Written exposure therapy

1. Introduction

Version followed: Sloan & Marx (2019), Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals (APA, 1st edition), five-session scripted protocol, as shown in the publisher's sample pages and the Center for Deployment Psychology (CDP) WET training slides (April 2023). A second edition (APA, 2025) exists. Its introduction says the evidence base has grown, adds a new chapter on telehealth, group format, primary care (which typically allows only 30-minute sessions) and use with a translator, substantially revises the difficult-situations chapter, adds case examples, and gives the full script as chapter 8 [source: 2nd-edition sample pages pp. 5–6; APA 2nd-edition page]. Check the 2nd edition for changes before relying on session details here [uncertain: chapters 3–7 of either edition were not available to check]. Two extras come from the developers' VA trial comparing WET with prolonged exposure (NCT03962504): repeating sessions when the client does not follow the instructions, and the safety-monitoring rules. Session format and trial details draw on the full texts of the 2018 WET-vs-CPT trial and the 2023 WET-vs-PE trial (both JAMA Psychiatry), the developers' own training slides (2022, including a primary-care adaptation) and the introductions of both editions. The verbatim script is in the book (appendix in the 1st edition, chapter 8 in the 2nd). It is paraphrased here, not reproduced.

Written Exposure Therapy (WET) is a brief, individual, trauma-focused exposure treatment for adults with PTSD. It was developed by Denise Sloan and Brian Marx (National Center for PTSD; Boston University). Over five sessions the client writes by hand or types for 30 minutes per session about one traumatic event, alone, following scripted instructions. The therapist reads out the instructions, then holds a short check-in about what writing was like, not about the trauma itself. No homework is set. [source: APA book page; sample pages pp. 4–5; CDP slides 4–5, 22]

How change happens: WET comes from exposure therapy and from Pennebaker's research on emotional disclosure through writing. The book's acknowledgements name Pennebaker's work as a major inspiration, and the PHCoE brief describes WET as an adaptation of Pennebaker & Beall (1986). The training slides give the client this rationale: trauma memories are stored in a 'splintered', disorganised way. Repeatedly writing a detailed account that includes feelings and thoughts organises the memory, gives the person more control over it, and reduces avoidance. A later phase of the writing addresses how the event has changed the person's life and its meaning. [source: sample pages pp. ix, xiii; CDP slides 31–33, 37; PHCoE brief] The PHCoE brief places WET within emotional processing theory and cites Wisco, Baker & Sloan (2016): arousal during session 1 followed by less arousal between sessions predicted improvement. The PHCoE brief also says the mechanisms are not well understood. [source: PHCoE brief; Wisco et al., uncertain]

Professional frame: WET is a psychotherapy protocol, not a creative-arts therapy. It needs no arts-therapy registration (for example HCPC, BAAT or AATA). The developers state that only licensed clinicians with appropriate experience and training, or trainees supervised by such clinicians, should use it [source: 2nd-edition sample pages p. 7]. In their trials the therapists were master's- or doctoral-level clinicians experienced in trauma-focused work, and whether less-trained providers can deliver WET effectively is unknown. The book says plainly that it is not a self-help resource and not a manual for paraprofessionals such as peer counsellors. No WET-specific credential or register is known [uncertain]. Training is offered by the CDP and through PESI courses presented by the developers. [source: sample pages p. 5; 2nd-edition sample pages p. 5; CDP slides; PESI page] Use WET only within your licensed scope and with PTSD assessment skills. Supervised practice on first cases is advisable. [synthesis]

Materials and physical safety: all that is needed is paper and pen or a keyboard, a quiet private room and a timer. Physical risk is minimal. Allow for hand fatigue or pain during 30 minutes of handwriting, offer typing, and keep the room free of interruptions. [source: CDP slides 22, 26; ergonomics is synthesis]

2. Framework

Format. Individual sessions, usually weekly in the VA trial. Session 1 lasts about 60 minutes and sessions 2–5 about 40 minutes. Each session has a 30-minute writing period timed by the therapist. The sources differ on how the remaining time is split:

2012 motor-vehicle-accident trial (46 survivors, WET vs waitlist): five weekly sessions of psychoeducation, rationale and repeated written exposure, with instructions to write about the deepest thoughts and feelings about the accident, and no in vivo assignments. Minutes are not reported in this source. [source: Wisco, Sloan & Marx 2013, describing Sloan et al. 2012]
The book introduction (1st ed.) gives about 10 minutes of check-in after the writing. [source: sample pages p. x]
The foreword describes about 20 minutes of face-to-face time per session. [source: sample pages]
The PHCoE brief gives about 25 minutes of therapist time in session 1 and 10 minutes in later sessions. [source: PHCoE brief]
2018 WET-vs-CPT trial (126 adults, mixed trauma): session 1 about 60 minutes, with psychoeducation and the rationale followed by 30 minutes of writing. Sessions 2–5 about 40 minutes: the therapist first gives feedback on how closely the client followed the previous instructions and how to follow them better, then the client writes for 30 minutes without interruption. No homework. [source: Sloan et al. 2018, full text]
2023 WET-vs-PE trial (178 veterans): session 1 about 60 minutes (PTSD symptoms, rationale, 30 minutes of writing). Sessions 2–5 about 45 minutes: feedback on the prior narrative, 30 minutes of writing, then a brief discussion of what writing was like. Five to seven sessions of 45–60 minutes were allowed. One or two sessions could be added if the client had not written about the trauma in the first two sessions, and treatment could not end before session 5. [source: Sloan et al. 2023, full text]
Primary-care adaptation in the developers' 2022 training slides: six sessions. Session 1 is psychoeducation and rationale only, with no writing. Sessions 2–6 are check-in, feedback and 20 minutes of writing. This is a different version; do not mix it with the standard protocol. [source: Sloan & Marx 2022 slides]

