Written Exposure Therapy: The Case for Latinos

1 Theoretical and Research Basis for Treatment

Latinos are substantially affected by trauma, and the lifetime prevalence rate of posttraumatic stress disorder (PTSD) for this group is between 4.4% and 7.0% (Alcántara, Casement, & Lewis-Fernandez, 2013). Research generally indicates that Latinos exhibit a higher conditional risk for developing PTSD after exposure to a traumatic event (Alcántara et al., 2013) but often underutilize services to alleviate trauma-related symptoms (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Logistical barriers (e.g., location, cost, or time-commitment) as well as psychological barriers (e.g., unfamiliarity with services or concern about immigration status) often preclude individuals in need from receiving evidence-based treatment (Kaltman, Hurtado de Mendoza, Gonzales, & Serrano, 2014; Sloan, Marx, & Keane, 2011).

Prolonged exposure therapy (PET) meets efficacious status as an empirically supported treatment for PTSD. PET has demonstrated efficacy via various randomized clinical trials and meta-analyses (De Jongh et al., 2016; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Despite that PET has demonstrated success, it is not without its pitfalls. Dropout rates from trauma-specific treatments (i.e., that contain explicit retelling of the traumatic memory) are high (approximately 36%; Imel, Laska, Jakupcak, & Simpson, 2013) and one potential reason for poor attrition is that imaginal exposure can be notably difficult for clients to engage in (Imel et al., 2013; Najavits, 2015). Moreover, some clients do not reap the benefits of PET. In a study examining outcomes of a national implementation of PET for veterans, 38% did not show clinically significant reductions in symptoms and 46% still scored above cutoffs for PTSD diagnosis after completion of treatment (Eftekhari et al., 2013).

Despite the substantial impact and risk, there are no randomized clinical trials that specifically investigate the use of PET with Latinos, and Latinos are unrepresented in the outcome studies that examine PET (Benuto, Bennett, Norton, Massey, & Casas, 2019). However, an effectiveness study, the sample of which was largely composed of Latinos with PTSD (Benuto, O’Donohue, Bennett, & Casas, 2019), found positive treatment outcomes for Latinos who underwent PET. In addition, case studies have documented effectiveness of PET with a Latina female with a complex trauma history (Benuto & Bennett, 2015) and a Latino man who was victimized during a robbery (López, Shealy, & Rheingold, 2014). Despite these positive notes, exposure therapy is not without its limitations (i.e., the potential for the client to have difficulty tolerating imaginal exposure) and cultural factors may exacerbate some of these limitations. For example, rapport between the therapist and the client is a commonly cited reason that clients remain in trauma-specific therapies despite considering dropping out (Hundt, Barrera, Arney, & Stanley, 2017). However, rapport may be more difficult to build if the clinician does not appropriately attend to cultural factors that may be influencing symptom presentation or response to treatment. Lack of consideration of cultural factors, as well as cultural misunderstandings or language barriers, have been suggested as important reasons that Latinos tend to underutilize or drop out of mental health services (Benson-Florez, Santiago-Rivera, & Nagy, 2017).

Indeed, López et al. (2014) highlighted how engagement of clients with PTSD can be challenging due to early treatment dropout if the client is unwilling to confront trauma-related stimuli or experience anxiety during exposure. They also identified specific barriers relevant to the Latino population, including the tendency for Latino men to resist mental health treatment, logistical difficulties (e.g., transportation or language), and cultural values (e.g., machismo and immigration status). The authors noted that increased attention to these engagement issues is needed with ethnic minorities and other underserved populations.

