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Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wsub20
Expressive Writing as a Therapeutic Process for DrugDependent Women Sarah Meshberg-Cohen PhD
a b c
b
, Dace Svikis PhD & Thomas J. McMahon PhD
c
a
Department of Veteran Affairs , VA Connecticut Healthcare System , West Haven , Connecticut , USA b
Department of Psychology , Virginia Commonwealth University , Richmond , Virginia , USA
c
Department of Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA Accepted author version posted online: 14 Jun 2013.Published online: 03 Mar 2014.
To cite this article: Sarah Meshberg-Cohen PhD , Dace Svikis PhD & Thomas J. McMahon PhD (2014) Expressive Writing as a Therapeutic Process for Drug-Dependent Women, Substance Abuse, 35:1, 80-88, DOI: 10.1080/08897077.2013.805181 To link to this article: http://dx.doi.org/10.1080/08897077.2013.805181
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SUBSTANCE ABUSE, 35: 80–88, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0889-7077 print / 1547-0164 online DOI: 10.1080/08897077.2013.805181
Expressive Writing as a Therapeutic Process for Drug-Dependent Women
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Sarah Meshberg-Cohen, PhD,1,2,3 Dace Svikis, PhD,2 and Thomas J. McMahon, PhD3 ABSTRACT. Background: Although women with substance use disorders (SUDs) have high rates of trauma and posttraumatic stress, many addiction programs do not offer trauma-specific treatments. One promising intervention is Pennebaker’s expressive writing, which involves daily, 20-minute writing sessions to facilitate disclosure of stressful experiences. Methods: Women (N = 149) in residential treatment completed a randomized clinical trial comparing expressive writing with control writing. Repeated-measures analysis of variance was used to document change in psychological and physical distress from baseline to 2-week and 1-month follow-ups. Analyses also examined immediate levels of negative affect following expressive writing. Results: Expressive writing participants showed greater reductions in posttraumatic symptom severity, depression, and anxiety scores, when compared with control writing participants at the 2-week follow-up. No group differences were found at the 1-month follow-up. Safety data were encouraging: although expressive writing participants showed increased negative affect immediately after each writing session, there were no differences in pre-writing negative affect scores between conditions the following day. By the final writing session, participants were able to write about traumatic/stressful events without having a spike in negative affect. Conclusions: Results suggest that expressive writing may be a brief, safe, low-cost, adjunct to SUD treatment that warrants further study as a strategy for addressing posttraumatic distress in substance-abusing women.
Keywords: Expressive writing, substance abuse, trauma INTRODUCTION Studies point to overwhelming rates of trauma in the lives of women with substance use disorders (SUDs). In SUD treatment settings, 55% to 99% of women report at least one lifetime trauma.(1) As many as 80% of women seeking drug abuse treatment report lifetime histories of physical or sexual assault,(2) and many display posttraumatic stress disorder (PTSD) symptomatology.(3) Trauma and addiction comorbidity studies reveal these women are likely to have poorer health, increased disability, more severe clinical profiles, and poorer treatment adherence than those without trauma or PTSD.(4) Although trauma interventions have traditionally not been incorporated into SUD treatment programs, studies indicate that
1Department of Veteran Affairs, VA Connecticut Healthcare System, West
Haven, Connecticut, USA 2Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA 3Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence should be addressed to Sarah Meshberg-Cohen, PhD, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA. E-mail: [email protected]
addressing trauma during SUD treatment may improve treatment outcomes.(5) Historically, there has been an ongoing debate regarding which problem to treat first, the trauma or the SUD. Among SUD treatment providers, the general consensus was that addressing trauma during the early phase of SUD recovery may “open Pandora’s box” and derail SUD treatment improvement.(5) Recent research, however, suggests the opposite: that trauma should be treated concurrently, even in the earliest stages of SUD treatment.(6) Accumulating evidence over the past 2 decades indicates that disclosure of traumatic or stressful experiences through Pennebaker’s expressive writing has widespread benefits. The typical laboratory research for Pennebaker’s expressive writing involves randomly assigning individuals to 1 of 2 conditions (eg, expressive writing [emotional disclosure] versus control writing [neutral topic]). Expressive writing involves writing about the most traumatic or stressful event of one’s life for 15 to 20 minutes a day over 3 to 5 consecutive days, and is typically done with no feedback given.(7) Studies have demonstrated the efficacy of expressive writing as a brief therapeutic intervention, with significant reductions in distress,(8) and improved psychological(9) and physical health.(10) For instance, Pennebaker’s expressive writing has revealed that writing about a stressful or traumatic event is associated with a reduction in the degree to which the experience is distressing or painful,(11) reduced depression among depressed women,(12) a
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decrease in health center and doctor’s visits,(10,13) fewer missed days of work or school,(14) improved immune functioning,(15) and decreases in sympathetic nervous system activity.(16) In a meta-analysis of expressive writing studies, Smyth(17) found a 23% symptom improvement in the traumatic disclosure writing condition over a control writing condition. The average effect size was comparable or larger than those found in other psychological, educational, or behavioral interventions.(8) Cognitive processing therapy (CPT), which also employs writing about stressful events, has recently revealed decreases in PTSD and depression symptoms.(18) Furthermore, research indicates no harm to participants has been encountered as a result of Pennebaker’s expressive writing. Although there is a rise in negative affect immediately after trauma writing, it is usually transient; and at follow-up, participants generally report that they feel better than they did before writing.(19) Although much attention has focused on benefits of Pennebaker’s expressive writing, to date, it has not been examined in populations affected by SUDs. Expressive writings’ efficiency (15 to 20 minutes over 3 to 5 days), efficacy, and low cost suggest that writing as a means for disclosing traumatic experiences may be a powerful adjunct to traditional SUD treatment. The purpose of this study was to determine whether Pennebaker’s expressive writing is beneficial as a brief adjunct to traditional treatment for women currently undergoing residential treatment for SUDs. This randomized clinical trial (RCT) tests 2 hypotheses. First, it was hypothesized that participants randomized to the expressive writing condition would show more improvement in psychological and physical health at the 2-week and 1-month follow-ups, compared with control writing participants. Although it was expected that there would be improvements for both writing conditions as a function of being in residential treatment, expressive writing participants were expected to show greater improvement. Second, it was hypothesized that negative affect measured immediately after each writing session would be higher among expressive writing participants compared with control writing participants, but that these increases in negative affect would be short-lived.
METHODS Participants Participants were 149 women admitted to a gender-specific residential SUD treatment facility from June 17, 2007 to November 6, 2008. Specific services within this facility include individual counseling, motivational enhancement therapy groups, and case management for such needs as housing, transportation, and childcare. To be eligible for the study, women had to (a) be at least 18 years old; (b) meet DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for a SUD; and (c) have approval for 60 days of residential treatment from a third-party payer to help facilitate presence for the 1-month follow-up. Women were ineligible if they (a) had an acute mental disorder (eg, current suicidality) that would make it difficult to provide informed consent and/or follow the study protocol; or (b) had literacy problems that would prevent them from being able to complete the writing sessions or the research assessments.
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Measures With the exception of demographic questions and the Structured Clinical Interview for DSM-IV-TR Alcohol and Substance Use Disorders Module (SCID),(20) measured at baseline, the same battery of measures was administered at baseline, and at the 2-week and 1-month post-writing follow-ups. All assessments were completed on-site and instructions were read aloud by the researcher. The primary outcome measure included the Posttraumatic Stress Diagnostic Scale (PDS).(21) Secondary outcomes included the Center for Epidemiological Studies—Depression Scale (CES-D),(22) Pennebaker Inventory of Limbic Languidness (PILL),(23) and Brief Symptom Inventory (BSI).(24) Process measures included the Positive and Negative Affect Scale (PANAS),(29) measured pre- and post-writing sessions, as well as the Essay Evaluation Measure (EEM),(30) measured post-writing session, and the follow-up questionnaire, measured at 2 weeks and 1 month post-writing intervention. The SCID(20) is a diagnostic interview assessing SUD diagnosis, including alcohol and other drugs. The SCID has demonstrated good validity and high interrater reliability for SUDs.(25) The PDS(21) is a 49-item self-report measure focused on PTSD symptom severity and diagnosis, with items parallel to DSM-IV criteria.(26) The PDS has high test-retest reliability (r = .83), high internal consistency (α = .92), and high convergent validity.(27) Trauma symptom severity was defined as the sum scores for items focused on reexperiencing, arousal, and avoidance symptoms. At baseline, internal consistency for trauma symptom severity for this sample was .99. The CES-D(22) is a 20-item self-report measure of depression, and has high internal consistency in psychiatric settings (α. = .90). Internal consistency at present study baseline for this sample was .87. The PILL(23) is a 54-item scale that assesses the frequency of common physical symptoms and sensations (eg “headaches,” “congested nose,” “coughing”). Chronbach’s alphas for the PILL range from .88 to .91, with 2-month test-retest reliabilities of .79 to .83. PILL has a mean score of 112.7 (SD = 24.7).(23) At baseline, internal consistency for this sample was .94. The BSI,(24) a 53-item self-report measure, is a shortened version of the Symptom Check List-90 (SCL-90). It assesses 9 symptoms of distress (Somatization; Obsessive-Compulsive; Interpersonal Sensitivity; Depression; Anxiety; Hostility; Phobic Anxiety; Paranoid Ideation; Psychoticism). The BSI has high scale-by-scale correlations with the SCL-90, as well as high internal consistency (Cronbach’s α = .71–.85), convergent, discriminant, and test-retest reliability (r = .68–.91), and construct validity.(28) At baseline, internal consistencies for the 9 BSI indices for this sample were .74 to .87.
