Complementary Therapies in Clinical Practice 34 (2019) 240–246

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Complementary Therapies in Clinical Practicejournal homepage: www.elsevier.com/locate/ctcp

Expressive writing to improve resilience to trauma: A clinical feasibility trial
a

a

a

a

Oliver Glass , Mark Dreusicke , John Evans , Elizabeth Bechard , Ruth Q. Wolever
a
b

b,∗

T

Duke Integrative Medicine, 3475 Erwin Road, Durham, NC, 27705, USA
Osher Center for Integrative Medicine at Vanderbilt, 3401 West End Ave, Suite 380, Nashville, TN, 37203, USA

ARTICLE INFOABSTRACT

Keywords:
Expressive writing
Mindful writing
Resilience
Therapeutic writing
TraumaBackground and purpose: Trauma is highly prevalent, with estimates that up to 90% of the U.S. population havebeen exposed to a traumatic event. The adverse health consequences of trauma exposure are diverse and often
long-lasting. While expressive writing has been shown to improve emotional and physical health in numerous
populations, the feasibility and potential effectiveness of a novel expressive writing program provided in aclinical setting to improve resilience is unknown. Our objective was to determine the feasibility and potential
effectiveness of a 6-week expressive writing course provided in a clinical setting to improve resilience in individuals with a history of trauma.
Materials and methods: This prospective, observational trial of a 6-week expressive writing intervention(Transform Your Life: Write to Heal) was conducted in an academic outpatient integrative clinic. Eligible participants were a self-referred sample of 39 English-speaking adults who identified as having had a trauma, or
significant emotional/physical upheaval, within the past year. Main outcome measures included: Feasibility:
Enrollment, Retention in Program and Trial, Adherence. Acceptability: Adverse Events; Participant Ratings.
Primary Psychological Outcome: Connor-Davidson Resilience Scale (CD-RISC). Secondary Psychological Outcomes:
Perceived Stress Scale – 10 item (PSS-10); Center for Epidemiologic Studies Depression Scale (CES-D);
Rumination Response Scale (RRS).
Results: All measures of feasibility including those related to enrollment, retention, and adherence support
feasibility. All measures of acceptability including adverse events and participant ratings support the intervention as being safe, well-received and personally valuable. Resilience scores increased from baseline(64.3 ± 14.40) to post-intervention (74.2 ± 13.15), t(37) = 4.61, p < 0.0005; Cohen's d = 0.75. In addition,across the same period, Perceived Stress scores decreased close to a standard deviation (20.5 ± 7.43 to
14.3 ± 6.64), t(37) = −4.71, p < 0.0005, Cohen's d = 0.76; depression symptoms decreased (from19.0 ± 13.48 to 12.7 ± 11.68), t(37) = −3.21, p = 0.003, Cohen's d = 0.52; and rumination scores decreased
from 48.5 ± 12.56 to 39.8 ± 10.07), t(37) = −5.03, p < 0.0005, Cohen's d = 0.82. Effect sizes ranged frommedium to large.
Conclusion: The Transform Your Life: Write to Heal program is feasible to offer in a clinical setting, was wellreceived by participants, and demonstrated preliminary findings of effectiveness. Our study suggests that thisnovel 6-week writing intervention including expressive, transactional, poetic, affirmative, legacy, and mindful
writing prompts increases resilience, and decreases depressive symptoms, perceived stress, and rumination in an
outpatient sample of those reporting trauma in the past year. The program appears suitable to be evaluated in alarger randomized controlled trial.

1. Introduction

including affect dysregulation, negative self-image, and problems with
impulse control, aggression, somatization, dissociation, and substanceabuse [2–4]. Expressive writing using the Pennebaker Paradigm is awell-established therapeutic intervention to enhance coping withstressful or traumatic events [5,6]. This study evaluates the feasibility

An estimated 90% of the U.S. population has been exposed to a
traumatic event [1]. Individuals who experience trauma are at higher
risk for a wide range of significant psychological and health issues,

Corresponding author. Osher Center for Integrative Medicine at Vanderbilt, Department of Physical Medicine & Rehabilitation, Department of Psychiatry &Behavioral Sciences, Vanderbilt University Medical Center, Vanderbilt University School of Nursing, 3401 West End Ave, Suite 380, Nashville, TN, 37203, USA.
E-mail addresses: oliver.glass@duke.edu (O. Glass), mark.dreusicke@duke.edu (M. Dreusicke), jfevans77@gmail.com (J. Evans),elizabeth.matteson@duke.edu (E. Bechard), ruth.wolever@vanderbilt.edu (R.Q. Wolever).
∗https://doi.org/10.1016/j.ctcp.2018.12.005
Received 28 September 2018; Received in revised form 17 November 2018; Accepted 13 December 20181744-3881/ © 2018 Published by Elsevier Ltd.

Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

and potential effectiveness of a novel expressive writing program delivered through an outpatient integrative medicine clinic to improve
resilience in a sample with recent, but not immediate, history of
trauma.
Expressive writing has been shown to improve emotional and physiological health in both clinical and non-clinical populations [7–10].
Perhaps the most well-studied framework of expressive writing is thePennebaker Paradigm. A number of studies have shown this paradigm
to be an effective therapy to improve emotional, psychological, andphysiological health in those who have experienced trauma [11–15].
Characterized by a series of short prompts, the Pennebaker Paradigm
asks participants to express their emotions about traumatic experience,and guides them through a series of steps that foster their ability to takefour different perspectives: (1) a direct dive into expressive writing
about the trauma itself; (2) a second opportunity to express further, andpotentially deeper, emotions about the trauma; (3) an invitation to viewthe trauma from a new or different perspective; and (4) encouragement
to create a cohesive story about the trauma that will help them move
forward. A recent systematic review points out the “importance ofmodifying the traditional expressive writing protocol to enhance its
efficacy” (p. 99) [16]. The novel program in this study, Transform Your
Life: Write to Heal [5], does just that. It expands the Pennebaker Paradigm into a therapeutic framework that leverages 6 different writing
styles. This novel approach recognizes that while a simple expressive
writing sequence may be effective for a large number of people, more
people may benefit from a broader spectrum of writing styles. Eachstyle helps the participant find new vantage points from which to explore their traumas and cultivate healing. Like a kaleidoscope, this allows intervention participants opportunities to explore many ways ofnarrating their experience, including how they want to see it in the
future. The program is designed to foster resilience: the capacity for
individuals to successfully adapt and recover from adverse, stressful, ortraumatic experiences [17]. However, this innovative program has yet
to be formally evaluated. The present study aimed to determine thefeasibility and potential effectiveness of providing this 6-week expressive writing course in an outpatient clinic to improve resilience inindividuals with a history of trauma.

Table 1Baseline demographics (N = 39).

2. Materials and methods
2.1. Study design
This prospective, observational trial was fully approved by the Duke
Health System Institutional Review Board in Durham, NC. All participants provided informed consent at the start of enrollment. The trial isregistered at ClinicalTrials.gov identifier: NCT02510898.

Variable

Number or Mean% or SD

Age
GenderMale
FemaleRace
CaucasianAfrican American or Black
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Other
Not reported
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Not reported
Marital Status
MarriedSingleSeparated
Divorced
WidowedCurrent Living Situation
With spouse/partner
Alone
With roommate
With relative
Employment Status
Full-timePart-time
RetiredOn disability
Full-time homemakerFormal Education
No high school diploma
High school or equivalent diploma> high school, but < college degree
College degree
Graduate or professional degree
Annual Household Income
Less than $20,000$20,000 - $50,000$50,001 - $100,000$100,001 - $150,000
More than $150,000
Not reported

55.08

13.27

8
31

20.51%
79.49%

37
0
2
0
0
0
0

94.9%
0%
5.1%
0%
0%
0%
0%

0
38
1

100%
0%

20
7
0
10
2

51.3%
17.9%
0%
25.6%
5.1%

21
11
3
4

53.8%
28.2%
7.7%
10.3%

17
12
8
1
1

43.6%
30.8%
20.5%
2.6%
2.6%

0
0
4
11
24

0%
0%
10.3%
28.2%
61.5%

3
11
13
7
4
1

7.9%
28.9%
34.2%
18.4%
10.5%

2.3. Procedure
Interested participants were screened over the phone for eligibility.
Immediately prior to the first class, eligible participants took part in agroup informed consent process. They then completed a packet ofquestionnaires assessing resilience, perceived stress, depression symptoms, and rumination. Participants then participated in the 6-session
Transform Your Life: Write to Heal program over 7 weeks in
January–March 2016. At the very end of the final class, participants
were asked to complete the post-program questionnaires again, andwere required to do so within 4 weeks.

