PTSD: National Center for PTSD

Written Exposure Therapy for PTSD

Denise M. Sloan, Ph.D. and Brian P. Marx, Ph.D.

Written Exposure Therapy (WET; 1) is a manualized exposure-based psychotherapy for PTSD that is recommended by the VA/DoD Clinical Practice Guideline (2). A growing number of studies indicate that WET is effective for PTSD, even among patients with complicated presentations and other comorbid disorders (3-6). In addition, compared with other trauma-focused treatments, a low number of those who receive WET drop out of treatment (e.g., less than 15%; 7).

Continuing Education

State of the Science for Written Exposure Therapy

This online course reviews the critical elements of WET and describes efficacy and effectiveness data as well as implementation suggestions for clinical practice.

Theoretical Model

The WET treatment protocol was developed through a series of systematic studies. Based upon a fear extinction/emotional processing treatment model, these studies examined the extent to which trauma survivors with PTSD symptoms experienced symptomatic relief from writing about their experiences. The amount of writing necessary to bring about clinically significant symptom change was also evaluated (1).

This work indicated that 5, 30-minute writing sessions in which patients are directed to write about a traumatic experience in detail, paying particular attention to their thoughts and emotions that occurred at the time of the event, resulted in a reduction of pathological fear and subsequent significant PTSD symptom reduction. Using an empirically derived set of instructions for repeatedly writing about their traumatic experience, the patient learns that:

• The trauma memory is not dangerous and can be experienced without significant distress.
• Distress associated with remembering the trauma is transient.
• Emotional distress gradually reduces with time, even without doing anything.
• Physiological responses, such as rapid heart rate and sweating, are not dangerous.
• High negative affect can be tolerated.
• It is possible to develop new ways of thinking about the trauma event and its meaning.

Patients are not required to conduct in-vivo exposures outside of sessions. However, research has found that confronting previously avoided people, situations and places related to the trauma often occurs spontaneously among patients receiving WET (8).

Although evidence supports the hypothesis that fear extinction is an underlying mechanism of WET (9), it is possible that other mechanisms are also responsible for the clinically significant symptom reductions observed among those who receive WET, and some support has been found for additional mechanisms such as cognitive change (10,11).

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Session Content

The WET protocol consists of 5 sessions, with each session lasting approximately 50 minutes. During each session, patients write narratives about their traumatic experiences in response to specific writing instructions. There are no between-session assignments.

In the first treatment session, the therapist provides their patient with psychoeducation about PTSD and a treatment rationale. Following this, the patient completes the first, 30-minute narrative. Following the 30 minutes of writing, the therapist checks in with the patient about their experience while they completed their written narrative. In the remaining 4 sessions, the clinician provides feedback to the patient on the previous session's writing, specifically on how well they followed the writing instructions. The clinician then delivers instructions for the writing to be done during that day's session, the patient completes the 30-minute writing assignment, and then the clinician checks in with the patient about their experience while doing the writing. At the end of the session, patients are instructed to allow themselves to experience any trauma-related feelings, thoughts, or memories that may arise between sessions without making any attempts to avoid them. Treatment sessions are highly scripted, ensuring standardization of treatment delivery and increasing provider adherence to the protocol.

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Overall and Relative Effectiveness

To date, findings from 8 published randomized controlled trials (RCTs; 5,8,12-17) support the effectiveness of WET. Patients who receive WET show significant reductions in PTSD symptoms, with large within-group effects observed in each of the studies. Moreover, many of those who receive WET no longer meet diagnostic criteria for PTSD after treatment (8,12, 16) and maintain their treatment gains up to a year later (5,8,12,16). Three RCTs have demonstrated that WET is non-inferior to both Cognitive Processing Therapy (5,12) and Prolonged Exposure Therapy (PE;16) in terms of PTSD symptom reduction, despite having less than half as many therapy sessions in the treatment protocol. Moreover, in these studies, significantly fewer patients who received WET dropped out of treatment than patients who received CPT and PE. One study found WET outcomes to not be significantly different from outcomes for trauma-focused cognitive behavior therapy for adolescent participants (13), and another study found it to be superior to a treatment as usual condition for the treatment of PTSD symptoms and rehospitalization among service members who were admitted to a psychiatric unit for suicidal risk (17). Studies examining moderators (e.g., severity of PTSD, comorbid psychiatric disorders, baseline depression, race, sex) of WET treatment outcomes have revealed no significant moderators of PTSD symptom change (3,6,17).

