Writing About Natural Disasters
Structured writing about a natural disaster
buffers the effect of intrusive thoughts on
negative affect and physical symptoms
Joshua M. Smyth, Ph.D., Department of Psychology, 430 Huntington Hall, Syracuse
University, Syracuse NY 13244-2340. Email: email@example.com
Jill Hockemeyer, MS, North Dakota State University
Chris Anderson, MS, North Dakota State University
Kim Strandberg, North Dakota State University
Michelle Koch, North Dakota State University
H. Katherine O'Neill, Ph.D., North Dakota State University
Susan McCammon, Ph.D., East Carolina University.
Joshua M. Smyth, Ph.D.
Department of Psychology,
Jill Hockemeyer, MS
Susan McCammon, Ph.D.
East Carolina University,
There is evidence that individuals experiencing natural disasters are at risk for long term physical and mental health problems, particularly if experiencing unbidden thoughts (intrusions) about the disaster. Interventions provided post-disaster, especially those that involve emotional expression, may help protect individuals from these negative effects. This study examined if a brief, easily administered, structured writing task (expressing thoughts and emotions about the natural disaster) would attenuate the relationship between intrusions about the disaster and both negative affect and physical symptoms. Individuals recently displaced by a hurricane and subsequent flooding were randomly assigned to the experimental (emotional writing) group (n=27) or to the control (neutral writing) group. A community reference group (n=56) was also obtained. In the control group, disaster-related intrusions more than three months post-disaster were associated with higher levels of negative affect and more physical symptoms (p's<.01). In the experimental group, disaster-related intrusions were unrelated to both negative affect and physical symptoms (p's>.15). These data suggest that future research examine the clinical utility of structured writing interventions for individuals who have experienced natural disasters or other trauma.
Structured writing about a natural disaster
buffers the effect of intrusive thoughts on
negative affect and physical symptoms
There is considerable evidence that the experience of extremely stressful events can lead to both short and long-term psychological and physical health risks. This risk is exacerbated when the stressor is external and uncontrollable, such as the case of a natural disaster. Interventions designed to reduce distress and promote psychological adjustment can greatly reduce the psychological and physical costs associated with a natural disaster. Interventions applied shortly after the traumatic experience when individuals' resources (both physical and psychological) are at their lowest may be particularly needed, and also may reduce the likelihood of post-traumatic symptomatology (flashbacks, intrusions, or - in its most extreme form - post-traumatic stress disorder [PTSD]).
There is evidence that individuals experiencing intensely traumatic events benefit from the opportunity to disclose (e.g., Pennebaker, Barger, & Tiebout, 1989). Accordingly, an individual experiencing a natural disaster may particularly benefit from post-disaster disclosure interventions (Pennebaker & Harber, 1993). One relatively recent disclosure intervention involves the expression of thoughts and feelings associated with a traumatic event through writing. This process is somewhat distinct from typical construals of disclosure and emotional expression in that there is not another person as a target or recipient of the disclosure. We have previously argued that this may avoid some of the potentially negative (social) consequences of disclosing negative emotions in a social context (e.g., Smyth & Pennebaker, 1999).
Typically, research participants are asked to anonymously write their deepest thoughts and feelings about a stressful/traumatic event from their entire life for a period of 20-30 minutes, over one to three sessions. This intervention has been shown to reliably reduce stress and improve both mental and physical health when compared to writing about emotionally neutral topics in both healthy individuals and individuals with chronic physical illness (see Pennebaker, 1993; Smyth, 1998; Smyth, Stone, Hurewitz, & Kaell, 1999). Additionally, ongoing work in our laboratory suggests that structured writing may be beneficial for adults with PTSD (Tulloch, Hockemeyer, Jorgenson, Henderson, & Smyth, 1999). Accordingly, a structured writing intervention, asking individuals to express their deepest thoughts and feelings about experiencing a natural disaster, seems a promising post-disaster intervention. We use the term "structured" to indicate that the writing is typically done under certain constraints (e.g., topic, specificity, duration, and number of writing sessions). This distinction is important in that it suggests the process of this writing intervention is unlike other "scriptotherapeutic" endeavors, such as homework assignments in the context of therapy, keeping a personal journal, and so forth.