One novel mechanism for addressing many of the problems associated with PET is the use of written exposure therapy (WET). The use of WET has been noted via case study to be effective in reducing the burden of PTSD. Specifically, Austern (2017) explored the use of a stepped-care model for treating PTSD in Veterans through three hybrid case examples, highlighting the common problems in delivering evidence-based treatments in a real-world setting. In this model, WET serves as the first step of treatment, requiring only 75 total minutes of face-to-face contact. In comparison, PET and cognitive processing therapy (CPT; Resick, Monson, & Chard, 2016) require over 500 min of face-to-face-contact. CPT is a manualized treatment for PTSD that focuses on restructuring the client’s maladaptive trauma-related thoughts; the protocol calls for the client to provide a written account of the traumatic event, although treatment has been adapted for administration without this written component (Chard, Donahue, & Bryan, 2012). In Austern’s model, clients are only moved up the steps to receive PET or CPT if they did not first benefit from WET.

Prior research supports the use of writing exercises as the medium for individuals to disclose traumatic experiences. Frattaroli (2006) conducted a meta-analysis on 146 randomized studies that examined the use of experimental disclosure (via writing or talking) about a stressful or traumatic event and found overall significant effects on psychological health, physical health, and general functioning. Since then, Sloan and colleagues (Sloan, Lee, Litwack, Sawyer, & Marx, 2013; Sloan & Marx, 2004; Sloan, Marx, Bovin, Feinstein, & Gallagher, 2012; Sloan, Marx, & Epstein, 2005, 2007) have conducted pioneering work in this area and found that written disclosure significantly reduces PTSD symptom severity and that significant fear activation occurs during the initial writing session and that reductions of fear activation and extinction occur by the last session. Sloan et al. (2012) noted that five 30-min sessions (where clients are asked to write about the same trauma memory and to focus on the details of the trauma with particular attention to the emotions they felt, the meaning of traumatic event, and “hot spots”) are sufficient to produce reductions in arousal and negative affect among clients who have PTSD; during the first session of WET, clients are provided with a treatment rationale and psychoeducation regarding the symptoms of PTSD and other maladaptive behaviors that maintain PTSD symptoms. One of the hallmarks of the WET protocol is that it is tolerable for clients and thus presents as an intervention that may work more effectively for Latinos.

2 Case Introduction

“Sara ¹ ” is a Latina female (age 29 years) who was referred by an integrated health care center to a specialized clinic for victims of interpersonal violence in an urban city in the mountain west. She was initially taken to the integrated health care center after her family members observed her to be sad and withdrawn. The integrated health care center referred her to the specialized clinic for trauma treatment as she reported a history of stalking in her home country. The specialized clinic also had Spanish-service availability, with a fully bilingual psychologist capable of providing treatment in Spanish.

3 Presenting Complaints

When Sara met with the therapist at the specialized clinic, she reported that she had immigrated to the United States approximately 2 months ago to escape stalking by a Latin American gang. She shared that when she was crossing the border from Mexico to the United States, the coyotes (i.e., individuals who smuggle persons across the U.S.–Mexico border) sexually assaulted her. She reported feeling terrified and helpless both during and after the assault. She indicated that the assault occurred after she (and the other individuals who were crossing the border) had been walking for several days. They had stopped in the middle of the night to sleep and she was assaulted when the others were sleeping. Sara reported experiencing terror and fear when she was assaulted and shared that she felt helpless to defend herself as the men were armed with guns.

Sara shared that after the assault, she would pray for border patrol to catch them, as she remained afraid for the 3 days following the assault. When she was finally apprehended by border patrol, she reported feeling immense relief. She described that when she was being processed through immigration, she informed an immigration officer that she was fleeing gang violence; this afforded her entry to the United States on the basis of asylum. She was sent to her family in the mountain west (in lieu of being deported).

With regard to Sara’s symptoms, she described experiencing intense shame at having been sexually assaulted and denied telling anyone what had happed to her. She described recurrent nightmares and intrusive thoughts about the assault which would leave her in (what she labeled as) a state of “panic.” She shared that no matter how hard she tried, she was unable to rid herself of the unwanted thoughts or feelings associated with what happened to her. She also described difficulty engaging in activities she previously enjoyed, in part due to avoidance of trauma reminders (i.e., she was no longer interested in engaging in social activities where there would be men whom she did not know). Sara also endorsed difficulty concentrating and sleeping as well as hypervigilance and feeling fearful that the men who assaulted her would come after her. Finally, Sara described challenges in adjusting to being in a new country including missing her mother immensely and feeling “lost” with regard to daily activities (i.e., in her home country, she was enrolled in higher education; she spent her days in the United States feeling very lonely and bored).

