University of Massachusetts Boston
University of Massachusetts Boston
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Graduate Masters Theses
Doctoral Dissertations and Masters Theses
12-31-2018
Healing from Heterosexism Through Expressive Writing
Healing from Heterosexism Through Expressive Writing
Kathleen M. Collins
University of Massachusetts Boston
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HEALING FROM HETEROSEXISM THROUGH EXPRESSIVE WRITING
A Thesis Presented
by
KATHLEEN M. COLLINS
Submitted to the Office of Graduate Studies,
University of Massachusetts Boston,
in partial fulfillment of the requirements for the degree of
MASTER OF ARTS
December 2018
Clinical Psychology Program
© 2018 by Kathleen M. Collins
All rights reserved
HEALING FROM HETEROSEXISM THROUGH EXPRESSIVE WRITING
A Thesis Presented
by
KATHLEEN M. COLLINS
Approved as to style and content by:
________________________________________________
Heidi M. Levitt, Professor
Chairperson of Committee
________________________________________________
Alice S. Carter, Professor
Member
________________________________________________
Takuya Minami, Associate Professor
Member
_________________________________________
David W. Pantalone, Program Director
Clinical Psychology Program
_________________________________________
Lizabeth Roemer, Chair
Psychology Department
iv
ABSTRACT
HEALING FROM HETEROSEXISM THROUGH EXPRESSIVE WRITING
December 2018
Kathleen M. Collins, B.A., Sarah Lawrence College
M.A., New School for Social Research
M.A., University of Massachusetts Boston
Directed by Professor Heidi M. Levitt
Simply by existing within our society, LGBTQ people encounter widespread exposure to
heterosexist attitudes, behaviors, and policies on a daily basis that ignore, invalidate, or
outright discriminate against them. This marginalization contributes to myriad
psychological consequences such as depression, suicidality, anxiety, and substance abuse.
Despite the fact that LGBTQ people experience mental health issues and some
subsequently seek treatment, few interventions exist that specifically address LGBTQ
minority stressors; those that do exist tend to treat mental health consequences of societal
heterosexism, rather than offering ways to heal from heterosexist experiences directly. In
the current study, I explored the ability of three variations of online expressive writing
exercises to reduce distress related to experiencing a heterosexist event. In addition to
v
comparing baseline to post-intervention and follow-up scores on measures of
psychological distress (including depression, negative affect, trauma-related distress, and
internalized homophobia scales) between the three writing conditions and between
demographic groups, I conducted a qualitative task analysis on participant responses to
study the process by which participants benefitted from the writing exercises. This study
contributes to the development of population-specific interventions for LGBTQ people,
as well as to the understanding of the processes by which LGBTQ people derive benefit
from writing about heterosexist experiences.
vi
ACKNOWLEDGEMENTS
First, I would like to thank my mentor Dr. Heidi Levitt for her guidance and
wisdom throughout the course of this project. I would also like to thank my committee
members Dr. Alice Carter and Dr. Takuya Minami for their valuable insight.
Second, I would like to thank my parents for their unwavering encouragement to
pursue my dreams. I also want to thank my partner Shanna for her love, support, and
ability to make me laugh throughout stressful times.
Finally, I would like to thank everyone who participated in this study for sharing
their stories. This project simply would not be possible without their vulnerability,
strength, and commitment to supporting LGBTQ research.
vii
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
…………………………………………………………………
vi
LIST OF TABLES
……………………………………………………………………………..
ix
LIST OF FIGURES ……………………………………………………………………………
x
CHAPTER Page
1. SPECIFIC AIMS OF STUDY ………………………………………………
1
Aim 1 ………………………………………………………………………….
1
Aim 1a
……………………………………………………………………
2
Aim 1b …………………………………………………………………..
2
Aim 1c
……………………………………………………………………
2
Aim 2 ………………………………………………………………………….
2
Aim 3 ………………………………………………………………………….
