Perceived Barriers and Preliminary PTSD Outcomes in an Open Pilot Trial of Written Exposure Therapy With Latinx Immigrants

Abstract

Latinx immigrants experience substantial disparities in mental health treatment access, particularly for posttraumatic stress disorder (PTSD). The availability of brief, flexible interventions in Spanish may assist in reducing these disparities. Written Exposure Therapy (WET) is a five-session PTSD intervention that appears as effective as longer, gold-standard interventions, but has yet to be tested among Latinx immigrants. To test the acceptability and preliminary effectiveness of WET, 20 Spanish-speaking, Latinx immigrants conducted structured interviews at pretreatment, were offered WET, and completed posttreatment structured interviews. Open thematic coding of pre- and posttreatment interview questions examined perceived barriers and benefits of WET. Quantitative components examined symptom change across PTSD (PCL-IV-C) and depression (PHQ-9). Quantitative results indicated clinically meaningful and statistically significant change in PTSD symptoms using intent-to-treat analyses (M_diff = 17.06, SD_diff = 9.97, range = 0–29, t(15) = 6.84, p < .001). Open thematic coding identified four barrier-related themes and three benefit-related themes at pretreatment. At posttreatment, three barrier-related themes and two benefit-related themes were identified. Qualitative results largely suggested that perceived barriers were common to other PTSD interventions (e.g., exposure components). Only one participant identified barriers specific to WET. Results suggested WET may reduce PTSD symptoms among Latinx immigrants. WET also appeared to be acceptable and primarily viewed as beneficial among this population. WET is a promising intervention with Latinx immigrants and warrants further testing larger trials, including testing implementation strategies that may improve access to care.

Latinxs with a mental health diagnosis receive mental health services at approximately 60% the rate of non-Latinx Whites (Center for Behavioral Statistics and Quality, 2018). Further, despite experiencing traumatic events at higher rates, these disparities appear to persist for treatment of posttraumatic stress disorder (PTSD; Fortuna et al., 2008; Kaltman et al., 2010, 2016). While data are limited, this may be particularly true for Latinx immigrants who often face greater barriers in accessing care than their U.S.-born counterparts. Such barriers include language, cost/insurance, travel, time from work, and cultural perceptions surrounding mental health difficulties (Bernal & Sáez-Santiago, 2006; Bridges et al., 2012; Kaltman et al., 2016; Sanchez et al., 2012). Therefore, it is important to develop and assess treatments that have the potential to address previously identified barriers to service utilization among Latinx immigrants with PTSD.

In addition, financial barriers, such as lack of health insurance and cost of services, represent significant barriers to mental health care for Latinx immigrants. Cost-related barriers are potentially compounded with longer treatment protocols, as additional sessions necessarily increase the costs of continuing treatment by requiring patients to take time off work, make child-care arrangements, and travel to a limited number of Spanish-speaking providers (Kouyoumdjian et al., 2003). The recognition of these barriers has, in part, resulted in multiple novel models of delivering treatment, such as integrated primary care mental health models in which mental health professionals have six or fewer visits that last 30 minutes or less as part of a public health emphasis (Blount, 1998). Few interventions exist, however, that effectively treat PTSD in a similar time-limited fashion among Latinx immigrants. To further research on PTSD treatment that potentially addresses these barriers, the current study examines mixed-methods data from an open pilot of a Spanish-language version of Written Exposure Therapy (WET), a five-session PTSD intervention. The study examines potential adaptations to WET that may be necessary for the use of WET with Latinx immigrants, perceived benefit, and preliminary evidence of efficacy in symptom reduction.

Efficacious Trauma-Focused Treatment Dropout

Over the past three decades, multiple interventions have demonstrated significant effectiveness in reducing PTSD. These include, but are not limited to, treatments such as Prolonged Exposure (PE; Foa et al., 2007) and Cognitive Processing Therapy (CPT; Resick et al., 2016), each of which lasts between 12 and 20 sessions. Despite the effectiveness of several empirically supported treatments for PTSD, a significant portion of individuals discontinue treatment or “drop out” (Imel et al., 2013). The average dropout rate across trauma-focused PTSD treatments in clinical trials is 18% or higher based on meta-analytic studies (Bradley et al., 2005; Hembree et al., 2003; Imel et al., 2013), but dropout varies considerably from 0% to 48%. Importantly, treatment modality (e.g., exposure-based treatment) does not appear to be a significant predictor of dropout (Imel et al., 2013). Treatment length, however, appears to be one of the few treatment-related factors that does predict dropout. Specifically, Imel et al. (2013) found that each additional treatment session predicted an additional 1 percentage in dropout, which may reflect the increase in barriers to care as treatment extends. These data, however, reflect the rates among general samples and may be exacerbated among communities that experience disparities in treatment dropout, particularly given that structural barriers (e.g., cost or transportation) will expand as treatment length increases. The increasing dropout rates as treatment extends creates a potential conflict, given findings that attending more sessions forecasts better outcomes (Holmes et al., 2019; Szafranski et al., 2017). Thus, interventions expanding effective PTSD treatment access needs to prioritize brief interventions that retain significant efficacy, ultimately maximizing potential treatment gains within each session attended (i.e., efficiency).

Written Exposure Therapy Overview and Efficacy

WET consists of five treatment sessions that last approximately 45 minutes each (Sloan et al., 2012, 2013; Sloan & Marx, 2017). Thus, WET entails fewer sessions without extending the length of each individual session. WET builds on prior research regarding expressive writing in which participants, for 30 minutes, write about the currently most distressing traumatic event they have experienced (Pennebaker, 2004; Sloan et al., 2005). WET differs from prior expressive writing interventions in its formalized protocol and its focus on PTSD psychoeducation and treatment. In the first session, the clinician provides the patient with brief psychoeducation about PTSD that is linked to an exposure-based rationale for why writing about past traumatic events leads to symptom reduction (i.e., because it reduces avoidance). Following psychoeducation, the clinician provides instructions for writing about their traumatic event, including discussion about selecting a traumatic event for patients who have experienced multiple potentially traumatic events. Patients then write for 30 minutes without the clinician present and provide as much clarity and detail about their sensory, cognitive, and emotional experiences at the time of the traumatic event. After the 30-minute writing period, the clinician completes a brief “processing” with the patient that focuses on the experience of writing about the traumatic event. Sessions 2 through 5 are similar, with 30 minutes allotted to writing about the same traumatic event and 10 minutes for check-in.