There is considerable evidence that the traumatic experiences, such as natural disasters, can produce negative effects through altered cognitive processes. In particular, unbidden and uncontrollable thoughts (i.e., intrusions) after traumatic experiences have consistently been shown to be positively associated with dysfunction and negative mood states (e.g., Horowitz, 1979; Lutgendorf et al., 1997; Tait & Silver, 1989). Intrusive thoughts may be a particularly important predictor of poor outcomes following disaster. Baum (1990) studied community residents in the area surrounding Three Mile Island (a nuclear power plant in Pennsylvania, USA) following reports of a radiation leak and subsequent reactor shutdown. Individuals in the vicinity of the power plant showed a variety of altered psychophysiological parameters (higher levels of stress hormones, poorer immune function), higher levels of psychological distress, and prolonged cardiovascular responses to stress (Baum, 1990). Interestingly, at a six year follow up, only those individuals who reported relatively high levels of intrusive thoughts about the disaster showed signs of chronic stress and dysfunction (Baum, 1990).
Intrusive thoughts, within a cognitive processing framework, are thought to represent a breakdown in the process of cognitively assimilating traumatic experiences that are not easily accommodated in an individual's world view (Janoff-Bulman, 1992). The intense negative emotions and autonomic activation associated with these intrusions are thought to be a mechanism whereby intrusions lead to poor health. In fact, such processes have been noted to pose an immediate risk factor for death following natural disasters (Leor, Poole, & Kloner, 1996) and during missile attacks in war (Kark, Goldman, & Epstein, 1995). It has been argued extensively elsewhere that structured writing about traumatic experiences promotes the assimilation of traumatic memories through the transduction of sensory, affective, disorganized memories into a linguistic, coherent representation (Smyth, 1998; Smyth & Pennebaker, 1999; Smyth & Greenberg, 2000). In addition to the cognitive assimilation of stressful events, structured writing may also serve as an exposure paradigm, desensitizing or habituating individuals to the negative emotional responses associated with thoughts of traumatic experiences (Creamer, Burgess, & Pattison, 1990; Tulloch, et al., 1999). Lepore (1997) has noted that writing tends not to reduce the frequency of intrusions, but rather reduces their emotional impact. He found that, following writing, intrusions were unrelated to depressed mood in participants writing about a stressful event but intrusions were related to depressed mood in participants who had written about emotionally neutral topics (Lepore, 1997). This suggests that, prior to structured writing, intrusions are associated with negative emotional states and autonomic arousal whereas, following structured writing, intrusions are not associated with such negative consequences (as a result of cognitive assimilation, desensitization, or both).
The goal of this study is to evaluate the efficacy of a brief structured writing task on post-disaster adjustment. We hypothesize that individuals randomly assigned to complete the "active" form of writing (writing about the natural disaster) will show better post-disaster adjustment than individuals randomly assigned to write about emotionally neutral topics. We examine adjustment as indicated by the impact of intrusive thoughts (our measure of cognitive processing) on levels of negative mood and physical symptoms. Specifically, we hypothesize that the relation between intrusive thoughts and negative affect and/or physical symptoms would be attenuated or eliminated in the experimental group at follow up, but not in the control group.
The inclusion criteria for this study were: (1) being 18 years of age or older; (2) residing within an area legally designated as a disaster area; (3) having experienced major or total structural damage to one's residence as a result of the disaster, or having been required to leave the residence (i.e., evacuation). Experimental procedures took 30-40 minutes per participant. Potential participants first had the study explained in detail and provided informed consent. They then completed self-report measures assessing demographic information, psychological and physical symptoms, and cognitive processing. Following pretest assessment, participants were randomly assigned to either the experimental or control group. Participants in the experimental group were instructed to write in a structured way (integrating their thoughts and feelings) about their experience with the disaster. Control participants wrote in a similar fashion, but were asked to write about planning the upcoming week (i.e., time- management). This intervention has been successfully utilized in a variety of populations (see Pennebaker, 1993; Smyth, 1998), and control participants report the time-management exercise is personally valuable (although there is no evidence that it facilitates adjustment). Participants were asked to provide consent to be re-contacted in three months for follow up assessment. In addition, a sample of participants was drawn from a geographically proximal area not affected by disaster for comparison processes. These participants did not receive any intervention and merely completed assessment measures at baseline and follow up.
