Contents lists available at ScienceDirect Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp Expressive writing to improve resilience to trauma: A clinical feasibility trial Oliver Glass a , Mark Dreusicke a , John Evans a , Elizabeth Bechard a , Ruth Q. Wolever b,∗ a Duke Integrative Medicine, 3475 Erwin Road, Durham, NC, 27705, USA b Osher Center for Integrative Medicine at Vanderbilt, 3401 West End Ave, Suite 380, Nashville, TN, 37203, USA ARTICLE INFO Keywords: Expressive writing Mindful writing Resilience Therapeutic writing Trauma ABSTRACT Background and purpose: Trauma is highly prevalent, with estimates that up to 90% of the U.S. population have been exposed to a traumatic event. The adverse health consequences of trauma exposure are diverse and often long-lasting. While expressive writing has been shown to improve emotional and physical health in numerous populations, the feasibility and potential effectiveness of a novel expressive writing program provided in a clinical setting to improve resilience is unknown. Our objective was to determine the feasibility and potential effectiveness of a 6-week expressive writing course provided in a clinical setting to improve resilience in in- dividuals with a history of trauma. Materials and methods: This prospective, observational trial of a 6-week expressive writing intervention (Transform Your Life: Write to Heal) was conducted in an academic outpatient integrative clinic. Eligible parti- cipants were a self-referred sample of 39 English-speaking adults who identified as having had a trauma, or significant emotional/physical upheaval, within the past year. Main outcome measures included: Feasibility: Enrollment, Retention in Program and Trial, Adherence. Acceptability: Adverse Events; Participant Ratings. Primary Psychological Outcome: Connor-Davidson Resilience Scale (CD-RISC). Secondary Psychological Outcomes: Perceived Stress Scale – 10 item (PSS-10); Center for Epidemiologic Studies Depression Scale (CES-D); Rumination Response Scale (RRS). Results: All measures of feasibility including those related to enrollment, retention, and adherence support feasibility. All measures of acceptability including adverse events and participant ratings support the inter- vention as being safe, well-received and personally valuable. Resilience scores increased from baseline (64.3 ± 14.40) to post-intervention (74.2 ± 13.15), t(37) = 4.61, p < 0.0005; Cohen's d = 0.75. In addition, across the same period, Perceived Stress scores decreased close to a standard deviation (20.5 ± 7.43 to 14.3 ± 6.64), t(37) = -4.71, p < 0.0005, Cohen's d = 0.76; depression symptoms decreased (from 19.0 ± 13.48 to 12.7 ± 11.68), t(37) = -3.21, p = 0.003, Cohen's d = 0.52; and rumination scores decreased from 48.5 ± 12.56 to 39.8 ± 10.07), t(37) = -5.03, p < 0.0005, Cohen's d = 0.82. Effect sizes ranged from medium to large. Conclusion: The Transform Your Life: Write to Heal program is feasible to offer in a clinical setting, was well- received by participants, and demonstrated preliminary findings of effectiveness. Our study suggests that this novel 6-week writing intervention including expressive, transactional, poetic, affirmative, legacy, and mindful writing prompts increases resilience, and decreases depressive symptoms, perceived stress, and rumination in an outpatient sample of those reporting trauma in the past year. The program appears suitable to be evaluated in a larger randomized controlled trial. 1. Introduction An estimated 90% of the U.S. population has been exposed to a traumatic event [1]. Individuals who experience trauma are at higher risk for a wide range of significant psychological and health issues, including affect dysregulation, negative self-image, and problems with impulse control, aggression, somatization, dissociation, and substance abuse [2–4]. Expressive writing using the Pennebaker Paradigm is a well-established therapeutic intervention to enhance coping with stressful or traumatic events [5,6]. This study evaluates the feasibility https://doi.org/10.1016/j.ctcp.2018.12.005 Received 28 September 2018; Received in revised form 17 November 2018; Accepted 13 December 2018 ∗ Corresponding author. Osher Center for Integrative Medicine at Vanderbilt, Department of Physical Medicine & Rehabilitation, Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, Vanderbilt University School of Nursing, 3401 West End Ave, Suite 380, Nashville, TN, 37203, USA. E-mail addresses: oliver.glass@duke.edu (O. Glass), mark.dreusicke@duke.edu (M. Dreusicke), jfevans77@gmail.com (J. Evans), elizabeth.matteson@duke.edu (E. Bechard), ruth.wolever@vanderbilt.edu (R.Q. Wolever). Complementary Therapies in Clinical Practice 34 (2019) 240–246 1744-3881/ © 2018 Published by Elsevier Ltd. T