Journal of Early Intervention - ed

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Journal of Early Intervention

DOI: 10.1177/105381510102400404 2001; 24; 287 Journal of Early Intervention

Leasha M. Barry and George H.S. Singer Journal Writing

Reducing Maternal Psychological Distress After the NICU Experience Through

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287

Reducing Maternal Psychological DistressAfter the NICU Experience ThroughJournal Writing

LEASHA M. BARRY & GEORGE H. S. SINGERUniversity of West Florida

Parents of infants served in Neonatal Intensive Care Units (NICU) often experience extremelevels of stress that might be associated with elevated symptoms of depression andposttraumatic stress. We examined the effect of a brief journal writing exercise on thedepressive and posttraumatic stress symptoms of mothers of NICU graduates using anexperimental group-comparison design. Participants were 38 women who had an infanthospitalized in an NICU in the previous 2 to 14 months. Dependent measures were a measureof depression, the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1977) and a measureof posttraumatic stress, the Impact of Events Scale Revised (IES-R; Weiss, 1996). We foundstatistically significant differences between the treatment and control groups at posttest.

Admission to the Neonatal Intensive CareUnit (NICU) is an increasingly common path-way to early intervention services for childrenand their families (Guralnick, 2000; McNab,1998). Many early intervention programs thatfollow a NICU hospitalization have incorpo-rated family-centered approaches for provid-ing services (Dunst, Johanson, Trivette, &

Hamby, 1991; Malone, 2000). Programs usinga family-centered approach might offer ser-

vices such as access to information, parent ed-ucation, and parent training (Dunst et al.,1991; Malone, 2000). Primary topics of pa-rental education and training programs afterthe NICU are promotion of responsive inter-action between parents and infants and care-

giving skills of parents (Mahoney, 1999; Nur-combe, 1984; Spiker, Furguson, & Brooks-

Gunn, 1993). Typically, individuals trained inearly child development provide these servic-es through brief home visits (Powell, 1993).

Family-centered care in medical treatmentand early intervention in hospital settings areimportant and contribute to improved out-

comes for NICU graduates (Als et al., 1994;Hostler, 1994). These services, however, often

fail to address a major component of the larg-er social issue of family-centered care. Mostearly intervention programs do not address thepotential psychological distress parents of in-fants hospitalized in the NICU experience andthe long-term effects of that distress on familyand child outcomes (Benfield, Leib, & Reuter,1976).The NICU experience leads some mothers

to an emotional crisis that exceeds symptomsof postpartum depression mothers of normalterm or birth weight babies experience (Doer-ing, Moser, & Dracup, 1999; Oehler, Hannan,& Catlett, 1993; Thompson, Oehler, Catlett, &

Johndrow, 1993). Normal postpartum depres-sion occurs in 6% to 13% of childbearingwomen (O’Hara & Swain, 1996; Stuart &

O’Hara, 1993). Low birth weight (LBW) istypically categorized by weight into three cat-egories : LBW (< 2,500 grams), very low

birth weight (VLBW; < 1,500 grams), and ex-tremely low birth weight (ELBW; < 1,000grams). Thompson et al. (1993) reported de-pression rates ranging from 33% to 48% inmothers of VLBW infants, depending on thetime of measurement. For some parents, the




288

NICU experience is so intensely stressful thatthey suffer symptoms similar to individualswho experience posttraumatic stress disorder(PTSD; deMier, Hynan, Harris, & Manniello,1996; Hynan, 1987; Wilson, 1989).The Diagnostic and Statistical Manual of

Mental Disorders defines traumatic life eventsas &dquo;...witnessing an event that involves

death, injury, or threat to the physical integrityof another person; or learning about unex-pected or violent death, serious harm, or threatof death or injury experienced by a familymember...&dquo; (American Psychiatric Associa-tion, 1994, p. 424). Having an infant hospi-talized in an intensive care unit is, by defini-tion, a traumatic life event for parents.