2.2. ParticipantsParticipants were recruited through flyers and e-announcements
sent to the Duke Integrative Medicine email list serve beginning inNovember 2015. Eligible participants were at least 18 years of age, able
to read and write in English, and self-identified as having had a physicalor emotional trauma or significant upheaval within the past 12 months,
but not within the 4 weeks prior to screening. Consistent with current
evidence suggesting that exploration of deep emotions about a traumatic event may do more harm than good in the immediate days andweeks following the upheaval [18], the study protocol excluded individuals who reported trauma within the 4 weeks prior to screening,
and required that they be provided referrals and resources as appropriate. Potential traumas included, but were not limited to: death of a
loved one, divorce, job loss, personal injury or critical illness, or significant change in financial status. Although the program was provided
at no cost to those who enrolled in the study, no incentives or compensation were offered for study participation. Baseline demographics
are shown in Table 1.

2.4. Intervention
2.4.1. Framework
Over a 6-week period, the Transform Your Life: Write to Heal program guides participants through a purposefully designed progressionof 26 writing prompts. The program begins with expressive writing
using the Pennebaker Paradigm, and ends with mindful writing. During
each of the first 5 sessions, participants write in response to 4 prompts.
In the last session, they write in response to 6 prompts. The design ofthese prompts requires the participant to utilize a specific type of241Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

writing that moves them through an intentional progression of exploring and meaningfully narrating the trauma in a way that supports
post-traumatic growth. Participants begin writing in a challenging, andsometimes emotionally overwhelmingly space, and evolve to a space ofemotional equanimity and mindfulness.
The first style of writing follows the traditional PennebakerParadigm in helping individuals to dive deeply into their emotions
around a particular traumatic experience, a dive whose depth anddarkness is sometimes known only to the writer. The second writing
style, transactional writing, then guides participants to cultivate compassion for self and others, and can help provide much-needed solace
after difficult times. Third, participants use prompts for poetic writingthat stems from a broad interpretation of Aristotle's Poetics: Poetic
writing uses metaphor and narrative structure to express the humancondition. In addition, the intentional use of specific poems cultivates
mindfulness. Fourth, affirmative writing prompts are used to support
participants to identify personal strengths and to begin to create narratives that affirm who they want to become in the future. Fifth, legacy
writing invites an honest look at what individuals want to contribute to
the world and to their loved ones. Legacy writing further amplifies
values that may be especially important to them. Finally, mindful
writing reinforces the concept of being aware and attentive, withtherapeutic distance from what is observed that allows one to accept
what is. The prompts for mindful writing were developed based upon
the 7 qualities of mindfulness described by Jon Kabat-Zinn in Full
Catastrophe Living [19]. While all expressive writing is mindful writingin that participants become aware of thoughts and feelings during
writing, undergirding the process with particular attention to mindfulness qualities encourages writers to learn to obtain a more objective
distance allowing them to manage their thoughts and feeling with nonjudgment, loving-kindness, and compassion.

2.4.3. Facilitator qualifications
The program facilitator for the pilot trial holds a Master of Arts in
Teaching (English), a Master of Arts (English), and a Doctorate of
Education with post-doctoral specialization in curriculum and instruction for post-secondary writing and literature. He has 34 years of experience designing and teaching expository and expressive writing inundergraduate and graduate settings, and has authored five books including Wellness & Writing Connections, and Expressive Writing:Words that Heal. The latter was co-authored with James Pennebaker,
PhD and describes the program in this pilot trial in detail. In addition,
the facilitator studied mindfulness with Jeff Brantley, MD and has had apersonal meditation practice for over ten years. This training andpractice enabled him to develop mindful writing as an additional
writing style that is seminal to the program under study.
2.5. Measures
2.5.1. Feasibility
Feasibility was defined in 3 parts: 1) ability to meet enrollment
goals in planned timeline; 2) retention across the course, defined ascompletion of the intervention [attendance to at least 4 of 6 (67%)
classes] and completion of the study (provision of post-interventiondata); and 3) adherence, defined as completion of at least 5 of the 6(83%) post-writing surveys before the final post-intervention data collection. Ability to complete the session's post-writing survey requiredcompletion of all respective writing prompts, and was used as a proxyfor completion of the writing.
2.5.2. Acceptability
Acceptability was formally assessed in two ways: 1) by the numberof adverse events reported (to indicate safety); and 2) by the averagescores to a particular question on a brief post-writing survey.
Specifically, following the exercises for each type of writing (expressive,transactional, poetic, affirmative, legacy and mindful writing), participants were asked to use a 0-to-10 scale to indicate "to what degree thewriting [as] meaningful and valuable for you." In addition, acceptability of the intervention was assessed informally by the comments
participants wrote on their post-writing surveys regarding the program.

