Narrative Medicine

1
Narrative Medicine and Substance Use Disorder
Narrative Medicine is a relatively new branch of medicine that has been gaining
popularity over the past two decades. It consists of approaching the practice of medicine with the
patients’ narratives, that is their life stories, in a thoughtful and sensitive way in order to gain a
better understanding of the full clinical picture. The premise of the study, headed by Renee
Nicholson and Dr. Allison Lastinger, was to apply the concepts of narrative medicine to the
population with Substance Use Disorder. This is an innovative approach to treating a growing
crisis in the region, with the rising rates of opioid usage and the devastation it is bring to West
Virginia and the nation. Below is an outline and main conclusions for the preliminary research.
I. Where are we now
A. Substance Use
I’ll begin with a brief history of Substance Use Disorder (SUD), how different
approaches have been used, how bad the problem is. I have not written this part yet
B. Narrative medicine
I have begun writing this part. Here are the headings
1. History of allopathic medicine
A brief history of allopathic medicine and its issues
2. Narrative medicine, an overview
The rise of narrative medicine and where/what populations it has been applied
3. Mechanism of action
How narrative medicine actually works

[SHORTENED TITLE UP TO 50 CHARACTERS] 2
II. Narrative medicine and SUD
A. Reflective writing and health behaviors
I review the studies that have looked at reflective writing and if it impacts behavior, with
focus of the SUD population. I have begun writing this part. This starts the process of supporting
our second hypothesis that expressive story telling helps modify patient’s problem behaviors.
B. Oral narrative and SUD
This is the bulk of the studies. I have split writing and oral emotional disclosure for two
reasons: 1) There is a lot more evidence for oral story-telling, particularly with the AA/NA/12-
step programs. 2) the SUD population tends to have less education, so I am theorizing that oral
disclosure would be more beneficial than written.
Story telling in AA is a little different than the narratives that we will be collecting, but I
think it will work. I will probably break this up into some sub headings, but I have not gotten
there yet. Specifically, I have a lot of research backing that story telling sustains recovery for
various reasons, but one is to help build a fellowship. This will lead to our first hypotheses of
perceived social support and readiness for change.
III. Conclusion
My main points that will be supported by the literature are
A. Study design
1) Oral, rather than written disclosure, is a more appropriate form for developing a
narrative for the SUD population
2) The best way to measure change behavior is to look at the stage of change, like TTM.
3) Inpatient population is the best time for developing a narrative, as opposed to
outpatient
B. Research Hypotheses
Obviously, our research hypotheses
1) There is a positive linear relationship between perceived social support and readiness
for change.
2) Expressive storytelling improves readiness for change, reduces ambivalence about
change, increases self-efficacy to abstain from substance use, and modifies the
processes patients use to avoid problem behaviors.

The following is my work in progress that got cut short due to the pandemic. It Articles
about narrative medicine/expressive writing benefits, It beings with a list of articles and books
that I read. Anything highlighted are appropriate articles that I have not yet read or analyzed.
Next comes a more detailed look at each of the articles. I put the reference on top, anything
summarizing the article is in plain text and my own analyses and observations are in bold.
Again, this is a work in progress due to the Covid-19 pandemic and is to show my ability to
research in depth on a topic.
1. Smyth JM, Stone AA, Hurewitz A, Kaell A. (1999) Effects of writing about stressful
experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a
randomized trial. JAMA.1999;281:1304-1309.
2. Pennebacker JW (2000). Telling stories: the health benefits of narrative. Lit
Med.2000;19:3-18.
3. Sloan, D.M., & Marx, B.P. (2004). Taking pen to hand: Evaluating theories underlying
the written disclosure paradigm. Clinical Psychology: Science and Practice, 11, 121–
137.
4. Frisina, P.G., Borod, J.C., & Lepore, S.J. (2004). A meta-analysis of the effects of
written emotional disclosure on the health outcomes of clinical populations. The
Journal of Nervous and Mental Diseases, 192, 629–634.
5. Korotana, L., Dobson, K., Pusch, D., & Josephson, T. (2016). A review of primary care
interventions to improve health outcomes in adult survivors of adverse childhood
experiences. Clinical Psychology Review, 46, 59-90. doi:10.1016/j.cpr.2016.04.007
6. Pavlacic, J.M., Buchanan, E.M., Maxwell, N.P., Hopke, T.G., & Schulenberg, S.E.
(2019). A meta‐analysis of expressive writing on posttraumatic stress, posttraumatic
growth, and quality of life. Review of General Psychology, 23, 230– 250.
7. Baikie, K., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive
writing. Advances in Psychiatric Treatment, 11(5), 338-346. doi:10.1192/apt.11.5.338
8. Sullivan, M. (2003). The new subjective medicine: Taking the patient's point of view on
health care and health. Social Science & Medicine. 56(7), 1595-604.
Articles about change behaviors and using narrative Medicine, good impact, written:
1. Smith, S., Kloss, J., Kniele, K., & Anderson, S. (2007). A comparison of writing exercises
to motivate young women to practise breast self-examinations. British Journal of Health
Psychology, 12(1), 111-123. doi:10.1348/135910706X93637
2. Conroy, D., & Hagger, M. (2018). Imagery interventions in health behavior: A meta-
analysis. Health Psychology : Official Journal of the Division of Health Psychology,
American Psychological Association, 37(7), 668-679. doi:10.1037/hea0000625
3. Tubman, J., Montgomery, M., & Wagner, E. (2001). Letter writing as a tool to increase
client motivation to change: Application to an inpatient crisis unit. Journal of Mental
Health Counseling, 23(4), 295-311.
4. Sarah Meshberg-Cohen PhD, Dace Svikis PhD & Thomas J. McMahon PhD (2014)
Expressive Writing as a Therapeutic Process for Drug-Dependent Women, Substance
Abuse, 35:1, 80-88, DOI: 10.1080/08897077.2013.805181
Article about using narrative and change behavior: no impact/bad impact:
1. Ames, S., Patten, C., Offord, K., Pennebaker, J., Croghan, I., Tri, D., . . . Hurt, R. (2005).
Expressive writing intervention for young adult cigarette smokers. Journal of Clinical
Psychology, 61(12), 1555-70.
2. Baikie, K.A., Wilhelm, K., Johnson, B. et al. (2006). Expressive writing for high-risk
drug dependent patients in a primary care clinic: A pilot study. Harm Reduction Journal.
3: 34. https://doi.org/10.1186/1477-7517-3-34
Article with narrative and substance abuse:
1. Lund, P. (2016). Christianity in narratives of recovery from substance abuse. Pastoral

