Article

Journal of Correctional Health Care

2016, Vol. 22(3) 240-246
ª The Author(s) 2016
Stress Reduction Through Reprints and permission:
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a Brief Writing Intervention DOI: 10.1177/1078345816654230
jcx.sagepub.com
With Women in Jail

Tyson Pankey, MPH1,

Patricia J. Kelly, PhD, MPH2, and
Megha Ramaswamy, PhD, MPH3

Abstract
Objective: To assess the feasibility/acceptability of writing as a stress reduction strategy with
incarcerated women. Methods: The authors implemented a writing intervention in which six
women wrote on topics of their choosing for 20 minutes on 5 consecutive days. Feasibility was
assessed with investigator field notes; daily post-writing evaluations assessed intervention accept-
ability. The study also assessed the continuation of writing at 1-month postintervention and
acceptability of instruments for evaluation of future interventions. Results: Implementation barriers
were minimal; participants voiced enthusiasm about the program and continued to write 3 to 4 days
per week in the month postintervention. No problems were encountered in the completion of
evaluation instruments. Conclusion: Writing is a feasible, reproducible stress relief intervention for
incarcerated women.

Keywords
writing interventions, incarcerated populations, women, stress, jail, pilot study

Introduction
Faced with shrinking budgets and growing populations, correctional facilities offer minimal services
to facilitate rehabilitation. Writing programs, an exception to this practice, appear to garner support
from both correctional staff and inmates, perhaps because of their cost-effectiveness and sustain-
ability. Authors such as Wally Lamb and playwright Eve Ensler, among others, have documented
their success in leading writing workshops in prison and jail settings (Gavin, Katz, & Sunshine,
2003; Lamb, 2008). Unfortunately, limited data exist on measurable outcomes resulting from these
writing initiatives.

1
Department of Counseling Psychology, School of Education, University of Wisconsin–Madison, Madison, WI, USA
2
School of Nursing and Health Studies, University of Missouri–Kansas City, Kansas City, MO, USA
3
Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA

Corresponding Author:
Patricia J. Kelly, PhD, MPH, School of Nursing and Health Studies, University of Missouri–Kansas City, 2464 Charlotte Street,
Kansas City, MO 64108, USA.
Email: kellypj@umkc.edu
Pankey et al. 241

The physiological effects of stress have been well documented, beginning with the pioneering
work of Hans Selye more than 70 years ago (Szabo, Tache, & Somogyi, 2012). These effects include
physical health problems as varied as cardiovascular disease, chronic pelvic pain, and obesity, and
immediate and long-term mental health conditions such as substance use and post-traumatic stress
disorder (Hamer, 2012; Hemmingsson, 2014; Pierce & Christianson, 2015). These problems are
common among women in jail and prison populations, with prevalence rates as high as 80% (Kelly,
Peralez-Dieckmann, Cheng, & Collins, 2010; Lynch, Fritch, & Heath, 2012). Incarceration intro-
duces a range of acute stressors among women in the criminal justice system. For a population
already burdened with high rates of physical and sexual victimization, the stressors of separation
from family; noise; and loss of privacy, individual space, and personal clothing inherent in incar-
ceration further undermine physical and mental health (Binswanger et al., 2010; Massoglia, 2008).
Expressive writing, in the form of three to five consecutive sessions in which individuals write
about traumatic and emotional experiences of their lives, can be a vehicle for minimizing life and
incarceration stressors (Danoff-Burg, Mosher, Seawell, & Agee, 2010). While the mechanisms that
underlie the beneficial effects of expressive writing are unclear, the efficacy of this approach has
been tested across diverse populations, including combat veterans, parents with a pregnancy loss,
motor vehicle accident survivors, victims of sexual assault and intimate partner violence, and
prisoners with substance abuse issues (Kersting et al., 2013; Proctor, Hoffmann, & Alison, 2012;
Sloan, Marx, Bovin, Feinstein, & Gallagher, 2012). For example, 70 women with a history of
childhood sexual abuse who participated in five expressive writing sessions had significantly
decreased symptoms of depression and post-traumatic stress disorder (Meston, Lorenz, & Stephen-
son, 2013). The 149 women in substance abuse treatment who participated in a clinical trial of
expressive writing had significantly lower post-traumatic symptom severity, depression, and anxiety
at the end of a 2-week expressive writing intervention and at 1-month follow-up (Meshberg-Cohen,
Svikis, & McMahon, 2014). Finally, meta-analysis of six studies concluded that writing therapy had
outcomes similar to those of cognitive–behavioral therapy; not mentioned in this analysis was the
significantly lower cost associated with a writing intervention (van Emmerik, Reijintes, & Kam-
phuis, 2013).
While stress is a significant problem among incarcerated women, minimal information is avail-
able about the feasibility and efficacy of a writing intervention in this population. Participation in
such an intervention has the potential to reduce stress for this high-risk group and provides the
additional benefit of a possible sustainable practice when women return to their communities. The
objective of this study was to assess the feasibility and acceptability of implementing a brief writing
intervention to mitigate stress among a group of women moving through a local jail.

