Prior disclosure and emotional expression: Interactive effects on post-traumatic stress disorder symptoms

Abstract

Background

Previous research has revealed mixed findings with regard to the effects of disclosure on trauma recovery. More recently, studies on psychological trauma have found associations among religion, meaning, and health. This study investigated prior disclosure as a moderator for the association between religious emotional expression and adaptive trauma processing, as measured by post-traumatic stress disorder (PTSD) symptoms.

Methods

Using Pennebaker’s written emotional expression paradigm, 105 participants were assigned to either a conventional trauma-writing condition or religious trauma-writing condition. PTSD symptoms were assessed at baseline and again at one-month post writing.

Results

A two-way interaction was found between prior disclosure and writing condition on PTSD symptoms at follow-up. For the religious trauma-writing condition only, there was a significant difference between low versus high disclosure participants in PTSD symptoms at follow-up, such that low prior disclosure participants registered fewer PTSD symptoms than high prior disclosure participants, while prior disclosure did not have such effect in the conventional trauma-writing condition.

Limitations: This two-way interaction may be further qualified by other important psychosocial variables, such as differences in personality, coping style, social support, or use of prayer as a form of disclosure, which were not assessed in this study.

Conclusion

Religious emotional expression may encourage adaptive trauma processing, especially for individuals with low prior disclosure. These findings encourage further investigation of the conditions under which disclosure and religion may be a beneficial factor in trauma adaptation and treatment.

Keywords

prior disclosure religion emotional expression PTSD symptoms

Introduction

The occurrence of traumatic events has been found to be consistently high in a general population, across the lifespan, with varied prevalence rates from approximately 39%–69%.^1–3 Although exposure to traumatic events does not necessarily lead to the development or diagnosis of post-traumatic stress disorder (PTSD), its effects on mental and physical health, as well as quality of life have been well documented.⁴ As a result, much effort has been devoted to the understanding of recovery from exposure to traumatic events. Disclosure of traumatic experience is an important concept, both in theory and in the essential role it plays in the therapeutic process. The generally adaptive nature of disclosure in recovery from psychological trauma has been documented in previous research. Recent studies, however, have begun to investigate the specific aspects of disclosure, as well as its interactions with other constructs in predicting trauma adaptation. For example, Marriott et al.⁵ focused on the timing of disclosure and the different degrees of betrayal trauma. Although all of the study participants eventually reported disclosing of the traumatic event, the timing of disclosure was associated with the perceived severity of betrayal. Currier et al.⁶ reported that variations in individuals’ need for disclosure predicted posttraumatic growth. Also, others have found disclosure to interact with the type of participants in predicting trauma recovery.^6,7

While the content and form of disclosure may vary, and do not necessarily involve emotional expression, Pennebaker’s⁸ written emotional expression paradigm has been a widely studied and utilized form of disclosure. Conceptually, one would expect prior disclosure to either mediate or moderate the effects of emotional expression on adaptive trauma processing. However, Greenberg and Stone⁹ had reported that regardless of prior disclosure, Pennebaker’s written emotional expression protocol was associated with better health outcomes.

Another construct that has received attention in its association with trauma reaction and adaptation is religion. Religion has been implicated both as a response to negative life events, and in the process of recovery from psychological trauma.^10,11 Previous research on trauma adaptation using Pennebaker’s paradigm has suggested that religion could act as a source from which psychological well-being may be derived during the process of emotional disclosure.^12,13 However, potential interactive effects between religion and other psychosocial factors on trauma adaptation remains an area to be investigated. Given the steadily increasing popularity of disclosure-based brief therapy, and the apparent role that religion plays after exposure to traumatic events, examination of these related constructs and interactive effects may inform clinical applications of religion and/or disclosure-based therapies.¹⁴

The current study sought to examine religion and prior disclosure in the association between emotional expression and adaptive trauma processing, as measured by PTSD symptoms. Using Pennebaker’s paradigm, we examined prior disclosure in both a conventional trauma-writing condition (CTC) and a religious trauma-writing condition (RTC), and hypothesized that prior disclosure would have differential effects on PTSD symptoms after participants repeatedly wrote about their traumatic experience from a religious versus a conventional perspective. Specifically, we expected to find (1) a main effect of prior disclosure, such that participants with lower prior disclosure would benefit more from expressive writing in general, than those with higher prior disclosure, and (2) this main effect would be significantly more pronounced in the religious writing group than it is for the conventional writing group, that is, an interaction between prior disclosure and writing condition (religious vs. conventional) on PTSD symptoms.

Methods

Participants

Participants were college students from National Central University in Taiwan. All of the participants completed both baseline (T1) and follow-up (T2) assessments. The final sample included 105 students (48 male, 57 female), and their average age was 20.7 years (SD = 3.47). Fifty-three participants (21 male, 32 female) were assigned to CTC and 52 (27 male, 25 female) were assigned to RTC.

Procedure

Students were recruited to sign up for a “Personal Story” study. After signing the consent form, participants completed baseline measures (T1). Then, they were escorted to a private room and given instructions specific to their experimental condition.

Participants were randomly assigned to one of two conditions: CTC or RTC. Participants in the CTC received the traditional trauma-writing instructions,¹⁵ asking that they write about the most traumatic experience of their life. In addition to receiving conventional instructions, participants in the RTC were asked to write about their traumatic experience from a religious or spiritual perspective that best reflected their own beliefs about God, religion, or spirituality.¹⁶ We believe these instructions would effectively accommodate individuals with various degrees of religiousness, from not-at-all religious to the very religious. For the nonreligious, these instructions would still encourage participants to take a different perspective in processing their traumatic experience, and thus possibly facilitate trauma adaptation.