Psychology, 65(3), 351-368. doi:10.1007/s11089-016-0687-3
2. Hänninen, V., & Koski-Jännes, A. (1999). Narratives of recovery from addictive
behaviours. Addiction, 94, 1837–1848.
3. Orford, J. (2008). Asking the right questions in the right way: the need for a shift in
research on psychological treatments for addiction. Addiction, 103, 875–885.
4. Lederman, L. C. & Menegatos, L. M. (2011) Sustainable Recovery: The Self-
Transformative Power of Storytelling in Alcoholics Anonymous, Journal of Groups in
Addiction & Recovery, 6:3, 206-227, DOI: 10.1080/1556035X.2011.597195
5. Alves, P., Sales, C., Ashworth, M., & Faisca, L. (2018). “there are things i want to say
but you do not ask”: A comparison between standardised and individualised evaluations
in substance use treatment. International Journal of Mental Health and Addiction,
(2018). doi:10.1007/s11469-018-9985-6.
6. Herrera-Sanchez, I., Rueda-Mendez, S., & Medina-Anzano, S. (2019). Storytelling in
addiction prevention: A basis for developing effective programs from a systematic
review. Human Affairs, 29(1), 32-47. doi:10.1515/humaff-2019-0004
7. Sundin, M., & Lilja, J. (2019). Substance use and strategies to avoid relapses following
treatment: A narrative approach with clients undertaking a twelve-step program in
Sweden. Journal of Substance Use, 24(2), 125-129.
doi:10.1080/14659891.2018.1523959
8. BOOK: Narrative means to sober ends. AM READING THIS!
9. BOOK: Hänninen, V. and Koski-Jännes, A. (2004) 'Stories of attempts to recover from
addiction' in Rosenqvist, P.; Koski-Jännes, A. and Ojesjo, L. (eds) Addiction and the
Life Course NAD: Helsinki, pp. 231-246. This is a book from the Nordic counsel of
alcohol and drug research, call “addiction and life course” by Pia Resonqvist
10. Book: O'Halloran, S. (2008). Talking oneself sober : The discourse of alcoholics
anonymous. Amherst, N.Y.: Cambria Press. (2008). Retrieved February 26, 2020,
Articles about what are the change processes of change in addiction
1) Koski-Jännes, A., & Turner, N. (1999). Factors influencing recovery from different
addictions. Addiction Research, 7, 469–492.
2) Weegmann, M., & Piwowoz-Hjort, E. (2009). “Naught but a story”: narratives of
successful AA recovery. Health Sociology Review, 18, 273–283.
3) Morgenstern J., Bux D., Labouvie E., Blanchard K. A., Morgan T. J. 2002. Examining
mechanisms of action in 12‐Step treatment: the role of 12‐Step cognitions. J Stud
Alcohol. 63: 665–72.
Articles about TTM and narrative medicine
1. Kelly, R., Wood, A., Shearman, K., Phillips, S., & Mansell, W. (2012). Encouraging
acceptance of ambivalence using the expressive writing paradigm. Psychology and
Psychotherapy, 85(2), 220-8. doi:10.1111/j.2044-8341.2011.02023. “Ambivalence” is a
stand in for the pre-contemplation stage
2. Christenson, J., & Miller, A. (2016). Slowing down the conversation: The use of letter
writing with adolescents and young adults in residential settings. Contemporary Family
Therapy : An International Journal, 38(1), 23-31. doi:10.1007/s10591-015-9368-0
3. Waters, K., Holttum, S., & Perrin, I. (2014). Narrative and attachment in the process of
recovery from substance misuse. Psychology and Psychotherapy: Theory, Research and
Practice, 87(2), 222-236. doi:10.1111/papt.12005
4. Petraglia, J. (2007). Narrative intervention in behavior and public health. Journal of
Health Communication, 12(5), 493-505.
5. Wilson, M., Saggers, S., & Wildy, H. (2013). Using narratives to understand progress in
youth alcohol and other drug treatment. Qualitative Research Journal, 13(1), 114-131.
doi:10.1108/14439881311314694
Articles about TTM and substance use
1. Snow, M., Prochaska, J., & Rossi, J. (1994). Processes of change in alcoholics
anonymous: Maintenance factors in long-term sobriety. Journal of Studies on Alcohol,
55(3), 362-71.
2. Swora, M. (2004). The rhetoric of transformation in the healing of alcoholism: The
twelve steps of alcoholics anonymous. Mental Health, Religion & Culture, 7(3), 187-209.
This may be helpful
3. Prochaska, J., & Velicer, W. (1997). The transtheoretical model of health behavior
change. American Journal of Health Promotion : Ajhp, 12(1), 38-48. Seminal article.
Have put in request
4. Patterson, D., Wolf, S (Adelv unegv Waya), & Nochaski, T. (2010). Combining the
transtheoretical stages of change model and the 12 steps of alcoholics anonymous to
monitor treatment progression. Journal of Social Work Practice in the Addictions, 10(2),
224-227. doi:10.1080/15332561003730262
5. BOOK: Center for Substance Abuse Treatment (U.S.). (2012). Enhancing motivation for
change in substance abuse treatment (Rev. 2012 ed., Treatment improvement protocol
(tip) series, 35) [Rev. 2012.]. Rockville, MD: U.S. Department. of Health and Human
Services, Substance Abuse and Mental Health Services Administration, Center for
Substance Abuse Treatment. (2012).
These are articles about Narrative medicine good impact, particularly with SUD that I
can’t put up there because I already printed it out, but I will slot them in as appropriate.
1. Grasing, K., Mathur, D., & Desouza, C. (2010). Written emotional expression
during recovery from cocaine dependence: Group and individual differences in craving
intensity. Substance Use & Misuse, 45(7-8), 1201-15. doi:10.3109/10826080903474003
2. Young, C., Rodriguez, L., & Neighbors, C. (2013). Expressive writing as a brief
intervention for reducing drinking intentions. Addictive Behaviors, 38(12), 2913-2917.
doi:10.1016/j.addbeh.2013.08.025
3. Rodriguez, L., Young, C., Neighbors, C., Campbell, M., & Lu, Q. (2015).
Evaluating guilt and shame in an expressive writing alcohol intervention. Alcohol, 49(5),
491-498. doi:10.1016/j.alcohol.2015.05.001
Smyth, J.M., Stone, A.A., Hurewitz, A, Kaell, A.(1999). Effects of writing about stressful
experiences on symptom reduction in patients with asthma or rheumatoid arthritis: A randomized
trial. Journal of American Medical Association. 281 (14):1304-1309.
Addressing if psychological needs helps with physical symptoms using objective
measures. Using nonphamalogical methods to treat patients This is important for patients with
substance abuse, to see if their symptoms and issues can be addressed another way. RA and
asthma are common and can have a substantial economic and personal burden Like substance
abuse
They took out people with defined psychotherapy disorder or mood-altering medications.
This is unlike those with substance abuse problems.
Testing if writing about stressful things would help decrease symptoms of rheumatoid
arthritis (RA) and asthma. 107 completed the study, 58 asthma with 22 in control and 39 in
experimental. 49 in RA: 19 control and 32 experimental. Total: 41 control and 71 in
experimental. Randomly assigned via computer. More in experimental than control by design: so
they could do further exploration with that group.
Wrote for 20 minutes, three consecutive days in private room in laboratory. Control
group: wrote about neutral topic-plans for the day. Told it was time management to reduce stress.
Experimental group: wrote about most stressful event of their lives Not necessarily about the
disease process they were experiencing. Interesting. Told they were interested in their
experience of stress. Both groups were told it would help with stress. Given instructions in
sealed envelope for less bias.
Tested at baseline, 2 weeks, 2 months and 4 months after writing. Asthma patients were
tested by the forced expiratory volume in 1 second (FEV). RA patients measure in structured
interview that assess the disease activity, symptom severity, distribution of pain, tenderness and
swelling and the severity of deformities, along with impairment sin ADLs and general
psychosocial functioning. The asthma group was purely objective in nature, the RA group
has more holistic qualitative measures. Double blind: raters unaware
Findings: writing about emotionally traumatic experiences reduced symptoms in both
groups from baseline at 4 months.
For asthma patients: improvement was seen immediately at 2 weeks, remained high at 2
and 4 months. For RA improvement was not seen until 4 month period, but not at 2 week or 2
month. Why? They say maybe the mechanisms that underly improvement differ in the two
groups: RA takes time to change immune response.
In both groups, about half of the patients did not improve: Those who improved may
have improved a LOT to make it significant but why is a different matter. Further research is
needed on structured writing and illness. Enter narrative medicine techniques!!

