Individuals with minoritized sexual orientations and/or gender identities (e.g., lesbian, gay, bisexual, transgender, queer [LGBTQ+]) have greater prevalence of trauma exposure and are at increased risk for depression, posttraumatic stress disorder (PTSD), disordered eating, hazardous substance use, and suicide compared with their cisgender, heterosexual counterparts (Shipherd et al., 2021; Livingston et al., 2016; Livingston et al., 2015; Hazenbuehler, 2009). It is well established that LGBTQ+ individuals’ increased risk for psychiatric disorders is due to exposure to both chronic and severe forms of discrimination and stigma-related stressors (e.g., Meyer, 2003). Therefore, targeting the deleterious impacts of discrimination and stigma-related experiences represents an important strategy to offset disparity and promote wellness among members of the LGBTQ+ community.
Expressive writing is a brief and evidence-based intervention strategy that may be effective at reducing the negative impacts of discrimination experiences among LGBTQ+ individuals. Supported by over 30 years of research (e.g., Pennebaker & Beal, 1986), expressive writing involves writing about thoughts and emotions related to a traumatic or stressful experience based on structured prompts. The standard expressive writing paradigm involves participants writing based on a prompt for three to five consecutive days for 15 to 30 minutes each day.
Specific to discrimination experiences among LGBTQ+ people, this writing paradigm has been adapted and tested in several experimental studies and one randomized-controlled trial (RCT). These studies instructed participants to write for 15-20 minutes a day for three days in an online format without feedback or guidance from a therapist (Levitt et al., 2010; Pachankis et al., 2021; Pachankis & Goldfriend, 2010). The writing prompts for these studies asked participants to write about the most difficult or painful situation they have encountered based on their sexual orientation or gender identity. If there were many discriminatory events the participant experienced, it was recommended that participants focus on the one that was “most recent, feels most alive to you, or does not yet feel emotionally resolved” (Levitt et al., 2021; p. 155). One writing prompt that was developed by Pachankis et al. (2010) and examined in a RCT (Pachankis et al., 2021) is a variation of the standard writing prompt:
As [gay/lesbian/bi/pan] individuals living in [geographic location], nearly all of us have experienced stressful life events because of who we are. Nearly everyone has a story about being the target of others’ slurs, bullying, or physical aggression. Sometimes these experiences occur in our schools, workplaces, and other public spaces. Other times, these experiences occur in our own homes and churches.
Today, please write about the most difficult or painful situation that you have encountered in your lifetime because of your sexual identity. Consider what your deepest thoughts and feelings are about this situation. Just follow your train of thought wherever it goes, without worrying about spelling, grammar, or structure. Please write for the whole 20 minutes until the timer has expired.
The writing prompts for the following two days were similar to the above prompt (see Appendix A for full example). Participants were given an option to write about a different event than the event they focused on the first day. Another example of an expressive writing prompt for discrimination based on sexual or gender identity was developed using an emotion-focused therapy framework (Levitt et al., 2021). This prompt instructed participants to 1) describe as many feelings related to the event as the participant may be experiencing, 2) examine any needs associated with these feelings, and 3) consider the actions the participant may want to take to address these needs, writing on each component for five minutes.
Expressive writing on discrimination experiences among LGBTQ+ people can reduce depressive and anxiety symptoms, substance use, and perceived stress, as well as increase positive affect while affirming individuals’ LGBTQ+ identities (Braitman, et al., 2008; Crowley, 2014; Lewis et al., 2005; Levitt et al., 2021; Pachankis & Goldfried, 2010; Pachankis et al., 2021). Moreover, qualitative interviews with LGBTQ+ people who have completed expressive writing have found that they feel validated by being provided the opportunity to process these experiences and report that the intervention increases self-efficacy in coping with future discriminatory experiences (Collins et al., 2022). Content analysis of online, self-led expressive writing indicates that people tend to express a wide range of emotions related to events, engage in meaning-making, express self-compassion, and report empowerment and a greater sense of self-agency (Collins & Levitt, 2022). Although many LGBTQ+ people report benefitting from expressive writing about discrimination experiences, some people continue struggling with self-blame, avoidance, and feelings of hopelessness (Collins & Levitt, 2022). For these individuals, further facilitation of processing emotions and cognitions as well as skill-building to mitigate the negative consequences of discriminatory experiences in psychotherapy may be beneficial.
