Journal of Traumatic StressDecember 2013, 26, 776–779

BRIEF REPORT

Written Exposure Therapy for Veterans Diagnosed with PTSD:A Pilot Study

Denise M. Sloan,1,2,3 Daniel J. Lee,2,3 Scott D. Litwack,2 Alice T. Sawyer,2,3 and Brian P. Marx1,2,3

1VA National Center for PTSD, Boston, Massachusetts, USA2VA Boston Healthcare System, Boston, Massachusetts, USA

3Psychiatry Department, Boston University School of Medicine, Boston, Massachusetts, USA

There is a need to identify alternative treatment options for posttraumatic stress disorder (PTSD), especially among veterans where PTSDtends to be more difficult to treat and dropout rates are especially high. One potential alternative is written exposure therapy, a briefintervention shown to treat PTSD among civilians effectively. This study investigated the feasibility and tolerability of written exposuretherapy in an uncontrolled trial with a sample of 7 male veterans diagnosed with PTSD. Findings indicated that written exposure therapywas well tolerated and well received. Only 1 of the 7 veterans dropped out of treatment, no adverse events occurred during the courseof treatment, and veterans provided high treatment satisfaction ratings. Clinically significant improvements in PTSD symptom severitywere observed for 4 veterans at posttreatment and 6 veterans at the 3-month follow up. Moreover, 5 of the 7 veterans no longer metdiagnostic criteria for PTSD 3 months following treatment. These findings suggest that written exposure therapy holds promise as a brief,well tolerated treatment for veterans with PTSD. However, additional research using randomized controlled trial methodology is neededto confirm its efficacy.

To ensure that all veterans receive evidence-based care forposttraumatic stress disorder (PTSD), the Department of Veter-ans Affairs (VA) has disseminated cognitive processing therapy(CPT; Resick & Schnicke, 1992) and prolonged exposure (PE;Foa, Hembree, & Rothbaum, 2007) throughout the VA healthcare system. Even with these efforts, many veterans experi-ence long waits to receive these treatments (Maguen, Madden,Cohen, Bertenthal, & Seal, 2012) and when they do receivetreatment, as many as 35% of treated veterans may be un-responsive or do not complete treatment (e.g., Gros, Yoder,Tuerk, Lozano, & Acierno, 2011). Given the apparent barriersto accessing and benefiting from evidence-based treatments forPTSD, the VA needs to identify, disseminate, and implementalternative methods that are tolerable to patients and by whichclinicians can swiftly and easily deliver the presumed activeingredients (i.e., repeated confrontation of feared memories,

This study was supported by a National Institute of Mental Health grant(R34MH077658–02) awarded to Denise M. Sloan.

Correspondence concerning this article should be addressed to Denise M.Sloan, National Center for PTSD (116B-2), VA Boston Healthcare System,150 S. Huntington Avenue, Boston, MA 02130. E-mail: Denise.Sloan@va.gov

Published 2013. This article is a US Government work and is in the publicdomain in the USA. View this article online at wileyonlinelibrary.comDOI: 10.1002/jts.21858

images, and situations; Institute of Medicine, 2008) of theseevidence-based treatments (Sloan, Marx, & Keane, 2011).

Written exposure therapy (Sloan, Marx, Bovin, Feinstein,& Gallagher, 2012), one possible alternative, is a brief, easyto administer, exposure-based intervention in which individ-uals write repeatedly about their identified traumatic stressor.This intervention is a modification of Pennebaker and Beall’s(1986) written disclosure procedure, which Sloan and col-leagues (Sloan & Marx, 2004; Sloan, Marx, & Epstein, 2005;Sloan, Marx, Epstein, & Lexington, 2007) found to signifi-cantly reduce PTSD symptom severity, but not be significantlydifferent than a control writing condition in the extent to which italtered PTSD diagnostic status among trauma survivors (Sloan,Marx, & Greenberg, 2011). To enhance its potency, the investi-gators subsequently modified the written disclosure procedureto include psychoeducation, a treatment rationale, and a greaternumber of writing sessions to increase the dose of therapeuticexposure (Sloan et al., 2012). This modified protocol is nowreferred to as written exposure therapy to differentiate it fromthe earlier protocol.

The modified protocol was investigated in a recent ran-domized controlled trial with motor vehicle accident survivorswith PTSD. Written exposure therapy was associated with sig-nificant reductions in PTSD symptom severity, relative to await-list comparison condition, with large between-group effectsizes observed (Sloan et al., 2012). Treatment gains were also

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Written Exposure Treatment for Veterans 777

maintained at a 6-month follow-up assessment. In addition, par-ticipants reported high levels of satisfaction with the treatment,with only 9% of participants dropping out. Although writtenexposure therapy shows promise, it has not yet been tested withveterans.

