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Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders



Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.
Family Practice Vol. 19, No. 2
© Oxford University Press 2002 Printed in Great Britain
Effects of guided written disclosure of stressful
experiences on clinic visits and symptoms in
frequent clinic attenders
Yori Gidrona, Elaine Duncanb, Alon Lazarc, Aya Bidermand,
Howard Tandeterdand Pesach Shvartzmand
Gidron Y, Duncan E, Lazar A, Biderman A, Tandeter H and Shvartzman P. Effects of guided written
disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders.
Family Practice
2002; 19: 161–166.
Background. Psychosocial variables such as major stressful life events/daily stressful events
have been associated with health care utilization.
Objective. Our aim was to examine the effects of a guided disclosure protocol (GDP) of past
traumas on symptoms and clinic visits among frequent clinic attenders.
Methods. Forty-one frequent clinic attenders (>2 visits/3 months) took part. Patients were
randomly assigned individually to either a casual content writing control group (
= 19) or a
trauma content writing experimental GDP group (
= 22). GDP patients wrote about an upsetting
event chronologically (day 1), verbally described their thoughts and feelings and descibed the
event’s impact on life (day 2), and finally wrote about their current perspective on and future
coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms
and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits
Results. Compared with controls, GDP patients reported lower symptom levels at 3 months
(2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month
(5.1 versus 9.7) follow-ups. The percentage of GDP patients making >10 visits during the 15 month
follow-up was smaller (10%) than among controls (33%).
Conclusions. The findings extend previous findings to frequent clinic users, using a new form
of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be
an inexpensive additional intervention in primary care for reducing symptoms and clinic visits
among frequent clinic users.
Keywords. Clinic visits, frequent attenders, memory shift, somatization, written disclosure.
An estimated 40–75% of visits to primary care providers
are related to psychosocial problems.1,2 Among the
psychosocial variables known to be associated with
health care utilization are somatization, major stressful
life events, daily stressful events and a psychiatric dis-
order.3,4 The combination of daily stressful events with
sensitivity to and over-reporting of body sensations or
somatization was predictive of clinic visits in several
studies.3,5 Among somatizers, who frequently visit health
clinics, 66–75% did not benefit from medical and surgical
procedures.6These studies suggest that attempts at re-
ducing utilization of health clinics among frequent users
need to consider and treat problems related to daily or
major stressful events.
People who reported inhibiting the disclosure of past
stressful traumatic events (e.g. sudden death of a spouse)
were found to be more ill in the subsequent year.7In
contrast, active disinhibition by writing for 3–4 days of
past traumatic events has been found to reduce health
centre visits, to enhance immunocompetence (pro-
liferation of T-helper cells8,9), to enhance the action
of hepatitis B vaccinations10 and, most importantly, to
improve clinically relevant health outcomes of asthmatic
and rheumatoid arthritis patients.11 A meta-analysis
Received 18 December 2000; Revised 14 August 2001;
Accepted 1 November 2001.
Departments of aSociology of Health, cBehavioral Sciences
dFamily Medicine, Ben-Gurion University, Be’er-Sheeba,
Israel and bDepartment of Psychology, Glasgow Caledonian
University, Glasgow, UK.
showed that such brief trauma disclosure has positive
overall health benefits.12
A deeper examination of disclosure studies reveals
that not all patients or students benefit from the usual
unstructured written disclosure. One recent study13
found that disclosure of stressful events had no effect
on clinic visits among frequent attenders. Corroborative
evidence provides important clues as to how to enhance
the effects of brief disclosure, without adding therapist
interventions. Foa et al.14 found that rape victims who
disclosed their traumatic event chronologically had
less psychiatric symptomatology later. Pennebaker and
Francis15 showed that subjects who disclosed their
trauma while writing words indicative of self-reflection
(e.g. “I realize”) had the greatest health benefits. Another
study found that only those who wrote in moderate
cognitive complexity, but not in little or high levels of
cognitive complexity, had positive health benefits from
writing.16 These findings strongly suggest that people
need and may benefit from guidance in the content and
manner of written trauma disclosure.
Furthermore, a broad range of studies on post-traumatic
stress disorder suggests that traumatic memories are
encoded in a somato-sensoric (e.g. visual cortex) and
affective limbic (e.g. amygdala) memory mode17,18 possibly
with characteristics of implicit and relatively automatic
memory processes.19 In contrast, linguistically labelling
emotionally negative stimuli (‘these are angry faces’) has
been shown to diminish amygdala activity compared
with processing such stimuli in an affective and sensory
manner.20 Guiding individuals in disclosing their trauma
chronologically, in using self-reflection and in linguistic-
ally labelling stressful physical and emotional experiences
(rather than simple ventilation and re-experience), may
help shift the encoding of traumatic memories from an
uncontrolled, somato-sensory and affective memory mode
to a relatively more controlled cognitive and explicit
memory mode.21 Such a shift in memory processing
may reduce the extent of uncontrollable intrusions of
traumatic memories and, thus, the need to inhibit them
and the potential ‘health costs’ due to actively inhibiting
them.7One study which provided direction in writing
found that a self-regulatory disclosure (having subjects
plan future coping strategies) resulted in reductions in
clinic visits similar to the usual non-directed disclosure.22
However, the self-regulatory disclosure did not include
instructions to organize events’ descriptions chronologic-
ally, or to reprocess physical/emotional memories more
cognitively. Enhancing the shift in the mode of traumatic
memories seems to be crucial for health benefits.