Participants were required to attend a total of three writing sessions within a seven-day period, with no more than one session per day. Approximately, one month after the third session, students returned to complete a follow-up assessment (T2).

Measures

Religiousness. A self-rated level of religiousness was assessed using a single-item that asked participants to respond to the question: “How religious are you?” Participants responded on a five-point scale, where 1 = not at all and 5 = extremely. The religiousness item was administered at T1 and was used as a control variable.

PTSD symptoms. The Impact of Event Scale—Revised (IES-R)¹⁷ was used to measure PTSD symptoms. Participants were asked to report the degree of distress experienced in the past seven days. Items are rated on a five-point scale: 0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely, with higher scores indicating more PTSD symptoms. A total score is derived by summing responses to the items, with possible scores ranging from 0 to 88. In the current sample, the IES-R has high reliability (α = .94). This was administered at T1 and at T2.

Prior disclosure. Participants were asked to indicate the degree with which they had disclosed the traumatic event they wrote about to others on a four-point frequency scale, where 0 = I have never told anyone about this, today was the first time and 4 = I have told everyone whom I have had the opportunity to tell. This was used as a predictor in the analyses.

Demographic and background. Participants were asked to indicate their age and gender, as well as the approximate month and year during which the traumatic event occurred. Date of trauma occurrence was used to compute time lapsed since trauma, which was calculated by taking the difference between self-reported date of trauma occurrence and date at T1. These variables were used as control variables in the analyses.

Results

Random assignment and manipulation check

A one-way analysis of variance (ANOVA) was conducted on all baseline measures of the main study variables to assess the effectiveness of random assignment. These included age, gender, religiousness, time lapsed since trauma, and baseline PTSD symptoms. The mean for IES-R in the current sample was 23.79 (SD = 16.85). As expected, no significant differences were found among the experimental conditions for any of these variables at baseline (ps > .076).

The effectiveness of our study manipulation was evaluated by examining whether RTC participants used a higher percentage of religious words in their writing than CTC participants. As expected, results showed that participants in the RTC used a significantly higher percentage of religious words than participants in the CTC, F(1, 101) = 8.64, p < .005.

Main effects analysis

The main effects model included gender, age, self-rated religiousness, time lapsed since trauma, and baseline PTSD symptoms in Step 1. Step 2 of the analysis included experimental condition as the predictor. Results indicated that IES-R at T1 predicted IES-R at T2 (p < .000). Participants who scored high on PTSD symptoms at baseline also obtained high scores on the same measure at one-month follow-up. There were no significant difference between CTC and RTC for IES-R at T2 (p = .92). Contrary to our expectations, no significant effects for any of the remaining predictors were found in this analysis (ps > .31).

Moderation analyses

Analyses involving the prior disclosure by writing condition product term were added to the previous model as a third step to examine the interaction between treatment condition and prior disclosure. Results showed a significant interaction between writing condition and prior disclosure on PTSD symptoms at T2 (β =−.33, p < .03). A plot of interaction is shown in Figure 1. Post-hoc simple slopes analyses indicated that the simple slope for RTC was significantly different from zero, t(42) = 2.47, p < .02, and the simple slope for low CTC was not (p > .28). For participants in the RTC, those who talked less about their traumatic experience registered fewer PTSD symptoms at one-month follow-up than those who talked more about their traumatic experience with others.

Figure 1.

Interactive effect of writing condition and prior disclosure on T2 PTSD symptoms. Predicted values of PTSD symptoms are plotted 1 standard deviation above and below the mean for frequency of talking about their traumatic experience. The slope for RTC is significantly different from zero (p < .02), and the slope for CTC is not (p > .28).

Discussion

In this study, we investigated the association between religion and prior disclosure of traumatic experience on PTSD symptoms. Results showed a significant interaction between prior disclosure and type of emotional expression, such that participants with low prior disclosure had lower PTSD symptoms at follow-up than those with high prior disclosure, and this association was only significant in the RTC. It appears that religious trauma-writing was particularly beneficial for participants who did not disclose the experience to others, while traditional trauma-writing had similar effects regardless of prior disclosure.

Religion has a long history serving as an important resource for those who encounter adversity. Not only is it is often perceived as a safe place for those in need, but religion, in its many forms, also offers a nonjudgmental perspective to interpret negative events in life.¹⁸ Although previous research has found a positive association between disclosure of traumatic events and trauma adaptation, individuals may choose not to disclose, for various reasons, including feelings of shame and guilt, and fear of rejection or judgment.^19,20 Perhaps, religious expressive writing could provide individuals with a safe space, in which traumatic experience and feelings may be processed more freely. As a result, those with low prior disclosure may have the opportunity to express their emotions and benefit from the adaptive process.

Limitations

The current study included a nonclinical sample, which consisted of college students. The mean for PTSD symptoms (IES-R) was more elevated than previous studies of college students,^21,22 bringing it closer to means reported among traumatized groups that did not meet the diagnostic criteria for PTSD.^23,24 Although this would minimize the possibility of having a floor effect, replications of results from the current study in clinical samples (with diagnosed PTSD patients) would be needed in order to confirm effects found in this study.

Also, this study did not collect detailed information regarding possible reasons for variance in prior disclosure. This two-way interaction may be further qualified by other important psychosocial variables, such as differences in personality, coping style, social support, or use of prayer as a form of disclosure. However, a larger sample size or a series of systematic studies may be required in order to properly examine these interactions.

Conclusions

Religion may act as a resource from which individuals derive comfort after traumatic events. It appears that religious emotional expression may encourage adaptive trauma processing, especially for individuals with low prior disclosure. Future studies replicating and expanding the current study may be integrated within interventions aimed at reducing the negative effects of trauma and better inform this line of investigation.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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