Psychology & Health
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Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features Sarah M. C. Robertson , Stephen D. Short , Leslie Sawyer & Scott Sweazy To cite this article: Sarah M. C. Robertson , Stephen D. Short , Leslie Sawyer & Scott Sweazy (2020): Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features, Psychology & Health, DOI: 10.1080/08870446.2020.1827146 To link to this article: https://doi.org/10.1080/08870446.2020.1827146
Published online: 30 Sep 2020.
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PSYCHOLOGY & HEALTH https://doi.org/10.1080/08870446.2020.1827146
Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features Sarah M. C. Robertson
, Stephen D. Short
, Leslie Sawyer and Scott Sweazy
Department of Psychology, College of Charleston, 66 George St, Charleston, SA, USA ABSTRACT
ARTICLE HISTORY
Objective: Meta-analyses assessing the efficacy of expressive writing (EW) interventions have produced mixed results. The current study aimed to assess the efficacy of an EW intervention in the reduction of anxiety symptoms in first-year college students. In an effort to understand more about moderating variables that influence EW outcomes, the current study also assessed the role of linguistic features in symptom reduction. Design and measures: Ninety participants were assigned to complete either an EW intervention or a non-emotional writing intervention. Participants completed 3 consecutive days of writing and two follow-up visits. Anxiety was measured at each study visit with the Beck Anxiety Inventory, and linguistic features were assessed with the LIWC software program. Results: Results indicated that all participants demonstrated significant decreases in anxiety over time. Participants in the EW group who demonstrated the greatest decreases in anxiety utilized more first-person singular pronouns and fewer affect words. Conclusions: Results are explained in the context of two prominent theories regarding the therapeutic mechanisms of EW: cognitive processing theory and exposure theory. Exposure theory received more support than cognitive processing theory.
Received 14 May 2020 Accepted 17 September 2020 KEYWORDS
Expressive writing; anxiety; college students; linguistic analysis; linguistic features
The transition from high school to college can be an incredibly stressful time for students. Starting college is typically related to a number of concerns for students including leaving family and friends, adjusting to a new living environment with a roommate, financial responsibilities, academic demands, pressure to succeed, quality of sleep, overall physical health, and generating social relationships (Beiter et al., 2015; Vaez & Laflamme, 2008). In addition to these concerns, first-year college students are also typically in the emerging adulthood developmental phase that occurs between 18 and 25 years of age (Arnett, 2000). This developmental phase is characterized by instability, identity exploration, and feeling ‘in-between’ (Arnett, 2000). In sum, firstyear college students face practical stressors (e.g., making a doctor’s appointment, CONTACT Sarah M. C. Robertson [email protected] George St, Charleston, SC29424SA, USA. ß 2020 Informa UK Limited, trading as Taylor & Francis Group
Department of Psychology, College of Charleston, 66
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creating a healthy schedule, finding their classrooms on campus) in addition to existential stressors (e.g., discovering their purpose in life, developing and maturing their sense of self), that can be quite challenging to contend with. Because the first year of college is filled with so many different types of stressors, researchers have focused on understanding the mental health status of this group. Recent data indicate that 32.5% of college freshmen have frequently felt anxious in the last year (Stolzenberg et al., 2019) and Blanco et al. (2008) reported that in a nationally representative sample of college students, 11.94% of participants met full criteria for an anxiety disorder. Given that college freshmen deal with significant stress during their first year of college, it is important for researchers to investigate mechanisms to decrease anxiety during this period of time. The current study aimed to assess the efficacy of expressive writing (EW) in reducing symptoms of anxiety, examine the role of linguistic features in the reduction of anxiety symptoms, and ultimately inform our theoretical understanding of how an EW intervention works in the context of anxiety. EW is typically a brief intervention that requires participants to write for 15–20 minutes over the course of 3–5 days about an emotional topic (Pennebaker, 1993). Participants are usually asked to write freely and continuously during the intervention, without consideration for spelling or grammar errors. Pennebaker and Beall (1986) first examined the efficacy of EW and demonstrated that EW is associated with a reduced number of self-reported physician visits. Subsequently, more than 400 articles have been published on the psychological and physical effects of EW (Niles et al., 2014). Meta-analytic reviews of EW outcomes have concluded that EW has been typically associated with small but significant effect sizes on improvements in psychological health, physical health, and overall functioning (Frattaroli, 2006; Pavlacic et al., 2019; Smyth, 1998). However, other meta-analyses have demonstrated that EW is not associated with significant improvements in psychological health or physical health (Frisina, et al., 2004; Mogk et al., 2006; Reinhold et al., 2018). It has become clear from this large body of work that EW may not be universally efficacious.
Theoretical approaches Cognitive processing theory (Boals & Klein, 2005; Pennebaker, 1997) and exposure theory (Bootzin, 1997) are two prominently supported theories related to the efficacy of EW. First, cognitive processing theory asserts that EW can be helpful because it requires participants to make meaning of their experiences and it potentially changes the way in which participants think about a difficult experience from their past (Boals & Klein, 2005; Pennebaker, 1993). Interventions rooted in cognitive processing theory help people challenge and modify their erroneous beliefs about previous aversive experiences, which ultimately allows them to fully process their experience (Kaczkurkin & Foa, 2015). Important work has been conducted to assess the potential relationship between cognitive processing theory and linguistic features in the context of EW. When Pennebaker and colleagues asked participants who had demonstrated significant improvement in an EW protocol to describe why they thought their experience in the study was beneficial, they reported that having the opportunity to make meaning of their experience was particularly important (Pennebaker et al., 1990). They also
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found that participants who utilized an increasing percentage of cognitive words demonstrated improved physical health outcomes (Pennebaker, 1993). According to the cognitive processing theory, stressful (but non-traumatic) events may have aberrant cognitive representations (Boals & Klein, 2005). Boals and Klein (2005) also assert that “expressive writing about a stressful event may produce beneficial effects because the writing changes the cognitive representation of the event and the language used in the narratives is reflective of the underlying cognitive representation” (Boals & Klein, 2005, p. 255). Providing students with a way to explore their thoughts and feelings about their stressful transition to college could provide them with an opportunity to make meaning of their experience and ultimately reduce their distress as a result. This benefit could be especially pronounced for participants whose writing is focused on developing insight and creating meaning from their experience. Second, exposure theory, commonly discussed in the context of clinical psychology and anxiety disorder treatment, posits that choosing to confront and process the feared stimuli in our environment is associated with long-term improvement in anxiety and well-being. There are several theoretical mechanisms that explain how and why exposure therapy works, including habituation, extinction, and emotional processing (Moscovitch et al., 2009). Habituation refers to a decreased psychological or physiological response to a stimulus that occurs after repeated exposure to the stimulus, extinction refers to a decreased response when a conditioned stimulus is presented repeatedly without an unconditioned stimulus being present, and emotional processing refers to the process of modifying negatively-valenced emotional memories by activating the original memory and encoding new information that is initially incompatible with the original memory (Moscovitch et al., 2009). Importantly, in order for these theoretical mechanisms to reduce distress, it is required that the person be exposed to the distressing memory, and that the exposure (e.g., in vivo exposure, imaginal exposure, virtual reality exposure, interoceptive exposure) match the content of the original memory (Moscovitch et al., 2009). Some previous work has assessed the relationship between exposure theory and linguistic features in EW. Dunnack and Park (2009) found that an increased use of first-person pronouns (e.g., “I”, “me”) over the course of four weekly writing sessions was associated with improved psychological adjustment. They asserted that the utilization of first-person pronouns is associated with self-focus, and that this self-focus is consistent with exposure therapy’s focus on confronting difficult previous experiences. Results from past research examining the effect of EW on symptoms of anxiety have been mixed. For instance, Pennebaker and Beall (1986) required college student participants to write about personal traumas they had experienced (e.g., death of loved one, relationship breakup, etc.). Although students demonstrated more negative moods (including anxiety) after each EW session as compared to control writing, they also made fewer illness-related visits to their physicians. Similarly, Pennebaker et al. (1990) noted that college student participants who completed EW regarding their transition to college demonstrated higher levels of anxiety when compared to the control group 2–3 months after writing. However, these adverse effects of EW on anxiety were not found at follow-up approximately six months after writing. More recently, when college students in an EW group were asked to write about the most stressful
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experiences of their lives, nearly half wrote about an assault or illness/injury, yet at the end of the study they did not significantly differ in anxiety symptoms when compared to a control group 6 months post-writing (Sloan et al., 2009). Conversely, Alparone et al. (2015) found that when undergraduates completed an EW task related to the most traumatic experience of their lives, those in the EW group demonstrated a significant decrease in anxiety symptoms when compared to the control group four months after the completion of the EW protocol. Indeed, the literature indicates mixed findings in the assessment of EW in reducing symptoms of anxiety across time. Because of the mixed findings in the field of EW and anxiety, researchers have recently assessed for moderators that might explain why some participants seem to improve more than others (Frattaroli, 2006; Sloan & Marx, 2018). Some prior work has examined the role of linguistic features in the reduction of anxiety symptoms. For example, an increase in cognitive words (e.g., should, could, doubt) across several days of writing was associated with decreased anxiety in a sample of Italian undergraduate students without a history of psychiatric disorders (Alparone et al., 2015). Also, in a sample of both students and adults from the community with no history of a psychiatric disorder, very high use (greater than 1 standard deviation above the mean) of negative affect words predicted higher anxiety symptoms three months post-writing (Niles et al., 2016).
