Atlas›Domain VI · Brief, integrative, trauma, hypnosis & coaching›Guide 033
Guide VI-033

Written exposure therapy

Denise M. Sloan, Brian P. MarxBoston
A 16 · L 67 · M 1721 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Sloan & Marx (2019), Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals (APA), standard individual 5-session format, as taught in the Center for Deployment Psychology (CDP) training (April 2023), the developers' own training slides (March 2022) and Q&A, and as described in the developers' trial reports (Sloan et al., 2018, and Sloan et al., 2023, both JAMA Psychiatry) and their review (Sloan & Marx, 2024). Verification: session count and length, the session-by-session writing schedule including session 5, the lack of any SUDS rules, and the 6-session primary-care layout are checked against the two trial reports, the 2024 review and the 2022 slides. No legitimate preview of either manual edition was found, so details found only in the manual are [uncertain]. The 2nd edition (Sloan & Marx, 2025, APA; xv + 158 pp.; DOI 10.1037/0000441-000) is known only from publisher and catalogue descriptions: it keeps a scripted session-by-session protocol and adds telehealth, group delivery, primary care with 30-minute sessions, working with a language interpreter, managing difficult situations, and case examples. Its specific changes are not reflected here [uncertain]. [source: Sloan et al. 2018; Sloan et al. 2023; Sloan & Marx 2024; TUM catalogue record; Akademika and Woodslane listings]

Written Exposure Therapy (WET) is a brief, manualised, exposure-based treatment for PTSD developed by Denise M. Sloan and Brian P. Marx (National Center for PTSD, VA Boston Healthcare System / Boston University). The client writes by hand about one index trauma for 30 minutes in each of five sessions, following scripted instructions; the therapist gives psychoeducation and a rationale in session 1, reads the instructions, times the writing, holds a short non-processing check-in, and gives feedback on how closely the previous narrative followed the instructions. There is no homework; the only between-session request is not to push away trauma-related thoughts, images and feelings. [source: CDP 2023 slides; NCPTSD WET page; Sloan & Marx 2024]

How change happens (as the developers describe it): WET adapts Pennebaker's expressive-writing paradigm into imaginal exposure. Repeatedly approaching the memory in writing is thought to work through fear extinction / emotional processing (activating the trauma memory and taking in information incompatible with it) and inhibitory learning (new learning that the memory can be tolerated competes with fear and avoidance). The client learns that the memory is not dangerous, that distress is temporary and falls, that bodily arousal is harmless, that strong emotions can be tolerated, and that new meanings of the event are possible. Cognitive change is not targeted directly but tends to follow. The developers say mechanisms are hard to isolate. The rationale given to clients is that writing helps organise a memory stored in a fragmented way and gives them more control over it. [source: Sloan & Marx 2024; NCPTSD WET page; CDP 2023 slides; ABPP newsletter (Worley)]

2. Framework

Format. Individual, five sessions, normally weekly (the longest interval studied is one week; the developers expect longer gaps to dilute gains). Session 1 lasts 60 minutes in every source. Later sessions last 40 minutes in the WET vs CPT trial (Sloan et al., 2018) and in CDP training, and about 45 minutes in the WET vs PE trial report (Sloan et al., 2023) and Sloan & Marx (2024); the NCPTSD page gives about 50. Plan 60 minutes for session 1 and 40–45 minutes for each later session. Every session contains a 30-minute writing period. The same therapist delivers all sessions. In the WET vs PE trial, therapists could add one or two sessions when the client had not written about the event itself early on, and treatment could not end before session 5 (hence the five to seven sessions reported in that trial). [source: Sloan et al. 2018; Sloan et al. 2023; CDP 2023 slides; WET vs PE protocol v10, 2022; developers' Q&A; Sloan & Marx 2024]

Phase 0: Pre-treatment assessment. Goal: confirm WET fits and pick the index trauma. Use a PTSD diagnostic assessment (CAPS-5 in trials) or the PCL-5, plus a depression screen (PHQ-9 in CDP training); assess suicide risk, psychosis, bipolar stability, substance use severity, cognitive impairment and current safety. Select one index trauma. Move on when: PTSD or significant subclinical PTSD tied to a clearly identified Criterion A event that the client remembers in enough detail, no ongoing danger, and the client accepts the rationale. (The 2019 manual has a full chapter on pre-treatment assessment; its content is [uncertain].) [source: CDP 2023 slides; WET vs PE protocol; APA book page]