Working split for the standard protocol: the 2nd edition describes a first session of about 1 hour (the clinician explains PTSD and why repeated structured writing helps) and four further sessions of about 40 minutes each, with 30 minutes of writing every session and a brief check-in at the end [source: 2nd-edition sample pages p. 4]. Within that, a workable allocation is: in session 1, about 25–30 minutes of psychoeducation, rationale and questions, then 30 minutes of writing and a short check-in; in sessions 2–5, about 5 minutes of check-in and feedback before writing, 30 minutes of writing, and about 5 minutes of post-writing check-in [synthesis from the trial descriptions above; the manual's own minute allocation is uncertain]. The extra sessions come from the repeat rule below. [source: sample pages pp. x, 4; CDP slide 5; trial protocol §8; Sloan et al. 2018; Sloan et al. 2023; PHCoE brief]

Standard structure of every session. The CDP slides give eight steps:

Screening measures (first session only).
Check-in and feedback on the previous narrative.
Reading the instructions aloud.
Pre-writing SUDS rating.
30 minutes of timed writing.
Post-writing SUDS rating.
Post-writing check-in.
Wrap-up.

Weekly self-report measures, such as the PCL-5 and PHQ-9, are collected before each session. [source: CDP slides 23, 28, 41]

Phases and goals

Before treatment (assessment): confirm PTSD or significant subthreshold PTSD linked to a clear Criterion A event, and that the event is remembered in enough detail. Choose the index trauma and introduce the SUDS. [source: CDP slides 21, 23, 27; book ch. 3, contents list only]
Session 1 (orientation and first exposure): psychoeducation about PTSD, the rationale for writing, questions answered, then the first writing instruction. The client writes about the event from the beginning in detail, including sensory detail and thoughts and feelings during and just after it. The whole account need not be finished in one session. [source: CDP slides 29–35; sample pages p. 4]
Session 2 (consolidating the detailed account): same instruction with feedback on how well the client followed it. A temporary rise in symptoms is common around this point. [source: CDP slide 36]
Sessions 3–4 (most distressing part, and meaning): keep writing about the same event, focusing on the most upsetting part or rewriting from the start. Add how the trauma has changed the client's view of life, its meaning and their relationships. Avoidance often drops around session 4. [source: CDP slides 36–38]
Session 5 (final writing and ending): the standard session, then a review of what helped and of coping tools. Give the client the written instructions to use in future, and name the areas that still need work. [source: CDP slide 39]

Version note on the writing sequence. The sources order the writing focus slightly differently. The 2023 trial paper says sessions 1–3 focus on the details of the index trauma and the thoughts and feelings during it, and sessions 4–5 on how the event has affected the client's life. The developers' 2022 primary-care slides (six sessions) start the impact writing at session 4, alongside rewriting the account or focusing on its most upsetting part, and end with a session on current feelings and how the trauma relates to the present and future. The CDP slides, followed above, bring in the meaning writing at session 3, but only if the earlier narratives were adequate. In every version the trauma account continues alongside the impact writing. Follow the sequence in the manual edition you hold. [source: Sloan et al. 2023; Sloan & Marx 2022 slides; CDP slides 36–38] [uncertain: which sequence the 1st- and 2nd-edition scripts use]

Criteria for moving between phases

Move to the session 3 instructions on meaning only if the writing in sessions 1–2 was adequate. If the narrative was mostly facts, mostly about events before the trauma, or off target, delay the change. [source: CDP slide 37]
In the VA trial, a client who did not follow the instructions in session 1 and/or 2 repeated that session, up to two extra sessions in total. No further sessions were added if avoidance continued. [source: trial protocol §8]
If symptoms have not fallen by session 3, discuss with the client why. [source: CDP slide 36]
After session 5, the options for residual symptoms are: add sessions, repeat WET with a different trauma, switch to another evidence-based PTSD therapy, or treat the remaining problems with another evidence-based treatment. [source: CDP slide 40]

Indications and cautions. Suitable for PTSD or subclinical PTSD with significant distress or impairment and a clearly identified Criterion A event. Trials included sexual and physical assault, childhood abuse, combat and motor vehicle accidents. People with multiple or chronic trauma can be treated. [source: CDP slide 21; sample pages pp. 4–6; PHCoE brief]

The training slides advise against WET when:

the client has no memory, or only scarce memory, of the event;
trauma is ongoing or there are imminent safety concerns;
the client strongly does not want to confront the memory;
the impairment is not due to PTSD, or PTSD is not the primary problem;
the client cannot write in the therapist's primary language.

