Benefits of Combining Cognitive-Behavioral Bibliotherapy with Expressive Writing Interventions

1. Benefits of Combining Cognitive-Behavioral Bibliotherapy with Expressive Writing Interventions David Manier & Sabrina Esbitt Lehman College – CUNY New York, NY Email: dmanier@aol.com 18 July 2009 STAR Conference Semmelweis University Budapest, Hungary

2. Acknowledgments • This research was supported by a grant from the U. S. National Institutes of Health – Minority Research and Infrastructural Support Program (NIH – MRISP). I would also like to thank my students Maribel Rivera, Adelaida Olivares, Paicy Veras, and David Madlala.

3. College Student Stress • The target population for this research has been students at Lehman College – CUNY. Lehman College is located in the Bronx, and reflects its demographics. Our students are approximately 50% Hispanic, 40% African American, ¾thfemale. Students at Lehman are non-traditional: older (25), frequently the first in their families to attend college, most work (i.e., support themselves), some have children. The proportion of students completing a bachelor’s degree within six years is less than fifty percent (many never receive their undergraduate diplomas).

4. Emotional DisclosureInterventions • James Pennebaker and colleagues have developed Emotional Disclosure (ED) as a way to reduce the negative effects of stress, and to produce benefits. • There are different varieties of ED, but the most widely researched is Expressive Writing, in which people write about their “deepest thoughts and feelings” related to the stresses in their lives.

5. Expressive Writing Instructions • What I would like you to do during the three sessions here is to write about the stresses that you are facing in your life, especially those related to going to college. In your writing, I want you to let go and explore your very deepest emotions and thoughts. You can write about [ ... ] major conflicts or problems that you have experienced or are experiencing now, especially as they relate to going to college. [ ... ] You might also tie your writing to other parts of your life, for example, your work, your childhood, your parents, people that you love, who you were, who you are, or who you want to be. The main thing is to explore your deepest thoughts and feelings.

6. Many studies have indicated that the emotional disclosure (ED) intervention can have a range of benefits for those experiencing stress, including college students. But ED is not a panacea, and its benefits can be modest. My ongoing research seeks to enhance those benefits by combining ED with bibliotherapy(EDwBT), in which participants read about basic principles of cognitive-behavioral therapy (CBT) prior to engaging in expressive writing.

7. Although researchers have studied various factors to account for the benefits of ED, recent studies emphasize the importance of cognitive mechanisms. As participants write for three 30-minute sessions about their “deepest thoughts and feelings” about stresses in their lives, it changes the way they think about these stresses. The hypothesis guiding my research is that this change in thinking can be enhanced by having participants read about basic principles of CBT before engaging in ED. From the many varieties of CBT, we chose to have participants read about principles adapted from rational-emotive behavioral therapy as developed by Albert Ellis (1999), which has been presented in a straightforward form that is easily read and understood by participants: Thoughts  Feelings  Actions

8. The following are excerpts from a text Esbitt and I developed (based on Ellis), read by EDwBT participants prior to their engaging in the emotional disclosure intervention: • Even though we cannot control everything that happens in life, there is something that we can control: our own point of view. Remarkably often, how upset, angry, or depressed we get may depend on the view we take of things. In fact, psychological research has demonstrated that the way we feel is strongly influenced by the way we think.

9. Ellis’s approach can be summed up in terms of a simple formula that is based on the first five letters of the alphabet (A-B-C-D-E): • A. (A~ctivating event). The actual “problem,” the real world event that upsets you, such as failing a class or fighting with a friend. The events that you experience “activate” thoughts and feelings in you. For example, John may see his girlfriend talking and laughing with a guy he doesn’t know. This may activate the thought that she is planning to break up with him.

10. B. (Irrational B~eliefs). Irrational beliefs are thoughts we have that are related to the activating event. Irrational beliefs are unhealthy and make the discomfort associated with the activating event worse. They are irrational because they aren’t realistic and are usually extreme, such as “I am a horrible person,” “I can’t stand this professor,” or “I just have to get good grades.” These thoughts are unrealistic because, even if you have done something wrong, it doesn’t make you horrible, even if you don’t like a professor, you can probably stand her, and she may not be completely awful, and even though you want to get good grades, it’s not really true that you must get them.