2
2. BACKGROUND AND SIGNIFICANCE
………………………………
4
Definition of Heterosexism
…………………………………………….
6
Consequences of Heterosexism ………………………………………
8
Mechanisms of Change Related to Heterosexism ……………..
10
Expressive Writing Exercises …………………………………………
11
Emotion-Focused Adaptation of Expressive Writing …………
13
Current Study ……………………………………………………………….
14
3. METHOD ………………………………………………………………………….
16
Participants
…………………………………………………………………..
16
Quantitative analyses ……………………………………………….
16
Qualitative analyses …………………………………………………
17
Recruitment
…………………………………………………………………
19
Quantitative analyses ……………………………………………….
19
Qualitative analyses …………………………………………………
20
Measures and Data Collection ……………………………………….
20
Quantitative analyses ……………………………………………….
20
Qualitative analyses …………………………………………………
23
4. RESULTS …………………………………………………………………………..
30
Quantitative Results ………………………………………………………
30
Preliminary analyses ………………………………………………..
30
Aim 1a
…………………………………………………………………..
31
Aim 1b …………………………………………………………………..
34
Aim 1c
…………………………………………………………………..
36
Aim 2 …………………………………………………………………….
37
viii
Qualitative Results ………………………………………………………..
46
Synthesized model of productive resolution
………………..
46
Unproductive blocks ……………………………………………….
55
CHAPTER Page
5. DISCUSSION …………………………………………………………………….
58
Interpreting Why the Control Condition Did Not Serve as a
Control Condition ……………………………………………………
60
Differentiating Long-Term and Short-Term Effects of
Expressive Writing
………………………………………………….
62
Conceptualizing Heterosexism as a Form of Trauma
………..
64
Exploring the Relationship Between Trauma and Depression
65
Critiquing Outcome Scores as Indicators of Progress ………..
67
Describing the Utility of the Task Analysis Results
…………..
69
Strengths and Limitations ………………………………………………
72
Conclusion …………………………………………………………………..
74
APPENDIX
A. EXPRESSIVE WRITING PROMPTS ………………………………….
75
B. QUESTIONNAIRES …………………………………………………………..
77
CESD-R ……………………………………………………………………..
77
PANAS ………………………………………………………………………
78
IES-R ………………………………………………………………………….
79
TIHS
……………………………………………………………………………
81
C. PROCESS RATING SCALE
………………………………………………..
82
REFERENCE LIST ……………………………………………………………………………
83
ix
LIST OF TABLES
Table
Page
1. Sample Demographics ………………………………………………………….
18
2. ANCOVA Summary Table of Mean Outcome Scores by Condition
after Controlling for Baseline Scores
……………………………….
32
3. Mixed ANOVA Summary Table for Condition ……………………….
33
4. One-Way Repeated ANOVA Summary Table …………………………
34
5. ANCOVA Summary Table of Mean Outcome Scores Between
Demographic Groups after Controlling for Baseline Scores .
39
6. Mixed ANOVA Summary Table for Sexual Orientation …………..
41
7. Mixed ANOVA Summary Table for Gender Identity ……………….
43
8. Mixed ANOVA Summary Table for Racial/Ethnic Identity ………
46
x
LIST OF FIGURES
Figure
Page
1. Rational model of two potential pathways of resolving
distress related to a heterosexist event ……………………………..
27
2. Estimated marginal means of CESD-R scores on full sample..
…..
35
3. Estimated marginal means of IES-R scores on full sample
………..
36
4. Direct assessment of progress scores
……………………………………..
37
5. Synthesized model of the stages through which productive
cases progress
……………………………………………………………….
54
1
CHAPTER 1
SPECIFIC AIMS
The overarching goal of this study is to test an expressive writing intervention for
LGBTQ individuals who are coping with an experience of heterosexism. Specifically,
the current study addresses the following three aims:
Aim 1
The first aim seeks to empirically test whether LGBTQ participants benefitted
from an expressive writing exercise aimed at helping people cope with experiences of
heterosexism and whether the effects differed between conditions..
