Brief writing therapy effective as treatment for military members with PTSD, study shows

A brief, five-session treatment for post-traumatic stress disorder (PTSD) called Written Exposure Therapy is as effective as a longer, gold-standard treatment for military service members, a new study shows.

In their paper published today by JAMA Network Open, researchers say the treatment option potentially can make effective PTSD treatment more appealing and accessible to military personnel and increase their likelihood of completing treatment. It also can serve as a valuable new tool for military mental health providers trying to manage demanding patient loads.

Led by Denise Sloan, PhD, of the U.S. Department of Veterans Affairs’ National Center for PTSD and Boston University School of Medicine, who developed Written Exposure Therapy with her colleague Brian Marx, PhD, the study involved the collaboration of investigators at The University of Texas Health Science Center at San Antonio (UT Health San Antonio) as part of the work of the STRONG STAR Consortium. The U.S. Department of Defense funded the study.

Photo of Dr. Alan Peterson, UT Health San Antonio/STRONG STAR
Alan Peterson, PhD

“This clinical trial evaluated an innovative treatment approach for combat PTSD,” said STRONG STAR Consortium Director Alan Peterson, PhD, professor of psychiatry and behavioral sciences at UT Health San Antonio and a co-author on the study. “The therapy utilizes a key component of effective, exposure-based PTSD treatment – getting individuals to confront and process traumatic memories they may be avoiding – but does so with a brief course of writing therapy that may appeal to people who have avoided or discontinued other types of therapy. So we’re excited to see that it can work successfully with a military population.”

Previous research has shown Written Exposure Therapy to be effective with civilians with PTSD. However, this was the first large clinical trial to evaluate the therapy with active duty military personnel. As such, it aimed to determine whether the briefer Written Exposure Therapy is as effective in this population as a top PTSD treatment called Cognitive Processing Therapy. Patients were 169 service members being treated for PTSD at outpatient clinics in San Antonio and Killeen, Texas, randomly assigned to one of the two therapies.

Written Exposure Therapy consists of five weekly sessions. During the first session, which lasts an hour, the therapist explains PTSD and the rationale for treatment, and then patients write about their trauma for a half hour. They follow the same writing procedure in the next four sessions, which last 45 minutes each.

Cognitive Processing Therapy consists of 12 one-hour sessions that take place twice per week. Patients learn to challenge dysfunctional thinking about their traumas, themselves, others, and the world. In the effort to develop more balanced thinking, the therapy includes Socratic questioning by the therapist, worksheets, and assignments completed between sessions.

PTSD symptom severity improved significantly for many of the patients in both treatment groups. The investigators found that 37.5 percent of those in the Cognitive Processing Therapy group and 42.7 percent of those receiving Written Exposure Therapy still showed reliable improvement in their PTSD symptoms 30 weeks after the first therapy session. The difference is not considered statistically significant.

Further, the dropout rate was much lower for the patients receiving the briefer, less-demanding Written Exposure Therapy, with 77 percent completing all five sessions. Only 55 percent of those receiving Cognitive Processing Therapy completed all 12 sessions.

Although effective treatments are available, many service members do not seek treatment for various reasons, including military-related demands on time.

Studies have found that of the more than 2 million military personnel who deployed in support of the wars in Iraq and Afghanistan, up to 17 percent, or as many as 300,000, may have PTSD, the signature psychological wound of post-9/11 service. Although effective treatments are available, many service members do not seek treatment for various reasons, including military-related demands on time.

“The option of a brief PTSD treatment is likely to be of high value in a military setting, where military service operations may limit treatment engagement,” the investigators wrote in the journal article.

The researchers noted that Written Exposure Therapy was not effective for all patients, which is consistent with previous studies showing that combat PTSD is more difficult to treat than PTSD in civilians.

“It is important to have different treatment options that suit different individuals,” said Dr. Peterson. “Knowing this brief treatment is as effective as a well-established therapy, we can place a new tool in the clinician’s toolbox and potentially help more war fighters recover from their psychological wounds.”

Image of PTSD puzzleDr. Peterson added, “The brevity of the therapy, the omission of homework between sessions, and the option to write instead of talk about their trauma all may appeal to those who might otherwise avoid treatment. This could make them more willing to initiate treatment and then to complete it and hopefully recover. In addition, the nature of the therapy may make it easy to disseminate among clinicians managing heavy caseloads, since it requires less training and then less time to deliver. So therapists can treat more patients in a shorter time.”

With the potential of this therapy for service members with PTSD, STRONG STAR investigators already are engaged in and applying for new grants to adapt and use Written Exposure Therapy for other behavioral health conditions impacting military service members and veterans, including suicide risk.

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

Denise M. Sloan, PhD; Brian P. Marx, PhD; Patricia A. Resick, PhD; Stacey Young-McCaughan, RN, PhD; Katherine A. Dondanville, PsyD; Casey L. Straud, PsyD; Jim Mintz, PhD; Brett T. Litz, PhD; Alan L. Peterson, PhD; for the STRONG STAR Consortium

First published: Jan. 11, 2022, JAMA Network Open


Additional media coverage:

Texas Public Radio: Fort Hood study shows writing therapy is highly effective treatment for PTSD


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