Writing Wrongs: Expressive Writing for Microaggressions

Racial and ethnic based stressors, such as microaggressions, are pervasive, distressing, and result in lasting negative repercussions for minoritized students at predominantly white institutions (PWIs). These racial and ethnic based stressors are experienced in addition to the universally experienced stressors of higher education. Negative repercussions of microaggressions include increased drop out or transfer rates, distress, fatigue resulting in decreased academic performance, and depression and posttraumatic stress symptoms. Expressive writing (EW) may be a scalable intervention for addressing the negative repercussions resulting from microaggressions experienced by minoritized students at PWIs. Previous research suggests that EW for stressful life events results in benefits such as reduced depression and posttraumatic stress symptoms, improved coping strategies, and reduced activity restriction. Despite such benefits, EW was not designed to specifically address microaggressions in a minoritized student population. Informed by the ADAPT-ITT model, our research group conducted a pilot study with similar procedures. This pilot study demonstrated the acceptability of an adapted version of the EW intervention titled Writing Wrongs (WW), as well as recommended future modifications for WW. In the current study we aim to conduct a randomized-controlled trial to establish the efficacy of WW in alleviating clinical symptoms. We hypothesize that WW will improve symptoms of racial and discriminatory trauma and symptoms of depression, anxiety, and posttraumatic stress over time and compared to an assessment-only condition. We will conduct exploratory analyses to examine short-term changes in affect within and across sessions and across conditions. We will recruit minoritized students enrolled at a PWI. Participants will complete a pre-intervention assessment prior to being randomized into the two conditions. Participants in the intervention condition will engage in three sessions of WW and complete measures of clinical symptoms across multiple time points (i.e., pre-intervention, immediately after the final writing session, one week after the final session). Participants in the assessment-only condition will be administered the same measures at the same timepoints and given access to the WW after completing the study. If found to be efficacious, WW has the potential to be widely disseminated to minoritized college students who experience microaggressions.

In 2021, approximately 46% of the university student population in the United States identified with a minoritized racial or ethnic group. Minoritized students who attend predominantly White institutions (PWIs) experience universal higher education stressors in addition to compounding stressors related to their racial and ethnic identity such as racism, discrimination, and microaggressions. Recent literature provides significant evidence for the negative health and academic repercussions of the compounding experience of racial and ethnic discrimination, including microaggressions. A number of interventions have demonstrated efficacy in reducing the negative health outcomes resulting from the experiences of racism and discrimination broadly. To our knowledge, no current intervention specifically focuses on the experience of microaggressions. In developing or adapting an intervention to address the negative repercussions resulting from the experience of microaggressions for minoritized students at PWIs, it is vital to consider not only the efficacy of the intervention but also the acceptability and feasibility of the intervention. Following the recommendations of the World Health Organization, scalable interventions may aid in addressing previously identified mental health treatment seeking barriers for minoritized students. One such scalable intervention includes Expressive Writing, a type of repeated exposure practice that asks individuals to write about a stressful life event. Utilizing the ADAPT-ITT model to inform the culturally sensitive adaptation of Expressive Writing for microaggressions in minoritized students, our research group conducted a pilot study demonstrating acceptability and opportunities for improvement of the adapted intervention titled Writing Wrongs. The current study aims to continue this line of research in examining the efficacy of Writing Wrongs, an adapted expressive writing intervention tailored to address microaggressions experienced by minoritized students at PWIs.

ADAPT-ITT To establish and consider an intervention targeting microaggressions for minoritized students at PWIs, it is vital to do more than just exporting an established intervention to a new topic or population. Utilizing the ADAPT-ITT model to inform the adaptation of expressive writing for the experience of microaggressions for minoritized students at PWIs allows for a standardized evidence-based culturally sensitive adaptation process. This model has demonstrated efficacy in adapting established interventions to new groups and topics. Interventions adapted using this model include HIV interventions, HIV prevention programs for Latine girls, PTSD interventions for people living with HIV, sexual health interventions for American Indian and Alaskan Native young adults, and chronic disease self-management for individuals who experience serious mental illness. The ADAPT-ITT model consists of eight phases ranging from identifying needs and potential solutions, Assessment, to determining the efficacy of the intervention, Testing.

