Last updated on 4th November 2012
Courage is not the absence of fear, but rather the judgement that something else is more important than fear. James Hollingworth
In yesterday's post - "One of the most exciting therapeutic writing studies for years" - I introduced Denise Sloan & colleagues' fascinating new research showing an augmented approach to traditional expressive writing (called "written exposure therapy") can be an effective treatment for posttraumatic stress disorder. The outcomes they achieved were startlingly good with effect sizes and drop out rates that seem even better than those achieved with current, much more time consuming, state of the art PTSD treatments. In fact, written exposure therapy may well be
helpful more generally whenever one is tackling problems contributed to by experiential avoidance. As Wikipedia neatly explains "Experiential avoidance has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences - even when doing so creates harm in the long-run." Many research studies have shown how this kind of avoidance increases the likelihood and severity of a whole string of psychological problems, including posttraumatic stress disorder (Leiner, Kearns et al. 2012), depression (Shallcross, Troy et al. 2010; Newby and Moulds 2011), panic & agoraphobia (Gloster, Wittchen et al. 2011), generalized anxiety disorder (Stapinski, Abbott et al. 2010), social anxiety (Kashdan, Breen et al. 2010), anxiety disorders in general (Marques, Kaufman et al. 2009), effects of child abuse (Shapiro, Kaplow et al. 2012), binge eating (Lillis, Hayes et al. 2011), psychotic illness (Goldstone, Farhall et al. 2011), general mental health & level of wellbeing (Kashdan, Barrios et al. 2006; Barber, Bagsby et al. 2010; Fledderus, Bohlmeijer et al. 2010), academic performance (Sullivan, Worth et al. 2006), persistent pain problems (Chou and Shekelle 2010), and possibly even Alzheimer's Disease (Wilson, Boyle et al. 2011). One can get a sense of how one rates on experiential avoidance, compared with others, by taking the brief seven-item "Acceptance & action questionnaire (AAQ-II)" or by completing the more detailed sixty-item "Multidimensional experiential avoidance questionnaire" (Gamez, Chmielewski et al. 2011).
"Written exposure therapy" (WET) was developed as a very effective, easily teachable treatment for posttraumatic stress disorder (Sloan, Marx et al. 2012). The approach is also likely to be helpful for other disorders involving experiential avoidance, especially where there are difficult memories involved as is often the case with depression and a number of anxiety disorders. Subjects using written exposure therapy are asked to write for half an hour on five occasions - typically at weekly intervals - about a specific memory that is particularly upsetting for them. As is usual when using expressive writing more generally, the instruction is to write continuously without being concerned about spelling or grammar - this is more to combat 'writer's block' than because it necessarily makes the writing itself more therapeutic. Written exposure challenges the tendency to avoid thoughts and feelings about the memory so that they can now be adequately processed. Subjects are asked to write about the details of what happened, the feelings that occurred at the time and afterwards, and especially the "hot spots" - the sections of the event where emotional distress was strongest and memory often most disorganized. This is a tough thing to be asked to do, so it's really important that participants understand why they are being asked to do it - in the words of the quote at the beginning of this handout "Courage is not the absence of fear, but rather the judgement that something else is more important than fear." Sloan & colleagues worked hard to make sure that subjects in their PTSD research trial understood and really felt that the writing approach had a very good chance of helping them. It's worth checking that one has achieved high scores on the three simple scales of the "Credibility/expectancy questionnaire". If not, then further explanation & discussion is needed to explain why the writing treatment is likely to be so worthwhile and personally relevant. It tends to be particularly important & helpful to write or talk about distressing feelings & memories for those who most typically avoid this kind of experience (Leiner, Kearns et al. 2012). There is much more relevant background information on the "PTSD assessment, images, memories & information" and "Life review, traumatic memories & therapeutic writing" pages of this website. It's worth considering whether to track one's progress using questionnaires such as the revised "Impact of event scale (IES-R)", "Posttraumatic cognitions inventory" & "Intrusive memories assessment scale" - all downloadable from the "PTSD assessment" page. See too the post "Expressive writing & timing issues" for discussion about the probable acceptability of using more flexible writing regimes than the typical once weekly format recommended here for "written exposure therapy".
Quoting the key Sloan et al research paper "Participants were instructed to write about the same ... event during each writing session. The importance of delving into their deepest emotions and thoughts (at the time of the event) was emphasized, as well as the importance of providing detailed information (about the event e.g., the participant was asked to describe what he/she saw, heard, and smelled). The participant was instructed to repeat the detailed account (of the event) during the second session, with a reminder to also include information on what he or she was thinking and feeling as the event was happening. At the end of the writing instructions for each session, the therapist reminded the participant that the event was being recounted, not relived. For the remaining four sessions, participants were instructed to focus on providing a detailed description of the part of the event that was most distressing to them ("hot spot"), as well as to describe how the event had affected their lives (e.g., how the event changed the way the person interacts with others, how the event has changed the way in which the person views his/her life). During each of the five treatment sessions, the therapist read the writing instructions to the participant, made sure that the participant understood the instructions, and answered any clarifying questions that the participant had. The therapist then exited the room, leaving a printed copy of the writing instruction for that session with the participant so that he/she could refer to them, if necessary, while completing the writing exercise. The therapist returned to the room after 30 min and inquired whether the participant experienced any difficulties during the writing session and address any problem or concerns that may have arisen. The therapist also checked the written narrative to make sure that the instructions were followed. The session ended with the therapist instructing the participant to allow him/herself to experience any trauma-related memories, images, thoughts or feelings, whatever they might be, in the week between sessions. This instruction was provided to reiterate the importance of confronting trauma memory, rather than engaging in avoidance ... ". Immediately after each session, participants were asked to rate the quality & intensity of their feelings while writing, using the following scales:
1 2 3 4 5 6 7 8 9
very pleasant neutral very unpleasant
1 2 3 4 5 6 7 8 9
very calm neutral very aroused
Remembering that the writing instructions are to confront one's deepest thoughts & feelings, it's likely to be therapeutically important that - at least for significant sections of the writing - scores on these scales should be high.
"Written exposure therapy" is a fascinating & very encouraging addition to the broad cluster of ways that therapeutic writing can be of benefit. For examples of other writing approaches, see "PTSD - writing suggestions", "An intriguing & encouraging development in therapeutic writing", "Therapeutic writing & speaking: inspiration from values", "Writing (& speaking) for resilience & wellbeing: personal growth" and "Writing - positive pasts & best futures".