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WET in Clinical Practice Guidelines

WET is recommended as a second-line treatment for PTSD in the 2023 VA/DoD Clinical Practice Guideline for Managing PTSD and it is listed as an emerging recommended treatment in the International Society for the Study of Traumatic Stress (ISTSS) guideline (15). It is not mentioned in American Psychological Association (APA, 16), National Institute for Health and Care Excellence (NICE, 17), or Australian guidelines (18).

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Research With Military Personnel and Veterans

To date, there have been multiple studies examining the efficacy and effectiveness of WET with military service members and Veterans. As previously noted, one RCT study compared WET with CPT in the treatment of PTSD among active-duty service members and found WET to be effective in the treatment of PTSD and non-inferior compared with the more time-intensive treatment (5). Another study comparing WET with PE among military Veterans found WET to be effective in the treatment of PTSD and non-inferior compared with PE (16). Another study examined the effectiveness of WET with Veterans presenting for PTSD treatment in VA, and this study also found WET to be effective (6). An open trial investigating the effectiveness of WET delivered in a Veterans who were in an inpatient psychiatry unit observed WET to be effective in the treatment of PTSD (25), as well as another study examining the effectiveness of WET when delivered to Veterans in a residential substance use treatment program (19). A trial examining the delivery of WET to service members while they were admitted to a psychiatric inpatient unit for suicide risk found WET to be effective in reducing PTSD symptoms (26).

In addition to these studies, there are currently multiple studies underway that are investigating the effectiveness of WET with Veterans and service members (see clinicaltrials.gov).

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Research With Comorbidities and Special Populations

Findings to date indicate WET is safe and effective for PTSD patients with comorbid mood disorder symptoms, (4,6, 26-29) substance use disorders, (30,31), suicidal risk (17,19,26), and eating disorders (20). WET is as effective as CPT at significantly reducing co-morbid depression symptoms (4).

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Emerging Issues

As previously described, multiple studies examining the effectiveness of WET with Veterans and service members, as well as in primary care, acute inpatient settings, and residential treatment programs are currently underway. We know of at least one study comparing the effectiveness of WET delivered in its original, individual patient format with the effectiveness of WET delivered in a group format . WET has been delivered successfully using video telehealth platforms (i.e., VA Video Connect) with the narratives collected electronically (e.g., secure messaging) or screenshots taken at the end of the session. Findings indicate WET is as effective when delivered remotely via telehealth as in person (6,14). Delivery of WET over the phone without accompanying video is not currently recommended. An implementation program of WET conducted within VA is examining if different training formats are needed to disseminate WET, as well as examining the effectiveness of different training models (6,32).

Although the treatment protocol is typically delivered as 5 weekly, 50-minute sessions (1), research supports treatment delivery in a massed format (17,19,25). Two studies underway are investigating the efficacy of WET delivered using a 6, 30-minute per session version of the protocol in primary care settings.

