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Emotional and Cognitive Processing in

Sexual Assault Survivors' Narratives
a a a
Komal Sharma-Patel , Elissa J. Brown & William F. Chaplin
a
Psychology Department , St. John's University , Flushing , New
York , USA
Published online: 21 Feb 2012.

To cite this article: Komal Sharma-Patel , Elissa J. Brown & William F. Chaplin (2012) Emotional and
Cognitive Processing in Sexual Assault Survivors' Narratives, Journal of Aggression, Maltreatment &
Trauma, 21:2, 149-170, DOI: 10.1080/10926771.2012.639053

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 Journal of Aggression, Maltreatment & Trauma, 21:149–170, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1092-6771 print/1545-083X online
DOI: 10.1080/10926771.2012.639053

Emotional and Cognitive Processing in

Sexual Assault Survivors’ Narratives

KOMAL SHARMA-PATEL, ELISSA J. BROWN,

and WILLIAM F. CHAPLIN
Psychology Department, St. John’s University, Flushing, New York, USA
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Sexual assault sequelae include posttraumatic stress disorder

(PTSD), depression, and substance use. Seminal treatment models
have been developed based on emotional (Foa & Kozak, 1986) and
cognitive (Resick & Schnicke, 1992) theories, and determined to be
efficacious. Studies also have documented the utility of Pennebaker
and Beall’s (1986) narrative writing paradigm for trauma-
related depressive and PTSD symptoms. Recently investigations
have sought to explicate its benefit, focusing on mechanisms of
action. This study aimed to examine the emotional activation and
cognitive processing across narrative writing sessions with under-
graduate sexual assault survivors. Results revealed statistically
significant reductions in depressive symptoms and alcohol use, but
not PTSD symptoms. Clinically meaningful and statistically signif-
icant emotional activation and habituation occurred within and
across sessions. Implications and limitations are discussed.

KEYWORDS cognitive processing, emotional processing, sexual

assault survivors, written narrative task

More than two decades of research has established the serious mental health
outcomes of sexual assault, with high rates of lifetime posttraumatic stress
disorder (PTSD), current PTSD, and depressive disorders (Koss, Figueredo, &
Prince, 2002; Ozer, Best, Lipsey, & Weiss, 2003). Additionally, a number of
studies have documented alcohol use disorders as common sequelae of sex-
ual assault survivors (e.g., Kilpatrick, Acierno, Resnick, Saunders, & Best,

Submitted 11 November 2010; revised 18 February 2011; accepted 23 March 2011.

Address correspondence to Komal Sharma-Patel, PARTNERS Program, 152–11 Union
Turnpike, Flushing, NY 11367. E-mail: sharmak@stjohns.edu

149
 150 K. Sharma-Patel et al.

1997; Ullman, Filipas, Townsend, & Starzynski, 2005). Given the widespread
use of alcohol among college-aged students (e.g., O’Hare, 2005) and subse-
quent risky sexual behaviors (e.g., Kilpatrick et al., 1997; O’Hare, 2005), it is
important to determine whether established trauma-based interventions are
effective in reducing risky alcohol use behaviors (Foa & Williams, 2010).
Likewise, an extensive body of research (Ehlers et al., 2010) has pro-
vided support for the efficacy and effectiveness of cognitive-behavioral
treatments for rape-related PTSD and depression, including prolonged expo-
sure (PE; Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991) and
cognitive processing therapy (CPT; Nishith, Resick, & Griffin, 2002; Resick &
Schnicke, 1992). Furthermore, treatment outcome studies with rape survivors
comparing PE to CPT have found unequivocal improvements in maladaptive
cognitions, PTSD, and depression (e.g., Nishith et al., 2002).
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Despite the established efficacy of PE and CPT, several challenges

persist in providing treatment to sexual assault survivors (e.g., low ser-
vice utilization, cost, stigma), suggesting the need to examine innovative
interventions. Of the several alternatives to standard treatment that have
been investigated for a variety of psychosocial difficulties, including depres-
sion and PTSD, the written narrative task for stressful and traumatic events
(Pennebaker & Beall, 1986) has been found to be beneficial, particularly
for undergraduate women (Smyth, True, & Souto, 2001). Importantly, the
task’s theoretical underpinnings (i.e., emotional and cognitive processing)
appear to be consistent with cognitive-behavioral approaches. Parallel to
leading treatment outcome researchers (e.g., Ehlers et al., 2010), investiga-
tors of the written narrative task have advocated for a shift in research to
examining such active mechanisms of therapeutic change. Although recent
investigations have provided preliminary empirical support of this (e.g.,
Epstein, Sloan, & Marx, 2005; Sloan & Epstein, 2005), the studies have
had methodological limitations (e.g., no standard measure of cognitive vari-
ables, specificity of sample), precluding any conclusions. This study aims
to investigate the narrative task, hypothesizing reductions in symptoms with
concomitant improvements in emotional and cognitive processing variables.