The current study examined the efficacy of written exposuretherapy with a small sample of veterans diagnosed with PTSDin an uncontrolled trial. We expected that veterans treated withwritten exposure would show significant reductions in PTSDsymptom severity. We also expected treatment dropout rates tobe low and treatment satisfaction to be high.

Method

Participants

Of the nine veterans who were initially assessed, eight meteligibility criteria for the study. One declined to enroll in thetreatment due to restricted available time. The seven veteranswho enrolled in the treatment study were all White men with aprimary diagnosis of PTSD. The average age was 54.29 years(range 29–66 years; SD = 13.88). All participants were serviceconnected for mental health and/or physical health conditions.Service connection ranged from 30%–100%, with two partic-ipants receiving 100% service connection for PTSD. Six par-ticipants reported PTSD resulting from combat trauma (fourVietnam era, one Gulf War era, one Operation Iraqi Freedom)and one reported PTSD related to a military sexual trauma. Theaverage number of years since the trauma exposure was 30.85(range 7.30–42.50 years; SD = 15.45). All but one participantwas receiving psychotropic medication, and those receivingmedication had been on a stable dose for at least 2 months. Allparticipants had an extensive outpatient psychosocial treatmenthistory, and four also reported a psychiatric inpatient treatmenthistory. Two of the seven participants were working at leastpart-time.

Measures

The Clinician-Administered PTSD Scale (CAPS; Weathers,Keane, & Davidson, 2001) was used to assess PTSD diag-nosis and symptom severity. The CAPS assesses the 17 coresymptoms of PTSD as defined by the Diagnostic and Statisti-cal Manual of Mental Disorders (4th ed.; DSM-IV; AmericanPsychiatric Association, 1994) and allows the interviewer torate along 5-point ordinal scales the frequency and intensity ofeach symptom, the impact of symptoms on the patient’s socialand occupational functioning, the overall severity of the symp-tom complex, and the global validity of ratings obtained. TheCAPS has a sensitivity of .81, a specificity of .95, and a test-retest reliability of between .90 and .96 over a 1-week period(Weathers et al., 2001). The CAPS was administered at eachassessment period to assess treatment outcome.

The Structured Clinical Interview for DSM-IV Axis I Disor-ders with Psychotic Screen (SCID; Spitzer, Williams, Gibbon,

& First, 1994) is a semistructured interview used to assess ma-jor Axis I disorders as well as to screen for the presence ofpsychotic symptoms. In the current study, the SCID mood dis-orders, substance use disorders, and psychotic screen moduleswere administered during the initial assessment to assess forstudy eligibility.

The Client Satisfaction Questionnaire (CSQ-8; Larsen,Attkisson, Hargreaves, & Nguyen, 1979) was administeredon the last treatment session to examine satisfaction with thetreatment. The CSQ-8 has good test-retest reliability, internalconsistency, and sensitivity to treatment (Nguyen, Attkison, &Stegner, 1983).

Procedure

The study was approved by the VA Boston Healthcare SystemInstitutional Review Board. Veterans were recruited throughclinic referrals and flyers posted throughout the local VA medi-cal center. To participate, individuals had to have a current diag-nosis of PTSD and be at least 18 years of age. Individuals witha current psychotic disorder, current substance dependence, orwho were currently receiving psychosocial treatment for PTSDwere excluded from the study. Individuals receiving medica-tion were allowed to participate as long as their regimen wasstabilized 2 months prior to study entry. All participants pro-vided written, informed consent. Two doctoral-level cliniciansconducted the diagnostic assessments. The clinician assessorsdid not serve as study therapists.

Written exposure therapy consists of five treatment sessions.The first session is 1 hour in duration and the remaining foursessions are 40 minutes in duration. The first session includespsychoeducation about PTSD and provides the treatment ra-tionale. This information is followed by general instructionsfor writing about the traumatic experience during each ses-sion and specific instructions for the written narrative duringthe first session. The therapist reads the instructions and thenleaves the printed instructions with the participant who com-pletes writing alone. Briefly, participants are instructed to writeabout their index trauma during each writing session, provid-ing as much detail as possible; participants are also instructedto include details on what they were thinking and feeling asthe event occurred. Participants are instructed that they maywrite about the event as they look back upon it. The instruc-tion to write about the traumatic event from a distance per-spective was included based on research indicating that takinga distance perspective allows individuals to better engage intrauma recounting (e.g., Kross & Ayduk, 2011). At the con-clusion of 30 minutes of writing, the therapist re-enters theroom, instructs the participant to stop writing, and then in-quires how the writing session went. Typically, a few minutesare spent discussing the participants’ reaction to their writingsession. Contact with the study therapist is minimal, with ap-proximately 30 minutes of total contact during the first sessionand approximately 10–15 minutes of total contact time for theremaining four sessions. See Sloan et al. (2012) for additional