Process Measures The PANAS(29) assesses negative affect (NA) and positive affect (PA), using 10 items for NA and 10 items for PA. It was administered pre- and post-writing, and only the negative affect scale was used in this study. The NA scale has high internal consistency reliabilities, ranging from .84 to .87, and they are unchanged by the time point used. Internal consistency for the post-writing NA scale on day 1 of writing for this sample was .92. The EEM(30) served as manipulation check to evaluate participants’ self-reports of their response to the experimental and control
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manipulation after each writing session. It assesses participants’ report, along separate 7-point scales, ranging from 1 (not at all) to 7 (a great deal), the extent to which their essays were meaningful, personal, and revealing, and the extent they had actually talked to others, had wanted to talk to others, and had actively held back from talking to others about the subject(s) of the essays.(31) After the first writing session, internal consistency of the measure for this sample was .79. The follow-up questionnaire was an investigator-developed survey that examined issues of cross-contamination inherent in studies done in residential settings. The follow-up questionnaire served as a fidelity check, and measured possible diffusion of treatment. The questionnaire included closed- and open-ended questions and surveyed whether participants heard about, shared, or received writing instructions from others in the facility. It also addressed whether the participant found the writing helpful and talked about the subject matter from her essays during treatment.
Procedures The university’s institutional review board approved research procedures. A CONSORT diagram (Figure 1) summarized study screening, enrollment, treatment, assessment, and retention of participants. Admission records identified potential study participants and those women were approached within the first few days of treatment. Those who met inclusion criteria were invited for participation in a study that involved writing stories related to their life.(32) Women providing informed consent were randomly assigned (using a random numbers table) to 1 of 2 conditions: (a) expressive writing (emotional topic) or (b) control writing (neutral topic). Writing instructions were based on protocols used by Pennebaker et al.(10) and Sloan and Marx.(32) In addition to being read aloud by the investigator before each writing session, a copy of the writing instructions was attached to the front flap of each journal so that participants could reread instructions at any time.
Writing Procedure Once enrolled, participants completed baseline assessments, four 20-minute writing sessions on consecutive days, and both a 2-week and a 1-month follow-up assessment. In order to reduce unintentional expectancy effects and investigator bias, one experimenter administered baseline assessments and all writing instructions, while a different experimenter, blind to study condition, administered PANAS, EEMs, and follow-up assessments.
Writing session 1 The day after completing baseline assessments, each participant was administered the writing instructions. Participants were asked not to discuss the study or writing instructions. After receiving writing instructions from one experimenter, participants were introduced to a second experimenter. The second experimenter had participants complete a PANAS(29) prior to handing them a blank notepad. Participants located a comfortable place where they would not be disturbed (e.g., their room), and wrote about their assigned topic for 20 minutes. Twenty minutes later, the second experimenter administered the PANAS and EEM.(33) Notepads, marked by participant ID, were then dropped
into a cardboard box along with participants’ responses to PANAS and EEM responses.
Writing sessions 2 through 4 Participants were greeted for each session by the first experimenter, who read the writing instructions aloud. The second experimenter instructed participants to complete PANAS before writing for 20 minutes. The PANAS and EEM were completed after each writing session.
2-Week and 1-month follow-ups Participants completed follow-up assessments 2 weeks and 1 month post-writing intervention. A 2-week follow-up was added after 22 participants had already been enrolled; this was done to insure some data collection from participants who might leave against medical advice (AMA) prior completing their 60-day treatment, as well as to assess the shorter-term effects of the intervention. Participants received a $5 gift card after completing the baseline assessment, a $5 gift card after each writing session ($20 total), a $10 gift card after completing the 2-week follow-up, and a $15 gift card upon completion of the 1-month follow-up.
Data Analysis Kolmogorov-Smirnov and Shapiro-Wilk statistics determined that primary and secondary outcomes were normally distributed. t and chi-square tests examined whether significant baseline differences existed between conditions. A series of analyses of variance (ANOVAs) were then used to test for between-group differences in (a) 2-week clinical outcomes, and (b) clinical outcomes at the end of the 1-month follow-up. For the first research hypothesis, 2-week effects were examined with a 2 (condition: expressive writing, control writing) by 2 (time: baseline, 2-week follow-up) repeated-measures ANOVA separately for each outcome measure (PDS, CES-D, PILL, BSI). One-month effects were also tested by examining betweengroup differences over time using a 2 (condition: expressive writing, control writing) by 2 (time: baseline, 1-month follow-up) repeatedmeasures ANOVA for each outcome measure (PDS, BSI, CES-D, PILL). Condition × Time interaction effects were examined for differential treatment effects with post hoc analysis of the main effect of time within each treatment group. Since an investigator was present during assessments, missing data were minimal. In the intention-to-treat analyses, with the entire sample (149 participants), however, missing outcome data for “noncompleters” (e.g., participants who did not complete all writing sessions, the 2-week, and/or the 1-month follow-up assessments) were addressed by carrying forward each participant’s previous score. For the second research hypothesis, a repeated-measures analysis of negative affect was derived from PANAS. A 2 (condition: expressive writing, control writing) by 4 (session: writing 1, writing 2, writing 3, writing 4) by 2 (time: pre- and post-writing sessions) repeated-measures multivariate analysis of variance (MANOVA) examined the interaction between pre-post writing NA and condition at each of the 4 sessions. t and chi-square tests compared writing conditions on items of the EEM and follow-up questionnaire to evaluate participants’ selfreports of their response to the experimental manipulation. Because
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FIGURE 1 CONSORT flow diagram. Non-Completers >1 writing session: n = 1 left Against Medical Advice (AMA); n = 3 conflicting medical appointment Non-Completers > 2 writing sessions: n = 1 left AMA; n = 3 conflicting medical appointment Non-Completers 2-Week Follow-Up: n = 7 left AMA (n = 2 Expressive Writing; n = 5 Control Writing); n = 1 medical reasons (Control Writing); n = 1 discharged before expected 60 days (Expressive Writing) Non-Completers 1-Month Follow-Up: n = 6 left AMA (n = 2 Expressive Writing; n = 4 Control Writing); n = 4 discharged before expected 60 days (n = 2 Expressive Writing; n = 2 Control Writing); n = 2 Incarceration (n = Control Writing) (Color figure available online).
participants completed the EEM 4 times (after each writing session), the mean of the 4 days for each participant was used in analyses.
RESULTS
(assessed by PDS). Over half met diagnostic criteria for current PTSD. SUD women with comorbid PTSD reported significantly more types of trauma than women without PTSD, t(147) = 5.1, P < .005. A majority of participants indicated cocaine as one of their primary drugs of dependence, with over half meeting DSM-IV criteria for substance dependence for more than one drug.
Participant Characteristics Overall, women enrolled in the study (Table 1) were an average of 36.3 (SD = 8.6) years old; and had completed an average of 11.2 (SD = 1.8) years of education; most (92.7%) were single/never married; and a majority (70%) identified their race as African American. Most participants reported at least one lifetime trauma at baseline
Randomization Participants randomized to expressive writing had higher CES-D depression scores than controls (M = 25.2 [SD = 12.0] versus M = 21.1 [SD = 10.9]), t(148) = 2.2, P < .05), and higher BSI Anxiety scores (M = 1.3 [SD = 1.1] versus M = 0.8 [SD = 0.8]),
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SUBSTANCE ABUSE TABLE 1 Participant Characteristics: Expressive Writing (n = 82) and Control Writing (n = 67)
Characteristic
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Age (years) Education (last grade completed) Marital status Married Single/Never married Race Caucasian African American Hispanic Other At least one trauma Mean number of different types of trauma events PTSD diagnosis (n = 81) No PTSD diagnosis (n = 68) PTSD diagnosis Trauma symptom severity CES-D depression score CES-D cutoff ≥16 PILL score DSM-IV substance dependence diagnosis (current) Alcohol Amphetamine/ Stimulant Cannabis Cocaine Hallucinogen Inhalant Opioid Sedative More than one drug ∗P
TABLE 2 Effects of Expressive Writing versus Control Writing on 2-Week and 1-Month Follow-Up (Intent-to-Treat) Expressive writing (n = 82)
Expressive writing % or M (SD)
Control writing % or M (SD)
Total sample % or M (SD)
37.7 (8.7) 11.5 (1.6)
34.6 (8.2) 10.9 (2.0)
36.6 (8.3)∗ 11.2 (1.8)
4.4% 95.6%
9.8% 90.2%
7.3% 92.7%
25.6% 69.5% 1.2% 3.7% 96.3% (n = 79) 3.8 (SD = 2.2)
23.5% 70.6% 0.0% 5.9% 95.5% (n = 64) 3.6 (SD = 2.4)
24.7% 70.0% 0.7% 4.7% 96.0% (n = 143) 3.7 (SD = 2.3)
4.6 (SD = 2.2) 2.8 (SD = 1.8) 58.5% (n = 48) 21.3 (SD = 13.4) 25.2 (SD = 12.0) 76.8% 118.8 (SD = 37.6)
4.5 (SD = 2.6) 2.8 (SD = 1.8) 49.3% (n = 33) 17.5 (SD = 12.4) 21.1 (SD = 10.9) 67.2% 113.5 (SD = 34.2)
4.6 (SD = 2.3) 2.8 (SD = 1.8) 54.4% (n = 81) 19.5 (SD = 13.1) 23.3 (SD = 11.7)∗ 72.5% 116.4 (SD = 36.0)
32.9% 0.0%
23.9% 1.5%
28.9% 0.7%
11.0% 80.5% 1.2% 0.0% 47.6% 6.1% 63.4%
9.0% 83.6% 0.0% 0.0% 41.8% 4.5% 49.3%
10.1% 81.9% 0.7% 0.0% 45.0% 5.4% 57.0%
< .05.