Aim 1a. The hypothesis of Aim 1a was that LGBTQ participants who completed
the emotion-focused writing condition, which provides more structure to support the
processing of the event, would exhibit larger reductions in psychological distress.
Psychological distress was measured using the negative subscale of the Positive and
Negative Affect Schedule (PANAS), the Center for Epidemiological Studies Depression
Scale Revised (CES-D), the Impact of Events Scale Revised (IES-R), and the Wright
Internalized Homophobia Scale (TIHS).
2
Aim 1b. The hypothesis of Aim 1b was that LGBTQ participants would
experience reductions in general psychological distress following the writing exercises,
regardless of condition.
Aim 1c. The hypothesis of Aim 1c was that LGBTQ participants would report
that they made progress in dealing with their specific heterosexist event. Participants’
reported progress was measured using a composite Direct Assessment of Progress score
created by combining six Likert-type scale questions (three on Day 4, three at follow-up)
directly assessing how much progress participants felt they made in dealing with the
event, how helpful they found the exercise, and how they felt about the exercise overall.
Aim 2
The second aim sought to explore if demographic factors determine which
participants benefitted most from the expressive writing exercises. Specifically, I
explored whether or not LGBTQ participants who differ in gender identity, sexual
orientation, or race had significant differences in the reduction of psychological distress.
As this aim was exploratory in nature, there were no a priori hypotheses about the results
of these analyses.
Aim 3
Finally, the third aim sought to answer the question of how the process of
engaging in emotion-focused expressive writing about a heterosexist event leads to
reduced psychological distress. This aim was analyzed by conducting a qualitative task
analysis on a selection of participant writing responses from the emotion-focused
expressive writing condition. Task analyses involve developing a theory-based rational
model of the expected process, which is then iteratively applied to a subset of actual
3
participant responses to create an updated empirical model. The model is refined through
continued comparison to additional sets of participant responses and results in a
synthesized rational-empirical model.
4
CHAPTER 2
BACKGROUND AND SIGNIFICANCE
Relatively little research has focused on designing interventions to address issues
faced by lesbian, gay, bisexual, transgender, and queer (LGBTQ) clients. This scarcity is
surprising in a population that demonstrates a high prevalence of both mental health
issues and utilization of mental health services (Cochran, Sullivan, & Mays, 2003; King,
Semlyen, Killaspy, Nazareth, & Osborn, 2007). LGBTQ-affirmative therapy has been
developed as a useful approach to working with sexual and gender minority clients on a
variety of presenting issues (Bieschke, Perez, & DeBord, 2007). However, affirmative
therapies constitute an overall approach rather than a specific intervention (Johnson,
2012). While affirming a client’s identity and experience is beneficial during therapy,
therapists must also consider what happens in the client’s life outside of the therapy
room. LGBTQ mental health issues can be conceptualized within a minority stress
framework, which posits that people with marginalized identities experience additive
stress as a result of their oppression (Meyer, 2003). The unique stressors that LGBTQ
people face, such as rejection or harassment due to one’s identity, are in addition to
stressors that affect many people within a given culture; this implies that the additional
5
stress caused by pervasive social attitudes about sexual and gender minorities contributes
to the higher rates of mental health problems in this population (Meyer, 2003).
This documented relationship between sociopolitical oppression and personal
distress is consistent with both feminist theory and minority stress theory (Szymanski,
Kashubeck-West, & Meyer, 2008) and suggests that population-specific interventions
should not only target presenting problems, such as depression or anxiety, but should
address them in the context of social forces that contribute to the development of these
problems. Researchers at the Center for LGBTQ Evidence-Based Applied Research
(CLEAR) are currently working to establish an evidence base for integrative affirmative
therapy (IAT), an approach that emphasizes positive identity development and the role of
minority stress in order to reduce psychological distress (Goldblum, Pflum, Skinta,
Evans, & Balsam, 2016). This consideration of context as essential to the development
of personal problems is an inspiring advancement in the field of LGBTQ psychotherapy
research. Even so, specific interventions for achieving this goal remain unclear. IAT’s
treatment planning model initially involves resolving conflict related to sexual orientation
before moving on to reducing distress and aching life goals while affirming orientation.
