The Effect of Written Exposure and Cognitive Processing Therapy on Decreasing Alexithymia and Experiential Avoidance in Women with Post-Traumatic Stress Disorder

Harandeh, Neda; Jadidi, Mohsen; Hassani, Seyedeh Fatemeh

doi:10.30491/hpr.2025.549133.1514

The Effect of Written Exposure and Cognitive Processing Therapy on Decreasing Alexithymia and Experiential Avoidance in Women with Post-Traumatic Stress Disorder

Document Type : Original Article

Authors

Neda Harandeh ¹

Mohsen Jadidi ²

Seyedeh Fatemeh Hassani ³

¹ Department of Psychology, Kish International Branch, Islamic Azad University, Kish Island, Iran

² Department of Psychology, ShQ.C., Islamic Azad University, Tehran, Iran

³ Department of Psychology, TeMS.C., Islamic Azad University, Tehran, Iran

10.30491/hpr.2025.549133.1514

Abstract

Background: Post-Traumatic Stress Disorder (PTSD) affects women at approximately twice the rate of men, often leading to complex symptoms like alexithymia and experiential avoidance.
Objectives: This study aimed to compare the effectiveness of Written Exposure Therapy (WET) and Cognitive Processing Therapy (CPT) on decreasing alexithymia and experiential avoidance in women with PTSD.
Methods: This research was a quasi-experimental study conducted in 2024. The statistical population included all women aged 18 to 40 with PTSD referred to counseling centers and psychological clinics in Tehran. A convenience sample of 90 eligible participants was selected and randomly assigned to a WET group (n = 30), a CPT group (n = 30), and a control group (n = 30). The WET group received five sessions, while the CPT group received 12 sessions. Data were collected using the Toronto Alexithymia Scale and the Acceptance and Action Questionnaire-II, and analyzed using repeated-measures ANOVA.
Results: Both WET and CPT interventions were effective, leading to significant reductions in alexithymia (F = 68.42, P<0.001, η²p = 0.44) and experiential avoidance (F = 59.87, P<0.001, η²p = 0.41) at post-test and three-month follow-up. The findings showed that WET was more effective than CPT in decreasing alexithymia (mean reduction: 16.6 vs. 14.2 points), whereas CPT had a greater effect on reducing experiential avoidance (mean reduction: 12.6 vs. 16.6 points) (P<0.05).
Conclusion: Both therapies significantly reduce alexithymia and experiential avoidance, with WET showing greater efficacy for alexithymia and CPT for experiential avoidance, sustained at three-month follow-up. These findings inform clinicians in selecting targeted interventions based on patients’ predominant symptoms, enhancing personalized treatment for women with PTSD.

Keywords

Post-Traumatic Stress Disorder

Cognitive Processing

Alexithymia

Experiential Avoidance

Written Exposure Therapy

1. Mansour M, Joseph GR, Joy GK, Khanal S, Dasireddy RR, Menon A, et al. Post-traumatic stress disorder: A Narrative Review of Pharmacological and Psychotherapeutic Interventions. Cureus. 2023;15(9): e44905. doi:10.7759/cureus.44905

2. Schein J, Houle C, Urganus A, Cloutier M, Patterson-Lomba O, Wang Y, et al. Prevalence of post-traumatic stress disorder in the United States: a systematic literature review. Curr Med Res Opin. 2021;37(12): 2151-61. doi:10.1080/03007995.2021.1978417

3. Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J Psychotraumatol. 2017;8(sup4):1351204. doi:10.1080/20008198.2017. 1351204

4. Rowland GE, Mekawi Y, Michopoulos V, Powers A, Fani N, Bradley B, et al. Distinctive impacts of sexual trauma versus non-sexual trauma on PTSD profiles in highly trauma-exposed, Black women. J Affect Disord. 2022;317:329-38. doi:10.1016/j.jad.2022.08.099

5. ElBarazi A, Ahmed S. Supporting Women to Heal from Trauma and Post-Traumatic Stress Disorder. Illn Crises Loss. 2022;32(1):65-79. doi:10.1177/10541 373221113138

6. Miethe S, Wigger J, Wartemann A, Fuchs FO, Trautmann S. Posttraumatic Stress Symptoms and its Association with Rumination, Thought Suppression and Experiential Avoidance: a Systematic Review and Meta-Analysis. J Psychopathol Behav Assess. 2023; 45(2):480-95. doi:10.1007/s10862-023-10022-2

7. Putica A, Van Dam NT, Steward T, Agathos J, Felmingham K, O'Donnell M. Alexithymia in post-traumatic stress disorder is not just emotion numbing: Systematic review of neural evidence and clinical implications. J Affect Disord. 2021;278:519-27. doi:10.1016/j.jad.2020.09.100