Measure Trauma symptom severity Depression PILL BSI Anxiety Index BSI Somatic Index ∗P
Baseline Mean (SD)
12-Week Month posttest posttest Mean Mean (SD) (SD)
Control writing (n = 67)
Baseline Mean (SD)
12-Week Month posttest posttest Mean Mean (SD) (SD)
21.3 (13.4)
18.0∗ (12.3)
17.0 (12.6)
17.5 (12.6)
18.0 (11.7)
14.5 (12.1)
25.2 (12.0) 118.8 (37.6) 1.2 (1.0)
21.9∗ (10.7) 113.4 (36.4) 0.9∗ (0.9)
19.4 (11.8) 106.8 (39.1) 0.9 (1.0)
21.1 (10.9) 113.5 (34.2) 0.8 (0.8)
21.3 (11.8) 108.8 (28.3) 0.9 (0.8)
17.6 (11.1) 105.6 (39.0) 0.6 (0.7)
1.0 (0.8)
1.0 (0.8)
0.8 (0.8)
0.8 (0.8)
1.0 (0.9)
0.7 (0.8)
< .05.
compliance for both conditions were high. Specifically, 97.6% of expressive writing and 97.0% of control writing participants completed at least 2 writing sessions, and most (94.6%) completed all 4 writing sessions.
Follow-up assessment attrition Among expressive writing participants, there were no differences between “completers” versus “noncompleters” on dependent variables at 2-week follow-up. Among control participants, women who did not complete the 2-week follow-up were significantly more depressed at baseline compared with those who completed the follow-up (M = 28.0 [SD = 6.8] versus M = 20.0 [SD = 11.1]), t(65) = 2.1, P < .05), and were more likely to have had clinically elevated depression (≥16 CES-D cutoff) at baseline (100% versus 62.1%), χ 2(2, N = 67) = 5.1, P < .05. No differences between “completers” versus “noncompleters” were found at 1-month follow-ups on any dependent variables, P > .05.
Hypothesis 1: 2-Week and 1-Month Effects of Expressive Writing
Trauma symptom severity t(148) = 3.0, P < .005. There were no other baseline differences between conditions.
Attrition
Writing session attrition A chi-square analysis showed no significant relationship between condition assignment and number of writing sessions completed, P > .05. As depicted in the CONSORT diagram, rates of
There was a Condition × Time interaction for levels of traumatic stress at 2-week follow-up, F(1, 149) = 5.8, P < .05, partial η2 = .04. Planned contrasts revealed a significant decrease in trauma symptom severity from baseline to 2 weeks among expressive writing, F(1, 82) = 8.6, P < .005, partial η2 = .10, but not among control writing participants, P > .05. There was no interaction for trauma symptom severity at 1-month follow-up, P > .05; however, both conditions revealed significant improvements (Table 2). Expressive writing participants revealed a significant decrease from baseline to 1-month follow-up, F(1, 82) = 11.1, P < .005, partial η2 = .12, as did controls, F(1, 67) = 7.3, P < .01, partial η2 = .10.
MESHBERG-COHEN, SVIKIS, AND McMAHON
Depression There was a significant Condition × Time interaction for depression, F(1,149) = 4.3, P < .05, partial η2 = .03 at 2 weeks. Planned contrasts demonstrated significant decreases in depression among expressive writing, F(1, 82) = 7.4, P < .01, partial η2 = .08, but not among control writing participants, P > .05. There was no interaction at the 1-month follow-up (P > .05); however, both conditions revealed significant improvements in depression. Expressive writing participants showed significant improvements in depression at 1-month follow-up, F(1, 82) = 16.1, P < .005, partial η2 = .17, as did control participants, F(1, 67) = 9.3, P < .005, partial η2 = .12.
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Physical health There was no Condition × Time interaction in the reduction of physical health symptoms and sensations at the 2-week, P > .05, or 1-month, P > .05, follow-up. However, significant improvements were found at 1-month follow-up for both the expressive writing, F(1, 82) = 18.3, P < .005, partial η2 = .18, and control writing, F(1, 67) = 4.5, P < .05, partial η2 = .06, conditions.
BSI There was a significant Condition × Time interaction for anxiety, F(1, 149) 13.9, P < .005, partial η2 = .09. Expressive writing participants showed significant improvements in anxiety scores at the 2-week follow-up, F(1, 82) = 14.1, P < .005, partial η2 = .15, whereas control participants did not, P > .05. There was no interaction at 1-month follow-up, P > .05. There was a trend approaching a significant interaction for the Somatic Index, F(1, 149) = 3.8, P = .05. Whereas the control condition revealed an increase in somatic symptoms from baseline to 2-week follow-up, F(1, 67) = 4.4, P < .05, partial η2 = .06, the expressive writing condition revealed no differences, suggesting a possible protective factor of the writing. This trend was not maintained at the 1-month follow-up, yet overall improvements were seen for both conditions. There were no interactions between conditions over time for the remaining 7 BSI indices (all > .05).
Hypothesis 2: Expressive Writing on Negative Affect There was a significant Condition × Session × Time interaction for PANAS negative affect scores, F(4, 149) = 7.3, P < .005, partial η2 = .30. Additionally, univariate F tests revealed that groups did not differ in negative affect prior to writing, suggesting that the immediate increase in negative affect after writing was brief (Table 3). Univariate tests revealed a significant interaction between time by condition at writing session 1, F(1,149) = 29.9, P .05. As illustrated, analyses revealed that the main
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effects decreased over time; by writing session 4, expressive writing participants were able to write about traumatic event without having the spike in negative affect afterward.
Manipulation and Fidelity Checks
EEM When compared with control writing participants, expressive writing participants described their essays as more meaningful, t(139) = 9.1, P < .0005, more personal, t(139) = 13.3, P < .0005, and more revealing of one’s emotions, t(139) = 18.0, P < .0005. They were more likely to have wanted to discuss it with others, t(139) = 8.7, P < .0005, than control writing participants. They also reported being more likely to have talked with others about the content of their essays, t(139) = 10.0, P < .0005, and also to have actively held back from talking with others about the content, t(139) = 4.5, P < .0005, than controls.
Follow-up questionnaire Only 2 (1.7%) participants in the control condition reported hearing about the expressive writing instructions from another participant. Furthermore, expressive writing participants were more likely than controls to report finding the writing to be helpful (98.6% versus 72.0%), χ 2(2, N = 120) = 18.6, P < .005; continue journaling using the writing instructions given after the sessions ended (42.0% versus 14.0%), χ 2(2, N = 120) = 10.8, P < .005; and to have talked about the subject matter form their essays during treatment (15.9% versus 0.0%), χ 2(2, N = 120) = 8.8, P < .005. All (100%) of the expressive writing participants who talked about the subject matter from their essays during their treatment found it to be helpful. Expressive writing participants reported that expressive writing helped them work through issues and deal more effectively with emotions related to trauma/stress (Table 4).
DISCUSSION The present study collected benchmark data on whether Pennebaker’s expressive writing could be applied to women in TABLE 3 Negative Affect: Pre-Post Writing Sessions
Session Writing session 1, time 1 Writing session 1, time 2 Writing session 2, time 1 Writing session 2, time 2 Writing session 3, time 1 Writing session 3, time 2 Writing session 4, time 1 Writing session 4, time 2
Expressive writing Mean (SD)
Control writing Mean (SD)
18.7 (7.9) 24.0 (10.9)∗∗ 17.6 (8.2) 22.4 (11.2)∗∗ 16.8 (7.7) 19.5 (9.5)∗∗ 17.6 (8.4) 18.7 (9.0)
16.2 (7.2) 15.2 (8.2) 13.3 (4.9) 13.5 (5.2) 14.1 (6.2) 13.4 (5.1) 13.9 (6.2) 13.6 (5.4)
Note. Time 1: PANAS was assessed after writing instructions were given, but prior to writing. ∗∗ P < .005.
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SUBSTANCE ABUSE TABLE 4 Follow-Up Questionnaire: 5 Randomly Selected Quotes from Each Condition
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Question 4: Did you find the writing helpful? Why? Why not? Expressive writing participants “Very helpful. I’ve never in my life experienced something like this. It hit the core of everything.” “It made me realize that what happened to me wasn’t my fault.” “Very helpful. It got me in touch with my feelings and helped me work through some of my issues and problems. It was good for me.” “Made me bring some of the issues that wrote about, especially the attempted rape and how I was not able to have sex because of fear.” “Because it made me think back to some issues that were hindering me from moving forward. It helps me let go and move forward. I feel much better.” Control writing participants “It was just being plain, you can’t express no emotions.” “Kind of neutral! Not aware of what the goal was. Helps me in my purpose in gaining knowledge of it.” “Because it made me realize that I can write just about anything.” “I found out that it was kind of hard trying to remember everything I did in a day’s time.” “Shallow subject matter.”
gesting that stimulus-related habituation may take place regardless.(7) Studies to-date comparing instructions for participants to write about the same or different topics each day have yielded mixed results. For instance, Sloan and colleagues(35) found college students with a trauma history who wrote about the same trauma experience at each session showed improvements at followup, whereas those instructed to write about a different trauma each day did not. Other studies have obtained more robust results when participants were allowed to choose their writing topic at each session.(8,36) The importance of short-term improvements at 2 weeks versus 1 month should not be discounted, particularly since we are dealing with a clinical population and a chronic disorder. It is likely that extending the intervention in ways that “boost” the intervention (e.g., more writing sessions during different points in treatment) would be helpful. Although writing conditions did not differ at 1 month, both conditions demonstrated positive changes on core outcomes. The present study is unique, however, in that it was conducted in the context of residential treatment, which, in and of itself, is likely to produce improvements in physical and psychosocial functioning over time.
Depression residential SUD treatment. Trauma rates in this study were comparable to those previously reported in the literature,(5) supporting the rationale for the clinical trial and study hypotheses.