Current study It is our position that examining linguistic features can inform our understanding of how EW impacts symptoms of anxiety and the theoretical underpinnings of this effect. It is possible to objectively measure the degree to which a person utilizes cognitive words, emotion words and words related to the self in descriptions of events using the Linguistic Inquiry Word Count (LIWC) software program (Pennebaker, Booth, et al., 2015). Because the cognitive processing theory posits that EW is helpful because it requires participants to make meaning of their experiences, we anticipate that a higher degree of cognitive processing words (e.g., “think”, “because”, “could”, “maybe”) should be negatively associated with anxiety symptoms. The exposure model posits that EW is helpful because it requires participants to reflect on their distressing memory, which in turn allows for habituation, extinction, and emotional processing. In the context of the college transition period, a person can undergo exposure by reflecting on themselves and describing their emotions. We therefore predicted that first person singular pronouns (e.g., “I”, “me”) and affect words (e.g., “sad”, “anxious”) would be negatively associated with anxiety symptoms (Danoff-Burg et al., 2010). It should be noted that Pennebaker, Mehl and Niederhoffer (2003) wrote about a “linguistic fingerprint” that was associated with improvement following EW procedures. The authors noted that participants were more likely to benefit if they used a high number of positive emotion words and a moderate number of negative emotion words. More recently, Zbozinek and Craske (2017) have argued that increasing positive affect is a way to optimize extinction learning and exposure therapy. They note that “positive affect during extinction may benefit long-term extinction learning through enhancing encoding, rehearsal, retrieval, and increasing positive valence of the feared stimulus”
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(p. 31). Other authors (Taylor et al., 2017) suggest that using positive emotion words in the context of exposure might help people better tolerate the negative emotions involved in exposure therapy. For these reasons, we felt it important to assess the frequency of all emotional words, regardless of valence. Because both the cognitive processing theory and exposure theory have received empirical support in the literature (Frattaroli, 2006), we anticipate higher percentages of both cognitive and exposure words will be significantly associated with anxiety symptom reduction. It was predicted that: 1. 2.
EW would be associated with reductions in anxiety in first-year college students. Linguistic features would significantly predict anxiety symptoms, such that participants using a higher degree of cognitive words and exposure words would demonstrate greater decreases in anxiety.
Methods Participants Participants included 90 first-year students who were taking an Introduction to Psychological Science course at a midsized college in the Southeastern United States. Participants were recruited through a departmental website, and participants received course credit for their participation in the study. Because a final follow-up visit for the study was completed after the conclusion of their psychology course, they received $5 for the completion of their final follow-up visit. Seventy-eight participants identified as female, and 12 participants identified as male. No participants identified as non-binary, third gender, or preferred not to describe their gender. Participants were, on average, 18.26 years old (SD ¼ 0.74). The sample consisted of White (n ¼ 67), African American (n ¼ 13), Latino (n ¼ 7), Asian (n ¼ 1), American Indian (n ¼ 1), and mixed/other (n ¼ 1) participants. All participants were never married. In terms of employment status, 41 participants were unemployed and not seeking employment, 24 participants were unemployed and seeking employment, 24 participants were employed part-time, and 1 participant was employed full time. Participants were recruited throughout the fall and spring semesters for this study. A total of 66 participants initiated the experimental protocol over the course of 8 weeks in the fall semester, and 24 participants initiated the experimental protocol over the course of 8 weeks in the spring semester.
Procedure Writing day 1 On the first day of the experiment, participants were taken to a private room with a desk. Once they entered their private writing room, participants were asked to put their belongings (including their phone) in a corner of the room away from their writing desk. They were asked to not touch their belongings for the duration of the study as a way to encourage their engagement with the writing task. Participants received and reviewed written information about the study through an Informed Consent form. All participants were given an opportunity to ask a research assistant any questions
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about the study protocol. Once the Informed Consent form was completed, participants completed a battery of written measures, including a demographic form and the Beck Anxiety Inventory. (Please note that the battery of written measures also included a measure of depression and a measure of social support. Neither of these measures were analyzed in the current manuscript.) Once these baseline measures were completed, participants initiated the writing phase of the protocol. Participants were assigned to either the EW group or the non-emotional writing group which served as a control group. Participants assigned to the EW condition wrote about their deepest thoughts and feelings about coming to college, while those in the nonemotional writing condition were asked to describe any event or object of their choosing without describing their emotions. We felt it was important to enhance engagement with the writing task by allowing non-emotional writing participants to choose their own writing topic, rather than require these participants to write about a predetermined topic. The primary investigator was responsible for assigning participants to each condition. Block randomization was utilized to ensure an equal number of participants were assigned to each experimental group, and the allocation sequence was pre-determined using a coin flip. Participants were given several sheets of blank notebook paper and a writing instrument. They were left alone for 20 minutes in their private writing room. Once 20 minutes elapsed, a research assistant knocked on the door and instructed them to discontinue their writing. The research assistant then placed the writing in a sealed envelope. Participants were told that the research assistant would not have access to the writing, but that the principal investigator would review each piece of writing within 24 hours. The principal investigator was responsible for reading each piece of writing within 24 hours in order to ensure there was not any suicidality reported. When suicidality was mentioned, the principal investigator immediately contacted the participant to ensure that they were aware of the resources available to them on campus, and to contract for safety. This happened twice during the current study, and in both cases the participants contracted for safety and indicated a willingness to contact the Counseling Center on campus. Both of these participants continued participating in the study. After the writing phase of the study visit was completed, participants were asked if they had any questions or concerns about the study. They then were given written contact information for the principal investigator should they have any questions. Participants were also asked to confirm their availability for their study session the next day. Researchers were not blinded to study condition, as they were required to give each participant the appropriate writing prompt.
Writing day 2 This visit took place one day after the completion of Writing Day 1. This visit was nearly identical to Writing Day 1. The only difference was that participants were not required to complete an Informed Consent form or a demographic form again. Writing day 3 This visit took place one day after the completion of Writing Day 2. This visit was identical to Writing Day 2.