8. Kelly MM, DeBeer BB, Meyer EC, Kimbrel NA, Gulliver SB, Morissette SB. Experiential avoidance as a mediator of the association between posttraumatic stress disorder symptoms and social support: A longitudinal analysis. Psychol Trauma. 2019;11(3): 353-9. doi:10.1037/tra0000375

9. Eftekhari Moghaddam N, Shahbazi M, Kazemian Moghaddam K. Predicting Marital Quality Based on Emotional Empathy and Alexithymia in Nursing Students. Hosp Pract Res. 2023;8(3):325-30. doi:10.30491/hpr.2024.452346.1421

10. Passardi S, Peyk P, Rufer M, Wingenbach TSH, Pfaltz MC. Facial mimicry, facial emotion recognition and alexithymia in post-traumatic stress disorder. Behav Res Ther. 2019;122:103436. doi:10.1016/j.brat. 2019.103436

11. Putica A. Examining the role of emotion and alexithymia in cognitive behavioural therapy outcomes for posttraumatic stress disorder: Clinical implications. Cogn Behav Ther. 2024;17:e15. doi:10.1017/S1754470X2400014X

12. Patel TA, Blakey SM, Halverson TF, Mann AJD, Calhoun PS, Beckham JC, et al. Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample. Int J Cogn Ther. 2023;1. doi:10.1007/s41811-023-00164-2

13. Laman-Maharg B, Valentiner DP, Sz ll s S, Mounts NS. Experiential Avoidance, Post-Traumatic Stress Symptoms, and Academic Impairment. Psychol Rep. 2024:00332941241226682. doi:10.1177/00332941241226682

14. Nishith P, Morse G, Dell NA. Effectiveness of Cognitive Processing Therapy for PTSD in serious mental illness. J Behav Cogn Ther. 2024;34(1): 100486. doi:10.1016/j.jbct.2024.100486

15. Ito M, Katayanagi A, Miyamae M, Inomata T, Takagishi Y, Kikuchi A, et al. Cognitive Processing Therapy for Posttraumatic Stress Disorder in Japan: A Randomized Clinical Trial. JAMA Netw Open. 2025; 8(2):e2458059. doi:10.1001/jamanetworkopen.2024. 58059

16. Moring JC, Dondanville KA, Fina BA, Hassija C, Chard K, Monson C, et al. Cognitive Processing Therapy for Posttraumatic Stress Disorder via Telehealth: Practical Considerations During the COVID-19 Pandemic. J Trauma Stress. 2020;33(4): 371-9. doi:10.1002/jts.22544

17. DeJesus CR, Trendel SL, Sloan DM. A systematic review of written exposure therapy for the treatment of posttraumatic stress symptoms. Psychol Trauma. 2024;16(Suppl 3):S620–s6. doi:10.1037/tra0001659

18. Sloan DM, Marx BP. State of the Science: Written Exposure Therapy for the Treatment of Posttraumatic Stress Disorder. Behavior Therapy. 2024;55(6):1222-32. doi:10.1016/j.beth.2024.02.004

19. Larsen SE, Andrews AR, Astin MC, Lamp KE, Lee JY, Melka SE, et al. Implementation and Adaptations of Written Exposure Therapy: Lessons Learned Across Settings. Cogn Behav Pract. 2025;32(3):415-29. doi:10.1016/j.cbpra.2024.02.001

20. Bagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure. J Psychosom Res. 1994;38(1):23-32. doi:10.1016/0022-3999(94) 90005-1

21. Besharat MA. Assessing reliability and validity of the Farsi version of the Toronto Alexithymia Scale in a sample of substance-using patients. Psychol Rep. 2008;102(1):259-70. doi:10.2466/pr0.102.1.259-270

22. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42(4):676-88. doi:10.1016/j.beth.2011.03.007

23. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian Version of Acceptance and Action Questionnaire –II. Psychol Methods Models, 2012;3(2):65-80.

24. Resick PA, Wachen JS, Dondanville KA, LoSavio ST, Young-McCaughan S, Yarvis JS, et al. Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors. Behav Res Ther. 2021;141:103846. doi:10.1016/j.brat.2021.103846

25. Hahn CK, Salim SR, Tilstra-Ferrell EL, Brady KT, Marx BP, Rothbaum BO, et al. Written Exposure Therapy for PTSD Integrated with Cognitive Behavioral Coping Skills for Cannabis Use Disorder After Recent Sexual Assault: A Case Series. Behav Sci. 2025;15(7):877. doi:10.3390/bs15070877

26. Benito K, Pittig A, Abramowitz J, Arch JJ, Chavira D, de Kleine R, et al. Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda. Clin Psychol Sci. 2025;13(4):687-719. doi:10.1177/21677026241240727