Infants who survive the NICU are at ele-

vated risk for later complications (McNab,1998). One study (Hack et al., 1994) reportedthat 30% of VLBW infants and 12% of LBW

infants in their study were diagnosed withmental retardation at school age (IQ < 70).More than 70% of VLBW infants have med-ical complications associated with early birth(Landry, Chapieski, Richardson, Palmer, &

Hall, 1990). These later complications mightremind parents of the original NICU experi-ence, and it is likely that they add to the great-er anxiety and depressive symptoms someparents experience (Taylor, Klein, Minich, &

Hack, 2001 ).The risks that NICU graduates face are ex-

acerbated when their parents experience de-pression (Warner, 1995). Children raised byparents who experience major clinical depres-sion are at greater risk for experiencing majorclinical depression (Downey & Coyne, 1990;Warner, 1995; Wickramatratne & Weissman,1998), medical problems (McLennan, 2000),conduct disorder (Wickramatratne & Weiss-

man), and difficulty in learning (Kaplan,Bachorowski, & Zarlengo-Strouse, 1999).Parents who experience depression might failto practice disease prevention with theiryoung children and are less likely to use safe-ty precautions such as car seats (McLennan,2000). In addition, individuals who experiencedepression often suffer from memory loss

(Lauer, Giordani, Boivin, & Halle, 1994; Rei-

dy & Richards, 1997) and deficits in cognitive

ability (Austin, Ross, Murray, & O’Carroll,1992). Parents who experience depression aremore likely to have difficulty learning or re-calling information from parent training pro-vided through established early interventionprograms.

Families need an effective, theoreticallybased, psychological intervention, available

within the limited resources of follow-up andearly intervention programs. The largest ob-stacle for implementing early intervention ser-vices is cost (Beckman, 1996). Effective im-

plementation of an intervention requires thatthe intervention be inexpensive and cost ef-fective. In addition, a brief intervention is

needed as it becomes increasingly difficult toprovide long-term psychological therapy be-cause of the limits in insurance policies. Abrief intervention would also benefit mothers

of infants because mothers are often so pre-

occupied with their baby’s health that little

time remains for their own personal well be-ing (Miles, Carlson, & Funk, 1996).James Pennebaker (1985) developed a the-

ory of inhibition that relates confiding trau-matic events to health outcomes. The basic

premise of the theory is that failing to confideor share traumatic personal experiences is a

type of inhibition (Pennebaker, 1988; Penne-baker & Beall, 1986). Individuals who fail toshare traumatic events must restrain them-

selves from sharing their thoughts and feel-ings (Pennebaker, 1988; Pennebaker &

O’Heeron, 1984). This effort expended for re-stricting communication requires physiologi-cal work, which has short-term and long-termhealth outcomes (Pennebaker, 1988; Penne-baker & Beall, 1986).

Pennebaker (1988) proposed that traumaticevents that are highly emotionally charged orassociated with feelings of guilt are more like-ly to be inhibited. People might avoid sharingthese kinds of experiences with others. TheNICU falls into this category of experiencesthat are unlikely to be shared. Mothers typi-cally describe the NICU as highly emotionallycharged. Many mothers express feelings of

guilt over what has happened to their infant,and some parents describe the pain of losingtheir &dquo;ideal&dquo; child (Affleck, Tennen, & Rowe,




289

1991). Mothers who experience the NICU re-port social isolation, disconnection from fam-

ily and community, and a reluctance to talkabout the experience (Lindsay et al., 1993).Feeling social isolation, guilt, and believingthat others do not understand makes it unlike-

ly that these mothers have the opportunity todisclose their experience.

Researchers have found both health and

psychological benefits from journal writing incollege students (Donnelly & Murray, 1991;Pennebaker, Kiecolt-Glaser, & Glaser, 1988;Smyth, 1998). In Pennebaker’s research,health benefits were found when college stu-dents were required to either write or talk

about a previously experienced traumaticevent for a few minutes at a time over several

days (Pennebaker, 1988; Pennebaker et al.,1988). In this research, participants were nottalking or writing to anyone in particular.They wrote in confidential journals or spokeinto an audio recorder in privacy. This re-

search indicates that the cognitive and healthbenefits of confiding are attainable for indi-viduals without the social interaction assumed

necessary in traditional therapy.Other researchers have established psycho-

logical benefits of writing about personal ex-periences (Donnelly & Murray, 1991; Smyth,1998). Smyth completed a meta-analysis ofnine studies using a writing intervention thatalso considered psychological measures.