In this brief format, WET has demonstrated efficacy in waitlist-controlled trials (Sloan et al., 2012, 2013) and a noninferiority trial comparing WET with CPT (Sloan et al., 2016, 2018; Thompson-Hollands et al., 2018). In one example of randomized control trial of WET for PTSD, the intervention was delivered among motor vehicle accident survivors with superior reductions PTSD for the WET condition compared with waitlist (Sloan et al., 2012). In the WET condition, 95% of participants indicated a remission of PTSD diagnosis compared with 25% of those assigned to the waitlist condition. In an open trial of WET among a sample of veterans diagnosed with chronic PTSD, 71% of veterans exhibited clinically significant reductions in PTSD symptoms and no longer met diagnostic criteria (Sloan et al., 2013). In a noninferior study comparing WET to CPT, 126 participants were randomly assigned to complete 5 sessions of WET or 12 sessions of CPT (Sloan et al., 2016). Follow-up assessment sessions were completed at 6, 12, 24, 36, and 60 weeks following treatment. WET was noninferior to CPT in their reduction of PTSD symptoms both in the immediate (Sloan et al., 2018) and full 60-week follow-up (Thompson-Hollands et al., 2018). Both WET and CPT had large treatment effects on PTSD symptom severity and the majority of participants from each condition no longer met diagnostic criteria for PTSD. While efficacy did not differ between the two treatments, dropout was significantly lower for WET, including only 6% in the WET condition compared with 39% in the CPT condition, potentially reflecting the advantage posed by WET’s brevity.

WET and Barriers to Mental Health Access for Latinx Immigrants

The studies examining WET’s efficacy have to-date only tested the intervention with English-speaking and primarily non-Latinx White samples. While the intervention appears to reduce structural barriers, it remains unclear if these reductions are sufficient and the extent to which sociocultural or attitudinal barriers may still prevent access. First, the availability of Spanish-language resources is one of the largest and most consistent barriers for Latinx immigrants (Flores, 2006). While a Spanish translation would not immediately resolve the lack of available Spanish-speaking clinicians, it could reduce time demands on an interpreter given that an interpreter they may only be needed for 15–20 minutes per session. Its structure may also afford flexibility to implement within additional clinical systems that aim to reduce access disparities, such as integrated primary care mental health, given that clinicians are not present during the writing. This kind of adaptation may be critical given data that integrated settings reduce access disparities (Bridges et al., 2014) and primary care is the most common source of mental health care for immigrant Latinx populations (Alegría et al., 2007). Integrated primary care and similar adaptations are intentionally designed to reduce the barriers frequently evidenced in traditional mental health services, including structural barriers (less cost, less time) and sociocultural variables, such as stigma and perceived utility (Blount, 1998). In particular, stigma toward mental health services appears higher among Latinx immigrants relative to their U.S.-born counterparts and non-Latinx White populations (Wong et al., 2017). This kind of adaptation fits with recent calls to focus cultural and equity-centered adaptation on fitting interventions to existing delivery systems (Gonzales, 2017). WET appears well-suited to afford such flexibility, but its acceptability and potential efficacy among Latinx immigrants has yet to be examined even for its current form.

It is also possible that the way in which WET achieves some of its brevity and flexibility (e.g., having the clinician present for only 15–20 minutes per session) represents a potential barrier for Latinx immigrants. For example, the reduced contact with the clinician may conflict with cultural beliefs regarding the importance of close personal relationships (Añez et al., 2005). Further, the reduced psychoeducation components may be more challenging for populations with lower mental health literacy. This could affect Latinx populations given some data suggesting mental health literacy may be a barrier to access care for Latinx immigrants (Coffman & Norton, 2010). Finally, in line with adaptation frameworks for cognitive-behavioral interventions (Rathod et al., 2019), extension of the intervention to a new population still requires assessment of potential cultural conflicts with the treatment rationale and treatment components to ensure fit with Latinx immigrant populations. Thus, while WET may hold significant promise, investigations are needed to examine acceptability, preliminary effectiveness, and any additional adaptations necessary among Latinx immigrants.

Purpose

WET appears efficacious in addressing PTSD with significantly fewer treatment sessions and lower dropout rate. Treatment length has been associated with higher dropout in PTSD treatment and Latinx immigrants experience disparate barriers to care. We therefore sought to translate WET into Spanish using culturally appropriate language, assess the perceived barriers and benefits of the intervention, and test the potential symptom reduction in a sample of Latinx immigrants.

Method

Participants

Participants were 20 adult Latinxs who reported speaking Spanish as their primary language. All participants were born outside of the contiguous U.S., including one participant who was born in Puerto Rico (n = 1, 5%). Although recruitment focused on immigrants and being born outside of the U.S. was a screening criterion (see Procedures below), the participant born in Puerto Rico (a U.S. territory) was included in the study as they still reported Spanish as their primary language and migrated from a region where Spanish is the dominant language. The majority were women (n =18; 90.0%) and were born in Mexico (n = 11; 55.0%). Further, the majority reported never having received any kind of mental health services previously (n = 15; 75.0%). Table 1 contains additional participant background and descriptive information.

Table 1.

Participant Descriptive and Background Information

	N (%)	M (SD)	Min-Max
Gender
Women	18 (90%)
Country/Region of Birth
El Salvador	3 (15.0%)
Guatemala	3 (15.0%)
Honduras	1 (5.0%)
Mexico	11 (55.0%)
Puerto Rico	1 (5.0%)
Received treatment previously	4 (25.0%)
Age		36.95 (8.79)	19–52
PCL-IV Scores
Pretreatment		49.45 (8.04)	36–67
Posttreatment-no imputation*		26.33 (7.25)	18–40
Posttreatment-imputation*		34.31 (15.67)	18–67
PHQ-9 Scores
Pretreatment		12.13 (6.04)	1–22
Posttreatment-no imputation*		3.75 (5.50)	0–19
Posttreatment-imputation*		6.06 (6.71)	0–19

Note:

^*As a conservative method for estimation, imputation was conducted using last observation carried forward (LOCF), which effectively presumes that any participants who discontinued treatment did not benefit at all from the intervention.

Procedure

Protocol Translation

Prior to beginning data collection, we translated the protocol using forward and back translation. Discrepancies were resolved using consensus building across the five-member translation team. Once the protocol was translated, the entire protocol was reviewed in Spanish by the team as a whole, which had representation from three different Spanish dialects: Mexico, El Salvador, and Guatemala. Resolution processes emphasized ensuring that lay individuals would be able to understand the language used in the protocol. Except for one member (the first author), all translation team members were either first- or second-generation immigrants and spoke Spanish as a primary language with family members. The first author, who supervised translation, is not a native speaker but has formal training in translation, has a bachelor’s degree in Spanish, and conducts therapy in Spanish. Once the protocol had been translated and reviewed, recruitment began.

Recruitment

Prior to beginning portions involving participants, the project was approved by the Institutional Review Board at the University of Nebraska-Lincoln. Participants were recruited through primary care clinics and cultural community centers. Mental health providers at primary care clinics and cultural center employees were given flyers to hand out to potential participants whom they suspected of having PTSD. Participants were also directly referred by both providers and cultural center employees. Once participants either contacted the lab or were contacted by research staff, they were screened for likely PTSD using the PCL-IV with scores greater than 45. While a clinical cutoff of 50 was initially recommended (Weathers et al., 1993), a lower score was used given data that cut-scores at approximately this level (i.e., 44–48) may improve accuracy in some populations and would allow for inclusion of participants with subsyndromal elevations in PTSD symptoms (McDonald & Calhoun, 2010). During recruitment and screening, participants were informed that the primary purpose of the study was to understand their opinions regarding the treatment. Participants were also explicitly informed that the study would occur in two phases and for the first phase, they did not need to be interested in receiving the treatment in order to participate. They were informed that after learning about the treatment in the first phase, they would be given the opportunity to receive the treatment during a second phase.

