الفهرس 
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Abstract
Abuse of illicit substances is widespread in Egypt, especially in young age
groups. Stigma and negative emotions among substance using population are
intense to a degree that can prevent help seeking, hinder recovery, and accelerate
relapse. Expressive disclosure writing (EDW) is considered a simple and cheap
therapy that focuses on expression of deep thoughts and feelings associated
traumatic experience, which leads to reorganization of self evaluations and less
psychological distress.
This study aimed to evaluate the effect of expressive disclosure writing (EDW) on
self stigma and depression, anxiety, and stress symptoms among substance
dependent clients.
Materials & Method
The current study was conducted at the inpatient rehabilitation unit of the addiction
center of Al Maamoura hospital of psychiatric medicine, in Alexandria.
This study comprised 165 participants: aged 18 years or older, free from major
mental disorders (schizophrenia, suicide, etc), could read and write. A number of
79 attended the posttest while complete case analysis was done for 45 participants.
The following tools were used for data collection
1- Sociodemographic and clinical data structured interview schedule was used
to elicit the sociodemographic and clinical characteristics of the participants.
2- Self Stigma in Alcohol Dependence Scale (SSAD) Schomerus et al., (2011)
is a 5 point response Likert scale that consists of 4 subscales 16 items each,
which measured self stigma.
3- Depression Anxiety Stress Scale–21 (DASS–21) Lovibond & Lovibond
(1995) is a 4 point response scale that consists of 3 subscales 7 items each,
which measured symptoms of depression, anxiety, and stress.
The SSAD and the DASS–21 were translated into Arabic and back translated into
English. The content validity was examined by 5 experts in the field of psychiatric
nursing. A pilot study was conducted, and translated scales showed accepted
internal consistency reliability.
A short preliminary session was held to orient potential participants with the study,
verbal informed consent was obtained, and baseline measures were done on the
same day or the day after depending on the available time and willingness of the
participants. Data collection from the control group took place first. Then the
interventional section was performed.
Participants in the intervention group received intervention in 2 parts. Part I
comprised a CBT psycho-education component provided in two 60-minutes group
sessions as a preparation for the EDW phase i.e. both involved illustrations about
the connection and interchangeable effect of thoughts, emotions, and behavior as
well harmful effects of negative thoughts and emotions, how to decrease
defensiveness and be more in touch with one’s life events and experiences, how to
identify and name thoughts and emotions, and how to use EDW to actively
disclose distressful experience. Part II comprised 15-minutes sessions of EDW on
5 consecutive days. Before the start of each session, Pennebaker’s writing
instructions were read loudly to participants.
Self stigma and depression, anxiety, and stress were measured at baseline and at
posttreatment.
The following are the main results obtained from the study:
- Participants were an average of 32.3 (SD = 6.723) years old, 95.5% were men,
the 49.9% were single, 77.5% had secondary education or less, 63% had
occupational work, and 65.5% had sufficient income.
There were significant statistical baseline differences between the intervention
and control groups as related to gender of participants, marital status, and the
number of days after hospital admission.
- Most participants were dependent on more than one substance with heroin and
opioid chemical preparations were reported by 78.6% of the participants.
- Participants had an average abuse duration of 14.3 (SD = 8.9) years, an average
number of hospital admission of 3.9 (SD = 4.8) times, and an average of 38.5
(SD= 49.3) days since last hospital admission.
- Participants included in the final analysis in the control group had no statistically
significant baseline differences compared with those excluded from the analysis
because of incomplete records except for having a fewer number of days since
hospital admission t (75.28) = 2.85, p = .006, Cohen’s d = 0.71.
- Participants included in the final analysis in the EDW group had no statistically
significant baseline differences compared with those excluded from the analysis
because of incomplete records except for scores of applying stigma to oneself
that were significantly lower at pretest in the included participants than in
participants excluded from the analysis because of incomplete observations t
(44.00) = 3.387, p = .001, Cohen’s d = 0.86.
- For only all intervention participants who attended the posttest, mean scores of
all self stigma variables showed no change whereas mean scores of depression,
anxiety, stress, and overall distress were significantly less at posttreatment
(means ranged between 5.5 and 18.0) than at pre treatment (means ranged
between 8.4 and 24.7).
- For participants included in the complete case analysis, the mean scores of self
stigma variables and depression, anxiety, and stress scores had insignificant
improvement from pre to posttreatment within both groups.
- In crude analysis of all participants who attended the posttest, t-test indicated no
significant effect of EDW on self stigma (Cohen’s d ranged between 0.03 and -
0.44) and depression, anxiety, and stress (Cohen’s d ranged between 0.05 and -
0.18).
- No significant effect of EDW on all self stigma subscales for the complete case
analysis except for scores of ”applying stigma to oneself” which significantly
decreased from pre to posttreatment in the EDW group as indicated by the
independent t-test, and the effect size was medium (Cohen’s d = -0.6).
- ANCOVA analysis adjusted for baseline scores revealed no significant group
differences at posttreatment in scores of applying stigma to oneself F (1, 42) =
0.262, p = .612, and Cohen’s d = 0.16.
- ANCOVA analysis adjusted for baseline scores revealed no significant pre to
posttreatment effect of EDW on scores of depression, anxiety, stress, or the total
psychological distress. All effect sizes were small to moderate (Cohen’s d
ranged from -0.03 to -0.45).
Accordingly the following are the main recommendations of the present
study:
- There is a need to identify factors that moderate the effect of EDW on
stigma.
- Moreover, the program should be further enhanced so as to boost effects
of EDW. Modifications may involve using techniques such as response
training, positive writing and finding meaning in the experience of
substance use, group discussions of written content, and providing
support for less expressive and illiterate individuals to do it orally or
symbolically (through drawing and painting).
Further randomized control trials are needed to test the effectiveness of
EDW on self stigma and depression, anxiety, and stress symptoms
among substance users.