Exposure‐Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Systematic Review and Meta‐Analysis

Abstract

We undertook a systematic review to assess the efficacy of exposure‐based writing therapies (WTs) for trauma‐exposed adults with subthreshold or clinical levels of posttraumatic stress disorder. Four databases (PsycINFO, Medline, Wiley Online, PILOTS) were searched for randomized controlled trials (RCTs) of exposure‐based WTs. A total of 13 RCTs that reported on results from 17 WT versus control comparisons were included. The primary outcomes were posttraumatic stress symptom severity at posttreatment and/or clinical response. An overall unclear or high risk of bias was identified in 84.6% of studies. In comparison to both waitlist k = 3, Hedges’ g = −0.97, 95% CI [‐1.20, ‐0.73], and placebo writing conditions, k = 9, Hedges’ g = −0.48, 95% CI [‐0.87, ‐0.08], WTs were more beneficial to participants. There was no evidence of a difference between WTs that were longer in duration compared to other psychotherapy, k = 2; pooled OR = 1.42; 95% CI [0.83, 2.43]. These findings indicate that exposure‐based WTs are effective when compared to waitlist and placebo writing control conditions. The evidence needs to be considered in the context of the modest number of studies conducted to date, the high methodological heterogeneity between the studies, and the high or unclear risk of bias across many studies. Further research is needed to increase the evidence base regarding the efficacy of WTs for posttraumatic stress. Future research should also measure the mediators and predictors of outcomes to further develop protocols and understand which variants of WTs work for different populations or individuals.

The Emerging Literature on Exposure‐Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Response to Thompson‐Hollands et al.’s (2020) Commentary on Dawson et al. (2020)

“…We thank Thompson‐Hollands et al. (2020) for their thoughtful commentary on our recent systematic review, which explored the efficacy of exposure‐based writing therapies (WTs) for posttraumatic stress symptoms (PTSS; Dawson et al., 2020). The points raised in the commentary highlight the challenges of integrating evidence about the efficacy of an emerging therapeutic technique that is grounded in and translated from various conceptual positions.…”

“…Advantages of broad reviews are that they allow for the exploration of the consistency of findings across participant populations and different implementations of an intervention (Thomas et al., 2020). Our review identified four types of WTs (see Supplementary Table S4 of Dawson et al., 2020). To make recommendations for future research, we planned to perform subgroup analyses to explore different characteristics of the WT interventions.…”

“…However, subgroup analyses of intervention characteristics were considered inappropriate as interventions had multiple intervention characteristics of interest (e.g., length of intervention, writing time, writing medium) that would confound inferences. We were able to undertake subgroup analyses on participant differences among studies (i.e., clinical samples vs. combined clinical and subthreshold samples; student samples vs. community samples; see the Discussion section and Supplementary Materials of Dawson et al., 2020). As noted by Thompson‐Hollands et al.…”

Seeking to Understand the Conditions Under Which Exposure‐Based Writing Therapy for Posttraumatic Stress Disorder is an Effective Approach: A Commentary on Dawson et al. (2020)

“…Having conducted several of the studies included in Dawson and colleagues’ (2020) recently published meta‐analytic review of exposure‐based writing interventions for posttraumatic stress disorder (PTSD), we read the results with great interest. Their findings indicated that exposure‐based writing interventions are more efficacious than both waitlist and placebo writing control conditions.…”

“…Combining the outcomes of the expressive writing studies as done by Dawson et al. (2020) obscures these important methodological differences across studies.…”