“Van Emmerik & Kamphuis (2015). Writing therapies for post-traumatic stress and post-traumatic stress disorder: A review of procedures and outcomes.” – Article summary

For PTSD treatment, it is important to spend sufficient time on psychoeducation. The patient should understand the likely causes of their symptoms and how the treatment is supposed to alleviate these symptoms.

Writing therapy is effective for the treatment of PTSD and consists of three phases:

1. Imaginal exposure to traumatic memories
   This includes exposing patients to traumatic memories to achieve habituation and extinction of the fearful and other negative emotional responses that are the result of reactivation. In this phase, the patients write in first person as if the event was currently happening. The clinician reads and identifies the most painful facts and feelings with the patient.
2. Cognitive restructuring and coping
   This targets maladaptive cognitions and coping behaviours that may underlie the symptoms. The patient has to write advice to a close friend or associate who has experienced the same traumatic event (i.e. how to deal with the event and its consequences). The clinician identifies and challenges any dysfunctional aspects of the advice.
3. Social sharing and closure
   This aims to foster or promote social support by instructing patients to share their experiences in a letter to a close friend. The letter describes the most important aspects of the traumatic event and its impact on the patient’s life. It explicitly states its purpose. This is a symbolic closing ritual and can help patients get closure for the traumatic event. The clinician checks the letter for grammar, spelling and content as it may be actually sent.

There are several guidelines for writing the letters:

• Patients should complete three writing assignments of 45 minutes each. The first five minutes should be used to get oriented and retrieve the experience from memory.
• Patients should complete the writing assignments well before bedtime and a relaxing activity of at least 15 minutes should be undertaken directly after writing.
• Patients should be alone while writing.
• Patients are advised to use a notebook which is used exclusively for the writing assignments.
• Patients should be explicitly be told that spelling, grammar and writing style are not important except for the last letter (i.e. closure letter).
• Patients send their completed writing assignments well before treatment sessions to allow the therapists to read them before each session.

Writing therapy is an effective alternative for people who do not benefit from TF-CBT or EMDR. It also appears to be effective in online settings (i.e. online writing). Writing may trigger specific processing mechanisms of the experience. One unique aspect is that it focused on social sharing. This may increase social support.

Imaginal exposure promotes the connection of previously unconnected traumatic memories into autobiographical memory. This reduces the probability that these memories are involuntarily activated. Furthermore, it may facilitate the retrieval of traumatic memories that are otherwise difficult to retrieve. This, in turn, can lead to modification of the appraisals of the event.