2.4.2. Logistics
The program was held in a workshop room at Duke Integrative
Medicine, an integrative medicine clinic providing patient-centeredprimary care and a wide range of evidence-based complementary
therapies. After signing in at the beginning of each class, participantssat 2 per table and were asked to quietly settle themselves. The facilitator described the procedure for the day's work with minimal instructions that were administrative in nature. Participants were given
15 min per each writing prompt, and the facilitator kept time, announcing when to move to the next task. Participants were also given
5 min to complete a post-writing survey at the end of each 15-minwriting session. The survey implicitly encourages the participant toobtain some therapeutic distance in order to assess the writing exercise.
If participant's schedules precluded attendance at a class, they wereencouraged to write in response to the prompts, complete and return
the post-writing survey to be used as data. The specific writing prompts
and post-writing surveys used in each session are published in
Expressive Writing: Words That Heal [5].
Participants were assured that their writing was solely for theirbenefit and personal processing, and no one else would ever view what
they wrote unless they shared it themselves. No discussion was permitted between participants before, during, or after writing. The program facilitator asked participants not to speak to each other in order torespect each participant's privacy and allow for personal processing. At
each session, participants were directed to take the first prompt andwrite according to the directions. One participant wrote using a keyboard with electronic notepad because he could not physically writewith a pen; all other participants wrote in notebooks furnished for the
study. All participants wrote their study identification number (rather
than name) on each post-writing survey and left the surveys face-down
for the facilitator at the end of the class. When the day's final writing
assignment ended, participants placed their notebooks in a locked box
on the desk in the front of the room and signed out.

2.5.3. Psychological outcomes
2.5.3.1. Primary outcome: resilience. The primary outcome was assessedwith the Connor-Davidson Resilience Scale (CD-RISC), a validated 25item scale that has been studied in a wide variety of populations,
including those with a history of trauma [20].
2.5.3.2. Secondary outcomes. Depression symptoms. Depression
symptoms were assessed using the 20-item Center for EpidemiologicalStudies Depression Scale - Revised (CESD-R), a common screening test
that measures depressive feelings and behaviors within the past week
[21].
Perceived stress. Perceived Stress was assessed with the 10-item
Perceived Stress Scale (PSS-10), a well-known questionnaire used toevaluate responder's perceptions about their level of stress and theirability to cope with stress over the last month. Using a 4-point Likerttype scale, participants endorse the degree to which each item bestreflects their thoughts and feelings within the past month. Results fromthis questionnaire have demonstrated acceptable levels of validity andreliability [22].
Rumination. Defined as “compulsively focused attention on thesymptoms of one's distress,” [23] rumination was measured using the22-item Rumination Response Scale (RRS).
Sociodemographics. Basic sociodemographic information was selfreported at baseline.
242Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

2.6. Data analysis

intervention (74.2 ± 13.15), t(37) = 4.61, p < 0.0005. This mean
increase of 10.0 ± 13.33 points, 95% CI [5.6, 14.4], produced a large
effect size (Cohen's d = 0.75).