Pennebaker, J.W. (2000). Telling Stories: The Health Benefits of Narrative. Literature and
Medicine 19(1), 3-18. doi:10.1353/lm.2000.0011.
More of an essay then a research article. Had a group of students: half wrote about
their most traumatic experiences and asked to explore their emotions, half told to write about
neutral description of their living room or the room they were in.
Those who were in the experimental group wrote about vreally traumatic things, things
you would not think looking at these upper-middle class college students.
Those in the experimental group had less visits to the university health center after then
experiment then before.
Not a lot of details. I doubt the results were significant. If they were, then they would
have been published like a research article.
Why does writing help? Presents three ideas:
1) People become more health conscientious after writing and change behaviors. Not much
support of this
2) Value in expression. However, other forms of expression don’t benefit the same results.
Need to have the language aspect. Talks about another study he did with just movement
vs movement and language. Language is important.
3) Converting emotions and images/thoughts into words changes how we organize and think
about trauma. “By integrating thoughts and feelings, then, the person can more easily
construct a coherent narrative of the experience. Once formed, the event can be
summarized, stored, and forgotten more efficiently”
“Once a complex event is put into a story format, it is simplified. The mind doesn't
need to work as hard to bring structure and meaning to it.”
Finding meaning in experiences is important because once you find meaning, then
you can act upon it accordingly. i.e. why did the person honk? Is the light green? Is it
someone I know? Once I know the meaning of the act, I can ignore it or go through the light
or wave.
The more you talk about an event, the more succinct you get.
There is a role of the social aspects of disclosure: able to let it go? After writing, some
participants were able to talk and laugh more. Having a traumatic secret can be isolating.
Sloan, D.M., & Marx, B.P. (2004). Taking pen to hand: Evaluating theories underlying
the written disclosure paradigm. Clinical Psychology: Science and Practice, 11, 121–137.
Starts with similar work: Pennebaker and Beall, 1986: those who expressed their
traumatic/stressful experience in writing visted the campus infirmary less and reported fewer
physical health complaints. Meta-analysis that I have mentioned before, Smyth 1998, confirms
and extends those fidings. More studies, most finding that written emotional disclosure can be
helpful for health outcomes. But why?!?!
This article looked at 27 studies that look at written disclosure from 1986-2004. Most
tudies look at 3 writing exercise of 15-45 mines, longer for people with trauma. I can do the
math to figure out the mean/medium and AD if needed.
Three theoretical models for why written disclosure in beneficial.
1) Emotion inhibition- those who inhibit their emotions equal more stress, so sharing those
emotions means less stress and improved immune functioning and health. Less support in
the literature for this theory
2) Cognitive adaptations- when we have traumatic/stressful experience, we need to process
it by changing existing schema, resolve the experience with our inner models so by
writing about an experience gives structure, organization and cohesion, which allows
person to assimilate the experience and, like emotional inhibition, decrease stress and
improve physical health. The research shows some promise, but difficult to test
empirically. The studies look the language used. Interesting study, those who write in a
“narrative way” Smyth et al (2001) had less illness related restriction. This could be
used in our study.
3) Exposure/emotional processing- more complicated, but essentially, you have a bad
experience and become fearful and try to avoid it and start to develop all these
maladaptive behaviors because of this avoidance, but writing about the experience helps
to exposure you to that fearful thing in a safe way, so you can process it and no longer put
your energy into avoiding it. The research not entirely supportive, very little research
looking at the emotional response to the writings.
In discussion, states one theory may not fully cover it.
This will be a good article to cite if we are going to get in to the theoretic of why
narrative medicine works. It also gives some insight into how many sessions and how often.
Frisina, P., Borod, J., & Lepore, S. (2004). A meta-analysis of the effects of written
emotional disclosure on the health outcomes of clinical populations. The Journal of Nervous and
Mental Disease, 192(9), 629-34.
Written emotional disclosure has a greater effect on physical than psychological
outcomes
Nine studies were looked at from 200-2003. Needed to have at least one quantitative
measure of health could be mental, physical or behavior, needed to write not just discuss Are we
writing? I think so, so this is applicable, need to be experimental not just quasi. Disease that
were studied: asthma, arthritis, and cancers of renal, prostate and breast.
Compared to another metanalysis done by Smyth in 1998 that looked at healthy people,
this one looked at the already sick and found that there was a positive impact, but not as much as
the healthy people. Expressive writing works better for those that need to improve physical not
psychological health outcomes. Does help with depression and anxiety, not PTSD and severely
depressed/suicidal. Although, those can cause “disordered cognition” so trying to get someone
with PTSD or severe depression may be inappropriate.
This one says that having medications could be skewing the results, but the smoking
one says that by not having medications that could be decreasing the results. Crazy.
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Korotana, L., Dobson, K., Pusch, D., & Josephson, T. (2016). A review of primary care
interventions to improve health outcomes in adult survivors of adverse childhood experiences.
Clinical Psychology Review, 46, 59-90. doi:10.1016/j.cpr.2016.04.007

This is another meta analysis that looks at lots of different things for adults who have had
bad childhoods. Substance use was just one thing that was looked, lots of different outcomes.
Cognitive Behavior Therapy (CBT) has best outcomes but that expressive writing also has a
positive impact. So, putting them together would be, logically, the best.
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Pavlacic, J.M., Buchanan, E.M., Maxwell, N.P., Hopke, T.G., & Schulenberg, S.E.
(2019). A meta‐analysis of expressive writing on posttraumatic stress, posttraumatic growth, and
quality of life. Review of General Psychology, 23, 230– 250.
Another meta anylses showing a small scale impact to on post traumatic stress outcomes,
but a large effect if those they were working with had an official diagnosis of PTSD.
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Baikie, K., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive
writing. Advances in Psychiatric Treatment, 11(5), 338-346. doi:10.1192/apt.11.5.338
This is a review of expressive writing and how to structure a treatment session, who
would benefit and why.
Health outcomes: Fewer stress-related visits to the doctor, improved immune system
functioning, Reduced blood pressure, Improved lung function, Improved liver function, Fewer
days in hospital, Improved mood/affect, Feeling of greater psychological well-being, Reduced
depressive symptoms before examinations , Fewer post-traumatic intrusion and avoidance
symptoms
Social and behavioural outcomes: Reduced absenteeism from work, Quicker re-
employment after job loss, Improved working memory, Improved sporting performance, Higher
students’ grade point average, Altered social and linguistic behavior
People/medical conditions that it has helped: lung functioning in asthma, RA disease
severity Pain and health in cancer, immune response in HIV, hospitalizations in CF, Pain with
chronic pelvic pain, and post-op course
Why it helps: catharsis (unlikely), confronting previously inhibited emotions, cognitive
processing to give a coherent narrative helps organize and structure traumatic memories making
it easier for our internal schemas to process, and repeated exposure means extintion of negative
feelings and habituation This may be important for the addict
The recommendations for this study, however are to maintain confidentiality and
anonymity, the writing will not be read unless they want it to be and keep the writing separate
from EMR. This is were we are challenging that idea, we think that incorporating a
narrative into the EMR will be beneficial.

Sullivan, M. (2003). The new subjective medicine: Taking the patient's point of view on
health care and health. Social Science & Medicine. 56(7), 1595-604.
Starts with a history of medicine, the allopathic approach. A body is a body.
Crises in focusing on preventing a “premature” death and the ethics on decideng who
should get the resources if we are fighting death, who determines who is premature.
Push for more autonomy of the patient, 1957 Salgo vs. Leland Stanfor Jr, doctors must
give details of the health to patients so that patients can make their own decisions. Absence of
consent is negligence- 1960 Natanson vs Kline.
In 1960s and 1970s growing movement of autonomy. People have the right to say they
want to die, even if determined premature by physicians. Shift in the approach of allopathic
medicine. 1980s lead to shift for patient-centered outcomes. But how to determine what these
are, not until Alves in this decade has that been studied for substance use, include the
patients!
The coincides with decreasing reimbursement and tying reimbursement to outcomes.
This makes a conundrum: what if the patients’ chosen outcomes are not what the insurance
company wants? What is the patient’s outcome expectations are not what the physicians
think is reasonable?
This shows physicians into the role of mediator and therapists. But this is
unavoidable.
Author points out that there is not a “gold standard” to validate measures that are patient
generated. Points to the differences between subjective and objective. Shift from health status to
quality of life.
Quality of life questionnaires are inadequate, too limiting, cannot adequately capture a
patients POV. Easier to measure health status.
Health state utilities: looks at the value of their health state. How close they are to dying
vs. the trade off to shorten length of life: Quality Adjusted Life Year.
If you are going to look at preferences, then the questions becomes Whose preferences?
The payer, the buyer or the providers? Looking at the money, does is make economic sense to
give it to the ones who are closest to death?
Is medicine supposed to improve the body? The health? Or the life?
Outcomes research is showing that only the patient can determine is the treatment was
successful. Health is not biological; a patient is more than a body. Subjective health is more
meaningful to a patient.
Theory is underdeveloped: using medicine to improve quality of life as opposed to death
and disease rates, Medical effectiveness needs to be determined from patient’s lives.
For our study, the first step would be to understand the patient’s who experience,
not just the disease process at hand. Narrative medicine can help with this.
Smith, S., Kloss, J., Kniele, K., & Anderson, S. (2007). A comparison of writing exercises
to motivate young women to practise breast self-examinations. British Journal of Health
Psychology, 12(1), 111-123. doi:10.1348/135910706X93637
Objective: to examine the efficacy of writing exercise to increase from pre-contemplation
to contemplation to ultimately promote a healthy behavior: self breast examinations (BSE) in
college-aged women.
391 college women, pretested to see who was in precontemplation (PC) stage of BSE,
came down to 69 participants but 14 lost to attrition, Final 55 women
Three groups: stage matched PC to consciousness-raising writing exercise (n=16), stage
mismatched to action oriented exercise(n=19) and control with no writing (n=20). Was a writing
exercise but not necessarily narrative medicine
Baseline: Descriptive info questionnaire, SOCQ and self-reported performance of BSE.
Wrote for 20 mins two times, one week apart.
Stage matched PC group: writing about thoughts and feelings surrounding breast cancer
and BSE. Similar to reflective writing, i.e. narrative medicine
Mismatched group: write about plan to perform BSE
Control: no writing assignment
5 weeks after initial visit, was given the SOCQ and self reported BSE performance
Result: experimental groups endorsed significantly more contemplation than controls at
the 5‐week follow‐up but were not significantly different from each other. Ie any writing about
BSE makes you more likely to increase your change behavior, advance on the TTM
In discussion, state “To our knowledge this is the first study to adapt Pennebaker's written
emotional expression paradigm to promote health behaviour change”
“written emotional disclosure as a strategy to motivate behavioural change” this is a
good quote
Preliminary finding: does not need to be stage matched, but that any written disclosure
will help
Control group: actually had some women to have perform the action at 5 weeks of BSE,
even through they did no writing. Maybe just being asked and having someone looking at
them can change the behavior, Hawthorne effect.

