Schreibtherapie nach traumatischen Belastungen: Therapieansätze und Wirkmechanismen

Zusammenfassung

Das (schriftliche) Mitteilen von Informationen, Gedanken und Gefühlen zu persönlich relevanten Themen wird mit positiven Auswirkungen auf das Wohlbefinden und die psychische Gesundheit assoziiert. Anwendungsmöglichkeiten des expressiven Schreibens als psychotherapeutische Intervention bei Belastungsfolgen durch belastende/traumatische Lebensereignisse wurden auch im klinischen Kontext intensiv diskutiert. Strukturelle und inhaltliche Variationen des ursprünglich von Pennebaker entwickelten Schreibparadigmas zeigen jedoch sehr unterschiedliche Effekte hinsichtlich allgemeiner psychischer Gesundheitsparameter und der posttraumatischen Belastungssymptomatik. Dieser Übersichtsartikel präsentiert aktuelle Befunde zu Einsatzmöglichkeiten und Wirksamkeit des expressiven Schreibens bzw. schreibtherapeutischen Ansätzen bei posttraumatischen Belastungsstörungen. Bisher diskutierte Wirkfaktoren (Inhibition, Habituation, Konstruktion eines kohärenten Narrativs, Emotionsregulation, soziale Integration) des expressiven Schreibens werden im Hinblick auf ihre Relevanz für die PTBS ausgewertet. Abschließend werden Anwendungsmöglichkeiten in der klinischen Behandlungspraxis diskutiert.

Abstract

The (written) disclosure of information, thoughts and emotions of individually significant tops is associated with positive effects on well-being and the psychological health. The applicability of expressive writing as a psychotherapeutic intervention for stress reactions after stressful/traumatic life events were also intensely discussed in the clinical context. However, structural and content-related variation of the initial writing paradigm resulted in significantly different effects on general psychological health and posttraumatic stress symptoms.

This overview provides current findings to application and efficacy of expressive writing respectively writing therapy for posttraumatic stress disorder. Mechanisms of expressive writing (inhibition, habituation, construction of a coherent narrative, emotion regulation, social integration) are analyzed with regard to their relevance concerning PTSD. Finally, potentials for application in the clinical practice are discussed.