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References

1. Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A brief treatment approach for mental health professionals. American Psychological Press. http://dx.doi.org/10.1037/0000139-001
2. 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/
3. Marx, B. P., Thompson-Hollands, J., Lee., D. J., Resick, P. A., & Sloan, D. M. (2021). Estimated intelligence moderates Cognitive Processing Therapy outcome for posttraumatic stress symptoms. Behavior Therapy, 52, 162-169. http://dx.doi.org/10.1016/j.beth.2020.03.008
4. Thompson-Hollands, J., Marx, B. P., Lee, D. J., Resick, P. A., & Sloan, D. S. (2018). Long-term treatment gains of a brief exposure-based treatment for PTSD. Depression and Anxiety, 3(10), 985-991. https://doi.org/10.1002/da.22825
5. Sloan, D. M., Marx, B. P., Resick, P. A., Young-McCaughan, S., Dondanville, K. A, Straud, C. L. Mintz, J., Litz, B. T., & Peterson, A. L. for the 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 Open Network, 5(1), e2140911. https://doi.org/10.1001/jamanetworkopen.2021.40911
6. LoSavio, S. T., Worley, C. B., Aajmain, S., Rosen, C., Stirman, S. W., & Sloan, D. M. (2023). Effectiveness of Written Exposure Therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. Psychological Trauma: Theory, Research, Practice, and Policy, 15(5), 748-756. https://doi.org/10.1037/tra0001148
7. DeJesus, C., Trendel, S., & 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/10.1016/tra0001659
8. 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
9. Wisco, B. E., Baker, A. S., & Sloan, D. M. (2016). Mechanisms of change in written exposure treatment of posttraumatic stress disorder. Behavior Therapy, 47(1), 66-74. https://doi.org/10.1016/j.beth.2015.09.005
10. 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
11. Lee, D. J., Marx, B. P., Thompson-Hollands, J., Gallagher, M. W., Resick, P. A., & Sloan, D. M. (2021). The temporal sequence of change in PTSD symptoms and hypothesized mediators in Cognitive Processing Therapy and Written Exposure Therapy for PTSD. Behaviour Research and Therapy, 144, 103918. https://doi.org/10.1016/j.brat.2021.103918
12. 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(3), 233-239. https://doi.org/10.1001/jamapsychiatry.2017.4249
13. Ahmadi, S. J., Musavi, Z., Samim, N., Sadeqi, M., & Jobson, L. (2022). Investigating the feasibility, acceptability and efficacy of using modified-Written Exposure Therapy in the aftermath of a terrorist attack on symptoms of posttraumatic stress disorder among Afghan adolescent girls. Frontiers in Psychiatry, 13, Article 826633. https://doi.org/10.3389/fpsyt.2022.826633
14. Ellis, R. A., Darnell, B. C., & Orcutt, H. K. (2023). Comparing Written Exposure Therapy delivered via telehealth to trauma-focused expressive writing in undergraduates: A proof-of-concept trial. Journal of Traumatic Stress, 36(6), 1157-1166. https://doi.org/10.1002/jts.22969
15. Zolfa, R., Moradi, A., Mahdavi, M., Parhoon, H., Parhoon, K., & Jobson, L. (2023). Feasibility and acceptability of Written Exposure Therapy in addressing posttraumatic stress disorder in Iranian patients with breast cancer. Psycho-Oncology, 32(1), 68-76. https://doi.org/10.1002/pon.6037
16. Sloan, D.M., Marx, B.P., Acierno, R., Messina, M., Muzzy, W., Gallagher, M.W., Litwack, S., & Sloan, C. (2023). Written Exposure Therapy versus prolonged exposure in the treatment of PTSD: A randomized non-inferiority clinical trial. JAMA -Psychiatry https://doi.10.1001/jamapsychiatry.2023.2810
17. Kearns, J. C., Straud, C. L., Stanley, I. H., Sloan, D. M., Fina, B. A., Young-McCaughan, S., Tyler, H. C., Kaplan, A. M., Blankenship, A. E., Schrader, C. C., Green, V. R., Bryan, C. J., Peterson, A. L., & Marx, B. P., for the STRONG STAR Consortium. (2025). Written Exposure Therapy for posttraumatic stress symptoms and suicide risk: A randomized controlled trial with high-risk patients admitted to a military inpatient psychiatric unit. Suicide and Life-Threatening Behavior, 55, e70008. https://doi.org/10.1111/sltb.70008
18. Yun, J. A., Lee, C. H., Jeong, S. H., Yu, J. C., & Choi, K. S. (2024). Effectiveness of written exposure therapy for Korean patients with post-traumatic stress disorder: non-randomized treatment-as-usual waitlist-controlled study. Cognitive Behaviour Therapy, 54(3),408–425. https://doi.org/10.1080/16506073.2024.2410815