Enrollment, retention and adherence data were tracked by the research coordinator using an EXCEL spreadsheet. Other study data werecollected directly from the participants, entered and managed by the
research coordinator using REDCap electronic data capture tools hosted
at Duke University. Statistical analyses were performed using SPSS
V.22. Resilience, stress, depression and rumination data were normally
distributed and all intervention analyses are per-protocol. Pairedsample t-tests were used to assess change over time, with statisticalsignificance set at 0.05 (2-tailed) for each test. Effect sizes are mostly
presented using Cohen's d [24]. In addition, a second calculation is
performed for resilience to facilitate comparisons with relevant literature. The second manner of calculating effect size is as follows:
ES = post-measure minus pre-measure divided by standard deviation of
the difference.

3.4.2. Secondary outcomes
Perceived Stress Scale (PSS-10) scores decreased from baseline(20.5 ± 7.43) to post-intervention (14.3 ± 6.64), t(37) = −4.71,
p < 0.0005. The mean decrease of −6.1 ± 8.03 points, 95% CI [-8.8,−3.5] demonstrated a large effect size (Cohen's d = 0.76).
CESD-R scores decreased from baseline (19.0 ± 13.48) to intervention (12.7 ± 11.68), t(37) = −3.21, p = 0.003. The mean decrease of −6.2 ± 11.98 points, 95% CI [-10.2, −2.3], revealed a
medium effect size (Cohen's d = 0.52). Sixty-one point five percent(61.5%) of participants scored at least 16 at baseline, while 26.3% ofparticipants did so post-intervention.
Rumination Response Scale (RRS) scores decreased from baseline(48.5 ± 12.56) to post-intervention (39.8 ± 10.07), t(37) = −5.03,
p < 0.0005. The mean decrease of −8.6 ± 10.58 points, 95% CI[-12.1, −5.2], revealed a large effect size (Cohen's d = 0.82).

3. Results
3.1. Sociodemographics

4. Discussion

The sample was predominantly white (95%) and female (81%). All
participants had education beyond high school, and more than 60% had
a graduate or professional degree. Thirty-four percent had an annual
household income of less than $50K. Table 1 provides additional details.

We report outcomes for a structured 6-week program that significantly extends the Pennebaker Paradigm. This program, Transform
Your Life: Write to Heal, is feasible to offer through an academic outpatient clinic, and was well-received by participants. We further showthat the program significantly improved a number of important psychological variables in a population with a fairly recent history ofgeneral trauma; improvements were observed in resilience, depression
symptoms, perceived stress, and rumination.
The program was highly feasible by all defined measures, and was
well-accepted by participants. Enrollment targets were reached in 3
weeks, a full 7 weeks before the ending of the planned recruitment
period. Moreover, 97% of participants completed the study and 97%
completed the intervention. In addition, 92% were deemed adherent to
the intervention, completing at least 20 of the 26 writing exercises in
response to the structured prompts, and responding to at least 5 of the 6
respective post-writing surveys.
The program was also quite acceptable to participants. There wereno adverse events reported, and participant feedback on the postwriting surveys consistently indicated that the writing exercises werepersonally meaningful and valuable to them. Anecdotally, many participants reported finding themselves writing about traumas that had
happened much further in the past than the “qualifying” trauma that
had happened in the previous 12 months. The fact that the program
allowed them to process whatever arose, including layered trauma frommany years ago, is also a significant plus. The participant quotes inTable 3 speak for themselves about the power of this work.
All of the psychological variables measured improved across the
program, with consistently medium to large effect sizes. Prime among
these was enhanced resilience, the ability to successfully adapt andrecover from adverse, stressful, or traumatic experiences. The Cohen's deffect size for CD-RISC scores in our pilot is considered large [24].
Likely due to the uncontrolled design of the trial, our effect sizes are
greater than the effect sizes for other psychological variables seen inseveral key meta-analyses [25–27], and consistent with the seminal
meta-analysis of randomized experiments using Pennebaker's written
emotional expression paradigm [28]. The latter found positive effects inhealthy individuals for general functioning (5 studies; Cohen'sd = 0.33) and for psychological well-being (9 studies; Cohen'sd = 0.66). The meta-analytic literature on the impact of expressive
writing is equivocal, likely due to a number of factors including: 1)
whether or not health and psychological variables are aggregated together [25]; 2) the meta-analytic trial inclusion criteria (e.g., trial design, length of outcome tracking, specificity of outcome) and methodology (including use of Hedge's correction for inclusion of small trials);