Although efficacy research on expressive writing on discrimination experiences is in the early stages, current efficacy data and its brief and flexible format make it a promising intervention for addressing the deleterious effects of minority stress on LGBTQ+ individuals. However, additional research is needed to help expand this potentially useful intervention. Specifically, research on ways to enhance the effectiveness of the intervention strategy (e.g., writing with pen and paper, receiving provider feedback on writing, providing psychoeducation on minority stress) and on the intervention’s mechanisms of change (e.g., exposure, cognitive processing, self-regulation) is needed. Additionally, as noted by LGBTQ+ people who completed expressive writing exercises (Collins et al., 2022), research on how expressive writing can be used for processing discriminatory experiences related to intersecting identities (e.g., LGBTQ+ identity and racial/ethnic identity) will greatly improve the impact and applicability of this intervention strategy. Overall, expressive writing on discriminatory experiences is an easily implementable, brief intervention strategy that has the potential for mitigating high risk mental health outcomes among the LGBTQ+ community.
About the Authors
Nicholas A. Livingston, PhD, (he/him) is a research psychologist in the National Center for PTSD, Behavioral Science Division, and assistant professor of psychiatry at Boston University School of Medicine. Areas of clinical and research expertise include minority stress and LGBTQ+ health, trauma and PTSD, and substance use.
Brian P. Marx, PhD is deputy director of the Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System and Professor of Psychiatry, Boston University School of Medicine. His research interests include the assessment and treatment of PTSD and suicide prevention.
Katherine M. Iverson, PhD (she/her) is a clinical psychologist, health services researcher, and implementation scientist in the National Center for PTSD, Women’s Health Sciences Division, and associate professor psychiatry at Boston University School of Medicine. Areas of research and clinical expertise include enhancing health care services for individuals who experience trauma interpersonal trauma, particularly intimate partner violence.
References
Collins, K. M., & Levitt, H. M. (2022). Healing from heterosexism: A discovery-oriented task analysis of emotion-focused writing. Journal of Gay & Lesbian Mental Health, 26(1), 2-23.
Collins, K. M., Levitt, H. M., & Maroney, M. R. (2022). Peeling back the layers: How expressive writing about heterosexist events benefits sexual minority adults. Journal of Homosexuality, 69(3), 445-473.
Crowley, J. P. (2014). Expressive writing to cope with hate speech: Assessing psychobiological stress recovery and forgiveness promotion for lesbian, gay, bisexual, or queer victims of hate speech. Human Communication Research, 40(2), 238-261.
Hatzenbuehler M. L. (2009). How does sexual minority stigma "get under the skin"? A psychological mediation framework. Psychological bulletin, 135(5), 707–730.
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Livingston, N. A., Heck, N. C., Flentje, A., Gleason, H., Oost, K. M., & Cochran, B. N. (2015). Sexual Minority Stress and Suicide Risk: Identifying Resilience through Personality Profile Analysis. Psychology of sexual orientation and gender diversity, 2(3), 321–328.
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Appendix A
Expressive Writing Prompts
Day 1: As [gay/lesbian/bi/pan] individuals living in Northeast Tennessee, nearly all of us have experienced stressful life events because of who we are. Nearly everyone has a story about being the target of others’ slurs, bullying, or physical aggression. Sometimes these experiences occur in our schools, workplaces, and other public spaces. Other times, these experiences occur in our own homes and churches.
Today, please write about the most difficult or painful situation that you have encountered in your lifetime because of your sexual identity. Consider what your deepest thoughts and feelings are about this situation. Just follow your train of thought wherever it goes, without worrying about spelling, grammar, or structure. Please write for the whole 20 minutes until the timer has expired.
Day 2: Today, please continue writing about the most difficult or painful situation that you have encountered in your lifetime because of your sexual identity. You could continue to write about topics you addressed before, or you could write about something different. In either case, continue to really explore your very deepest emotions and thoughts about this situation.
Remember to follow your train of thought wherever it goes, without worrying about spelling, grammar, or structure. Please write for the whole 20 minutes until the timer has expired.
Day 3: Today is the last day of writing. Please explore your deepest thoughts and feelings about the most difficult or painful situation that you have encountered in your lifetime because of your sexual identity. Remember that this is the last day of writing, so by the end of the session, you might want to find a way to bring closure to your ideas. For example, you might write about how this situation relates to your current life or your future. Feel free to go in any direction you feel most comfortable with and delve into your deepest emotions and thoughts.
Remember to follow your train of thought wherever it goes, without worrying about spelling, grammar, or structure. Please write for the whole 20 minutes until the timer has expired.
Note: Expressive writing prompts were made in consultation with LGBTQ+ people. Scenarios should be tailored to match the individuals’ own sexual orientation. From Pachankis et al., 2020.