Conroy, D., & Hagger, M. (2018). Imagery interventions in health behavior: A meta-
analysis. Health Psychology : Official Journal of the Division of Health Psychology, American
Psychological Association, 37(7), 668-679. doi:10.1037/hea0000625
Meta analysis using mental imagery. Focus on future action, task or event. Not sure if
this counts as narrative medicine in our sense. Does state “involve self directed imagining or
visualizing specific events, actions, or outcomes, including concomitant feelings and responses,
with the express purpose of increasing motivation toward a target action or task” so this is
narrative medicine adjacent: ask to explore thoughts and feelings and be reflective and
gain deep understanding.
Found that in the 26 studies that they looked at, five criteria saw a significant change in a
health behavior, not at mental health, but rather a real behavior like healthy eating, increasing
physical activity, reduction of alcohol consumption or smoking cessation This is like substance
abuse, need to show a physical behavior of change to make a real difference.
No difference if there was a written component alongside the imagery. More a difference
in the older non-student populations more like what we will find in this study.
Tubman, J., Montgomery, M., & Wagner, E. (2001). Letter writing as a tool to increase
client motivation to change: Application to an inpatient crisis unit. Journal of Mental Health
Counseling, 23(4), 295-311.
States that: “Letter writing can be effective tool in “window of opportunity” settings
(such as crisis units) for increasing client motivation to adopt positive behavioral changes.
Essentially this article is about how letter writing can help, but not a study.
Focuses on letter writing in a group setting, asking open ended questions and being
reflective, affirming clients as they make their statements and summarizing what the client is
saying. Very much like narrative medicine
Does offer a case example: M, a client with substance abuse disorder. Was apart of a
group and wrote a letter that he share to the group of 8-12 people. Was asked this open ended
questions but became angry. Next day came to facilitator for one on one and told his full story
Narrative medicine!! Sharing with the facilitator
6 weeks later, came back and stated the letter writing and subsequent sharing helped his
maintain his sobriety, brought more understanding of himself to make healthy behavior changes.
Again, not directly about narrative medicine, but narrative medicine adjacent.
But does state that letter writing “process of writing and sharing personal narrative” so
seeing letter writing as a tool to share a personal narrative.

Sarah Meshberg-Cohen, S.; Svikis, D. & McMahon, T.J. (2014) Expressive Writing as a
Therapeutic Process for Drug-Dependent Women, Substance Abuse, 35:1, 80-88, DOI:
10.1080/08897077.2013.805181
Looks at specifically women who have SUD (substance use disorder). Builds on
Pennebaker’s idea that because more people with SUD also have some sort of trauma in their
life, expressive writing/disclosure of life experiences can help, so says the research. Lots of
research to back this up
States “writing as a mean of disclosing traumatic experiences may be a powerful adjunct
to traditional SUD treatment.” Purpose of study is to determine if it is a good adjunct to
traditional therapy. Negative effects ore usually transient.
Hypothesis of study: both groups would have recovery (because they are in a treatment
center) but that the experimental group will have more recovery and that the negative affect of
writing will be short lived: increase with experimental group but will decrease
Study: 149 women in a residential SUD treatment facility. Primary outcome measures
were the stress diagnostic scale, secondary depression scale, limbic languidness, brief symptom
inventoryThis is something that we need to cover. How to measure change? What are the
proper outcome measures. Varys in the literature
Writing protocols were determined from the lit review: 4-20 minute writing sessions on
consecutive days. Ours will be oral, and based more on the AA story telling aspect. Grouped
into experimental: writing about emotional topic, and control: writing about neural topic.
Given baseline assessments. 2 weeks and 1 month follow up assessment.
Not all participants did all 4 sessions, but most did. I’m sure the writing was
anonymous. This is different for our study. In our lit review, we need to explore how its
more than the act of putting into words, but rather sharing a community and becoming
accountable that will effect change.
At 2 week: the experimental showed greater reduction in trauma symptoms depression,
and anxiety, but this had disappeared by the 1 month. Both groups improved (but were in a
residential treatment session). Trauma issues in experimental group shortlives
Talks about habituation when writing, how that can help with extinction.
Implications: “trauma-focused interventions can be incorporated.. without triggering
more harm.” Good quote: “expressive writing was found to be a brief and low cost adjunct to
current residential SUD treatment. Expressive writings’ efficacy, efficiency, and cost-
effectiveness, suggest that writing as a means of disclosing traumatic experiences may be a
useful adjunct to traditional SUD treatment.” Can use this in our lit review/
Points out limitation that most of the participants had less than a high school level
education, but did not mention if this effected their ability to write.
Ames, S., Patten, C., Offord, K., Pennebaker, J., Croghan, I., Tri, D., . . . Hurt, R. (2005).
Expressive writing intervention for young adult cigarette smokers. Journal of Clinical
Psychology, 61(12), 1555-70.
Bases for research: stress causes smoking, and expressive writing about emotional
experiences can help with stress management, theorized (Pennebaker, 1997) that it reduces active
mental inhibition ¨when we try not to think about something it effects our CNS and ANS and
becomes a low level stressor. Whatever the reason, expressive writing has been found to be
helpful in a variety of things!
Also, if we are using our energy “working memory” to not think about something, then
there si less attention available for the problems at hand (Klein 2002) .
Study: 60 participants, ages 18-21 years old, current smokers. Two groups: Brief office
intervention (BOI) vs brief office intervention plus expressive writing (EW). 30 in each group
but lost like 7 to attrition. VERY SMALL SAMPLE SIZE.
BOI: meet once a week for 4 weeks, initial session 60-70 mins, other 15-20 mins. Went
through an established intervention from the DHHS
EW: same intervention as BOI but also instructed to write at home for 20 mins a day for
4 days. Needed to take them 2nd office visit focused on smoking, not whole narrative, not
given structure to do it, not sure about compliance, compliance only self reported and to
bring to 2nd session only visually inspected but not read
Looked at tobacco usage at baseline, 4 weeks, 12 weeks, and 24 weeks: self reported and
measured expired air CO. Also looked at psychological stress with Life Experience Survey and
Perceived Stress Scale and Positive/Negative Affect Scale

Did not find a difference in cigarette smoking nor in stress.
Limitations, ideas for why it was not effective:
Participants said the structure and support of having people was the most effective.
1) “expressive writing may not have offered benefit because participants were not truly writing
in a self-reflective manner.” Was confidential, not sure what people wrote about
2) “Finally, it is plausible that expressive writing may not actually be an effective stress
management intervention in the context of smoking cessation. The lack of differences between
the two treatment groups at any time point on perceived stress supports this hypothesis.
Unfortunately, there is little to draw on from the existing literature to address these questions,
and the mechanisms of action by which expressive writing exerts its effects is currently
unknown. It is possible that expressive writing is less effective in promoting behavior change in
some areas, such as tobacco cessation or substance use, than in others.”
3) “Another possibility is that expressive writing may be more effective for participants in
different stages of change. Given the small sample size of the study it was not possible to assess
differences in the expressive writing task in relation to the participant’s stage of change. Further
investigation to address these questions is needed.” BIG! This shows that research is needed
to look at stages of change
They also stated that “the focus of their writing was to be on their very deepest thoughts
and feelings related to smoking or stopping smoking and the ways smoking related to problems
or conflicts in life. This topic of focus may actually have negatively impacted some individuals’
smoking cessation efforts by causing them to focus more on their cigarette use and thereby
unwittingly increasing craving for use.” Expressive writing can make a short term bad mood. If
just done by themselves at home instead of structure interview, this could make it worse.
As I said before, it was so focused on smoking, may be counter productive. But the
research shows that the end goal of total abstinence may not be the best for looking at the
change behavior, but that we need to look at stages of change and where we are
Also states that limitation with no pharmacological therapy. Change needs to happen in
all the facets of a person, not just one. This may be why our approach will be better: clients
will be receiving all the “traditional” help with medical and pharmacological and
psychological and case management support, but this might be the extra something that
helps get the person there.

