Online Structured Writing Therapy for Post-traumatic Stress Disorder and Complicated Grief

  • Jeroen RuwaardEmail author
  • Alfred Lange


Post-traumatic stress disorder (PTSD) and complicated grief are related disorders for which well-described and effective cognitive-behavioural therapeutic procedures exist that are firmly rooted in theoretical work. As a result, several research groups have been able to successfully translate these procedures into e-mental health applications for the prevention, detection and treatment of the disorders. This chapter reviews online structured writing therapy (oSWT), a standardised therapist-guided Internet-based cognitive-behavioural treatment (ICBT) for post-traumatic stress disorder and complicated grief, which can be fully delivered online, without face-to-face contact between the patient and therapist. This protocol integrates three principal elements of trauma-focused therapy: (1) exposure through self-confrontation, (2) cognitive reappraisal and (3) strengthening of social support. A unique characteristic of oSWT is that it implements these three elements through writing assignments. In the past two decades, oSWT has been validated in a series of controlled studies and in routine clinical practice, with positive results. This chapter reviews these efficacy and effectiveness trials, elaborates on the details of the therapeutic procedures of the treatment protocol and identifies future research themes.


Bereavement Cognitive behaviour therapy Computer-assisted therapy Post-traumatic stress disorders therapy Structured writing assignments Trauma and stressor-related disorders Internet Treatment protocol 



Brief symptom inventory


Depression anxiety stress scale


Internet-based cognitive behaviour therapy


Impact of event scale


Linguistic inquiry and word count


Online structured writing therapy


Post-traumatic stress disorder


Structured writing therapy


Working alliance inventory


Waiting-list/delayed treatment condition


Acknowledgements and Disclosure of Conflict of Interest

The authors would like to acknowledge Bart Schrieken of Interapy PLC, for his valuable contributions. At present, both authors have no financial ties to this company.