Phase 1: Session 1 – psychoeducation, rationale, first writing. Goal: client understands PTSD, avoidance and why writing helps, and starts approaching the memory. Contents: weekly measures; psychoeducation read from the script with a pause to ask which symptoms are familiar; rationale; SUDS introduced; writing instructions read and handed over; pre-SUDS; 30 minutes writing; post-SUDS; check-in; narrative collected; end-of-session instruction to allow trauma thoughts during the week. [source: CDP 2023 slides; Sloan & Marx 2024]

Phase 2: Session 2 – detail. Goal: a full, detailed account of the event with sensory detail and the thoughts and feelings felt during and right after it. Contents: measures; brief check-in; feedback on narrative 1; instructions (continue where you stopped, or rewrite the whole event if finished, going deeper into feelings); SUDS; 30 minutes writing; SUDS; check-in; end-of-session instruction. A symptom spike around session 2 is expected. [source: CDP 2023 slides; developers' 2022 slides; ABPP newsletter]

Phase 3: Sessions 3–4 – meaning and impact. Goal: keep approaching the memory (whole event again or its most upsetting part) while writing about how the trauma has changed the client's life, view of life, sense of meaning and relationships. Criterion to move here: the client wrote adequately about the event itself in sessions 1–2; if not, delay the shift and repeat detail-focused instructions. In the WET vs PE trial, sessions 1 and/or 2 were repeated if instructions were not followed, up to two extra sessions, and no more even if avoidance continued. Avoidance often falls by about session 4; if symptoms have not fallen after session 3, discuss why. [source: CDP 2023 slides; WET vs PE protocol; developers' 2022 slides] Schedule check: Sloan & Marx (2024) and CDP training add the impact focus at session 3, as does the 6-session primary-care layout at its third writing session; the WET vs PE trial report summarises sessions 1–3 as detail-focused and sessions 4–5 as impact-focused. This guide follows the developers' 2024 description [uncertain: the manual's exact schedule is unverified]. [source: Sloan & Marx 2024; Sloan et al. 2023; developers' 2022 slides]

Phase 4: Session 5 – consolidation and ending. Goal: client writes about the most upsetting part and its impact, how the event relates to current life and the future, and what they learned from confronting the memory and how they will use it. After the check-in, review progress: what helped, reminder that they keep the written instructions and the approach skills, areas for further work. Decide before the final session whether more sessions are needed. [source: Sloan & Marx 2024; developers' 2022 slides; CDP 2023 slides]

After session 5 – residual symptoms. Options named by the trainers: add writing sessions, repeat WET on another trauma (usually only a couple of extra sessions are needed), switch to another PTSD evidence-based treatment, or treat remaining problems with another EBP (e.g. CBT for depression). Criteria for extra sessions: whether the client followed instructions and whether SUDS and PCL-5 remain high. [source: CDP 2023 slides; developers' 2022 slides]

Named variants (not the version followed). (a) Primary-care adaptation, as laid out in the developers' March 2022 training slides for the BETTER project. It has six sessions. Session 1 covers psychoeducation, the rationale, an explanation of SUDS and scheduling, with no writing. Sessions 2–6 each have a 20-minute writing period. Sessions 2–3 use the detail instructions, impact on the client's life is added from session 4, and the session-6 instructions continue the feelings, thoughts and impact focus and invite the client to start wrapping up. The session-6 narrative is not collected; instead, client and therapist decide what to do with the narratives already collected. The slides do not state total session length. Sloan & Marx (2024) note that primary care typically allows six 30-minute sessions and that a modified WET for that setting is being tested in two RCTs (Kaysen et al., 2023; Meredith et al., 2024). The 2nd edition of the manual adds guidance for 30-minute primary-care sessions (publisher description); whether it matches the 2022 slides is [uncertain]. (b) Group, massed (several sessions in one week), telehealth, adolescent and translated versions are reported in studies. Sloan & Marx (2024) list group and massed studies and report that one comparison found no outcome difference between remote and in-person delivery. Only telehealth procedures were found in detail (see 4.18). [source: developers' 2022 slides; Sloan & Marx 2024; NCPTSD WET page; publisher listings for the 2nd ed.]