Baikie, K.A., Wilhelm, K., Johnson, B. et al. (2006). Expressive writing for high-risk
drug dependent patients in a primary care clinic: A pilot study. Harm Reduction Journal. 3: 34.
https://doi.org/10.1186/1477-7517-3-34
Looks at effectiveness and acceptability of expressive writing for high-risk drug
dependent patients in primary care clinic looking a psychological and physical outcomes.
Participants could not be in immediate crises, needed to be enrolled in program with
comprehensive medical, counselling and social welfare services.
Psych outcome measures: Depression anxiety stress scall (DASS-21)
Physical health outcome measure: 12 item short form health survey
53 participants: asked to do 15minute, 4 consecutive days, onlye 18 did all four. Quite
different than the inpatient population with Meshberg-Cohen et al (2014) who were
inpatient. Maybe if they are already in the change stage, they do not need the same support.
Acceptability: most people 86% found expressive writing moderately to extremely
beneficial/ it is well-received, both bytMechberg-cohen, and this study.
No difference in the psych and physical outcome measures at two week follow up.
They talk about in instructions to write about “recent stressful even” not most
LIMITATIONS
Noteworthy that this is well received among a difficult population
We should add something to see if this exercise is well received by our research
group
Quote from the conclusion “given the difficulty implementing psychosocial interventions
in this population and previous findings of health benefits after expressive writing, further
research with a larger sample is warranted, as expressive writing may prove to be a useful
intervention for harm reduction in people with substance abuse problems.”

Lund, P. (2016). Christianity in narratives of recovery from substance abuse. Pastoral
Psychology, 65(3), 351-368. doi:10.1007/s11089-016-0687-3
This article is more about Christianity and using faith in the recovery of substance abuse.
Interview 21 people, all adults 18men and 3 women, all Protestant in Finland:
inclusionary criteria all had serious substance abuse, been in recovery at least 3 years, attended
interviews voluntarily, all used Christianity in their recovery, self reported. Limiting, because
there is no way of knowing what it means to “take advantage of the Christian faith in their
recovery.”
Good quote, “Recovery was not limited to quitting their substance abuse, but included
re-establishing relationships; reordering their use of time; learning to cope with everyday skills,
obstacles and burdens; and managing their finances.”
Interview structured to “comprehensive picture that would reveal the original events and
experiences as much as possible” Interviewed twice with activity in between
First interview: began with life story for comprehensive picture the second part was
clarifying questions to invite sharing 40mins-1hr50mins, average 1hr 15 min. Not just talk
about recovery, but whole life
Homework: recall quotations, songs to helped with recover.
Second interview: discussed the meaning of the songs and quotations. Then given 8
prompts specifically about Christian faith and asked to comment, 31min to 1hr34 min. Avg: 56
min More time spent talking about whole life, not just recovery and/or Christianity
Then did a narrative analysis: looked at how faith was used to gain and maintain sobriety,
20 stories fit into 4 categories.
1) “Third time lucky”: 4 participants, chaotic childhood, tried decades to become sober and
relate to Christianity, with 2x relapsing third attempt was successful
2) “First be rid of wickedness, then be rid of holiness”: 7 participants: initially able to quit
substance and become a strict Christian (too extreme), then years later be liberated to a
more merciful Christianity
3) “A license to Live”: 7 participants: shame involved in trying to accept self due to
traumatic childhood, bulling, sexual abuse. Drugs were the escape. Christianity helped
accept self. This is a part where narratives in and of themselves can help with
recover, right?
4) “Out of the blue” 2 participants. This is the typical “hitting rock bottom” with god
uplifting
Biggest point in this research for us: that recovery is a process, that looking at the
change process is important for recovery

Hänninen, V., & Koski-Jännes, A. (1999). Narratives of recovery from addictive
behaviours. Addiciton, 94, 1837–1848.
Deals with narratives after addiction to learn what are the processes of change. Does have
some interesting quotes:
“self-narrative structures the conception of the past by focusing on the events
considered to be essential in shaping the life course. It also provides future orientations.
The formation of a self-narrative is particularly important in times of life change…in
forming their stories people make us of the cultural stock of narratives and myths that is
accessible to them. In a new situation, they browse more or less consciously through this
cultural warehouse of narrative models to find one that fits their own experience. These
models are then tried on, rejected or approved, adjusted to or transformed. The authors
can be seen as theorists of their own life who use existing literature as a guide for
understanding their problems in the same way as researchers, who test and modify
existing theories or create entirely new ones on the basis of their data”
Also states.
“A narrative ca n be seen to articulate different but interrelated spheres of
meaning emotional ,causal and ethical on account of which a narrative s always more
than a mere review of the succession of events. The specific potential of a narrative to
grasp the multi-layered nature of human life ca n be seen to result from the inter -play
between these spheres”
Study: 51 participants, recovered for 3 years. Asked to write in third person: 47 wrote, 4
were recorded. Coded into 5 stories
 AA story: hitting rock bottom, finding AA, prodigal son and victim of disease: mostly
AA/alcoholics
 Personal growth story: difficulty being seen as child, gradual acceptance, butterfly out
of cocoon, victim from other’s actions: mostly AA/alcoholic
 Co-dependency story: secrets in family/childhood, inherited/cyclic, breaking the
cycle, victim of a victim: mostly polydrug users
 Love story: no love as a child, able to find love. Addiction was justified as
compensation: mostly eating disorders
 Mastery story: feeding the addiction was a weakness, not feeding it is
control/hero/master: mostly smokers
Does not say how many in each. For our study, the important part is nearly all of
these are rooted in childhood and finding a way of understanding your life is important.
Narratives can help with this.
“The profound differences between the story types found in this study indicate
that an addiction can stem from various kind s of problems and that there are many routes
to recovery….Clients in treatment should be encouraged to create and express a story that
fits their own experience, to make full us e of the cultural stock of stories and not to
comply blindly with any pre-existing narrative model.”
This is important for narratives. People need to tell their own story to be able to
have the ability to be able to handle new situations.

Orford, J. (2008). Asking the right questions in the right way: the need for a shift in
research on psychological treatments for addiction. Addiction, 103, 875–885.
Quote from another article about this article ““What has been unsatisfactory, according to
Orford, was the inability to integrate research on unaided change, the use of inappropriate time-
scales for the change process, the failure to take the system or social network view, and the lack
of the patient’s view. He calls for studying change processes instead of named techniques and for
studying those change processes within broader, longer-acting systems, of which treatment is
only a part. Additionally, he recommends acknowledging a variety of sources and underlines the
importance of qualitative research (Orford 2008)” I forget which article. I can find if needed.
Essentially. This article looks at why addiction treatment is so bad. the problems that are
most deal with our research include the following 4 of the 7 listens
Failings of existing treatment and research into addiction recovery:
 It neglects relationship in favour of technique: This states that the therapist-clinet

relationship is most important, than what the therapist actually does. Needs to look
more at “working alliance. If the theory that narrative medicine will better link
the medical community into this alliance, this fellowship, then this study should
be right in there
 It imposes inappropriate time scales on the process of change: Sort of looks at
relapses and everything in terms of 12 months. Our time scale is short, however, we
are looking at one small part of the change process, and it’s “extensity” what it
could lead to
 It fails to take a systems or social network view: the whole social network is
important. We are not looking at the whole social network, hoewver, our
treatment, again if my theory is correct, is to help the participant understand
that the medical community is a social network, and that could impact them
 It does not into the patient’s view: this is a big one for us. Addiction treatment does
not treat the patients as “clients” People need to play active role and feel that their
viewpoints are respected. This is what we can help with!
Suggests the following ways treatment research should change:

1) Stop studying named techniques and focus instead on studying change proceses. It
offers this quote “One way forward, then would be to develop and test a theory (or
better theories) of addiction behaviour change.. it might draw on a model of processes
of change that claims to transcend particular treatment types, for example self‐
liberation or consciousness raising (from the transtheoretical model of change [19,
69])” This is what we are doing, Looking at the process of change, not the final
outcome.
2) Start studying change processes within the broader, longer‐acting systems of which
treatment is a part. Talks about how this can be looking at AA/NA/GA, churches,
social network. This is a little removed form us, but kinda applicable
3) Bring our science up to date by acknowledging the variety of sources of useful
knowledge: talks about using more than just quantitative research. More applicable to
us, the author talks about a shift in the research, and by extension, the medical
filed/treatment specialists that would “shift the balance” and “acknowledging the
importance of lay knowledge” this is what narrative medicine is aimed at, to go
more into “new subjective medicine” and focus on the patient. Make the patient
the expert.
Lederman, L.C & Menegatos, L.M. (2011) Sustainable Recovery: The Self-
Transformative Power of Storytelling in Alcoholics Anonymous, Journal of Groups in Addiction
& Recovery, 6:3, 206-227, DOI: 10.1080/1556035X.2011.597195
Builds on previous research: 1979 Robinson found that storytelling is important in AA:
not telling a story led to increased attrition with AA. Theorized “talking is the mechanism of
change”
How and why is the question?
Other research points to self-acceptance and reinterpretation of reality. Receive social
support and information, make sense of their illness and develop a new identity.
Discusses the idea of narrative coherence: creates a story free of contradictions and that is
has narrative fidelity: is a good enough reason for action. Coherent and believable. This is a
paradigm from Fisher
Survey 178 AA members. Not just ask to tell story but asks WHY telling story is
beneficial. Online questionnaire of self-identified recovering alcoholics in AA. Not an
experimental study
Open ended questions and they did a thematic date analysis. Emergent themes:
1) Reminders of painful past. Sharing the story reminded them of what it was like when they
were using
2) Reinforcing Recovery. Reiterated the progress they have made. Sense of gratitude.
Reinforces AA concepts
3) Losing sense of terminal uniqueness: that others have experienced the same thing. A
sense of belonging to a fellowship. This we can use, while the medical community is
not also sharing, but they sharing with us, it begins this idea of fellowship and
feeling like you are being understood
4) Developing one’s relationship with self. Helps them clarify their thoughts and change
understanding of the past. This is what we can do A little contradictory, but they felt
sharing helped them focus on others. Maybe link it back to the idea that once it is
shared it can be stored and forgotten, not needed to use energy to maintain it.
5) Helping others. See above. Help other alcoholics by knowing they are not alone.
After developing these themes, the authors applies Fisher’s narrative paradigm: ask if it is
narrative coherence and fidelity. These stories have both. They conclude that:
“Storytellers begin to uncover their aspirational selves, to get a glimpse at their
own potential and possibilities, as they share and listen to their own stories. As such, the
stories are a form of self-talk that is self-persuasive, and it is through that self-persuasion
that they find the way to sustain their sobriety and refrain from drinking alcohol.”
They conclude that by telling their stories leads to self-persuasion to change themselves
to sustain sobriety. Iterative process, ongoing, and requires the continuation of telling and
retelling. They suggest that people who work with SUD become more 12-step literate.
Suggests that other studies look at storytelling as other mechanisms of change and if
telling out loud in formal/informal wats can help create a commitment to health and wellbeing.
We can use this with out research

Alves, P., Sales, C., Ashworth, M., & Faisca, L. (2018). “There are things I want to say
but you do not ask”: A comparison between standardised and individualised evaluations in
substance use treatment. International Journal of Mental Health and Addiction.
doi:10.1007/s11469-018-9985-6.
This study compares people using standard measures vs. sharing a personal story. For
people with substance use disorder
Like other fields of medicine, standardize outcome measures are used in order to show
the outcomes, to create goals and inform treatment session. These outcome measures are created
by experts. Even when asked, it is hard for patients to come up with their own outcome
measures (Neale et al, 2015-“ You’re all going to hate the word ‘recovery’ by the end of this”:
service users’ views of measuring addiction recovery” ***this might be a study that I may need
to look up***) this highlights the gap between the scientific/medical community’s and the
actual patients
People who have substance use disorders tent to be stigmatizes and seldom get their
views taken into account, so by doing an individualized outcome measure: either talking or
writing- we could help. People prefer interview based over writing this is based on the one
author’s previous research, specifically about developing their own outcome measures
Method: 93 people:
Two individualized measures: that asks open-ended questions written and an interview
based, semi-structures. 29 people got individual then standard then individualize, the rest got
standard then individualized
Standard measures: three standard measures that are used in the mental health field
frequently
49% had problems captures on individual measures not on standardized and about one
quarter of the problems reported by patients were not covered by the standard outcome measures
Individualized can give patients a voice beyond just the problems with the
alcohol/substance
For us, this highlights that a less structured interview and dealing with the patient
would help elicit a more personalized approach. Listening to stories would allow medical
professionals to understand the issues of the complex problem of recovery/substance use
disorder
Herrera-Sanchez, I., Rueda-Mendez, S., & Medina-Anzano, S. (2019). Storytelling in
addiction prevention: A basis for developing effective programs from a systematic review.
Human Affairs, 29(1), 32-47. doi:10.1515/humaff-2019-0004
Research shows that drug prevention may work in one context but not others. Problem
needs to be contextualized to understand all the issues
Must change everything at once, not just one thing
Narratives offer contextualizations
This is a metanalysis to look at different approaches in addiction prevention
interventions. Looked at 29 studies with “story telling” and some sort of drugs/ drinking.
Different types of story telling : telling a story for another purpose (like to analyze
themes), in therapeutic setting to tell story just to tell story, in social situation to tell story for
teaching or a proactive of mutual help for each other, also fictional stories to help represent an
object/concept.
The author’s conclusions:
1) Stories are a gateway for health intervention, esp. marginalized and at-risk populations
like our populations
2) Narrative need to be based on strengths and capabilities for positive development and
used to critically asses negative consequences not like our study, but we can link it to
that other study that found that the good impact outweighs the minor
discomfort/negative impact, and that we will have other support systems in place
3) The narratives act as motivators, and have potential to stimulate change this is where we
come in, it has the “potential” we are quantifying it. The story telling reinforces
addiction recovery
Their conclusions is that a future line of research to determine effectiveness of
storytelling as a motivating mechanism for change. Prevention programs should have multiple
components, and incorporating story telling would help in developing a culturally adapted
intervention.
Koski-Jännes, A., & Turner, N. (1999). Factors influencing recovery from different
addictions. Addiction Research, 7, 469–492.
Factors and motivations for recovery change for different addictions.
Looked at 76 participants. Qualitative analysis. 16 poly drug users, with 9 also heavy
drinkers. Pretty small sample size
Most common route for polydrug users: inpatient with continues care plus NA/AA
meetings.
The factors influencing change for polydrug user: Revival (finding god/religion), twelve-
step factor: having that mutual support.
Twelve step: Also involves sharing/narratives, story telling. LOOK INTO THIS!!!,
the “first order” and story sharing
---------------------------------------------------------------------------------------------------
Weegmann, M., & Piwowoz-Hjort, E. (2009). “Naught but a story”: narratives of
successful AA recovery. Health Sociology Review, 18, 273–283.
This deals with mostly AA, not drug users, however, there is a lot of crossover
between alcoholics and polydrug users (Koski-Jännes & Turner, 1999) that there can be
similarities drawn.
Discusses the importance for narratives and sharing in AA/NA as a way to reappraise
their situation and embark on major change (like abstinence). It focuses on story telling
Interviewed 9 people, 8 AA and 1 NA Again, very small sample size been sober at least
9 years, mean 14 years. Not written but spoken. Mostly found help in maintaining change by
fellowship.
Limited because these people would already be in the
precontemplation/contemplation stage of change is going to AA meeting. Our group may
not be in that situation.
Quote from the article, find this reference: Hänninen, V. and Koski-Jännes (2004:243-
244) who argue that, 'The stories thus suggest that in order to get going on the way to recovery,
people need to form a credible model of their problems, which can be used to guide their
attempts at recovery'
Kelly, R., Wood, A., Shearman, K., Phillips, S., & Mansell, W. (2012). Encouraging
acceptance of ambivalence using the expressive writing paradigm. Psychology and
Psychotherapy, 85(2), 220-8. doi:10.1111/j.2044-8341.2011.02023.
From Procaska & Velicer 1997: Ambivalence is during the contemplation stage or
according to Prochaska and Velicer (1997), people in contemplation stage. The balance out the
pros and cons and get stuck. Called “chronic contemplation” Not ready for action oriented
approach.
This study, Kelly et al (2012) looks at using expressive writing to help combat this
ambivalence. 40 participants, all college age. They were tested on ambivalence using the Striving
Ambivalence measure as well as Depression Anxiety and Stress scale for pretest and askes to list
10 personal goals and rate ambivalence and distress about ambivalence towards each goal. 2
groups.
Control: neutral topic writing, how they use their time
Experimental: write about goals and write about deepest thoughts and feelings with ambivalence
and significant experiences and how goals relate to other aspects of their lives.
Both wrote for 20 mins, three consecutive days. All anonymous.
Post test: rate their ambivalence and distress towards each goal three weeks later.
Results: those in the experimental group felt less distress about their ambivalence. No difference
in how ambivalent they are.
Hmmm, this does not bode well for our study. It means people are ok with being in
the contemplation stage?”
“The reduction in distress about ambivalence …could be interpreted as indicating that
expressive writing encourages or facilitates acceptance of ambivalence; if the same level of goal-
related ambivalence remains, but the individual is no longer as distressed by it…Learning
through writing about one’s ambivalence to tolerate this ambivalence, despite the ambivalence
itself remaining, might be a sign of developing maturity…expressive writing could potentially be
used as a therapeutic technique to encourage acceptance.
However it does day “the lack of change in actual ambivalence levels is not seen to be
problematic, because the intervention reduced the aspect of ambivalence that was correlated with
psychological symptoms; distress about ambivalence” We could interpret this as people in the
chronic contemplation stage may be feeling distress about it, knowing they need to change
but not feeling like they can. But, using narrative medicine, we can decrease this stress, as
this study shows, and this can help with overcoming the chronic contemplations.
The study also states “Prochaska’s transtheoretical model of the stages of change (e.g.,
Prochaska & DiClemente, 1983; Prochaska & Velicer, 1997) might conceptualize this as moving
from the ‘precontemplation’ stage to the ‘contemplation’ or ‘action’ stage; a change, which could
arise through the increased awareness afforded by the expressive writing process. Future studies
could address these possibilities”