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1 Month Follow-Up This visit took place one month after the completion of Writing Day 3. No writing procedures were completed on this day. Participants completed a battery of measures again, including the BAI. They also scheduled their 6 Month Follow-Up visit. 6 Month Follow-Up This visit took place five months after the completion of the 1 Month Follow-Up visit. No writing procedures were completed on this day. Participants completed a battery of measures again, including the BAI. Because this was the final study visit, participants were fully debriefed on this day as to the hypotheses being studied. They were given $5 for participating in the study, given that this visit took place after their Introduction to Psychological Science course was completed. They were also given contact information for the principal investigator if they had questions or concerns about study procedures or hypotheses. After the completion of the entire study protocol, six months after a participant began study procedures, research assistants transcribed the written material to electronic format in order for the text to be analyzed by the LIWC software. This entire procedure was approved by the governing Institutional Review Board (IRB) at the institution at which this research took place. Please see Figure 1 for a review of experimental procedures. Given the sensitive nature of the data being collected for this study, only three advanced undergraduate students of senior status worked as research assistants on this project. Research assistants received thorough training in issues related to study ethics, privacy and confidentiality. Training procedures included completing a Collaborative Institutional Training Initiative (CITI) course, learning the study protocol in detail, conducting mock study sessions in which the principal investigator posed as a research participant, and carefully considering how to respond if a participant seemed to be distressed (e.g., crying, trembling, or verbal communication of distress) as a result of their participation in the study. The principal investigator was always available to meet with participants who appeared to be distressed. However, in the current study, no participants communicated verbal or non-verbal indications of distress after the completion of the study protocol (outside of the 2 participants previously mentioned that indicated distress during the written portion of the study protocol). All study procedures were completed during the Fall 2017-Spring 2018 academic year. Data collection was stopped once 90 participants had completed the study.
Measures Beck anxiety inventory (BAI; Beck & Steer, 1993) The BAI is a 21-item measure that assesses both physiological and cognitive symptoms of anxiety. Participants are provided with a list of common anxiety symptoms and asked to report how often they experience these symptoms (0 ¼ not at all, 1 ¼ mild, 2 ¼ moderate, 3 ¼ severe). Total scores range from 0-63, with higher totals representing greater symptoms. Total scores between 0 and 7 are considered ‘Minimal’, 8 and
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Figure 1. Experimental procedures conducted at each study visit.
15 are considered ‘Mild’, 16 and 25 are considered ‘Moderate’ and above 25 are considered ‘Severe’. In the current sample, internal consistency was strong (a range ¼ .91 .94 across each timepoint). This measure has been demonstrated to have strong internal consistency and validity in college student populations (Osman et al., 1997).
Writing prompts The writing instructions for the EW group were as follows (Pennebaker et al., 1990):
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“For all three writing days of this experiment, your task is to write about your very deepest thoughts and feelings about coming to college. In your writing, try to let yourself go and write continuously about your emotions and thoughts related to leaving home, coming to college, and preparing for the future. You can write about leaving your friends, family, or high school, or about adjusting to a new social and academic world here. You could also focus on your classes, your future, your parents’ or your own expectations. The primary task, however, is for you to reflect on your most basic thoughts and emotions about coming to college. You have 20 minutes to complete this task.”
The writing instructions for the non-emotional writing participants were as follows (Pennebaker & Francis, 1996): “For all three writing days of this experiment, your task is to describe in writing any particular object or event as objectively and as dispassionately as you can, without mentioning your emotions, opinions, or beliefs. You have 20 minutes to complete this task.”
Linguistic inquiry word count (LIWC; Pennebaker, Booth, et al., 2015) The LIWC is a software program that analyzes the linguistic content of text and calculates the percentage of words that fall into nearly 100 categories. While the authors of this measure acknowledge that verifying the psychometric properties of a word usage measure is challenging (Tausczik & Pennebaker, 2010), there is evidence that the LIWC achieves adequate levels of both reliability and validity when measuring emotion words, cognitive words and pronouns (Pennebaker, Boyd, et al., 2015). The LIWC has been utilized by a number of narrative researchers (Pennebaker, Boyd, et al., 2015; Troop et al., 2013). Given that the focus of the current study was to examine the use of words relevant to both the cognitive processing model and the exposure model, the following word categories were assessed: Cognitive processes Cognitive Processes words include the following subscales: Insight (e.g., think, know), Causation (e.g., because, effect), Discrepancy (e.g., should, would), Tentative (e.g., maybe, perhaps), Certainty (e.g., always, never), and Differentiation (e.g., hasn’t, but, else). First person singular pronouns Examples of words in this category include I, me, and mine. First Person Singular Pronouns are a subcategory of the ‘Personal Pronoun’ category. Affect Affect words include the following subscales: Positive emotion (e.g., love, nice, sweet) and Negative emotion (e.g., hurt, ugly, nasty). The following are subscales of the Negative emotion category: Anxiety (e.g., worried, fearful), Anger (e.g., hate, kill), and Sadness (e.g., crying, grief). There are no subscales of the Positive emotion category. Data reported in Pennebaker, Boyd, et al. (2015) indicate the LIWC 2015 has demonstrated both sufficient validity and reliability across all subscales analyzed in the current study. For example, measures of corrected Cronbach’s alpha were .92 for the
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Cognitive Processes scale, .81 for the First Person Singular Pronouns scale, and .57 for the Affect scale (Pennebaker, Booth, et al., 2015).
Analysis The longitudinal data collected for the current study were analyzed using multilevel (i.e. hierarchical linear) modeling (see Bickel, 2007; Raudenbush & Bryk, 2001; Snijders & Bosker, 2011) with the individual’s anxiety scores at each time point (i.e., level 1) nested within each individual (i.e., level 2). Each wave of assessment was coded as the variable time, which was measured in the unit of weeks elapsed since baseline. Thus, Writing Day 1, Writing Day 2, Writing Day 3, 1 Month Follow-Up, and 6 Month FollowUp assessments were coded as 0, 0.14, 0.28, 4.35, and 26.07 weeks, respectively. Although the outcome variable of Anxiety was measured at each time point, coding of the participants’ linguistic features on measures of the LIWC (i.e., first person singular pronouns, affect, and cognitive processes) was only possible for each time point (i.e., Writing Day 1, Writing Day 2, & Writing Day 3) when writings were requested. Writing was not requested at the two follow-up assessments (i.e., 1 Month Follow-Up and 6 Month Follow-Up) and so coding using the above linguistic features measures was not possible at these last two assessments. Thus, in order to use these linguistic features measures as predictors of anxiety across all five time points, a mean score for each variable was calculated using data from each participant’s first three time points. The mean LIWC scores were then used as level 2 linguistic features predictors in multilevel models. Preliminary analyses supported the use of multilevel modeling, with a random-intercept model fitting the data better than a fixed intercept model, v2(1) ¼ 28.42, p < .001. Thus, to test our first hypothesis an initial model was estimated to determine if anxiety significantly changed across time, writing condition, and if the change across time depended on writing condition. Specifically, time (centered at Writing Day 1) was a level 1 predictor, a dummy-coded writing condition (0 ¼ non-emotional writing, 1 ¼ EW) was a level 2 predictor, and the possible cross-level time x writing condition interaction were included in the model. Next, to test our second hypothesis that linguistic features may influence the effect of EW on anxiety across time, three separate multilevel growth curve models were estimated with each model containing the level 1 continuous predictor time, the level 2 dummy-coded predictor writing condition, the level 2 mean linguistic features measure (i.e., first person singular pronouns, affect, and cognitive processes) predictor, all possible two-way interactions, and the three-way interaction between the predictors. The number of level-2 units particularly influence the power to detect effects in multilevel models (Lane & Hennes, 2018; Snijders & Bosker, 1993). The current study’s 5 timepoints of measurement (i.e., level 1 units) nested within 90 participants (i.e., level 2 units) fell within sample size recommendations for adequate power for detecting effects in MLM models (Moerbeek et al., 2008; Scherbaum & Ferreter, 2009), and for examining cross-level interactions (Mathieu et al., 2012). All models contained random slopes and intercepts and were estimated using maximum likelihood, and thus full information maximum likelihood (FIML; see Enders, 2010 for review) was utilized to handle missing data. FIML estimation has been shown
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Table 1. Means and standard deviations for anxiety, and writing quality predictors by writing condition across time.