3. Guiding principles

  • Approach, not avoidance. Every decision serves the client approaching the memory and its emotions; spot avoidance in all its forms, in the narrative and in the check-in. [source: ABPP newsletter; Sloan & Marx 2024]
  • Stick to the script. Read the psychoeducation, rationale and writing instructions word for word, changing only the named trauma and examples; give the client a printed copy each session. [source: developers' 2022 slides; CDP 2023 slides]
  • Minimal therapist involvement. The writing does the work; you set it up, time it and stay quietly present. Do not talk during writing. [source: CDP 2023 slides; developers' Q&A]
  • One index trauma. Choose the event most linked to current symptoms and avoidance and use it in every session; do not switch mid-course. [source: CDP 2023 slides]
  • Write it as you see it now, with feelings from then. Clients write about the event "as you look back upon it now" (reminding them it is not happening now) but describe the emotions felt during and just after it. [source: developers' 2022 slides; developers' Q&A]
  • Do not process in session. The post-writing check-in is about the experience of writing, not the content; no cognitive restructuring, no challenging, no extended discussion of meaning ("RESIST the URGE!" in CDP training). [source: CDP 2023 slides]
  • Feedback is about following instructions, not content. Praise what was done well, name what to add (emotions, thoughts, the event itself rather than lead-up). [source: CDP 2023 slides; NCPTSD WET page; developers' 2022 slides]
  • No homework, but no avoidance between sessions. Ask clients to let trauma thoughts, images and feelings come during the week, and ask at each session whether they did. [source: Sloan & Marx 2024; CDP 2023 slides]
  • Expect and normalise temporary worsening. Prepare clients for a spike around session 2. [source: CDP 2023 slides; developers' 2022 slides]
  • Writing quality is irrelevant. Spelling, grammar, education level and literacy level do not predict outcome; reassure clients. [source: developers' Q&A]
  • The narrative stays a private written exposure. The client does not read it aloud, does not type or edit it at home, and the therapist reads it between sessions, not during the session. [source: developers' 2022 slides]
  • Keep the rhythm. Weekly or more often (massed formats are supported); avoid long gaps. [source: developers' Q&A; NCPTSD WET page]
  • Memories are the client's experience, not facts to uncover. WET is for clients who remember the event; it is not a memory-recovery method, and gaps are not to be filled by suggestion (WET is not recommended when the client has no or scarce memory of the event). [source: CDP 2023 slides; brief house rule] [synthesis for the memory-recovery caution]
  • Measure every session. Weekly PCL-5 (and depression measure) plus pre/post SUDS drive decisions about adherence and extra sessions. [source: CDP 2023 slides; WET vs PE protocol]

4. Intervention inventory

WET is deliberately lean: its procedures are the session components below. All example language is illustrative paraphrase, not the manual script, which you should obtain and read verbatim in practice. [source for section: CDP 2023 slides; developers' 2022 slides; developers' Q&A; Sloan & Marx 2024; NCPTSD WET page]

4.1 Candidacy screening

  • Purpose / when: Before session 1, to decide whether WET fits.
  • Steps: (1) Confirm PTSD (or subclinical PTSD with marked distress or impairment) with a structured interview or the PCL-5. (2) Confirm a clearly identified Criterion A event the client remembers in some detail. (3) Check the trainers' "not recommended" list: no or only scant memory of the event; ongoing risk of trauma or imminent safety concerns; strong reservations about confronting the memory; impairment mainly due to something other than PTSD (PTSD not primary); unable to write in the therapist's language. (4) Check the trial exclusions used by the developers: current psychosis or unstable bipolar disorder, severe substance use disorder, high suicide risk (intent with a plan), significant cognitive impairment. Low-to-moderate suicide risk is not a bar; high-risk clients are stabilised first. (5) If the client cannot physically write, the developers have occasionally used an audio recorder but note this turns WET into a different (spoken) treatment, so another therapy may fit better.
  • Example language (illustrative): "This treatment asks you to write about one event in detail, five times. Before we decide, I need to understand what you remember of it and how your life is right now."
  • Watch for: Hidden ongoing danger (e.g. current abusive relationship), dissociative symptoms severe enough to block writing, and a wish to 'find out what happened', which WET is not for. [synthesis for these watch points]

4.2 Selecting the index trauma

  • Purpose / when: Pre-treatment or start of session 1; one event for all sessions.
  • Steps: Ask which event (a) is most tied to current PTSD symptoms and avoidance, (b) has reminders the client most tries but fails to avoid, (c) causes the most distress, (d) stands out most, and (e) the client can recall and describe in detail. If several fit, choose one and keep it. For repeated trauma (e.g. childhood abuse), pick one representative, most distressing occasion [synthesis on 'representative occasion'; the developers report clients with chronic childhood abuse did as well as single-event clients].
  • Example language (illustrative): "When the memories intrude, which one comes most? Which one do you work hardest to keep away from?"
  • Watch for: Choosing a less upsetting event to avoid the worst one; if the client later reveals a more central event, see Section 5. [source: CDP 2023 slides; developers' Q&A]