11. C. (Emotional or behavioral C~onsequences). These are the feelings or behaviors that result from how you think about the event. Returning to the example of failing a class, if a person has the irrational belief that because he failed one class, he is a failure, the emotional consequences could be that he would feel depressed. The behavioral consequences could be that he would give up and stop studying, so that he would do worse in his classes, because he feels stupid and loses his confidence. In this example you can see how what you think (“I must pass this class”) can affect how you feel (“I hate myself for failing this class”) and can even affect your behavior ( “I might as well drop out of school”).

12. D. (D~isputing or challenging irrational beliefs and assumptions). To dispute means to argue, and that’s what you have to do with your unhealthy irrational beliefs. You may actually know that your irrational beliefs are wrong. But when you’re in a tough situation, like after failing a test, you may find that all your logic goes out the window (“I’m so stupid! How could I fail that exam! I might as well give up!”) That’s why you need to figure out the kinds of irrational beliefs you may have, and argue with them as soon as they come up. By recognizing your irrational beliefs and disputing them as soon as they occur, you can stop them in their tracks.

13. E. (The E~ffects of changing your thinking) The problem with irrational beliefs is that they are unrealistic and extreme. If we decide to change the way we think, we can affect how we feel. And this can lead to important life changes: We can stop making ourselves feel so upset when we are disappointed. We can control our anger, and get less angry to begin with, when we have conflicts with other people. We can bounce back more quickly from sadness, or even from tragedy. Rather than getting depressed and giving up because things didn’t turn out as we wanted, we may find within ourselves the power to try harder and work to make things better.

14. Ellis’ ABCDE method can be applied to the problems of students. By changing the way you think about your problems, it can change the way you feel, which in turn can change the way you act. Students who follow Ellis’s approach can become better adjusted to their experience, and as a result do better in school. Rather than getting depressed and giving up after failing an exam, you may find that changing the way you think can change what you do (“Yes, I’m disappointed, but I know that I don’t have to be perfect, and what happened is not really so horrible – life goes on, and I will try harder and do better next time!”)

15. Examples used in Bibliotherapy • In addition to a summary of Ellis’s theories, we gave our participants examples of student stress, and how it could be viewed (and mitigated) using Ellis’s approach. We based our examples on actual stresses described by students in our previous expressive writing studies. Our examples were selected based on their frequent occurence within past student narratives, and therefore their presumed pertinence to participants.

16. Here’s an example. In this vignette, given to students to read, a counselor is talking to a student, “Mary,” who feels terrible because she has discovered that her boyfriend cheated on her. Counselor : It’s important that you pay attention to what you are thinking and feeling. Notice the kinds of irrational thoughts you have, especially really extreme kinds of thoughts, like “I’m worthless” or “I’m ugly.” Thoughts so extreme and unreasonable as that are just the kind you have to fight, because they aren’t true and they only hurt you. Catch yourself if you start thinking, “It was my fault, there’s something wrong with me,” and remind yourself that while you may really wish that your boyfriend didn’t cheat on you, that you are still valuable and lovable, regardless of what he does or if you are still with him.

17. A summary of Mary’s problem, using the ABCDE model: • A. (Activating event) Mary’s boyfriend cheated on her. • B. (Irrational Beliefs) “If my boyfriend cheats on me, it means I am unlovable.” • C. (Emotional or behavioral consequences) Mary is depressed and hates herself. She blames herself, and can’t stop thinking about what she might have done to cause this to happen. Because she can’t stop obsessing about her relationship, Mary has a hard time studying or concentrating, which only makes her feel worse. • D. (Disputing or challenging irrational beliefs and assumptions) Mary’s irrational belief is that if her boyfriend cheated on her, she is unlovable. But Mary has inherent value as a person – a value that cannot be taken away. Mary is lovable regardless of whether she is with her boyfriend or not, and whether someone cheats on her or not. A rational, healthy belief would be that she may really want to be loved, but that if she is not, it doesn’t mean that she is unlovable. • E. (The effects of changing your thinking) By believing that she is lovable and attractive as she is, instead of relying on her boyfriend to make her feel that way, Mary comes to feel much less anxious and depressed. She is still sad and hurt that her boyfriend cheated on her, but she no longer hates herself or feels that she is unlovable because of what happened. Mary now has to decide how she will handle her situation, but by remembering that her sense of herself does not have to depend on her boyfriend’s approval, she feels confident and is better able to make a good decision.