Smyth reported an effect size of d = 0.66.

Other researchers compared journal writing toone-on-one therapy and found equivalent self-reported benefits when the two groups receiv-ing treatment were compared (Donnelly &

Murray, 1991). The process of changing in-formation into a written or oral form mightprovide temporal organization, increased un-derstanding, and sequencing of thoughts andfeelings (Pennebaker & Francis, 1996). Jour-nal writing about traumatic life events has alsobeen associated with decreased intrusive

thoughts of the event, decreased physicalstress, and decreased long-term stress-relatedillness (Pennebaker, 1988; Pennebaker &

Beall, 1986).It is unknown for whom and in what situ-

ations journal writing might be warranted. The

preponderance of research thus far has fo-cused on participants with no particular selec-tion criteria. These studies imply that journalwriting might be beneficial to anyone who ex-periences traumatic life events, particularly forthose who have not disclosed the event pre-

viously. The present study aims to further thisresearch by applying journal writing to a par-ticular homogenous group selected for a par-ticular traumatic experience.

Writing about traumatic experiences mightbe accomplished at minimal financial cost.

Journal writing about the NICU experiencecould be administered with little effort as partof discharge planning, in early interventionprograms, or in follow-up clinics. To addressthe need for a theoretically-based, psycholog-ical intervention in early intervention that canbe implemented within the limitations of theseprograms, this study evaluated the effects ofa brief journal writing intervention on the psy-chological distress experienced by mothers ofinfants previously hospitalized in an NICU.

METHOD

ParticipantsThirty-eight women participated in the study.To participate in the study, participants (a) hadto be mothers of infants who were hospital-ized in an NICU for at least one week in the

past 14 months, (b) had self-reported that theywere able to express their thoughts in writtenEnglish, (c) had to be over 18 years of age,and (d) indicated they were not attendingcounseling or psychotherapy. Three hundrednotification letters were sent to women who

met the above criteria 2 to 14 months postdischarge. Sixty-four women (21 %) returnedpostcards indicating interest in the study. Thir-ty-eight women or 59% of those interestedcompleted the protocol within the given timeframe. Participants received a $25 stipend pro-rated in three payments.

Setting and MaterialsParticipants completed dependent measuresand wrote in journals at the location of theirchoice. Participants received and returned allcorrespondence through the U.S. postal ser-




290

vice. Envelopes and postage were provided toparticipants. Journals were 4 X 6 inch hard-cover bound books with lined pages.

Design ..

The design was an experimental 2 X 2 X 2analysis; two groups (between: treatment andwaiting list control) measured at two times

(within: pretest and posttest) using two depen-dent measures. The treatment and waiting listor control groups were randomly assigned andcomprised of 19 participants each. Measureswhere administered prior to intervention (pre-test) and 4 weeks after intervention (posttest)for both groups. The dependent measures, de-scribed in the next section, were the SymptomCheck List 90 Revised (SCL-90-R) and theImpact of Events Scale Revised (IES-R).These measures assess psychological distressand symptoms of posttraumatic stress disor-der, respectively.

Measures

Symptom Check List-90-R (SCL-90-R). The

Symptom Check List-90-R (Derogatis, 1977)is a 90-item self-report measure of psycholog-ical distress symptoms. Participants report thedegree to which they have experienced eachsymptom over the previous 7 days. The Glob-al Symptom Index of the scale was used inthis study because it has been successful in

the past in measuring psychological symp-toms of mothers who have had infants hos-

pitalized in a NICU (Meyer et al., 1995; Oeh-ler et al., 1993; Thompson et al., 1993). Pre-vious studies have established a clinical cutoff

score as one or more of the following; a Glob-al Symptom Index t score greater than 62 orany two subscales having a t score greaterthan 62.