  1. Amstadter AB, Broman-Fulks J, Zinzow H, Ruggiero KJ, Cercone J (2009) Internet-based interventions for traumatic stress-related mental health problems: a review and suggestion for future research. Clin Psychol Rev 29(5):410–420. doi: 10.1016/j.cpr.2009.04.001 CrossRefPubMedPubMedCentralGoogle Scholar
  2. Andersson G (2010) Guided, internet-delivered cognitive behavioral therapy for posttraumatic stress disorder and other comorbid anxiety disorders. In: Brunet A, Ashbaugh AR, Herbert CF (eds) NATO science for peace and security series – E: human and societal dynamics, vol 72, Internet use in the aftermath of trauma. IOS Press, Amsterdam, pp 243–254, Retrieved from Google Scholar
  3. Arrindell WA, Ettema JHM (2003) Symptom checklist SCL-90: Handleiding bij een multidimensionele psychopathologie-indicator. Swets Test Publishers; Harcourt Test Publishers, Lisse/AmsterdamGoogle Scholar
  4. Benight CC, Ruzek JI, Waldrep E (2008) Internet interventions for traumatic stress: a review and theoretically based example. J Trauma Stress 21(6):513–520. doi: 10.1002/jts.20371 CrossRefPubMedGoogle Scholar
  5. Boelen PA, van den Hout MA (2008) The role of threatening misinterpretations and avoidance in emotional problems after loss. Behav Cogn Psychother 36(01):71–88. doi: 10.1017/S1352465807004079 CrossRefGoogle Scholar
  6. Brewin CR, Holmes EA (2003) Psychological theories of posttraumatic stress disorder. Clin Psychol Rev 23(3):339–376. doi: 10.1016/S0272-7358(03)00033-3 CrossRefPubMedGoogle Scholar
  7. Brewin CR, Andrews B, Valentine JD (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 68(5):748–766. doi: 10.1037//0022-006X.68.5.748 CrossRefPubMedGoogle Scholar
  8. Brunet A, Ashbaugh AR, Herbert CF (eds) (2010) NATO science for peace and security series – E: human and societal dynamics, vol 72, Internet use in the aftermath of trauma. IOS Press, AmsterdamGoogle Scholar
  9. Cuijpers P, Marks IM, Van Straten A, Cavanagh K, Gega L, Andersson G (2009) Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther 38(2):66–82. doi: 10.1080/16506070802694776 CrossRefPubMedGoogle Scholar
  10. De Haas S, Höing M, Schrieken B, Tsagana A, Wijnker C, Michels C, Lange A (2009) Behandeling via het Internet voor jeugdige slachtoffers van seksueel geweld: een pilotstudie [Online treatment of young victims of sexual violence: a pilot study]. Maandblad Geestelijke Volksgezondheid 64(11):981–997Google Scholar
  11. Derogatis LR, Melisaratos N (1983) The Brief Symptom Inventory: an introductory report. Psychol Med 13(3):595–605CrossRefPubMedGoogle Scholar
  12. Donnelly DA, Murray EJ (1991) Cognitive and emotional changes in written essays and therapy interviews. J Soc Clin Psychol 10(3):334–350. doi: 10.1521/jscp.1991.10.3.334 CrossRefGoogle Scholar
  13. Ehlers A, Clark DM (2000) A cognitive model of posttraumatic stress disorder. Behav Res Ther 38(4):319–345. doi: 10.1016/S0005-7967(99)00123-0 CrossRefPubMedGoogle Scholar
  14. Foa EB, Kozak MJ (1986) Emotional processing of fear: exposure to corrective information. Psychol Bull 99(1):20–35. doi: 10.1037/0033-2909.99.1.20 CrossRefPubMedGoogle Scholar
  15. Frank JD (1973) Persuasion and healing. John Hopkins University Press, BaltimoreGoogle Scholar
  16. Haley J (1973) Uncommon therapy: the psychiatric techniques of Milton H. Erickson. MD. Norton, New YorkGoogle Scholar
  17. Harvey AG, Bryant RA, Tarrier N (2003) Cognitive behaviour therapy for posttraumatic stress disorder. Clin Psychol Rev 23(3):501–522CrossRefPubMedGoogle Scholar
  18. Hirai M, Clum GA (2005) An Internet-based self-change program for traumatic event related fear, distress, and maladaptive coping. J Trauma Stress 18(6):631–636. doi: 10.1002/jts.20071 CrossRefPubMedGoogle Scholar
  19. Hirai M, Skidmore ST, Clum GA, Dolma S (2012) An investigation of the efficacy of online expressive writing for trauma-related psychological distress in Hispanic individuals. Behav Ther 43(4):812–824. doi: 10.1016/j.beth.2012.04.006 CrossRefPubMedGoogle Scholar
  20. Horvath AO, Greenberg LS (1989) Development and validation of the Working Alliance Inventory. J Couns Psychol 36(2):223–233. doi: 10.1037/0022-0167.36.2.223 CrossRefGoogle Scholar
  21. Ivarsson D, Blom M, Hesser H, Carlbring P, Enderby P, Nordberg R, Andersson G (2014) Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: a randomized controlled trial. Internet Interv 1(1):33–40. doi: 10.1016/j.invent.2014.03.002 CrossRefGoogle Scholar