4.3 Weekly symptom measures

  • Purpose / when: Before every session; tracks response and flags worsening or risk.
  • Steps: Client completes PCL-5 (and in CDP training a PHQ-9 at screening; the trial also used the BDI-II each session) before the session starts. Note change from baseline. In the WET vs PE trial, endorsement of the suicidal-ideation item triggered a structured suicide-risk assessment, and sustained worsening of at least 10 PCL-5 points over three weeks judged treatment-related led to withdrawal.
  • Example language (illustrative): "Your score went up a little this week, which is common around now. Let's keep an eye on it."
  • Watch for: Expected early spike (session 2); no fall by session 3 (discuss); suicidal ideation (assess per standard practice). [source: CDP 2023 slides; WET vs PE protocol]

4.4 Psychoeducation about PTSD (session 1)

  • Purpose / when: Session 1, before the rationale; normalises symptoms and introduces avoidance as the maintaining factor.
  • Steps: Read the scripted overview of PTSD (common reactions to trauma, symptom clusters, how avoidance keeps symptoms going). Pause after the symptom description and ask briefly whether any are familiar; check understanding but do not turn it into a long discussion.
  • Example language (illustrative): "Many people after a trauma have memories that intrude, feel on edge, and try hard to stay away from reminders. Do any of these sound like you?"
  • Watch for: Long story-telling at this point (gently move on: the story belongs in the writing). [source: CDP 2023 slides; developers' 2022 slides; Sloan & Marx 2024]

4.5 Treatment rationale (session 1)

  • Purpose / when: Session 1, after psychoeducation; builds willingness to approach.
  • Steps: Explain two aims: writing helps put together a memory stored in a broken-up way, and helps the client gain control over it rather than it controlling them. Explain that avoidance keeps the memory raw, that writing in detail repeatedly lets distress rise and fall, and that the client will learn the memory can be held without harm. Check understanding several times; invite questions.
  • Example language (illustrative): "Right now the memory comes in pieces, when it wants. By writing it out on purpose, you put it in order and you decide when you face it."
  • Watch for: Fears that writing will make things worse or that they will lose control; acknowledge temporary distress and the structure (30 minutes, therapist present). [source: CDP 2023 slides; developers' 2022 slides; NCPTSD WET page]

4.6 SUDS ratings

  • Purpose / when: Introduced in session 1; rated before and after each writing period.
  • Steps: Explain a 0–100 distress scale with personal anchors (0 calm, 100 the worst distress imaginable). Ask for a rating just before writing starts and immediately after it ends; record and watch the pattern across sessions.
  • Example language (illustrative): "On a scale from 0 to 100, where 100 is the most upset you can imagine, where are you right now?"
  • Watch for: Very low ratings with a thin narrative (possible avoidance) [synthesis]. Post-writing ratings that fall across sessions fit with the treatment working [synthesis]. No source found gives numeric thresholds or interpretation rules. The developers' 2022 slides list "What if SUDS doesn't change?" as a question without a slide answer, and use SUDS that are "still high" (together with PCL-5 scores) only as one input when deciding on extra sessions before the final session. The trial reports and Sloan & Marx (2024) do not mention SUDS [uncertain: manual guidance unverified]. [source: CDP 2023 slides; developers' 2022 slides; Sloan & Marx 2024]

4.7 Reading the writing instructions and handing them over

  • Purpose / when: Every session, immediately before writing.
  • Steps: Read that session's instructions word for word, substituting the client's named event; answer brief questions; give the client a printed copy to keep beside them while writing (and to keep after treatment).
  • Example language (illustrative): "I'll read today's instructions exactly as written so you get the same thing every time. You can keep this copy in front of you."
  • Watch for: Requests to negotiate the task (e.g. 'just a summary'); restate the instruction. US Defense Health Agency guidance likewise says to read the instructions verbatim, without improvising or rewording, and to have the client write without breaks or distractions [source: O'Reilly 2020, PHCoE]. [source: developers' 2022 slides; CDP 2023 slides]