SYMPTOM DEVELOPMENT THEORIES

Emotional Processing Theory
Building on early theories of fear (as reviewed in Lang, Davis, & Ohman,
2000), Foa and colleagues (e.g., Foa et al., 1991, 1999; Foa & Kozak, 1986)
conducted extensive research supporting the emotional or informational
processing theory of rape-related PTSD (Buckley, Blanchard, & Neill, 2000).
This theory argues that traumatic memories are fragmented, disorganized
networks comprised of trauma cues (e.g., environmental triggers), inter-
nal responses (e.g., physiological and emotional reactions), and cognitive
 Emotional and Cognitive Processing 151

interpretations (trauma beliefs) resulting in reexperiencing, avoidance, and

arousal symptoms.
To recover from a traumatic event, the survivor must process the event.
Hembree and Foa (2003) proposed that three factors are critical to the
successful processing of traumatic events: emotional engagement with the
trauma memory, organization of the trauma narrative, and correction of
dysfunctional cognitions about the world and self. In a summary of the
mechanisms thought to be involved during PE (Foa et al., 1991), Brewin
and Holmes (2003) argued that repeated activation of the trauma habitu-
ates the fear reaction by reducing the level of fear associated with other
memory elements (e.g., thoughts and emotions, places, objects). Operant
models focus on reversing avoidance and escape behaviors (e.g., avoid
triggers of trauma). With repeated exposure, the trauma narrative becomes
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more organized and easier to integrate into memory. Habituation needs to

occur within a session and between sessions for the alleviation of anxiety
(Foa & Kozak, 1986). Lastly, exposure allows the trauma experience to be
discriminated from other potentially threatening events, thereby addressing
dangerous world beliefs, and allows the trauma survivor to experience self
as competent and courageous.

Cognitive Processing Theory

In contrast to Foa et al., Resick and Schnicke (1992) focused on sexual
assault survivors’ cognitive processing of their experience and extend the
theory beyond fear to include shame, guilt, and other emotions. Cognitive
theories of adverse experiences state that people hold basic assumptions
about their self, future, and world that provide a framework for their behav-
iors, thoughts, and emotions, and that distortions of these assumptions can
lead to the development and maintenance of psychopathology (Beck, 2005).
According to Resick and Schnicke, sexual-assault-related mental health prob-
lems develop from an incongruity between preexisting beliefs (schemas) and
traumatic experiences via inappropriate assimilation or overaccommodation.
For example, a preexisting belief might be that “Rape doesn’t happen to good
women.” When faced with discrepant information (i.e., being raped), the sur-
vivor might alter (assimilate) her existing schemata in varying ways (“The
rape didn’t happen,” or “I must have done something bad to get raped”).
Overaccommodation might result in beliefs like, “Men can’t be trusted.”
Ehlers and colleagues’ (Dunmore, Clark, & Ehlers, 2001; Ehlers & Clark,
2000; Michael, Halligan, Clark, & Ehlers, 2007) explication of cognitive the-
ory of PTSD development and maintenance includes peritraumatic variables
(appraisals during assault), posttrauma cognitions of perceived threat and
lack of control, maladaptive coping strategies (rumination, avoidance), and
global “trauma-sensitive” beliefs about the self (“there is something wrong
with me”), others (“cannot trust or rely on people”), and world (“the world is
 152 K. Sharma-Patel et al.

dangerous”). They also identified aspects of rumination (i.e., occurrence of

“why” and “what-if” type questions) as critical to predicting PTSD (Michael
et al., 2007). Similar to Foa and colleagues (e.g., Foa et al., 1991), they also
proposed that persistent PTSD is associated with poorly elaborated and poorly
integrated memories of the trauma. Thus, in addition to the trauma narra-
tive, CPT includes cognitive restructuring (i.e., modification of trauma-specific
schema-discrepant information; Cason, Resick, & Weaver, 2002).
Researchers have gathered considerable evidence in support of cog-
nitive theory of the development and maintenance of symptomatology
(e.g., depression, PTSD; Dunmore et al., 2001; Ehlers & Clark, 2000; Koss
et al., 2002). Brillon, Marchand, and Stephenson (1999) concluded that self-
blame strongly predicted adjustment in sexual assault survivors. Relevant
to this study, they also reported that endorsement of dysfunctional beliefs
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about safety, trust, esteem, intimacy, self, and others was related to post-
traumatic stress symptoms, providing support to the recent explication of
the cognitive processing theory that incorporated McCann, Sakheim, and
Abrahamson’s (1988; cf. Cason et al., 2002) themes. Ehlers and colleagues
also have presented findings on their cognitive theory with a recent empha-
sis on rumination as a “powerful predictor” of symptoms (e.g., Michael
et al., 2007; Steil & Ehlers, 2000). Collectively, these studies underscore
the need to extend the scope of investigations to both emotional activa-
tion and dysfunctional beliefs when examining mechanisms of change in
interventions.

WRITTEN NARRATIVE TASK OF TRAUMA

Briefly, Pennebaker (1997) posits that writing about a traumatic event

allows the individual to organize the traumatic memory and most impor-
tantly, allows for cognitive change (i.e., accommodation) over the course
of writing. Recent randomized controlled studies (e.g., Sloan, Marx, &
Epstein, 2005) have examined and Beall’s (1986) narrative writing paradigm
for trauma-related mental health problems, and found clinically significant
reductions in depressive and PTSD symptoms in undergraduate students
writing on a range of stressful or traumatic events including sexual assault.
A series of randomized controlled trials of an Internet-based narrative writ-
ing treatment approach for PTSD and depressive symptoms (Lange, Rietdijk,
Hudcovicova, van de Ven, Schrieken, & Emmelkamp, 2003; Lange, van de
Ven, Schrieken, & Emmelkamp, 2001) also have provided significant empiri-
cal support for its use with undergraduate and nonstudent populations with
diverse trauma histories. Collectively, these studies have established the effi-
cacy of the narrative writing paradigm for trauma experiences. However,
the mechanisms of action remain unknown. The few studies that focused
on understanding the underlying mechanisms of the narrative writing task
 Emotional and Cognitive Processing 153

examined either the exposure or cognitive approach, with mixed findings

for both theories (Sloan & Marx, 2004b).