Schlüsselwörter

expressives Schreiben - Schreibtherapie - Trauma - Selbstöffnung

Keywords

expressive writing - writing therapy - trauma - disclosure

• Literatur

• 1 Pennebaker JW, Beall SK. Confronting a traumatic event: Toward an understanding of inhibition and disease. J Abnorm Psychol 1986; 95: 274-281
• 2 Frattaroli J. Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin 2006; 132: 823-865
• 3 Saß H, Wittchen HU, Zaudig M Hrsg Diagnostisches und Statistisches Manual Psychischer Störungen. (DSM-IV-TR). Göttingen: Hogrefe; 2003
• 4 Dilling H, Mombour W, Schmidt MH Hrsg Internationale Klassifikation psychischer Störungen. ICD-10 Kapitel V (F). Klinisch-diagnostische Leitlinien. 5. Aufl. Bern: Huber; 2005
• 5 Van der Kolk BA, Fisler R. Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. J Trauma Stress 1995; 8: 505-525
• 6 Brewin CR, Dalgleish T, Joseph S. A dual representation theory of posttraumatic stress disorder. Psychol Rev 1996; 103: 670-686
• 7 Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000; 38: 319-345
• 8 McNally RJ. Remembering trauma. Cambridge, MA: Harvard University Press; 2003
• 9 Smyth J. Written emotional expression: Effect sizes, outcome types, and moderating variables. J Consult Clin Psychol 1998; 66: 174-184
• 10 Frisina PG, Borod JC, Lepore SJ. A Meta-Analysis of the Effects of Written Emotional Disclosure on the Health Outcomes of Clinical Populations. J Nerv Ment Dis 2004; 192: 629-634
• 11 Mogk C, Otte S, Reinhold-Hurley B. Health effects of expressive writing on stressful or traumatic experiences – a meta-analysis. Psychosoc Med 2006; 3 Doc06
• 12 Sloan DM, Marx BP, Bovin MJ et al. Written exposure as an interven­tion for PTSD: A randomized clinical trial with motor vehicle accident survivors. Behav Res Ther 2012; 50: 627-635
• 13 Lange A, van de Ven JP, Schrieken B et al. Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial. J Behav Ther Exp Psychiatry 2001; 32: 73-90
• 14 van Emmerik AAP, Kamphuis JH, Emmelkamp PMG. Treating Acute Stress Disorder and Posttraumatic Stress Disorder with Cognitive Behavioral Therapy or Structured Writing Therapy: A Randomized Controlled Trial. Psychother Psychosom 2008; 77: 93-100
• 15 Lange A, Ruwaard J. Ethical dilemmas in online research and treatment of sexually abused adolescents. J Med Internet Res 2010; 12: e58
• 16 Knaevelsrud C, Maercker A. Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry 2007; 7: 13
• 17 Lange A, Rietdijk D, Hudcovicova M et al. Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J ConsultClin Psychol 2003; 71: 901-909
• 18 Knaevelsrud C, Böttche M, Freyberger HJ et al. Integrative Testimonial Therapy (ITT) – a therapist-assisted internet-based writing therapy for traumatized child survivors of the 2^nd World War with posttraumatic stress. [submitted]
• 19 van Emmerik AAP, Reijntjes A, Kamphuis JH. Writing Therapy for Posttraumatic Stress: A Meta-Analysis. Psychother Psychosom 2013; 82: 82-88
• 20 Sloan DM, Marx BP. Taking Pen to Hand: Evaluating Theories Underlying the Written Disclosure Paradigm. Clin Psychol Sci Prac 2006; 11: 121-137
• 21 Greenberg MA, Stone AA. Emotional disclosure about traumas and its relation to health: Effects of previous disclosure and trauma severity. J Pers So Psychol 1992; 63: 75-84
• 22 Foa EB, Steketee G, Rothbaum B. Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy 1989; 20: 155-176
• 23 Mayou RA, Ehlers A, Bryant B. Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study. Behav Res Ther 2002; 40: 665-675
• 24 Michael T, Ehlers A, Halligan SL. Enhanced priming for trauma-related material in posttraumatic stress disorder. Emotion 2005; 5: 103-112
• 25 Foa EB, Kozak MJ. Emotional processing of fear: Exposure to corrective information. Psychol Bull 1986; 99: 20-35
• 26 Bradley R, Greene J, Russ E et al. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 2005; 162: 214-227
• 27 Sloan DM, Marx BP. A closer examination of the written disclosure paradigm. J Consult ClinPsychol 2004; 72: 165-175
• 28 Sloan DM, Marx BP, Epstein EM. Further examination of the exposure model underlying written emotional disclosure. J Consult Clin Psychol 2005; 73: 549-554
• 29 Sloan DM, Marx BP, Epstein EM et al. Does altering the instructional set affect written disclosure outcome?. Behavior Therapy 2007; 38: 155-168
• 30 Smyth JM, Hockemeyer JR, Tulloch H. Expressive writing and post-traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity. Br J Health Psychol 2008; 13: 85-93
• 31 Batten SV, Follette VM, Rasmussen Hall ML et al. Physical and psychological effects of written disclosure among sexual abuse survivors. Behavior Therapy 2002; 33: 107-122
• 32 Gidron Y, Peri T, Connolly JF et al. Written emotional disclosure in posttraumatic stress disorder: Is it beneficial for the patient?. J Nerv Ment Dis. 1996. 184. 505-507
• 33 Brown EJ, Heimberg RG. Effects of writing about rape: Evaluating Pennebaker’s paradigm with a severe trauma. J Trauma Stress 2001; 14: 781-790
• 34 Schoutrop MJA, Lange A, Hanewald G et al. The effects of structured writing assignments on overcoming major stressful events: An uncontrolled study. Clin Psychol Psychot 1997; 4: 179-185
• 35 Engelhard IM, Van den Hout MA, Kindt M et al. Peritraumatic dissociation and posttraumatic stress after pregnancy loss: A prospective study. Behav Res Ther 2003; 41: 67-78
• 36 Halligan SL, Michael T, Clark DM et al. Posttraumatic stress disorder following assault: the role of cognitive processing, trauma memory, and appraisals. J Consult Clin Psychol 2003; 71: 419-431
• 37 Lyttle N, Dorahy HD, Huntjens RJC. Conceptual and Perceptual Priming and Dissociation in Chronic Posttraumatic Stress Disorder. J Abnorm Psychol 2010; 119: 777-790