Phase 1: Pretreatment Symptoms and Perceptions of Treatment Procedures

During the first interview, participants first completed a mixed-methods interview regarding their perceptions of the treatment. Interviews were completed by trained bilingual, bicultural research assistants. Qualitative components of the interview consisted of open-ended questions regarding perceived barriers and perceived benefits of the intervention. Quantitative components assessed current PTSD symptoms (PCL-IV; Blanchard et al., 1996; Weathers et al., 1993), current depression symptoms (PHQ-9; Kroenke et al., 2001; Kroenke & Spitzer, 2002; Martin et al., 2006), intent to receive the intervention (yes/no), and demographics.

Phase 2: Written Exposure Therapy and Posttreatment Assessment

The second phase of the study consisted of providing the five sessions of WET to interested participants and a posttreatment mixed methods interview. WET was provided by a licensed, PhD psychologist (the first author), and two clinical psychology graduate trainees (the second and third authors). Treatment sessions took place in university-based facilities and in private rooms at a local cultural center. As with initial WET trials, participants wrote for 30 minutes about a single traumatic event and wrote about the same event across all writing sessions. For participants who had experienced multiple traumatic events, they were instructed to select the event that causes the most distress at present. If participants experienced multiple highly similar events and had difficulties selecting a single event that was most distressing, they were allowed to write about an amalgam event consisting of details they found most distressing from all events. All participants were able to identify a single incident that caused the most distress.

Although all participants completed the treatment within the allotted timeframe, participants were informed that they would need to complete the five sessions within a maximum of 10 weeks. Per the WET protocol, all sessions were scheduled 1 week apart. Flexibility with scheduling and location were allowed in order to ensure that steps were taken to reduce known barriers to treatment access, including transportation and time. This allowed for evaluation of barriers to the intervention to focus on the specific components of the intervention, rather than the typical implementation structure of mental health services generally.

Following completion of treatment, participants were scheduled for a posttreatment interview within a week of their final treatment session. The final interview was again conducted by trained research assistants in order to avoid posttreatment interviews being conducted by the clinician who provided treatment. This was done to ensure participants were able to express any negative opinions regarding the intervention or any persistent high symptoms. The posttreatment interview mirrored the initial interview with a mixed methods structure. Qualitative portions focused on open-ended questions regarding perceived barriers and benefits, while quantitative portions focused on current depression and PTSD symptoms. The repetition of the qualitative portion of the interview was completed to assess potential barriers they perceived barriers others may encounter when receiving the treatment from the perspective of having gone through all treatment procedures.

Measures

Perceived Barriers and Benefits

Perceived barriers and benefits were assessed using a structured interview with open-ended questions, followed by a researcher-defined checklist of common barriers to trauma-focused mental health services. The open-ended questions were asked first in order to avoid any potential contamination of participant responses from researcher suggestions. The specific questions asked were: “Now that you have read the manual, what are some reasons that you think you or people you know might not want to receive the treatment?” (translated from Spanish). If participants reported barriers pertaining only to mental health services generally, they were prompted by asking, “What might be some reasons people would not use this treatment specifically?” If participants provided brief responses (one sentence or less), they were prompted by the research assistant to “Tell me more” (translated from Spanish). Participants were prompted or queried a maximum of three times to avoid frustration. For any identified barriers, participants were asked if “there was anything we could do to reduce these barriers” (translated from Spanish). Participants were then asked to identify “what are barriers to mental health services generally” with similar prompt and query procedures. As participants dictated their responses to the open-ended questions, the research assistants simultaneously transcribed the responses verbatim. This approach was derived from collaboration with community partners due to potential fear or discomfort some participants may have with being recorded. Finally, participants were asked to select from a list of common barriers that included (translated from Spanish): (1) having to write, (2) having to recount the traumatic experience, (3) there are too many appointments, (4) the appointments are too long, (5) I do not understand the explanation of posttraumatic stress, (6) the wording of the therapy is hard to understand, (7) I do not think this treatment will help me, and (8) other reason that was not mentioned before.

PTSD Symptoms

PTSD symptoms were assessed using the PTSD Checklist for DSM-IV, Civilian version (PCL-IV; Blanchard et al., 1996; Weathers et al., 1993). The PCL-IV was used as validated Spanish versions of the PCL for DSM-5 were not available at the time the study began. Additionally, results with other studies indicate significant overlap between the two measures and that DSM-5 criteria can still be assessed with the PCL-IV (Rosellini et al., 2015, p. 5). The PCL-IV contains 17 items that directly map onto the DSM-IV PTSD criteria with scores on each item ranging from 1 (not at all) to 5 (extremely). These scores can either be summed within the three symptom domains from the DSM-IV (reexperiencing, hyperarousal, and avoidance) or summed to form a total symptom severity score. The PCL-IV has demonstrated validity in assessing change in PTSD symptoms and has demonstrated high agreement with clinician-administered measures to diagnose PTSD (Blanchard et al., 1996; McDonald & Calhoun, 2010). Nevertheless, given that the measure was primarily administered by undergraduate research assistants, we use the term likely PTSD to refer to cases in which diagnostic criteria appear to have been met using the PCL-IV. With regard to clinically significant change, prior investigations suggest that a 10-point reduction in overall PCL-IV scores indicates meaningful change (Monson et al., 2008). The PCL-IV has demonstrated good test-retest reliability and internal consistency, though the exact number of factors in the PCL-IV and other measures of PTSD symptoms has demonstrated significant variability in psychometric studies (Asmundson et al., 2000; McDonald & Calhoun, 2010; Miles et al., 2008; Vera-Villarroel et al., 2011; Wilkins et al., 2011). Test-retest reliability that most closely approximate the time interval examined here has been shown to vary between .66 and .68 (Wilkins et al., 2011). Though nearly all of this work has occurred with the English version, the Spanish language PCL-IV-C has also demonstrated good internal consistency (Vera-Villarroel et al., 2011).

Depression Symptoms

Depression symptoms were assessed using the nine item, Patient Health Questionnaire (PHQ-9; Kroenke & Spitzer, 2002; Martin et al., 2006). The PHQ-9 assesses how often in the last two weeks a person has experienced each of the nine symptoms, with scores ranging from 0 (not at all) to 3 (nearly every day). These scores are then summed to form a total symptom severity score. The PHQ-9 is among the most commonly used measures of depression. It has demonstrated good concurrent validity and internal consistency, including in Spanish-speaking samples in the U.S. and outside the U.S. (Amtmann et al., 2014; Manea et al., 2012, p. 9; Merz et al., 2011; Muñoz-Navarro et al., 2017, p. 9; Titov et al., 2011; Wulsin et al., 2002; Zhong et al., 2014, p. 9). Clinical cutoff scores have also been established in U.S. and international samples, with some studies suggesting similar sensitivity and specificity performance across scores from eight to 11 (Manea et al., 2012). Based on these results, we elected to use an overall symptom score of 11 as an indicator of likely depression.