Written Narrative Task and Emotional Processing Theory

If emotional processing underlies the written narrative task paradigm, Sloan
and Marx (2004b) proposed that activation and habituation of negative emo-
tion should be observed with concomitant reductions in PTSD symptoms.
In studies of emotional reactivity and PTSD symptoms, emotional reactivity
has been associated with reductions in intrusion and avoidance symptoms
(Epstein et al., 2005; Sloan & Epstein, 2005; Sloan & Marx, 2004b; Sloan et al.,
2005) but also with no effect (e.g., Kloss & Lisman, 2002). Sloan and Marx
(2004b) described an unpublished study in which trauma survivors assigned
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to the experimental condition showed significantly greater emotional reactiv-

ity to the first session that then decreased by the last session, and significant
reductions in PTSD and depressive symptoms at follow-up. Sloan et al.
(2005) examined the relation among emotional arousal, habituation, and
PTSD symptoms in participants randomly assigned to writing about the same
traumatic experience at each writing session, different traumatic events, or
neutral events. Both groups writing about traumatic experiences evidenced
emotional arousal and habituation. The same-trauma group demonstrated
reductions in PTSD symptoms. Collectively, these studies’ findings suggest
that writing about the same traumatic event at each writing session versus
writing about different traumatic experiences at each session might be more
effective in reducing clinical symptoms of PTSD and depression.
Other studies have demonstrated that the written narrative task can
elicit emotional reactivity but have reported mixed results for habituation
(e.g., Kloss & Lisman, 2002). Two investigations (Kloss & Lisman, 2002;
Smyth, Hockemeyer, & Tulloch, 2008) found increased anxiety (emotional
reactivity) when writing about traumatic events, but no decreases in anxiety
or PTSD symptoms (habituation) subsequent to the narrative task. However,
in their randomized control trial, Smyth et al. (2008) reported significant
emotional habituation of general stress across sessions, suggesting an overall
improvement and also a need to further examine reactivity and habituation
within and across sessions.

Written Narrative Task and Cognitive Processing Theory

If cognitive processing theory underlies the written narrative task paradigm,
reductions in trauma-related distortions pertaining to sexual assault (e.g.,
safety, trust, power, control, esteem, intimacy), self (e.g., blame), and
rumination or undoing (e.g., frequently thinking about trauma and how they
could have stopped or prevented it) should be observed with concomitant
reductions in posttraumatic and depressive symptoms (Resick & Schnicke,
 154 K. Sharma-Patel et al.

1992). Klein and Boals (2001) conducted two studies of the written narra-
tive task and found that those undergraduates who wrote about negative
events (vs. positive and trivial) evinced reductions in intrusive and avoid-
ance symptoms at two-month follow-up that were linked to increased use
of causal words. Park and Blumberg (2002) reported reductions in perceived
threat (cognitive variable) and PTSD symptoms in the trauma-writing group
(vs. control condition) at four-month follow-up. In another study (Sloan,
Marx, Epstein, & Dobbs, 2008), rumination (cognitive processing variable)
moderated the effects of writing condition on depressive symptoms, with
improvements in symptoms persisting 6 months postwriting task for expres-
sive writing group (vs. control). Relatedly, Alvarez-Conrad, Zoellner, and
Foa (2001) transcribed trauma narratives reported during exposure therapy
by female sexual and physical assault survivors and found that linguistic vari-
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ables measuring cognitive processes (e.g., causal and insight words) were
related to posttreatment change in PTSD, anxiety, and depressive symp-
toms. These studies offer a basis for this study’s methodology (i.e., linguistic
measure of cognitive processes) and aims.
Recent investigations (e.g., Hunt, Schloss, Moonat, Poulos, & Weiland,
2007) have reported preliminary results in the examination of emotional and
cognitive mechanisms. Epstein et al. (2005) examined changes in physiolog-
ical reactivity and linguistic indexes of cognition and emotion in participants
writing about an upsetting (stressful) or neutral event and found that those
in the former group (vs. control) exhibited significantly elevated heart rate
activity during the first session. This elevated reactivity was associated
with significant reductions in depressive symptoms at one-month follow-
up. Additionally, those writing about a stressful event used more negative
emotion words, more positive emotion words, and more insight or causal-
ity words relative to the control group. Limits included no measurement of
PTSD symptoms or trauma-specific cognitions. Finally, Hunt et al. (2007)
examined the effects of cognitive restructuring, emotional processing, and
their combination on depressive symptoms after the illness or death of a
pet. The combined condition evidenced greatest improvements in depres-
sive symptoms. Limitations of the study included a single assessment method
(linguistic) of emotional arousal and cognitive variables and the specificity
of the sample (pet owners).

THIS STUDY

Emerging research on the utility of the written narrative paradigm has shifted
from investigating whether the written narrative task is beneficial to under-
standing who benefits from it (ethnicity, age, individual differences) and
under what conditions (e.g., number of sessions, duration, and time between
sessions; Epstein et al., 2005; Sloan & Epstein, 2005; Sloan & Marx, 2004b).
To better understand the possible underlying mechanisms of change of the
 Emotional and Cognitive Processing 155

narrative task and by extension, therapies that incorporate repeated narra-

tive tasks, they posit that more than one approach might be associated with
greater benefits and thus, recommend examining multiple correlates (i.e.,
affective and cognitive processing).
In this study, undergraduate participants who experienced attempted
or completed sexual assault participated in a writing task with instructions
to include emotional and cognitive processing. Participants wrote about the
traumatic experience on three days approximately one week apart (Times
2–4) and symptoms were reassessed at Time 5. Sexual-assault-related seque-
lae included PTSD, depression, and alcohol use. We hypothesized that
(a) participants writing about their sexual assault experience at repeated
time points would evidence a reduction in PTSD, depressive, and alcohol
abuse symptoms; (b) emotional processing would include initial increases
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in negative emotion words and subjective units of distress (SUDS; i.e.,

reactivity) within sessions, between-sessions decreases in negative emotion
words and SUDS (i.e., habituation), and increase of positive emotion words;
and (c) cognitive processing would include between-session increases in
adaptive coping (i.e., insight) and decreases in maladaptive coping (i.e.,
undoing/discrepancy) across writing sessions.

