Winner of the 2006 Helpsam.org Research Grant Award
Susan D. Moore, M.A.
Boston University
The written narrative disclosure paradigm developed by Pennebaker and Beall (1986) has garnered much attention in the psychotherapy research literature. Work by Pennebaker and others suggests that writing repeated narratives about traumatic life experiences can increase physical and psychological health (e.g., Pennebaker, Colder, & Sharp, 1990; Greenberg & Stone, 1992). Narrative writing may increase awareness of internal experiences, foster conscious acknowledgement of previously unconscious experiences, and promote the distillation of meaning from troubling events (Brody & Park, 2004). The narrative disclosure task may be considered an analogue for studying psychotherapy, since both processes involve potential for catharsis and exposure to negative affect in a safe environment. Indeed, a number of psychologists have called for its use in clinical settings. Yet questions remain regarding individual difference and process variables that may predict response as well as the task's impact on mental health outcomes. This study aims to fill gaps in the literature by investigating whether individual differences in mindfulness and experiential avoidance predict depression, anxiety, general psychological symptomatology, and self-acceptance outcomes achieved through written disclosure. The study will investigate how the processes of mindfulness and experiential avoidance shift over time as a result of written disclosure, and how these shifts relate to changes over time in psychological outcomes. Finally, the study will investigate how emotional word content relates to individual difference, process, and outcome variables. Results may highlight important transformative processes in psychotherapy as well as the underlying processes involved in writing as an intervention for psychological change.
Experiential Avoidance
Perhaps the newest and most integrative advance in psychotherapy process research is the idea that the inability to attend to, regulate, and accept one’s emotional reactions, termed experiential avoidance, is at the heart of most psychological symptoms and disorders (Hayes et al., 1996). Experiential avoidance has been found to correlate significantly with general psychopathology, depression, and anxiety (Hayes et al., 2004). In studies of childhood sexual abuse survivors, experiential avoidance has been associated with psychological impairment (Polusny et al., 2004) and has mediated the relationship between status as an abuse survivor and psychological distress (Marx & Sloan, 2002). Plumb et al. (2004) found that coping by means of experiential avoidance after a traumatic event predicted increased psychological distress and, to a lesser degree, PTSD symptom severity.
Mindfulness
Experiential avoidance can be reduced with a variety of techniques designed to increase emotional awareness and acceptance, including mindfulness. Mindfulness has been defined as a two-component phenomenon comprising elements of self-regulated attention and an attitude of acceptance toward one’s experiences (Bishop et al., 2004). Recent research has found mindfulness to be negatively correlated with neuroticism, rumination, depression, and anxiety (Brown & Ryan, 2003), as well as alexithymia (the inability to articulate feelings), experiential avoidance, and general psychological symptomatology (Baer et al., 2004).
Brody and Park (2004) theorized that writing repeated narratives may involve the process of mindfulness, given that it requires self-directed attention that can heighten awareness of internal states. This heightened awareness is thought to promote psychological health by transforming implicit experiences into explicit ones and by newly applying language to such experiences, some of which may have been non-verbal (pre-conscious). Currently, little research addresses both mindfulness and narrative writing, and the ideas put forth by Brody and Park (2004) have yet to be tested empirically.
The Narrative Disclosure Paradigm
There is evidence to suggest that writing repeated narratives about upsetting experiences has beneficial effects on psychological functioning. Sloan and Marx (2004a) found that traumatized women who completed an emotional disclosure task experienced significant reductions in depressive and PTSD symptomatology. Additional studies have found decreases in depression after narrative disclosure (e.g., Lepore, 1997), although it should be noted that some such studies have not used psychometrically sound measures of symptomatology (Sloan & Marx, 2004b). Meta-analyses suggest that across studies and types of outcomes, the task yields positive results of medium effect size in healthy participants (d = .47; Smyth, 1998) and moderate effect size in clinical populations (d = .19; Frisina et al., 2004). Men often obtain greater benefits from the written emotional disclosure task than women (Smyth, 1998).