Expressive Writing BAI First Person Singular Affect Cognitive Processes Non-emotional Writing BAI First Person Singular Affect Cognitive Processes
Writing Day 1
Writing Day 2
Writing Day 3
1 Month Follow-Up
6 Month Follow-Up
n ¼ 45 8.73 (6.7)a 12.53 (2.44)a 6.65 (1.93) 14.91 (2.56) n ¼ 45 11.84 (11.01)a 3.54 (4.02) 2.76 (2.15) 9.16 (3.85)
n ¼ 43 6.88 (6.01)b 12.26 (3.01) 5.92 (1.44)a 15.63 (2.97)a n ¼ 44 9.27 (8.95)b 2.90 (3.63) 2.69 (2.21) 9.53 (4.03)
n ¼ 43 5.44 (5.45)c 11.16 (2.63)b 6.71 (1.88)b 14.19 (3.55)b n ¼ 44 8.41 (8.7)b 2.98 (3.89) 2.76 (2.02) 9.26 (4.13)
n ¼ 42 6.3 (8.08) – – – n ¼ 43 8.93 (10.12)b – – –
n ¼ 33 5.19 (6.15)b,c – – – n ¼ 37 9.15 (10.63) – – –
Note. Reported values reported as M (SD). For each row values with different subscripts (i.e., a, b, c) differ at the p ¼ .05 level by Bonferroni pairwise comparisons, whereas pairs of values with the same or no subscript do not significantly differ. For example, in the EW group, mean BAI significantly differs between Day 1, Day 2, Day 3, and Day 1 significantly differs from 6 months, but Days 2 and 3 do not significantly differ from 6 months.
to provide unbiased results in linear models (Bickel, 2007) with moderate samples (Schafer & Graham, 2002). The nlme package (Pinheiro et al., 2017) within R software (R Core Team, 2016) was used to estimate all models, and when significant interactions were present, online utilities provided by Preacher et al. (2006) were used to conduct simple slopes analyses that examined the influence of linguistic features on anxiety across time for both the non-emotional writing and EW groups.
Results Table 1 displays the means and standard deviations for the measures of anxiety and linguistic features predictors by group and across time. An independent samples t-test confirmed that the EW group (M ¼ 8.73, SD ¼ 6.7) did not significantly differ from the non-emotional writing group (M ¼ 11.84, SD ¼ 11.01) in Writing Day 1 anxiety, t(88) ¼ 1.62, p ¼ .11. Independent samples t-tests were also conducted to determine if the EW group significantly differed from the non-emotional writing group in any of the calculated level 2 mean linguistic features scores (i.e. average of Writing Day 1, Writing Day 2 and Writing Day 3 linguistic features scores). The average first person singular pronoun use for the EW group (M ¼ 11.97, SD ¼ 1.93) was significantly higher than the non-emotional writing group (M ¼ 3.11, SD ¼ 3.1), t(88) ¼ 9.60, p < .001, d ¼ 3.43. Similarly, the average affect for the EW group (M ¼ 6.45, SD ¼ 1.37) was significantly higher than the non-emotional writing group (M ¼ 2.71, SD ¼ 1.65), t(88) ¼ 11.70, p < .001, d ¼ 2.47. The EW group (M ¼ 14.92, SD ¼ 2.13) also demonstrated significantly higher average cognitive processes than the non-emotional writing group (M ¼ 9.3, SD ¼ 3.25), t(88) ¼ 9.60, p < .001, d ¼ 2.02. These findings confirm that linguistic features differed between the two groups, as would be expected given the different writing tasks that were assigned.
Attrition analyses Overall missing data were low (Writing Day 1: 0% missing, Writing Day 2: 3.3% missing, Writing Day 3: 3.3% missing, 1 Month Follow-Up: 5% missing, 6 Month Follow-Up:
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Figure 2. CONSORT 2010 Flow Diagram.
22.2% missing). In the EW condition, two participants dropped out of the study because they didn’t enjoy study procedures, 1 participant dropped out of the study because they discontinued their enrollment in the introductory psychology course, and 9 participants didn’t complete their 6-month follow-up and didn’t return emails from study researchers. In the non-emotional writing condition, 1 participant dropped out of the study because they didn’t enjoy study procedures, 1 participant dropped out because they discontinued their enrollment in the introductory psychology course, and 6 participants didn’t complete their 6-month follow-up and didn’t return emails from study researchers. Please see Figure 2. Prior to testing our hypotheses, attrition analyses were conducted to examine if participants missing data at the 6-month follow-up (n ¼ 20; 22.2%) differed from participants who completed the 6-month follow-up. Chi-square analyses indicated that neither gender, v2(1) ¼ 1.87, p ¼ .17, nor race (dummy-coded as White or non-White), v2(1) ¼ 0.65, p ¼ .42, were associated with missing data at the 6 month follow-up.
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Table 2. Results from initial multilevel regression analyses without writing quality predictors. Intercept Time Writing Condition TimeWriting Condition
b
SE
df
t
p
semi-partial R2
8.23 0.07 1.36 0.00
0.80 0.03 0.80 0.03
327 327 88 327
10.30 2.48 1.70 0.05
.05) between participants who completed and those who did not complete the 6 month follow-up.
Primary analyses Table 2 displays the results from our initial multilevel growth curve model with time, writing condition, and the time x writing condition interaction predicting anxiety. Only the main effect of time (b ¼ 0.07) was significant, t(327) ¼ 2.48, p < .01. There was a significant decrease in anxiety across time, but this decrease did not depend on writing condition, and there was no significant difference in anxiety between the nonemotional writing and EW groups. Table 3 contains the results of the separate models where each LIWC linguistic feature (i.e., first person singular pronouns, affect, and cognitive processes) was added as a predictor along with all possible main effects, two-way and three-way (i.e., time x writing condition x linguistic features measure) interactions. The results from each model are described below.
LIWC dimensions First person singular pronouns The time x writing condition x first person singular pronoun three-way interaction (b ¼ 0.05) was significant, t(325) ¼ 1.98, p < .05, and supported our second hypothesis. The effect of one’s first person singular pronoun use on their anxiety across time depended on their writing condition. Figure 3A displays the simple slopes for change in anxiety across time at the mean first person singular pronoun use (M ¼ 7.54) and one standard deviation (SD ¼ 5.12) above and below the mean for participants in the EW group. Participants in the EW group who were either one standard deviation below the mean in first person singular use (2.42) or at the mean in first person singular pronoun use (7.54) did not significantly change in anxiety across time. However, participants in the EW group one standard deviation above the mean in first person singular pronoun use (12.66) did significantly decrease in anxiety across time, b ¼ 0.95, SE ¼ 0.29, t(86) ¼ 3.30, p < .01. A region of significance analysis revealed the decrease in anxiety across time for individuals in the EW group was significant for individuals with first person singular use above 11.41. Figure 3B displays the simple slopes for change in anxiety across time at the mean first person singular pronoun use (M ¼ 7.54) and one standard deviation (SD ¼ 5.12)
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Table 3. Results from multilevel regression analyses with LIWC covariates. Model with Selected LIWC Covariate First Person Singular (FPS) Intercept Time Writing Condition FPS TimeWriting Condition TimeFPS Writing ConditionFPS TimeWriting ConditionFPS Affect Intercept Time Writing Condition Affect TimeWriting Condition TimeAffect Writing ConditionAffect TimeWriting ConditionAffect Cognitive Processes (CP) Intercept Time Writing Condition CP TimeWriting Condition TimeCP Writing ConditionCP TimeWriting ConditionCP
semi-partial R2
b
SE
df
t
p
10.25 0.10 0.21 12.24 0.01 0.48 0.95 0.05
1.60 0.06 0.37 7.31 0.01 0.23 0.69 0.02
325 325 86 86 325 325 86 325
6.39 1.71 0.57 1.67 0.63 2.02 1.37 1.98
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/gpsh20
Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features Sarah M. C. Robertson , Stephen D. Short , Leslie Sawyer & Scott Sweazy To cite this article: Sarah M. C. Robertson , Stephen D. Short , Leslie Sawyer & Scott Sweazy (2020): Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features, Psychology & Health, DOI: 10.1080/08870446.2020.1827146 To link to this article: https://doi.org/10.1080/08870446.2020.1827146
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PSYCHOLOGY & HEALTH https://doi.org/10.1080/08870446.2020.1827146
Randomized controlled trial assessing the efficacy of expressive writing in reducing anxiety in first-year college students: the role of linguistic features Sarah M. C. Robertson
, Stephen D. Short
, Leslie Sawyer and Scott Sweazy
Department of Psychology, College of Charleston, 66 George St, Charleston, SA, USA ABSTRACT
ARTICLE HISTORY
Objective: Meta-analyses assessing the efficacy of expressive writing (EW) interventions have produced mixed results. The current study aimed to assess the efficacy of an EW intervention in the reduction of anxiety symptoms in first-year college students. In an effort to understand more about moderating variables that influence EW outcomes, the current study also assessed the role of linguistic features in symptom reduction. Design and measures: Ninety participants were assigned to complete either an EW intervention or a non-emotional writing intervention. Participants completed 3 consecutive days of writing and two follow-up visits. Anxiety was measured at each study visit with the Beck Anxiety Inventory, and linguistic features were assessed with the LIWC software program. Results: Results indicated that all participants demonstrated significant decreases in anxiety over time. Participants in the EW group who demonstrated the greatest decreases in anxiety utilized more first-person singular pronouns and fewer affect words. Conclusions: Results are explained in the context of two prominent theories regarding the therapeutic mechanisms of EW: cognitive processing theory and exposure theory. Exposure theory received more support than cognitive processing theory.