Traumatic Event Exposure

Participants completed the Trauma History Questionnaire (THQ; Hooper et al., 2011). The measure was modified to include items about traumatic event exposure during immigration, including whether immigration itself was traumatic, in line with similar measures of immigration-related trauma (de Arellano et al., 2018). The standard THQ contains 24 initial questions regarding traumatic event exposure with follow-up questions regarding when the event happened and how many times. The standard THQ contains behaviorally specific wording regarding multiple types of traumatic events across three categories: crime-related events (4 items), general disaster and trauma (13 items), and physical and sexual experiences (7 items). More specifically, these items assess physical assault, physical abuse by a caregiver, sexual assault, threats of violence, sudden or violent death of a loved one, home invasions, disasters, serious accidents, war and combat, life-threatening illness, and exposure to dead bodies. The THQ has demonstrated good test-retest reliability and construct validity (Hooper et al., 2011). The Spanish-language version has similarly demonstrated construct validity (Heilemann et al., 2002).

Demographics

Demographics were self-reported across age (“how old are you?”), gender (“Please identify your gender-Check all that apply”), race/ethnicity (“Please identify your race or ethnicity-Check all that apply”), country of origin (“In what country were you born?”), and history of receiving mental health services. Receiving mental health services was assessed using multiple items, including whether they had ever received any mental health services before. If they answered yes, they were asked follow-up questions regarding the type of service, when they received the services, and the diagnosis they received.

Analyses

Qualitative data regarding perceived barriers and benefits of the intervention were analyzed by the second and third authors using thematic analysis (TA), a method for systematically identifying, organizing, and offering insight into patterns of meaning (i.e., “themes”) in qualitative data (Braun & Clarke, 2006, 2012). The two coders are both Latina, were born in Latin America (Cuba and Colombia), were clinical psychology Ph.D. students at the time, and are native Spanish speakers. A predominantly inductive approach was utilized, where the researchers derived codes and themes from the data. Thematic analysis consisted of several stages. First, the second and third authors independently familiarized themselves with the data by reading the responses several times and began taking observational notes (“memos”). Next, each response was thoroughly read again to generate initial codes. Once both authors independently conducted their review of the data and development of initial codes, the authors met to develop a consensus on codes. These data were then coded by assigning codes to relevant sections of the responses. Next, the authors identified areas of similarity and overlap between codes in order to generate themes that described coherent and meaningful patterns in the data. The themes were reviewed and refined by conducting one final read of all the responses to determine whether the generated themes meaningfully captured the most important and relevant elements of the data. Finally, themes were defined and named, which yielded the overall results of the analysis. Themes were compared across treatment completion status, but no unique themes were identified among any of the treatment groups. Thus, themes are presented collectively.

For quantitative analyses of treatment outcomes, intent-to-treat analyses were used. Given that no participants who discontinued treatment completed the final evaluation, we used a last observation carried forward (LOCF) method, such that missing posttreatment scores were imputed using pretreatment symptom scores for any participants who did not complete the final evaluation (Del Re et al., 2013). We selected this method because for this study, it was more conservative relative to other approaches, such as mean substitution, case-wise deletion, or linear interpolation (i.e., subtracting the mean of symptom change from each). Further, while more advanced methods like multiple imputation may be appropriate for similar small samples (McNeish, 2017), analyses also suggested that the LOCF was more conservative, particularly because the only observation to carry forward is the baseline measure. All analyses of treatment effects are therefore examined using LOCF. Treatment effect sizes were then calculated using Cohen’s d in comparing pretreatment to posttreatment. Dependent samples t-tests were also calculated. Regarding reliable change, we utilized the approach outlined by Jacobson and Truax (1991). Expressed mathematically where “RC” is the change in scores from pretreatment to posttreatment:

$$RC=\frac{\left(M_{pre}-M_{\mathit{\text{post}}}\right)}{s_{\mathit{\text{diff}}}}$$

Using this model and test-retest reliability indicated for each measure (r_PCL-IV = .66; r_PHQ-9 = .69) s_diff = 6.63 for the PCL-IV and 4.76 for the PHQ-9. Following recommendations by Jacobson and Truax (1992) where RC > 1.96 indicates reliable change, the threshold for reliable change was 12.99 and 9.32 for the PCL-IV and the PHQ-9, respectively. We examined both the number of participants exceeding this threshold and the median RC value observed in this sample.

To explore potential barriers associated with treatment completion, χ² tests were also examined comparing each barrier across those who completed treatment, those who started but did not complete treatment, and those who did not start treatment. Analyses were conducted using SPSS version 25.0.

Results

Trauma Exposure and Depression and PTSD Symptoms at Phase 1 Interviews

During Phase 1 interviews (i.e., before being offered the treatment), participants on average reported symptoms that fell within the clinical range on the PCL-IV (M = 49.45, SD = 8.04, range = 36–67). All participants, except for one, fell within the minimum screening criteria for likely PTSD and most fell within more stringent criteria of scores greater than or equal to 44 (n = 15, 75.0%). Approximately half had scores greater than or equal to 50 (n = 10, 50%). Additionally, the majority of participants met symptom-specific criteria for likely PTSD on the PCL-IV (n = 17, 85.0%). A majority of participants also reported symptoms with scores higher than clinical cutoffs for major depression on the on the PHQ-9 (n = 12, 60.0%). Trauma exposure varied significantly across participants, with most participants reporting exposure to multiple traumatic event types. (Mean = 7.95, Median = 9, Mode = 5, Range = 1–14). The most common event type reported was experiencing a robbery (n = 13, 65.0%), though this was not selected as the primary traumatic event by any participants. The events that participants selected for the writing varied significantly, though forms of traumatic loss were most common (n = 4).

Perceived Barriers and Benefits of Treatment at Phase 1

Seven themes were identified in the qualitative interview data. With regard to perceived barriers, three overarching themes were identified, including structural barriers (e.g., language or literacy), psychosocial barriers (e.g., stigma), and concerns related to exposure/trauma focus. Perceived benefits of treatment also consisted of three themes: longing/need for recovery and perceived utility, wanting to write or directly address the traumatic event, and addressing systemic barriers. While not noted as a barrier or benefit, the final theme was no perceived barriers to treatment. For example: “No tiene ninguna barrera” (“It does not have any barriers”; Participant 5). The six themes related to perceived barriers and benefits are described in more detail below.

Structural Barriers

Structural barriers included a variety of logistical issues that participants believed would make it difficult to access treatment. Five participants identified such barriers. Structural barriers were most often discussed in terms of barriers that apply to mental health services more generally (compared to the specific treatment program for this study). For example: “Tiempo, muchas personas trabajan … No saber manejar, no tener transporte” (“Time, many people work…not knowing how to drive, not having transportation”; Participant 4)

Although the treatment was offered for free, participants identified cost as a barrier as well. “Yo pienso que personas se limitan gastar dinero para tratamiento” (“I think people are limited in spending money for treatment”; Participant 10).

Participant 2 also mentioned having to write/literacy as a barrier to treatment stating, “Como yo no sé escribir. Estuve en la escuela pero no aprendí nada.” (Like I don’t know how to read. I was in school, but I didn’t learn anything”; Participant 2).