19. Van Doren, N., Chang, F. H., Nguyen, A., McKenna, K. R., Satre, D. D., & Wiltsey-Stirman, S. (2025). A pilot study of twice-weekly group-based Written Exposure Therapy for Veterans in residential substance use treatment: Effects on PTSD and depressive symptoms. Addiction Science & Clinical Practice, 20(1), 11. https://doi.org/10.1186/s13722-024-00531-0
20. Keshen, A. R., Trappenberg, N., Bartel, S., Harris, A., Taylor, V., Whitney, J., Gamberg, S., Price, C., & Trottier, K. (2025). Concurrent delivery of Written Exposure Therapy for posttraumatic stress disorder treatment in an intensive eating disorder program: A case series. Eating Disorders, 1–8. https://doi.org/10.1080/10640266.2025.2453258
21. 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
22. 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
23. National Institute for Health Care Excellence (NICE). (2018). Guideline for post-traumatic stress disorder. National Institute for Health and Clinical Practice. Retrieved from: https://www.nice.org.uk/guidance/ng116/chapter/Recommendations
24. Phoenix Australia Centre for Posttraumatic Mental Health. (2021). Australian guidelines for the prevention and treatment of acute stress disorder, posttraumatic stress disorder and Complex PTSD. Australian Government, National Health and Medical Research Council. Retrieved from: https://www.phoenixaustralia.org/australian-guidelines-for-ptsd/
25. Ennis, C. R., Raines, A. M., Boffa, J. W., Shapiro, M. O., Dornbach-Bender, A., Ferrie, M. L., Fondren, A. H., Vidaurri, D. N., Walton, J. L., Chambliss, J. L., & Franklin, C. L. (2024). Massed Written Exposure Therapy delivered to Veterans with posttraumatic stress symptoms on an acute inpatient mental health unit. Journal of Traumatic Stress, 37(4), 643–651. https://doi.org/10.1002/jts.23042
26. Tyler, H., Fina, B. A., Marx, B. P., Young-McCaughan, S., Sloan, D. M., Kaplan, A. M., Green, V. R., Blankenship, A., Bryan, C. J., Peterson, A. L., & STRONG STAR Consortium. (2022). Written Exposure Therapy for suicide in a psychiatric inpatient unit: A case series. Cognitive and Behavioral Practice, 29(4), 924-937. https://doi.org/10.1016/j.cbpra.2021.06.011
27. Andrews, A. R., III, Acosta, L. M., Canchila, M. N. A., Haws, J. K., Holland, K. J., Holt, N. R., & Ralston, A. L. (2022). Perceived barriers and preliminary PTSD outcomes in an open pilot trial of Written Exposure Therapy with Latinx immigrants. Cognitive and Behavioral Practice, 29(3), 648-665. https://doi.org/10.1016/j.cbpra.2021.05.004
28. Morissette, S. B., Ryan-Gonzalez, C., Blessing, A., Judkins, J., Crabtree, M., Hernandez, M. F., Wiltsey Stirman, S., & Sloan, D. M. (2023). Delivery of Written Exposure Therapy for PTSD in a university counseling center. Psychological Services, 20(1), 122-136. https://doi.org/10.1037/ser0000608
29. Stoycos, S. A., Straud, C. L., Blankenship, A. E., Marx, B. P., Peterson, A. L., Resick, P. A., Stanley, I., Young-McCaughan, S., & Sloan, D. M., (2023). Benchmarking secondary outcomes to posttraumatic stress disorder change in response to Cognitive Processing Therapy and Written Exposure Therapy for posttraumatic stress disorder. Journal of Anxiety Disorders, 100, 102794. https://doi.org/10.1016/j.cbpra.2022.02.024
30. Schumacher, J. A., Kinney, K. L., Morris, M. C., & McAfee, N. W. (2022). Biweekly delivery of a group-based adaptation of Written Exposure Therapy (WET) for PTSD in residential substance treatment. Cognitive Behavioral Practice. Advance online publication. https://doi.org/10.1016/j.cbpra.2022.02.024
31. Schacht, R. L., Wenzel, K. R., Meyer, L. E., Mette, M., Mallik, K. K., Rabalais, A., Berg, S. K., & Fishman, M. (2023). A pilot test of Written Exposure Therapy for PTSD in residential substance use treatment. The American Journal on Addictions, 32(5), 488-496. https://doi.org/10.1111/ajad.13442
32. Worley, C.B., Rosen, C.R., Losavio, S.T., Aajmain, S.T., Wiltsey Stirman, S., & Sloan, D.M. (2023). An examination of individual and organizational theory in a pilot virtual facilitated learning collaborative to implement Written Exposure Therapy. Psychological Services, 20(4), 820-830. https://doi.org/10.1037/ser0000698

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