Received 14 May 2020 Accepted 17 September 2020 KEYWORDS
Expressive writing; anxiety; college students; linguistic analysis; linguistic features
The transition from high school to college can be an incredibly stressful time for students. Starting college is typically related to a number of concerns for students including leaving family and friends, adjusting to a new living environment with a roommate, financial responsibilities, academic demands, pressure to succeed, quality of sleep, overall physical health, and generating social relationships (Beiter et al., 2015; Vaez & Laflamme, 2008). In addition to these concerns, first-year college students are also typically in the emerging adulthood developmental phase that occurs between 18 and 25 years of age (Arnett, 2000). This developmental phase is characterized by instability, identity exploration, and feeling ‘in-between’ (Arnett, 2000). In sum, firstyear college students face practical stressors (e.g., making a doctor’s appointment, CONTACT Sarah M. C. Robertson [email protected] George St, Charleston, SC29424SA, USA. ß 2020 Informa UK Limited, trading as Taylor & Francis Group
Department of Psychology, College of Charleston, 66
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creating a healthy schedule, finding their classrooms on campus) in addition to existential stressors (e.g., discovering their purpose in life, developing and maturing their sense of self), that can be quite challenging to contend with. Because the first year of college is filled with so many different types of stressors, researchers have focused on understanding the mental health status of this group. Recent data indicate that 32.5% of college freshmen have frequently felt anxious in the last year (Stolzenberg et al., 2019) and Blanco et al. (2008) reported that in a nationally representative sample of college students, 11.94% of participants met full criteria for an anxiety disorder. Given that college freshmen deal with significant stress during their first year of college, it is important for researchers to investigate mechanisms to decrease anxiety during this period of time. The current study aimed to assess the efficacy of expressive writing (EW) in reducing symptoms of anxiety, examine the role of linguistic features in the reduction of anxiety symptoms, and ultimately inform our theoretical understanding of how an EW intervention works in the context of anxiety. EW is typically a brief intervention that requires participants to write for 15–20 minutes over the course of 3–5 days about an emotional topic (Pennebaker, 1993). Participants are usually asked to write freely and continuously during the intervention, without consideration for spelling or grammar errors. Pennebaker and Beall (1986) first examined the efficacy of EW and demonstrated that EW is associated with a reduced number of self-reported physician visits. Subsequently, more than 400 articles have been published on the psychological and physical effects of EW (Niles et al., 2014). Meta-analytic reviews of EW outcomes have concluded that EW has been typically associated with small but significant effect sizes on improvements in psychological health, physical health, and overall functioning (Frattaroli, 2006; Pavlacic et al., 2019; Smyth, 1998). However, other meta-analyses have demonstrated that EW is not associated with significant improvements in psychological health or physical health (Frisina, et al., 2004; Mogk et al., 2006; Reinhold et al., 2018). It has become clear from this large body of work that EW may not be universally efficacious.
Theoretical approaches Cognitive processing theory (Boals & Klein, 2005; Pennebaker, 1997) and exposure theory (Bootzin, 1997) are two prominently supported theories related to the efficacy of EW. First, cognitive processing theory asserts that EW can be helpful because it requires participants to make meaning of their experiences and it potentially changes the way in which participants think about a difficult experience from their past (Boals & Klein, 2005; Pennebaker, 1993). Interventions rooted in cognitive processing theory help people challenge and modify their erroneous beliefs about previous aversive experiences, which ultimately allows them to fully process their experience (Kaczkurkin & Foa, 2015). Important work has been conducted to assess the potential relationship between cognitive processing theory and linguistic features in the context of EW. When Pennebaker and colleagues asked participants who had demonstrated significant improvement in an EW protocol to describe why they thought their experience in the study was beneficial, they reported that having the opportunity to make meaning of their experience was particularly important (Pennebaker et al., 1990). They also
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found that participants who utilized an increasing percentage of cognitive words demonstrated improved physical health outcomes (Pennebaker, 1993). According to the cognitive processing theory, stressful (but non-traumatic) events may have aberrant cognitive representations (Boals & Klein, 2005). Boals and Klein (2005) also assert that “expressive writing about a stressful event may produce beneficial effects because the writing changes the cognitive representation of the event and the language used in the narratives is reflective of the underlying cognitive representation” (Boals & Klein, 2005, p. 255). Providing students with a way to explore their thoughts and feelings about their stressful transition to college could provide them with an opportunity to make meaning of their experience and ultimately reduce their distress as a result. This benefit could be especially pronounced for participants whose writing is focused on developing insight and creating meaning from their experience. Second, exposure theory, commonly discussed in the context of clinical psychology and anxiety disorder treatment, posits that choosing to confront and process the feared stimuli in our environment is associated with long-term improvement in anxiety and well-being. There are several theoretical mechanisms that explain how and why exposure therapy works, including habituation, extinction, and emotional processing (Moscovitch et al., 2009). Habituation refers to a decreased psychological or physiological response to a stimulus that occurs after repeated exposure to the stimulus, extinction refers to a decreased response when a conditioned stimulus is presented repeatedly without an unconditioned stimulus being present, and emotional processing refers to the process of modifying negatively-valenced emotional memories by activating the original memory and encoding new information that is initially incompatible with the original memory (Moscovitch et al., 2009). Importantly, in order for these theoretical mechanisms to reduce distress, it is required that the person be exposed to the distressing memory, and that the exposure (e.g., in vivo exposure, imaginal exposure, virtual reality exposure, interoceptive exposure) match the content of the original memory (Moscovitch et al., 2009). Some previous work has assessed the relationship between exposure theory and linguistic features in EW. Dunnack and Park (2009) found that an increased use of first-person pronouns (e.g., “I”, “me”) over the course of four weekly writing sessions was associated with improved psychological adjustment. They asserted that the utilization of first-person pronouns is associated with self-focus, and that this self-focus is consistent with exposure therapy’s focus on confronting difficult previous experiences. Results from past research examining the effect of EW on symptoms of anxiety have been mixed. For instance, Pennebaker and Beall (1986) required college student participants to write about personal traumas they had experienced (e.g., death of loved one, relationship breakup, etc.). Although students demonstrated more negative moods (including anxiety) after each EW session as compared to control writing, they also made fewer illness-related visits to their physicians. Similarly, Pennebaker et al. (1990) noted that college student participants who completed EW regarding their transition to college demonstrated higher levels of anxiety when compared to the control group 2–3 months after writing. However, these adverse effects of EW on anxiety were not found at follow-up approximately six months after writing. More recently, when college students in an EW group were asked to write about the most stressful
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experiences of their lives, nearly half wrote about an assault or illness/injury, yet at the end of the study they did not significantly differ in anxiety symptoms when compared to a control group 6 months post-writing (Sloan et al., 2009). Conversely, Alparone et al. (2015) found that when undergraduates completed an EW task related to the most traumatic experience of their lives, those in the EW group demonstrated a significant decrease in anxiety symptoms when compared to the control group four months after the completion of the EW protocol. Indeed, the literature indicates mixed findings in the assessment of EW in reducing symptoms of anxiety across time. Because of the mixed findings in the field of EW and anxiety, researchers have recently assessed for moderators that might explain why some participants seem to improve more than others (Frattaroli, 2006; Sloan & Marx, 2018). Some prior work has examined the role of linguistic features in the reduction of anxiety symptoms. For example, an increase in cognitive words (e.g., should, could, doubt) across several days of writing was associated with decreased anxiety in a sample of Italian undergraduate students without a history of psychiatric disorders (Alparone et al., 2015). Also, in a sample of both students and adults from the community with no history of a psychiatric disorder, very high use (greater than 1 standard deviation above the mean) of negative affect words predicted higher anxiety symptoms three months post-writing (Niles et al., 2016).