4.8 The timed 30-minute writing period

  • Purpose / when: The core exposure, every session.
  • Steps: (1) Remove distractions; silence phones. (2) Client writes by hand on lined paper (trainers encourage handwriting; do not have the client type and send it). (3) Stay in the room, seated so you can see the client peripherally without staring; read something quietly. (4) Do not speak, check in or interject. (5) Time 30 minutes; a 5-minute warning is optional. (6) If the client finishes early, tell them to go back to the beginning and keep writing. (7) If the client stops because distress is high, encourage them to continue; the developers report this usually works. (8) Stop them at 30 minutes.
  • Example language (illustrative): "Keep going: start again from the beginning and add whatever more you can remember." / "I know this is hard. Stay with it and keep writing."
  • Watch for: Long pauses, staring, writing off-topic, or signs of dissociation (see 4.19). [source: CDP 2023 slides; developers' Q&A; developers' 2022 slides]

4.9 Session 1–2 writing content: the event in detail

  • Purpose / when: First two writing sessions.
  • Steps (content of the instruction, paraphrased): Write about the index trauma as you remember it now; start at the beginning; describe how it happened, who was there, where; include what you saw, heard, smelled and felt in your body; include the thoughts and emotions you had during and right after it. You do not need to finish the whole event in one session. Session 2: if you did not finish, continue from where you stopped; if you did, write the whole event again, going into your "very deepest feelings". Write "as you look back upon it now".
  • Example language (illustrative): "Today, start at the beginning of what happened and write it in as much detail as you can: what you saw, heard and smelled, and what you were thinking and feeling at the time."
  • Watch for: Facts-only accounts, long lead-up with little of the event itself, current feelings instead of feelings at the time. These become feedback (4.14). [source: developers' 2022 slides; CDP 2023 slides; ABPP newsletter; developers' Q&A]

4.10 Sessions 3–4 writing content: impact and meaning

  • Purpose / when: From session 3, once sessions 1–2 contained adequate event detail.
  • Steps (paraphrased): Continue writing about the trauma, either from the beginning again or focusing on the part that is most upsetting; now also write about how it has changed your life: how you see life, its meaning, yourself and how you relate to others. The instruction asks the client to "really let go" with their deepest thoughts and feelings. Session 4 repeats this, emphasising the most upsetting part and how the event changed their life.
  • Example language (illustrative): "Keep writing about the hardest part. Also start writing about what this event has done to your life: how you see the world, other people and yourself now."
  • Watch for: Drifting entirely into present-day problems with no contact with the memory; keep both elements. [source: CDP 2023 slides; developers' 2022 slides; ABPP newsletter]

4.11 Session 5 writing content: the event, its impact, and going forward

  • Purpose / when: Final writing session.
  • Steps (paraphrased): Continue writing about the thoughts and feelings tied to the most upsetting part and how the event has changed your life; then write about what you have learned by confronting the memory and how you will carry those lessons into your life from here. [source: Sloan & Marx 2024, who describe the session-5 instructions in these terms] In the 6-session primary-care layout, the final instructions instead continue the feelings, thoughts and impact focus and invite the client to begin wrapping up the writing. [source: developers' 2022 slides] The exact manual wording is not reproduced here; read the manual script in practice.
  • Example language (illustrative): "In this last writing, stay with the hardest part and what it has meant, and then write about where you go from here and what facing this memory has taught you."
  • Watch for: Early 'wrapping up' that skips the memory entirely.

4.12 Post-writing check-in

  • Purpose / when: After the second SUDS rating every session; about 5–10 minutes.
  • Steps: Ask about the experience of writing, not the content. Questions the developers suggest: how the writing went; what it was like to write about the event; whether they remembered more than expected; whether it was easier or harder than expected. Acknowledge effort; normalise distress. Do not interpret, challenge thoughts or explore meaning. Make sure the client is oriented and settled enough to leave [synthesis for the last point].
  • Example language (illustrative): "How was that for you? Did anything come back that you hadn't expected?" / "That took real courage. Feeling stirred up after this is normal and it passes."
  • Watch for: Your own urge to process (CDP training flags this as the most common therapist drift); client trying to start a content discussion (acknowledge, then redirect: the writing is where that goes). [source: developers' 2022 slides; CDP 2023 slides; WET vs PE protocol]