Given the studies reviewed above, it seems appropriate
to examine the effects of a guided written disclosure on
clinic visits of community patients who visit health clinics
more than the norm. These patients may require
psychological assistance in addition to usual care, and
place a burden on health providers. We developed a new
guided disclosure which aims at helping patients shift
their trauma memory from implicit to explicit memory,
possibly providing them with more control over these
stressful memories. The purpose of this study was to test
the effects of a guided written disclosure on symptoms
associated with somatization and on health care utiliza-
tion among frequent attenders at an Israeli community
clinic. We hypothesized that frequent attenders de-
scribing past traumas/stressful events in a guided manner
would report fewer symptoms associated with somatiza-
tion and make fewer visits later than controls writing
about casual topics.
Fifty Israeli out-patients attending a community clinic
in Be’er Sheeba (south of Israel) were recruited for this
study by their family physician according to the follow-
ing inclusion criteria: (i) between the ages of 21 and
65 years; (ii) having visited the clinic at least twice during
the past 3 months (above the mean number of visits at
urban clinics in Israel;23 (iii) no known mental illness or
major cognitive difficulties; (iv) no known chronic illness
(e.g. hypertension, diabetes); and (v) judged by their
family physician to be able to write in Hebrew (hence
this was not a randomly selected sample). All patients
provided written informed consent and the study
was approved by the Ethics Committee of the Soroka
University Medical Center. Data of eight chronic patients
who entered the study by mistake were excluded, and
the data of one patient who was a staff member of a com-
munity clinic (and, thus, may receive informal medical
care) were also excluded. The final sample included 41
patients. We encountered minimal refusal to participate.
Background and medical data
Background data included patients’ age, gender and
years of education. In addition, the season during which
each subject was first met and asked to write was
registered (coded: 1 = autumn; 2 = winter; 3 = spring;
4 = summer). Medical measures included a simple one-
item assessment of global health24 rated for each patient
by his/her family physician (4 = irreversible illness with
serious disability; 3 = serious chronic illness without
disability; 2 = minor chronic problems; 1 = excellent
health). This parameter was used to verify a similar health
status in experimental and control groups (in addition to
the inclusion criteria). The numbers of clinic visits during
the 3 months prior to the study, during the 3 months after
writing and during a mean of 15 months after the first
follow-up were extracted from patients’ records.
Psychological measures
To assess symptoms associated with somatization,
we used a brief 6-item scale derived from the Hopkins
Symptoms Check List25 which included frequency of
Family Practice—an international journal
muscle pains, low back pains, and feelings of heaviness,
weakness, numbness and faintness during the past month.
Each item was answered with a 4-point frequency scale
(0 = never; 1 = hardly; 2 = sometimes; 3 = all the time),
and the sum across all six items yielded the symptoms
score. Life events were assessed with a brief list of nine
events based on a previously validated version of The
Life Events Readjustment Scale.26 This scale included
46 items relevant to Israelis. In order to have a brief and
age-appropriate scale, we selected for this study only
items whose stressfulness was estimated as .60/100 in
the original study26 and which seemed age-appropriate
to our sample (examples of items are death of a spouse,
divorce, being a Holocaust survivor). Items can be pro-
vided upon request from the first author. This parameter
served to verify a similar history of life events in the
experimental and control groups.
Writing conditions
We developed a new guided disclosure protocol (GDP;27)
whose rationale is derived from a broad range of findings
from clinical studies and cognitive neuroscience reviewed
above. The GDP aims to provide patients with greater
control over their trauma memories, and hence reduce
their need to inhibit them, and reduce the potential
health cost associated with such inhibition. In the
GDP condition, patients were asked to write about their
most stressful or upsetting experience from the past few
years for 15 minute periods, over three consecutive days.
On day 1, patients were asked to describe the event in its
chronological order, in a ‘journalistic manner’, without
expression of emotions. On day 2, they were asked to
describe their thoughts and feelings at the time of the
event (to enhance cognitive processing and verbal label-
ling of sensory and affective responses), and whether the
event affected their life (to enhance self-reflection).
Finally, on day 3, they wrote how they currently thought
and felt about the event (to enhance perspective), and
what they would do in the future, should they encounter
similar events (to enhance self-regulation).
Controls were asked to write for three consecutive
days about the following neutral topics: daily activities
(day 1), their house (day 2) and their current or last job
(day 3), without emphasizing any emotionality. This
is similar to previous trials, and mainly controls for
expectations and experimenter contact. All participants
were seen at their homes by a research assistant.