2-Week and 1-Month Outcomes Supporting hypothesis 1, expressive writing participants showed greater reductions in trauma symptom severity, depression, and anxiety than control writing participants at the 2- week follow-up. Expressive writing may be a protective factor in somatic symptoms. Although no group differences were found at the 1-month followups, both conditions showed significant positive changes, likely due to being in residential treatment for 30 days.(34) Due to baseline differences between conditions, results should be interpreted with caution.
Trauma Short-term (2-week) findings are consistent with research suggesting that writing about emotional experiences using Pennebaker’s expressive writing results in a decreased degree to which the experience is emotionally distressing or painful.(35) One potential reason is based on exposure theory, which suggests that attempting not to think about traumatic events in order to avoid overwhelming emotions may generate further feelings of distress and fear.(11) Thus, expressive writing may act as a medium for exposure to previously avoided stimuli. Repeat exposure over several writing sessions may allow for habituation and extinction of negative emotional associations and/or offer corrective information to the person about the stimuli, responses, and meaning of the event.(32) Although it is generally thought that exposure to the same traumatic event is essential for extinction, expressive writing does not require writing about the same event at each session, sug-
Expressive writing participants showed significant reductions in depressive symptoms at the 2-week follow-up, whereas controls did not. Results are consistent with research among women who had endured intimate partner violence,(12) showing greater drops in depression among those in the traumatic disclosure as compared with the control writing condition. However, given that baseline depression differences existed, this finding should also be interpreted with caution.
Health There were no differences between the 2 conditions in the reduction of physical health symptoms and sensations over time, which conflicts with an extensive body of research that suggests physical health benefits from expressive writing.(37) However, there were improvements in physical symptoms regardless of condition at 1-month follow-up. Although we did not find the health improvements we expected from Pennebaker’s expressive writing, the present study uses a sample of women who, generally speaking, were receiving little to no health care treatment prior to admittance. Once admitted into treatment, they began receiving psychotherapy and/or medication, which likely influenced symptoms and selfreports above and beyond improvements we may otherwise witness as a result of the writing intervention.
BSI Expressive writing participants reported greater reductions in anxiety than controls at 2 weeks; however, there were no group difference at the 1-month follow-up. Again, caution should be used when interpreting these findings due to baseline differences. Nonetheless, these outcomes suggest that expressive writing might assist with emotion regulation by promoting attention, habituation, and cognitive restructuring. Expressive writing can potentially help influence attention toward or away from different dimensions of
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a stressor.(11) Another theory suggests that cognitive restructuring may initiate changes in stress-related thoughts and appraisals. To the degree that people can cognitively negotiate stressful experiences, they should experience a decrease in and possible extinction of anxiety and intrusive thoughts. Analyses revealed a trend approaching significance for the Somatic Index, which might suggest that expressive writing could have a protective effect during the early stages of residential treatment. If women with SUDs are likely to show initial increases in somatic problems (start of treatment), possibly as a result of their bodies readjusting to no longer being physically dependent on drugs, then expressive writing may benefit women by preventing somatic deterioration.
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Expressive Writing on Negative Affect Consistent with hypothesis 2, negative affect produced by expressive writing was short-lived. Increased negative affect immediately following writing is consistent with previous literature,(38) and provides evidence for emotional engagement and (fear) activation.(39) Trauma experts claim emotional engagement is essential for habituation.(40) In order for successful habituation, individuals should endure strong negative emotions initially,(11) followed by gradual reductions in negative emotions within and across writing sessions. Such habituation may indicate desensitization to traumarelated thoughts and memories (i.e., stimulus-specific habituation), and possibly an enhanced tolerance of ones’ negative emotional responses to stress-provoking stimuli in general (i.e., responsespecific habituation).(11) Thus, initial spikes in distress and consequent habituation may be reflective of emotional processing and enhanced self-regulation, and should be associated with improvements in one’s reaction (psychological and physical) to traumatic memories.(41)
Limitations The study had a number of limitations. First, although participants were randomized to conditions, expressive writing participants started with higher pre-writing scores; while depression and anxiety scores were the only significant pre-writing differences, these differences raise concerns that the effects could be the result of a regression to the mean. Another limitation is that 1 month is a relatively short follow-up period. Future studies should examine group differences over longer periods of time post-intervention (including post–residential treatment outcomes and substance use), even though some studies show the most dramatic effects more immediately following the intervention. Furthermore, it was realized 22 participants into recruitment that short-term follow-up would be beneficial in catching participants who did not stay the intended 60 days; therefore, we did not have 2-week assessments on those 22 participants. It would also be useful to examine potential moderators, such as high versus low avoidance personalities.(42) Finally, individuals with more severe mental health problems (e.g., SUD, PTSD) may require more writing sessions or longer writing sessions to realize positive effects.
Study Implications and Applications This study has a number of important implications. First, it provides evidence that trauma-focused interventions can be incorporated into
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traditional residential SUD treatment without triggering more harm. Women safely expressed their deepest emotions and thoughts, many for the first time, about a traumatic and/or stressful event without any indications of a lasting increase in psychiatric distress. During follow-up assessments, the majority of expressive writing participants reported that it helped them work through issues and deal more effectively with emotions related to trauma/stress. These reports were offered spontaneously by participants, as well as through the follow-up questionnaire. To the best of our knowledge, this study was the first to examine the utility of Pennebaker’s expressive writing with drug-dependent women. The ability to reduce trauma symptom severity, depression, and anxiety early in drug treatment can be beneficial in many ways (e.g., increasing patients’ ability to concentrate during counseling sessions, reducing risks for leaving treatment prematurely, and reducing risks for relapse). Thus, future studies should explore whether extending the intervention in ways that maintain or further “boost” short-term improvements at a later time, possibly through more writing sessions distributed over the course of SUD treatment, may enhance longer-term effects. Future analyses should examine essay content and congruence between topic chosen and measures of traumatic stress, as well as whether the same versus difference topic across all writing sessions. The population also represents women of diverse race, substance use diagnoses, and psychiatric symptom severity. The majority of women had less than a high school level of education, were underemployed, uninsured, single/never married, and were thus a vulnerable population with a variety of medical and psychosocial problems and fewer resources than others with SUDs. It is noteworthy that in a population that generally has difficulty adhering to treatment, expressive writing was well received and regarded as helpful by the participants themselves.(43) Thus, expressive writing was found to be a brief and low-cost adjunct to current residential SUD treatment. Expressive writings’ efficacy, efficiency, and cost-effectiveness suggest that writing as a means of disclosing traumatic experiences may be a useful adjunct to traditional SUD treatment.
FUNDING This research was supported by NIH grant NIDA R36 DA02402101 and from the VCU Institute for Women’s Health.
REFERENCES [1] Najavits LM, Weiss RD, Shaw SR. The link between substance abuse and posttraumatic stress disorder in women: a research review. Am J Addict. 1997;6:273–283. [2] Hien D, Cohen L, Campbell A. Is traumatic stress a vulnerability factor for women with substance use disorders? Clin Psychol Rev. 2005;25:813–823. [3] Brown PJ, Stout RL, Mueller T. Substance use disorder and posttraumatic stress disorder comorbidity: addiction and psychiatric treatment rates. Psychol Addict Behav. 1999;13:115–122. [4] Clark HW, Masson CL, Delucchi KL, Hall SM, Sees KL. Violent traumatic events and drug abuse severity. J Subst Abuse Treat. 2001;20:121–127.
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[5] Hien DA, Cohen LR, Miele GM, Litt LC, Capstick, C. Promising treatments for women with comorbid PTSD and substance use disorders. Am J Psychiatry. 2004;161:1426–1432. [6] Brady KT, Dansky B, Back S, Foa E, Carroll K. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings. J Subst Abuse Treat. 2001;21:47–54. [7] Sloan DM, Marx BP. Taking pen to hand: evaluating theories underlying the written disclosure paradigm. Clin Psychol Sci Pract. 2004;11:121–137. [8] Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Consult Clin Psychol. 1998;66: 170–184. [9] Lepore SJ, Smyth JM. The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-being. Washington, DC: American Psychological Association; 2002. [10] Pennebaker JW, Mayne TJ, Francis ME. Linguistic predictors of adaptive bereavement. J Pers Soc Psychol. 1997;72:863–871. [11] Lepore SJ, Greenberg MA, Bruno M, Smyth JM. Expressive writing and health: self-regulation of emotion-related experiences, physiology, and behavior. In: Lepore SJ, Smyth JM, eds. The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-being. Washington, DC: American Psychological Association; 2002:99–117. [12] Koopman C, Ismailji T, Holmes D, Classen CC, Palesh O, Wales T. The effects of expressive writing on pain, depression and posttraumatic stress disorder symptoms in survivors of intimate partner violence. J Health Psychol. 2005;10:211–221. [13] Pennebaker JW, Kiecolt-Glaser J, Glaser R. Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol. 1988;56:239–245. [14] Francis ME, Pennebaker JW. Putting stress into words: the impact of writing on physiological, absentee, and self-reported emotional wellbeing measures. Am J Health Promot. 1992;6:280–287 [15] Booth RJ, Petrie, KJ, Pennebaker JW. Changes in circulating lymphocyte numbers following emotional disclosure: evidence or buffering? Stress Med. 1997;13:23–29. [16] McGuire KM, Greenberg MA, Gevirtz R. Autonomic effects of expressive writing in individuals with elevated blood pressure. J Health Psychol. 2005;10:197–209. [17] Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Consult Clin Psychol. 1998;66:170–184. [18] Resick PA, Uhlmansiek M, Clum G, Galovski T, Scher CD, Young-Xu YA. Randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol. 2008;76:243–258. [19] Pennebaker JW, Colder M, Sharp LK. Accelerating the coping process. J Pers Soc Psychol. 1990;58:528–537. [20] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute; 2002. [21] Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychol Assess. 1997;9:445–451. [22] Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:285–401. [23] Pennebaker JW. The Psychology of Physical Symptoms. New York: Springer-Verlag; 1982.