Impact of Events Scale-Revised (IES-R).The IES-R (Weiss, 1996) is a brief self-reportof intrusion, avoidance, and hyper-arousal,which are symptoms of traumatic stress. TheIES-R targets levels of symptoms in the past7 days. Responses are scored on a 4-pointscale with anchors ranging from 1 (not at all)to 4 (often). The IES-R has successfully mea-sured changes in the trauma response over

time ranging from 1 week (Manuel & Ander-I

son, 1993) to 18 months follow-up (Sugden,1998).The scale is designed to measure three

broad domains of response to trauma. Intru-

sion is the reoccurrence of memories of or

memories related to the trauma. Avoidance is

numbness in the absence of thoughts or feel-ings about the traumatic experience or numb-ness with the intention to not have any

thought or feeling about the traumatic expe-rience. Hyper-arousal consists of the physio-logical states associated with the trauma re-

sponse, including lack of sleep, difficulty con-centrating, anger, and more. The scale has

been used widely in populations experiencingposttraumatic stress disorder including survi-vors of combat, rape, and natural disasters

(Keane, Fairbank, Caddell, Zimering, &

Bender, 1985). It has also been successful in

discriminating between groups of trauma vic-tims and no trauma victims (Leskin, Kalou-

pek, & Keane, 1998).

ProcedureTwo hospitals in the southwestern United

States equipped with Level 3 neonatal inten-sive care units participated in this study. Eachhospital served approximately 300 infants an-nually. Staff at the two participating hospitalssent a letter to 300 mothers who spoke En-glish, were over 18 years of age, and who hadan infant hospitalized in the NICU for at leastone week in the previous 2 to 14 months. Theletter briefly described the purpose of the

study and asked interested mothers to returna provided postcard to the hospital. These re-turned postcards formed a contact list that wasthen given to the experimenters. Experiment-ers called the mothers on the contact list to

explain the study and sent out the pretests, aninformed consent form, and a demographicquestionnaire. Those who wished to partici-pate were asked to return the completed formsin a provided stamped envelope.Upon receiving the completed pretests, the

participants were rank ordered and matched inpairs by their level of psychological distressas indicated by their score on the SCL-90-R.Participants in each matched pair were thenrandomly assigned to either the waiting list or




291

to the treatment group using a coin toss. Thetreatment group received written instructionsand a numbered journal. The control groupwas sent a letter of their control group status.In addition, all participants received a tele-phone call to explain the study and answerany questions. Four weeks after the journalswere returned, posttests were sent to all par-ticipants.

Written instructions. All participants in thestudy received the following written instruc-tions :

This study requires that you write in this jour-nal for at least thirty-minutes a day on four-days in a row. You may write for at least thir-ty-minutes at any time during each day that iseasy for you. Try to write while you are alone,in a quiet and relaxed place. During each ofthe four writing days, we want you to writeabout the most emotional and upsetting expe-riences of the NICU. These experiences mayinclude any experience or event beginningwith your pregnancy until the present day. Youmay write on different experiences each day orthe same experience on every day. Tell us yourstory. Questions to help you start writing:l. What were the most emotional or troubling

experiences during your infants [sic] stay atthe NICU? Describe what these experienceswere and write about your deepest thoughtsand feelings about those experiences in

great detail.2. What happened exactly and in what order?3. When and where did the experience take

place?4. Who was there?5. How did you feel then, at the time of the

experience?6. How do you feel now about the experience?7. Why do you believe the experience hap-

pened ?8. Have you learned anything as a result of the

experience? If so, what have you learnedfrom the experience?

