Expressive writing as a therapeutic process for drug-dependent women

Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial

There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.

Giving Voice to Women with Substance Use Disorder: Findings from Expressive Writing About Trauma

Background

Trauma exposure is a risk factor for substance use disorders (SUD) among women. This study explores written content from an expressive writing (EW) intervention conducted within a residential SUD program to examine themes across trauma experiences and characterize their deep insight into such experiences.

Materials and Methods

This qualitative study is a secondary data analysis of written content of the first writing session from women (n = 44) randomized to an EW condition while in residential SUD treatment.

Results

Nearly all participants (72.7% African American; mean age 37.3 years) reported a significant trauma event (93.2%) with an average of 3.7 types of trauma events (54.4% had a current posttraumatic stress disorder diagnosis). Four primary themes emerged: (1) trauma across the lifespan; (2) loss of safety; (3) altered self-concept; and (4) desire to move on. Most participants identified interpersonal trauma, especially at an early age, as well as parental neglect and physical and/or sexual violence. These themes indicate a pattern of interpersonal betrayal and paint a picture of trauma and the subsequent "rippling effect" such that the physical, mental, and emotional consequences were often as impactful as the event itself. However, there was also a desire to move on and gain a sense of normalcy.

Conclusions

Findings highlight the importance of the written word and addressing underlying trauma in addiction treatment to facilitate healing and the woman's desire to move on.

The delayed, durable effect of expressive writing on depression, anxiety and stress: A meta-analytic review of studies with long-term follow-ups

BACKGROUND

Expressive writing is a promising tool to heal the wounds with words.

AIMS

This meta-analysis evaluated the current state of efficacy of expressive writing on depression, anxiety and stress symptoms among healthy and subclinical samples.

MATERIALS AND METHODS

Thirty-one experimental studies (N = 4012) with randomized controlled trials and follow-up assessments were analysed.

RESULTS

Results showed that expressive writing had an overall small but significant effect (Hedges' g = -0.12, 95% CI [-0.21, -0.04]) on reducing symptoms of depression, anxiety and stress. Change score analyses suggested that the intervention effect emerged after a delay, as evidenced by assessments at follow-up periods. Moderator analyses indicated that the effect sizes varied as a function of one intervention feature: interval. Studies that implemented short intervals (1-3 days) between writing sessions yielded stronger effects (G_diff  = -0.18, p = .01) relative to studies that implemented medium intervals (4-7 days) or long intervals (>7 days). The effects of expressive writing remained consistent across other intervention features including focus, instruction, number of sessions, topic repetition and delivery mode.

DISCUSSION

Together, these findings provide evidence for the delayed, durable effect of expressive writing and underscore the importance of scheduling writing sessions at short intervals.

CONCLUSION

Implications for incorporating expressive writing into clinical practice and daily life are discussed.

Feasibility evaluation of psychosocial intervention for internally displaced youth in Kenya

BACKGROUND

There is limited evidence on the cultural appropriateness of first-stage psychosocial interventions for youth with mental health problems who experience conflict and disadvantage in low- and middle-income countries (LMIC).

AIMS

To evaluate the feasibility of such an intervention (Writing for Recovery - WfR) among youth with emerging emotional problems following internal displacement in Kenya.

METHOD

Fifty-four youth aged 14-17 years were randomly allocated to a six-session intervention or a waiting list control group. They completed measures of stressful life events; post-traumatic stress, depressive and anxiety symptoms; quality of life; and free text on their experience of the intervention.

RESULTS

Young participants reported high levels of trauma exposure and emotional problems. The intervention was perceived as flexible and culturally acceptable, with reported short-term impact. This was found to have promising post-intervention effect in reducing post-traumatic stress, but not depressive or anxiety symptoms; and in enhancing quality of life scores.

CONCLUSIONS

Similar psychosocial interventions that can be delivered by paraprofessionals are important for resource-constrained LMIC settings, but need to be integrated within a comprehensive scaled service model.