Current study It is our position that examining linguistic features can inform our understanding of how EW impacts symptoms of anxiety and the theoretical underpinnings of this effect. It is possible to objectively measure the degree to which a person utilizes cognitive words, emotion words and words related to the self in descriptions of events using the Linguistic Inquiry Word Count (LIWC) software program (Pennebaker, Booth, et al., 2015). Because the cognitive processing theory posits that EW is helpful because it requires participants to make meaning of their experiences, we anticipate that a higher degree of cognitive processing words (e.g., “think”, “because”, “could”, “maybe”) should be negatively associated with anxiety symptoms. The exposure model posits that EW is helpful because it requires participants to reflect on their distressing memory, which in turn allows for habituation, extinction, and emotional processing. In the context of the college transition period, a person can undergo exposure by reflecting on themselves and describing their emotions. We therefore predicted that first person singular pronouns (e.g., “I”, “me”) and affect words (e.g., “sad”, “anxious”) would be negatively associated with anxiety symptoms (Danoff-Burg et al., 2010). It should be noted that Pennebaker, Mehl and Niederhoffer (2003) wrote about a “linguistic fingerprint” that was associated with improvement following EW procedures. The authors noted that participants were more likely to benefit if they used a high number of positive emotion words and a moderate number of negative emotion words. More recently, Zbozinek and Craske (2017) have argued that increasing positive affect is a way to optimize extinction learning and exposure therapy. They note that “positive affect during extinction may benefit long-term extinction learning through enhancing encoding, rehearsal, retrieval, and increasing positive valence of the feared stimulus”
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(p. 31). Other authors (Taylor et al., 2017) suggest that using positive emotion words in the context of exposure might help people better tolerate the negative emotions involved in exposure therapy. For these reasons, we felt it important to assess the frequency of all emotional words, regardless of valence. Because both the cognitive processing theory and exposure theory have received empirical support in the literature (Frattaroli, 2006), we anticipate higher percentages of both cognitive and exposure words will be significantly associated with anxiety symptom reduction. It was predicted that: 1. 2.
EW would be associated with reductions in anxiety in first-year college students. Linguistic features would significantly predict anxiety symptoms, such that participants using a higher degree of cognitive words and exposure words would demonstrate greater decreases in anxiety.
Methods Participants Participants included 90 first-year students who were taking an Introduction to Psychological Science course at a midsized college in the Southeastern United States. Participants were recruited through a departmental website, and participants received course credit for their participation in the study. Because a final follow-up visit for the study was completed after the conclusion of their psychology course, they received $5 for the completion of their final follow-up visit. Seventy-eight participants identified as female, and 12 participants identified as male. No participants identified as non-binary, third gender, or preferred not to describe their gender. Participants were, on average, 18.26 years old (SD ¼ 0.74). The sample consisted of White (n ¼ 67), African American (n ¼ 13), Latino (n ¼ 7), Asian (n ¼ 1), American Indian (n ¼ 1), and mixed/other (n ¼ 1) participants. All participants were never married. In terms of employment status, 41 participants were unemployed and not seeking employment, 24 participants were unemployed and seeking employment, 24 participants were employed part-time, and 1 participant was employed full time. Participants were recruited throughout the fall and spring semesters for this study. A total of 66 participants initiated the experimental protocol over the course of 8 weeks in the fall semester, and 24 participants initiated the experimental protocol over the course of 8 weeks in the spring semester.
Procedure Writing day 1 On the first day of the experiment, participants were taken to a private room with a desk. Once they entered their private writing room, participants were asked to put their belongings (including their phone) in a corner of the room away from their writing desk. They were asked to not touch their belongings for the duration of the study as a way to encourage their engagement with the writing task. Participants received and reviewed written information about the study through an Informed Consent form. All participants were given an opportunity to ask a research assistant any questions
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about the study protocol. Once the Informed Consent form was completed, participants completed a battery of written measures, including a demographic form and the Beck Anxiety Inventory. (Please note that the battery of written measures also included a measure of depression and a measure of social support. Neither of these measures were analyzed in the current manuscript.) Once these baseline measures were completed, participants initiated the writing phase of the protocol. Participants were assigned to either the EW group or the non-emotional writing group which served as a control group. Participants assigned to the EW condition wrote about their deepest thoughts and feelings about coming to college, while those in the nonemotional writing condition were asked to describe any event or object of their choosing without describing their emotions. We felt it was important to enhance engagement with the writing task by allowing non-emotional writing participants to choose their own writing topic, rather than require these participants to write about a predetermined topic. The primary investigator was responsible for assigning participants to each condition. Block randomization was utilized to ensure an equal number of participants were assigned to each experimental group, and the allocation sequence was pre-determined using a coin flip. Participants were given several sheets of blank notebook paper and a writing instrument. They were left alone for 20 minutes in their private writing room. Once 20 minutes elapsed, a research assistant knocked on the door and instructed them to discontinue their writing. The research assistant then placed the writing in a sealed envelope. Participants were told that the research assistant would not have access to the writing, but that the principal investigator would review each piece of writing within 24 hours. The principal investigator was responsible for reading each piece of writing within 24 hours in order to ensure there was not any suicidality reported. When suicidality was mentioned, the principal investigator immediately contacted the participant to ensure that they were aware of the resources available to them on campus, and to contract for safety. This happened twice during the current study, and in both cases the participants contracted for safety and indicated a willingness to contact the Counseling Center on campus. Both of these participants continued participating in the study. After the writing phase of the study visit was completed, participants were asked if they had any questions or concerns about the study. They then were given written contact information for the principal investigator should they have any questions. Participants were also asked to confirm their availability for their study session the next day. Researchers were not blinded to study condition, as they were required to give each participant the appropriate writing prompt.
Writing day 2 This visit took place one day after the completion of Writing Day 1. This visit was nearly identical to Writing Day 1. The only difference was that participants were not required to complete an Informed Consent form or a demographic form again. Writing day 3 This visit took place one day after the completion of Writing Day 2. This visit was identical to Writing Day 2.