9. Has the experience helped you in any way?If so, how has it helped you?

AnalysisEquivalence of comparison groups at pretest.One-way ANOVA was used to establish theequivalence of the two groups at pretest foreach dependent measure. T-test comparisonswere computed to establish equivalence of thetwo groups on demographic variables.Main analysis. A MANCOVA of the glob-

al scales of each measure at posttest with

group as a fixed variable and pretest as a co-variate was performed. Effect sizes were usedin addition to traditional probability statistics.The d coefficient is an index of the standard-ized difference of means between groups at

posttest (Thompson, 1999).Clinical significance. To demonstrate the

clinical significance of the treatment effect,the treatment group and the control groupwere analyzed by using the proportions ofthose experiencing clinical symptom levels ofpsychological distress at pretest to those ex-periencing clinical symptom levels of psycho-logical distress at posttest as indicated byscores on the SCL-90-R. In addition to this

comparison, the individual participant scoreson the pretest and posttest of the SCL-90-Rwere then displayed using a scatterplot to il-lustrate the reduction of symptom levels forindividual participants in each comparisongroup.

RESULTS

Demographic InformationDemographic information is summarized in

Table 1. Equivalence of the two groups on de-mographic variables was established using in-dependent sample t-tests. No statistically sig-nificant differences in demographic variableswere found between the two groups at a p <

.05 level.

Equivalence of Comparison Groups AtPretestThe design of this study employed random as-signment to treatment and control groupsbased on matched pairs at pretest. A one-wayANOVA of pretest scores yielded an F (1, 37)= .331, p = .569. This statistically nonsignif-icant F score indicates that there were no sta-

tistically significant differences between thecomparison groups at pretest on the assess-ment of psychological distress. A one-wayANOVA of the scores of posttraumatic stressat pretest yielded an F (1,37) = .033, p =

.856. Again, this statistically nonsignificant Fscore indicates that the two groups were

equivalent on the dependent measures at pre-




292

Table 1.

Summary of Demographic Variables

test. In addition, multivariate tests were con-ducted on all subscales of the two dependentmeasures. There were no statistically signifi-cant differences between the two groups on

any subscales at pretest, p < .10. It is impor-tant to note the high variability in the data thatcontributes to the statistically nonsignificantdifferences found at pretest.

Preliminary AnalysisAnalysis of clinical scores at pretest of the 38women who participated in the study indicatesthat 14 women, 37% of participants, reportedsymptoms beyond the clinical cutoff score forpsychological distress as measured by the

global symptom index of the SCL-90-R. Sev-en women experiencing these symptoms werein the treatment group and 7 were in the con-trol group. Analysis of the subscales of theSCL-90-R indicates that an additional 5 wom-en reported symptoms qualifying as clinicallysymptomatic by reporting clinical levels on atleast two of the nine subscales. Three of thesewomen were in the control group and 2 werein the treatment group. Including these 5

women with the 14 women assessed by theglobal symptom index produces a 50% rate of

clinical scores for psychological distress at

pretest.

Main AnalysisA MANCOVA with group as a fixed variableand pretest scores of the two dependent mea-sures as covariates, produced an omnibus F(2, 33) = 14.952, p = .000, Cohen’s d = 1.25.The SCL-90-R produced an F (1, 37) =26.164, p = .000 and the IES-R produced anF (1, 37) 17.817, p = .000. The means andstandard deviations of the two dependent mea-sures at pre and posttest are presented in Table2. The effect sizes, Cohen’s d, of the differ-ences between groups at posttest are also pro-vided in Table 2.

Subsequent analyses were completed on thesubscales of the IES-R. The means and stan-

dard deviations of the scales by group at post-test are displayed in Table 2. A MANCOVAof the three subscales with pretest as a covar-iate produced an omnibus F (3, 31 ) = 6.134,p = .002, Cohen’s d = .803. The subsequentunivariate analysis for each subscale found

that the intrusion scale of the IES-R at posttestproduced an F = 12.453, p - .001. The

avoidance scale of the IES-R at posttest pro-




293

Table 2.Mean (SD) Pretest and Posttest Scores on Dependent Measures for Treatment and ComparisonGroups

Note. Treatment and control groups were comprised of n = 19 participants each.

duced an F = 5.332, p = .027. The hyper-arousal subscale of the IES-R produced an F= 19.192, p = .000 (see Table 2 for effectsizes).