3.2. Feasibility
3.2.1. Enrollment
Eighty-one participants responded to the study advertisements and
47 were screened on the phone in order of their response to ensure
eligibility requirements. Thirty-nine met study eligibility criteria, provided informed consent and were enrolled in the trial. The other 34
individuals were not screened because the study was full, and were
notified and thanked over the phone for their interest in participating.
While a three-month recruitment cycle was planned, the study filled inthree weeks. See Fig. 1 for CONSORT Flow Diagram.
3.2.2. Study retention
Completion of the intervention measured by attendance wasachieved by 38 of the 39 consented participants, or 97% of the sample.
Final data collection was also achieved for 97% of the participants, with
38 of the 39 consented individuals completing the post-intervention
data collection and allowing for per-protocol analyses.
3.2.3. Adherence
Thirty-six of the 39 participants (92%) completed 5 of the 6 postwriting surveys and were deemed adherent. Thirty-two of them (82%)
completed all 6 surveys.
3.3. Acceptability
No adverse events were reported. Participant responses to thequestion, "to what degree was the writing meaningful and valuable foryou" averaged 8.3 on a 0-to-10 point scale for all types of writing. See
Table 2 for scores on specific types of writing. In addition, sample
comments from participants are reported in Table 3 as an informal
demonstration of the acceptability of the intervention.
3.4. Psychological outcomes
See Table 4 for primary and secondary psychological outcomes.
3.4.1. Primary outcome: resilience
CD-RISC scores increased from baseline (64.3 ± 14.40) to post243

Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

Fig. 1. CONSORT Diagram/Patient flow.

and 3) the specific samples studied (e.g., healthy populations versus
clinical populations; all clinical populations versus a specific diagnostic
group). There is also another likely contributor to the ambiguous outcomes from meta-analytic trials that to our knowledge, has not yet beenstudied: that of measuring positive emotion related variables rather
than negative emotions and symptoms. For example, a 2016 metaanalysis of RCTs assessing expressive writing in patients with breast
cancer found that outcomes for depression, anxiety and fatigue favored
expressive writing, but the effect sizes were not significant. However,they also found that the effect size for quality of life was significant[16]. In other areas of psychology, positive emotions have been found
not only to down-regulate the physiological and psychological adverse
impact of negative emotions central to anxiety, depression, and stressrelated disorders, but also to promote psychological well-being andresilience [29]. Positive emotions have specifically been shown topromote approach-oriented behaviors and facilitate the acquisition ofinternal resources, both central concepts in healing from trauma[29,30]. In addition to measuring negative outcomes including depression, stress and rumination, we intentionally chose as our primarymeasure the positive psychology construct of resilience. It is possiblethat positive emotion and well-being variables behave differently thansymptom lists or negative emotion variables in response to expressive

writing.
Finally, to put our findings into additional context, we comparedthem to a 3–6 month randomized pharmacologic-based trial in patientswith PTSD that showed an average effect size of 0.72, with the largest
effect size for any single medication studied being 1.06 [31]. In thispharmacology trial, the authors calculated effect sizes as post-measureminus pre-measure divided by standard deviation of the difference[24,31]. Our effect size for CD-RISC scores, when calculated in the samemanner, is 4.62, a considerably larger effect. In addition, CESD-R scoresshowed a 32.6% decrease in mean depressive symptom scores, with amedium Cohen's d effect size of 0.52. Furthermore, 35% of the participants who began the program with a score indicative of a likely
clinical depression ended the program no longer meeting this criterion.
Improvements in perceived stress and rumination were also in the large
range (Cohen's d: 0.76–0.82). We offer this information to suggest that
Transform Your Life: Write to Heal, with an expansion of the PennebakerParadigm, may provide a useful short-term non-pharmacologicaltreatment strategy to improve resilience in patients with fairly recent
trauma.
Expressive writing is a low-cost, easily-accessible intervention, withhigh adherence and acceptability for participants. Further, the program
appears to help participants process their recent traumas and improve

Table 2
Acceptability Ratings: Meaningfulness and Value of the Writing Exercises. Participants used a scale of 0–10 to answer, "To what degree was the writing
meaningful and valuable for you?"Type of Writing