We conducted a pilot study to address the first six steps of this model. The first two phases require identification of a need and potential adapted or adopted solution. Microaggressions are subtle instances where expressions of insult, degradation, or minimization of an individual or a group within which they identify. Research demonstrates the significant negative health and academic effects of experiencing microaggressions for minoritized students. Expressive writing, a repeated exposure-based practice that asks individuals to write about a stressful life event, may be a scalable intervention that can target the experience of microaggressions as well as address treatment seeking barriers present for minoritized students. Given the established efficacy of expressive writing as an intervention targeting stressful life events and the flexible administration method, an adaptation of expressive writing may provide education on microaggressions as well as an intentional space for individuals to discuss discrimination. In our pilot study, Writing Wrongs, a culturally sensitive online adaptation of expressive writing, was administered along with the standardized version of expressive writing to a sample of minoritized students at a PWI to address the remaining four steps of the ADAPT-ITT model. Writing Wrongs tailors the expressive writing intervention prompt to specifically elicit thoughts and feelings related to the experience of a microaggression. Utilizing a mixed methods approach, we found no attrition following the pre-intervention assessment session as well as participant feedback reflecting that Writing Wrongs was helpful, appropriate, enjoyable, and a necessary intervention. These results provide initial support from the target population, minoritized students, for Writing Wrongs. When comparing standardized expressive writing with Writing Wrongs, participants expressed a preference for Writing Wrongs. Furthermore, participants most often wrote about microaggressions in response to the Writing Wrongs prompts as opposed to the standardized prompt. This finding provides evidence for the importance of the Writing Wrongs adaptation in providing the opportunity for students to reflect on microaggressions purposefully and potentially develop coping skills targeted towards such experiences. The results of our pilot study, along with topical expert consultation, informed changes to Writing Wrongs including modification of the prompt (e.g., change wording used, add more specific prompts) and administration method (e.g., provide additional resources for further education or intervention).

Method Participants All study procedures have been approved by the Auburn University Institutional Review Board. Students will be recruited from Auburn University using the SONA Human Subject Pool Software and public advertisements. Potential participants will complete an eligibility screener with the inclusion criteria of identification with a racial/ethnic minoritized group and being enrolled as a full-time student at Auburn University, a PWI located in the Southeastern United States.

Procedures Eligible participants will complete an informed consent session with a research assistant via a secure Zoom link. After the consent session, participants will be randomly assigned into the Writing Wrongs Intervention or Assessment-only Control Condition. All participants will complete online surveys across five sessions. The first four sessions will be completed on consecutive days. The first session will be a pre-intervention assessment. During the following three sessions, the Writing Wrongs Intervention Condition will receive a 20-minute writing activity, and both conditions will complete assessments of their current experience of symptoms and emotional states. All participants will also complete a post-intervention assessment during the fourth session and a one-week post-intervention follow-up assessment. In total, participants will complete a pre-intervention assessment, two Writing Wrongs sessions or assessment-only sessions depending on assigned condition, a third Writing Wrongs session with a post-intervention assessment or an assessment-only session depending on condition assignment, and a one-week post-intervention assessment. The Assessment Control Condition will be given access to the Writing Wrongs intervention following study completion.

Hypothesis and Data Analytic Strategy We hypothesize that Writing Wrongs will improve symptoms of racial and discriminatory trauma as well as symptoms of depression, anxiety and posttraumatic stress over time and compared to the Assessment Control Condition. We will also conduct exploratory analyses to compare change in positive and negative affect within and across sessions for the Writing Wrongs and Assessment Control Condition. Our primary analyses will be conducted with IBM SPSS Statistics (Version 27), and missing data will be handled with multiple imputation. Our exploratory analyses will be conducted with Mplus (Version 8.4), and we will use full information maximum likelihood to handle missing data. The primary outcomes of the intervention's effect on symptoms of racial and discriminatory trauma will be examined using a 2 x 5 repeated measures ANOVA. The secondary outcomes of mental health symptoms (i.e., depression, anxiety, and posttraumatic stress symptoms); and writing session variables will be examined using 2 x 3 repeated measures ANOVAs. ANOVA factors will be condition (i.e., Writing Wrongs and Assessment Only), time, and the condition-by-time interaction . For our exploratory analyses examining change in positive and negative affect, we will conduct a latent change score model to estimate change in affect within and across each session and to test differences across conditions.

Eligibility Criteria:
Inclusion Criteria:

* Auburn University Full-time Student
* Identifies with a Racial/Ethnic Minoritized Group

Exclusion Criteria:

* Under age 18