For clients who are not experiencing conflict about their orientation, the treatment plan
describes that, “In phases three to five, clients who are clearer about their sexual
orientation and identity are provided a more explicit LGB-affirmative approach”
(Goldblum et al., 2016, p. 337); however, explanations of the affirmative approach are
not particularly explicit (Johnson, 2012).
Current LGBTQ-affirmative interventions that have been tested often involve
cognitive-behavioral techniques that are modified to incorporate issues relevant to sexual
6
and gender minorities, such as internalized stigma and developmental milestones like
coming out (Austin & Craig, 2015; Matthews & Salazar, 2012; Pachankis,
Hatzenbuehler, Rendina, Safren, & Parsons, 2015; Ross, Doctor, Dimito, Kuehl, &
Armstrong, 2008). LGBTQ people face a range of chronic stressors aside from the more
commonly-cited milestones like coming out, such as various forms of microaggressions
(Balsam, Molina, Beadnell, Simoni, & Walters, 2011; Nadal et al., 2011) and the
psychological impact of unequal civil rights (Levitt et al., 2008; Rostosky, Riggle, Horne,
& Miller, 2009). While IAT and cognitive-behavioral interventions are promising, they
typically involve coping with the internalized sequelae of discrimination (e.g.,
depression, anxiety, internalized homophobia) rather than explicitly navigating reactions
to external events. Developing ways to guide clients through processing their thoughts
and feelings about these chronic, and sometimes seemingly minor, stressors may prevent
the internalization of stigma, as well as reduce psychological distress associated with
experiencing discrimination from others.
Definition of Heterosexism
The root of identity-related stressors that LGBTQ individuals face is heterosexism
in its many forms. Heterosexism refers to the pervasive attitude in Western culture
concerning the superiority of heterosexual orientations, relationships, and behaviors, and
the subsequent inferiority of all orientations that deviate from heterosexual; it
simultaneously refers to the systemic oppression of non-heterosexual identities (Herek,
2004). Heterosexism is a nuanced concept that is similar to, and is often used
interchangeably with, related terms like homophobia, homonegativity, and
heteronormativity. These terms all stem from the same systems of oppression and are
7
perpetuated by the same types of behavior, but they represent slightly different
constructs. A critical aspect of heterosexism is that it refers to a cultural ideology, as
opposed to individually held and transmitted prejudices (Herek, 2004).
Heterosexism is perpetuated through individual factors, such as attitudes and
behaviors, as well as systemic factors, such as policies and actions that discriminate
against non-heterosexuals. These stressors range from distal, such as stressful events and
hypervigilance stemming from expectation of such events, to proximal, including
internalization of heterosexist attitudes that cause individual psychological distress
(Meyer, 2003). Stressful heterosexist events can be as minor as being assumed
heterosexual and carrying the burden of coming out repeatedly in new environments, to
stressors as major as being fired solely based on your sexual orientation.