Clinical SignificanceAn additional measure of the treatment effect

and its clinical significance was computed bycomparing the proportions of those who wereexhibiting clinical levels of distress at pretestcompared to those exhibiting clinical levels atposttest as measured by the SCL-90-R. In the

Figure 1.Scatter plot of individual scores on the globalsymptom index of the SCL-90-R at Time 1 byTime 2 for all participants.

treatment group there were 7 out of 19 people(37%) at pretest exhibiting clinical levels ofpsychological distress. At posttest in the treat-ment group 3 out of 19 people (16%) wereexhibiting clinical levels of distress. The con-trol group remained constant between pre- and

posttest with 7 out of 19 (37%) reporting clin-ical levels of psychological distress.A comparison of SCL-90-R raw scores at

pre- and posttest is displayed in Figure 1 as a

scatter plot with pretest on the x-axis, postteston the y-axis and cases labeled by group. Thestandardized clinical cutoff score of 62 is

equivalent to a raw score of 0.74 in the figure.The graph demonstrates that the treatment

group falls below the line of one-to-one cor-

relation, indicating improvement or a decreasein symptom levels over time. Meanwhile, thecontrol group predominately falls above theone-to-one correlation line indicating increas-ing symptom levels at posttest.

Fidelity IndicatorsThe 38 participants completed all assessmentand demographic information. Nineteen par-ticipants wrote in journals and returned them.Adherence to journal writing directions wasassessed by looking for four separate journalentries per journal. All 19 participants whowrote in journals and returned them answeredfour self-report questions indicating they had




294

finished 30 minutes of writing at these four

different times. It is unknown if these writingdays were actually consecutive. Seventeen ofthe journals indicated each new day of writingby showing a date, a new page, or writing&dquo;day 1,&dquo; and so forth. Participants wrote onaverage approximately 2,446 words in their

journals. The 2 participants who did not in-dicate new days in their journals wrote ap-proximately the same number of words as

those who did indicate new days. All journalwriting consisted of NICU-related experienc-es. This indicates that the participants com-plied with the study’s requests for participa-tion.

DISCUSSION

The results of this study support the predictionthat a brief journal writing intervention canreduce the psychological distress of some

mothers who have experienced having a childin the NICU. Follow-up psychological care israrely provided for families in early interven-tion hospital settings because of cost. In thisstudy, brief journal writing for 30 minutes aday on 4 consecutive days reduced psycho-logical distress for mothers of NICU gradu-ates. These mothers wrote about the most in-

tensely stressful events regarding their infantsNICU stay. The results of this study are con-sistent with the growing body of literature

demonstrating the psychological benefits of

journal writing (Smyth, 1998). This studycontributes an extension of the literature byapplying a journal writing exercise in an ap-plied setting with participants selected for acommon traumatic experience.The researchers conceptualized the NICU

as an acute traumatic event. For some moth-

ers, however, their infants continue to expe-rience difficulty to thrive, suffer from chroniclung disease, or experience lifelong disabili-ties (Taylor et al., 2001). The difference be-tween acute trauma and chronic traumatic ex-

periences needs further exploration. Future re-search directions include the application of thetreatment in this study to individuals who ex-perience chronic traumatic life events or

chronic illness in comparison to those who ex-

perience acute traumatic experiences. In ad-dition, the intervention presented here mightalso be beneficial for individuals who expe-rience acute traumas other than the NICU.A potential limitation of the findings is the

effect of a social interaction between the re-

searcher and participants. It is unknown whatpart of the intervention procedure might haveinfluenced the results because of the non-

equivalent comparison of a treatment groupwho received the entire protocol and a controlgroup who received less interaction. The par-ticipants wrote in journals following direct in-structions and guided questions and then re-turned their journal to a researcher. It is un-

known if the treatment effect is altered when

journals are written with the anticipation ofsharing them versus keeping the journals pri-vate. Future research might include a compar-ison of participants who write in journals thatare later shared and participants who write injournals that are kept private. Implications forearly intervention include the need to incor-porate sharing the journal with someone elseas part of the journal writing treatment as-sessed in this study.The results of this study provide further