Expressive

Transactional

PoeticAffirmative

LegacyMindfulOverall Average

Average Rating
N for that rating

8.67
39

8.45
38

6.92
38

8.78
36

8.68
37

8.15
33

8.28
37

244

Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

Table 3
Participant Comments regarding each session of the Writing Intervention.
Writing Style
Session 1: Expressive Writing

Session 2: Transactional Writing

Participant Commentinteresting that the more I write, the less sad I feel. More emotionally settled than happy. A bit hopeful.“• “It's
was useful - it felt like an opportunity to 'tidy up' and close the loop on the emotional experience. It's helpful to feel like you've• “Thisacknowledged the pain that's there and also found a healthy perspective on it.”process was very new to me and it felt great to express thoughts that come out differently written as in my own head. I find it difficult• “Thisto express myself verbally and am hopeful this strategy will allow an outlet to my deeper feelings.”
writing assignment was enlightening. Focus on others' feelings and emotions for something I caused brought clarity to me. I realize• “Thisthat as I look for closure - for healing - it may help this person too if I ask for forgiveness. It has the potential to heal me (not just me!) andthis other person too. Powerful!”

found it extremely valuable to take on the perspective of someone in a support role for another having gone through my experience. I• “Irealizethat if I can feel this compassion for a loved one, then I can direct it toward myself. I also was reminded that what happened to me
was not my fault, and was not a failure on my part, so my anger does not need to be focused on my own body.”

Session 3: Poetic Writing

Session 4: Affirmative Writing

writing process allowed me to explore forgiveness more fully than other times I've worked on forgiveness - not a replacement for other• “Theapproaches, but an important complement.”
was a great writing experience. It felt wonderful to take an issue that I struggle with daily, saddle the horse to drive out this demon,• “Thisand giving myself permission to let it go - forever, after exhausting the beast.”
writing was fun and showed me how funny and expressive I can be ('everyone' tells me so, but I've avoided delving there). It also
• “Thisallowed me to see that my body, and in this case, my legs, want more from me. As physical as I am, I am being called to be more physical - ina more mindful and self-nurturing way.”realize that I have been obsessing over a negative situation & now I can choose to think about something positive instead & that will
• “Imakeme feel better & much more peaceful even when I find myself with the person who is involved in the negative situation. I have a
choice to make, positive or negative.”assignment was incredibly helpful & beneficial process. Above anything else it is a great reminder of how my own thoughts prevail• “Thisover my circumstances & how I can determine how I choose to live.”
process of using the positive experience to overwhelm the bad experiences of the week and my ongoing pain and challenges was• “Theextremely valuable. I'm supposed to practice diffusion w/these negative thoughts or my therapist tells me this is useful, but I hadn't realized
Session 5: Legacy Writing•••

Session 6: Mindful Writing•••

the impact this can have on a negative thought until now. Being able to overlay my happy, comedic, playful experience or upsetting
experiences from this week made them less upsetting and important.”“I want to say that I was thinking while walking up to the front entrance today that I feel much less traumatized than I did a month ago.
Whether it's because things have changed in my life or it's being part of the study, I couldn't say. But 'something' is working and making a
difference. This was a useful assignment that I fulfilled in a heartfelt way. I got to a deeper level of honesty, compassion and gratitude thanI've previously done. I feel better!”“I see the value in this assignment. I know that there have been many joyful times in my life. I just have trouble remembering them. I think of
all the writing exercises that this one might be most valuable to me if I engaged in it regularly.”“It is so easy to forget how powerful a good and positive memory can be. It disarms anger and frustration, and reminds us of our capacity tofeel joy. I found myself, as I was writing, curious to see if I will ever experience such profound joy again, rather than lamenting that I may
not. I found I did not need to recall how I felt or what I thought; simply writing about the events of the experience brought the feelings back.”“The best part of this exercise was the opportunity to write about the beauty of living as me. Accentuating the gift of being - the six steps byZinn to return to this place of peace, wholeness, simplicity, beauty. Expansion and invitation to LIVE unfettered and open - what gift. The
beauty of accepting life as life presents herself in each moment. Gift passed onto others miraculously and mysteriously.”“I felt that this was a very valuable exercise to work through the feelings of past trauma. It also helped me to realize how far I've come in thejourney of healing.”“Absolutely an unexpected wonderful end to the experience over the weeks & by far my favorite part… The very last session gave voice, an
instrument or vehicle for feeling deeply felt emotions I feel about both, even tears of release of pent up loss/pain, & being present, changed
accepting in the present. I felt love. I experienced an inner light. Tears welled in my eyes without reliving pain or grief. The writing caught
me unsuspecting, surprising myself.”

