مزایای نگارش بیانی در کاهش نشخوار فکری و نشانه های افسردگی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|31339||2006||12 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Behavior Therapy, Volume 37, Issue 3, September 2006, Pages 292–303
Depression-vulnerable college students (with both elevated prior depressive symptoms and low current depressive symptoms) wrote on 3 consecutive days in either an expressive writing or a control condition. As predicted, participants scoring above the median on the suppression scale of the Emotion Regulation Questionnaire (Gross & John, 2003) showed significantly lower depression symptoms at the 6-month assessment when they wrote in the expressive writing versus the control condition. Additional analyses revealed that treatment benefits were mediated by changes in the Brooding but not the Reflection scale of the Ruminative Response Scale (Nolen-Hoeksema & Morrow, 1991). A “booster” writing session predicted to enhance treatment benefits failed to have a significant effect.
According to recent estimates, close to 20% of individuals will experience an episode of depression at some point in their lives (Gotlib & Hammen, 2002). Among individuals who have recovered from depression, approximately 75% to 80% will have another depressive episode (Judd, 1997 and Keller & Boland, 1998). In fact, the risk of subsequent depression is best predicted by past depression and increases with the number of previous episodes (Hammen, 1990). The aim of the current study was to explore the benefits of an expressive writing intervention in reducing subsequent depression symptoms among formerly depressed (and hence depression vulnerable) individuals. Cognitive theories (e.g., Beck, 1967 and Beck, 1976) account for the phenomenon of recurrent depression by proposing that depressive schemas are dormant when an individual is remitted from a depressive episode but emerge in the face of stress or negative life events, bringing about depressive episodes in predisposed individuals. In support of this idea, it has been shown that formerly depressed individuals possess negative processing biases (e.g., Gilboa & Gotlib, 1997, Hedlund & Rude, 1995, Ingram et al., 1998, Miranda & Persons, 1988, Rude et al., 2001 and Wenzlaff et al., 2001) and that such biases are predictive of subsequent depression (e.g., Metalsky et al., 1982, Rude et al., 2003, Rude et al., 2002 and Segal et al., 1999). It is likely that maladaptive emotion-regulation strategies also contribute to the vulnerability of formerly depressed individuals. Research on mood-control strategies suggests that formerly depressed individuals are prone to both thought suppression and rumination. Wenzlaff and colleagues (e.g., Rude et al., 2002 and Wenzlaff, 1993) have found higher rates of self-reported thought suppression in formerly depressed individuals. Presumably, these individuals actively try to suppress and inhibit dysfunctional negative thoughts in order to control their mood and prevent relapse into depression. Studies using cognitive load indicate that when formerly depressed individuals are taxed by time pressures and competing cognitive demands, they show negative processing biases that are not otherwise apparent (Wenzlaff, 1993, Wenzlaff & Bates, 1998, Wenzlaff & Eisenberg, 2001 and Wenzlaff et al., 2001). Paradoxically, tendencies to ruminate as well as tendencies to suppress and avoid negative thoughts are observed among individuals recovered from depression. Rumination may be linked to thought suppression in part because suppression requires considerable cognitive resources and is prone to fail in the presence of competing cognitive strains. When this occurs, suppressed thoughts may become chronically accessible (Wegner, 1994, Wegner & Wenzlaff, 1996 and Wenzlaff, 1993). Rumination, defined as, “… cognitions and behaviors that repetitively focus the depressed individual’s attention on his or her symptoms and the possible causes and consequences of those symptoms” (Nolen-Hoeksema, 1998, p. 404), has been linked to vulnerability to depressed mood and onsets of depressive episodes. For example, a prospective study of college students by Just and Alloy (1997) found that ruminative response styles increased the chances of a nondepressed individual experiencing a depressive episode over 18 months after recruitment and that rumination increased the severity of the episode. In addition, a longitudinal study of bereavement found that individuals with a more ruminative style of responding during the time of their loss had higher levels of depressive symptoms during the 18 months following the loss (Nolen-Hoeksema & Davis, 1999 and Nolen-Hoeksema et al., 1999). Because persistent rumination and attempts to suppress negative thoughts may indicate incomplete or unsuccessful cognitive processing (Lepore & Greenberg, 2002 and Lumley et al., 2002), an intervention that promotes cognitive processing of adverse events would be likely to reduce accessibility to depressive cognitive structures and thereby help prevent future depressive episodes. One such intervention is expressive writing. Benefits of the expressive writing paradigm have been replicated across diverse populations in multiple countries (for reviews, see Lepore & Smyth, 2002 and Pennebaker, 1997). The procedure of expressive writing usually unfolds as follows: Participants randomly assigned to the experimental condition are asked to write about emotionally upsetting experiences for 15 to 20 minutes a day for 3 to 4 consecutive days, whereas control group participants are asked to write about superficial topics, such as time management. Numerous studies have found that writing about one’s deepest thoughts and feelings about emotional upheavals can positively affect mental and physical health (Sloan & Marx, 2004 and Smyth, 1998). Compared to controls, participants who engaged in expressive writing have made fewer physician visits for illnesses in the months following the intervention (e.g., Pennebaker & Beall, 1986 and Stanton et al., 2000), shown improved immune and hormonal functioning (e.g., Booth et al., 1997 and Pennebaker et al., 1988), and improved functioning in other biological markers of stress or disease (e.g., Petrie, Booth, Pennebaker, Davison, & Thomas, 1995). Behavioral enhancements attributable to expressive writing include improved grade point average in college students (e.g., Lumley & Provenzano, 2003), reduced absenteeism from work (Francis & Pennebaker, 1992), and faster job re-acquisition in laid-off workers (Spera, Buhrfeind, & Pennebaker, 1994). Despite compelling evidence for the benefits of expressive writing on a wide range of outcome variables, few studies have assessed the impact of expressive writing on depression symptoms. What little evidence there is, is promising, however. Lepore (1997) observed a significant decline in depressive symptoms as measured by the SCL-90-R among college students assigned to expressive writing over the month preceding an exam. More recently, Sloan and Marx (2004) found fewer depressive symptoms at a 4-week follow-up in women with PTSD symptoms assigned to expressive writing compared to control participants. In addition, Graf (2004) found that psychotherapy outpatients who completed two written disclosure homework exercises displayed significantly greater declines in symptoms of depression and anxiety, as measured by the Depression Anxiety Stress Scales (Lovibond & Lovibond, 1995), than did the control group. However, none of these studies focused on the specific population of formerly depressed, depression-vulnerable individuals. Furthermore, these studies allowed only relatively brief follow-up periods to assess postintervention benefits (approximately 1 month). Therefore, the primary purpose of the current study was to examine possible benefits of the expressive writing paradigm in reducing the recurrence of depression symptoms over a 6-month period in a sample of students with a history of depression. In order to maximize the chances of observing elevated depression scores in controls and, hence, treatment differences, assessments were made 5 weeks and again 6 months following the writing intervention. Since expressive writing is thought to benefit individuals by lifting inhibitions against expression and by allowing previously avoided material to be processed and organized, we expected it to produce the largest gains for the subgroup that relied most heavily on suppression to regulate their emotions. This prediction is in line with previous evidence as summarized by Lumley et al. (2002): “… people who recognize having negative emotions but who are ambivalent over expressing them, who attempt to inhibit or avoid them, or who have intrusive thoughts and worry, are most likely to benefit from disclosure” (p. 89). Hence, we predicted that participants with higher scores on the Suppression Scale of the Emotion Regulation Questionnaire (Gross & John, 2003) would benefit most from expressive writing. In addition, hypotheses about expressive writing’s mechanism of action—specifically, the role of reductions in rumination in mediating benefits of writing—were explored. On the face of it, the expectation that expressive writing will reduce rumination seems paradoxical, since rumination has been characterized as paying too much attention to distress. Whereas Nolen-Hoeksema and colleagues (e.g., Nolen-Hoeksema, Parker, & Larson, 1994) have suggested distraction from distressing thoughts as an alternative to rumination, the expressive writing intervention asks individuals to focus on distressing thoughts and emotions. However, a number of researchers (e.g., Rude et al., in press, Segerstrom et al., 2003, Trapnell & Campbell, 1999, Treynor et al., 2003 and Watkins, 2004) have observed that both productive and unproductive ways of attending to one’s distress exist. Hence, it appears that rumination may consist of paying the wrong kind of attention to problems. While consensus does not yet exist as to what the “right kind” of attention is, it appears that attention directed toward problem-solving or attention devoid of negative judgments may be more productive than rumination. The Ruminative Responses Scale (RRS; Nolen-Hoeksema & Morrow, 1991), used in most of the research on ruminative thinking and depression, has been shown to be multifactorial (Roberts et al., 1998, Rude et al., in press and Treynor et al., 2003). After excluding items that were explicitly confounded with depression symptoms, Treynor et al. identified two factors in the remaining items: the Brooding factor was strongly associated with depression and the Reflective Pondering or Reflection factor was fairly weakly correlated with concurrently measured depression and did not predict subsequent increases in depression. Rude et al., in press noted that brooding differs from reflection primarily in the self-judgment contained in the items of the RRS. For example, brooding items include, “Think, ‘Why do I always react this way?’" and “Think, ‘Why do I have problems other people don’t have?’” Reflection items, on the other hand (“Go away by yourself and think about why you feel this way”), convey attention to distress without an added layer of judgment. Rude et al. argued that it is likely not the focusing of attention on problems and their attendant distress that drives harmful effects of rumination, but rather the negative judgment of the experience. We speculated that the mechanism through which expressive writing might benefit depression-prone individuals would be reductions in the unproductive self-judgment of experience that characterizes the brooding dimension of rumination. Since instructions given in the expressive writing paradigm encourage participants to “let go” and explore their “deepest thoughts and feelings” about troubling events, it seems likely that expressive writing would counter the inhibiting self-judgments that seem to characterize the brooding state. Hence, we predicted that improvements in depression symptoms would be mediated by improvements in brooding scores—that confronting one’s distressing thoughts and feelings would tend to reduce self-judgments about difficult emotional experiences (brooding), and that this would in turn reduce participants’ susceptibility to depression symptoms over the follow-up period. On the other hand, we did not expect simple attention to distress (reflective pondering) to be altered by or to mediate benefits of expressive writing. Finally, the utility of a “booster” writing session in enhancing benefits of expressive writing was explored. Booster sessions are hypothesized to consolidate prior therapeutic gains in cognitive therapy of depression and depression-related phenomena (Beck, Rush, Shaw, & Emery, 1979). Several studies have found significant effects of booster sessions in the maintenance of psychotherapeutic gains from cognitive-behavioral interventions (e.g., Clarke et al., 1999 and Riedel et al., 1986). Hence, this study aimed to explore the therapeutic effectiveness of a booster expressive writing session.