This study initially recruited 109 students (76 females and 33 males) from the Eastern coast of the United States. Of these, 53 had been displaced from their homes as a result of a hurricane ("Floyd") and subsequent flooding, 56 were not displaced. The hurricane and flooding were quite severe: Red Cross data indicate that 215,636 people were displaced from their home state to shelters in another state. Students from local schools and universities were displaced for a month or more. Participants displaced from their homes as a result of the hurricane and flooding (n=53) were randomly assigned to either the experimental group (n=27; mean age=22.4 [sd=5.0]) or the control group (n=26; mean age=22.9 [6.8]). The remaining 56 (mean age=20.3 [3.6]) were from areas geographically contiguous to that affected by the disaster, but that were not directly impacted. These student participants comprised the community reference group.
The intervention was performed after the hurricane and subsequent flooding had caused extensive displacement of individuals living on the eastern seaboard of the United States and the area had been declared a disaster area. Three of the authors (H.K.O., J.H., C.A.) flew to the affected area and, with the help of one author affiliated with the local university (S.M.), were able to contact individuals affected by the disaster as well as residents of nearby communities not directly impacted by disaster. Investigators arrived to administer the intervention 5 weeks after the disaster occurred (very shortly after participants were able to return to their homes). Student services had provided drop-in student support groups (two times each week) for several weeks following the disaster, and the Red Cross had a disaster relief center in the region. Unfortunately, we have no data on participant utilization of such services (although randomization should make previous utilization equivalent between groups). The investigators explained in general terms the purpose of the study (although care was taken not to break the experimental manipulation), and obtained informed consent from all interested participants.
Prior to the intervention, all participants (including the community reference group) completed several questionnaires. These included the revised impact of events scale (Horowitz et al., 1979; Weiss, 1996), the negative affect schedule (NAS) (Watson, Clark, & Tellegen, 1988), and a questionnaire assessing physical symptoms (Moos, Cronkite, & Finney, 1990). These questionnaires were assessed again at three month follow up. Each is described briefly below.
Impact of events scale. Cognitive processing was assessed by utilizing the Impact of Events Scale-Revised. This 22-item self-report inventory results in three sub- scales regarding cognitive responses to the traumatic event (in this case, their experience with the natural disaster): Avoidance (i.e., emotional numbness and removing it from memory), intrusions (i.e., troubled dreams and reminders brought back feelings about it), and hyperarousal (i.e., trouble concentrating and easily startled). Higher scores on each sub-scale indicate higher rates of avoidance, intrusions, or hyperarousal, with such higher scores representing relatively more dysfunction. The impact of events scale is a widely used instrument to assess traumatic impact, and previously has demonstrated adequate reliability and validity (Weiss, 1996). Reliability over all 3 subscales (i.e., for the total score) in the current study was =.94.
Negative affect schedule. Negative emotions were assessed using the NAS, a mood scale containing 10 descriptive words, designed to measure a general dimension of subjective distress (Watson, Clark, & Tellegen, 1988). Participants were asked to rate on a five point scale how much (0="not at all" to 4= "Quite a bit") they had experienced negative emotions in the past month due to the natural disaster. Individual items are summed to create a global measure of negative affect, with higher scores indicating greater negative mood. This scale has previously established good reliability and validity (Watson, Clark, & Tellegen, 1988). Reliability in the current study was =.89.