support for previous research establishing thebenefits of disclosure (Pennebaker, 1985). Inthis study, mothers who disclosed their NICUexperience through journal writing showed re-duced psychological and posttraumatic stresssymptoms. In previous research, reductions ofstress-related illness have also been demon-

strated (Pennebaker et al., 1988). These ben-efits support Pennebaker’s prediction thatkeeping traumatic life events private takes ef-fort that is detrimental to an individual’s psy-

chological and physical health.Implications for practice reach beyond the

NICU. Other populations who experiencetraumatic life events might benefit from dis-closure through journal writing. Generaliza-tion of findings implies that individuals whohave not previously disclosed a personal trau-matic experience might gain the most benefitfrom disclosure through journal writing.

Participants in this study were selected inpart by their ability to read and write fluently.This has important implications to consider




295

prior to implementation. Individuals who arenot fluent in a written language will clearlynot experience benefits from journal writing.Early intervention practitioners should beaware of the possible limitations of this inter-vention for individuals who are unable to

write fluently. In addition, culturally diversegroups might value writing differently andwill experience benefits accordingly. Futureresearch directions might focus on culturaland linguistic diversity and the benefits of

journal writing after traumatic experiences.The findings in this study were consider-

ably stronger than those found in most pre-vious research analyzing the benefits of jour-nal writing, with the exception of a studyDonnelly and Murray (1991) conducted. It is

likely that the difference in findings is relatedto the specific sampling used in this study;increasing the power of the analysis by in-

creasing the homogeneity of the sample. Pre-vious research on journal writing has predom-inately used college students in introductorypsychology classes as participants. The partic-ipants had not been selected for specific trau-matic experiences but wrote about whateverhappened to be stressful for them. The partic-ipants in this study were selected from a pop-ulation who share an intensely stressful ex-

perience. In addition, this sample was

matched on pretest scores before they wererandomly assigned to treatment or control

groups. These sampling and assignment pro-cedures increase the homogeneity of thegroup, and thereby increase the power of theanalyses. Furthermore, the participants in thisstudy experienced the stressful event in a rel-atively contained period. Previous studies an-alyzing journal writing have not selected fortime differences so that in any given study oneperson might write about a childhood trauma,whereas another person might write about anevent from the previous month. Also, the par-ticipants in this study chose to participate ina journal writing study that was presented tothem as an experimental treatment. These par-ticipants sought out a therapy-like experience.By contrast, some participants in previous re-search participated in studies as a requirementfor a class. The participants in this study

might have exhibited a higher treatment effectbecause they were seeking help.

Benefits of journal writing were found

across most participants regardless of their

distress level at pretest as illustrated in Figure1. The intervention not only helped motherswho were experiencing severe symptoms ofpsychological distress, but also helped moth-ers who would otherwise have gone untreated.It is possible that many mothers who appearto be doing fine could benefit from a brief

journal writing intervention. Implications forearly intervention practice also include theneed for an awareness of the traumatic nature

of the NICU experience for mothers and anawareness of the psychological benefits of dis-closing traumatic life events (Pennebaker,1985).

The authors wish to be clear that further

research is needed before suggesting that jour-nal writing might be a substitute for brief

counseling. Rather, it is proposed that journalwriting is a cost-effective means of reducingpsychological distress some mothers’ experi-ence. It is so cost effective that it could be

suggested to mothers who have an infant dis-charged from an NICU, or a child admitted toearly intervention programs or related servic-es. This intervention might benefit manymothers who at this point receive no help intheir psychological adjustment to the stressfullife experience of the NICU. Finally, the in-tervention assessed in this study provides apossible means of expanding early interven-tion services to families.

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Address correspondence to Leasha Barry, Univer-sity of West Florida, 11000 University Parkway,Building 85, Room 189, Pensacola, Florida 32514.E-mail: [email protected].




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Journal of Early Intervention - ed