A single-blind randomized controlled prospective
design was used. Potential participants were screened by
their physician, who then approached them over the
phone and asked them whether they would be interested
in taking part in a study testing the effects of writing
on health of patients. Consenting patients were then
assigned randomly to either the casual content control
condition (n= 19) or the GDP experimental condition
(n= 22). Upon arrival of the researcher at the patient’s
home, the patient completed the informed consent form.
Prior to the first disclosure, and 3 months later, patients’
symptom scores and number of clinic visits were
assessed. Reassessment of symptoms at 3 months post-
disclosure was done by a researcher who was blind to
the patients’ group status. Reassessment of clinic visits
was done by the family physician who was blind to the
patients’ group status. The first follow-up of clinic visits
took place 3 months after writing (parallel to reassess-
ment of symptoms), and the second took place in July,
2000, between 10 and 20 months after the first follow-up
(mean = 15.2 months). During the second follow-up,
symptoms were not reassessed.
Data analysis
To test whether patients in the GDP group adhered to
the writing task, a manipulation check compared the
frequency of using negative affect words (e.g. ‘anxious,
sad’) and insight (e.g. “I realize that I was shaken by the
event”) in the GDP and control groups using t-tests. To
control for fluency of writing, these analyses were per-
formed on the number of words in each category divided
by the total number of words a patient wrote, across all
three writing days. The equivalence of both groups at
baseline on all measures was verified with t-tests for
continuous data and chi-square tests for dichotomous
data. A repeated-measures analysis of variance (ANOVA)
was conducted in relation to symptoms and clinic visits,
with time of assessment (time: baseline versus follow-
ups) being the within-subjects factor and group (group:
GDP versus control) being the between-subjects factor.
We expected a time by group interaction such that
conditions will differ in relation to symptoms and clinic
visits only at follow-up(s).
Equality of groups at baseline and adherence
to the writing task
No statistically significant differences were found
between the groups in relation to age, gender, years of
education, health status, season of writing sessions,
number of past traumatic events, number of clinic visits
in the 3 months prior to the study and the duration of the
second follow-up in relation to clinic visits. However, the
experimental group (see below) reported significantly
lower levels of symptoms at baseline than controls.
Patients in the GDP group adhered quite well to the
writing instructions in relation to chronological organ-
ization (day 1), describing past emotions and impact on
life (day 2) and current perspective (day 3). Support-
ing this quantitatively, GDP patients wrote proportion-
ally significantly more words reflecting negative affect
and insight (all significant at P,0.01) than controls.
Table 1 depicts the means (and standard deviations) of
Effects of guided written disclosure in frequent attenders 163
background, medical and psychological data of patients
in the GDP (experimental) group and in the casual
writing (control) group.
Effects of writing on health outcomes
The means (SD) of symptoms and clinic visits at baseline
and both follow-ups (for clinic visits only) are shown
in Table 1. Concerning symptom levels, the ANOVA
revealed a significant time effect [F(1,29) = 8.2, P,0.01]
and a significant group effect [F(1,29) = 4.5, P,0.05].
Contrary to our hypotheses, the interaction effect of
time by group was not significant [F(1,29) = 0.4, NS]. At
baseline and at the 3 month follow-up, GDP patients
reported significantly less frequent symptom levels than
controls [t(39) = 2.2, P,0.05; t(29) = 1.9, P,0.05,
respectively; degrees of freedom differ due to subject
attrition at follow-up]. However, GDP patients appeared
to show (though not significantly) larger reductions
in symptom reporting (41%) than controls (20%; see
Table 1).
Concerning clinic visits, the ANOVA revealed a
significant time effect [F(2,36) = 14.6, P,0.0001] and a
significant group effect [F(1,36) = 6.1, P,0.05]. Most
importantly and as hypothesized, we also found a signifi-
cant time by group interaction [F(2,36) = 3.3, P,0.05],
such that GDP patients visited their clinic significantly
fewer times than controls at the 3 month follow-up
[t(36) = 2.84, P,0.01] and also at a mean of 15 months
later [t(28) = 1.98, P,0.05], but not at baseline (P.0.05).
These findings are depicted in Figure 1. GDP patients
showed a reduction of 58% in clinic visits compared with
14% in controls at the 3 month follow-up compared with
3 months prior to writing. Since groups differed signifi-
cantly on the symptom score at baseline, we repeated
this latter test after controlling statistically for the effects
of baseline symptoms. GDP patients still visited their
clinics significantly less frequently than controls after
controlling for the effects of baseline symptoms at the
3 month follow-up [F(1,35) = 4.9, P,0.05] and 15 months
later [F(1,35) = 6.2, P,0.05].