  22. Jacobson NS, Truax P (1991) Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 59(1):12–19. doi: 10.1037/0022-006X.59.1.12 CrossRefPubMedGoogle Scholar
  23. Joseph S (2000) Psychometric evaluation of Horowitz’s Impact of Event Scale: a review. J Trauma Stress 13(1):101–113. doi: 10.1023/A:1007777032063 CrossRefPubMedGoogle Scholar
  24. Kersting A, Dölemeyer R, Steinig J, Walter F, Kroker K, Baust K, Wagner B (2013) Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychother Psychosom 82(6):372–381. doi: 10.1159/000348713 CrossRefPubMedGoogle Scholar
  25. Klein B, Mitchell J, Abbott J, Shandley K, Austin D, Gilson K, Kiropoulos L, Cannard G, Redman T (2010) A therapist-assisted cognitive behavior therapy internet intervention for posttraumatic stress disorder: pre-, post- and 3-month follow-up results from an open trial. J Anxiety Disord 24(6):635–644. doi: 10.1016/j.janxdis.2010.04.005 CrossRefPubMedGoogle Scholar
  26. Knaevelsrud C, Maercker A (2006) Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients? J Med Internet Res 8(4):e31. doi: 10.2196/jmir.8.4.e31 CrossRefPubMedPubMedCentralGoogle Scholar
  27. Knaevelsrud C, Maercker A (2007) Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry 7:13. doi: 10.1186/1471-244X-7-13 CrossRefPubMedPubMedCentralGoogle Scholar
  28. Knaevelsrud C, Maercker A (2010) Long-term effects of an internet-based treatment for posttraumatic stress. Cogn Behav Ther 39(1):72–77. doi: 10.1080/16506070902999935 CrossRefPubMedGoogle Scholar
  29. Knaevelsrud C, Wagner B, Karl A, Mueller J (2007) New treatment approaches: integrating new media in the treatment of war and torture victims. Torture (Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture) 17(2):67–78Google Scholar
  30. Knaevelsrud C, Brand J, Schulz W, Lange A, Ruwaard J, Wagner B (2015) Internet-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: a parallel group randomized controlled trial. J Med Internet Res 17(3):e71. doi: 10.2196/jmir.3582 CrossRefPubMedPubMedCentralGoogle Scholar
  31. Lange A (1985) Motivating clients in directive family therapy. In: Zeig JK (ed) Ericksonian psychotherapy, vol 2, Clinical applications. Brunner Mazel, New YorkGoogle Scholar
  32. Lange A (1994) Writing assignment in the treatment of grief and trauma’s from the past. In: Zeig JK (ed) Ericksonian methods. The essence of the story, 1st edn. Brunner/Mazel, Levittown.Google Scholar
  33. Lange A, Ruwaard J (2010) Ethical dilemmas in online research and treatment of sexually abused adolescents. J Med Internet Res 12(5):e58. doi: 10.2196/jmir.1455 CrossRefPubMedPubMedCentralGoogle Scholar
  34. Lange A, Van der Hart O (1983) Directive family therapy. Brunner/Mazel, New YorkGoogle Scholar
  35. Lange A, De Beurs E, Dolan C, Lachnit T, Sjollema S, Hanewald G (1999) Long-term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life. J Nerv Ment Dis 187(3):150–158CrossRefPubMedGoogle Scholar
  36. Lange A, Van de Ven J, Schrieken B, Bredeweg B, Emmelkamp PM (2000a) Internet-mediated, protocol-driven treatment of psychological dysfunction. J Telemed Telecare 6(1):15–21. doi: 10.1258/1357633001933880 CrossRefPubMedGoogle Scholar
  37. Lange A, Van de Ven J, Schrieken B, Emmelkamp P, Bredeweg B, Van der Kolk J, Lydsdottir L, Massaro M, Reuvers A (2000b) ‘INTERAPY’: the effects of a short protocolled treatment of post-traumatic stress and pathological grief through the Internet. Behav Cogn Psychother 28(2):103–120Google Scholar
  38. Lange A, Van de Ven J, Schrieken B, Emmelkamp PM (2001) Interapy, treatment of posttraumatic stress through the Internet: a controlled trial. J Behav Ther Exp Psychiatry 32(2):73–90CrossRefPubMedGoogle Scholar
  39. Lange A, Schoutrop MJA, Schrieken B, Van de Ven J (2002) Interapy: a model for therapeutic writing through the internet. In: Lepore SJ, Smyth JM (eds) The writing cure. How expressive writing promotes health and emotional well-being, 1st edn. American Psychological Association, Washington, DC, pp 215–238CrossRefGoogle Scholar
  40. Lange A, Rietdijk D, Hudcovicova M, Van de Ven J, Schrieken B, Emmelkamp PM (2003a) Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J Consult Clin Psychol 71(5):901–909. doi: 10.1037/0022-006X.71.5.901 CrossRefPubMedGoogle Scholar
  41. Lange A, Van de Ven J, Schrieken B (2003b) Interapy: treatment of post-traumatic stress via the internet. Cogn Behav Ther 32(3):110–124. doi: 10.1080/16506070302317 CrossRefPubMedGoogle Scholar