[source: CDP slide 21]

The developers' own 2022 training slides add to this list. Poor candidates also include people with active psychosis, people with heavy substance use who will not abstain for two hours before and after sessions, and people with physical problems that prevent writing. Suitable candidates include people with co-occurring mental disorders, personality disorders, chronic or severe PTSD, multiple or chronic trauma, traumatic brain injury, or a first language other than English. [source: Sloan & Marx 2022 slides] Read the language point together with the CDP rule above: the client must be able to write in a language the therapist reads. [synthesis]

The developers' trials excluded high current suicide risk (intent with a plan in the VA protocol), psychosis, mania or unstable bipolar disorder, significant cognitive impairment, current substance dependence or severe substance use disorder, and concurrent PTSD psychotherapy. Clients on psychotropic medication had to be on a stable dose for at least 4 weeks. These are research exclusions, not rules in the manual. [source: Sloan et al. 2018; Sloan et al. 2023; trial protocol §7, §11] WET has not been tested with people under 18. [source: sample pages p. 5]

3. Guiding principles

Deliver the script as written. Read the instructions aloud word for word every session so delivery stays consistent. You can still be warm, but do not improvise new instructions. [source: sample pages p. 4; CDP slide 29]
The writing is the treatment, not the talk. The exposure happens on the page. The check-in is about how writing felt, not a processing session. The slides put it in capitals: "RESIST the URGE!" to process. [source: CDP slide 24; APA book page]
Stay with one index event. The client writes about the same trauma in all five sessions. If several events qualify, pick one and stay with it. Do not switch events mid-course. [source: CDP slides 27, 41]
Ask for detail plus emotion. Facts alone are not enough. The client includes what they thought, felt and sensed, and grammar does not matter. [source: CDP slides 22, 25; PHCoE brief]
Use the full 30 minutes. If the client finishes early, they go back to the beginning and write again. Do not stop early because the client is distressed. [source: CDP slide 22]
Stay silent and out of the way during writing. Do not interrupt or check in while the client writes. Time the period and consider a five-minute warning. Silence phones and keep your own noise down. [source: CDP slides 26, 42]
Give feedback on process, not content. Before the next session, read the narrative and give feedback on how closely the client followed the instructions, not on the story itself. Give more feedback early and less later. [source: CDP slides 25, 36]
No homework, but no avoidance between sessions. Do not assign homework ("Don't assign homework!"). Instead ask the client to let trauma-related thoughts, images and feelings come between sessions without pushing them away. [source: CDP slides 22, 35, 42]
Expect and normalise a temporary rise in symptoms. Prepare the client for a possible spike around session 2 so they do not read it as harm. [source: CDP slides 36, 42]
Measure every session. Take SUDS before and after writing, and collect weekly self-report measures such as the PCL-5 and PHQ-9. Use the scores to steer decisions, especially at session 3. [source: CDP slides 23, 28, 36, 41]
Stay within scope and keep monitoring safety. Use WET with adults whose main problem is PTSD. Screen for and monitor suicide risk and other safety concerns throughout, and stop or change treatment when deterioration is sustained. [source: CDP slide 21; trial protocol §11; current-practice detail is synthesis]

4. Intervention inventory

The manual's components are listed in session order (4.1–4.14). The safety and access procedures that run alongside them follow (4.15–4.19). Example wording is illustrative throughout and is not the manual's script.

4.1 Pre-treatment assessment and suitability decision

Purpose: confirm that WET fits: PTSD as the primary problem, a clear Criterion A event, enough memory detail, no ongoing trauma or imminent danger. Also get baseline scores. [source: CDP slides 21, 23; book ch. 3 per APA contents list]
Steps:
1. Assess PTSD with a structured method. The trials used the CAPS-5 given by independent evaluators. In clinic, the slides suggest at least the PCL-5 and PHQ-9 before starting. [source: CDP slides 15, 23; trial protocol §7]
2. Screen for co-occurring problems the trials excluded: severe substance use disorder, psychosis or unstable bipolar disorder, high suicide risk, significant cognitive impairment. [source: trial protocol §7]
3. Check that the client can write for 30 minutes in your shared language (see 4.19).
4. Check readiness. If the client has strong reservations about confronting the memory, explore them before offering WET, or offer an alternative. [source: CDP slide 21]
5. Agree on the limits of confidentiality, including what you must act on if the narrative reveals ongoing risk to the client or others. [source: trial protocol consent section; applying this to narratives is synthesis]
Example language (illustrative): "Before we decide, I'd like to understand which memory troubles you most and how much of it you can recall. This treatment works by writing about one event in detail."
Watch for: fragmentary or absent memory, current abuse or danger, a different primary diagnosis. Any of these points to a different plan.