Are the effects of writing on clinic visits clinically
We then examined whether the statistically significant
effects of the GDP writing condition on clinic visits were
clinically significant. To do this, we compared the per-
centage of patients in each group at the mean 15 month
follow-up who visited the clinic below versus at or above
10 times during that follow-up period. This cut-off re-
flected the mean number of urban clinic visits in Israel24
over a mean follow-up of 15 months. During this follow-
up period, 90% of GDP patients versus 67% of controls
visited the clinic fewer than 10 times, while 10% of GDP
patients versus 33% of controls visited the clinic at least
10 times. These differences in percentages between groups
were statistically significant [chi-square (1) = 3.10,
The main findings of this study are that frequent
attenders at primary care clinics who wrote in a guided
manner for three consecutive days about past stressful
events visited their clinic significantly fewer times
and reported less frequent symptoms associated with
somatization than those writing about casual topics. The
effects of group status on clinic visits seen at 3 months
after writing were also maintained a mean of 15 months
Family Practice—an international journal
TABLE 1Means (SD) of background, medical and psychological
data for GDP and control patients baseline, 3 month and long-term
Variable GDP Control
(experimental) n= 19
n= 22
Background, medical and psychological data
Gender 82% females 68% females
Age 43.9 (9.0) 44.6 (10.0)
Education 13.8 (2.7) 12.9 (2.6)
Health status (1–4) 1.7 (0.5) 1.6 (0.5)
No. of life events (0–9) 0.9 (1.2) 1.6 (1.2)
At baseline symptomsa4.1 (2.7) 5.9 (2.3)*
3 month follow-up symptomsa2.4 (3.6) 4.7 (2.6)*
At baseline clinic-visits 3.1 (1.4) 3.5 (1.9)
3-month follow-up visits 1.3 (1.4) 3.0 (2.2)**
Long-term follow-up visitsb5.1 (3.7) 9.7 (5.6)**
GDP = guided disclosure protocol.
*P, 0.05; **P, 0.01 (differences are between groups at each
assessment period).
aSymptoms were assessed with the somatization subscale of the
Hopkins Symptoms Check List;25 symptoms were not assessed at the
long-term follow-up.
bLong-term follow-up for clinic-visits was a mean of 15 months after
the first follow-up.
FIGURE 1Effects of group status and time on clinic visits
(vertical axis)
later. These effects were independent of baseline symp-
toms, which differed between groups despite random-
ization. Furthermore, the percentage of GDP patients
making at least 10 clinic visits during the mean 15 month
follow-up was significantly lower than among controls, a
clinically significant finding of potential economc value
as well. In fact, many GDP patients would now not meet
the inclusion criteria for the study after taking part in the
experimental condition and reducing their clinic visits.
These findings support those of previous studies9–11
and extend them to a community sample of frequent
clinic atttenders. Unlike the findings of a recent study,13
our disclosure protocol was successful in reducing clinic
visits. Our disclosure protocol differs substantially from
previous unstructured interventions. By building upon
findings of content analyses of previous clinical studies
and upon findings in cognitive neuroscience concerning
the manner in which trauma is encoded in memory, we
attempted to maximize the effects of writing by guiding
patients to write chronologically, with labels and insight.
This guidance attempted to shift trauma processing from
an implicit somato-sensoric and limbic memory mode, to
an explicit cognitive and verbal memory mode. Though
we could not demonstrate these changes in brain pro-
cesses with the measures used in the present study, we
attempted to achieve this processing shift by asking
patients a series of questions across the three writing
days, rather than inviting them to ventilate without any
guidance. Not guiding patients may even result in insuffi-
cient or too much cognitive processing of past traumas,
both of which have been associated with adverse health
outcomes compared with moderate processing.16 The
GDP may bring both extremes to a moderate level of
cognitive complexity.
To the best of our knowledge, these findings are the
first positive findings to be shown with frequent clinic
users. We did not examine the mechanism(s) of these
effects. However, based on previous studies, written
disclosure may reduce overutilization of health clinics by
its positive effects on immunity and/or emotional well-
being.9,12 Our findings may be particularly relevant to
the medical treatment of frequent clinic users since such
patients are characterized by psychiatric diagnoses, past
daily/major stressors and high somatization levels.3–5
Future studies may wish to identify the mechanism(s)
underlying these findings more closely. The GDP offers
a simple, inexpensive and potentially effective addition
to typical medical treatment for reducing the overuse of
clinic visits as well as possibly reducing symptom levels
among frequent clinic users. This adjunctive form of
intervention may be important particularly since
somatizers do not benefit in most cases from medical/
surgical treatments.6In addition to improving patients’
well-being, such a finding may have an important
economic value by reducing clinic use.
This study did not include physical outcome measures
such as immune function, measures of organ function,
etc. previously shown to be positively affected by written
disclosure.9–11 However, our main aim was to examine
the effects of written disclosure on symptoms and clinic
visits in a sample of frequent clinic users. In addition, the
small and selective sample size reduces the generalize-
ability of our findings to more general samples of pri-
mary care patients. However, the statistically significant
effects obtained with a small sample claim for the
strength of the effect size of the GDP. In addition, we
deliberately aimed at testing the effects of the GDP
with frequent clinic attenders. Another limitation is the
lack of a usual non-guided trauma disclosure condition
to compare with the new GDP. This may have provided
evidence for our contention that the GDP provides a
more controlled, and thus healthier manner of process-
ing trauma than the usual non-guided protocol. Such a
comparison is under way in another study. Should these
findings be replicated with larger samples of patients
visiting primary care clinics, the GDP may constitute an
additional form of intervention for frequent attenders
in primary health care. With minimal physician interven-
tion, GPs may then also serve as confidants for people
with past traumatic life events and frequent clinic visits,
using a structured framework such as the GDP. This may
add a new dimension to the practice of primary care.