[24] Derogatis LR. Brief Severity Index (BSI). Minneapolis, MN: Pearson; 1979. [25] Coffey SF, Saladin ME, Drobes DJ, Brady KT, Dansky BS, Kilpatrick DG. Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence. Drug Alcohol Depend. 2002;65:115–127. [26] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychological Association; 2000. [27] Foa EB. Posttraumatic Stress Diagnostic Scale. Minneapolis, MN: National Computer Systems; 1996. [28] Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med. 1983;13:595–605. [29] Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol. 1988;54:1063–1070. [30] Greenberg MA, Stone AA. Emotional disclosure about traumas and its relation to health: effects of previous disclosure and trauma severity. J Pers Soc Psychol. 1992;63:75–84. [31] Lepore SJ. Expressive writing moderates the relation between intrusive thoughts and depressive symptoms. J Pers Soc Psychol. 1997;73:1030–1037. [32] Sloan DM, Marx BP. A closer examination of the structured written disclosure procedure. J Consult Clin Psychol. 2004;72: 165–175. [33] Pennebaker JW, Beall SK. Confronting a traumatic events: toward an understanding of inhibition and disease. J Abnorm Psychol. 1986;95:274–281. [34] Bartels SJ, Thomas WN. Lessons from a pilot residential treatment program for people with dual diagnoses of severe mental illness and substance use disorder. Psychosoc Rehab J. 1991;15:19–30. [35] Sloan DM, Marx BP, Epstein EM. Further examination of the exposure model underlying the efficacy of written emotional disclosure. J Consult Clin Psychol. 2005;73:549–554. [36] Pennebaker JW. Writing about emotional experiences as a therapeutic process. Psychol Sci. 1997;8:162–166. [37] Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. JAMA. 1999;281:1304–1309. [38] Esterling BA, L’Abate L, Murray EJ, Pennebaker JW. Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clin Psychol Rev. 1999;19:79–96. [39] Kloss D, Lisman SA. An exposure-based examination of the effects of written emotional disclosure. Br J Health Psychol. 2002;7:31–46. [40] Foa EB. Psychological processes related to recovery from a trauma and an effective treatment for PTSD. Ann N Y Acad Sci. 1997;821:410–424. [41] Sloan DM, Marx BP, Epstein EM, Lexington JM. Does altering the writing instructions influence outcome associated with written disclosure? Behav Ther. 2007;38:155–168. [42] Frisina PG, Borod JC, Lepore SJ. A meta-analysis of the effects of written emotional disclosure on the health outcomes of clinical populations. J Nerv Ment Dis. 2004;192:629–634. [43] Najavits LM, Weiss RD, Shaw SR, Muenz L. “Seeking Safety”: outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence. J Trauma Stress. 1998;11:437–456.
Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wsub20
Expressive Writing as a Therapeutic Process for DrugDependent Women Sarah Meshberg-Cohen PhD
a b c
b
, Dace Svikis PhD & Thomas J. McMahon PhD
c
a
Department of Veteran Affairs , VA Connecticut Healthcare System , West Haven , Connecticut , USA b
Department of Psychology , Virginia Commonwealth University , Richmond , Virginia , USA
c
Department of Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA Accepted author version posted online: 14 Jun 2013.Published online: 03 Mar 2014.
To cite this article: Sarah Meshberg-Cohen PhD , Dace Svikis PhD & Thomas J. McMahon PhD (2014) Expressive Writing as a Therapeutic Process for Drug-Dependent Women, Substance Abuse, 35:1, 80-88, DOI: 10.1080/08897077.2013.805181 To link to this article: http://dx.doi.org/10.1080/08897077.2013.805181
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SUBSTANCE ABUSE, 35: 80–88, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0889-7077 print / 1547-0164 online DOI: 10.1080/08897077.2013.805181
Expressive Writing as a Therapeutic Process for Drug-Dependent Women
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Sarah Meshberg-Cohen, PhD,1,2,3 Dace Svikis, PhD,2 and Thomas J. McMahon, PhD3 ABSTRACT. Background: Although women with substance use disorders (SUDs) have high rates of trauma and posttraumatic stress, many addiction programs do not offer trauma-specific treatments. One promising intervention is Pennebaker’s expressive writing, which involves daily, 20-minute writing sessions to facilitate disclosure of stressful experiences. Methods: Women (N = 149) in residential treatment completed a randomized clinical trial comparing expressive writing with control writing. Repeated-measures analysis of variance was used to document change in psychological and physical distress from baseline to 2-week and 1-month follow-ups. Analyses also examined immediate levels of negative affect following expressive writing. Results: Expressive writing participants showed greater reductions in posttraumatic symptom severity, depression, and anxiety scores, when compared with control writing participants at the 2-week follow-up. No group differences were found at the 1-month follow-up. Safety data were encouraging: although expressive writing participants showed increased negative affect immediately after each writing session, there were no differences in pre-writing negative affect scores between conditions the following day. By the final writing session, participants were able to write about traumatic/stressful events without having a spike in negative affect. Conclusions: Results suggest that expressive writing may be a brief, safe, low-cost, adjunct to SUD treatment that warrants further study as a strategy for addressing posttraumatic distress in substance-abusing women.
Keywords: Expressive writing, substance abuse, trauma INTRODUCTION Studies point to overwhelming rates of trauma in the lives of women with substance use disorders (SUDs). In SUD treatment settings, 55% to 99% of women report at least one lifetime trauma.(1) As many as 80% of women seeking drug abuse treatment report lifetime histories of physical or sexual assault,(2) and many display posttraumatic stress disorder (PTSD) symptomatology.(3) Trauma and addiction comorbidity studies reveal these women are likely to have poorer health, increased disability, more severe clinical profiles, and poorer treatment adherence than those without trauma or PTSD.(4) Although trauma interventions have traditionally not been incorporated into SUD treatment programs, studies indicate that
1Department of Veteran Affairs, VA Connecticut Healthcare System, West
Haven, Connecticut, USA 2Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA 3Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence should be addressed to Sarah Meshberg-Cohen, PhD, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA. E-mail: [email protected]
addressing trauma during SUD treatment may improve treatment outcomes.(5) Historically, there has been an ongoing debate regarding which problem to treat first, the trauma or the SUD. Among SUD treatment providers, the general consensus was that addressing trauma during the early phase of SUD recovery may “open Pandora’s box” and derail SUD treatment improvement.(5) Recent research, however, suggests the opposite: that trauma should be treated concurrently, even in the earliest stages of SUD treatment.(6) Accumulating evidence over the past 2 decades indicates that disclosure of traumatic or stressful experiences through Pennebaker’s expressive writing has widespread benefits. The typical laboratory research for Pennebaker’s expressive writing involves randomly assigning individuals to 1 of 2 conditions (eg, expressive writing [emotional disclosure] versus control writing [neutral topic]). Expressive writing involves writing about the most traumatic or stressful event of one’s life for 15 to 20 minutes a day over 3 to 5 consecutive days, and is typically done with no feedback given.(7) Studies have demonstrated the efficacy of expressive writing as a brief therapeutic intervention, with significant reductions in distress,(8) and improved psychological(9) and physical health.(10) For instance, Pennebaker’s expressive writing has revealed that writing about a stressful or traumatic event is associated with a reduction in the degree to which the experience is distressing or painful,(11) reduced depression among depressed women,(12) a
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decrease in health center and doctor’s visits,(10,13) fewer missed days of work or school,(14) improved immune functioning,(15) and decreases in sympathetic nervous system activity.(16) In a meta-analysis of expressive writing studies, Smyth(17) found a 23% symptom improvement in the traumatic disclosure writing condition over a control writing condition. The average effect size was comparable or larger than those found in other psychological, educational, or behavioral interventions.(8) Cognitive processing therapy (CPT), which also employs writing about stressful events, has recently revealed decreases in PTSD and depression symptoms.(18) Furthermore, research indicates no harm to participants has been encountered as a result of Pennebaker’s expressive writing. Although there is a rise in negative affect immediately after trauma writing, it is usually transient; and at follow-up, participants generally report that they feel better than they did before writing.(19) Although much attention has focused on benefits of Pennebaker’s expressive writing, to date, it has not been examined in populations affected by SUDs. Expressive writings’ efficiency (15 to 20 minutes over 3 to 5 days), efficacy, and low cost suggest that writing as a means for disclosing traumatic experiences may be a powerful adjunct to traditional SUD treatment. The purpose of this study was to determine whether Pennebaker’s expressive writing is beneficial as a brief adjunct to traditional treatment for women currently undergoing residential treatment for SUDs. This randomized clinical trial (RCT) tests 2 hypotheses. First, it was hypothesized that participants randomized to the expressive writing condition would show more improvement in psychological and physical health at the 2-week and 1-month follow-ups, compared with control writing participants. Although it was expected that there would be improvements for both writing conditions as a function of being in residential treatment, expressive writing participants were expected to show greater improvement. Second, it was hypothesized that negative affect measured immediately after each writing session would be higher among expressive writing participants compared with control writing participants, but that these increases in negative affect would be short-lived.
METHODS Participants Participants were 149 women admitted to a gender-specific residential SUD treatment facility from June 17, 2007 to November 6, 2008. Specific services within this facility include individual counseling, motivational enhancement therapy groups, and case management for such needs as housing, transportation, and childcare. To be eligible for the study, women had to (a) be at least 18 years old; (b) meet DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for a SUD; and (c) have approval for 60 days of residential treatment from a third-party payer to help facilitate presence for the 1-month follow-up. Women were ineligible if they (a) had an acute mental disorder (eg, current suicidality) that would make it difficult to provide informed consent and/or follow the study protocol; or (b) had literacy problems that would prevent them from being able to complete the writing sessions or the research assessments.
