Writing therapies for Post-Traumatic Stress and Post-Traumatic Stress Disorder
Van Emmerik, A., & Kamphuis, J.H. (2015)
A review of procedures and outcomes

Abstract

Writing is an effective psychological treatment of post-traumatic stress disorder. The model includes three phases: 1) focusing on imaginal exposure to traumatic memories 2) cognitive restructuring and coping 3) social sharing and closure.

Writing therapy

Therapeutic model

The basic therapeutic model of writing therapy includes three phases, whose effects cannot be completely disentangled.

Imaginal exposure to traumatic memories

The goal of the first phase is to expose clients to their traumatic memories, in order to achieve habituation and extinction of the fearful and other negative emotional responses that reactivation of these memories evoke.

Clients are asked to write a detailed account of the traumatic event, focusing on the most painful facts and emotions associated with the event. Clients are instructed to write in the first person and in the present tense. They must pay attention to their sensory experiences and bodily sensations during the event and to facts and feelings they have avoided.

The clinician’s primary task is to read the client’s essay and to determine with the client 1) what are the most painful facts and feelings 2) explore if any facts or feelings have been avoided 3) instruct the client to focus on precisely these facts and feelings in subsequent writing assignments.

Cognitive restructuring and coping

Targets the maladaptive cognitions and coping behaviours that may underlie the symptoms.

Clients write their best possible advice to an imaginal close associate that has experienced the traumatic event. The advice should concern how best to deal with the event and its consequences, making use of the client’s personal experiences.

Possible elements of the advice include: 1) aspects of the event that the other person has overlooked and that may shed a more positive light on the situation 2) alternative interpretations of the event 3) adaptive ways of coping 4) reflections on the meaning that the event may acquire.

The clinicians role is to identify and challenge any dysfunctional aspects of the advice and to instruct clients to apply the advice to themselves in a subsequent assignment.

Social sharing and closure

The goals are: 1) foster or promote social support by inviting clients to share their experiences in a dignified letter to a (true) close associate. The letter should describe the most important aspects of the traumatic event and its impact on the client’s life. The letter should explicitly state its purpose, the reason it is addressed to this particular person, and the reaction that is expected. 2) to help the client to achieve a sense of closure by devising and completing a symbolic closing ritual.

Practice and procedures

Phasing of the therapeutic model

There are 10 treatment sessions: 1-4 are devoted to imaginal exposure, 5-8 to cognitive restructuring and 9-10 to social sharing and closure.

It is not recommended to skip phases.

Psycho-education

Sufficient time should be devoted to explain to the client the likely causes of the symptoms, and how writing therapy is thought to alleviate these symptoms.

General writing instructions

General instructions apply to all assignments: 1) clients should aim to complete three assignments per week of 45 min each 2) they should be completed well before bedtime. A relaxing activity is scheduled directly after writing 3) distractions should be avoided 4) clients are advised to use a notebook, which is exclusively used for the writing assignments 5) style, grammar and spelling are not important 6) clients send in their completed assignments well before the treatment sessions.

Theoretical background

Three areas that require change for PTSD to remit are: 1) elaboration and integration into autobiographical memory of the traumatic memory 2) modification of problematic appraisals of the traumatic event or its sequelae 3) abandonment of behavioural and cognitive strategies that hinder these two processes.