Psychosocial Barriers

Psychosocial barriers included stigma related to mental health services and experiencing traumatic events. Five participants reported such barriers. These barriers were discussed as applying to all mental health services. For instance, Participant 12 noted the stigma of receiving care in general, but also said this barrier would not prevent them from using services: “No tengo una razón en porque no usaría. Personas piensas que estamos locos por usar la terapia.” (“I do not have any reason why I wouldn’t use it. Some people think we are crazy for going to therapy.”). Although this participant was comfortable using mental health services, she noted that there is stigma against seeking help for mental health.

For other participants, a barrier to seeking therapy was the stigma related to having experienced a traumatic event, especially sexual assault. In these cases, participants felt fearful or shameful about other people knowing about their trauma. For instance:

“A veces da vergüenza cuándo pasa por una violación. Te quedas callado y no lo hablas con familia y la educación que uno tiene ‘no se dice’. No se cuenta a nadie. Tienes que quedar con el.” (“Sometimes it makes you ashamed when you experience a rape. You stay quiet and don’t talk about it with family and the education you get is ‘it’s not talked about’. You don’t tell anyone. You have to keep it inside.” Participant 18).

“Están encerrados en su trauma. Pena, porque no quieren que sepan lo que pasa alrededor en su vida. Si es casado, tal vez su esposa o hijos, la persona no quiere que ni ellos sepan de lo que el vivió” (“They’re closed off in their trauma. Pain, because they don’t want others to know what’s happening in their life. If they are married, maybe their wife or kids, the person doesn’t even want them to know what they lived through.”; Participant 9).

Both of these participants articulated how trauma survivors may want to hide the event from people in their lives, and this desire or pressure to “keep it inside” makes it challenging to use mental health services.

Concerns Related to Exposure/Trauma Focus

Seven participants also noted perceived barriers related to the exposure-based components of treatment and having to confront the traumatic event during treatment. While this is similar to fears and shame related to experiencing the traumatic event, the barriers identified under this theme centered on the process of exposure components, either having to remember the traumatic event or having to write about it. For example, Participant 16 referenced wanting to avoid the memory itself and stated: “El tener que recordar, preferiría no recordar” (“Having to remember, I would prefer not remember”). Similarly, Participant 10 reported wanting to avoid discussing negative past experiences, but appeared to acknowledge its role in the therapy process: “Yo creo que principalmente prefieres guardarte tus malas experiencias y cosas que te pasa y guardar en la memoria y yo lo digo porque nunca he tenido terapia” (“I think principally you prefer to hold in your bad experiences and things that happen to you and put that away in your memory and I say that because I have never had therapy”; Participant 10)

Somewhat distinctly, Participant 3 highlighted perceived challenges in having to do exposures in a written format, and connected these challenges to how writing may limit emotional expression for the complexity of trauma-related symptoms. “Es difícil para alguien escribir el trauma Es posible que cuándo escribe es difícil documentar todas las emociones.” (“It’s hard for someone to write about the trauma … It’s possible that when you write, it’s hard to document all of the emotions.”)

Longing/Need for Recovery and Perceived Utility

When identifying perceived benefits of treatment, 16 participants framed the exposure in terms of a longing for recovery and to be “free” of trauma, while also noting either implicitly or explicitly that they perceived the treatment as beneficial. For instance, one participant stated, “Hay que liberarse del trauma” (“You have to free yourself from the trauma”; Participant 1). Another identified that writing about the trauma would result in “soltar lo que uno trae adentro” (“Letting go of what’s inside”; Participant 19). Participant 14 provided the most common type of response wherein participants articulated a combination of wanting to recover and perceiving a need for trauma-focused components of treatment (i.e., implying a perceived benefit of treatment). For example, one participant stated:

“Yo quiero salir adelante. Tengo dos hijos y si yo sigo en lo mismo, yo les doy algo negativo en vez de positivo. Yo les tengo que enseñar cómo vivir la vida y enseñar que pueden seguir con la vida y una tiene que enfrentar” (“I want to move forward. I have two children and if I keep going the same way, I’m going to give them something negative instead of something positive. I have to teach them how to live life and teach them that you can move forward with life and that you have to confront it (referring to the traumatic event).”

Wanting to Write or Directly Address the Traumatic Event

While some participants perceived the exposure-based components as a barrier, having to confront the traumatic event was perceived as beneficial for six participants. Many of these participants directly referenced writing as a perceived benefit of the treatment. As noted by Participant 1,

“Una de las ayudas es escribir. Me parece una buena técnica. Nos cuesta decir las cosas directamente a unas personas y algunas veces escribiendo más es mejor porque algunas gentes prefieren escribir que hablar.” (“One of the helpful things is writing. It seems like a good technique. It’s hard for us to say things directly to some people and sometimes writing more is better because some people prefer to write.” Participant 1)

While Participant 3 noted writing about the traumatic event as a barrier, they also provided a rationale for why it could be helpful: “Cuando se habla es como a la defensiva. En cambio, escrito es más pensado y menos probable de estar en esa duda.” (“When it’s spoken it’s like being on the defensive. On the other hand, written is more thought out and less likely to have that doubt.”). In addition, other participants spoke more directly about the perceived benefit of an exposure approach. For example, one participant stated that this direct approach was beneficial because it would result in “El poder de enfrentar el trauma y tratar de salir adelante” (“Being able to confront the trauma and try to move forward.”; Participant 11). Similarly, Participant 6 described the benefit of discussing the traumatic event, though they provided the following response when asked about barriers: “Conversando con otra persona, uno puede normarlizar todo … En mi caso, vivo encerrado … Si uno empieza a acordarse de las situaciones, tal vez uno puede recuperar la emoción.” (“Talking with another person, you could normalize everything…In my case, I live closed off…If you start to remind yourself of the situations, maybe you can recover the emotion.”).

Addressing Language Barriers

Although only reported by one participant, the benefit of having treatment in Spanish was also highlighted. Specifically, Participant 18 indicated that one of the benefits was: “Que vas a hablarlo de que te pasó y que es en español también. No tienes un traductor por un lado.” (“That you are going to talk about what happened to you and that it’s in Spanish, too. You don’t have a translator on one side.”). The ability to write and talk about the traumatic event in their native language was more desirable than having to engage with mental health professionals with a translator present.

Barriers Reported on Checklist

The barriers reported from the checklist at pretreatment differed somewhat from the themes identified in the qualitative data. Several participants did report barriers on the checklist that matched themes from thematic analyses, including having to “confront the traumatic event” (n = 9), difficulties understanding treatment instructions (n = 6, 30.0%) and explanations of PTSD (n = 4, 20.0%). Two barriers were reported from the checklist did not match the themes derived from participant interviews, including that there are too many sessions (n = 2, 10.0%) and the sessions last too long (n = 1, 5.0%). In other words, these two barriers were not discussed in the interviews, but were identified as barriers by some participants on the checklist.