4.2 Selecting the index trauma

Purpose: choose the one event the whole course will target. [source: CDP slide 27]
Steps: list candidate events with the client. Choose the one that:
- is most tied to current symptoms and avoidance;
- has reminders that are hardest to avoid;
- causes the most distress;
- stands out most;
- is remembered well enough to write in detail.
If several qualify, pick one and stay with it. [source: CDP slide 27]
Example language (illustrative): "Of these events, which one shows up most in your nightmares or in what you avoid? That's usually the one to write about."
Watch for: a client who picks a less distressing event to avoid the worst one. Name this gently and revisit the choice. [synthesis]

4.3 Introducing the SUDS and the measurement routine

Purpose: give the client a shared 0–100 language for distress and track change. [source: CDP slides 23, 28]
Steps:
1. Introduce the SUDS before session 1. Anchor 0 and 100 with the client's own examples.
2. Each session, take a SUDS rating just before and just after writing.
3. Collect the PCL-5 and PHQ-9 (or local equivalents) before each session and chart them. [source: CDP slides 23, 28, 41] These are self-report screening and tracking measures: use them to follow change, not to diagnose on their own, and check their validity for your client's language and culture [synthesis].
Example language (illustrative): "On a 0 to 100 scale, where 0 is completely calm and 100 is the most upset you can imagine, where are you right now?"
Watch for: high distress during writing in early sessions is expected. Across sessions, look for falling post-writing SUDS and falling weekly scores. [source: CDP slide 36; PHCoE brief on early arousal]

4.4 Setting up the writing environment and medium

Purpose: make 30 minutes of uninterrupted writing possible. [source: CDP slide 26]
Steps:
1. Decide with the client between handwriting and typing.
2. Decide whether the client writes alone or with you in the room. The slides leave this to clinical judgement and list pros and cons. The book's sample pages describe clients writing alone while staying in the clinic.
3. Silence phones and limit noise, including your own.
4. Have a timer, the printed instructions and spare paper ready. [source: CDP slide 26; sample pages p. x; trial protocol §8 (instructions left with the client)]
Example language (illustrative): "Would you rather type or write by hand? I'll be just outside and I'll knock when the 30 minutes are up."
Watch for: a device that lets the client drift into email or messages. Disable notifications. [synthesis]

4.5 Session 1 psychoeducation and rationale

Purpose: explain PTSD and why writing about the trauma helps, to build engagement. [source: sample pages p. 4; CDP slides 29–34]
Steps:
1. Tell the client you will read the instructions word for word.
2. Give a brief overview of common PTSD reactions, pausing to ask which ones the client recognises.
3. Explain the rationale: avoidance keeps the memory disorganised and powerful, and repeatedly writing a full account organises it and gives more control.
4. Explain that symptoms may rise briefly.
5. Answer questions. [source: CDP slides 29–34, 42]
Example language (illustrative): "When we push a memory away, it tends to stay in pieces and keep ambushing us. Writing it out fully, several times, helps it become a memory you can hold, not one that holds you."
Watch for: misunderstandings, for example "I just have to vent" or "I'll be made to relive it with you watching". Correct them now.

4.6 Reading the scripted writing instructions

Purpose: consistent delivery. In every session, the instructions are read aloud before writing. [source: sample pages p. 4; trial protocol §8]
Steps:
1. Read the session's instructions from the manual appendix word for word.
2. Ask for questions.
3. Leave a printed copy with the client during writing.
The general instructions every session include: write about the index event, include thoughts, feelings and details, ignore spelling and grammar, and if finished early start again from the beginning. [source: CDP slide 22; trial protocol §8]
Example language (illustrative): "As before, I'm going to read today's instructions exactly as they're written. Then you'll have 30 minutes."
Watch for: the client nodding along without taking it in. Ask them to say the task back in their own words. [synthesis]

4.7 Sessions 1–2 writing: the detailed account

Purpose: emotional and sensory exposure to the whole event. [source: CDP slides 34–36; PHCoE brief]
Steps: the client writes the event from the beginning. They include what they saw, heard, smelled and felt physically, and what they thought and felt during the event and right after it. They need not finish the whole story in session 1. In session 2 they continue with the same focus and take in your feedback. [source: CDP slides 34–36]
Example language (illustrative): "Write it as though it's unfolding now: what you noticed, what went through your mind, what you felt in your body."
Watch for: writing that is mostly about context before the event, factual reports with no emotion, or a jump to a different event. [source: CDP slide 25]

4.8 The 30-minute timed writing period

Purpose: a fixed dose of exposure. [source: CDP slides 5, 22, 42]
Steps:
1. Start the timer and leave the client alone, or sit quietly if you stay in the room.
2. Do not interrupt or check in.
3. Consider a five-minute warning.
4. At 30 minutes, end the writing and take the post-writing SUDS. [source: CDP slides 28, 42; trial protocol §8]
Example language (illustrative): "You have five minutes left." Then at the end: "Time's up. Please finish your sentence. What's your SUDS rating now?"
Watch for: stopping early or writing only a few lines. The slides raise these as questions but give no scripted answer; see section 5. [source: CDP slide 46]

4.9 Post-writing check-in

Purpose: close the session, gauge the client's state, and learn how the task went, without processing the content. The developers describe this check-in as focused on the client's experience of writing, not on the traumatic event itself. [source: 2nd-edition sample pages p. 4; CDP slide 24; APA book page; trial protocol §8 (5–10 minutes)]
Steps:
1. Ask how the writing went and what was hard.
2. Reflect and normalise the feelings that came up.
3. Do not interpret, challenge thoughts or go back over the story.
4. Check the client's current state before they leave (see 4.17).
5. Collect the narrative. [source: CDP slides 24, 28]
Example language (illustrative): "What was it like to write today? Was there a point where it was hardest to keep going?"
Watch for: your own pull to discuss the meaning of the event, and the client asking you to "just read it now and tell me". Gently hold the frame. [source: CDP slide 24]

4.10 Reviewing the narrative between sessions and giving feedback

Purpose: check that the client is doing the exposure as instructed, and shape it. [source: CDP slide 25]
Steps:
1. Before the next session, read the narrative and check four things:
  - Were the instructions followed?
  - Did the client write only facts, or include feelings and thoughts?
  - Did they write about events before the trauma instead of the trauma itself?
  - Did they stay with the index event, and how long was the narrative?
2. At the start of the next session, give brief, specific feedback on following the instructions, not on the content.
3. Praise what was done well, then name one or two changes. [source: CDP slides 25, 28, 36]
Example language (illustrative): "You described the scene really clearly. This time, add more of what you were feeling and thinking at each moment, not just what happened."
Watch for: feedback that drifts into interpreting the story, or criticism that shames the client. Keep it on the task.

