using feedback to facilitate a patient’s approach.
From the first session, education about PTSD symptoms and avoidance is provided as well as a rationale for treatment. The first session also begins exposure with patients writing about their specific index trauma for 30 minutes. Patients are instructed to approach the memory including thoughts and feelings as they look back upon the event now. They are provided with a copy of the writing prompt for reference. After writing, a brief checking in with the therapist and a reminder to not avoid closes out the session. Here is the script:
You will likely have thoughts, images, and feelings concerning the trauma you just wrote about during the course of the upcoming week. It is important that you allow yourself to have these thoughts, images, feelings, whatever they might be, rather than trying to push them away. Please try to allow yourself to have whatever thoughts, images, feelings that may come up.
Between sessions therapists read the narrative and develop individualized feedback to aid patients in deepening their approach in the next session. There is no formal, between-session practice, but patients are encouraged to engage with the trauma memory between sessions. Writing about the trauma content continues in session two with encouragement to continue approaching trauma-related thoughts, feelings, and memories.
Session 2 writing prompt (To be read as a script):
Today, I want you to continue to write about the trauma as you look back upon it now. If you feel that you didn’t get the chance to completely describe the trauma in the last writing session, then you can pick up where you left off. If you completed writing about the trauma event in the last session, please write about the entire trauma again. While you are describing the trauma I really want you to delve into your very deepest feelings (e.g., fear, shock, sadness, anger) and thoughts (e.g., “is this really happening,” “I’m going to die”). Also, remember to write about the details of the trauma. That is, describe the setting, people involved, what you saw, heard, and felt. Also remember that you are writing about the trauma as you look back upon it now.
After several doses of exposure, patients are directed to begin exploring the impact of the trauma in sessions 3, 4, and 5. There is continued encouragement to focus on thoughts and feelings as they reflect upon the trauma today.
Session 4 writing prompt (To be read as a script):
I want you to continue to write about the trauma today. As with your writing in the last session, you can select a specific part of the trauma to write about; that is, the part of the trauma that was most upsetting to you. Today, I would also like you to write about how the trauma event has changed your life. You might write about if the trauma has changed the way you view your life, the meaning of life, and how you relate to other people. Throughout the session I want you to really let go and write about your deepest thoughts and feelings.
At session 5, there is an opportunity to reflect on this new skill of writing in detail about trauma including thoughts and feelings. Patients usually see a change in symptoms or functional changes by the end of the protocol. but may not be fully recovered (i.e. loss of diagnosis). However, what we know from the years of research with Written Exposure is the level of recovery attained by session 5 is not the best it will be. This treatment likely has a different mechanism of action than other EBPs (e.g., Alpert 2023; Shayani et al., 2024) for PTSD, and inhibitory learning and approach rather than avoidance are key. Yet, having a 5-session protocol that allows for quick gains and builds confidence in one’s ability to approach trauma is attractive for many patients who do not have the time to commit to longer courses of treatment. It is also encouraging as a psychologist to have access to another evidence-based intervention for PTSD.
For patient-facing resources check out these products from the National Center for PTSD:
References
Alpert, E., Hayes, A. M., Barnes, J. B., & Sloan, D. M. (2023). Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy. Behavior therapy, 54(2), 185–199. https://doi.org/10.1016/j.beth.2022.09.002
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
American Psychological Association (APA). (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Author. Retrieved from: https://www.apa.org/ptsd-guideline
DeJesus, C. R., Trendel, S. L., & Sloan, D. M. (2024). A systematic review of written exposure therapy for the treatment of posttraumatic stress symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 16(Suppl 3), S620–S626. https://doi.org/10.1037/tra0001659
Departments of Veterans Affairs and Defense (VA/DoD). (2023). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Author. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
Goldberg, S. B., Simpson, T. L., Lehavot, K., Katon, J. G., Chen, J. A., Glass, J. E., Schnurr, P. P, Sayer. N. A., & Fortney, J. C. (2019). Mental health treatment delay: A comparison among civilians and Veterans of different service eras. Psychiatric Services, (70)5, 358-366. https://doi.org/10.1176/app1.ps.201800444
Goldstein RB, Smith SM, Chou SP, Saha TD, Jung J, Zhang H, Pickering RP, Ruan WJ, Huang B, Grant BF. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol., 51(8), 1137-48. doi: 10.1007/s00127-016-1208-5.
Goetter, E. M., Bui, É., Ojserkis, R. A., Zakarian, R. J., Brendel, R. W., & Simon, N. M. (2015). A systematic review of dropout from psychotherapy for posttraumatic stress disorder among iraq and afghanistan combat veterans. Journal of Traumatic Stress, 28(5), 401-409. https://doi.org/10.1002/jts.22038
International Society for Traumatic Stress Studies (ISTSS). (2018). ISTSS PTSD prevention and treatment guidelines: Methodology and recommendations. Author. Retrieved from: http://www.istss.org/getattachment/Treating Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_ PreventionTreatmentGuidelines_FNL-March-19-2019.pdf.aspx
Lehavot, K., Goldberg, S. B., Chen, J. A., Katon, J. G., Glass, J. E., Fortney, J. C., Simpson, T. L., & Schnurr, P. P. (2018). Do trauma type, stressful life events, and social support explain women Veterans’ high prevalence of PTSD? Social Psychiatry Psychiatric Epidemiology, 53(9), 943-953. https://doi.org/10.1007/s00127-018-1550-x
Pennebaker J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162–166. https://doi.org/10.1111/j.1467-9280.1997.tb00403.x
Shayani, D. R., Alpert, E., Barnes, J. B., Sloan, D. M., & Hayes, A. M. (2024). Identifying predictors of long-term treatment outcomes using narratives from written exposure therapy and cognitive processing therapy for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy.Advance online publication. https://doi.org/10.1037/tra0001813
Sloan, D.M. & Marx, B.P. (2025). A Brief Treatment Approach for Mental Health Professionals, Second Edition. APA Press. https://www.apa.org/pubs/books/written-exposure-therapy-ptsd-second-edition
Sloan, D.M. & Marx, B.P. (2024). State of the Science: Written Exposure Therapy for the Treatment of Posttraumatic Stress Disorder. Behavior Therapy, 55. https://doi.org/10.1016/j.beth.2024.02.004
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 controlled trial with motor vehicle accident survivors. Behaviour Research and Therapy, 50(10), 627-635. https://doi.org/10.1016/j.brat.2012.07.001
Courtney Worley, PhD, ABPP, MPH, DBSM
Board Certified in Clinical Psychology
Correspondence: DrWorleyConsult@gmail.com