Barriers from the checklist were compared across those who (a) finished treatment, (b) started, but did not finish treatment, and (c) did not start treatment. One clear pattern emerged from these data, even reaching statistical significance, χ² (2) = 8.37, p = .015, in that all of the participants who started but did not finish treatment reported difficulties understanding the treatment’s explanations of PTSD compared to those who did not start treatment (n = 1, 25.0%) and those who finished treatment (n = 2, 15.4%). Descriptive statistics of all reported barriers and benefits on the investigator-defined checklist are reported in Table 2.

Table 2.

Barriers Reported From Checklist Among Those Who Did Not Start Treatment, Started but Did Not Finish Treatment, and Those Who Finished Treatment

Barrier from Checklist	Finished Tx		Started and Did Not Finish Tx		Did Not Start Tx
	n	%	n	%	n	%
Having to write
At baseline (n = 20)	6	46.2%	2	66.7%	1	25.0%
At posttreatment (n = 13)	4	30.8%	–	–	–	–
Having to recount the traumatic event
At baseline (n = 20)	5	38.5%	2	66.7%	2	50.0%
At posttreatment (n = 13)	10	76.90%	–	–	–	–
There are too many sessions
At baseline (n = 20)	1	7.7%	1	33.3%	0	25.0%
At posttreatment (n = 13)	1	7.7%	–	–	–	–
The sessions take too long
At baseline (n = 20)	0	0.0%	1	33.3%	0	0.0%
At posttreatment (n = 13)	1	7.7%	–	–	–	–
Difficulties understanding PSTD explanations*
At baseline (n = 20)	2	15.4%	3	100.0%	1	25.0%
At posttreatment (n = 13)	1	7.7%	–	–	–	–
Not perceiving WET as beneficial
At baseline (n = 20)	0	0.0%	0	0.0%	0	0.0%
At posttreatment (n = 13)	0	0.0%	–	–	–	–
The wording of the therapy is hard to understand
At baseline (n = 20)	3	23.0%	1	33.3%	0	0.0%
At posttreatment (n = 13)	2	15.4%	–	–	–	–

Note:

^*Significantly different across groups, p < .05.

Clinical Adaptations to Address Barriers in Current Trial

To ensure compliance with the WET manual, all adaptations fit within the prescribed treatment procedures. To address location and travel barriers, we completed a majority of the sessions at the cultural center. This also eased parking concerns that, while not formally assessed or mentioned by participants in the pretreatment interview, was a significant barrier to sessions on campus. Additionally, to address time-related barriers described above, we allowed for substantial scheduling flexibility by hosting sessions after 5 p.m. and allowing participants to frequently reschedule sessions as long as they completed one session every 2 weeks.

Preliminary Treatment Outcomes

Of the 16 participants who completed at least one treatment session, 13 completed the Phase 2 interview. Of these, 12 completed all five treatment sessions. It was mutually agreed to stop treatment sessions after the fourth session for one participant due to treatment progress with PTSD symptoms, and reported difficulties for panic attacks that, while not assessed formally, appeared to persist even after trauma-related symptoms had subsided. As a result, treatment for the current open trial was considered complete and the participant was referred for treatment of panic. Three other participants terminated treatment before the fifth session and did not respond to attempts for recontact. It is therefore unknown why participants discontinued. Thus, overall, 13 of 16 participants (81.25%) were considered to have completed treatment. Fig. 1.

Figure 1.

Treatment Enrollment.

PTSD Symptoms

All participants who completed the posttreatment evaluation reported symptoms that fell below clinical thresholds for likely PTSD according to the PCL-IV using domain-specific criteria. Only one participant reported an overall distress score that fell within the clinical range (40). No participants reported higher symptoms than at baseline. Further, the intent-to-treat analyses of symptom reduction in which baseline symptoms were carried forward for all participants who completed at least one treatment session were significant (M_diff = 17.06, SD_diff = 9.97, range = 0–29, t(15) = 6.84, p < .001) and appeared to meet thresholds for clinically meaningful change. Specifically, 12 participants demonstrated meaningful change scores according to PCL-IV conventions (i.e., >10) and reliable change (i.e., change scores > 12.99). This represents 92.3% of those completing treatment and 75.0% of those who started treatment. Median reliable change was 4.60 among those who initiated treatment (counting change scores as 0 for those who did not complete treatment), exceeding the recommended threshold of 1.96. The effect size was also large, d = 1.37. Fig. 2 shows reductions across PTSD symptoms.

Figure 2.

Pretreatment and Posttreatment PHQ-9 Scores.

Depression Symptoms

Most participants who completed treatment fell below clinical thresholds for likely depression at posttreatment (n = 12, 92.3%). After including all participants who attended at least one session and carrying forward baseline scores for anyone who did not complete the follow-up evaluation, a majority still fell below clinical thresholds for likely depression (n = 13, 87.5%). The difference between pretreatment and posttreatment scores (M_diff = 6.25, SD_diff = 5.56, range = 0 – 14) was also significant, t (15) = 4.50, p < .001. The majority of (n = 9) participants exceeded the threshold for reliable change (i.e., change scores > 9.32), representing 69.2% of those who completed treatment and 56.3% of those who initiated treatment. Median reliable change was 2.52, exceeding the recommended threshold of 1.96. Effect sizes were also large among those who initiated treatment, d = 1.01. Fig. 3 shows symptom reductions across depression symptoms.

Figure 3.

PCL Pretreatment and Posttreatment Scores.

Perceived Benefits and Barriers at Phase 2

Participants responses regarding perceived barriers and benefits of the treatment approach at Phase 2 differed from the themes identified in Phase 1. Three barrier-related themes and two benefit-related themes were identified at posttreatment. Barrier-related themes were (1) initial difficulties with exposure that diminished over time, (2) no perceived barriers, and (3) scheduling challenges. Benefit-related themes were (1) relief from exposure exercises and (2) perceiving all treatment components as beneficial.

First, seven participants identified the exposure-based components as a potential barrier, but, consistent with the rationale for exposure, each participant also noted that this barrier decreased over the course of treatment. For example, Participant 15 reported, “Me costó mucho escribir al principio y después se me hizo más fácil” (translated: “It was very hard to write at the beginning, but then it got easier”). Participant 1 also spoke about how the exposure was challenging but became easier, stating “El inicio de la escritura, el primer día en específico. Se volvió menos difícil a día.” (“The beginning of the writing, specifically the first day. It became less difficult by the day.”). Participant 16 framed these challenges and the paradox of how confronting these challenges provided relief in the starkest terms:

“Se me dificultó. Es una de las terapias más fuertes porque me hizo triste y deprimida por tres días. Sentímucha depresión y se me hizo muy difícil completar. Aunque me causó dolor, me ayudó descansar, como que estaba cargando algo muy pesado pero al final, siente alivio descansar” (“It was hard for me. It’s one of the toughest treatments because it made me sad and depressed for three days. I was very depressed and it was hard to finish. Although it caused me pain, it helped me relax, like I was carrying something very heavy but at the end, I felt relief”).

Similar to pretreatment, four participants reported there were no barriers to treatment, with Participant 4 putting it most succinctly—stating “ninguno” (none) when asked about what makes completing treatment difficult. Even when prompted further, none of these participants identified barriers specific to WET. However, two participants noted that scheduling sessions was a challenge even with the flexibility of the treatment. For instance, Participant 3 stated, “Los tiempos eran más difícil” (“The times were most difficult.”). Neither of these participants noted any additional barriers to WET.