The authors wish to thank Daniela Arnon, Vivian Torkel,
Racheli Eden, Zehorit Asulin, Hadas Noyman and
Dafna Baruch for their efforts and assistance in
conducting this study.
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Presented at: British Psychological Society, Division of Health-
Psychology, Bangor, UK, 1998.
Family Practice—an international journal
... Previous research on the effects of GWD on health outcomes led to mixed results and the effectiveness of writing interventions is still unclear and controversial [14]. Gidron et al. [15] found that frequent clinic attenders in the GWD group made fewer clinic visits and reported lower levels of symptoms associated with somatization compared to those in the control group. Martino et al. found that patients with breast cancer following GWD reported a significant reduction in intrusive thoughts and irritability compared to the control group [16]. ...
... Both Pennebaker's expressive writing and GWD share similar theoretical underpinnings; however, a key difference between them is the intervention format. Though participants are invited to write freely about their deepest thoughts and feelings in Pennebaker's expressive writing, GWD has a structured format providing guidance on how and what to disclose of adverse or traumatic events [15]. This guidance is meant to organize the chronological description of events and to facilitate the reprocessing of memories related to stressful events into existing schemas. ...
... Moreover, expressive writing did not improve skin-related quality of life and psychological distress in patients with psoriasis [19]. Whereas Pennebaker's expressive writing is focused on expression of emotions, GWD additionally enhances a cognitive reprocessing by means of structured guidance [15,18,21]. Hence, null findings in our study suggest that additional characteristics of GWD do not provide benefits to dermatological patients. ...
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Background. Skin diseases (e.g., psoriasis and systemic sclerosis) are generally associated with negative psychosocial outcomes. Although different psychological interventions have been used to improve the quality of life of dermatological patients, the effects of the guided written disclosure (GWD) protocol have not been previously examined in these patients. Moreover, little attention has been paid to positive psychology constructs. Methods. This study investigates the effectiveness of GWD on positive and negative functioning in dermatological patients. Pre- and 1-month post-intervention measures included emotion regulation, sense of inner peace, skin-related symptoms and functioning, sense of coherence, and psychological distress. Results. A total of 196 consecutive outpatients were randomly assigned to GWD and active control groups, of whom 60 (30.6%) completed the study and 45 (GWD: n = 24; AC: n = 21) provided complete data. Our results did not show any significant difference between the experimental and control groups in the outcome variables, whereas non-completers reported higher levels of distress, unpleasant skin-related emotions, and lower cognitive reappraisal compared to completers. Conclusions. These findings show a poor compliance, and suggest that expressive writing is not well accepted by patients and is not effective in improving positive and negative psychological functioning in dermatological patients.
... Moreover, we considered it the best option for the Write "n" Let Go program because it allows participants to reflect on a topic of their choice from different perspectives, potentially eliciting various changing paths or processes. This notion of writing in a guided manner was also proposed by Gidron et al. (2002), with the Guided Disclosure Protocol that aimed to help participants explore different perspectives of a traumatic experience and accomplished successful results (Duncan and Gouchberg, 2007). ...
... Gellaitry et al. (2010) tested a similar design applied to cancer patients, with positive results on satisfaction with emotional support. Their study also used 20-min writing tasks on 4 consecutive days and combined instructions that were based on the Guided Disclosure Protocol from King and Miner (2000) and Gidron et al. (2002). ...
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Background There are a plethora of studies on expressive writing and positive writing interventions, but few have addressed the combination of both paradigms. Additionally, research on the role of ambivalence toward change in the context of writing-based interventions is lacking. Ambivalence toward change is a natural movement of approaching and avoiding change that may occur in various situations. In psychotherapy, its resolution is associated with successful outcomes.AimThis study tested the efficacy of a combination of expressive and positive writing paradigms in an internet-based intervention to improve university students’ mental health. Additionally, focusing participants on a current, unresolved problem allowed us to explore the possible role of ambivalence toward change as a mediator of the intervention’s results.Methods We recruited 172 participants who were randomly divided into experimental (n = 85) and control (n = 87) groups. The intervention consisted of the identification of a current problem and four writing tasks on consecutive days. Assessment was conducted at baseline and posttest in both groups and at follow-up in the experimental group. Participants in the experimental condition were also assessed after each task. Measures of anxiety, depression, rumination, ambivalence toward change, distress, and wellbeing (optimism, affect, and satisfaction with life) were collected.ResultsMultivariate analysis of variance (MANOVA) showed that participants in the experimental group had a significant decrease from baseline to posttest in ambivalence toward change and rumination when compared with the control group. These results were maintained at follow-up. No differences were found in the remaining measures. Within the experimental group, ambivalence toward change, rumination, and distress significantly decreased throughout the intervention and the exploratory mediation analysis indicated that ambivalence toward change partially mediated the improvements in rumination and distress.DiscussionConsidering different perspectives about a current problem and using a combination of expressive and positive writing fostered the reduction of ambivalence toward change and rumination. Ambivalence toward change reduction after the second writing task may have created optimal conditions for the subsequent decrease in rumination and distress. Future studies should replicate this finding and dismantle the components that are more adequate in changing these variables.