  42. Langner R, Maercker A (2005) Complicated grief as a stress response disorder: evaluating diagnostic criteria in a German sample. J Psychosom Res 58(3):235–242. doi: 10.1016/j.jpsychores.2004.09.012 CrossRefPubMedGoogle Scholar
  43. Laska KM, Gurman AS, Wampold BE (2013) Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective. Psychotherapy (Chicago, IL). doi: 10.1037/a0034332 Google Scholar
  44. Lemmen A, Maas M (2001) Inhoudsanalyse van cognitieve categorieën in gestructureerde schrijfopdrachten via Interapy [Content analysis of structured writing.]. Department of Clinical PsychologyGoogle Scholar
  45. Lepore SJ, Smyth JM (eds) (2002) The writing cure: how expressive writing promotes health and emotional well-being, 1st edn. American Psychological Association, Washington, DCGoogle Scholar
  46. Litz BT, Engel CC, Bryant RA, Papa A (2007) A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. Am J Psychiatry 164(11):1676–1683. doi: 10.1176/appi.ajp.2007.06122057 CrossRefPubMedGoogle Scholar
  47. Martin DJ, Garske JP, Davis MK (2000) Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol 68(3):438–450. doi: 10.1037/0022-006X.68.3.438 CrossRefPubMedGoogle Scholar
  48. Messer SB, Wampold BE (2002) Let’s face facts: common factors are more potent than specific therapy ingredients. Clin Psychol Sci Pract 9(1):21–25. doi: 10.1093/clipsy.9.1.21 CrossRefGoogle Scholar
  49. Moreau C, Zisook S (2002) Rationale for a posttraumatic stress spectrum disorder. Psychiatr Clin North Am 25(4):775–790CrossRefPubMedGoogle Scholar
  50. Motraghi TE, Seim RW, Meyer EC, Morissette SB (2014) Virtual reality exposure therapy for the treatment of posttraumatic stress disorder: a methodological review using CONSORT guidelines. J Clin Psychol 70(3):197–208. doi: 10.1002/jclp.22051 CrossRefPubMedGoogle Scholar
  51. Mouthaan J, Sijbrandij M, de Vries G-J, Reitsma JB, van de Schoot R, Goslings JC, Luitse JS, Bakker FC, Gersons BP, Olff M (2013) Internet-based early intervention to prevent posttraumatic stress disorder in injury patients: randomized controlled trial. J Med Internet Res 15(8):e165. doi: 10.2196/jmir.2460 CrossRefPubMedPubMedCentralGoogle Scholar
  52. Nelson RJ (2013) Is virtual reality exposure therapy effective for service members and veterans experiencing combat-related PTSD? Traumatology 19(3):171–178. doi: 10.1177/1534765612459891 CrossRefGoogle Scholar
  53. Norcross JC, Wampold BE (2011) Evidence-based therapy relationships: research conclusions and clinical practices. Psychotherapy (Chicago, IL) 48(1):98–102. doi: 10.1037/a0022161 CrossRefGoogle Scholar
  54. Pennebaker JW (1993) Putting stress into words: health, linguistic, and therapeutic implications. Behav Res Ther 31(6):539–548. doi: 10.1016/0005-7967(93)90105-4 CrossRefPubMedGoogle Scholar
  55. Pennebaker JW, Susman JR (1988) Disclosure of traumas and psychosomatic processes. Soc Sci Med 26(3):327–332. doi: 10.1016/0277-9536(88)90397-8 CrossRefPubMedGoogle Scholar
  56. Pennebaker JW, Booth RJ, Francis ME (2007) Operator’s manual Linguistic Inquiry and Word Count: LIWC2007., AustinGoogle Scholar
  57. Possemato K, Ouimette P, Knowlton P (2011) A brief self-guided telehealth intervention for post-traumatic stress disorder in combat veterans: a pilot study. J Telemed Telecare 17(5):245–250. doi: 10.1258/jtt.2011.100909 CrossRefPubMedGoogle Scholar
  58. Ruggiero KJ, Resnick HS, Acierno R, Carpenter MJ, Kilpatrick DG, Coffey SF, Carpenter MJ, Ruscio AM, Stephens RS, Kilpatrick DG, Stasiewicz PR, Roffman RA, Bucuvalas M, Galea S (2006) Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study. Behav Ther 37(2):190–205. doi: 10.1016/j.beth.2005.12.001 CrossRefPubMedGoogle Scholar
  59. Ruwaard J (2009) Computerized text analysis in computer-mediated therapy: the Interapy post-traumatic stress corpus (presentation slides): Presented at the Fourth Meeting of the International Society for Research on Internet Interventions; 14–16 October [presentation slides]. Amsterdam. Retrieved from
  60. Ruwaard J (2012) The efficacy and effectiveness of online CBT. Department of Clinical Psychology, the University of Amsterdam, AmsterdamGoogle Scholar
  61. Ruwaard J, Lange A, Schrieken B, Dolan CV, Emmelkamp P (2012) The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS One 7(7):e40089. doi: 10.1371/journal.pone.0040089 CrossRefPubMedPubMedCentralGoogle Scholar
  62. Schoutrop MJA, Lange A, Hanewald G, Davidovich U, Salomon H (2002) Structured writing and processing major stressful events: a controlled trial. Psychother Psychosom 71(3):151–157. doi: 10.1159/000056282 CrossRefPubMedGoogle Scholar