Heterosexism is not only transmitted through overtly hostile acts of
discrimination. Acts of violence, interpersonal harassment, lack of legal protection, and
lack of equal civil rights are certainly harmful to the LGBTQ community; however,
subtle micro-aggressive acts and comments that endorse heterosexism can be just as
harmful due to their insidious nature. Unlike overt violence or harassment, which may be
less likely to occur in a professional environment such as work or healthcare settings,
microaggressions that perpetuate heterosexism occur in both professional and casual
social environments. Harm caused by microaggressions is often unintentional and
unrecognized by the perpetrator, which results in microaggressions occurring in a wide
range of environments. This pervasiveness makes them difficult to escape and increases
the chance of having routine stressful heterosexist experiences. Given the ubiquity of
heterosexism and its negative effects on the wellbeing of LGBTQ individuals (Bostwick,
8
Boyd, Hughes, West, & McCabe, 2014); Burton, Marshal, Chisolm, Sucato, & Friedman,
2013; Gleason et al., 2016), there is a demonstrated need for interventions that help
people cope with heterosexism and heterosexist events. Helping LGBTQ people develop
skills for coping with heterosexist events as they occur may in turn reduce the severity of
mental health issues stemming from prolonged exposure to heterosexism.
Consequences of Heterosexism
Exposure to overt and covert heterosexism can have myriad psychological
consequences. The past few decades of research have documented higher rates of
psychological distress in LGBTQ individuals than in heterosexual individuals. This
distress includes higher rates of depression, anxiety, and substance abuse disorders
(Cochran, Mays, & Sullivan, 2003; King et al., 2008; Lehavot & Simoni, 2011; Meyer,
2003), as well as internalized heterosexist attitudes that both moderate, and are
independently related to, these psychological consequences (Herek, Cogan, Gillis, &
Glunt, 1998; Igartua, Gill, & Montoro, 2009; Russell & Bohan, 2006; Szymanski, Chung,
& Balsam, 2001; Szymanski & Henrichs-Beck, 2014; Szymanski et al., 2008). These
psychological issues result in LGBTQ individuals attempting suicide at higher rates than
their heterosexual counterparts (Haas et al., 2011), as well as seeking mental health
services at higher rates (Cochran et al., 2003; King et al., 2007).
Although psychological distress often is considered to be an internal experience,
distress due to heterosexism is related to both the immediate interpersonal environment
and the broader sociopolitical environment. LGBTQ individuals may face interpersonal
consequences like social isolation, relationship problems, and family conflict as a result
of their sexual orientation or gender identity (Pearson & Wilkinson, 2013; Ryan, Russell,
9
Huebner, Diaz & Sanchez, 2010; Szymanksi & Kashubeck-West, 2008). Interpersonal
conflicts may increase social isolation and its harmful psychological correlates, creating a
negative feedback loop that increases distress while simultaneously diminishing social
supports to help cope with that distress.
Systemic factors, like discriminatory legislation, also negatively impact LGBTQ
mental health. Negative affect, depressive symptoms, and stress are shown to increase in
LGB individuals (Rostosky et al., 2009) and their supportive family members (Horne,
Rostosky, Riggle, & Martens, 2008) when living in states that deny marriage to same-sex
couples. Transgender college students who are denied access to gender-appropriate
bathrooms or housing are more likely to have a lifetime suicide attempt, even after
accounting for experiences of interpersonal victimization that may also be associated
with suicide attempts (e.g., bullying; Seelman, 2016). The negative psychological impact
of discriminatory legislation and policies means that even LGBTQ individuals who have
a supportive social network may still face mental health challenges to which non-LGBTQ
people are not subjected.
In addition to being psychologically harmful, heterosexism can have significant
functional consequences for LGBTQ individuals. Societal heterosexism can restrict
access to job opportunities (Pichler, Varma, & Bruce, 2010), contribute to absenteeism in
school (Pizmony-Levy & Kosciw, 2016), impede psychotherapeutic progress (Shelton &
Delgado-Romero, 2011), and negatively influence treatment and rapport with healthcare
providers (Morrison & Dinkel, 2012). The consequences of avoiding school, not seeking
healthcare, and losing job opportunities only contributes to the psychological distress
seen in this population.