... A psychological intervention which has been subject to much empirical research in both clinical and non-clinical populations is Written Emotional Disclosure (WED) [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]. This therapy typically involves writing about a stressful or traumatic experience for 20 minutes a day over three consecutive days and has been found to have significant effects on a range of measures of physical and psychological wellbeing [28]. ...
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Background: Older adult carers of people who experience psychosis are at increased risk of developing physical and mental health problems due to the compounding factors of supporting their care-recipient and the health changes associated with ageing. Effective interventions exist but can be difficult to access and maintain prolonged engagement. Self-directed writing therapies, frequently referred to as Written Emotional Disclosure (WED), might be a suitable alternative intervention to improve the wellbeing of carers. Methods: This study aimed to determine the feasibility (recruitment, retention and primary outcome completion) and acceptability of a specific WED intervention known as Positive Written Disclosure (PWD). Informal carers of people with psychosis were randomised to PWD, neutral writing or no writing. Quantitative outcomes including positive and negative affect, carer wellbeing, quality of life, depression, anxiety, stress, self-efficacy, leisure time satisfaction as well as health care utilisation were collected at baseline, 1-, 3-, and 6-month assessments. Qualitative feedback was also collected via questionnaire and semi-structured interviews from those randomised to either writing group. Results: We successfully met our progression criteria, recruiting to target and within timeframes whilst attaining 97% retention and 84% primary outcome data completed at 6 months. Carers randomised to the positive writing group described the intervention as enabling them to have a more positive attitude and focus on activities for themselves. Both writing groups described their tasks as providing distraction from caring responsibilities. However, some carers found the narrow positive emotion focus challenging. Conclusions: PWD is a feasible and acceptable intervention for older adult carers of people with psychosis within a community setting. Further refinement of the writing protocol to include choice in type of emotion disclosed in addition to screening for some level of need may be required in future trials to reduce floor/ceiling effects of outcomes which may explain the lack of change observed.
... Building on these principles, expressive writing was designed to be used as an element in therapy or as an independent intervention to promote mean ing-making and integrate traumatic content into a personal narrative (De Luca Picione et al., 2017;De Luca Picione et al., 2018;Martino & Freda, 2016;Martino et al., 2013). One such expressive writing intervention, the Guided Written Disclosure Protocol (GWDP) has been used to reduce distress, anxiety, and PTSD symptoms in parents of children with cancer, whereas results for depression have been less promising (Cafaro et al., 2019;Dicé et al., 2018;Duncan & Gidron, 1999;Duncan et al., 1998;Gidron et al., 2002;Martino et al., 2019;Martino et al., 2013). This protocol is designed to help participants build an increasingly complex and coherent narrative by building on themes of meaning-making, insight, emotion-regulation, mastery and self-efficacy (Baikie & Wilhelm, 2005). ...
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Background Sex differences are widely reported in clinical psychology but are rarely examined in interventions. Method This mixed-method explorative study examined sex differences in 13 mothers and 10 fathers of children in the off-therapy phase of acute lymphoblastic leukaemia. Parents underwent an expressive writing intervention using the guided written disclosure protocol (GWDP). Results Mothers had more negative mood profiles than fathers but improved more during the intervention. Conclusion Though preliminary, our findings highlight the importance of sex as a potential moderator of intervention and treatment outcome that could be of great clinical significance.
... A sample of different studies points to some of the difficulties of achieving consistency and reliability of research outcomes regarding writing's effects. For example, Schoutrop et al. (2002) examine the impact of writing on the processing of stressful events, Klapow et al. (2001) show a reduced use of outpatient services and Gidron et al. (2002) show a reduced number of clinic visits. In the Schoutrop study, closer analysis of the impact of writing on effects of the trauma was not followed up. ...
Creative writing practices in medical settings and for therapeutic purposes
... Written disclosure protocols, in which individuals express their thoughts and emotions about traumatic or stressful life events, have been associated with improvements in both psychological and physical health 46 . The effectiveness of GDP in comparison to the standard disclosure protocols is under discussion and various studies have investigated the efficacy of the two. ...