4 History

Sara is the youngest in a family of two; she has one older sister. She reported that she was raised by her mother in an urban area in Latin America and that her father passed away before she was born. When Sara was 13 years old, her older sister moved to the United States. Otherwise, Sara indicated that her childhood was unremarkable. She described having a close relationship with her mother and extended family and expressed that she was raised in a very religious home. She indicated that she had graduated the equivalent of high school and had recently enrolled in higher education. She described one romantic relationship with a male partner; according to her report, this relationship ended in mutual agreement due to each partner wanting different things. She indicated that she had a strong social support system composed mostly of extended family members and her mother. At the time of treatment, she was living with a cousin with whom she had a close relationship. She indicated that she also is close to her sister and they see each other regularly.

5 Assessment

Sara completed a semi-structured diagnostic interview designed to gather information about her psychosocial history, presenting concerns, and psychological symptoms. Sara also completed the Spanish-language version of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) (PCL-5; Weathers et al., 2013) at intake, biweekly during treatment, at the termination session, and at the 1-month follow-up. Both the information she reported during the clinical interview and her score on the PCL-5 indicated the presence of PTSD.

6 Case Conceptualization

As a child, adolescent, and young adult, Sara had a fairly positive view of herself and the world; she was raised in a loving family with strong family values and described an inherent need to make her family proud. Her perspective of the world changed when she was stalked in her home country by a gang. She and her family collectively decided that she needed to relocate to the United States to ensure her physical safety. She was immediately removed from the stimulus that was frightening her (the gang that was stalking her) and developed the cognitive schema that the world was a scary place and she needed to escape when things were scary. When she was sexually assaulted, that cognitive schema was reactivated but because her life depended on the coyotes, she was not able to escape the situation until she was apprehended by border patrol. This led to the development of PTSD; after she was united with her family in the United States, she remained fearful and hypervigilant. This led her to avoid anything that might remind her of what happened to her. This avoidance led to feelings of isolation, made it difficult for her to engage in situations that were positively reinforcing, and created and maintained substantial negative affect. All of the above were exacerbated by her strong family values and religious background—Sara experienced a deep amount of shame associated with the fact that she was sexually assaulted and being separated from her mother was in and of itself a painful experience. See Figure 1 for an overview of the case conceptualization.

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Figure 1.

Case conceptualization.

7 Course of Treatment and Assessment of Progress

Sara was seen for an intake and seven treatment sessions. During the first treatment session, she was provided with psychoeducation about PTSD (i.e., common reactions to trauma), the treatment rationale for PET, and breathing retraining (following the PET treatment manual; Foa, Hembree, & Rothbaum, 2007). During Session 2, an in-vivo exposure hierarchy was created, a Subjective Units of Discomfort Scale (SUDS) was established, and Sara was assigned homework (completion of two items on her in-vivo exposure hierarchy that had relatively low SUDS designation).

During Session 3, imaginal exposure was begun. Sara was unable to engage in the process despite multiple attempts from the therapist; she would begin the exposure process and then cry uncontrollably. After 45 min of attempting to engage in imaginal exposure, Sara indicated that she would not complete the process and indicated that she was not sure she would return to therapy. The therapist provided her with empathy and support and rereviewed the rationale for treatment.

During Session 4, the therapist suggested written exposure in lieu of imaginal exposure, to which Sara readily agreed. She completed three sessions of written exposure successfully at which point her symptoms diminished. During the written exposure, Sara was instructed to write down what had happened starting with a few minutes before there was any indication that anything was wrong (when she laid down to sleep prior to being led away by the coyotes from the group she was with) and to continue writing about her experience until the part where she felt safe again (she was apprehended by border patrol). She was instructed to write the narrative in the first person and to visualize in her mind’s eye the trauma trajectory (consistent with the instructions in the PET treatment manual). She was asked to continue writing until the therapist instructed her to stop; her SUDS score was requested approximately every 5 min. The therapist tracked her SUDS and discontinued the written exposure once her SUDS had peaked and reduced (this occurred approximately 20 min into the written exposure exercise).