their psychological status. This psychological processing may actually
tap into specific mechanisms that warrant further study. For example,
while we did not have the power to assess this in our pilot trial, thelarge improvement in rumination suggests that it may be a mechanismin the healing process.
While this first evaluation of the Transform Your Life: Write to Heal
program shows that the program is well-suited to address fairly recent
traumas (from the previous year but not the previous 4 weeks), it isimportant to underline that our study participants were processing
traumas that were concluded. The results should not be extrapolated tothose with actively occurring or immediately recent traumas. Concern
about actively processing an immediately prior or ongoing trauma isreviewed by critics of the “diffusing” technique of the Critical Incident
Stress Debriefing (CISD) model. They note that talking about a trauma
while it is fresh and/or still unfolding may actually do more harm than
good [32,33]. In addition, at least one study has reported potentiallyharmful effects of expressive writing for adults in the immediate wakeof marital separation [34].
Despite the positive results of our study, there are at least four
limitations. First, the relatively small sample size and homogeneous
population of mostly white, female, highly-educated American participants may limit the generalizability of our results. Accordingly, a
recent study of expressive writing in Chinese-American breast cancer
survivors showed that writing about cancer facts was more helpful than

Table 4
Psychological outcomes.
Construct (Measure)Pre (Mean ± SD)

Post (Mean ± SD)

Differencea (Mean ± SD)

95% CI for Differencesp-value

Resilience (CD-RISC)
Depression Sxs (CESD-R)
Perceived Stress (PSS-10)
Rumination (RRS)

64.3 ± 2.34
19.0 ± 2.19
20.5 ± 1.21
48.5 ± 2.04

74.2 ± 2.13
12.7 ± 1.90
14.3 ± 1.08
39.8 ± 1.63

10.0 ± 2.16
−6.2 ± 1.94
−6.1 ± 1.30
−8.6 ± 1.72

5.59 to 14.36−10.18 to −2.30−8.77 to −3.49−12.11 to −5.15

p < 0.0005
p = 0.003
p < 0.0005
p < 0.0005

aNegative CESD-R, PSS-10, and RRS difference scores indicate improvement over time. Positive values for CD-RISC indicate improvement over time. CI =Confidence Intervals; Sxs = symptoms.

245Complementary Therapies in Clinical Practice 34 (2019) 240–246

O. Glass et al.

expressive writing of emotions, challenging implicit assumptions thatpsychosocial interventions tested in largely white populations can bedirectly generalized to other populations [35]. Second, it is significant
that the sample represented a highly educated sector. It is possible that
this highly educated group was well-positioned to process their traumas
through expressive writing but we cannot assume that this would betrue for all other sectors of the population. Hence, it will be quite important to replicate the trial with more socio-demographically diverse,
and less educated groups. Third, as the study is a prospective pilot trial,
we did not have a control group and the passage of time or other aspectsof natural healing may contribute to the findings. Finally, those individuals who chose to participate in the study were likely already interested in writing as an intervention, and this bias may have also influenced the results.

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5. Conclusions
This is the first trial to document that the 6-week Transform Your
Life: Write to Heal program is feasible to implement in an outpatientsetting, and was well-received by participants who have experienced
fairly recent trauma. Participants of the program significantly improved
their resilience, depression symptoms, perceived stress and rumination.
The relative ease and low-cost of implementing the program has important implications for translational work. Specifically, the program
may be an important part of trauma-informed care that is relevant to awide segment of the general population, and can be easily delivered inhealthcare settings. Further studies are warranted to examine its effectin RCTs with more ethnically and educationally diverse samples, andwith diagnostic groups with specific emotional and physical healthchallenges. Additionally, 6-month and 1-year follow-up will be critical
towards evaluating the longer-term impact.
Acknowledgement
This study was funded internally by Duke Integrative Medicine in
Durham, North Carolina.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ctcp.2018.12.005.
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