Recent research suggests that the individuals likely to benefit most from emotional disclosure are those who experience negative affect and yet avoid or inhibit their emotions (Pennebaker & Beall, 1986). Indeed, Solano and colleagues (2003) found that positive effects were observed only for participants high in alexithymia; research by Páez, Velasco, and Gonzáles (1999) supports this conclusion. In direct contrast, Smyth et al. (2002) found that alexithymia did not predict health outcomes or immediate emotional responses to narrative writing. Similarly, Smyth and colleagues (2002) found that behaviorally and psychologically avoidant individuals did not benefit any more or less than non-avoidant individuals from emotional disclosure. Lumley’s research (2004) suggests that alexithymic individuals are not likely to benefit from narrative interventions, perhaps due to their characteristic difficulties labeling and communicating specific emotions. In addition, Lumley argues that alexithymic individuals’ outward focus (i.e., attentiveness to external rather than internal events)—a focus perhaps shared by avoidant individuals—contributes to their difficulty engaging with the task and thus benefiting from it.
Clearly, the data on avoidance and emotional awareness as predictors of narrative disclosure task outcomes are puzzling. It is unknown whether or how the narrative writing task changes emotional regulation processes, and if emotional regulation skills represent critical individual differences that moderate responses to disclosure. Sloan and Marx (2004b) point out that methodological shortcomings—including insufficient sample sizes, too few writing sessions, and differing follow-up periods—may explain inconsistencies among studies. Further research is needed to determine how the emotional regulation variables described above relate to narrative disclosure task predictors and outcomes.
In summary, while narrative disclosure appears to represent a promising intervention for adults, questions remain regarding its mechanisms of action and individual attributes that differentiate responders from non-responders. Failure to use psychometrically sound assessment instruments hampers our current understanding of the psychological effects of narrative writing (Sloan & Marx, 2004b). It is also unclear whether the effects differ for members of ethnic minority groups, since previous research has been almost exclusively based on European-American samples. The present study will add to the empirical literature on the narrative disclosure paradigm, exploring relationships among disclosure, mindfulness, experiential avoidance, and mental health outcomes in an ethnically diverse sample.
Procedure Overview
On day 1 of the study, participants complete a demographic questionnaire and self-report measures of baseline mindfulness (Kentucky Inventory of Mindfulness Skills; Baer, Smith, & Allen, 2004), experiential avoidance (Acceptance and Action Questionnaire – Revised; Hayes et al., 2004), depression (Center for Epidemiologic Studies Depression Scale; Radloff, 1977), anxiety and general psychopathology (Brief Symptom Inventory; Derogatis & Melisaratos, 1983), and self-acceptance (Heartland Forgiveness Scale; Thompson et al., 2005). Participants are then randomly assigned to control or experimental conditions for 20-minute writing sessions. Control group participants write about an emotionally neutral topic (time management), while experimental group members write about their most traumatic experience. Participants return for two consecutive days to repeat the writing procedure. Care is taken that any participant experiencing distress during the study is offered referral to a mental health professional. Day 4 is a one-month follow-up assessment at which participants complete the psychological measures described above, are debriefed, and are provided monetary compensation.
Participants are undergraduates at
a large, private university. Power analyses and expectations for attrition
require recruitment of 300 participants to yield a minimum N of 192: 64
control and 128 experimental participants (men and women evenly distributed).
The sample is expected to include 30% ethnic minority and 70% White
participants.
Anticipated Findings
(1) At baseline, (a) higher mindfulness is expected to be associated with lower general psychological symptomatology, lower experiential avoidance, lower depression and anxiety, and higher self-acceptance; (b) higher experiential avoidance will be associated with higher depression, anxiety, and psychological symptomatology; and (d) there will be gender differences in depression, with women showing higher levels.
(2) While controlling for baseline levels, at follow-up the experimental group—when compared to the control group—will show: (a) higher mindfulness, (b) lower experiential avoidance, (c) higher self-acceptance, (d) lower depression, (e) lower anxiety, and (f) lower general psychological symptomatology.
(3) Males are expected to benefit more from the emotional disclosure task than females. Gender will also moderate relationships among predictor variables and outcomes (e.g., males high in experiential avoidance will benefit more from the task than females high in avoidance and all individuals low in avoidance).
(4) From pre- to post-task, participants who increase most in mindfulness, and decrease most in experiential avoidance, will show significantly more positive shifts in adjustment.
(5) A) Participants whose narratives contain increasingly higher percentages of negative affect words will show more improved psychological outcomes compared to those whose narratives show less change over time. B) Greater increases in affect words and cognitive insight words (e.g., “realize”) from first to last narrative will correspond with greater increases in mindfulness over the course of the study. C) Greater increases in positive and negative affect words over time will correspond with greater decreases in experiential avoidance.
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