METHOD
Participants
This investigation draws from a broader study that examined experiences of
sexual assault and perpetration, coping behaviors, and benefits of writing
about sexual assault (Sharma-Patel, 2010). The sexual assault screener was
completed by 461 undergraduate women attending a large urban university.
Attempted or completed sexual assault was endorsed by 118 (26%) partic-
ipants, of whom 38 (32%) consented to complete the narratives, 24 (63%)
attended the first session, and 19 (16%) completed all four sessions. A series
of analyses were conducted to examine whether there were significant dif-
ferences in age, sexual assault severity, and 15 coping tendencies between
those who were eligible in the second phase but refused and those who
consented; none of the analyses were significant (Sharma-Patel, 2010). Both
groups (consented to study and completers) were primarily of Caucasian
background. Demographic information on the 19 who completed the study
is presented in Table 1.

Measures
SEXUAL EXPERIENCES SURVEY
The Sexual Experiences Survey (SES; Koss & Gidycz, 1985) is a self-report
instrument designed to assess degree of sexual victimization of women. The
10 questions are administered in yes–no format and include victimization
 156 K. Sharma-Patel et al.

TABLE 1 Demographic Characteristics for

19 Participants Who Completed Study

Characteristic n %

Race/ethnicity
Caucasian/White 9 47.4
African American/Black 2 10.5
Latin American/Hispanic 2 10.5
Asian East 3 15.8
Asian South 1 5.3
Biracial 1 5.3
Other (multiracial) 1 5.3
Year in school (average age:
19.5 years, SD = 3.06)
First year 8 42.1
Sophomore 5 26.3
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Junior 4 21.1
Senior 2 10.5
Mode of assessment
Classroom 10 52.6
Online 9 47.4

experiences of increasing severity. Internal consistency and test–retest relia-

bility were established by Koss and Gidycz. In this study, the SES was used
to assess attempted or completed rape experienced by women and severity
of sexual assault among women; Cronbach’s alpha was .79.

PTSD SYMPTOMS SCALE–SELF REPORT

The PTSD Symptoms Scale–Self-Report (PSS–SR; Foa, Riggs, Dancu, &
Rothbaum, 1993) was used to assess the severity of sexual-assault-related
PTSD symptoms prior to completing the narrative task (Time 2) and one
week after the third writing session (Time 5). The scale contains 17 items,
each rated using a 4-point Likert scale ranging from 0 (not at all) to 3 (5 or
more times per week/very much/almost always). The total severity score is
calculated as the sum of the severity ratings for all items. Internal consistency
and reliability have been shown for sexual assault survivors (Ironson, Freud,
Strauss, & Williams, 2002). The total score was used in this current study;
Cronbach’s alpha was .88. To reduce the moderate positive skewness, PSS–
SR at Time 2 and 5 were square root transformed, with a constant added to
account for zero values.

BECK DEPRESSION INVENTORY

The Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979), a
self-report measure of attitudes and symptoms associated with dysphoria,
 Emotional and Cognitive Processing 157

consists of 21 items rated on a 4-point scale ranging from 0 (denial

of experiencing symptoms at all or no more than expected) to 3 (com-
plete or extreme deterioration in belief or behavior). Total scores of 0 to
9 indicate no depressive symptoms, 10 to 18 indicate a mild to mod-
erate level, 19 to 29 indicate a moderate to severe level, and 30 to
63 are evidence of a severe level of depressive symptoms. In a review
of 25 years of studies utilizing the BDI, Beck, Steer, and Garbin (1988)
found moderate internal consistency and test–retest reliability for nonpsy-
chiatric populations. The BDI has been used to assess depression in
sexual assault victims (Foa et al., 1991; Resick & Schnicke, 1992). The
BDI was administered at Times 2 and 5. For this study, Cronbach’s alpha
was .93.
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ALCOHOL USE DISORDERS IDENTIFICATION TEST

The Alcohol Use Disorders Identification Test (AUDIT; Babor, de la Fuente,
Saunders, & Grant, 1989) consists of 10 items that are hypothesized to
measure three domains: amount and frequency of drinking, symptoms of
alcohol dependence, and negative reactions to or consequences of drinking.
AUDIT total scores of 0 to 7 indicate low risk for alcohol-related prob-
lems, 8 to 12 indicate harmful or hazardous drinking, and 13 and over in
women indicate alcohol dependence (Babor, Biddle-Higgins, Saunders, &
Monteiro, 2001). The AUDIT was reported to have an overall sensitivity
of 80% and specificity of 98% for detecting problem drinking in health
care patients (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993).
AUDIT was administered at Times 2 and 5. For this study, Cronbach’s alpha
was .83.