4.13 End-of-session instruction: don't avoid

  • Purpose / when: Closing every session; the only between-session task.
  • Steps: Tell the client that thoughts, images and feelings about the trauma are likely during the week and to let them come rather than push them away. No written homework, no in-vivo exposure assignments (though clients often start approaching avoided places spontaneously). In session 1, add that feeling worse before better is common.
  • Example language (illustrative): "This week the memory may show up more. When it does, let it be there instead of shoving it away. That is part of the treatment."
  • Watch for: Clients who hear this as 'go and think about it deliberately for hours'; clarify it is about not avoiding, not rumination [synthesis]. [source: CDP 2023 slides; NCPTSD WET page; ABPP newsletter]

4.14 Reviewing the narrative between sessions

  • Purpose / when: After each session, before the next.
  • Steps: Collect the original at the end of the session (do not read it then). Before the next session, read it and check: did the client follow the instructions; did they include emotions and thoughts, not only facts; did they write about the trauma itself or mostly the lead-up; did they stay on the index event; did they write enough; are there signs of skipping the worst part? Note one or two strengths and one or two specific improvements. Return narratives later or keep them per your records policy; agree with the client at the end what happens to them.
  • Watch for: Subtle avoidance: jumping over the worst moment, passive voice, summary statements ('then it happened'), stopping before the event, writing about another event. [source: CDP 2023 slides; developers' 2022 slides; developers' Q&A] [synthesis for the list of subtle-avoidance markers]

4.15 Giving feedback on the narrative

  • Purpose / when: Start of sessions 2–5, after the brief check-in; longer early, shorter later.
  • Steps: (1) Start with what they did well. (2) Name specifically what to include more of, referring to the instruction (e.g. thoughts and feelings at the time, sensory detail, the most upsetting moment). (3) Keep it about adherence, not about the meaning of the content. (4) In the next check-in, ask whether they used the feedback.
  • Example language (illustrative): "You described what happened very clearly, step by step. What I'd like more of next time is what you were feeling and thinking in those moments, especially when you saw him fall."
  • Watch for: Feedback that turns into processing or reassurance about the content. Personalised feedback is essential in individual, group and telehealth delivery alike. [source: CDP 2023 slides; developers' 2022 slides; NCPTSD WET page; Sloan & Marx 2024]

4.16 Checking between-session avoidance

  • Purpose / when: Brief check-in at the start of sessions 2–5.
  • Steps: Ask how the week went, whether trauma thoughts came up, and whether they let them come or pushed them away. Praise approach; label avoidance non-judgmentally and repeat the instruction.
  • Example language (illustrative): "When the memory came up this week, what did you do with it?"
  • Watch for: Increased substance use, overwork or other avoidance used to cope with the spike [synthesis]. [source: Sloan & Marx 2024; developers' 2022 slides]

4.17 Final review and ending (session 5)

  • Purpose / when: After the session-5 check-in.
  • Steps: Review weekly scores with the client; ask what was most helpful; highlight the skill learned (approaching rather than avoiding the memory, tolerating distress); remind them they keep the written instructions and can use the approach in future; name remaining difficulties and the plan for them; discuss what to do with the narratives.
  • Example language (illustrative): "Look at where your scores started and where they are now. What do you think made the difference? If the memory starts running your life again, what will you do?"
  • Watch for: Abrupt ending feeling (CDP trainers flag this); prepare from session 4 that session 5 is the last. Full recovery is not guaranteed; frame residual symptoms honestly. [source: CDP 2023 slides; developers' 2022 slides; ABPP newsletter]

4.18 Telehealth delivery

  • Purpose / when: When sessions are by video.
  • Steps: Use video, not phone-only (phone only as a back-up if video drops). Review confidentiality and secure channels. Send the instructions in advance (mail, secure message, in person) or share on screen; the client keeps a copy. Client has lined paper and a pen. During writing keep the call open, tell them you are there, mute your microphone, angle your camera so you are not staring, and keep the client on camera. If video drops, reconnect or call immediately and continue by phone. Collect the narrative before the next session by secure messaging (preferred), scan, screenshot via webcam at session end, mail or drop-off; warn that phone photos may sync to shared cloud storage.
  • Watch for: Client leaving the camera view or a busy home setting; agree a private room beforehand [synthesis]. [source: developers' 2022 slides; developers' Q&A; NCPTSD WET page]