The most common perceived benefit (n = 11) among participants who completed treatment was the perceived benefit of exposure-based treatment and its written format (i.e., having to confront and write about the traumatic event). For instance, Participant 11 stated that the writing helped with changing their perspective of the event: “Yo pienso que la escritura, la parte fundamental, ayuda a ver las cosas de otro punto de vista” (“I think the writing, the fundamental part, helps to see things from another point of view”). Three participants indicated that the treatment was beneficial in its entirety. For instance, Participant 21 stated, “Me ayudó todo en todos los aspectos” (“Everything helped me in every way”). Participant 9 extended beyond this. After indicating no perceived barriers and only perceived benefits, she discussed how she had changed after the treatment saying, “Lo que me ayudó mucho es que ya no estaba muy caido y triste Yo soy más sociable con [mis compañeros de trabajo]. Este curso me ha ayudado con eso.” (“What helped me a lot is that I’m not so down and said … I’m more social with [my work friends]. This course has helped me with that.”). Participant 10 similarly said, “Puedo ver la diferencia con mis hijos” (“I can see the difference with my children.”). These participants indicated they perceived the treatment as beneficial and that these benefits helped their relationships with others.

Barriers From Checklist

Responses to the open-ended questions differed slightly from the researcher-defined checklist of barriers. Some participants reported difficulties understanding the treatment directions (n = 2; 15.4%) and understanding the explanations of PTSD (n = 1; 7.7%), which were not reported as barriers during the open-ended interviews. In comparing reported barriers across pre- and posttreatment among those who finished treatment, a higher proportion reported that having to confront the traumatic event was a barrier to completing treatment at posttreatment (n = 10, 76.9%) than at pretreatment (n = 5, 38.5%). Six of the participants who reported exposure as a barrier at posttreatment had not previously reported it as a barrier on the pretreatment checklist. In their posttreatment interview, three of those participants discussed exposure components as a barrier that subsided over time (Participant 1, Participant 15, Participant 20). The other three (Participant 3, Participant 4, and Participant 9) reported experiencing no barriers during the open-ended interview and described exposure as beneficial. Four participants reported exposure components as a barrier at both pre- and posttreatment in the checklist (Participant 10, Participant 11, Participant 16, Participant 21), but all of these participants discussed exposure and treatment as a benefit in the interview.

Alternatively, among those who completed treatment, having to write was perceived as a barrier by fewer people at posttreatment (n = 4, 30.7%) than at pretreatment (n = 6, 46.2%). Two participants (15.4%) reported difficulties understanding PTSD explanations at pre- and posttreatment. Only one participant (7.7%) reported difficulties understanding therapy directions at posttreatment, whereas three of those who completed treatment reported these difficulties at pretreatment (23.1%). Descriptive statistics of all reported barriers and benefits on the checklist are reported in Table 2.

Discussion

The primary purposes of the present study were to assess perceived barriers and benefits of a Spanish-language version of WET among Latinx immigrants and to evaluate preliminary PTSD symptom reduction. Overall, these results suggest that participants experienced significant decreases in PTSD symptoms and that participants who completed the intervention overwhelmingly viewed the treatment as beneficial. Initial interviews and thematic analysis also demonstrated that perceived barriers primarily centered on areas common to PTSD treatments, including trauma-focused components. Other treatments similarly have recipients write about the traumatic event (e.g., Cognitive Processing Therapy; Resick et al., 2016) and/or recount the traumatic event in detail (e.g., Prolonged Exposure; Foa et al., 2007). At the same time, participants did not endorse barriers related to the abbreviated length or writing format (e.g., writing alone), the two facets unique to WET among trauma-focused interventions that may also make the intervention more flexible and efficient compared with other interventions. These barriers also changed from pretreatment to posttreatment, with many participants who completed treatment endorsing that exposure-based components were challenging, but ultimately beneficial.

Specific to symptom improvement, multiple indicators of change suggested that participants experienced meaningful improvement in PTSD symptoms. This included nearly all participants meeting criteria for likely PTSD at pretreatment, but none who met these criteria at posttreatment. At the same time, a majority of all participants reported clinically meaningful change (PCL-IV changes scores > 10), even when including those who never even started treatment. Among those who completed treatment, only one did not meet this criterion, but still approached it (PCL-IV change score = 9) and also fell below the clinical threshold for likely PTSD at posttreatment. While the present study did not include a control condition, these results meet or exceed the rates of clinically significant change from prior trials of efficacious PTSD treatment, including randomized trials examining WET (Sloan et al., 2018). This occurred despite the relatively high rate of polyvictimization endorsed by participants, which some prior work has suggested may reduce treatment effectiveness at least initially (Cinamon et al., 2014). These quantitative findings are bolstered by participants’ posttreatment responses in that all participants who completed the intervention viewed it as beneficial with perceived benefits extending to their relationships with others.

In addition to the preliminary effectiveness data, the dropout rate for treatment in this study was comparable to the average rate for other PTSD treatment trials, which was 19% here and 18% in prior meta analyses of other PTSD treatments (Bradley et al., 2005). Few consistent patterns emerged regarding perceived barriers between those who did not complete treatment and those who did complete treatment. For instance, no unique themes were identified among these groups in the qualitative analysis. However, on the checklist of barriers created by the investigator, all of those who started but did not complete treatment indicated they had difficulties understanding the explanation of PTSD. This contrasted with a relatively small minority of each of the other two groups who reported the same barrier. This may indicate that careful training is warranted surrounding the delivery psychoeducation components but may also indicate that flexibility is needed within the treatment protocol to conduct assessments of the psychoeducation’s clarity and provide additional education if necessary. Further investigation and larger trials with Latinx immigrants and other similar populations is warranted to more fully examine rates and predictors of dropout.

Moving Toward Adaptations: Addressing Barriers and Case Illustrations

The barriers identified and our experiences conducting the intervention provide several avenues for future adaptations and clinical implications. First, identified structural barriers, psychosocial barriers, and concerns related to exposure components are common barriers for mental health treatment in general and other trauma-focused interventions (Bridges et al., 2012; Fox et al., 2001; Vega et al., 2010; Wrigley et al., 2005). These barriers seem to largely point to needed adaptations to the mental health system overall, including policy changes that cover mental health services for immigrants. As highlighted in the introduction, one potentially fruitful avenue for adaptation is the use of WET or an adapted version in integrated systems of care. These systems do not adhere to the typical 1-hour-per-week format and further adaptations may need testing. Still, these adaptations would likely be minimal, given WET’s structure. Concretely, using the Primary Care Behavioral Health Model (Robinson & Reiter, 2016), an assessment and treatment selection could occur in the first session. During follow-up sessions, the clinician may return to consultation with other providers while the treatment recipients write for 30 minutes (provided adequate instructions for how to reach the clinician discretely with questions or should they become overwhelmed). This structure would fit within the 6-session PCBH model. Our approach here was somewhat similar given the extensive collaborations with a local cultural center, relying on them for referrals and as a treatment location. Alternate models (e.g., those that only incorporate “warm handoffs”) could be tested to include conducting an initial writing in the office with follow-up writing to occur at home or a location of the recipient’s choosing with more flexible follow-up. Data are still needed to determine the efficacy of such approaches, but they represent the kinds of adaptations that may be necessary for reducing the structural barriers reported here.