Methods
We developed and implemented a brief writing intervention in a medium-sized Midwest county jail.
This pilot study, with a small convenience sample of women (N ¼ 6), assessed the feasibility and
acceptability of the approach, and acceptability of the use of research instruments to assess the
impact on stress for future interventions.

Data Collection
Data were collected at the start of the first session of the intervention, at the end of each of the five
sessions, and at 1-month postintervention. Demographic data collected included age, race and
ethnicity, level of education, number of children at home under age 18, and number of children
at home under age 5.
242 Journal of Correctional Health Care 22(3)

Feasibility was assessed through compilation of the emails, phone calls, and field notes about
implementation arrangements.
Intervention acceptability was assessed by documenting daily attendance, and the number of
women who shared their work during the sessions and who did additional writing between sessions.
We also collected daily postsession thoughts through an open-ended discussion format and a 4-item,
self-report survey, developed for this program, that assessed the extent to which the women currently
felt sad/upset or happy, the extent to which they felt their writing was valuable/meaningful, and the
extent to which they expressed their deepest thoughts and feelings. Responses were based on a 10-
point scale where a score of 1 meant not at all and 10 meant a great deal.
Acceptability of instruments to measure the impact of future programs was assessed with admin-
istration of the 10-item Perceived Stress Scale (PSS-10) at baseline, immediately after each inter-
vention, and 1-month postintervention. The PSS is the most widely used psychological instrument
for measuring the perception of stress in relation to health-related outcomes and the degree to which
an individual appraises life as unpredictable, uncontrollable, and overloaded (Dietrich, Verdolini,
Gartner-Schmidt, & Rosen, 2008). Total possible scores range from 0 to 40, with higher scores
indicating greater stress. Originally tested with both college students and community members, the
PSS-10 is a better predictor of health or health-related outcomes than several life-event scales and
has Cronbach’s a scores above .80 (Cohen, Kamarck, & Mermelstein, 1983). The PSS-10 has been
used with a similar population in a sample of 21 women from a medium-security prison who were
participating in a yoga intervention (Harner, Hanlon, & Garfinkel, 2010).

Data Analysis
Descriptive statistics were compiled for demographic characteristics, PSS-10 scores, and all remain-
ing study variables. Because this was a pilot study with a small sample size, our analyses did not
include significance testing. The means of reported post-writing scores were summarized across all
5 days of the intervention. Qualitative methodologies allowed for basic content analysis of partici-
pant writing and evaluations. Open coding was used to delineate conceptual categories for writing
content. Dominant themes emerging from participants’ expressive writing, daily post-writing eva-
luations, and program feedback were identified.

Procedures
Women were recruited by the jail staff via fliers posted throughout the facility and through word of
mouth in housing units. Inclusion criteria were English-speaking women aged 18 years or older who
were willing to write for at least 20 minutes across 5 consecutive days in a group setting and who
were within 2 weeks of release from jail (to allow for community follow-up). Fourteen women
signed up to participate in the intervention; of these, six were eligible. All participants signed
consent forms that contained wording allowing researchers to collect and return their writing, which
they were free to identify with pseudonyms. The university’s institutional review board approved the
study. As compensation, participants received a gift basket of food from the jail’s commissary.
The 5-day writing intervention took place in the jail’s law library and lasted for 2 hours daily.
Demographic data and a baseline stress assessment were collected at the start of the first session.
Each writing session began with an icebreaker activity to encourage group bonding. Brief prose
and poetry excerpts, selected for their relevance to the women (e.g., by Maya Angelou and
Langston Hughes), were distributed and read aloud by participants to encourage subsequent
expressive writing. Participants also were invited to share any personal writing they did outside
of the intervention period.
Pankey et al. 243