• 38 Koriat A, Goldsmith M, Pansky A. Toward a psychology of memory accuracy. Annu Rev Psychol 2000; 51: 481-538
• 39 Pennebaker JW. Writing about emotional experiences as a therapeutic process. Psychol Sci 1997; 8: 162-166
• 40 Smyth JM, True N, Souto J. Effects of writing about traumatic experiences: The necessity for narrative structuring. J Soc Clin Psychol 2001; 20: 161-172
• 41 Warner LJ, Lumley MA, Casey RJ et al. Health effects of written emo­tional disclosure in adolescents with asthma: a randomized, controlled trial. J Pediatr Psychol 2006; 31: 569-573
• 42 Park CL, Blumberg CJ. Disclosing trauma through writing: Testing the meaning-making hypothesis. Cognitive Ther Res 2002; 26: 597-616
• 43 Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav 2004; 26: 41-54
• 44 Bouton ME, Mineka S, Barlow DH. A modern learning theory perspective on the etiology of panic disorder. Psychol Rev 2001; 108: 4-32
• 45 Cloitre M, Miranda R, Stovall-McClough KC et al. Beyond PTSD: emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behav Ther 2005; 36: 119-124
• 46 Gratz KL, Bornovalova MA, Delany-Brumsey A et al. A laboratory-based study of the relationship between childhood abuse and experiential avoidance among inner-city substance users: the role of emotional nonacceptance. Behav Ther 2007; 38: 256-268
• 47 Badura AS. Theoretical and empirical exploration of the similarities between emotional numbing in posttraumatic stress disorder and alexithymia. J Anxiety Disorders 2003; 17: 349-360
• 48 Hyer L, Woods MG, Summers MN et al. Alexithymia among Vietnam veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry 1990; 51: 243-247
• 49 Monson CM, Price JL, Rodriguez BF et al. Emotional deficits in military-related PTSD: an investigation of content and process disturbances. Journal of Traumatic Stress 2004; 17: 275-279
• 50 Ehring T, Quack D. Emotion Regulation Difficulties in Trauma Survivors: The Role of Trauma Type and PTSD Symptom Severity. Behav Ther 2010; 41: 587-598
• 51 Tull MT, Barrett HM, McMillan ES et al. A Preliminary Investigation of the Relationship Between Emotion Regulation Difficulties and Posttraumatic Stress Symptoms. Behav Ther 2007; 38: 303-313
• 52 Lepore SJ, Greenberg MA, Bruno M et al. Expressive writing and health: Self regulation of emotion related experience, physiology, and behavior. In: Lepore SJ, Smyth J. (eds.). The Writing Cure. Washington, DC: American Psychological Association; 2002: 99-117
• 53 Baikie KA, McIlwain D. Who does expressive writing work for? Examination of alexithymia, splitting, and repressive coping style as moderators of the expressive writing paradigm. Brit J Health Psych 2008; 13: 61-66
• 54 Lumley MA. Alexithymia, emotional disclosure, and health: a program of research. J Pers 2004; 72: 1271-1300
• 55 Lumley MA, Tojek TM, Macklem DJ. The effects of written emotional disclosure among repressive and alexithymia people. In: Lepore SJ, Smyth JM. (eds.). The writing cure: How expressive writing promotes health and emotional well-being. Washington, DC: American Psychological Association; 2002: 75-95
• 56 Pennebaker JW, Chung CK. Expressive writing, emotional upheavals, and health. In: Friedman HS, Silver RC. (eds.). Foundations of health psychology. New York: Oxford University; 2007: 263-284
• 57 Niedtfeld I, Schmidt AF, Scholz OB. Wie wirkt Expressives Schreiben? Differenzielle Wirkfaktoren des Schreibens über belastende Lebensereignisse. Verhaltenstherapie 2008; 18: 91-99
• 58 Brewin CR, Andrew B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in traumaexposed adults. J Consult Clin Psych 2000; 68: 748-766
• 59 Horn AB, Mehl MR. Expressives schreiben als Copingtechnik: ein Überblick über den Stand der Forschung. Verhaltenstherapie 2004; 14: 274-283
• 60 Pennebaker JW, Graybeal A. Patterns of natural language use: Disclosure, personality, and social integration. Curr Dir Psychol Sci 2001; 10: 90-93
• 61 Kim Y. Effects of expressive writing among bilinguals: Exploring psychological well-being and social behaviour. Brit J Health Psych 2008; 13: 43-47
• 62 Maercker A, Muller J. Social acknowledgment as a victim or survivor: A scale to measure a recovery factor of PTSD. J Trauma Stress 2004; 17: 345-351
• 63 Cienfuegos J, Monelli C. The testimony of political repression as a therapeutic instrument. Am J Orthopsychiat 1983; 53: 43-51
• 64 Schoutrop MJA, Lange A, Hanewald G et al. Structured writing and processing major stressful events: A controlled trial. Psychother Psychosom 2002; 71: 151-157
• 65 Radcliffe AM, Lumley MA, Kendall J et al. Written Emotional Disclosure: Testing Whether Social Disclosure Matters. J Soc Clin Psychol 2007; 26: 362-384
• 66 Schoutrop MJA. Structured writing in processing traumatic events [Dissertation]. Amsterdam: University of Amsterdam; 2000
• 67 Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psych 2000; 68: 438-450
• 68 Wagner B, Brand J, Schulz W et al. Online Working Alliance predicts Posttraumatic Stress Disorder in War-Traumatized Patients in the Middle East. Depress Anxiety 2012;
• 69 Knaevelsrud C, Maercker A. Does the quality of the working alliance predict treatment outcome in online therapy for trauma patients?. J Med Internet Res 2006; 8: e31
• 70 Knaevelsrud C, Maercker A. Long-Term Effects of an Internet-Based Treatment for Posttraumatic Stress. Cogn Behav Ther 2010; 39: 72-77
• 71 Resick PA, Williams LF, Suvak MK et al. Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. J J Consult Clin Psych 2012; 80: 201-210
• 72 Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims: A treatment manual. Newbury Park CA: Sage Publications; 1993
• 73 Schauer M, Neuner F, Elbert T. Narrative Exposure Therapy. A short-term intervention for traumatic stress disorder after war, terror or torture. Göttingen: Hogrefe & Huber; 2005