4.11 Corrective feedback and repeating sessions

Purpose: keep the dose effective when early sessions miss the target. [source: CDP slides 25, 37; trial protocol §8]
Steps:
1. If the session 1 or 2 narrative did not follow the instructions, give specific corrective feedback and repeat that session's instructions. The VA trial allowed up to two extra sessions in total.
2. Delay the session 3 change to meaning until the detailed account is adequate.
3. If avoidance continues after the repeats, stop adding sessions and review the treatment choice with the client. [source: trial protocol §8; CDP slide 37]
Example language (illustrative): "Last time most of the writing covered the drive there. Today, start at the moment things went wrong and stay with it."
Watch for: whether the next narrative improves. If it does not after two repeats, that is a sign to reconsider fit (see section 5).

4.12 End-of-session instruction (no homework, no avoidance)

Purpose: support exposure between sessions without assigning homework. [source: CDP slides 35, 42]
Steps: at the end of sessions 1–4, tell the client that trauma thoughts, images and feelings may come up during the week. Ask them to let these come and go rather than push them away. Assign nothing else. Remind them that a temporary spike in symptoms is expected. [source: CDP slides 22, 35, 42]
Example language (illustrative): "If memories come up this week, let them be there without fighting them. They'll pass. You don't need to write anything at home."
Watch for: clients who start writing at home on their own. Ask how it went, but do not encourage it. [synthesis]

4.13 Sessions 3–4 writing: the most upsetting part, and the impact

Purpose: deepen exposure to the most distressing part and work on the event's meaning. [source: CDP slides 37–38]
Steps:
1. Give the session 3 instructions. The client either keeps writing about the event, focusing on the most upsetting part, or rewrites from the beginning.
2. They also write about how the trauma has changed their life: how they see themselves and the world, the meaning they give it, and their relationships.
3. Repeat these instructions in session 4. [source: CDP slides 37–38]
Example language (illustrative): "Today, go to the part that's hardest to think about and stay there. Then write about how this event has changed the way you see yourself, other people and your future."
Watch for: writing only about the impact and skipping the event itself. The event writing must continue. [source: CDP slide 38 says to continue the trauma writing]

4.14 Session 5: final writing, review and ending

Purpose: final dose, consolidation and planning what comes next. [source: CDP slides 39–40, 45]
Steps:
1. Run the standard session through the post-writing check-in.
2. Review the course: weekly scores, what helped, what changed.
3. Remind the client of the coping tools they have and give them the written WET instructions to use in future.
4. Name the areas that still need work.
5. Agree the next step: discharge, extra sessions, WET for another event, another evidence-based PTSD therapy, or treatment for other problems.
The slides note that ending can feel abrupt, so allow time. [source: CDP slides 39–40, 45]
Example language (illustrative): "Let's look at where your scores started and where they are now, and talk about what you'd do if the memories flared up again."
Watch for: substantial residual PTSD or depression on the final measures. Do not discharge by default; use the options in step 5.

4.15 Suicide-risk and safety monitoring during WET

Purpose: exposure work can raise distress temporarily. Monitor risk systematically and respond quickly. [source: trial protocol §11; current practice is synthesis]
What the developers' VA trial did:
- Screened suicide risk at entry with a structured interview module and excluded high risk (intent with a plan).
- Gave a depression inventory at every session. Any endorsed suicidal thought on its suicide item triggered a structured risk assessment by a licensed psychologist.
- Asked about thoughts of harming others at entry and at every session.
- Gave participants an after-hours psychiatry on-call number.
- Responded to risk with direct questioning, a mental-status review (psychosis, mood, substance use), extra contacts, short-term goals and a collaborative action plan that included hospitalisation options.
- Removed participants from treatment when risk was high or the clinical condition deteriorated substantially. Sustained PTSD worsening was defined as an increase of 10 or more PCL-5 points over baseline, sustained across about three weeks or sessions, that the participant attributed to treatment.
The protocol is internally inconsistent on some of these thresholds. [source: trial protocol §§10–11]
Steps for routine practice (synthesis, adapted from the protocol and current standard practice):
1. Screen at intake with a structured screening tool, such as the Columbia Suicide Severity Rating Scale screener. A screen supports, and does not replace, clinical risk assessment.
2. Review the suicide item of the weekly PHQ-9 before each writing period. Any positive answer triggers a structured risk assessment before you decide whether to write that day.
3. Where any ideation is present, build a written collaborative safety plan before session 1 that covers warning signs, coping steps, contacts and crisis lines.
4. Counsel on lethal means where relevant: secure storage, or removal of firearms and stockpiled medication by a trusted person, for the duration of treatment.
5. Read each narrative before the next session, ideally the same day. If it contains statements of current intent, contact the client before the next session rather than waiting.
6. Passive ideation alone was not an exclusion in the VA trial, which excluded only high risk. Continuing exposure with close monitoring is a clinical judgement. Pause writing if intent or planning emerges and re-plan.
[synthesis; the trial set a high-risk exclusion only, and developer guidance on suicidal ideation during WET is uncertain]
Example language (illustrative): "Sometimes when people start facing a memory, dark thoughts get louder for a while. If that happens, I want to know straight away. Can we look at your safety plan together now?"
Watch for: a rising PHQ-9 suicide item, hopelessness in the impact writing, new substance use, and a missed session after a hard session. Follow up on each the same day.