4.19 Grounding for dissociation during writing

  • Purpose / when: Only if the client dissociates (developers report this is rare, helped by therapist presence and the concrete writing task).
  • Steps: The developers say to teach simple grounding; they do not specify which. A reasonable sequence [synthesis]: pause the writing; speak calmly using their name; orient to date, place and safety ('this is a memory, you are here with me'); have them press feet into the floor, name things they can see and hear, hold a cool object; once present (able to answer and track), resume writing, reminding them to write the event as they look back on it now. Teach the grounding before the next writing so they can use it themselves.
  • Example language (illustrative): "Maria, you're in my office, it's Tuesday. Feel your feet on the floor. Tell me three things you can see. Good. When you're ready, pick up the pen and continue from where you were."
  • Watch for: Repeated dissociation that prevents writing (see Section 5). [source: developers' Q&A] [synthesis for the steps]

4.20 Writing about bodily sensations (low emotional awareness)

  • Purpose / when: Clients who find it hard to name emotions.
  • Steps: Ask them to write the physical sensations they notice as they recall the event (and felt at the time), alongside whatever emotions they can name; feed back on this in the next session.
  • Example language (illustrative): "If it's hard to name feelings, write what your body was doing: heart pounding, stomach, hands. That counts."
  • Watch for: Gradual addition of emotion words over sessions. [source: developers' Q&A]

4.21 Repeating detail sessions and adding sessions

  • Purpose / when: When instructions were not followed early, or symptoms remain at the end.
  • Steps: If sessions 1–2 lacked adequate event detail, delay the shift to meaning instructions and repeat the detail instructions (trial rule: up to two repeat sessions, then continue even if avoidance persists). Before the final session, review adherence, SUDS and PCL-5; if still high, choose between a few more writing sessions, WET on another event, another trauma-focused EBP, or an EBP for another problem.
  • Example language (illustrative): "Last time, most of the writing was about the hours before. Today I'd like us to repeat the same instructions so you can get into the event itself."
  • Watch for: Endless extensions without adherence; switch approach instead [synthesis]. [source: CDP 2023 slides; WET vs PE protocol; developers' 2022 slides]

5. Handling problems

The manual's own troubleshooting guidance is not reproduced here [uncertain]. The 2019 edition has an FAQ chapter and case illustrations, and the 2025 2nd edition adds guidance on managing difficult situations, with case examples (publisher description). The CDP 2023 and developers' 2022 trainings list FAQs (stopping early, dissociation, the client not wanting to give the therapist the narrative, too-brief writing, SUDS not changing) without answers on the slides. Guidance below is from the developers' Q&A, trainings and trial reports where tagged; everything else is [synthesis].