The effect of expressive writing on sexual risk behavior among college women

Objective: The current study tested an expressive writing intervention aimed at reducing alcohol use and sexual risk behavior among college women that consume alcohol. Methods: A 2 X 2 mixed between- within-subjects experimental design was utilized to test the effect of expressive writing on alcohol use and sexual risk behavior over time among college women that drink. Study participants completed baseline assessments of alcohol use and sexual risk behavior and were randomly assigned to either a control writing condition (first day of college) or an expressive writing condition (negative alcohol-related event). Participants completed baseline assessments 30 days later. Data for this study were collected in the Fall 2017 semester. Results: A significant interaction effect was found for writing condition over time on sexual risk behavior. Conclusion: Findings provide preliminary support for the use of expressive writing as mechanism to reduce sexual risk behavior among college women that consume alcohol.

Holistic Psychosocial Approaches in the Care of Hispanic Victims of Trauma: An Overview

The collapse of the Champlain Towers South (CTS), a condominium in Miami, Florida, left a diverse group of survivors and healthcare clinicians tasked with finding ways of coping with the disaster. Within seconds, the CTS collapse became a global tragedy due to the coastal neighborhood's rich international mix of residents. Although this tragedy impacted communities across globe, a large population of Hispanic victims lived in CTS that were deeply affected. Culturally adaptive interventions and holistic healthcare for Hispanic individuals are highly relevant because Hispanic Americans represent one of the fastest growing demographic groups in the United States. To reach, engage, and address the needs of Hispanic victims, this article provides an overview of psychosocial factors that influence Hispanic victims with trauma and discusses holistic psychotherapeutic approaches in nursing care that can be applied to improve victims' well-being. Culture is an important consideration in health; therefore, this article highlights and operationalizes culturally tailored holistic nursing care that draws from the physical, mental, emotional, and spiritual dimensions of health and well-being that can be used in clinical settings with Hispanic clients who have experienced trauma.

Effectiveness of Best Possible Self and Gratitude Writing Intervention on Mental Health Among Parents of Troubled Children

The current study was conducted to determine if journaling focused on best possible self and gratitude could improve physiological and mental health outcomes in a sample of affected parents who have teenagers or adult children with emotional and/or behavioral problems. A quasi-experimental, pretest/posttest design was used with blood pressure measure and saliva collection at baseline, after a first journal entry, and after a 6-week journaling intervention. Among 42 parents who completed the pretest, 37 (88.1%) completed the 6-week guided journal and posttest. Findings of paired t tests indicated a statistically significant decrease in stress level (p < 0.001), anxiety (p < 0.001), somatic symptoms (p = 0.001), and depression (p = 0.01), as well as increased gratitude (p = 0.012) among participants. Repeated measures analysis of variance indicated the journaling intervention showed a statistically significant reduction in systolic blood pressure (p = 0.016), but not diastolic blood pressure, or cortisol level at the three testing times. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 31-39.].

A Meta-Analysis of Expressive Writing on Posttraumatic Stress, Posttraumatic Growth, and Quality of Life

Expressive writing is beneficial for promoting both positive psychological and physical health outcomes. Unfortunately, inhibiting emotions is related to impairments in psychological and physical health. James Pennebaker and others have used expressive writing as an experimental manipulation to gauge its efficacy in treating a wide variety of physical and psychological outcomes. While many studies have been conducted that examine the efficacy of expressive writing across such outcomes, a considerable amount of these studies tend to neglect necessary considerations, such as different levels of symptomatology, power, and meaningfulness of respective effect sizes. Six previous meta-analyses have been conducted that examine expressive writing’s effect on psychological outcomes. However, these studies focus on the experimental versus control group effect size. Thus, our meta-analysis sought to examine the efficacy of an expressive writing task on only the experimental conditions in studies measuring posttraumatic stress, posttraumatic growth, and quality of life using random effects models. Results indicated a small overall effect size for posttraumatic stress and negligible to small effect sizes for posttraumatic growth and quality of life. However, those studies requiring a diagnosis of posttraumatic stress disorder (PTSD) exhibited a medium to large effect size. Implications for future research design and interpretation of published research are discussed.

Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment.

METHODS

This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status.

RESULTS

Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group.

CONCLUSIONS

Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.

