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Posttraumatic stress disorder (PTSD) is prevalent on college campuses (12.4%; Boyraz et al., 2016) and is associated with greater mental and physical health problems, as well as negative academic outcomes (e.g., lower GPS and drop-out; Bachrach & Read, 2012; Boyraz et al., 2016). Given that mental healthcare on college campuses may be particularly affected by session limits and staff shortages (Gorman et al., 2022), brief interventions like Written Exposure Therapy (WET; Sloan et al., 2019) may be especially useful. 
WET (Sloan & Marx, 2019) is a brief 5-7 session treatment for PTSD that was developed out of a line of research examining expressive writing. This research found that the standard expressive writing paradigm (20 min writing, 3 sessions) was not sufficient to reduce symptoms in individuals with PTSD (Sloan et al., 2011). This work prompted changes to the expressive writing protocol that resulted in WET, including:

  • longer writing (30 min)
  •  increased number of sessions (5 sessions)
  • greater therapist involvement (check-ins and feedback on writing)
  • changes to writing instructions
  • adding psychoeducation on PTSD and treatment rationale

However, the changes made to the expressive writing protocol for WET have yet to be empirically tested. Importantly, the benefits of adding psychoeducation, therapist involvement, and adjustments to writing instructions have not been examined. 
WET has demonstrated efficacy in reducing PTSD symptoms, with comparable treatment effects to recommended evidence-based treatments for PTSD (Sloan et al., 2018, 2022, 2023), yet only one study has been conducted in college students (Morisette et al., 2019). There is also some evidence that WET can be provided via telehealth (LoSavio et al., 2023; Sloan et al., 2023), but more research is needed.
In a small proof-of-concept study (n = 33), we compared WET to an adapted trauma-focused expressive writing protocol in college students with elevated PTSD symptoms, via telehealth (Ellis, Darnell, & Orcutt, in press). We had two main research questions: 

1.      Is WET effective to reduce PTSD symptoms in college students when delivered via telehealth?
2.      Are there any preliminary differences between WET and expressive writing in reducing PTSD symptoms?
Non-treatment-seeking college students with elevated PTSD symptoms were randomized into either WET (n = 18) or expressive writing (n = 15). The expressive writing paradigm was adapted to match WET in duration (i.e., 30-minutes of writing , and 5 weekly sessions) and focus on a single traumatic event. All treatment sessions took place over videoconferencing, and PTSD symptoms were assessed at each session. 
Main findings included:

  • -        Both groups saw within-person reductions in PTSD symptoms from the first to last treatment session, with larger mean reductions on the PTSD Checklist for DSM-5 (PCL-5) in WET group (M =16.27) compared to expressive writing (M = 8.67).
  • Significantly more (61.5%) of the WET group saw reliable improvements in their PTSD symptoms, compared to the expressive writing condition (20%). 
  • No differences were found in the slope of change across time between groups. 

Results are promising for the use of WET provided via telehealth to non-treatment seeking college students. In line with other, larger studies of WET, on average, PTSD symptoms dropped below clinical cut-offs for probable PTSD and greater than half of participants saw symptom improvement. Further, WET delivered via telehealth appears tolerable, as drop-out in the current study was lower (12.12%) than other studies of trauma-focused treatment (e.g., 36%; Imel et al., 2013). Of interest, many of the participants wrote about sudden loss or sexual assault, which may point to WET being particularly helpful for these types of events.
We provide preliminary evidence that WET is advantageous over trauma-focused expressive writing for reducing PTSD symptoms, however more research with larger samples is necessary, as no differences emerged when examining the rate at which PTSD symptoms changed across treatment. Limitations of the current study include sample characteristics (i.e., the use of a small, non-treatment seeking sample), and study design (i.e., no control no -treatment group; no longer-term follow-ups, single unblinded study therapist; and no assessment of the expressive writing content). However, despite the limitations, the current study provides support for the use of WET delivered via telehealth for college students with subthreshold or greater PTSD symptoms.