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Measures With the exception of demographic questions and the Structured Clinical Interview for DSM-IV-TR Alcohol and Substance Use Disorders Module (SCID),(20) measured at baseline, the same battery of measures was administered at baseline, and at the 2-week and 1-month post-writing follow-ups. All assessments were completed on-site and instructions were read aloud by the researcher. The primary outcome measure included the Posttraumatic Stress Diagnostic Scale (PDS).(21) Secondary outcomes included the Center for Epidemiological Studies—Depression Scale (CES-D),(22) Pennebaker Inventory of Limbic Languidness (PILL),(23) and Brief Symptom Inventory (BSI).(24) Process measures included the Positive and Negative Affect Scale (PANAS),(29) measured pre- and post-writing sessions, as well as the Essay Evaluation Measure (EEM),(30) measured post-writing session, and the follow-up questionnaire, measured at 2 weeks and 1 month post-writing intervention. The SCID(20) is a diagnostic interview assessing SUD diagnosis, including alcohol and other drugs. The SCID has demonstrated good validity and high interrater reliability for SUDs.(25) The PDS(21) is a 49-item self-report measure focused on PTSD symptom severity and diagnosis, with items parallel to DSM-IV criteria.(26) The PDS has high test-retest reliability (r = .83), high internal consistency (α = .92), and high convergent validity.(27) Trauma symptom severity was defined as the sum scores for items focused on reexperiencing, arousal, and avoidance symptoms. At baseline, internal consistency for trauma symptom severity for this sample was .99. The CES-D(22) is a 20-item self-report measure of depression, and has high internal consistency in psychiatric settings (α. = .90). Internal consistency at present study baseline for this sample was .87. The PILL(23) is a 54-item scale that assesses the frequency of common physical symptoms and sensations (eg “headaches,” “congested nose,” “coughing”). Chronbach’s alphas for the PILL range from .88 to .91, with 2-month test-retest reliabilities of .79 to .83. PILL has a mean score of 112.7 (SD = 24.7).(23) At baseline, internal consistency for this sample was .94. The BSI,(24) a 53-item self-report measure, is a shortened version of the Symptom Check List-90 (SCL-90). It assesses 9 symptoms of distress (Somatization; Obsessive-Compulsive; Interpersonal Sensitivity; Depression; Anxiety; Hostility; Phobic Anxiety; Paranoid Ideation; Psychoticism). The BSI has high scale-by-scale correlations with the SCL-90, as well as high internal consistency (Cronbach’s α = .71–.85), convergent, discriminant, and test-retest reliability (r = .68–.91), and construct validity.(28) At baseline, internal consistencies for the 9 BSI indices for this sample were .74 to .87.
Process Measures The PANAS(29) assesses negative affect (NA) and positive affect (PA), using 10 items for NA and 10 items for PA. It was administered pre- and post-writing, and only the negative affect scale was used in this study. The NA scale has high internal consistency reliabilities, ranging from .84 to .87, and they are unchanged by the time point used. Internal consistency for the post-writing NA scale on day 1 of writing for this sample was .92. The EEM(30) served as manipulation check to evaluate participants’ self-reports of their response to the experimental and control
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manipulation after each writing session. It assesses participants’ report, along separate 7-point scales, ranging from 1 (not at all) to 7 (a great deal), the extent to which their essays were meaningful, personal, and revealing, and the extent they had actually talked to others, had wanted to talk to others, and had actively held back from talking to others about the subject(s) of the essays.(31) After the first writing session, internal consistency of the measure for this sample was .79. The follow-up questionnaire was an investigator-developed survey that examined issues of cross-contamination inherent in studies done in residential settings. The follow-up questionnaire served as a fidelity check, and measured possible diffusion of treatment. The questionnaire included closed- and open-ended questions and surveyed whether participants heard about, shared, or received writing instructions from others in the facility. It also addressed whether the participant found the writing helpful and talked about the subject matter from her essays during treatment.
Procedures The university’s institutional review board approved research procedures. A CONSORT diagram (Figure 1) summarized study screening, enrollment, treatment, assessment, and retention of participants. Admission records identified potential study participants and those women were approached within the first few days of treatment. Those who met inclusion criteria were invited for participation in a study that involved writing stories related to their life.(32) Women providing informed consent were randomly assigned (using a random numbers table) to 1 of 2 conditions: (a) expressive writing (emotional topic) or (b) control writing (neutral topic). Writing instructions were based on protocols used by Pennebaker et al.(10) and Sloan and Marx.(32) In addition to being read aloud by the investigator before each writing session, a copy of the writing instructions was attached to the front flap of each journal so that participants could reread instructions at any time.
Writing Procedure Once enrolled, participants completed baseline assessments, four 20-minute writing sessions on consecutive days, and both a 2-week and a 1-month follow-up assessment. In order to reduce unintentional expectancy effects and investigator bias, one experimenter administered baseline assessments and all writing instructions, while a different experimenter, blind to study condition, administered PANAS, EEMs, and follow-up assessments.
Writing session 1 The day after completing baseline assessments, each participant was administered the writing instructions. Participants were asked not to discuss the study or writing instructions. After receiving writing instructions from one experimenter, participants were introduced to a second experimenter. The second experimenter had participants complete a PANAS(29) prior to handing them a blank notepad. Participants located a comfortable place where they would not be disturbed (e.g., their room), and wrote about their assigned topic for 20 minutes. Twenty minutes later, the second experimenter administered the PANAS and EEM.(33) Notepads, marked by participant ID, were then dropped
into a cardboard box along with participants’ responses to PANAS and EEM responses.
Writing sessions 2 through 4 Participants were greeted for each session by the first experimenter, who read the writing instructions aloud. The second experimenter instructed participants to complete PANAS before writing for 20 minutes. The PANAS and EEM were completed after each writing session.
2-Week and 1-month follow-ups Participants completed follow-up assessments 2 weeks and 1 month post-writing intervention. A 2-week follow-up was added after 22 participants had already been enrolled; this was done to insure some data collection from participants who might leave against medical advice (AMA) prior completing their 60-day treatment, as well as to assess the shorter-term effects of the intervention. Participants received a $5 gift card after completing the baseline assessment, a $5 gift card after each writing session ($20 total), a $10 gift card after completing the 2-week follow-up, and a $15 gift card upon completion of the 1-month follow-up.
Data Analysis Kolmogorov-Smirnov and Shapiro-Wilk statistics determined that primary and secondary outcomes were normally distributed. t and chi-square tests examined whether significant baseline differences existed between conditions. A series of analyses of variance (ANOVAs) were then used to test for between-group differences in (a) 2-week clinical outcomes, and (b) clinical outcomes at the end of the 1-month follow-up. For the first research hypothesis, 2-week effects were examined with a 2 (condition: expressive writing, control writing) by 2 (time: baseline, 2-week follow-up) repeated-measures ANOVA separately for each outcome measure (PDS, CES-D, PILL, BSI). One-month effects were also tested by examining betweengroup differences over time using a 2 (condition: expressive writing, control writing) by 2 (time: baseline, 1-month follow-up) repeatedmeasures ANOVA for each outcome measure (PDS, BSI, CES-D, PILL). Condition × Time interaction effects were examined for differential treatment effects with post hoc analysis of the main effect of time within each treatment group. Since an investigator was present during assessments, missing data were minimal. In the intention-to-treat analyses, with the entire sample (149 participants), however, missing outcome data for “noncompleters” (e.g., participants who did not complete all writing sessions, the 2-week, and/or the 1-month follow-up assessments) were addressed by carrying forward each participant’s previous score. For the second research hypothesis, a repeated-measures analysis of negative affect was derived from PANAS. A 2 (condition: expressive writing, control writing) by 4 (session: writing 1, writing 2, writing 3, writing 4) by 2 (time: pre- and post-writing sessions) repeated-measures multivariate analysis of variance (MANOVA) examined the interaction between pre-post writing NA and condition at each of the 4 sessions. t and chi-square tests compared writing conditions on items of the EEM and follow-up questionnaire to evaluate participants’ selfreports of their response to the experimental manipulation. Because
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FIGURE 1 CONSORT flow diagram. Non-Completers >1 writing session: n = 1 left Against Medical Advice (AMA); n = 3 conflicting medical appointment Non-Completers > 2 writing sessions: n = 1 left AMA; n = 3 conflicting medical appointment Non-Completers 2-Week Follow-Up: n = 7 left AMA (n = 2 Expressive Writing; n = 5 Control Writing); n = 1 medical reasons (Control Writing); n = 1 discharged before expected 60 days (Expressive Writing) Non-Completers 1-Month Follow-Up: n = 6 left AMA (n = 2 Expressive Writing; n = 4 Control Writing); n = 4 discharged before expected 60 days (n = 2 Expressive Writing; n = 2 Control Writing); n = 2 Incarceration (n = Control Writing) (Color figure available online).
participants completed the EEM 4 times (after each writing session), the mean of the 4 days for each participant was used in analyses.
RESULTS
(assessed by PDS). Over half met diagnostic criteria for current PTSD. SUD women with comorbid PTSD reported significantly more types of trauma than women without PTSD, t(147) = 5.1, P < .005. A majority of participants indicated cocaine as one of their primary drugs of dependence, with over half meeting DSM-IV criteria for substance dependence for more than one drug.