Physical health symptoms. The physical symptom index consisted of twelve general symptoms (weakness, fever, erratic or racing heart rate, loss of appetite, fidgety or tense, restless, indigestion, cold sweats, trembling, headache, constipation, and insomnia) that the participant rated how often they experienced on a four point scale (1= "not at all" to 4= "fairly often") (Moos, Cronkite, & Finney, 1990). Individual symptoms were summed to create a global symptom index representing self-reported physical symptoms, with higher values indicating greater symptomatology. This scale has previously demonstrated acceptable reliability and validity (Evans, 1997; Moos, Cronkite, & Finney, 1990). Reliability in the current study was =.88.
After filling out questionnaires, both the experimental and control groups wrote for 20 minutes on their assigned topic (the community reference group was not required to write).
Individuals in the experimental group were given the following directions:
You have recently gone through an event that may have been quite stressful or traumatic. Over the next 20 minutes, we want you to write about your experiences with the hurricane and flooding. Don't worry about grammar, spelling, or sentence structure. The important thing is that you write about your deepest thoughts and feelings about the experience. You can write about anything you want, but whatever you choose, it should be something that has affected you very deeply. If you find that your writing leads you to write about other, related topics, feel free to do so. It is critical, however, that you let yourself go and touch those deepest emotions and thoughts that you have. Some people find this writing upsetting, and may cry or feel sad or depressed afterwards. This is quite normal, and we will allow you as much time as you want when you have finished writing to compose yourself.
Participants in the control group received the following instructions:
Over the next 20 minutes, we want you to write about an assigned topic. You should write about the specific topic in detail without discussing any of your thoughts and feelings surrounding the topic, but rather focus on a factual description. Many people's schedules have been greatly disrupted by the recent hurricane and flooding. We are interested in how you plan to manage your time. We want you to write about your plans for the upcoming week. Again, describe them in detail without referring to your thoughts or feelings associated with them.
Individuals wrote privately and were assured of their anonymity. Participants were then thanked for their participation and reminded that we would contact them in three months to follow up on how they were doing. We attempted to reach all participants three months after the intervention to complete the questionnaires a second time. Unfortunately, we were unable to contact several participants in each group. In all, 19 (70%) experimental, 23 (88%) control, and 31 (55%) reference participants completed the follow up assessment. These participants did not differ from those we could not contact on any available measure (p's>.20).
The severity of the flood's negative impact on participants was assessed on a four point scale (1=not at all, 4=extremely). A one-way ANOVA predicting severity of flood impact from group (experimental, control, reference) was significant (F(2,106)=57.5, p<.001). Post-hoc comparison of group means confirmed that both experimental and control participants were severely negatively impacted by the disaster (means 3.00, 3.19, respectively). Experimental and control group means were not significantly different from each other (p=.28), indicating successful randomization. The community reference group, as expected, was much less negatively impacted by the disaster (mean=1.79; significantly less negatively impacted than both the experimental and control groups, p's<.001).
Group changes over time.
Group means for all study variables at baseline and follow up can be seen in Table 1. Although not directly relevant to out hypotheses, we examined the main effects of group and of time, as well as the interaction effect of group and time, in the experimental and control groups (i.e., excluding the community reference group). A consistent pattern was observed, with a significant effect of time (i.e., a reduction in distress, cognitive indicators of poor processing, and physical symptoms) in both groups for all dependent variables except avoidance, which showed a statistical trend in the same direction (see Table 1). The main effect of group and the group by time interaction were not significant for any of the dependent variables (all F(1,41)s<1.84, ns).