Unique to WET, one participant who discussed the trauma-related exposure concerns did discuss challenges of having to do the exposure in a written format, which is among the more unique elements of WET (e.g., all trauma-related exposures in PE are spoken). While a spoken version was not an option offered in this trial, subsequent trials may include this option and compare its efficacy with written versions. The primary adaptations in this trial were that a few (2–3) participants required several reassurances that neither writing nor spelling were important, including during debriefing with clinicians often reiterating phrases like: “No importa la ortografía. Lo importante es que usted recuerde y entienda lo que está en la página.” (“The spelling/writing doesn’t matter. The important thing is that you remember and understand what’s on the page.”) These adaptations, however, are minor and largely in line with the WET manual.

Although concern regarding exposure and writing were discussed as barriers for some, multiple participants at pre- and posttreatment perceived writing about the traumatic event as beneficial. Participants at pre- and posttreatment perceived the exposure-based components of treatment as both a barrier and a beneficial mechanism of treatment. In both cases, these seemingly contradictory beliefs may fit with the rationale for exposure (i.e., that symptoms are maintained through avoidance due to the understandable discomfort in directly addressing traumatic events). Further, while concern related to conducting exposure was a common theme among participants, it did not appear indicative of treatment completion, as it was endorsed by a significant proportion of those who completed treatment (n = 5; 38.5%), those who started but did not complete treatment (n = 2; 66.7%), and those who did not start treatment (n = 2; 50.0%). We did not deviate from the manual in addressing these concerns, as the manual already contains language for doing so. Still, it may be important to have familiarity with exposure-based treatments and rationales, which was the case for all clinicians here and likely altered our responses. Taken together, this may suggest that the exposure-based components do not need significant adaptation.

Alternatively, multiple sociocultural themes were also identified. For most participants reporting such themes, they appeared to apply primarily to the stigma of traumatic event exposure, particularly sexual assault, and its related symptoms. Although not assessed in a formal fashion, this theme was extended by perceptions of each of the clinicians. Specifically, it was routinely discussed during supervision that many participants reported that treatment was the first time they were able to talk about their experiences with traumatic events. In fact, one of the noted challenges in supervision was staying consistent with the brief post-writing processing from the protocol. Many participants spontaneously began describing the traumatic event in detail, even after multiple segues toward other topics or the next session. On at least two occasions, one of the graduate-level clinicians extended post-writing processing by approximately 30 minutes and this was addressed during supervision. While supervision helped the student to adhere more closely to the manual, it remained a challenge for all clinicians to adhere to the 10- to 15-minute post-writing processing, with each clinician occasionally extending on this by 5 or fewer minutes. Anecdotally, this appeared to reflect a combination of the stigma associated with having experienced a traumatic event, receiving treatment and talking about the event for the first time, and experiencing it as sufficiently supportive to thoroughly discuss the traumatic event. These informal clinician perceptions are bolstered by some participants reporting feeling comfortable during treatment and that the ability to directly address and discuss the traumatic event was a key mechanism of treatment. While this is a common occurrence in trauma-focused care (i.e., that a recipient has never discussed the traumatic event before), clinicians may need to recognize this may be more common among those who have not previously received treatment. Similarly, enhanced sensitivity to the culturally specific stigma of experiencing traumatic events (e.g., sexual assault) or related mental health symptoms is warranted in post-writing processing. At the same time, such considerations and awareness would be consistent with the WET manual.

With regard to themes that were not identified, it did not appear that participants endorsed themes related to incongruence of any treatment component with culturally related values or beliefs about mental health. Nevertheless, this finding should be tempered by the fact that some participants did report difficulties understanding the explanations of PTSD and difficulties understanding treatment instructions. Participants received each set of explanations at least twice during the study (prior to treatment and at the first session). Further, clinicians individually tailored psychoeducation such that they highlighted the most relevant symptoms/explanations using recipients’ own words, a minor deviation from the manual. Thus, the reported difficulties in understanding psychoeducation may reflect a need to further revise or simplify the language provided. Nevertheless, none of the assessments in the present study directly pointed to cultural incongruence of WET among this Latinx immigrant sample. However, it should be noted that each clinician either has extensive experience working with immigrant Latinx populations or was a Latinx immigrant themselves. Thus, background cultural knowledge may have altered some of the delivery of the treatment and cultural familiarity or humility would still be important in using WET as described here. Still, no significant adaptations were noted, even anecdotally.

Clinical Implications

The present study has several clinical implications. First, this is the first open trial of WET designed specifically to treat PTSD for Spanish-speaking adults. This is an important first step in disseminating treatment to a greatly underserved population. Moving forward, WET may reduce barriers to accessing, engaging in, and completing treatment for a population who often experiences even greater barriers on average, though this now needs to be tested directly. For example, the treatment is relatively brief, with five, 45-minute sessions that can be completed in a locale convenient to the person being treated. This reduces several burdens treatment often poses for underserved communities, including cost of treatment, length of time needed to attend sessions, transportation, as well as other barriers. The structure may also lend itself well to other treatment modalities, including integrated primary care mental health and technology-based interventions.

Limitations

Limitations of the present study include a small sample size, lack of a control or comparison group, limited demographic variability (e.g., the vast majority of participants were women), and potential sampling bias. While the sample size allowed for qualitative saturation and promising quantitative results, there is also the chance that results may not be generalizable to the broader population. The small sample size also makes it difficult to examine predictors of treatment completion. Similarly, while providing the frequency with which each theme was endorsed does provide nuance regarding its relative important, the relatively small sample does limit our ability to directly test the relative frequencies of each with inferential statistics. The lack of a control or comparison group makes it difficult to determine if this treatment is equal to or better than other gold-standard treatments. Regarding limited demographic variability, the majority of the participants were women, thus limiting our abilities to determine if gender differences would exist in this population. Additionally, the majority of participants were born in Mexico and potentially limits the generalizability of results to immigrants from others Latin American countries. Finally, participants were referred to the study by their providers and flyers. While this is a common practice in community-based research, it can lead to selection biases as those who elected participate may be more likely to engage in treatment. At the same time, because of this recruitment strategy, participants may have also experienced barriers in accessing other mental health services, which may have contributed to some of the dropout observed in this study.

Conclusion and Future Directions

As the first study examining the acceptability and preliminary effectiveness of WET among Spanish speaking Latinx immigrants, results are promising that further research and broader dissemination could reduce numerous barriers to treatment access, engagement, and completion. Additional research with larger sample sizes and addition of a control and/or comparison group are necessary to support greater adoption and dissemination of this treatment as well as better generalizability of results. Nevertheless, these preliminary results appear promising and point to a potential intervention that may be used to treatment PTSD among Latinx immigrants.