Participant Characteristics Overall, women enrolled in the study (Table 1) were an average of 36.3 (SD = 8.6) years old; and had completed an average of 11.2 (SD = 1.8) years of education; most (92.7%) were single/never married; and a majority (70%) identified their race as African American. Most participants reported at least one lifetime trauma at baseline
Randomization Participants randomized to expressive writing had higher CES-D depression scores than controls (M = 25.2 [SD = 12.0] versus M = 21.1 [SD = 10.9]), t(148) = 2.2, P < .05), and higher BSI Anxiety scores (M = 1.3 [SD = 1.1] versus M = 0.8 [SD = 0.8]),
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SUBSTANCE ABUSE TABLE 1 Participant Characteristics: Expressive Writing (n = 82) and Control Writing (n = 67)
Characteristic
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Age (years) Education (last grade completed) Marital status Married Single/Never married Race Caucasian African American Hispanic Other At least one trauma Mean number of different types of trauma events PTSD diagnosis (n = 81) No PTSD diagnosis (n = 68) PTSD diagnosis Trauma symptom severity CES-D depression score CES-D cutoff ≥16 PILL score DSM-IV substance dependence diagnosis (current) Alcohol Amphetamine/ Stimulant Cannabis Cocaine Hallucinogen Inhalant Opioid Sedative More than one drug ∗P
TABLE 2 Effects of Expressive Writing versus Control Writing on 2-Week and 1-Month Follow-Up (Intent-to-Treat) Expressive writing (n = 82)
Expressive writing % or M (SD)
Control writing % or M (SD)
Total sample % or M (SD)
37.7 (8.7) 11.5 (1.6)
34.6 (8.2) 10.9 (2.0)
36.6 (8.3)∗ 11.2 (1.8)
4.4% 95.6%
9.8% 90.2%
7.3% 92.7%
25.6% 69.5% 1.2% 3.7% 96.3% (n = 79) 3.8 (SD = 2.2)
23.5% 70.6% 0.0% 5.9% 95.5% (n = 64) 3.6 (SD = 2.4)
24.7% 70.0% 0.7% 4.7% 96.0% (n = 143) 3.7 (SD = 2.3)
4.6 (SD = 2.2) 2.8 (SD = 1.8) 58.5% (n = 48) 21.3 (SD = 13.4) 25.2 (SD = 12.0) 76.8% 118.8 (SD = 37.6)
4.5 (SD = 2.6) 2.8 (SD = 1.8) 49.3% (n = 33) 17.5 (SD = 12.4) 21.1 (SD = 10.9) 67.2% 113.5 (SD = 34.2)
4.6 (SD = 2.3) 2.8 (SD = 1.8) 54.4% (n = 81) 19.5 (SD = 13.1) 23.3 (SD = 11.7)∗ 72.5% 116.4 (SD = 36.0)
32.9% 0.0%
23.9% 1.5%
28.9% 0.7%
11.0% 80.5% 1.2% 0.0% 47.6% 6.1% 63.4%
9.0% 83.6% 0.0% 0.0% 41.8% 4.5% 49.3%
10.1% 81.9% 0.7% 0.0% 45.0% 5.4% 57.0%
< .05.
Measure Trauma symptom severity Depression PILL BSI Anxiety Index BSI Somatic Index ∗P
Baseline Mean (SD)
12-Week Month posttest posttest Mean Mean (SD) (SD)
Control writing (n = 67)
Baseline Mean (SD)
12-Week Month posttest posttest Mean Mean (SD) (SD)
21.3 (13.4)
18.0∗ (12.3)
17.0 (12.6)
17.5 (12.6)
18.0 (11.7)
14.5 (12.1)
25.2 (12.0) 118.8 (37.6) 1.2 (1.0)
21.9∗ (10.7) 113.4 (36.4) 0.9∗ (0.9)
19.4 (11.8) 106.8 (39.1) 0.9 (1.0)
21.1 (10.9) 113.5 (34.2) 0.8 (0.8)
21.3 (11.8) 108.8 (28.3) 0.9 (0.8)
17.6 (11.1) 105.6 (39.0) 0.6 (0.7)
1.0 (0.8)
1.0 (0.8)
0.8 (0.8)
0.8 (0.8)
1.0 (0.9)
0.7 (0.8)
< .05.
compliance for both conditions were high. Specifically, 97.6% of expressive writing and 97.0% of control writing participants completed at least 2 writing sessions, and most (94.6%) completed all 4 writing sessions.
Follow-up assessment attrition Among expressive writing participants, there were no differences between “completers” versus “noncompleters” on dependent variables at 2-week follow-up. Among control participants, women who did not complete the 2-week follow-up were significantly more depressed at baseline compared with those who completed the follow-up (M = 28.0 [SD = 6.8] versus M = 20.0 [SD = 11.1]), t(65) = 2.1, P < .05), and were more likely to have had clinically elevated depression (≥16 CES-D cutoff) at baseline (100% versus 62.1%), χ 2(2, N = 67) = 5.1, P < .05. No differences between “completers” versus “noncompleters” were found at 1-month follow-ups on any dependent variables, P > .05.
Hypothesis 1: 2-Week and 1-Month Effects of Expressive Writing
Trauma symptom severity t(148) = 3.0, P < .005. There were no other baseline differences between conditions.
Attrition
Writing session attrition A chi-square analysis showed no significant relationship between condition assignment and number of writing sessions completed, P > .05. As depicted in the CONSORT diagram, rates of
There was a Condition × Time interaction for levels of traumatic stress at 2-week follow-up, F(1, 149) = 5.8, P < .05, partial η2 = .04. Planned contrasts revealed a significant decrease in trauma symptom severity from baseline to 2 weeks among expressive writing, F(1, 82) = 8.6, P < .005, partial η2 = .10, but not among control writing participants, P > .05. There was no interaction for trauma symptom severity at 1-month follow-up, P > .05; however, both conditions revealed significant improvements (Table 2). Expressive writing participants revealed a significant decrease from baseline to 1-month follow-up, F(1, 82) = 11.1, P < .005, partial η2 = .12, as did controls, F(1, 67) = 7.3, P < .01, partial η2 = .10.
MESHBERG-COHEN, SVIKIS, AND McMAHON
Depression There was a significant Condition × Time interaction for depression, F(1,149) = 4.3, P < .05, partial η2 = .03 at 2 weeks. Planned contrasts demonstrated significant decreases in depression among expressive writing, F(1, 82) = 7.4, P < .01, partial η2 = .08, but not among control writing participants, P > .05. There was no interaction at the 1-month follow-up (P > .05); however, both conditions revealed significant improvements in depression. Expressive writing participants showed significant improvements in depression at 1-month follow-up, F(1, 82) = 16.1, P < .005, partial η2 = .17, as did control participants, F(1, 67) = 9.3, P < .005, partial η2 = .12.
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Physical health There was no Condition × Time interaction in the reduction of physical health symptoms and sensations at the 2-week, P > .05, or 1-month, P > .05, follow-up. However, significant improvements were found at 1-month follow-up for both the expressive writing, F(1, 82) = 18.3, P < .005, partial η2 = .18, and control writing, F(1, 67) = 4.5, P < .05, partial η2 = .06, conditions.
BSI There was a significant Condition × Time interaction for anxiety, F(1, 149) 13.9, P < .005, partial η2 = .09. Expressive writing participants showed significant improvements in anxiety scores at the 2-week follow-up, F(1, 82) = 14.1, P < .005, partial η2 = .15, whereas control participants did not, P > .05. There was no interaction at 1-month follow-up, P > .05. There was a trend approaching a significant interaction for the Somatic Index, F(1, 149) = 3.8, P = .05. Whereas the control condition revealed an increase in somatic symptoms from baseline to 2-week follow-up, F(1, 67) = 4.4, P < .05, partial η2 = .06, the expressive writing condition revealed no differences, suggesting a possible protective factor of the writing. This trend was not maintained at the 1-month follow-up, yet overall improvements were seen for both conditions. There were no interactions between conditions over time for the remaining 7 BSI indices (all > .05).
Hypothesis 2: Expressive Writing on Negative Affect There was a significant Condition × Session × Time interaction for PANAS negative affect scores, F(4, 149) = 7.3, P < .005, partial η2 = .30. Additionally, univariate F tests revealed that groups did not differ in negative affect prior to writing, suggesting that the immediate increase in negative affect after writing was brief (Table 3). Univariate tests revealed a significant interaction between time by condition at writing session 1, F(1,149) = 29.9, P .05. As illustrated, analyses revealed that the main
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effects decreased over time; by writing session 4, expressive writing participants were able to write about traumatic event without having the spike in negative affect afterward.
Manipulation and Fidelity Checks
EEM When compared with control writing participants, expressive writing participants described their essays as more meaningful, t(139) = 9.1, P < .0005, more personal, t(139) = 13.3, P < .0005, and more revealing of one’s emotions, t(139) = 18.0, P < .0005. They were more likely to have wanted to discuss it with others, t(139) = 8.7, P < .0005, than control writing participants. They also reported being more likely to have talked with others about the content of their essays, t(139) = 10.0, P < .0005, and also to have actively held back from talking with others about the content, t(139) = 4.5, P < .0005, than controls.
Follow-up questionnaire Only 2 (1.7%) participants in the control condition reported hearing about the expressive writing instructions from another participant. Furthermore, expressive writing participants were more likely than controls to report finding the writing to be helpful (98.6% versus 72.0%), χ 2(2, N = 120) = 18.6, P < .005; continue journaling using the writing instructions given after the sessions ended (42.0% versus 14.0%), χ 2(2, N = 120) = 10.8, P < .005; and to have talked about the subject matter form their essays during treatment (15.9% versus 0.0%), χ 2(2, N = 120) = 8.8, P < .005. All (100%) of the expressive writing participants who talked about the subject matter from their essays during their treatment found it to be helpful. Expressive writing participants reported that expressive writing helped them work through issues and deal more effectively with emotions related to trauma/stress (Table 4).