4.16 Pacing trauma disclosure within the protocol

Purpose: WET is not graded. Full exposure to the index event starts in session 1. Within the protocol, pacing comes only from the parts listed below. [source: CDP slides 34–37]
Steps:
1. Tell the client they need not finish the whole account in session 1.
2. Increase depth over time through feedback (more detail, more emotion).
3. Bring in the most-upsetting-part focus only at session 3.
4. Keep the fixed 30-minute dose. [source: CDP slides 34–37]
Do not shorten writing time or let the client pick a less central event to make it easier. That changes the treatment. If the client cannot tolerate full exposure at all, reconsider readiness or choose a different evidence-based therapy. [synthesis]
Example language (illustrative): "You don't have to get it all down today. Start at the beginning and go as far as you can in the time, with as much feeling as you can let in."
Watch for: pacing used as avoidance. Narratives that never reach the worst moment by session 3 need direct feedback (4.11).

4.17 Closing a session after distressing writing

Purpose: make sure the client leaves safe and oriented without undoing the exposure. The training slides note that guidance on high arousal after writing is limited. [source: CDP slides 24, 45; steps are synthesis]
Steps (synthesis):
1. Use the check-in to name and normalise the feelings that came up.
2. If SUDS is still very high or the client seems dissociated, orient them to the present: their surroundings, the date, their feet on the floor, slow breathing. Do this without analysing the content.
3. Confirm they are safe to travel and have their safety plan and contacts.
4. Agree when they will next hear from you.
5. Avoid distraction routines or relaxation scripts presented as a way to stop the memory coming up. Present orientation as a way to get home safely, not to escape the feelings.
Example language (illustrative): "That was a hard session and you stayed with it. Before you go, look around the room with me and tell me three things you can see."
Watch for: leaving with SUDS near peak plus risk factors. Extend the session or arrange a same-day follow-up call.

4.18 Narratives: privacy, storage and the client's wishes

Purpose: protect very sensitive material and build trust. The CDP slides say the therapist collects the narrative at the end of each session. They raise the question of a client who does not want the therapist to read it, but give no answer. Neither the sources used here nor the VA protocol set retention or destruction rules for narratives. [source: CDP slides 28, 46; trial protocol, data sections] [uncertain]
Steps (synthesis):
1. Before session 1, explain that you will keep the pages, that you will read them only to check how closely the instructions were followed, and who else might see them, for example a supervisor or fidelity rater, with consent.
2. Agree with the client and your service whether narratives form part of the clinical record. This differs by jurisdiction and service policy, so check local law and your professional body's guidance.
3. Store paper copies in locked files and typed copies only on approved, encrypted systems. Never send them by ordinary email or keep them on personal devices.
4. At the end of treatment, agree whether pages are kept, returned or securely destroyed, in line with the retention rules for your records.
5. If the client does not want you to read the narrative, explore their fears, such as shame or fear of judgement. Explain that the review is about the task, not judging the content. If they still refuse, discuss the reduced ability to give feedback and record the decision.
6. If a narrative reveals ongoing risk to a child or vulnerable adult, or a named person at risk, follow your safeguarding and mandatory-reporting duties. These must have been explained during consent. [source: trial protocol confidentiality limits; the rest is synthesis]
Example language (illustrative): "What you write stays with me, stored securely. I read it only to see whether the instructions are working for you. At the end, we'll decide together what happens to it."
Watch for: clients who hold back for fear that family will find the pages, especially in telehealth. Solve the storage question before writing starts.

Developers' guidance on narratives (2022 slides, primary-care adaptation): the therapist reads the narrative after the session. The client is not asked to read it aloud or type it up, and should not edit or add to it after the session. The narrative from the final session is not collected. In that session the therapist and client decide together what to do with the narratives already collected, which are returned at the end of treatment. [source: Sloan & Marx 2022 slides] Whether the standard manual says the same was not verified. [uncertain]