Christenson, J., & Miller, A. (2016). Slowing down the conversation: The use of letter
writing with adolescents and young adults in residential settings. Contemporary Family Therapy:
An International Journal, 38(1), 23-31. doi:10.1007/s10591-015-9368-0
These authors find that reflective writing, which they deem “letter writing” is useful to
move clients through the stages of TTM
From pre-contemplation to contemplation: Impact letters. These are written by family
members to the clients to help them understand what their behavior has done. Allows them to
reflect on their behaviors, increase accountability, and see how they affected others.
The response letter should help change their perspective, be reflective.
From contemplation to planning/ action: accountability letters. They must describe what
they have done and acknowledge how it has impacted others. Steps 8 and 9 of the 12 steps.
Willingness to be open and honest provides an indicator for how ready for change they
are. Ruminating on the bad things can trigger feelings of disgust. Here we go, this is a
mechanism of action with narrative medicine. By expressing what has happened, being able
to move forward, this is how to move forward with change!!!
States offering accountability helps provide opportunities to reaffirm their worth and
value. Structured letter writing allows adolescents to be confronted with their behaviors and
allow space to accept responsibility
Not quite our study, because our letter writing/narratives will not be transactional.
Waters, K., Holttum, S., & Perrin, I. (2014). Narrative and attachment in the process of
recovery from substance misuse. Psychology and Psychotherapy: Theory, Research and Practice,
87(2), 222-236. doi:10.1111/papt.12005

This looked at seven recovery narratives. Found that they found value in attachment with
the psychologist and needed “a process of making sense of the abuse/trauma and its contribution
to addiction.” The attachment created a “secure base” for the people to explore their thoughts and
feelings. “The narratives provide rich examples of the proximity and closeness, safe haven,
secure base, and separation anxiety ultimately leading to the clients internalizing their
psychologists; which are the four components to a secure attachment (Bowlby 2000).”
They also stated “Future research is needed to explore readiness to work through
psychological distress to recover from substance misuse. Future research may investigate those
factors indicating this readiness, which could then be incorporated into initial assessments”
This is TTM
Petraglia, J. (2007). Narrative intervention in behavior and public health. Journal of
Health Communication, 12(5), 493-505.
Quotes. “The ability of individuals to contextualize behavior is fundamental to behavior
change”
“behavior change is essentially accomplished by weaving together past and present
perceptions into coherent stories, or narratives.”
“individual’s knowledge of the world, including knowledge about his or her health and
how it may be put at risk or promoted, draws from prior experiences, socially sanctioned norms,
and private interpretations that are woven into stories about who we are and how we got here”
“Generally, behavior change interventions depend on people’s conscious efforts to
understand the behavior change ideas being communicated in narratives. …[bears] a striking
resemblance to the transtheoretical model of behavior change (Prochaska, Redding, Harlow,
Rossi, & Velicer, 1994) and notions of self-efficacy, role-modeling, and social learning that
figure prominently in the public health literature on behavior change.”
This is what we can use. Narratives help with consciousness raising, which is a step
in the processes of change and used from pre-contemplation into contemplation
This article goes on to say that this type of understanding of behavior change is common
in western countries, but not in other populations. Also makes a claim that there is differences
between primarily written and primarily oral cultures. Can we make the argument that
Appalachia is an oral culture? People from oral cultures are less able to manipulate ideas
externally, so narrative interventions need to be sensitive to people who re less literate.
There has been a shift in public health thinking that we are more systems based, away
from the autonomous individual, and looking at the social aspects of health.
This article looks at another kind of narrative, instead of people developing their own, the
talk about EE-entertainment education, narratives developed by public health officials for
education in hopes people see themselves in it. An important note with this article.
Good quotes: Generally speaking, theories of narrative suggest that story-based
interventions may contribute to behavior change in very fundamental ways by:
1. helping individuals create cognitive and affective associations that influence
‘‘psychosocial’’ variables such as self-efficacy, outcome expectation, and risk perception; this is
us, narratives can make these associations, not just writing to reduce stress
2. suggesting ways in which reapplication of an earlier ‘‘technique’’ or problem-solving
strategy can be successfully brought to bear on a novel situation (cf. Newell and Simon, 1972);
3. prompting a shift in situation comprehension whereby value hierarchies can be
usefully rearranged (cf. Perleman, 1982) or by encouraging other framing effects (cf. Tversky &
Kahneman, 1981; Sharf & Vanderford, 2003) in which a person’s less risky sense of self can be
tapped.
“recasting story-centered projects and strategies in terms of narrative intervention can
open the door to a more practical and rigorous understanding of behavior change
communication.”
This article argues that public health should use narrative interventions to understand
more about behavioral change processes/ Exactly what we are doing!

