Forgiveness-Based Writing to Prevent Post-Traumatic Stress Disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans

PTSD is a complex physiological, cognitive, emotional, and behavioral reaction to trauma
comprising symptoms such as heightened arousal, emotional numbing, avoidance of
trauma-related cues, and re-experiencing aspects of the trauma. Estimates indicate that
16.6% of OEF/OIF veterans returning from deployment develop PTSD (Hoge et al., 2007), much
higher than the overall prevalence rate of 6.8% among adults in the United States (Kessler
et al., 2005). Although efficacious treatments for PTSD are available, considerably less is
known about preventing its progression from sub-threshold symptoms to full PTSD (Feldner,
Manson, & Friedman, 2007). This is disconcerting because studies show that sub-threshold
PTSD is a potential risk factor for the development of PTSD (e.g., Buckley, Blanchard, &
Hickling, 1996; Carty, O'Donnell, & Creamer, 2006). Thus, there is a need for the
development and evaluation of brief preventive interventions that can be easily and
effectively implemented with individuals who have sub-threshold PTSD, defined as meeting
either DSM-IV PTSD criteria B and C or B and D, but failing to meet all three, and
experiencing at least one month of significant impairment (Blanchard et al., 1994).

Although treatments for PTSD such as Cognitive Processing Therapy (CPT) and Prolonged
Exposure (PE) have been generally successful with individuals with full-blown PTSD (Foa et
al., 1991; Monson et al., 2006; Schnurr et al., 2007), these treatments have not been
systematically evaluated within a context of prevention and applied to individuals with
sub-threshold symptoms. Furthermore, despite the effectiveness of available treatments for
trauma symptoms, several identified barriers to treatment exist for veteran populations,
particularly those who live in rural settings.

These barriers to care highlight the need for brief, cost-effective, and self-managed
interventions aimed at reducing attrition, providing symptom relief, and preventing PTSD in
rural and underserved populations. One potentially valuable intervention is expressive
writing (i.e., writing thoughts and feelings about a significant life event). Expressive
writing is associated with large improvements in psychiatric and physical symptoms and can
be modified to suit the needs of specified groups (e.g., Frisina, Borod, & Lepore, 2004;
Pennebaker, 2004; Smyth, 1998). Forgiving others can decrease physiological arousal (Lawler
et al., 2003; Witvliet, Ludwig, & VanderLaan, 2001), depression, anxiety, and post-traumatic
stress (Reed & Enright, 2006), as well as anger and substance use (Lin et al., 2004), while
self-forgiveness is associated with improved quality of life and decreased mood disturbance
(Friedman et al., 2007; Romero et al., 2006). Thus, a forgiveness-based writing intervention
may be particularly powerful for addressing responses to trauma. Although previous studies
have examined forgiveness-based writing interventions (McCullough, Root, & Cohen, 2006;
Romero, 2008), none has examined the benefits of forgiveness-based writing for patients with
sub-threshold PTSD symptoms.

Inclusion Criteria:

- Men and women of all racial/ethnic backgrounds between the ages of 18 and 64, seen in
the identified settings (veteran participants must be OEF/OIF).

- Presence of sub-threshold PTSD as defined by Blanchard et al. (1994), related to
combat experienced in the past 2 years.

- Ability to read, write, and speak English.

- Ability to attend on-site baseline and follow-up appointments.

- Ability to be contacted by phone with study reminders.

Exclusion Criteria:

- Primary psychotic disorder unrelated to PTSD.

- Impaired cognitive functioning.

- Current suicidal or homicidal intent.

- Symptoms meeting full PTSD diagnostic criteria.