Target Article

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,  00,  1–10. https://doi.org/10.1002/jts.22969

Discussion Questions

  • Why is it important to test treatments, or novel treatment components, against their predecessors? What impact might these study designs have on future treatment development?
  • The current study suggests their might be differences in study findings based on the examination of cross-sections (pre/post) versus slopes of change. What are the advantages of each approach and why might you find discrepant findings using both approaches? How might differences in statistical approach impact interpretation of treatment effects?
  • How might the current study inform interventions for PTSD in college students? What unique barriers might there be to implementing PTSD treatment in this population?
  • What additional information (e.g., participant factors or study design) would have been helpful to collect to inform study findings?

About the Authors

Robyn A. Ellis, Ph.D
. is a postdoctoral research fellow at McLean Hospital and Harvard Medical School. Dr. Ellis completed her predoctoral internship at the Central Western Massachusetts VA hospital and received her Ph.D. in clinical psychology from Northern Illinois University in 2022. Her research aims to enhance interventions for co-occurring PTSD and substance use disorders through the identification of shared underlying psychophysiological mechanisms. Dr. Ellis can be contacted at rellis5@mclean.harvard.edu and @DrRobynAEllis on X.
Benjamin C. Darnell, Ph.D.
is postdoctoral research associate at the Massachusetts Veterans Epidemiology Research and Information Center of the VA Boston Healthcare System. He graduated from Northern Illinois University in 2021 with his doctorate in Clinical Psychology after completing his clinical internship at the Louis Stokes Cleveland VA Medical Center. His research includes investigating technologies to improve collaboration between researchers and providers and precision mental and behavioral healthcare, specifically related to trauma and moral injury. Dr. Darnell can be contacted at benjamin.darnell@va.gov.  
Holly Orcutt, PhD
.  Dr. Orcutt is a clinical psychologist and professor at Northern Illinois University. Dr. Orcutt can be contacted at horcutt@niu.edu. 

References Cited

Bachrach, R. L., & Read, J. P. (2012). The Role of Posttraumatic Stress and Problem Alcohol Involvement in University Academic Performance. Journal of Clinical Psychology, 68(7), 843–859. https://doi.org/10.1002/jclp.21874
Boyraz, G., Granda, R., Baker, C. N., Tidwell, L. L., & Waits, J. B. (2016). Posttraumatic stress, effort regulation, and academic outcomes among college students: A longitudinal study. Journal of Counseling Psychology, 63(4), 475–486. https://doi.org/10.1037/cou0000102
Gorman, K. S., Bruns, C., Chin, C., Fitzpatrick, N., Koenig, L., LeViness, P., & Sokolowski, K. (2022). The Association for University and College Counseling Center Directors annual survey. https://www.aucccd.org/director-surveys-public
Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 394–404. https://doi.org/10.1037/a0031474
LoSavio, S. T., Worley, C. B., Aajmain, S. T., Rosen, C. S., Wiltsey Stirman, S., & 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
Morissette, S. B., Ryan-Gonzalez, C., Blessing, A., Judkins, J., Crabtree, M., Hernandez, M. F., Wiltsey-Stirman, S., & Sloan, D. M. (2022). Delivery of written exposure therapy for PTSD in a university counseling center. Psychological Services. https://doi.org/10.1037/ser0000608
Sloan, D. M., & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. American Psychological Association. https://www.apa.org/pubs/books/4317524
Sloan, D. M., Marx, B. P., Acierno, R., Messina, M., Muzzy, W., Gallagher, M. W., Litwack, S., & Sloan, C. (2023). Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2023.2810
Sloan, D. M., Marx, B. P., Lee, D. J., & Resick, P. A. (2018). A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial. JAMA Psychiatry, 75(3), 233–239. https://doi.org/10.1001/jamapsychiatry.2017.4249
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., & 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(1), e2140911. https://doi.org/10.1001/jamanetworkopen.2021.40911
Sloan, D., Marx, B., & Greenberg, E. (2011). A test of written emotional disclosure as an intervention for posttraumatic stress disorder. Behaviour Research and Therapy, 49, 299–304. https://doi.org/10.1016/j.brat.2011.02.001