At the conclusion of the introductory activities, participants transitioned into a free write, which
was 20 minutes dedicated to silent and continuous expressive writing. While the strict paradigm of
expressive writing has participants continuously writing prose about traumatic events, to ensure
comfort in our sample with writing, account for variable levels of literacy, and respect possible
reluctance to discuss trauma in the current jail setting, researchers encouraged participants to write
either in poetry or in prose format about any topic they selected (Danoff-Burg et al., 2010).
After the writing segment, participants were given the opportunity to share their writing with the
group, which did not impose any literary critique or criticism of the work. At the end of each day’s
intervention, participants completed a self-report survey evaluating their experience with writing.
All participants’ evaluations and writings were collected at the conclusion of each session and
returned to them during the following writing session. Prior to dismissal each day, blank paper was
given to participants for journaling outside of the intervention period.

Results
The sample of this pilot study on expressive writing was made up of six women (mean age of 40.0,
SD + 8.02, range 26–56). Three women were White and three were African American. Two had
completed high school or had a general equivalency diploma and three had some college attendance
(one woman declined to report her education level). Women had a mean of 1.83 (SD + 1.83)
children under the age of 18 and 0.83 (SD + 1.60) children under the age of 5 living with them at
home prior to incarceration.
Implementation feasibility challenges were minimal, with jail authorities extremely welcoming
about the idea of a writing program.
Intervention acceptability was high, with all six women attending each of the five sessions. All
were willing to share their writing at the end of each day and, each morning, three or four shared the
additional writing they had done the previous night.
Participants had a mean score of 8.90 (SD + 1.32) on the extent to which they had expressed their
deepest thoughts and feelings while writing, 2.87 (SD + 3.03) for the degree to which they felt sad
or upset after writing, 8.40 (SD + 1.67) for the degree to which they felt happy, and 9.37 (SD +
0.81) for the degree to which the day’s writing was valuable and meaningful.
The content analysis of 111 pieces of participant writing found the majority of writing was
nonfictional; the most common topics were about the women themselves, their families, and their
children. Faith and spirituality were important undercurrents in the writing of five of the six women.
Overall, participants’ post-writing comments were positive and extremely supportive of the
intervention. The most commonly expressed sentiment was participants’ characterization of the
writing sessions as enjoyable. All participants described the laughter and joy the writing sessions
evoked. One wrote, ‘‘It was so nice to have the stories and laughs and interactions with everyone,’’
while another commented, ‘‘It made me feel like I was no longer incarcerated, it was very
enjoyable.’’
A second theme was an expression of appreciation and gratitude toward the research staff.
Women were thankful for the opportunity to participate in the brief writing intervention and appre-
ciative of the researchers’ nonjudgmental demeanor. One woman wrote, ‘‘I am feeling much happier
today, I want to thank you all for including me in this class.’’ Another participant said, ‘‘You all are
wonderful and you don’t look down on us.’’
Additional reoccurring themes included self-reflection and learning about others, writing as an
outlet to express feelings, and an overall feeling of relief generated by the intervention. One woman
stated, ‘‘I did not know I could write some of the things I was writing. Very good.’’ Another
participant commented, ‘‘It was really good, it got a lot of what I was feeling out and it kind of
was a relief off my shoulders.’’ One woman summarized, ‘‘It really is just so uplifting and nice to see
244 Journal of Correctional Health Care 22(3)

the smiling and the joy your research is bringing to my fellow inmates and myself. Very enjoyable
and I feel it does relieve stress. Thank you!’’
Of the six participants who completed the 1-month follow-up survey, five continued to write
independently, writing on an average of 3 to 4 days per week for approximately 21 minutes per
session. All six expressed interest in a potential community-based writing group.
Women were agreeable about completing the PSS and expressed no questions or concerns about
any of the items in the instrument. The mean score of the PSS at baseline was 25.00 (SD + 6.16);
immediate postintervention, the score was 13.00 (SD + 5.22); and at 1-month follow-up, 19.67 (SD
+ 4.68).