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Background: The two constructs traumatic stress and Post-Traumatic Growth (PTG) are distinct and the psychophysiological relationship is yet to be explained. It’s a long debate that the victims who survive through the traumatic event only perceive that their suffering has helped them in improving their lives after the event or the experience actually improved functioning. Objective: The purpose of designing this randomized control trial is to observe psychophysiological alterations associated with PTG in traumatic stress subjects. Methodology: This Multicenter study is planned to investigate the effectiveness of the guided disclosure protocol (GDP) for the promotion of PTG, in the traumatic stress subjects and to determine whether PTG is associated with psychophysiological alterations i.e. (C-Reactive Protein, Brain Derived Neurotropic Factor, Interlukin-6, Cortisol, Heart Rate Variability and brain waves). Study subjects meeting eligibility criteria will be randomized into two groups. GDP will be used as intervention vs the control. Blinded treatment will be provided and the subjects will be made to complete study questionnaires (Screening, Traumatic Stress Scale SSS, Trauma Symptom Checklist, Post-traumatic growth Inventory) at baseline and at post-intervention (3-months later). Discussion: This study might give us insight about the application and efficacy of GDP in a population that is seeking help and underrepresented to be clinical. Moreover, one of the more hopeful findings of this research will be significant information about trauma-related psychophysiological effects.
... Successful people throughout history have kept journals.Previous work indicates that writing about a stressful or emotional event for 15-20 minutes can, after several bouts of writing across time, provide both physical and psychological benefits for clinical (e.g. Depression) patients (Gidron, Y., Duncan, E., Lazar, A., et al.,(2002) as well as nonclinical populations. Although some investigations find that expressive writing is beneficial, its effects are clearly not unequivocal, which highlights the importance of identifying who will benefit and who will not. ...
This study has been conducted to study the impact of diary writing on mental health of adolescent girls. A sample of 100 girlsfrom Shri Ram Collage Muzaffernagar (U.P.), who are studying in first year of graduation, was selected from accidental sampling method.Sample was divided into two groups, 50 in experimental group and 50 in control group. Diary writing was selected as the independent variable, which was appliedfor 3 months where girls used to write down their thoughts and feelings; independently 30 minutes each for 5 days a week. Mental health of girls was assessed using the ‘Mental Health Inventory’. Statistical analysis of the data was performed using the SPSS software (version 18) the result indicated that there was a significant difference between experimental and control group on the level of mental health of adolescent girls. The findings of this study indicate that the practice of diary writing significantly improved the level of mental health of adolescent girls.
This chapter puts behavioral medicine in context of one of the most common health problems, the common cold. After describing the opening case, the chapter reviews the incidence, consequences, and pathophysiology of the upper respiratory tract infection (URTI). Psychological risk factors of the URTI are reviewed which include chronic stress, low positive affectivity, and little social support, to name but a few factors. The cognitive-behavioral consequences of the common cold are reviewed followed by the PNI pathways linking psychosocial factors to the URTI. We then learn about the effects of psychological interventions on preventing the URTI and finish this chapter by retuning to its opening case. This chapter represents one of the most profound and empirically consistent evidences for the role of behavioral medicine in a health condition.
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This study investigated whether emotional expression of traumatic experiences influenced the immune response to a hepatitis B vaccination program. Forty medical students who tested negative for hepatitis B antibodies were randomly assigned to write about personal traumatic events or control topics during 4 consecutive daily sessions. The day after completion of the writing, participants were given their first hepatitis B vaccination, with booster injections at 1 and 4 months after the writing. Blood was collected before each vaccination and at a 6-month follow-up. Compared with the control group, participants in the emotional expression group showed significantly higher antibody levels against hepatitis B at the 4 and 6-month follow-up periods. Other immune changes evident immediately after writing were significantly lower numbers of circulating T helper lymphocytes and basophils in the treatment group. The finding that a writing intervention influences immune response provides further support for a link between emotional disclosure and health. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We used a hospital computer to identify 50 patients (35 women, 15 men) satisfying research criteria for “frequent attenders” at a gastroenterology outpatient clinic (four or more visits to a general hospital clinic in the previous 12 months). Their mean duration of symptoms was 5 years, and 80% reported fatigue as a significant complaint. Thirteen (37%) of the women were also consulting a gynecologist, and in nine of these their status was normal. Seven (21%) of the 35 women who were interviewed had a history of childhood sexual abuse, and these patients reported significantly more lifetime somatic symptoms (9.7, SD = 3.8) than those without such a history (5.4, SD = 3.5, p = 12 visits over the previous 12 months), and the patients reported a mean number of 5.7 (SD = 2.1) specialist appointments in the previous year. There may be a case for using the hospital computer to identify frequent attenders proactively at an earlier stage of their hospital visits so that appropriate management can be instituted. If such patients can be identified in this way, their assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.