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1 Month Follow-Up This visit took place one month after the completion of Writing Day 3. No writing procedures were completed on this day. Participants completed a battery of measures again, including the BAI. They also scheduled their 6 Month Follow-Up visit. 6 Month Follow-Up This visit took place five months after the completion of the 1 Month Follow-Up visit. No writing procedures were completed on this day. Participants completed a battery of measures again, including the BAI. Because this was the final study visit, participants were fully debriefed on this day as to the hypotheses being studied. They were given $5 for participating in the study, given that this visit took place after their Introduction to Psychological Science course was completed. They were also given contact information for the principal investigator if they had questions or concerns about study procedures or hypotheses. After the completion of the entire study protocol, six months after a participant began study procedures, research assistants transcribed the written material to electronic format in order for the text to be analyzed by the LIWC software. This entire procedure was approved by the governing Institutional Review Board (IRB) at the institution at which this research took place. Please see Figure 1 for a review of experimental procedures. Given the sensitive nature of the data being collected for this study, only three advanced undergraduate students of senior status worked as research assistants on this project. Research assistants received thorough training in issues related to study ethics, privacy and confidentiality. Training procedures included completing a Collaborative Institutional Training Initiative (CITI) course, learning the study protocol in detail, conducting mock study sessions in which the principal investigator posed as a research participant, and carefully considering how to respond if a participant seemed to be distressed (e.g., crying, trembling, or verbal communication of distress) as a result of their participation in the study. The principal investigator was always available to meet with participants who appeared to be distressed. However, in the current study, no participants communicated verbal or non-verbal indications of distress after the completion of the study protocol (outside of the 2 participants previously mentioned that indicated distress during the written portion of the study protocol). All study procedures were completed during the Fall 2017-Spring 2018 academic year. Data collection was stopped once 90 participants had completed the study.
Measures Beck anxiety inventory (BAI; Beck & Steer, 1993) The BAI is a 21-item measure that assesses both physiological and cognitive symptoms of anxiety. Participants are provided with a list of common anxiety symptoms and asked to report how often they experience these symptoms (0 ¼ not at all, 1 ¼ mild, 2 ¼ moderate, 3 ¼ severe). Total scores range from 0-63, with higher totals representing greater symptoms. Total scores between 0 and 7 are considered ‘Minimal’, 8 and
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Figure 1. Experimental procedures conducted at each study visit.
15 are considered ‘Mild’, 16 and 25 are considered ‘Moderate’ and above 25 are considered ‘Severe’. In the current sample, internal consistency was strong (a range ¼ .91 .94 across each timepoint). This measure has been demonstrated to have strong internal consistency and validity in college student populations (Osman et al., 1997).
Writing prompts The writing instructions for the EW group were as follows (Pennebaker et al., 1990):
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“For all three writing days of this experiment, your task is to write about your very deepest thoughts and feelings about coming to college. In your writing, try to let yourself go and write continuously about your emotions and thoughts related to leaving home, coming to college, and preparing for the future. You can write about leaving your friends, family, or high school, or about adjusting to a new social and academic world here. You could also focus on your classes, your future, your parents’ or your own expectations. The primary task, however, is for you to reflect on your most basic thoughts and emotions about coming to college. You have 20 minutes to complete this task.”
The writing instructions for the non-emotional writing participants were as follows (Pennebaker & Francis, 1996): “For all three writing days of this experiment, your task is to describe in writing any particular object or event as objectively and as dispassionately as you can, without mentioning your emotions, opinions, or beliefs. You have 20 minutes to complete this task.”
Linguistic inquiry word count (LIWC; Pennebaker, Booth, et al., 2015) The LIWC is a software program that analyzes the linguistic content of text and calculates the percentage of words that fall into nearly 100 categories. While the authors of this measure acknowledge that verifying the psychometric properties of a word usage measure is challenging (Tausczik & Pennebaker, 2010), there is evidence that the LIWC achieves adequate levels of both reliability and validity when measuring emotion words, cognitive words and pronouns (Pennebaker, Boyd, et al., 2015). The LIWC has been utilized by a number of narrative researchers (Pennebaker, Boyd, et al., 2015; Troop et al., 2013). Given that the focus of the current study was to examine the use of words relevant to both the cognitive processing model and the exposure model, the following word categories were assessed: Cognitive processes Cognitive Processes words include the following subscales: Insight (e.g., think, know), Causation (e.g., because, effect), Discrepancy (e.g., should, would), Tentative (e.g., maybe, perhaps), Certainty (e.g., always, never), and Differentiation (e.g., hasn’t, but, else). First person singular pronouns Examples of words in this category include I, me, and mine. First Person Singular Pronouns are a subcategory of the ‘Personal Pronoun’ category. Affect Affect words include the following subscales: Positive emotion (e.g., love, nice, sweet) and Negative emotion (e.g., hurt, ugly, nasty). The following are subscales of the Negative emotion category: Anxiety (e.g., worried, fearful), Anger (e.g., hate, kill), and Sadness (e.g., crying, grief). There are no subscales of the Positive emotion category. Data reported in Pennebaker, Boyd, et al. (2015) indicate the LIWC 2015 has demonstrated both sufficient validity and reliability across all subscales analyzed in the current study. For example, measures of corrected Cronbach’s alpha were .92 for the
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Cognitive Processes scale, .81 for the First Person Singular Pronouns scale, and .57 for the Affect scale (Pennebaker, Booth, et al., 2015).
Analysis The longitudinal data collected for the current study were analyzed using multilevel (i.e. hierarchical linear) modeling (see Bickel, 2007; Raudenbush & Bryk, 2001; Snijders & Bosker, 2011) with the individual’s anxiety scores at each time point (i.e., level 1) nested within each individual (i.e., level 2). Each wave of assessment was coded as the variable time, which was measured in the unit of weeks elapsed since baseline. Thus, Writing Day 1, Writing Day 2, Writing Day 3, 1 Month Follow-Up, and 6 Month FollowUp assessments were coded as 0, 0.14, 0.28, 4.35, and 26.07 weeks, respectively. Although the outcome variable of Anxiety was measured at each time point, coding of the participants’ linguistic features on measures of the LIWC (i.e., first person singular pronouns, affect, and cognitive processes) was only possible for each time point (i.e., Writing Day 1, Writing Day 2, & Writing Day 3) when writings were requested. Writing was not requested at the two follow-up assessments (i.e., 1 Month Follow-Up and 6 Month Follow-Up) and so coding using the above linguistic features measures was not possible at these last two assessments. Thus, in order to use these linguistic features measures as predictors of anxiety across all five time points, a mean score for each variable was calculated using data from each participant’s first three time points. The mean LIWC scores were then used as level 2 linguistic features predictors in multilevel models. Preliminary analyses supported the use of multilevel modeling, with a random-intercept model fitting the data better than a fixed intercept model, v2(1) ¼ 28.42, p < .001. Thus, to test our first hypothesis an initial model was estimated to determine if anxiety significantly changed across time, writing condition, and if the change across time depended on writing condition. Specifically, time (centered at Writing Day 1) was a level 1 predictor, a dummy-coded writing condition (0 ¼ non-emotional writing, 1 ¼ EW) was a level 2 predictor, and the possible cross-level time x writing condition interaction were included in the model. Next, to test our second hypothesis that linguistic features may influence the effect of EW on anxiety across time, three separate multilevel growth curve models were estimated with each model containing the level 1 continuous predictor time, the level 2 dummy-coded predictor writing condition, the level 2 mean linguistic features measure (i.e., first person singular pronouns, affect, and cognitive processes) predictor, all possible two-way interactions, and the three-way interaction between the predictors. The number of level-2 units particularly influence the power to detect effects in multilevel models (Lane & Hennes, 2018; Snijders & Bosker, 1993). The current study’s 5 timepoints of measurement (i.e., level 1 units) nested within 90 participants (i.e., level 2 units) fell within sample size recommendations for adequate power for detecting effects in MLM models (Moerbeek et al., 2008; Scherbaum & Ferreter, 2009), and for examining cross-level interactions (Mathieu et al., 2012). All models contained random slopes and intercepts and were estimated using maximum likelihood, and thus full information maximum likelihood (FIML; see Enders, 2010 for review) was utilized to handle missing data. FIML estimation has been shown
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Table 1. Means and standard deviations for anxiety, and writing quality predictors by writing condition across time.