PERSONAL BELIEFS AND REACTIONS SCALE

The Personal Beliefs and Reactions Scale (PBRS; Mechanic & Resick, 2002)
consists of 55 statements rated on a 7-point scale ranging from 0 (not
at all true for you) to 6 (completely true for you). Higher scores on the
scales represent less distorted beliefs. Test–retest reliability was reported
to be .81 (Owens & Chard, 2001). For this study, items were revised to
reflect attempted or completed sexual assault. Five subscales were included:
Safety (beliefs regarding one’s perceived vulnerability to future harm), Trust
(beliefs about the reliability of others and the ability to trust one’s own
judgment), Power (beliefs about one’s abilities to meet challenges and con-
trol outcomes), Esteem (assessments of self-worth), and Intimacy (beliefs
about one’s capacity to be intimately connected in significant relationships).
Cronbach’s alphas for Safety, Trust, Power, Esteem, and Intimacy were .84,
.64, .71, .68, .53, respectively. Time 2 and 5 assessments were included for
the analyses.
 158 K. Sharma-Patel et al.

SUBJECTIVE UNITS OF DISTRESS SCALE

The SUDS is a self-report measure of discomfort, ranging from 0 (no feelings
of anxiety) to 10 (maximum level of anxiety). SUDS were taken five times
during each narrative session: beginning of writing task, 5-minute inter-
vals while writing (three time points), and at the end of the writing task.
SUDS scores have been used with sexual assault survivors during exposure
sessions to measure emotional reactivity and habituation (Foa et al., 1999).

LINGUISTIC INQUIRY AND WORD COUNT 2007

To examine the content of the narratives, the Linguistic Inquiry and Word
Count (LIWC–2; Pennebaker, Francis, & Booth, 2007) computer program
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was used. LIWC–2 uses a word count strategy whereby it searches for more
than 2,300 words or word stems that previously have been categorized
by independent judges into 22 linguistic dimensions, including psycholog-
ical processes (e.g., positive and negative emotion, cognitive processes).
Pennebaker, Mehl, and Niederhoffer (2003) reviewed studies and reported
good internal consistency. In this study, the following category items were
included in the analysis: Positive Emotion Words, Negative Emotion Words,
Insight, and Undoing/Discrepancy (discrepancies reflected in use of words
like should, would, could).

Procedure
Participants were recruited from large undergraduate classrooms and the
online participant pool of the undergraduate psychology department.
At Time 1, researchers administered the consent form and SES. Women
who disclosed attempted or completed sexual assault were contacted by
the investigators and asked to participate in the writing task. Those who
agreed to participate in the narrative were administered a second consent
form at Time 2, informing them that they would be completing measures
of feelings, thoughts, and behaviors about a “traumatic or stressful event”
four times over four weeks, and writing about the event three times over
three weeks. Participants were informed that they could withdraw from the
study at any time. Following informed consent, participants completed the
battery of questionnaires (BDI, AUDIT, PSS–SR, PBRS, Trauma Characteristic
Survey). Participants then completed the narrative task as described next.
The Time 3 and 4 assessments consisted of the PBRS and narrative task. The
Time 5 assessment included the BDI, AUDIT, PSS–SR, and PBRS. Participants
received reminder calls for subsequent sessions. On completion of the
study, participants received a gift card in the amount of $20. In addition,
participants were provided with a debriefing and referral to psychotherapy
services if necessary.
 Emotional and Cognitive Processing 159

WRITING TASK
Participants received the following instructions, adapted from Pennebaker
(1997) and Smyth et al. (2001):

You were recently asked to answer questions about a traumatic or stress-

ful event of your life. We would now like you to write briefly about
that event. The important thing is that you write your deepest thoughts,
feelings, and sensations about the experience with as much detail as pos-
sible. In other words, tell a story about what happened and how it made
you feel. Please include how this experience has affected your beliefs
about safety, trust, power, esteem, and intimacy. Some people find writ-
ing thoughts, feelings, and sensations about a stressful event upsetting,
and may cry, feel sad or depressed afterwards. This is quite normal and
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we will allow you as much time as you want when you have finished
writing to compose yourself. It is important for you to know that your
name will not be connected in any way with your essay. As you write,
the timer will go off periodically, at which point you should rate your
feelings of anxiety on a scale of 1 to 10 on the form provided.

Participants completed the task in a private office and were asked to put
their completed essay in a marked envelope.

RESULTS

At baseline, 7 (37%) participants met criteria for PTSD and 12 (63%) did not.
Ten (52.6%) participants presented with BDI scores indicative of no depres-
sive symptoms, 2 (10.5%) with mild to moderate, 5 (26.3%) with moderate
to severe, and 2 (10.5%) with severe depressive symptoms. Six (32%) par-
ticipants presented with AUDIT scores indicative of alcohol dependence, 5
(26%) indicative of harmful or hazardous behaviors, and 8 (42%) with low
risk. Chi-square tests revealed no differences between those who dropped
out and completers on PSS–SR, Pearson’s χ 2 (1, N = 24) = .505, p > .05;
BDI, Pearson’s χ 2 (1, N = 24) = 20.62, p > .05; or AUDIT, Pearson’s χ 2 (1,
N = 24) = 14.25, p > .05. Most participants reported knowing the per-
petrator (82%; i.e., friend, boyfriend, acquaintance), 1 reported weapon
use (4.3%), and 4 (17.4%) reported physical injury. Time since assault
ranged from 0.5 to 6 years. In regard to alcohol use, the participants varied
greatly in the number of drinks they endorsed for themselves (M = 2.71,
SD = 3.62) and their assailants (M = 3.63, SD = 3.92). Nine participants
(47%) reported no alcohol use and 6 (32%) indicated that their assailant
had no alcohol at the time of the assault. No participant reported seeking
psychotherapy for the assault.
 160 K. Sharma-Patel et al.