Tested the hypothesis from D. Mechanic's (1972) attribution theory of somatization that somatizers who are under stress will overuse ambulatory medical services. 214 patients from ambulatory care clinics completed the Diagnostic Interview Schedule and the Life Experiences Survey. The interaction of somatization, psychiatric diagnoses, and life stress were examined in predicting frequency of medical visits during the preceding year, after controlling for active medical problems and predisposing factors. As hypothesized, somatizers who were under stress made more visits to the clinics than did nonsomatizers or somatizers who were not under stress. Although stress affected somatizers most, stress was predictive of increased medical utilization for all patients. Results suggest that psychological services intended to reduce overutilization of outpatient medical services might best focus on stress management. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Integrates findings from the fields of cognitive science, child development, and trauma to address basic questions about posttraumatic stress disorder (PTSD). Mechanisms of divided attention and emotional flooding during traumatic experiences may explain classic memory (ME) findings in PTSD: psychogenic amnesia in the setting of hyperarousal, startle response, intrusive images, and avoidance behaviors. Cognitive research shows that blocked focal attention leads to impaired explicit processing but intact implicit recall. The hippocampal formation is crucial for explicit ME processing, involving a subsequent consolidation process that is postulated to make MEs permanent in the cortex. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This paper presents a coding system developed to explore changes in narratives of rape during therapy for posttraumatic stress disorder (PTSD) involving repeated reliving and recounting of the trauma. Relationships between narrative categories hypothesized to be affected by the treatment and treatment outcome were also examined. As hypothesized, narrative length increased from pre- to post-treatment, percentage of actions and dialogue decreased and percentage of thoughts and feelings increased, particularly thoughts reflecting attempts to organize the trauma memory. Also as expected, increase in organized thoughts was correlated negatively with depression. While indices of fragmentation did not significantly decrease during therapy, the hypothesized correlation between decrease in fragmentation and reduction in trauma-related symptoms was detected.
Four decades ago 204 men were selected as adolescents for an interdisciplinary study of health; since then they have been followed biennially. Of the 185 men who remained in the study and in good health until 1964 (age, 42 +/- 1 years), 100 men remained in excellent physical health over the next 11 years, 54 acquired minor problems, and 31 acquired serious chronic illness or died. Of 59 men with the best mental health, assessed from the age of 21 to 46 years, only two became chronically ill or died by the age of 53. Of the 48 men with the worst mental health from the age of 21 to 46, 18 became chronically ill or died. The relation between previous mental health and subsequent physical health remained statistically significant when the effects on health of alcohol, tobacco use, obesity, and longevity of ancestors were excluded by multiple regression analysis. The data suggest that good mental health retards midlife deterioration in physical health.
This study describes the utilization of surgical operations, frequency and outcome of medical and surgical treatment in a group of persistent somatizers compared with a control group of non-somatizers. The study was carried out using the Danish national medical register to identify persons in the general population (age range 17-49 yr) with at least 10 general admissions during an 8-yr period. Persistent somatizers were defined as persons with more than six medically unexplained general hospital admissions in their lifetimes before 1985. Conversely, non-somatizers were patients whose admissions could mainly be ascribed to well-defined somatic disorders. The findings show that persistent somatizers had been exposed to extensive surgery, outnumbering the non-somatizers. Surgical operations were of several categories, with gastrointestinal and gynaecological operations being the most frequent. The physicians used medical and surgical treatment nearly as often for treating persistent somatizers as in the treatment of the non-somatizers. Surgical or medical treatment was used in nearly half of the medically unexplained admissions. The outcome of the surgical treatment of the persistent somatizers was, however, generally unsuccessful in that the effect was unsatisfactory in three quarters of cases. Similarly, two thirds of the medical treatments were judged to be unsuccessful in persistent somatizers. The findings suggest that the costs of somatic diagnostic procedures and fruitless surgical and medical treatment attempts on persistent somatizers are enormous, and only exceeded by the risk of iatrogenic harm. This emphasizes the need for an early diagnosis of somatization and of treating it properly.
Examined the prediction from Mechanic's (1972) attribution theory of somatization that somatizers who are under stress will overuse ambulatory medical services. Two hundred fourteen volunteer patients from university ambulatory care clinics completed the Diagnostic Interview Schedule and the Life Experiences Inventory. We examined somatization, psychiatric diagnoses, and life stress-and the interaction of these factors-in predicting frequency of medical visits during the preceding year, after controlling for need (active medical problems) and predisposing factors. As hypothesized, life stress interacted with somatization in predicting number of medical visits; somatizers who were under stress made more visits to the clinics than did nonsomatizers or somatizers who were not under stress. Although stress affected somatizers most, stress was predictive of increased medical utilization for all patients. These results suggest that psychological services intended to reduce overutilization of outpatient medical services might best focus on stress reduction and be most beneficial to somatizers.
We investigated selective processing of threat information in persons with posttraumatic stress disorder (PTSD) by using a modified Stroop procedure. Subjects were 15 rape victims with PTSD, 13 rape victims without the disorder, and 16 nontraumatized control subjects. They were asked to name the color of four types of words: specific threat (rape-related) words, general threat (related to physical harm and death) words, neutral words, and nonwords. Rape victims with PTSD evidenced a longer response latency for color naming of rape-related words than for other target-word types. Response latencies of non-PTSD victims and nonvictim control subjects did not differ across word types. Possible mechanisms underlying the selective processing of threat material are considered, and clinical implications are discussed.