10
Mechanisms of Change Related to Heterosexism
Recent research has begun to identify the mechanisms through which exposure to
heterosexism results in psychological distress. Experiencing distal stressors (e.g.,
microaggressions, discriminatory legislation) can increase proximal stressors (e.g.,
internalized stigma) through psychological processes like rumination, hopelessness,
expectation of rejection, and interpersonal isolation, all of which influence the
development of mental health disorders (Hatzenbuehler, 2009). Exposure to both distal
stressors and proximal stressors can change from day to day depending on an individual’s
environment, which suggests that the psychological consequences of these stressors are
also not static. Indeed, Mohr and Sarno (2016) show that various identity-salient
experiences (ISEs), including both negative and positive ISEs with both heterosexual and
non-heterosexual people, can predict daily changes in stress and affect in LGB young
adults. The way that sexual and gender minority people process identity-related
experiences, both positive and negative, contributes to the psychological complexity of
such experiences. People may vary in what they find more stressful (e.g., a negative ISE
with a heterosexual versus an LGB person), as well as in how they understand and
respond to it.
Qualitative research has documented strategies employed by sexual and gender
minority individuals to cope with heterosexism, including seeking social support,
modifying behavior based on situation, challenging heterosexist attitudes in others and
themselves, and engaging in activism (Bjorkman & Malterud, 2012; Grossman et al.,
2009; Levitt et al., 2008; McDavitt et al., 2008). The relative lack of research testing the
efficacy of the strategies described by LGBTQ individuals makes it difficult to evaluate
11
these clinical interventions. Thus, there is a need to develop and test specific
interventions aimed at both coping with heterosexism and at understanding the
mechanisms behind how sexual minority stressors yield psychological distress.
The focus on treating internalized reactions to heterosexism in LGBTQ
psychotherapy research is incomplete. Direct effects of distal stressors, such as acute or
chronic heterosexist experiences, can cause distress independently of internalized
heterosexism (Szymanski & Henrichs-beck, 2014); an incomplete focus on internalized
heterosexism can result in clinicians guiding people to focus mainly on countering their
internalized responses, rather than the heterosexist messages in society. This is harmful
because it puts the onus on marginalized individuals to change, and also may ignore
distress caused by experiencing heterosexist events. Accordingly, there is a need for
understanding not only how to counter internalized heterosexism, but how to cope with
external experiences of heterosexism, and how to keep these distal stressors from
becoming internalized or psychologically harmful.
Expressive Writing Exercises
The expressive writing paradigm is based upon interventions aimed at helping
people cope with difficult emotions or situations through personal disclosure. The initial
study testing this method (Pennebaker & Beall, 1986) showed that participants who wrote
about an upsetting experience for 15 minutes over 4 consecutive days showed
improvements in physical health compared to participants who wrote about a neutral
topic. The original paradigm has been utilized with various methodological adaptations.
There is evidence that expressive writing can be helpful when lasting as few as 2 minutes
rather than the typical 15, or in one intensive session rather than on consecutive days
12
(reviewed in Smyth & Pennebaker, 2008). However, a meta-analysis of 146 studies
found that the majority of studies schedule sessions on consecutive days; furthermore,
using at least three sessions that last at least 15 minutes yields larger effect sizes in
psychological health, physical health, subjective impact, and overall effect size
(Frattaroli, 2006). The same meta-analysis reports that experimental disclosure has a
positive overall effect size (r= 0.075), which is especially promising considering this
benefit comes from a low-cost (e.g., inexpensive, low-risk) intervention. Thus, this
commonly used method of writing (at least 15 minutes on consecutive days) is shown to
be effective, although variations of this paradigm have been tested using different
timeframes, populations, and formats.