Relations between Criterion Variables at Time 2 and Time 5

To investigate time effects for completers, one-way within-subjects analy-
ses of variance (ANOVAs) were conducted with time of assessment as the
independent variable and PSS–SR, BDI, and AUDIT as dependent variables.
For PSS–SR total, there was not a significant time effect, F(1, 18) = .11,
p > .05. For BDI, there was a significant time effect, Wilks’s  = .77, F(1,
18) = 5.16, p < .05. The follow-up contrast indicated a significant linear
effect with means decreasing over time, partial η2 = .22 (Table 2). Eleven
(58%) participants reported an overall decrease in symptoms, of which 7
(37%) demonstrated a shift in severity level. For AUDIT, there was a signif-
icant time effect, Wilks’s  = .74, F(1, 18) = 5.28, p < .05. The follow-up
contrast indicated a significant linear effect with means decreasing over
time, partial η2 = .26 (Table 2). Ten participants (53%) reported a decrease
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in risky drinking behaviors, of which 4 demonstrated a shift in severity

level.

TABLE 2 Means and Standard Deviations for Criterion Variables

Time 2 Time 3 Time 4 Time 5

M SD M SD M SD M SD

Linguistic variables
Positive emotion words 3.51 1.22 3.79 1.11 3.62 1.16 —
Negative emotion words 2.70 1.45 2.88 1.13 3.08 1.44 —
Causal words 1.92 0.76 2.20 1.15 1.96 0.77 —
Insight words 2.95 1.04 3.21 0.80 3.39 1.07 —
Undoing/discrepancy 1.97 0.86 2.13 0.98 2.07 0.84 —
words
Symptom severity variables
PSS–SR re-experiencing 1.11 1.29 — — 2.00 1.94
scores
PSS–SR avoidance scores 3.79 3.43 — — 4.42 3.55
PSS–SR arousal scores 4.89 3.84 — — 3.89 3.59
PSS–SR total scores 9.79 7.64 — — 10.32 7.58
BDI total scores 12.63 10.83 — — 9.89 9.21
AUDIT total scores 9.21 6.49 — — 7.21 5.42
PBRS variables
Safety 5.31 0.95 — — 5.32 1.17
Trust 5.13 1.03 — — 5.29 1.23
Power 4.67 0.88 — — 5.07 0.89
Esteem 5.42 0.84 — — 5.53 1.00
Intimacy 5.09 0.82 — — 4.95 1.01
Note. N = 19. Linguistic variables derived from narrative task. PSS–SR = PTSD Symptoms Scale-
Self Report; BDI = Beck Depression Inventory; AUDIT = Alcohol Use Disorders Identification Test;
PBRS = Personal Beliefs and Reactions Scale.
 Emotional and Cognitive Processing 161

Relations of Linguistic Emotional Processing Variables within

and across Time Points
The second hypothesis stated that negative emotions words would initially
increase within-sessions and then decrease at subsequent sessions (i.e.,
quadratic effect) and positive emotion words would increase across sessions.
For completers, one-way within-subjects ANOVAs were conducted with time
of assessment as the independent variable and negative and positive emo-
tions as dependent variables, with follow-up polynomial contrasts selected
to examine nonlinear effects. For negative emotion words, there was not
a significant time effect, Wilks’s  = .91, F(1, 18) = .81, p > .05. There
was no significant increase in positive emotion words, Wilks’s  = .95, F(1,
18) = .46, p > .05.
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Relations of Self-Reported SUDS across and within Time Points

The second hypothesis also stated that self-reported subjective units of dis-
tress would indicate an initial increase of emotional reactivity at Time 2 with
a decrease over subsequent writing sessions (Time 3 and 4). Multilevel
(hierarchical) linear modeling (MLM) was utilized to test significant relations
between SUDS ratings within writing task intervals (prewriting task, 5 min-
utes, 10 minutes, 15 minutes, 20 minutes) and across times of assessment
(Time 2–5). Although the sample size was small, the number of measure-
ments within and across time lends support for the use of MLM (does not
require independence of error, allows for evaluation of individual differences
in growth curves as well as group differences and missing data; Tabachnik &
Fidell, 2005). Lastly, Tabachnik and Fidell cautioned against including many
predictors, particularly for small samples. Therefore, the models tested in
MLM did not include covariates (e.g., assault characteristics). Dunmore et al.
(2001) lent empirical support for this decision as they found that none of
the assault characteristics (e.g., relationship to perpetrator, time since assault,
weapon use, extent of injury) were correlated with PTSD at three assessment
time points.
A two-level hierarchical model assessed the effects of time of assess-
ment and within writing task time intervals on SUDS anxiety ratings.
First-level units were the within time writing intervals in which the par-
ticipants responded with current level of anxiety SUDS ratings. Second-level
units were the participants and time intervals between the writing tasks.
To examine the relations among the levels, two hierarchical models were
conducted with a linear term first (Model 2), followed by a model including
both a linear and quadratic terms (Model 3) so that incremental changes
in SUDS ratings could be examined. Data on the 19 participants consisted
of 285 data points; additional data were included for 2 participants who
dropped out and for whom no SUDS ratings were missing. See Figure 1 for
 162 K. Sharma-Patel et al.