Expressive Writing BAI First Person Singular Affect Cognitive Processes Non-emotional Writing BAI First Person Singular Affect Cognitive Processes
Writing Day 1
Writing Day 2
Writing Day 3
1 Month Follow-Up
6 Month Follow-Up
n ¼ 45 8.73 (6.7)a 12.53 (2.44)a 6.65 (1.93) 14.91 (2.56) n ¼ 45 11.84 (11.01)a 3.54 (4.02) 2.76 (2.15) 9.16 (3.85)
n ¼ 43 6.88 (6.01)b 12.26 (3.01) 5.92 (1.44)a 15.63 (2.97)a n ¼ 44 9.27 (8.95)b 2.90 (3.63) 2.69 (2.21) 9.53 (4.03)
n ¼ 43 5.44 (5.45)c 11.16 (2.63)b 6.71 (1.88)b 14.19 (3.55)b n ¼ 44 8.41 (8.7)b 2.98 (3.89) 2.76 (2.02) 9.26 (4.13)
n ¼ 42 6.3 (8.08) – – – n ¼ 43 8.93 (10.12)b – – –
n ¼ 33 5.19 (6.15)b,c – – – n ¼ 37 9.15 (10.63) – – –
Note. Reported values reported as M (SD). For each row values with different subscripts (i.e., a, b, c) differ at the p ¼ .05 level by Bonferroni pairwise comparisons, whereas pairs of values with the same or no subscript do not significantly differ. For example, in the EW group, mean BAI significantly differs between Day 1, Day 2, Day 3, and Day 1 significantly differs from 6 months, but Days 2 and 3 do not significantly differ from 6 months.
to provide unbiased results in linear models (Bickel, 2007) with moderate samples (Schafer & Graham, 2002). The nlme package (Pinheiro et al., 2017) within R software (R Core Team, 2016) was used to estimate all models, and when significant interactions were present, online utilities provided by Preacher et al. (2006) were used to conduct simple slopes analyses that examined the influence of linguistic features on anxiety across time for both the non-emotional writing and EW groups.
Results Table 1 displays the means and standard deviations for the measures of anxiety and linguistic features predictors by group and across time. An independent samples t-test confirmed that the EW group (M ¼ 8.73, SD ¼ 6.7) did not significantly differ from the non-emotional writing group (M ¼ 11.84, SD ¼ 11.01) in Writing Day 1 anxiety, t(88) ¼ 1.62, p ¼ .11. Independent samples t-tests were also conducted to determine if the EW group significantly differed from the non-emotional writing group in any of the calculated level 2 mean linguistic features scores (i.e. average of Writing Day 1, Writing Day 2 and Writing Day 3 linguistic features scores). The average first person singular pronoun use for the EW group (M ¼ 11.97, SD ¼ 1.93) was significantly higher than the non-emotional writing group (M ¼ 3.11, SD ¼ 3.1), t(88) ¼ 9.60, p < .001, d ¼ 3.43. Similarly, the average affect for the EW group (M ¼ 6.45, SD ¼ 1.37) was significantly higher than the non-emotional writing group (M ¼ 2.71, SD ¼ 1.65), t(88) ¼ 11.70, p < .001, d ¼ 2.47. The EW group (M ¼ 14.92, SD ¼ 2.13) also demonstrated significantly higher average cognitive processes than the non-emotional writing group (M ¼ 9.3, SD ¼ 3.25), t(88) ¼ 9.60, p < .001, d ¼ 2.02. These findings confirm that linguistic features differed between the two groups, as would be expected given the different writing tasks that were assigned.
Attrition analyses Overall missing data were low (Writing Day 1: 0% missing, Writing Day 2: 3.3% missing, Writing Day 3: 3.3% missing, 1 Month Follow-Up: 5% missing, 6 Month Follow-Up:
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Figure 2. CONSORT 2010 Flow Diagram.
22.2% missing). In the EW condition, two participants dropped out of the study because they didn’t enjoy study procedures, 1 participant dropped out of the study because they discontinued their enrollment in the introductory psychology course, and 9 participants didn’t complete their 6-month follow-up and didn’t return emails from study researchers. In the non-emotional writing condition, 1 participant dropped out of the study because they didn’t enjoy study procedures, 1 participant dropped out because they discontinued their enrollment in the introductory psychology course, and 6 participants didn’t complete their 6-month follow-up and didn’t return emails from study researchers. Please see Figure 2. Prior to testing our hypotheses, attrition analyses were conducted to examine if participants missing data at the 6-month follow-up (n ¼ 20; 22.2%) differed from participants who completed the 6-month follow-up. Chi-square analyses indicated that neither gender, v2(1) ¼ 1.87, p ¼ .17, nor race (dummy-coded as White or non-White), v2(1) ¼ 0.65, p ¼ .42, were associated with missing data at the 6 month follow-up.
PSYCHOLOGY & HEALTH
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Table 2. Results from initial multilevel regression analyses without writing quality predictors. Intercept Time Writing Condition TimeWriting Condition
b
SE
df
t
p
semi-partial R2
8.23 0.07 1.36 0.00
0.80 0.03 0.80 0.03
327 327 88 327
10.30 2.48 1.70 0.05
.05) between participants who completed and those who did not complete the 6 month follow-up.
Primary analyses Table 2 displays the results from our initial multilevel growth curve model with time, writing condition, and the time x writing condition interaction predicting anxiety. Only the main effect of time (b ¼ 0.07) was significant, t(327) ¼ 2.48, p < .01. There was a significant decrease in anxiety across time, but this decrease did not depend on writing condition, and there was no significant difference in anxiety between the nonemotional writing and EW groups. Table 3 contains the results of the separate models where each LIWC linguistic feature (i.e., first person singular pronouns, affect, and cognitive processes) was added as a predictor along with all possible main effects, two-way and three-way (i.e., time x writing condition x linguistic features measure) interactions. The results from each model are described below.
LIWC dimensions First person singular pronouns The time x writing condition x first person singular pronoun three-way interaction (b ¼ 0.05) was significant, t(325) ¼ 1.98, p < .05, and supported our second hypothesis. The effect of one’s first person singular pronoun use on their anxiety across time depended on their writing condition. Figure 3A displays the simple slopes for change in anxiety across time at the mean first person singular pronoun use (M ¼ 7.54) and one standard deviation (SD ¼ 5.12) above and below the mean for participants in the EW group. Participants in the EW group who were either one standard deviation below the mean in first person singular use (2.42) or at the mean in first person singular pronoun use (7.54) did not significantly change in anxiety across time. However, participants in the EW group one standard deviation above the mean in first person singular pronoun use (12.66) did significantly decrease in anxiety across time, b ¼ 0.95, SE ¼ 0.29, t(86) ¼ 3.30, p < .01. A region of significance analysis revealed the decrease in anxiety across time for individuals in the EW group was significant for individuals with first person singular use above 11.41. Figure 3B displays the simple slopes for change in anxiety across time at the mean first person singular pronoun use (M ¼ 7.54) and one standard deviation (SD ¼ 5.12)
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S. M. C. ROBERTSON ET AL.
Table 3. Results from multilevel regression analyses with LIWC covariates. Model with Selected LIWC Covariate First Person Singular (FPS) Intercept Time Writing Condition FPS TimeWriting Condition TimeFPS Writing ConditionFPS TimeWriting ConditionFPS Affect Intercept Time Writing Condition Affect TimeWriting Condition TimeAffect Writing ConditionAffect TimeWriting ConditionAffect Cognitive Processes (CP) Intercept Time Writing Condition CP TimeWriting Condition TimeCP Writing ConditionCP TimeWriting ConditionCP
semi-partial R2
b
SE
df
t
p
10.25 0.10 0.21 12.24 0.01 0.48 0.95 0.05
1.60 0.06 0.37 7.31 0.01 0.23 0.69 0.02
325 325 86 86 325 325 86 325
6.39 1.71 0.57 1.67 0.63 2.02 1.37 1.98
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