DISCUSSION The present study collected benchmark data on whether Pennebaker’s expressive writing could be applied to women in TABLE 3 Negative Affect: Pre-Post Writing Sessions
Session Writing session 1, time 1 Writing session 1, time 2 Writing session 2, time 1 Writing session 2, time 2 Writing session 3, time 1 Writing session 3, time 2 Writing session 4, time 1 Writing session 4, time 2
Expressive writing Mean (SD)
Control writing Mean (SD)
18.7 (7.9) 24.0 (10.9)∗∗ 17.6 (8.2) 22.4 (11.2)∗∗ 16.8 (7.7) 19.5 (9.5)∗∗ 17.6 (8.4) 18.7 (9.0)
16.2 (7.2) 15.2 (8.2) 13.3 (4.9) 13.5 (5.2) 14.1 (6.2) 13.4 (5.1) 13.9 (6.2) 13.6 (5.4)
Note. Time 1: PANAS was assessed after writing instructions were given, but prior to writing. ∗∗ P < .005.
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SUBSTANCE ABUSE TABLE 4 Follow-Up Questionnaire: 5 Randomly Selected Quotes from Each Condition
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Question 4: Did you find the writing helpful? Why? Why not? Expressive writing participants “Very helpful. I’ve never in my life experienced something like this. It hit the core of everything.” “It made me realize that what happened to me wasn’t my fault.” “Very helpful. It got me in touch with my feelings and helped me work through some of my issues and problems. It was good for me.” “Made me bring some of the issues that wrote about, especially the attempted rape and how I was not able to have sex because of fear.” “Because it made me think back to some issues that were hindering me from moving forward. It helps me let go and move forward. I feel much better.” Control writing participants “It was just being plain, you can’t express no emotions.” “Kind of neutral! Not aware of what the goal was. Helps me in my purpose in gaining knowledge of it.” “Because it made me realize that I can write just about anything.” “I found out that it was kind of hard trying to remember everything I did in a day’s time.” “Shallow subject matter.”
gesting that stimulus-related habituation may take place regardless.(7) Studies to-date comparing instructions for participants to write about the same or different topics each day have yielded mixed results. For instance, Sloan and colleagues(35) found college students with a trauma history who wrote about the same trauma experience at each session showed improvements at followup, whereas those instructed to write about a different trauma each day did not. Other studies have obtained more robust results when participants were allowed to choose their writing topic at each session.(8,36) The importance of short-term improvements at 2 weeks versus 1 month should not be discounted, particularly since we are dealing with a clinical population and a chronic disorder. It is likely that extending the intervention in ways that “boost” the intervention (e.g., more writing sessions during different points in treatment) would be helpful. Although writing conditions did not differ at 1 month, both conditions demonstrated positive changes on core outcomes. The present study is unique, however, in that it was conducted in the context of residential treatment, which, in and of itself, is likely to produce improvements in physical and psychosocial functioning over time.
Depression residential SUD treatment. Trauma rates in this study were comparable to those previously reported in the literature,(5) supporting the rationale for the clinical trial and study hypotheses.
2-Week and 1-Month Outcomes Supporting hypothesis 1, expressive writing participants showed greater reductions in trauma symptom severity, depression, and anxiety than control writing participants at the 2- week follow-up. Expressive writing may be a protective factor in somatic symptoms. Although no group differences were found at the 1-month followups, both conditions showed significant positive changes, likely due to being in residential treatment for 30 days.(34) Due to baseline differences between conditions, results should be interpreted with caution.
Trauma Short-term (2-week) findings are consistent with research suggesting that writing about emotional experiences using Pennebaker’s expressive writing results in a decreased degree to which the experience is emotionally distressing or painful.(35) One potential reason is based on exposure theory, which suggests that attempting not to think about traumatic events in order to avoid overwhelming emotions may generate further feelings of distress and fear.(11) Thus, expressive writing may act as a medium for exposure to previously avoided stimuli. Repeat exposure over several writing sessions may allow for habituation and extinction of negative emotional associations and/or offer corrective information to the person about the stimuli, responses, and meaning of the event.(32) Although it is generally thought that exposure to the same traumatic event is essential for extinction, expressive writing does not require writing about the same event at each session, sug-
Expressive writing participants showed significant reductions in depressive symptoms at the 2-week follow-up, whereas controls did not. Results are consistent with research among women who had endured intimate partner violence,(12) showing greater drops in depression among those in the traumatic disclosure as compared with the control writing condition. However, given that baseline depression differences existed, this finding should also be interpreted with caution.
Health There were no differences between the 2 conditions in the reduction of physical health symptoms and sensations over time, which conflicts with an extensive body of research that suggests physical health benefits from expressive writing.(37) However, there were improvements in physical symptoms regardless of condition at 1-month follow-up. Although we did not find the health improvements we expected from Pennebaker’s expressive writing, the present study uses a sample of women who, generally speaking, were receiving little to no health care treatment prior to admittance. Once admitted into treatment, they began receiving psychotherapy and/or medication, which likely influenced symptoms and selfreports above and beyond improvements we may otherwise witness as a result of the writing intervention.
BSI Expressive writing participants reported greater reductions in anxiety than controls at 2 weeks; however, there were no group difference at the 1-month follow-up. Again, caution should be used when interpreting these findings due to baseline differences. Nonetheless, these outcomes suggest that expressive writing might assist with emotion regulation by promoting attention, habituation, and cognitive restructuring. Expressive writing can potentially help influence attention toward or away from different dimensions of
MESHBERG-COHEN, SVIKIS, AND McMAHON
a stressor.(11) Another theory suggests that cognitive restructuring may initiate changes in stress-related thoughts and appraisals. To the degree that people can cognitively negotiate stressful experiences, they should experience a decrease in and possible extinction of anxiety and intrusive thoughts. Analyses revealed a trend approaching significance for the Somatic Index, which might suggest that expressive writing could have a protective effect during the early stages of residential treatment. If women with SUDs are likely to show initial increases in somatic problems (start of treatment), possibly as a result of their bodies readjusting to no longer being physically dependent on drugs, then expressive writing may benefit women by preventing somatic deterioration.
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Expressive Writing on Negative Affect Consistent with hypothesis 2, negative affect produced by expressive writing was short-lived. Increased negative affect immediately following writing is consistent with previous literature,(38) and provides evidence for emotional engagement and (fear) activation.(39) Trauma experts claim emotional engagement is essential for habituation.(40) In order for successful habituation, individuals should endure strong negative emotions initially,(11) followed by gradual reductions in negative emotions within and across writing sessions. Such habituation may indicate desensitization to traumarelated thoughts and memories (i.e., stimulus-specific habituation), and possibly an enhanced tolerance of ones’ negative emotional responses to stress-provoking stimuli in general (i.e., responsespecific habituation).(11) Thus, initial spikes in distress and consequent habituation may be reflective of emotional processing and enhanced self-regulation, and should be associated with improvements in one’s reaction (psychological and physical) to traumatic memories.(41)
Limitations The study had a number of limitations. First, although participants were randomized to conditions, expressive writing participants started with higher pre-writing scores; while depression and anxiety scores were the only significant pre-writing differences, these differences raise concerns that the effects could be the result of a regression to the mean. Another limitation is that 1 month is a relatively short follow-up period. Future studies should examine group differences over longer periods of time post-intervention (including post–residential treatment outcomes and substance use), even though some studies show the most dramatic effects more immediately following the intervention. Furthermore, it was realized 22 participants into recruitment that short-term follow-up would be beneficial in catching participants who did not stay the intended 60 days; therefore, we did not have 2-week assessments on those 22 participants. It would also be useful to examine potential moderators, such as high versus low avoidance personalities.(42) Finally, individuals with more severe mental health problems (e.g., SUD, PTSD) may require more writing sessions or longer writing sessions to realize positive effects.
Study Implications and Applications This study has a number of important implications. First, it provides evidence that trauma-focused interventions can be incorporated into
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traditional residential SUD treatment without triggering more harm. Women safely expressed their deepest emotions and thoughts, many for the first time, about a traumatic and/or stressful event without any indications of a lasting increase in psychiatric distress. During follow-up assessments, the majority of expressive writing participants reported that it helped them work through issues and deal more effectively with emotions related to trauma/stress. These reports were offered spontaneously by participants, as well as through the follow-up questionnaire. To the best of our knowledge, this study was the first to examine the utility of Pennebaker’s expressive writing with drug-dependent women. The ability to reduce trauma symptom severity, depression, and anxiety early in drug treatment can be beneficial in many ways (e.g., increasing patients’ ability to concentrate during counseling sessions, reducing risks for leaving treatment prematurely, and reducing risks for relapse). Thus, future studies should explore whether extending the intervention in ways that maintain or further “boost” short-term improvements at a later time, possibly through more writing sessions distributed over the course of SUD treatment, may enhance longer-term effects. Future analyses should examine essay content and congruence between topic chosen and measures of traumatic stress, as well as whether the same versus difference topic across all writing sessions. The population also represents women of diverse race, substance use diagnoses, and psychiatric symptom severity. The majority of women had less than a high school level of education, were underemployed, uninsured, single/never married, and were thus a vulnerable population with a variety of medical and psychosocial problems and fewer resources than others with SUDs. It is noteworthy that in a population that generally has difficulty adhering to treatment, expressive writing was well received and regarded as helpful by the participants themselves.(43) Thus, expressive writing was found to be a brief and low-cost adjunct to current residential SUD treatment. Expressive writings’ efficacy, efficiency, and cost-effectiveness suggest that writing as a means of disclosing traumatic experiences may be a useful adjunct to traditional SUD treatment.
FUNDING This research was supported by NIH grant NIDA R36 DA02402101 and from the VCU Institute for Women’s Health.
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