Participant 1 Participant 3
10 10
Time 2 (M = 3.8) Time 2 (M = 4.8)
9 9
Time 3 (M = 7.4) Time 3 (M = 0.8)
8 Time 4 (M = 1) 8 Time 4 (M = 0)

7 7

SUDS Rating
SUDS Rating

6 6
5 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 1 2 3 4 5
Writing Time Intervals Writing Time Intervals
Participant 10 Participant 13
10 10
Time 2 (M = 1.0) Time 2 (M = 6.4)
9 9
Time 3 (M = 0.8) Time 3 (M = 3.0)
8 Time 4 (M = 1.2) 8 Time 4 (M = 1.8)
7 7
SUDS Rating

SUDS Rating
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6 6
5 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 1 2 3 4 5
Writing Time Intervals Writing Time Intervals
Participant 8 Participant 17
10 10
Time 2 (M = 4.6)
9 9
Time 3 (M = 3.2)
8 8 Time 4 (M = 2.4)
7 7
SUDS Rating

SUDS Rating

6 6
5 5
4 4
3 3
Time 2 (M = 8.2)
2 2
Time 3 (M = 6.8)
1 Time 4 (M = 4.4)
1
0 0
1 2 3 4 5 1 2 3 4 5
Writing Time Intervals Writing Time Intervals

FIGURE 1 Selected participants SUDS ratings across times and within writing time intervals
(color figure available online).

selected individual SUDS rating across times of assessment and within writ-
ing time intervals for 19 participants who completed the study and Figure 2
for an aggregate of all participants across time.

LINEAR MODEL
The first model (Model 2) assessed the effects of time of assessment, within
writing task time intervals, and Time × Within Writing Task interaction (fixed
factors) on SUDS ratings. The baseline intercept-only model (Model 1) was
significant, F(1, 20) = 53.28, p < .001. For Model 2, the average slope
for the time of assessment was significant when all other predictors were
taken into account. On average, participants reported initial SUDS of 3.02,
 Emotional and Cognitive Processing 163

Aggregate of 19 Participants
10
Time 2 (M = 3.0)
9
Time 3 (M = 1.0)
8 Time 4 (M = 2.0)

SUDS Rating
6
5
4
3
2
1
0
1 2 3 4 5
Writing Time Intervals
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FIGURE 2 Aggregate of 19 Participants (color figure available online).

F(1, 23) = 33.84, p < .001, and, at each subsequent time of assessment,
the initial reported SUDS decreased by .60, F(1, 38) = 7.19, p < .05. The
linear effect of within writing task intervals also was significant, indicating
that participants reported a significant increase in SUDS as they wrote about
their sexual assault experiences, F(1, 30) = 9.29, p < .01. The interaction
effect of writing task interval by time of assessment was not significant, F(1,
235) = 1.80, p > .05. Model 2 was a significantly better fit than the baseline
intercept only (Model 1), χ 2 (5, N = 285) = 125.29, p < .001.

CURVILINEAR MODEL
To test the hypothesis that participants’ reported SUDS ratings would
decrease within session after the initial increase (i.e., quadratic effect), time-
within-writing task was recoded in two variables: (a) the midpoint of the
writing task intervals was centered as the mean, and (b) a product term
of the centered midpoint squared. Model 3 was conducted with centered
time within writing task (Level 1), time of assessment (Level 2), and prod-
uct term (Level 3) as fixed variables as predictors of SUDS ratings as the
dependent variable. The average slope and time of assessment remained
significant, F(1, 23) = 77.56, p < .001, and F(1, 18) = 19.27, p < .001.
The effect of the writing task intervals (Level 1) also remained significant,
indicating an increase in SUDS ratings at the midpoint of the writing ses-
sions, F(1, 251) = 34.04, p < .001. The quadratic term was significant, F(1,
251) = 8.47, p < .01. The residual also was statistically significant, indicating
that the model can be improved. Model 3 was a better fit than the baseline
model, χ 2 (4, N = 285) = 80.942, p < .001. Model 2 (linear) was a bet-
ter fit than Model 3 with the smaller –2 Log Likelhood value (1127.553 vs.
1171.900).
 164 K. Sharma-Patel et al.

Relations of Cognitive Processing Variables across Time Points

The third hypothesis was that coping would increase across sessions.
There were no significant increases in causal words, Wilks’s  = .95, F(1,
18) = .42, p > .05; or insight words, Wilks’s  = .88, F(1, 18) = 1.11,
p > .05; and no significant decrease in undoing words, Wilks’s  = .96,
F(1, 18) = .34, p > .05. Regarding beliefs related to safety, trust, power,
esteem, and intimacy, there were no significant differences for safety, Wilks’s
 = .99, F(1, 18) = .02, p > .05; trust, Wilks’s  = .99, F(1, 18) = .08,
p > .05; esteem, Wilks’s  = .98, F(1, 18) = .32, p > .05; or intimacy,
Wilks’s  = .77, F(1, 18) = .77, p > .05. For power, there was a significant
effect for time, Wilks’s  = .74, F(1, 18) = 6.21, p < .05, indicating an
increase in adaptive beliefs about power.
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DISCUSSION