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

778 Sloan et al.

Table 1PTSD Symptom Severity Score as a Function of Participant andAssessment Period

Participant Pretreatment Posttreatment 3-month follow-up

Participant 1 90 80 63b

Participant 2 49 27b 13b

Participant 3a 63 44 15b

Participant 4 45 23b 16b

Participant 5 45 44 25b

Participant 6 88 53b 69Participant 7 64 23b 20b

Note. PTSD = posttraumatic stress disorder.aParticipant dropped out of treatment, but returned for all subsequent assessments.bClinically significant reduction in PTSD symptom severity from pretreatment.

details of the treatment. The first author served as the studytherapist.

Results

One participant (14%) dropped out after three sessions, al-though he returned for all subsequent assessments. This par-ticipant indicated that he stopped treatment because he did notbelieve it would benefit him. No adverse events occurred dur-ing the course of treatment. Moreover, the participants reportedhigh levels of satisfaction with written exposure therapy (M =30.00, SD = 2.60, range 25–32).

Due to the small sample size, as well as the fact that weonly had one group of participants who all received treatment,we examined the extent to which written exposure therapychanged PTSD symptom severity for each participant usingthe clinically significant change score approach (Jacobson &Truax, 1991). CAPS total score served as the dependent vari-able. Prior research (e.g., Monson et al., 2008) suggests thata clinically significant change in the CAPS total score is rep-resented by a reduction equal to or greater than 20 points.We also examined changes in participants’ PTSD diagnosticstatus.

As displayed in Table 1, clinically significant reductions inPTSD symptom severity at posttreatment were observed forfour of the seven participants. By the 3-month follow up, all butone participant displayed clinically significant improvements.In addition, five of the seven participants no longer met diag-nostic criteria for PTSD both at posttreatment and follow-up.The two who continued to meet PTSD diagnostic criteria hadthe highest PTSD symptom severity at baseline (CAPS totalscores of 88 and 90).

Discussion

Our findings suggest that written exposure therapy may be apromising treatment option for veterans with PTSD. Specifi-

cally, written exposure therapy was well tolerated, as only oneparticipant dropped out of treatment. Additionally, none of theveterans requested or required therapist contact outside of thestudy for increased distress while engaged in the treatment, acommon concern of therapists when clients engage in traumaexposure (Becker, Zayfert, & Anderson, 2004). Veterans alsoreported high levels of satisfaction with the treatment. Althoughtwo of the seven veterans continued to meet PTSD diagnosticcriteria following treatment, all but one veteran displayed a clin-ically significant reduction in PTSD symptoms at the follow-upassessment.

Notably, there are other PTSD treatments that include theuse of writing in their protocols. For instance, as part of theCPT protocol, individuals provide a written account of theirtrauma. Resick et al. (2008) showed that participants who onlycompleted this portion of the CPT protocol displayed improve-ments in their PTSD symptoms that were comparable to par-ticipants who received the full CPT protocol and participantswho received a version of CPT that did not include the writ-ten accounts. Another treatment for refugee trauma survivorsthat involves the writing of patients’ trauma-focused autobi-ographies has been shown to reduce PTSD symptoms (for areview, see Robjant & Fazel, 2010). Coupled with these find-ings, our results further suggest that written narratives providea potent method by which trauma survivors may recover fromtheir experiences.

Our findings should be interpreted cautiously given the un-controlled nature of the study, small sample size, and the ho-mogeneity of the sample. In future work, we hope to addressthese limitations as well as examine for whom written expo-sure therapy may be most beneficial. Given the growing numberof veterans presenting to VA and non-VA facilities for PTSDtreatment, gaining a better understanding of what factors af-fect treatment efficacy will be increasingly important. In addi-tion, written exposure therapy may be particularly useful withina stepped care approach environment. For example, writtenexposure therapy may be used with veterans endorsing PTSDsymptoms who present to a primary care clinic. Written expo-sure therapy might also be used as an initial treatment for PTSD,followed by a determination as to whether or not the veteranrequires additional treatment. The use of telehealth care ap-proaches has substantially increased in VA health care settingsin recent years (Sloan et al., 2011), and written exposure ther-apy may work particularly well as a telehealth approach givenits format.

The findings of this study underscore the importance of un-derstanding how much therapy constitutes a sufficient dose foreffective PTSD treatment. Although limited research on thistopic exists, that which does indicates that patients may needfewer treatment sessions for effective PTSD treatment outcomethan what is included in PTSD evidence-based treatments (e.g.,van Minnen & Foa, 2006). As suggested by others (e.g., In-stitute of Medicine, 2008), additional investigation is neededregarding sufficient dose for PTSD treatment.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.