During Sessions 5 and 6, Sara engaged in two additional written exposures, each of which lasted 25 min. Sara’s SUDS scores reduced substantially across these two sessions. See Figure 2 for an overview of SUDS scores during each session. At the completion of each written exposure, the therapist asked Sara what the process was like for her and asked her to share her thoughts about her experience. Many of the thoughts that Sara shared were related to the shame she had surrounding having been sexually assaulted and to her fears of being tracked down by the coyotes. Her shame was heavily tied to her religious upbringing and the cultural value of Marianismo (i.e., the expectation in Latin American culture that a woman be humble, submissive, and sexually pure, although it has also been described as capturing more positive feminine qualities such as being strong, nurturing, and self-sacrificing; Castillo, Perez, Castillo, & Ghosheh, 2010; Da Silva, Verdejo, Dillon, Ertl, & De La Rosa, 2018). In addition, the cultural value of familismo (i.e., a strong sense of loyalty to the nuclear and extended family that may function as both a protective and a risk factor; Calzada, Tamis-LeMonda, & Yoshikawa, 2013) was also linked to her shame as she was concerned that her mental health was a burden to her family. Initially, this worked against her as it prevented her from asking for help; however, once she was able to disclose to her family what had happened, the cultural value of familismo allowed her to receive extensive emotional support from her family. Throughout treatment, cognitive distortions were challenged and cognitive restructuring was used to combat the shame that Sara was experiencing. After each written exposure session, Sara was asked to take the trauma narrative home and for homework, to review the trauma narrative (i.e., read through it at least 4-5 times each day). In addition, Sara was assigned two items on her in-vivo exposure hierarchy to address for homework. During the last treatment session (termination session), Sara was asked to provide a verbal review of the trauma narrative integrating the new, helpful way of conceptualizing the trauma. Her SUDS levels were tracked and only elevated slightly. At the 1-month follow-up, Sara maintained treatment gains and shared that she had enrolled in an English-language program, had started working, and was regularly (fearlessly) attending social events with her family (including socializing with men).

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Figure 2.

SUDS across imaginal exposures.

8 Complicating Factors

For Sara, there were three complicating factors. The first was with regard to her legal status. She entered the country as an undocumented person using coyotes to cross the border. When she was sexually assaulted, she felt she had no recourse as her survival in the desert was in the hands of her perpetrators. She was forced to continue through the desert with them until she was apprehended by border control. She felt tremendous relief when she was apprehended but was fearful to disclose to border patrol what had happened to her. Because she was fleeing her home country and disclosed this to border patrol, she was granted temporary asylum. When she was united with her family in the United States, out of shame she did not disclose to them what had happened to her while she was crossing the border. Thus, the second complicating factor was the immense shame Sara felt related to being sexually assaulted. This emotional experience limited her ability to access support and care. The third complicating factor was Sara’s inability to engage in imaginal exposure. Sara presented with severe PTSD and was unable to engage in the imaginal exposure process and ran the risk of dropping out of treatment. Taking this into account, the therapist opted to attempt written exposure as a substitute for imaginal exposure. This (may have) helped keep Sara from dropping out of treatment and was successful.

9 Access and Barriers to Care

As alluded to above, Sara’s primary barrier to care was related to the shame she felt around her sexual assault. This prevented her from accessing mental health services. While her family noted her to be depressed and that she would isolate herself, they attributed it to her adjustment to being in a new country and having left her mother behind in her home country. Her sister finally took her to an integrated health care center where she was referred her to a specialized clinic for Latina victims of interpersonal violence (for the reported stalking she experienced in her home country). Sara was fortunate in that there was the availability of a therapist who was Spanish-speaking but her monolingual status had the potential to act as a barrier to service. In addition, Sara did not have health insurance; fortunately, services were available at no cost. More broadly, it is possible that Sara’s immigration status served as a barrier until her sister brought her to treatment; undocumented immigrants often experience fear related to accessing health or social services or disclosing their immigration status (Kaltman et al., 2014).