What Do You Say Before You Relapse? How Language Use in a Peer-to-peer Online Discussion Forum Predicts Risky Drinking among Those in Recovery

Increasingly, individuals with alcohol use disorder (AUD) seek and provide support for relapse prevention in text-based online environments such as discussion forums. This paper investigates whether language use within a peer-to-peer discussion forum can predict future relapse among individuals treated for AUD. A total of 104 AUD sufferers who had completed residential treatment participated in a mobile phone-based relapse-prevention program, where they communicated via an online forum over the course of a year. We extracted patterns of language use on the forum within the first four months on study using Linguistic Inquiry and Word Count (LIWC), a dictionary-based text analysis program. Participants reported their incidence of risky drinking via a survey at 4, 8, and 12 months. A logistic regression model was built to predict the likelihood that individuals would engage in risky drinking within a year based on their language use, while controlling for baseline characteristics and rates of utilizing the mobile system. Results show that all baseline characteristics and system use factors explained just 13% of the variance in relapse, whereas a small number of linguistic cues, including swearing and cognitive mechanism words, accounted for an additional 32% of the total 45% of variance in relapse explained by the model. Effective models for predicting relapse are needed. Messages exchanged on AUD forums could provide an unobtrusive and cost-effective window into the future health outcomes of AUD sufferers, and their psychological underpinnings. As online communication expands, models that leverage user-submitted text toward predicting relapse will be increasingly scalable and actionable.

Stress Reduction Through a Brief Writing Intervention With Women in Jail

OBJECTIVE

To assess the feasibility/acceptability of writing as a stress reduction strategy with incarcerated women.

METHODS

The authors implemented a writing intervention in which six women wrote on topics of their choosing for 20 minutes on 5 consecutive days. Feasibility was assessed with investigator field notes; daily post-writing evaluations assessed intervention acceptability. The study also assessed the continuation of writing at 1-month postintervention and acceptability of instruments for evaluation of future interventions.

RESULTS

Implementation barriers were minimal; participants voiced enthusiasm about the program and continued to write 3 to 4 days per week in the month postintervention. No problems were encountered in the completion of evaluation instruments.

CONCLUSION

Writing is a feasible, reproducible stress relief intervention for incarcerated women.

Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations

BACKGROUND

Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.

DATA SOURCES

Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).

REVIEW METHODS

Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.

OBJECTIVES

To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.

RESULTS

From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.

LIMITATION

Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.

CONCLUSIONS

Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003343.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Posttraumatic Stress Disorder, Health Problems, and Depression Among African American Women in Residential Substance Use Treatment

BACKGROUND

Rates of posttraumatic stress disorder (PTSD) are high among women seeking treatment for substance use disorders (SUDs). Minority women, in particular, experience high rates of trauma and may be less likely to disclose trauma history. This article identifies items from pre-existing screening measures that can be used across settings to sensitively but noninvasively identify women with likely PTSD.

METHOD

For a sample of 104 African American women in residential SUD treatment who provided informed consent as a part of a larger randomized clinical trial, the prevalence of trauma and PTSD, as well as the relationships between trauma, health, depression, and distress, was examined. Measures included Posttraumatic Stress Diagnostic Scale (PDS), Center for Epidemiologic Studies-Depression Scale (CES-D), Pennebaker Inventory of Limbic Languidness (PILL), and Brief Symptom Inventory (BSI). Additional analyses were undertaken to determine if a subset of noninvasive items could serve to identify the presence of a probable PTSD diagnosis.

RESULTS

Most women (94.2%) reported at least one lifetime trauma, with over half (51.0%) meeting DSM-IV criteria for PTSD. Women with greater trauma symptom severity reported more health problems and higher levels of depression and distress. Five BSI items and one CES-D item were significantly associated with a probable PTSD diagnosis with a sensitivity of 88.7%, a specificity of 66.7%, a positive predictive value of 73.4%, a negative predictive value of 85.0%, and an accuracy of 77.9%.

CONCLUSION

Findings affirm that African American women with SUDs present for residential treatment with comorbid psychiatric and emotional conditions that warrant assessment and treatment. Results highlight potential benefits of brief screening with routine measures and coordinated access to ancillary psychiatric and medical services, in conjunction with substance treatment, such as in residential or primary care.