Table 1. Group means (and standard deviations) at baseline and follow up.
|Negative Affect ****||Control||22.5 (7.0)||17.4 (5.1)|
|Experimental||22.0 (6.9)||15.9 (5.8)|
|Reference||17.0 (5.7)||14.6 (5.0)|
|Intrusions ****||Control||15.5 (10.1)||10.6 (7.0)|
|Experimental||13.7 (8.8)||8.0 (6.1)|
|Reference||6.9 (7.2)||7.0 (8.2)|
|Avoidance +||Control||13.2 (10.0)||12.4 (9.9)|
|Experimental||12.1 (10.4)||11.2 (9.4)|
|Reference||8.6 (8.4)||9.5 (10.2)|
|Hyperarousal ***||Control||9.0 (10.2)||7.0 (6.2)|
|Experimental||9.9 (7.5)||5.4 (5.1)|
|Reference||4.5 (5.6)||5.1 (7.6)|
|Symptoms ****||Control||25.0 (8.4)||21.3 (6.2)|
|Experimental||27.5 (5.9)||21.9 (4.3)|
|Reference||22.2 (8.2)||23.0 (7.0)|
Note: A significant main effect of time (excluding the community
reference group) is indicated following the variable name.
Significance level is indicated + = .10; * = .05; ** = .01; *** = .001; **** = .0001.
We tested our hypotheses (that the relation between intrusive thoughts and negative affect [NA] and/or physical symptoms [Sx] would be attenuated or eliminated in the experimental group at follow up) in a two step fashion using only the two randomized groups (i.e., excluding the community reference group). First, we evaluated the group*intrusion interaction in predicting follow up NA (controlling for baseline levels). This was tested by evaluating (using linear regression) if the interaction term predicted significantly beyond the baseline and main effects (by forcing the interaction term in after baseline and main effects in a stepwise fashion). If this interaction term was significant, we examined if the relationship was positive in the control group and attenuated/eliminated in the experimental group. That is, did intrusive thoughts at follow up predict NA at follow up in the control group but not in the experimental group? The same analytic strategy was followed to examine Sx.
The interaction term for group*intrusions significantly predicted NA at follow up (controlling for baseline levels; t(40)=3.79, p<.01). Moving to step two, we deconstructed the interaction by examining the nature of the relationship between intrusive thoughts and NA in each group. In the control group, intrusive thoughts at follow up were, as predicted, positively associated with NA at follow up (r=.66, p<.01). In the experimental group, also as predicted, intrusive thoughts at follow up were not associated with NA at follow up (r=.18, ns).
The interaction term for group*intrusions was also significant for predicting Sx (after controlling for baseline levels; t(40)=2.96, p<.05). We again deconstructed the interaction by examining the nature of the relationship between intrusions and Sx in each group. In the control group intrusions at follow up, as predicted, positively predicted physical symptoms (r=.58, p<.01). Also as predicted, intrusions at follow up in the experimental group were not significantly related to physical symptoms (r=.31, p=.16).
This study of a brief easily administered intervention - structured writing about a traumatic experience - could facilitate adjustment to the experience of natural disaster. Community residents who had recently experienced a hurricane and subsequent flooding sufficient to force them out of their residences were asked to write about their thoughts and feelings regarding the disaster (experimental group), or about an emotionally neutral topic, time management (control group). Both of these groups were also compared to a similar group of individuals, residents from nearby communities not directly impacted by the disaster.
As expected, the individuals who were hard hit by the disaster initially showed higher levels of negative affect, and greater indication of stress-related psychological symptoms as assessed by the IES. Affected individuals reported high levels of avoidance, intrusions, and hyperarousal to thoughts related to the disaster, whereas the community reference group did not show such difficulties. Interestingly, all individuals in the study who were affected by the flood showed great improvement over time. In fact, levels of negative affect, intrusions, avoidance, and hyperarousal had returned almost to levels equivalent to the community reference group by the three month follow up. There are several reasons such improvement is notable. First, this suggests that individuals who are otherwise healthy, both physically and psychologically, can show great resilience in recovering from a natural disaster. Second, such data underscore the importance of adequately ruling out threats to internal validity. As shown in Table 1, both the control and experimental groups showed improvement/recovery over time. These data underscore the importance of including a relevant control group when testing interventions. Had a single group design been employed, the effects of time would have been confounded with (and falsely attributed to) any effects of an intervention.