10 Follow-Up

Sara was seen for a 1-month follow-up session. At the conclusion of treatment, she had concerns that her symptoms would reappear. The session was scheduled as a booster session, although by all accounts Sara’s PTSD symptoms remained resolved. She reported that she had enrolled in English as a Second Language (ESL) classes, had told both her mother and sister what had happened to her, and that she had attended several social functions where men were present, and she was even able to engage in dancing with them.

11 Treatment Implications of the Case

The major treatment implication of this case is that in certain instances, clients may be unable to engage in imaginal exposure. This reaction has been documented in large-scale research studies and in case studies. Although this may not be the case for all clients (indeed, the support for the efficacy of PET is strong), WET does provide an alternative treatment option that can be easily implemented. This may be particularly relevant for Spanish-speaking clients given the Spanish-speaking provider-gap that exists. Using an interpreter for PET would be inherently challenging and likely disruptive to the processing element of imaginal exposure. Because the client does not engage in discourse with the therapist during the re-accounting of the traumatic memory in WET (as compared with PET), WET could be more easily implemented using a translator. The use of a translator generally in psychotherapy may still present problems to address, however, such as difficulties in building rapport or conveying empathy to the client, or misunderstanding of roles (Kuay, Chopra, Kaplan, & Szwarc, 2015). An additional treatment implication is with regard to immigration status. Sara was assaulted when crossing the U.S.–Mexican border and her legal status led her to fear disclosing what had happened to her. She was not aware of the U-Visa Process; clinicians who work with victims should be aware of relevant legal processes and provide appropriate referrals to legal services.

12 Recommendations to Clinicians and Students

As noted by López et al. (2014), PET remains an efficacious treatment for PTSD but the implementation of PET in real-world settings is not without its challenges. This may be exacerbated in certain cultural contexts and with specific populations. Benuto, Newlands, Singer, Casas, & Cummings (2019). explored what specific culturally sensitive clinical practices practitioners engage in. Among these practices were logistical accommodations (including accommodations for the client based on his or her abilities), exhibiting flexibility, and making adjustments to treatment if the client is not improving. The specialized clinic offered flexible hours, free services, and the availability of services in Spanish. With regard to flexibility, the therapist was willing to make adjustments to the treatment protocol to reduce the risk of dropout. While deviating from a treatment manual has the potential to raise concerns, in this case, in the absence of this flexibility, Sara would have likely dropped out of treatment and continued to suffer indefinitely. These culturally sensitive clinical practices were highly applicable to this case.

Furthermore, the current study adds to the body of research that attention to pertinent cultural values (i.e., familismo) in case conceptualization and treatment can help achieve a beneficial outcome (Gonzalez-Prendes, Hindo, & Pardo, 2011; Torres, Crowther, & Brodsky, 2017). While the intention of the clinician working on this case was not to culturally adapt an intervention, the adjustment to treatment to meet the needs of the client could be construed as such. Benuto, Newlands, Singer, Casas, and Cummings (2019) examined culturally sensitive clinical practices among psychologists and found that it is common for psychologists to make adjustments to treatment. Indeed, Koslofsky and Domenech Rodriguez (2016) discussed how, while in the context of the research arena (via grant-funded research), interventions are formally culturally adapted. However, this does not always translate to the manner in which clinicians adapt treatments in real-world settings. This case study, to some degree, provides an in-depth overview of how clinicians can make adjustments to evidence-based treatments while maintaining the integrity of the active ingredients in the intervention and by doing so enhance outcomes for clients. In this case, we believe that the client would have terminated treatment had the adjustment to the intervention (to include written rather than oral exposure) not been made.