4.19 Access and remote delivery: literacy, language, disability, telehealth

Purpose: decide who can do WET as tested and what adaptations would mean. [source: CDP slides 21, 26, 18, 43]
What the sources say:
- The slides advise against WET when the client cannot write in the therapist's primary language, and leave typing versus handwriting as a choice.
- In the VA study, 122 of 277 veterans received WET by telehealth. Dropout was lower than in person and effectiveness was the same.
- The slides list unsettled questions: whether the camera stays on during writing, and how narratives are collected remotely.
Literacy, dictation and scribes are not addressed in the sources used here; the 2nd edition's chapter 5 covers use with a translator [source: 2nd-edition sample pages p. 6], but its guidance is not reproduced here. [source: CDP slides 18, 21, 26, 43; trial protocol] [uncertain]
Steps (synthesis):
1. Assess literacy discreetly, for example by asking how comfortable the client is writing a page about their week.
2. Make clear that spelling and grammar do not matter, as the protocol already says.
3. For motor, visual or dyslexia-related barriers, offer typing, larger print instructions and assistive software such as speech-to-text. Treat dictation or a scribe as an off-protocol adaptation. A spoken account in front of another person changes the treatment and is closer to an imaginal exposure therapy, which may then be the better choice.
4. If the client writes best in a language you do not read, reviewing the narrative is not possible without translation. Consider a clinician who shares the language, or an alternative therapy, rather than an untrained interpreter.
5. For telehealth, agree a private room and a plan for interruptions. Decide camera on or off. Agree on a secure way to send the narrative (an encrypted portal, or a photo uploaded through the service's secure system), then the client's own deletion or secure destruction of their copy. Check the client is safe and has their crisis contacts before ending the call.
Example language (illustrative): "Some people find typing or speech-to-text easier than handwriting. Which would work best for you? And where at home can you write for half an hour without anyone walking in?"
Watch for: writing at home with family nearby, which can censor the narrative or end the session early. Make a plan for where the pages go after the session.

Developers' telehealth guidance (2022 slides):

Get consent for telehealth, review the limits of confidentiality and agree secure channels.
Use video where possible, and phone only as a last resort.
Send the instructions in advance, or show them on screen or in the chat, so the client has a copy.
The client handwrites, preferably on lined paper. The slides say not to have clients type and send the narrative, and not to let them edit it afterwards.
During the writing, keep the video call open and tell the client you are available. Mute your microphone and angle the camera so the client can be seen writing.
If the video drops, reconnect or phone the client straight away and carry on rather than ending the session.
Collect the narrative before the next session, preferably by secure messaging. Scanning apps, fax or post are alternatives. Warn the client that phone photos may back up to accounts other people can see.

In the 2023 trial, 82% of WET participants were treated by video. [source: Sloan & Marx 2022 slides; Sloan et al. 2023] The handwriting rule conflicts with the CDP slides, which leave typing to the client's choice (4.4). The 2nd edition's telehealth chapter is not drawn on here. [uncertain]

5. Handling problems

The 1st edition's FAQ chapter and case illustrations cover multiple traumas, dissociation and reluctance to confront the memory. The 2nd edition has a substantially revised chapter on managing difficult situations (chapter 6) and case illustrations involving multiple traumas, dissociation and strong reluctance to confront the memory (chapter 7) [source: 2nd-edition sample pages p. 6]. The content of those chapters is [uncertain] here. The CDP slides and the developers' 2022 slides list several of these problems as FAQs without written answers: stopping writing mid-session, SUDS not changing, substance use, suicidality and session frequency. The 2022 slides do not address dissociation. Responses below are therefore marked by source. [source: sample pages pp. 5–6; APA 2nd-edition page; CDP slides 45–46; Sloan & Marx 2022 slides]

Multiple traumas (verified points). Multiple or chronic trauma is common and is not a contraindication; the developers count such clients as good candidates. Identify the index trauma clearly at the start and keep it for the whole course. If another event still needs work after session 5, add a few sessions targeting that second trauma. [source: Sloan & Marx 2022 slides; CDP slides 27, 40] No guidance was found on choosing between events of equal weight beyond the criteria in 4.2. [uncertain]