The first goal of this study was to examine whether writing about sexual
assault at repeated time points would result in reductions in PTSD, depresso-
genic symptoms, and risky alcohol use behaviors. Consistent with previous
studies (e.g., Sloan & Marx, 2004a), participants who wrote about traumatic
experiences evidenced statistically significant reductions in symptoms of
depression. Not previously examined, statistically significant reductions in
alcohol use also were evidenced. No previous study has included alcohol
use as an outcome in examinations of the written narrative tasks. Contrary to
previous studies (e.g., Sloan et al., 2005), improvements in PTSD symptoms
were not observed, most likely due to low levels of PTSD symptomatology
at initial assessment or insufficient power. In explaining their similar findings
with participants diagnosed with PTSD, Smyth et al. (2008) suggested that
high-risk groups might require additional components (e.g., skills training)
to benefit from the writing task.
This study also examined patterns of emotional processing over the
course of writing about sexual assault, predicting that SUDS anxiety would
decrease across time subsequent to an initial increase “peak” during the first
assessment. This hypothesis was partially supported, with the mixed linear
model regressions revealing several important findings. One, participants’
first SUDS rating significantly decreased at each subsequent assessment.
This finding suggests that participants perceived significantly less stress as
they repeatedly wrote about their sexual assault experiences. Two, partici-
pants reported an increase in SUDS anxiety as they engaged in the narrative
task irrespective of the time of assessment (e.g., first vs. second vs. third
session). Although this finding was not initially predicted, it provides addi-
tional evidence for Foa’s emotional processing theory (Foa, Steketee, &
Rothbaum, 1989) as it reflects the activation of the affect associated with
the traumatic content, a critical processing component. Three, across writing
 Emotional and Cognitive Processing 165

sessions, initial within-sessions increases in SUDS anxiety were followed

by decreases from the midpoint onward. These findings suggest the “emo-
tional engagement” process across sessions and reflect the habituation effect
(i.e., reduction of the fear associated with the trauma; Foa & Chambless,
1978; Grayson, Foa & Steketee, 1982). Moreover, these results are con-
sistent with other studies (Sloan & Epstein, 2005) that reported increased
reactivity during the writing task and subsequent reductions in depressive
symptoms. Although the small sample size precluded the direct examination
of SUDS in relation to symptom reduction, the results collectively provide
the foundation for future longitudinal exploratory investigations.
Expected cognitive processing was not evidenced in linguistic or quan-
titative analyses. This finding is inconsistent with previous research that has
linked symptom reduction to decreases in linguistic variables measuring cog-
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nitive distortions (Alvarez-Conrad et al., 2001; Klein & Boals, 2001). Most
likely, the sample size might have been too small to detect significant but
modest changes in cognitions. Alternatively, the writing task might not have
provided adequate time to facilitate the correction of dysfunctional cogni-
tions. In cognitive therapies, clients are taught to identify, self-monitor, and
challenge their assumptions through Socratic questioning and more adaptive
beliefs are generated and practiced. The writing task might be adequate only
for monitoring; the instructions might need to be tailored to elicit challenging
of the distortions (e.g., Kallay, Vaida, Borla & Opre, 2008).
There were several limitations of this study. Methodologically, despite
remuneration, recruitment was a significant barrier, with lower than antic-
ipated participation as compared to previous comparable studies (e.g.,
Sloan & Marx, 2004a). Although preliminary analyses on coping and sex-
ual assault severity did not yield significant differences between those who
did and did not participate in the second phase (Sharma-Patel, 2010), there
might have been significant differences on unmeasured constructs. Second,
the majority of analyses were conducted with only 19 participants; thus, all
quantitative analyses should be viewed with caution. Third, the study took
place over a one-month time span. The findings observed could represent
acute trends that dissipate over a longer period. Fourth, given the small
volunteer sample, the participants recruited for this study might have been
more open to exploring their sexual assault experiences. Also, despite the
supporting evidence from efficacy trials, the inclusion of a control condition
could have elucidated the effects of writing about sexual assault compared
to neutral events or other traumatic experiences.
In spite of limitations, there are a number of research and clinical
implications. This study is the first short-term longitudinal investigation of
the written narrative task on sexual assault utilizing multiple assessment
methods of the assault experience (subjective writing task, standard mea-
sure of assault-related cognitions) and inclusion of emotional and cognitive
processing measures (linguistic, self-report within and across times). The
 166 K. Sharma-Patel et al.

use of psychometrically robust measures and sophisticated analyses also

are strengths. To our knowledge, it is the first study to investigate within-
and between-session effects and corroborate the use of a relatively simple
method of assessing “emotional activation” via self-report. The exploratory
findings demonstrating emotional activation as the “active” component or the
mechanism of change for the writing task, similar to PE and CBT-established
treatments for trauma, adds empirical backing to employing brief alterna-
tives to traditional therapies. These findings could also imply that emotional
arousal might be necessary but not sufficient in facilitating improvements
across outcomes (symptoms, cognitions). Investigators also should exam-
ine whether manipulations of the writing task components (instructions,
length of writing time, dose) can improve sexual-assault-related cognitions.
Mediators and moderators of change should also be further explored.
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Clinically, this study demonstrated the utility of writing about sexual

assault experiences for populations that present with a moderate level of
depressive symptoms but do not present for treatment (Soliday, Garofalo, &
Rogers, 2004), as none of the current participants had sought treatment.
The written narrative task is “transportable,” as it can be executed on the
Internet or at home. For instance, the written narrative task could be an
effective, safe, and cost-efficient intervention (Smyth et al., 2008) for young
adolescents who might not disclose sexual assault experiences. Additionally,
given that 50% of college students’ sexual assaults were associated with par-
ticipant alcohol use, assailant alcohol use, or both, and the reductions in
harmful behaviors subsequent to the writing task, future research is war-
ranted to further explain the clinical implications. In sum, understanding the
complexity of reactions to sexual assault and alternative “treatments” that
can reduce negative sequelae could better direct innovative interventions
and overcome barriers to service access and delivery. Future research with
larger samples and follow-ups can examine the duration of obtained effects.

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