  • Too distressed to keep writing. Encourage continuing; the developers report redirection usually works. Remind them the event is a memory, they are safe here, and the 30 minutes will end. If they still cannot continue, let them take a brief pause and resume rather than ending the session [synthesis for the pause]. [source: developers' Q&A]
  • Stops early or 'has nothing more to say'. Tell them to start again from the beginning and add detail; worry about forgotten details is answered with reassurance, as details often return while writing. [source: CDP 2023 slides; developers' Q&A]
  • Dissociation. Ground (4.19), then resume. If dissociation recurs every session and prevents writing, pause WET, teach grounding and arousal skills over one or two sessions, and reconsider candidacy or a treatment with more in-session therapist guidance [synthesis]. [source: developers' Q&A for grounding]
  • High arousal at the end of a session. CDP trainers note the manual gives little guidance. Normalise and predict the temporary increase; use the check-in to orient the client; do not let them leave visibly dissociated or acutely unsafe; offer a short grounding exercise and agree how they will get home [synthesis]. [source: CDP 2023 slides]
  • Facts only, no feelings. Feedback naming the missing element; for low emotional awareness, have them write bodily sensations (4.20). [source: CDP 2023 slides; developers' Q&A]
  • Writes mainly the lead-up or another event; skips the worst moment. Specific feedback pointing to the instruction and the moment to include; repeat the detail instructions rather than moving to meaning instructions; up to two repeats, then proceed. [source: CDP 2023 slides; WET vs PE protocol]
  • Writes too little. Check for literacy or physical difficulty versus avoidance. Writing quality and education level do not predict outcome; reassure. Ask for one more step of detail each time [synthesis for the last step]. [source: developers' Q&A]
  • Does not want the therapist to read the narrative. Both trainings list this as a question ("What if patient doesn't want to give therapist the narrative?" in the developers' 2022 slides) but give no answer on the slides; the answer may be in the manual's FAQ or difficult-situations material [uncertain]. What the sources do settle: collecting and reviewing the narrative is called an essential part of treatment, and having the client read it aloud or type and send it instead is not acceptable, because either changes the intervention. [source: developers' 2022 slides] [synthesis]: explore the fear (shame, judgement, being seen as 'bad'); explain that you read it only to give feedback on following the instructions, not to judge the content; offer not to discuss content they do not want discussed; if they still refuse, discuss whether a different treatment fits.
  • Symptoms rise (expected around session 2). Normalise in advance and again when it happens. If PCL-5 rises substantially and stays up over several weeks, reassess (the developers' trial withdrew participants with a sustained rise of 10+ points judged treatment-related). [source: CDP 2023 slides; WET vs PE protocol]
  • No improvement by session 3. Discuss why: is the client following instructions, avoiding between sessions, writing about the right event, facing new stressors? [source: CDP 2023 slides for 'discuss'] [synthesis for the checklist]
  • Non-adherence to 'don't avoid' between sessions (drinking, distraction, overwork). Name it without blame; link it to the rationale; ask what got in the way; restate the instruction. [synthesis]
  • Missed or delayed sessions. Keep the weekly rhythm; long gaps reduce gains in trauma-focused therapy and the developers expect the same for WET. Reschedule quickly; if more than a couple of weeks have passed, consider repeating the previous writing instructions [synthesis for the repeat]. Dropout is lower in WET than in CPT or PE, which developers link to brevity, no homework and writing rather than speaking. [source: developers' Q&A; Sloan & Marx 2024]
  • Wants to process content or discuss meaning in the check-in. Acknowledge it warmly; say that is exactly what the writing is for and suggest putting it in next week's narrative; keep the check-in on the experience of writing. [source: CDP 2023 slides for not processing] [synthesis for wording]
  • Rupture: client feels the therapist is distant or 'just reading a script'. Acknowledge the structure was explained up front, validate the feeling, explain your quiet presence is deliberate (it leaves the space for their writing) and that you read every word between sessions; keep feedback warm and personal. [synthesis]
  • Reveals a different, more central trauma mid-course. Sources say to choose one event and stay with it; [synthesis]: if the new event is clearly the main driver, finish the current course or, if early (session 1–2), switch with the client's agreement and restart the detail instructions; otherwise plan a WET course on the second event afterwards, which the trainers name as an option.
  • Strong anger toward a perpetrator. Anger is an appropriate reaction; the developers observe clients usually become more hopeful and that rage tends to fall; it should not impair functioning. Monitor for risk to others (homicidal risk was screened every session in the trial). [source: developers' Q&A; WET vs PE protocol]
  • Suicidal ideation emerges. Assess risk with standard practice at every session where it is flagged; low to moderate risk can continue with a safety plan; high risk (intent with plan) means pausing WET and stabilising first, with lethal-means counselling about storage and removal as part of safety planning. [source: developers' Q&A; WET vs PE protocol] [synthesis for safety-plan and lethal-means steps]
  • Ongoing danger discovered (e.g. current domestic violence). Pause WET; move to safety planning and protective steps; WET is not recommended while risk of trauma continues. [source: CDP 2023 slides] [synthesis for the pause]
  • Asks to type, dictate or record instead. Handwriting is the tested standard; do not have them type and send it or edit it later. A recorder was used for a few clients who could not physically write, but the developers regard spoken recounting as a different treatment. [source: developers' 2022 slides; developers' Q&A]
  • Client wants to know what 'really happened' or to fill memory gaps. WET is not a memory-recovery method; ask them to write what they remember, as they remember it now, and do not suggest content; gaps are acceptable. [synthesis]
  • Therapist drift (adding cognitive work, extending check-ins, softening instructions). Re-read the script, use a self-check of essential elements (verbatim instructions, timed 30 minutes, SUDS, collection and feedback, non-processing check-in, one event, no homework); seek consultation. CDP training also advises attention to secondary traumatic stress from reading narratives. [source: developers' 2022 slides; CDP 2023 slides]

Sources

Sources:

Further pages:

Books and papers cited:

  • Sloan, D. M., & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. American Psychological Association.
  • Sloan, D. M., & Marx, B. P. (2025). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals (2nd ed.). American Psychological Association. xv + 158 pp.; DOI 10.1037/0000441-000 (details from catalogue and retailer descriptions).
  • Kaysen et al. (2023) and Meredith et al. (2024), primary-care WET trials (cited in Sloan & Marx 2024).
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