18. Research Procedure We had 131 participants (demographically similar to the Lehman student population), who were randomly assigned to one of four conditions: • Experimental Bibliotherapy (Exp Bib) – read CBT narratives prior to engaging in each of three ED (expressive writing) sessions (told to write about their “deepest thoughts and feelings” about coming to college). • Control Bibliotherapy (Ctrl Bib) – read mundane narratives (about the history and architecture of the college) prior to engaging in three control writing sessions (told to write about the history and architecture of the college). • Experimental No Bibliotherapy (Exp No Bib) – engaged in three ED (expressive writing) sessions (as above), but were not given texts to read. • Control No Bibliotherapy (Ctrl No Bib) – engaged in three control writing sessions about mundane topics (as above). • Participants were given several questionnaires to establish a Time 1 baseline, and then (within a week’s time) participated in three writing sessions, on three consecutive days, for 30 minutes each day. Posttest measures were given on two subsequent occasions, first after a six-week delay (Time 2), and then again after a twelve-week delay (Time 3).

19. Measures • To measure student adjustment, we used the Student Adaptation to College Questionnaire (SACQ – Baker & Siryk, 1984). • To assess perceived stress, we used the College Stress Inventory (CSI - Solberg, Hale, Villareal, & Kavanaugh, 1993). • To assess self-efficacy, we used the College Self Efficacy Inventory (CSEI - Solberg, O’Brian, Villareal, Kennel, & Davis, 1993). • To assess perceived social support, we used the Social Provision Scale (SPS - Cutrona & Russell, 1987). • To assess irrational beliefs, we used the Survey of Personal Beliefs (SPB - Damaria, Kassinove, & Dill, 1989).

20. CHANGES IN STUDENT ADJUSTMENT TO COLLEGE (SACQ) OVER TIME (higher scores indicate improvement) * * * * * significant at p <.01

21. CHANGES IN SELF-EFFICACY (CSEI) OVER TIME (higher scores indicate improvement) * * * * * significant at p <.01

22. CHANGES IN DEPRESSED MOOD (BDI) OVER TIME (lower scores indicate improvement) * * * * * significant at p <.01

23. CHANGES IN PERCEIVED SOCIAL SUPPORT (SPS) OVER TIME (higher scores indicate improvement) * * * * * significant at p <.01

24. CHANGES IN PERCEIVED STRESS (CSI) OVER TIME (lower scores indicate improvement) * * * * * significant at p <.01

25. CHANGES IN BELIEFS (SPB) OVER TIME (higher scores indicate improvement) ALL differences are significant at p <.01, except exp vs. cntrl at T1

26. Our results indicate that some stress-related benefits of ED for college students can be enhanced when ED is combined with bibliotherapy (EDwBT). Compared to participants who engaged in ED alone, we found a pattern of increased benefits in participants in the EDwBT condition on measures of college adjustment (SACQ), self-efficacy (CSEI), perceived stress (CSI), perceived social support (SPS), mood (BDI), and a measure of irrational cognitions and beliefs (SPB).