We specifically were interested to see if the structured writing exercise performed by the experimental group would attenuate or eliminate the relationship between intrusions of the disaster and negative affect and/or physical symptoms. The data supported our hypotheses and are consistent with the work of Lepore (1997) and others. Intrusions, unbidden uncontrollable thoughts about the disaster, three months post writing were related to higher levels of negative affect and more physical symptoms in individuals who had written about time planning issues. In sharp contrast, intrusions in individuals who had written about their deepest thoughts and feelings regarding the disaster were unrelated to negative affect and to physical symptoms. Given the belief that such intrusions may drive the negative psychological and physiological consequences of trauma (e.g., Baum, 1990; Leor et al., 1996; Kark et al., 1995), such results may have important clinical utility.
Several other elements of this intervention make it particularly desirable for use in natural disaster situations: (1) it is brief and easily administered; (2) it does not require large numbers of highly trained personnel; (3) it is "portable" and can be administered to individuals under almost any circumstances; and (4) it can be used to address the stress or other consequences caused by any disaster (i.e., it is not disaster-specific). Such factors, although outside the domain of treatment efficacy, are critically important in determining the utility and effectiveness of potential interventions. That is, if shown to be efficacious, will an intervention actually be adopted for use and prove useful in practice?
Prior to recommending that structured writing exercises be used as supplemental treatment for individuals experiencing natural disasters or other traumas, several questions remain. Several mechanisms have been proposed to explain how such writing exercises can lead to improvement or, in this case, buffer individuals from the negative consequences of unbidden thoughts of a past experience. Theories proposed include, but are not limited to, cognitive processing and assimilation theories (e.g., Lepore, 1997; Pennebaker, 1993; Smyth, 1998; Smyth & Pennebaker, 1999), exposure based/desensitization theories (e.g., Bootzin, 1997; Tulloch et al., 1999), and self regulation theories (e.g., King & Miner, 2000). This study unfortunately does not provide information sufficient to determine which of these mechanisms may be at work. Although it appears that, after writing, individuals are able to experience thoughts about a disaster without concomitant distress, it is not clear if one of the aforementioned theories is at work, all of them to some partial degree, or perhaps different processes for different individuals. Clearly additional research on this issue is needed.
Another question remaining revolves around the relative health and good recovery of these participants. That all participants, whether receiving the "active" form of treatment or not, showed admirable recovery raises the issue of generalizability to other samples. In particular, it is currently not clear if these results would generalize to individuals who are already at risk. Such at risk individuals might include those who have pre-existing medical or psychological conditions, the elderly, or those that lack access to support resources (either instrumental resources such as adequate shelter and food, or social resources such as supportive friends or family). It is not clear if similar results would be observed following the experience of relatively more severe disasters or trauma. For example, individuals who have had friends or family killed during a disaster may not respond in the same fashion (although if the intervention would be more or less helpful is open to debate and research). This concern is exacerbated by the fact that we had some experimental attrition between the intervention and follow up. Although the highest attrition rate was observed in the community reference group, making self-selection into follow up less plausible, we cannot rule out this possibility (it is also important to note that individuals failing to complete the study were no different at baseline on any available measure than those that completed the study).
In summary, these preliminary data suggest that a brief, portable, easily administered, structured writing task can reduce the negative consequences of a natural disaster several months after writing. For participants completing the "inert" writing (time planning, the control group), unbidden thoughts about the disaster as long as three months later were associated with higher levels of negative affect and more physical symptoms. Individuals who wrote for 20 minutes about their deepest thoughts and feelings surrounding the natural disaster (the experimental group) did not, however, show this relationship. Three months after writing, intrusions about the disaster were unrelated to both negative affect and physical symptoms.
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Many thanks to Crystal Williamson for her assistance with data collection. This study was conducted while the first author was assistant professor of psychology at North Dakota State University, and was partially supported by a Quick Response research grant from the Natural Hazards Center, Boulder, CO, USA.
Joshua M. Smyth, Jill Hockemeyer, Chris Anderson, Kim Strandberg, Michelle Koch, H. Katherine O'Neill & Susan McCammon © 2002. The authors assign to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive licence to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive licence to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the authors.
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