  63. Seitz DCM, Knaevelsrud C, Duran G, Waadt S, Loos S, Goldbeck L (2014) Efficacy of an internet-based cognitive-behavioral intervention for long-term survivors of pediatric cancer: a pilot study. Supportive Care Cancer (Official Journal of the Multinational Association of Supportive Care in Cancer) 22(8):2075–2083. doi: 10.1007/s00520-014-2193-4 CrossRefGoogle Scholar
  64. Sloan DM, Marx BP (2004) Taking pen to hand: evaluating theories underlying the written disclosure paradigm. Clin Psychol Sci Pract 11(2):121–137. doi: 10.1093/clipsy.bph062 CrossRefGoogle Scholar
  65. Spence J, Titov N, Dear BF, Johnston L, Solley K, Lorian C, Wootton B, Zou J, Schwenke G (2011) Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder. Depress Anxiety 28(7):541–550. doi: 10.1002/da.20835 CrossRefPubMedGoogle Scholar
  66. Spence J, Titov N, Johnston L, Dear BF, Wootton B, Terides M, Zou J (2013) Internet-delivered eye movement desensitization and reprocessing (iEMDR): an open trial. F1000Research 2:79. doi: 10.12688/f1000research.2-79.v2 Google Scholar
  67. Steinmetz SE, Benight CC, Bishop SL, James LE (2012) My Disaster Recovery: a pilot randomized controlled trial of an Internet intervention. Anxiety Stress Coping 25(5):593–600. doi: 10.1080/10615806.2011.604869 CrossRefPubMedGoogle Scholar
  68. Sundin EC, Horowitz MJ (2003) Horowitz’s Impact of Event Scale evaluation of 20 years of use. Psychosom Med 65(5):870–876CrossRefPubMedGoogle Scholar
  69. Thompson RF (2009) Habituation: a history. Neurobiol Learn Mem 92(2):127–134. doi: 10.1016/j.nlm.2008.07.011 CrossRefPubMedGoogle Scholar
  70. Van der Oord S, Lucassen S, Van Emmerik AAP, Emmelkamp PMG (2010) Treatment of post-traumatic stress disorder in children using cognitive behavioural writing therapy. Clin Psychol Psychother 17(3):240–249. doi: 10.1002/cpp.670 PubMedGoogle Scholar
  71. Van der Velden K (ed) (1977, 1980, 1989) Directieve therapie/1,2,3 [Directive Therapy]. Van Loghum Slaterus, DeventerGoogle Scholar
  72. Van Emmerik AAP, Kamphuis JH, Emmelkamp PMG (2008) Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: a randomized controlled trial. Psychother Psychosom 77(2):93–100. doi: 10.1159/000112886 CrossRefPubMedGoogle Scholar
  73. Van Emmerik AAP, Reijntjes A, Kamphuis JH (2013) Writing therapy for posttraumatic stress: a meta-analysis. Psychother Psychosom 82(2):82–88. doi: 10.1159/000343131 CrossRefPubMedGoogle Scholar
  74. Van Voorhees BW, Gollan J, Fogel J (2012) Pilot study of Internet-based early intervention for combat-related mental distress. J Rehabil Res Dev 49(8):1175–1190. doi: 10.1682/JRRD.2011.05.0095 CrossRefPubMedGoogle Scholar
  75. Wagner B, Maercker A (2007) A 1.5-year follow-up of an Internet-based intervention for complicated grief. J Trauma Stress 20(4):625–629. doi: 10.1002/jts.20230 CrossRefPubMedGoogle Scholar
  76. Wagner B, Knaevelsrud C, Maercker A (2006) Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Stud 30(5):429–453. doi: 10.1080/07481180600614385 CrossRefPubMedGoogle Scholar
  77. Wagner B, Brand J, Schulz W, Knaevelsrud C (2012a) Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients. Depress Anxiety 29(7):646–651. doi: 10.1002/da.21962 CrossRefPubMedGoogle Scholar
  78. Wagner B, Schulz W, Knaevelsrud C (2012b) Efficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: a pilot study. Psychiatry Res 195(1–2):85–88. doi: 10.1016/j.psychres.2011.07.026 CrossRefPubMedGoogle Scholar
  79. Wampold BE, Imel ZE, Laska KM, Benish S, Miller SD, Flückiger C, Del Re AC, Baardseth TP, Budge S (2010) Determining what works in the treatment of PTSD. Clin Psychol Rev 30(8):923–933. doi: 10.1016/j.cpr.2010.06.005 CrossRefPubMedGoogle Scholar
  80. Wang Z, Wang J, Maercker A (2013) Chinese My Trauma Recovery, a Web-based intervention for traumatized persons in two parallel samples: randomized controlled trial. J Med Internet Res 15(9):e213. doi: 10.2196/jmir.2690 CrossRefPubMedPubMedCentralGoogle Scholar
  81. Ware J, Kosinski M, Keller SD (1996) A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34(3):220–233CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Clinical, Neuro, and Developmental PsychologyVrije Universiteit AmsterdamAmsterdamThe Netherlands
  2. 2.Department of Clinical PsychologyUniversiteit van AmsterdamAmsterdamThe Netherlands

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