27. Predictor/Outcome Correlations for ED without Bibliotherapy Perceived Stresses (CSI) -0.58** Adjustment to College (SACQ) -0.25, n.s. Mood (BDI) 0.36* Self- efficacy (CSEI) **p<.01 *p<.05

28. Predictor/Outcome Correlations for ED with Bibliotherapy Perceived Stresses (CSI) -0.84** Adjustment to College (SACQ) Irrational Beliefs (SPB) -0.73** -0.84** Mood (BDI) 0.36* **p<.01 *p<.05 Self- efficacy (CSEI)

29. Correlational analysis suggests that ED and EDwBT have different patterns of effects. Using a series of regression analyses, our data indicate that EDwBT is associated with changes in cognitions / beliefs (SPB), and those changes are associated with changes in mood (BDI), which in turn are associated with changes in levels of college adjustment. (ED alone was not significantly correlated with decreases in depressed mood in our sample.)

30. Content Analysis Our ongoing research represents a mix of qualitative and quantitative methods. My research lab is currently analyzing the narratives produced by students using a coding scheme, based in part on the cognitive approach to stress discussed previously, and in part on an inductive method, responding to the content of the narratives themselves. This is providing us with a content analysis of the narratives. We are using independent raters, blind to the scores and the experimental conditions of the participants, and are achieving high rates of interrater reliability.

31. For example, we are coding instances when students discuss particular types of stressors Types of Stressors (adapted from Baker & Siryk, 1989): • Academic (scheduling conflicts and inaccessible classes, lack of necessary basic skills, e.g., difficulty writing essays, time demands, professor problems, class environment, difficulty of meeting academic demands and assignments). • Financial (Financial Aid/Paying for School, Living Costs, transportation, rent, food, clothing and other personal expenses, paying for health care). • Social (Family – Child rearing, Domestic chores, Parental demands; Peers, Intimate Relationships, Religious, Work, Community, Cultural Adjustment). • Personal & Emotional (Affective – depression, anxiety, anger; Cognitive – worrying, ruminating; History of traumatic experiences, Substance abuse, Problems with time management, Health problems, Mental illness, Race, Religion, Gender).

32. Irrational Beliefs • Based on the rational-emotive therapy model of Albert Ellis, we are analyzing student narratives to find irrational beliefs, such as catastrophizing (exaggerating negative aspects) and universal expectations (e.g., “my parents must always approve of me”). We are finding that, in the EDwBT group, the irrational beliefs present in their narratives decrease over time, and that subjects in the EDwBT group are showing fewer irrational beliefs in their narratives than ED subjects.

33. Results • We are finding high correlations between raters’ evaluations of the participants’ narratives and the scores that participants’ achieved on self-report questionnaires (r>.50, p<.05). For example, participants who scored high on the SACQ wrote narratives that tended to be rated (by raters blind to condition and SACQ scores) as indicating high levels of adjustment and low levels of irrational beliefs.

34. Narrative Example(a well-adjusted student) • “I feel stressed when I have a lot of school work to do. Right now, I am feeling more calmed because I will set time aside to study for my final exams next week. I will push myself hard not to get distracted by television, the internet, and being on the phone. A few weeks ago I was sad and depressed about my possibilities of passing calculus and the lab. Now, I think that if I work harder and study a lot I may be able to pass the final exams and therefore the class. [ ... ] For my Calculus class, I understand that sometimes we may have trouble with a certain course at first for whatever reason. But if you just stay focused and study the material well enough you will understand and you’ll be able to get a good grade in the course. I feel optimistic. I won’t say that “I know I will fail calculus.” I have to be positive. I know that if I say “I will fail calculus” that will make me feel sad and depressed which will just affect my action of giving up on the course and on the final exam. Thoughts – Feelings - Actions. Instead, I’ll say “I can pass calculus” which will make me feel happy and therefore I’ll be enthusiastic about studying to pass the final exam.”

35. Future Research • Although we have found high levels of correlations between ratings of narratives and the results of self-report questionnaires, we have not yet established reliable predictors of higher GPA or of successful completion of college within six years. • We have shown that EDwBT is associated with better outcomes than ED alone. However, we have not yet studied EDwBT vs. BT alone differences.

36. Nagyon Köszönöm Thank you very much David Manier Lehman College City University of New York dmanier@aol.com