Discussion
The primary purpose of this project was to assess the feasibility of a brief writing intervention among
women moving through the criminal justice system and to examine the feasibility of instruments to
assess the impact on stress in future interventions. Despite giving women the option to select their
own writing topic, our study findings suggest that participants naturally chose to write about
emotionally charged topics. The majority of women’s writing in this study dealt with real-life
emotionally salient issues such as family, children, and self-evaluation. Results from post-writing
evaluations indicate that women expressed deep thoughts and feelings in their writing and also
considered their own writing to be deeply valuable and meaningful. The introspective element of
participants’ writing may have elicited the emotional and cognitive processing thought to be a
critical mechanism underlying the benefits of expressive writing. Early work by Pennebaker theo-
rized that disclosing one’s inhibited feelings leads to a reduction in stress and, resultantly, improved
immune functioning and health. It is this disinhibition of emotion that is considered to be the change
agent in the expressive writing paradigm (Pennebaker, 2004; Sloan & Marx, 2004).
Women reported enjoying the platform this intervention provided for self-expression and the
opportunity to share thoughts and experiences with other women. The act of participating in a
supportive and uncritical writing group may have provided therapeutic effects, which in turn may
have reduced levels of stress in this highly taxed population. Taking part in the group writing
intervention may also have provided women with the interpersonal communication and emotion-
focused coping skills necessary to become less vulnerable to stressors.
Although this study did not explicitly adhere to the standard expressive writing paradigm, in
which individuals write about the most traumatic and emotional experiences of their lives, this study
found writing to be beneficial to the experience of stress among incarcerated women. Normative
data for the PSS scores range from a mean of 11.9 to 14.2 (Dietrich et al., 2008). At baseline,
participants’ mean PSS-10 scores were more than 10 points higher than these numbers; by the end of
the 5-day intervention, there was a 12-point decrease in these scores, placing participants in norma-
tive ranges of PSS scores among healthy U.S. adults. While mean PSS scores at 1-month follow-up
indicated an increase in perceived stress among participants, the scores did not return to those
observed at baseline, suggesting that participants may have continued to experience reductions in
stress because of their ongoing writing behavior. Journal use remained relatively high during the 4
weeks following the writing intervention (an average of 3–4 days per week), which may have
elicited some therapeutic effects. While it is highly speculative to assume causality with such a
small sample size and without a comparison group, results do suggest the potential for future
investigation with a strong study design.
Given the budgetary issues confronting many correctional facilities today, the cost-effectiveness
of a writing intervention further enhances its utility. Costs incurred during this project included
expenses for paper, writing utensils, printing, and participant compensation. Women did not need to
provide any materials in order to participate, nor was the jail responsible for program supplies.
Pankey et al. 245

Program space, however, was provided in-kind by the facility. The few resources and staffing
needed to implement a writing intervention highlight the potential for long-term sustainability both
within correctional facilities and in a community setting. Information gathered from this interven-
tion will be used to design more tailored and robust writing interventions in the future.
A major limitation of this study is the small sample size; however, the sample was deemed
appropriate for a pilot study and the racial demographics of the sample were similar to those of the
greater female population at the jail. Another limitation was the project’s reliance upon self-reported
survey instruments. Future interventions might incorporate analyses of objective biological markers
of individuals’ stress, such as salivary cortisol. Finally, this pilot study lacked a control group, which
most expressive writing studies include. Lack of comparative data hinders this study’s ability to
draw definitive conclusions regarding the impact of writing to mitigate stress among incarcerated
women. Current study findings may not be generalizable to all women incarcerated in jail.

Conclusions
This project demonstrates the feasibility and efficacy of a writing intervention among women
moving through the criminal justice system. The authors believe this approach could be a successful
and sustainable strategy for addressing stress and trauma in this population. Women behind bars
would seem to be enthusiastic about writing freely among a group of peers and most commonly
write about emotionally salient topics such as their children, families, and self. Providing incarcer-
ated women with the opportunity to express their feelings and experiences through writing may
assist in the alleviation of the physical and psychological burden of stressful life events. Future
research should focus on a more thorough analysis of stress in the lives of women moving in and out
of the criminal justice system and the extent to which free writing may promote improved mental
and physical health. Analysis of salivary cotinine, as a biological indicator of stress, would provide a
more objective measurement of changes in stress across an intervention period.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publica-
tion of this article. For information about JCHC’s disclosure policy, please see the Self-Study Program.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

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