Expressive writing exercises have been used with people facing a variety of
psychological issues, including depression (Baike, Geerligs, & Wilhelm, 2012; Baum &
Rude, 2013; Stice, Burton, Bearman, & Rhode, 2007), trauma (Smyth, Hockemeyer, &
Tulloch, 2008), and life transitions (Pennebaker, Colder, & Sharp, 1990; Spera,
Buhrfeind, & Pennebaker, 1994), as well as in people coping with physical conditions
such as cancer (Henry, Schlegal, Talley, Molix, & Bettencourt, 2010; Smyth & Helm,
2003). These exercises have reliably led to psychological improvement, as measured by
scales assessing depression (Henry et al 2010; Pachankis & Goldfried, 2010; Stice et al.,
2007), anxiety (Baikie, et al., 2012; Hirai, Skidmore, Clum, & Dolma, 2012), positive
and negative affect (Pachankis & Goldfried 2010; Pennebaker et al., 1990), self-esteem
(Pennebaker et al., 1990), and avoidance behaviors (Swanbon, Boyce, & Greenberg,
2008), as well as reduced physiological measures (e.g., cortisol in response to traumatic
memories; Smyth et al., 2008). These positive effects typically have been demonstrated
13
using a pen-and-paper method, but online formats also have demonstrated effectiveness
in yielding positive psychological change (Baike et al., 2012; Lange, van de Ven,
Schrieken, Bredeweg, & Emmelkamp, 2000; Possemato, Ouimette, & Geller, 2010).
An expressive writing approach also has been used with participants from
minority groups to address minority-specific issues and their psychological correlates.
Such issues include internalized racism (Kaufka, 2009), trauma-related distress in
Hispanic individuals (Hirai et al., 2012), gay-related stress in both men (Pachankis &
Goldfried, 2010; Pérez-Benítez, O’Brien, Carels, Gordon, & Chiros, 2007; Swanbon et
al., 2008) and women (Lewis et al., 2005), and coping with hate speech in LGB
individuals (Crowley, 2014). This confirms that expressive writing is effective for a
range of participants, as well as offers a promising method for helping marginalized
individuals cope with psychological distress associated with minority-related stressors.
This is particularly relevant to the current study due to the lack of population-specific
interventions for LGBTQ individuals, a population that is known to seek mental health
services (Cochran et al., 2003).
Emotion-Focused Adaptation of Expressive Writing
The instructions given to participants in expressive writing studies are often
general; participants are typically asked to write about their “deepest thoughts and
feelings” about an upsetting event (Frattaroli, 2006). Given the success of expressive
writing exercises in addressing emotionally evocative topics with a relatively simple
prompt, the question arises of whether a more structured approach would enhance these
effects. While emotions are often the subject of disclosures in psychotherapy or
expressive writing, therapeutic approaches differ in the emphasis placed on emotions,
14
cognitions, behaviors, and other aspects of human experience. A prompt that elaborates
on the typical expressive writing instructions, perhaps by guiding participants through
steps to access, experience, and process their emotions, may prove particularly effective.
An emotion-focused adaptation of the typical expressive writing prompt may help
clients truly access and reflect on their deepest thoughts and feelings more effectively
than the broad, unstructured instructions. An emotion-focused therapy (EFT) approach is
centered around facilitating clients’ acknowledgement and exploration of their emotions,
both adaptive and maladaptive, within an empathic relationship between therapist and
client (Greenberg, 2002). This experience of engaging with one’s emotions, particularly
those that are inadvertently avoided or considered unacceptable, can empower clients
through strengthening their self-awareness and facilitating a coherent self-organization as
opposed to experiencing internal conflict (Elliot & Greenberg, 2007). Expressive writing
is completed individually, so there would not be a trained professional facilitating
empathic exploration of the participants’ emotional experiences during the exercise;
however, EFT prompts can be worded in such a way that they guide participants through
the process of exploring their emotions. This guidance can encourage them to approach
the task with nonjudgmental curiosity and validate that it can be difficult to engage with
certain emotions. Indeed, the lack of a therapist during an expressive writing exercise
may free participants to introspect in a sustained manner and to express concerns that
they might fear would invoke a therapists’ judgment.
Current Study
The current study tested the ability of a series of online expressive writing
exercises to reduce psychological distress in LGBTQ adults who have experienced a