Stops writing before 30 minutes, or writes very little. The protocol rule is that a client who finishes early goes back to the beginning and writes again. [source: CDP slide 22] Ask what made it hard to continue. Repeat the instruction to keep writing even if they repeat themselves. Give specific feedback on adding detail and feeling. Use a repeat session if needed (4.11). [synthesis; the slides ask this but give no answer, slide 46]
Only facts, no feelings (low emotional engagement). Give corrective feedback on including thoughts and feelings at each moment, and delay the session 3 change. [source: CDP slides 25, 37] The slides acknowledge that some clients may do worse without a therapist helping them engage. If two repeat sessions do not help, consider an exposure therapy led by the therapist, such as prolonged exposure. [source: CDP slide 45; trial protocol §8; the switch is synthesis]
Writes about context before the trauma, or drifts to other events. Point out kindly where the narrative went. Ask them to start at the moment of threat next time, and remind them that all five sessions target the same event. [source: CDP slides 25, 41]
Wants to change the target event mid-course. Keep the index event. Offer a second course of WET for another event later if it is still needed. [source: CDP slides 27, 40, 41]
Symptom spike and wish to quit, typically around session 2. Remind them you predicted this. Show their SUDS and weekly scores. Explain that avoidance tends to fall around session 4. Agree to continue to session 3 and then review together. [source: CDP slides 36, 42; the review agreement is synthesis] If PTSD worsening is sustained for about three weeks (10 or more PCL-5 points above baseline in the trial), reconsider continuing. [source: trial protocol §§10–11]
Overwhelm during writing (crying, leaving the room, asking to stop). Do not interrupt the writing by default; silence is part of the protocol. If the client comes out or asks for help, briefly acknowledge them, encourage them to return and keep writing, and remind them the feeling will peak and pass. If they cannot, end the writing, hold the check-in, use present-moment orientation (4.17) and review readiness before the next session. [synthesis; the slides note guidance on high arousal is limited, slide 45]
Dissociation. Raised as an FAQ in the slides; the 2nd edition includes a dissociation case in chapter 7 [source: 2nd-edition sample pages p. 6], whose guidance is [uncertain] here. Before starting, assess how often and how severely the client dissociates. Agree a signal or self-orientation strategy, such as looking up and naming objects, or holding a cold drink, then returning to the page. Have the client write in the present tense, which keeps them in the account rather than outside it. If dissociation repeatedly prevents writing, consider a treatment with more therapist involvement. [synthesis]
Strong reluctance to confront the memory. The slides advise against WET when reservations are strong. [source: CDP slide 21] For moderate ambivalence, revisit the rationale and the brevity of the treatment (five sessions, no homework), and let the client choose. Never coerce exposure. [synthesis]
Missed or late sessions. Not addressed in the sources used here. [uncertain] Treat a missed session after a hard writing session as avoidance and phone the client the same day, including a risk check. Reschedule within the week and resume where you left off. If more than about two weeks pass, consider repeating the last instruction set. [synthesis]
Client does not want the therapist to read the narrative. An FAQ in the slides with no answer given. [uncertain] See 4.18 step 5. Offer to read it only for structure and to give only task-focused feedback. [synthesis]
No improvement by session 3. Discuss the reasons with the client, as the slides direct. [source: CDP slide 36] Check, in turn, adherence to the instructions, the choice of index event, avoidance between sessions (suppressing thoughts, substance use) and a different primary problem. Adjust or change treatment. [synthesis]
Rupture: the client feels left alone or finds the script cold. Explain at the start why you leave the room and read the instructions word for word. Make the check-in warm and personal. Validate the courage it took to write. If the client needs you nearby, stay in the room quietly; the slides allow this. [source: CDP slide 26; the rest is synthesis]
The therapist's pull to process content, for example guilt or self-blame in the impact writing. Hold back: the slides say "RESIST the URGE!" [source: CDP slide 24] Note any stuck beliefs that remain. If they persist after session 5, offer extra sessions or a cognitive therapy such as cognitive processing therapy. [source: CDP slide 40; the CPT suggestion is synthesis]
The narrative reveals new risk (ongoing abuse, a child at risk, intent to harm someone). Follow safeguarding and mandatory-reporting duties at once. In the trial, a named person at risk triggered the legally required report. Pause WET if the trauma turns out to be ongoing, since ongoing trauma is a contraindication. [source: trial protocol §11; CDP slide 21]
Suicidal ideation emerges or rises. Assess the same day, update the safety plan and lethal-means steps, and decide with the client whether to write that session. Pause if intent or planning is present. [source: trial protocol §11; details are synthesis, see 4.15]
Substance use increases during treatment. Ask every session. The trial removed participants who needed detoxification or residential treatment. Otherwise address use as avoidance and consider extra support. [source: trial protocol §10; the rest is synthesis]
Literacy or language difficulties appear mid-course. Switch to typing or speech-to-text, and stress that spelling does not matter. If written exposure is still not feasible, move to a spoken exposure therapy rather than forcing writing. [synthesis]
Telehealth problems (interruptions, someone else present, no secure way to send the narrative). Pause the timer, re-establish privacy, and restart or reschedule. Solve the narrative transfer before session 1 (4.19). [synthesis; the slides list these as open questions, slide 43]
Residual symptoms at session 5. Offer extra WET sessions, WET for another event, another evidence-based PTSD therapy, or treatment for other problems. [source: CDP slide 40]

Sources

Web sources:

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. Contents, description and introduction (sample pages).
Sloan, D. M., Marx, B. P., et al. (2018). Randomized noninferiority trial of WET vs cognitive processing therapy for PTSD. JAMA Psychiatry. Full text (126 adults, Boston VA; dropout 6.4% WET vs 39.7% CPT; WET non-inferior at all assessments). [uncertain: full author list, exact title, volume and pages not recorded]
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, 80(11), 1093–1100. doi:10.1001/jamapsychiatry.2023.2810.
Sloan, D. M., Marx, B. P., Bovin, M. J., Feinstein, B. A., & Gallagher, M. W. (2012). Written exposure as an intervention for PTSD: A randomized clinical trial with motor vehicle accident survivors. Behaviour Research and Therapy, 50, 627–635. doi:10.1016/j.brat.2012.07.001. Citation and design (46 survivors, WET vs waitlist, five weekly sessions) verified via Wisco, Sloan & Marx (2013). The paper itself is not drawn on here. [uncertain: per-session minutes and dropout]
Wisco, B. E., Sloan, D. M., & Marx, B. P. (2013). Cognitive emotion regulation and written exposure therapy for PTSD. Clinical Psychological Science. Author PDF.
Wisco, B. E., Baker, A. S., & Sloan, D. M. (2016). Mechanisms of change in written exposure treatment of posttraumatic stress disorder. Behavior Therapy, 47, 66–74. As cited in the PHCoE brief. [uncertain]
Pennebaker, J. W., & Beall, S. K. (1986). Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281. As cited in the PHCoE brief. [uncertain]

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