Wilson, M., Saggers, S., & Wildy, H. (2013). Using narratives to understand progress in
youth alcohol and other drug treatment. Qualitative Research Journal, 13(1), 114-131.
doi:10.1108/14439881311314694
This paper looks at adolescents in Perth, Australia of people undergoing (inpatient?)
treatment. 2-week detox and 12 week rehabilitation. All polydrug users. Ages 17-20.
Eight participants. Were observed and interviewed. They came up with their own stages
1-5, and says this is different from the TTM because it is for adolescents. It seems similar to
me. You can uses this in the lit review as an example of recovering process going through
stages of change, not just Prochaska’s.
First few stages deals with consciousness raising:
I’m not an addict, I shouldn’t be here, I’m going to shut myself off Stage 1.
I’m not an addict, I shouldn’t be here. I’m going to psuh boundaries- stage 2
Stage 3, the person is “beginning to let fo of the past” So, in theory, those first 2 stages
they still are in the past. Narrative medicine will help to “let go” of it
Stage 4: preparing for discharge home, seeing possibilities.
Stage 5: future-oriented, needing to maintain momentum for change
I’m having a thought. In inpatient treatment, people go through these stages.
Mechanism of action for Narrative medicine is letting go of the past, not just of the
trauma/stress that causes addiction, but maybe by telling narratives the people can let go of
that person they were, the addict, and be able to have room to formulate a new person.
Snow, M., Prochaska, J., & Rossi, J. (1994). Processes of change in alcoholics
anonymous: Maintenance factors in long-term sobriety. Journal of Studies on Alcohol, 55(3),
362-71.
Specifically looking at what takes people from action to maintenance and what keeps
them in maintenance. Mailed questionnaires and got responses from 191 people who self-
identified as once having a drinking problem, no longer drink by self-report and express a goal of
abstinence.
Processes that help: stimulus control, helping relationships, behavioral management,
evaluation, consciousness raising, social liberation, dramatic relief, substance usage (taking
supportive medication). This shows that even those more associated with earlier stages, the
experimental processes (consciousness raising and dramatic relief) still help with
maintenance (the behavioral processes). But behavioral processes still more important that
the experimental ones.
85% had gone to at least on AA meeting and 51% continue to attend. That helping
relationship idea for fellowship.
Interesting: the most common factor was helping relationships and stimulus control,
mostly among those who had ever gone to AA. This can show that even those not going to AA
needed that fellowship, they just get it elsewere.
States that spirituality is an area that is difficult to conceptualize in the TTM. Not sure if
it is a process of change or a level of change or a combination

Swora, M. (2004). The rhetoric of transformation in the healing of alcoholism: The
twelve steps of alcoholics anonymous. Mental Health, Religion & Culture, 7(3), 187-209.
How does AA work? The article summarizes many theories, and states “more recently,
AA stories and storytelling have been the focus of the scholars of AA.”
Narrative is a vehicle for transformations for alcoholics. 3 ways
1) Story telling encodes what AA is and what are the beliefs and propositions
2) Encodes a model of what alcoholism is and what it means to be one
3) “Cognitive tool” used for self understanding This is where we are working
This article bemoans the lack of studies into spirituality. EBP means efficacy should be
measures that AA does no focus on the measurable. Funny, they very much do: 90 in 90,
counting days/weeks/years, etc.
Funny, this author highlighted the same passage that I did about spirituality and the
TTM from Snow et al, 1994.
Sobriety is not just not drinking, it is because a person open to change and growth and
seeing the world differently. This goes in with the systems change: can no just change one
thin, need ot change EVERYTHING, including outlook of life, to be successful.
AA shows that a fellowship is therapeutic but not therapy.
Author argues that AA can not be understood through traditional medical model, better
understood in terms of religious healing. Also agrees that AA is a fellowship, which explains way
Snow et al. found how important helping relationships are in action and maintenance stages.
Patterson, D., Wolf, S (Adelv unegv Waya), & Nochaski, T. (2010). Combining the
transtheoretical stages of change model and the 12 steps of alcoholics anonymous to monitor
treatment progression. Journal of Social Work Practice in the Addictions, 10(2), 224-227.
doi:10.1080/15332561003730262
Stage of change Processes of change AA

steps
Precontemplation  Acknowledge problem 1
 Increase awareness of negatives
 Evaluate self-regulatory activities
Contemplation  Make decision to act 2-3

 Engage in preliminary action
Preparation  Develop change place 4

 Set goals and priorities to achieve change
Action  Apply behavior change methods for 6 months 5-9

 Increase self-efficacy to perform behavior
change
Maintenance  Maintain supportive contacts 10-

12
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we
understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message
to alcoholics, and to practice these principles in all our affairs

Rodriguez, L., Young, C., Neighbors, C., Campbell, M., & Lu, Q. (2015). Evaluating guilt and
shame in an expressive writing alcohol intervention. Alcohol, 49(5), 491-498.
doi:10.1016/j.alcohol.2015.05.001
Not SUD sufferers. College students, 429 of them. Large sample size!
Points out that other studies do not look health behavior change. Also, does not study
mechanisms of change
Hypotheses question: will shame/guilt brought up by expressive writing decrease drinking
intentions But these feelings are short-lived
Measures readiness to change and future drinking intentions pre and post
Placed into 3 groups: positive: write about good drinking even, negative: write about bad
drinking event, and neutral: write about first day of college.
Ompcared to control, those who wrote about negative event reported that they intended to drink
less. Ie, less per week, less during a future typical drinking function and less during a future peak
drinking function.
States “the act of self-reflection.. enacts motivation change” This would be during the
preparation stage and contemplation the weighing of pros and cons.
There theory is guilt and shame will lead to less drinking. Guilt and shame over what has done. I
disagree. That would add stress. These are not stree related drinkers like in the sud
population.

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1

Narrative Medicine and Substance Use Disorder

I. Where are we now

I have begun writing this part. Here are the headings

1. History of allopathic medicine

A brief history of allopathic medicine and its issues

2. Narrative medicine, an overview

How narrative medicine actually works

II. Narrative medicine and SUD

A. Reflective writing and health behaviors

B. Oral narrative and SUD

disclosure would be more beneficial than written.

perceived social support and readiness for change.

My main points that will be supported by the literature are

narrative for the SUD population

3) Inpatient population is the best time for developing a narrative, as opposed to

Obviously, our research hypotheses

2) Expressive storytelling improves readiness for change, reduces ambivalence about

processes patients use to avoid problem behaviors.

research in depth on a topic.

1. Lund, P. (2016). Christianity in narratives of recovery from substance abuse. Pastoral

Articles about TTM and substance use

intensity. Substance Use & Misuse, 45(7-8), 1201-15. doi:10.3109/10826080903474003

intervention for reducing drinking intentions. Addictive Behaviors, 38(12), 2913-2917.

experiences on symptom reduction in patients with asthma or rheumatoid arthritis: A randomized

trial. Journal of American Medical Association. 281 (14):1304-1309.

Addressing if psychological needs helps with physical symptoms using objective

This is unlike those with substance abuse problems.

experimental. 49 in RA: 19 control and 32 experimental. Total: 41 control and 71 in

they could do further exploration with that group.

sealed envelope for less bias.

has more holistic qualitative measures. Double blind: raters unaware

Findings: writing about emotionally traumatic experiences reduced symptoms in both

groups from baseline at 4 months.

groups: RA takes time to change immune response.

needed on structured writing and illness. Enter narrative medicine techniques!!

Medicine 19(1), 3-18. doi:10.1353/lm.2000.0011.

experiment then before.

have been published like a research article.

Why does writing help? Presents three ideas:

need to work as hard to bring structure and meaning to it.”

helpful for health outcomes. But why?!?!

math to figure out the mean/medium and AD if needed.

Three theoretical models for why written disclosure in beneficial.

Mental Disease, 192(9), 629-34.

Written emotional disclosure has a greater effect on physical than psychological

with PTSD or severe depression may be inappropriate.

interventions to improve health outcomes in adult survivors of adverse childhood experiences.

Clinical Psychology Review, 46, 59-90. doi:10.1016/j.cpr.2016.04.007

(2019). A meta‐analysis of expressive writing on posttraumatic stress, posttraumatic growth, and

quality of life. Review of General Psychology, 23, 230– 250.

writing. Advances in Psychiatric Treatment, 11(5), 338-346. doi:10.1192/apt.11.5.338

would benefit and why.

days in hospital, Improved mood/affect, Feeling of greater psychological well-being, Reduced

depressive symptoms before examinations , Fewer post-traumatic intrusion and avoidance

students’ grade point average, Altered social and linguistic behavior

People/medical conditions that it has helped: lung functioning in asthma, RA disease

chronic pelvic pain, and post-op course

Why it helps: catharsis (unlikely), confronting previously inhibited emotions, cognitive

feelings and habituation This may be important for the addict

narrative into the EMR will be beneficial.

Starts with a history of medicine, the allopathic approach. A body is a body.

consent is negligence- 1960 Natanson vs Kline.