Expressive writing intervention promotes resilience among juvenile ...

Children and Youth Services Review 73 (2017) 220–229

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Children and Youth Services Review journal homepage: www.elsevier.com/locate/childyouth

Expressive writing intervention promotes resilience among juvenile justice-involved youth Chloe A. Greenbaum ⁎, Shabnam Javdani New York University, 246 Greene St, New York, NY 10003, United States

a r t i c l e

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Article history: Received 16 July 2016 Received in revised form 27 November 2016 Accepted 27 November 2016 Available online 03 December 2016 Keywords: Juvenile justice Child welfare Adolescents Trauma Resilience Program evaluation

a b s t r a c t Youth involved in child welfare and juvenile justice systems suffer from alarmingly high rates of mental health challenges. In particular, exposure to trauma (e.g., maltreatment) is one critical experience that amplifies their risk for delinquency and recidivism. Despite a profound need to address these youth's mental health needs, there is a paucity of trauma-informed and youth-centered treatments that are clinically feasible in underresourced residential settings (e.g., juvenile detention facilities). In response to this gap, our research team collaborated with the juvenile justice subsection of a large American city's child welfare system with the goal of creating an intervention tailored to the needs of underserved system-involved youth. The resultant program, WRITE ON (Writing and Reflecting on Identity To Empower Ourselves as Narrators), leverages research on the therapeutic benefits of expressive writing to implement a brief, cost-effective intervention in youth residential settings. This paper describes intervention development and presents findings from the pilot study, which comprised a multisite experimental evaluation of youth (N = 53) residing in short-term detention facilities. This pilot study aimed to: 1) assess intervention implementation fidelity, including participant satisfaction, and 2) evaluate the mental health outcomes of youth receiving WRITE ON as compared to those in a comparison support group (CSG). Results indicated that the intervention was delivered with good fidelity, participants reported high levels of satisfaction, and WRITE ON participants exhibited significant (p b 0.01) gains in resilience compared to their counterparts in the CSG. Collectively, results suggest that a larger clinical trial investigating the effectiveness of WRITE ON with system-involved youth is warranted. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction In addition to physical, financial, and educational difficulties, youth involved in the child welfare and juvenile justice systems suffer from alarmingly high rates of mental health challenges. Studies have estimated that 40–80% of youth served by these systems experience psychiatric illnesses, representing rates greatly exceeding those of youth in community samples (Burge, 2007; Krezmien, Mulcahy, & Leone, 2008; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Disconcertingly, many of these youth do not receive adequate mental health services (Burns et al., 2004; United States Department of Justice, 2005). Numerous studies have underscored the need for more coordination between the child welfare and juvenile justice systems in order to increase youth's access to, and receipt of, mental health services (e.g., Chuang & Wells, 2010). Several major cities have responded to this call to action by merging their child welfare and juvenile justice systems. The present study reports on an expressive writing-based intervention developed ⁎ Corresponding author. E-mail addresses: [email protected] (C.A. Greenbaum), [email protected] (S. Javdani).

http://dx.doi.org/10.1016/j.childyouth.2016.11.034 0190-7409/© 2016 Elsevier Ltd. All rights reserved.

and implemented in collaboration with one such merged government agency in a large American city. 1.1. Mental health needs and treatment of juvenile justice-involved youth The considerable mental health needs of incarcerated youth are well documented. For example, findings from a random sample of 1829 detained youth revealed that nearly two-thirds of boys and three-quarters of girls met diagnostic criteria for one or more psychiatric disorders (Teplin et al., 2002). Furthermore, the study found that 92.5% of participants had experienced at least one trauma (e.g., maltreatment, neglect), and 56.8% had been exposed to six or more traumatic events (Abram et al., 2004). The interplay between these individuals' trauma exposure, mental health problems, and delinquency is notable. Incarcerated youth with trauma histories are at significantly greater risk for suicide attempts and recidivism than those with no history of abuse (Halemba, Siegel, Lord, & Zawacki, 2004; Sedlak & McPherson, 2010). Moreover, a number of investigations have suggested that entry into the juvenile justice system may exacerbate pre-existing conditions (e.g., Kupers & Toch, 1999), and that youth with mental health challenges are more likely to stay incarcerated for longer periods of time

C.A. Greenbaum, S. Javdani / Children and Youth Services Review 73 (2017) 220–229

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(United States Congress House Committee on Government Reform and Oversight, 2004). Youth's transitions into incarceration, characterized by removal from their families and communities, are often inherently traumatizing or re-traumatizing (e.g., Adams, 2010), and their physical and mental health outcomes may worsen by mere virtue of being detained (Chesney-Lind & Pasko, 2012). Notably, there is a pronounced disparity between the need for and the availability of mental health services for these individuals. Investigations by the United States Department of Justice (2005) revealed that juvenile detention and correctional facilities across the country fail to address the mental health needs of detained youth. Research has further elucidated the under-utilization of mental health treatments within this population, with studies finding that only one-third of incarcerated youth with documented psychiatric disorders receive treatment while incarcerated (Pumariega et al., 1999). These patterns are disquieting in light of data showing that under-treatment may contribute to the onset and maintenance of criminal behaviors (Pumariega et al., 1999; United States Congress House Committee on Government Reform and Oversight, 2004) in addition to being associated with chronic physical and mental health challenges affecting youth, their families, and communities (Massoglia, 2008). As such, the mental health of incarcerated adolescents can be reasonably construed as a significant public health concern. Research has highlighted several reasons for the juvenile justice system's failure to address this population's needs. Although there exist a handful of mental health interventions that have been identified as “promising” (e.g., multisystemic therapy; for a review, see National Mental Health Association, 2004), these practices necessitate family involvement, the employment of mental health professionals, screening for and identification of psychiatric disorders, and integrated support among multiple systems (e.g., educational and child welfare systems). The implementation of these treatments is impeded by inadequate screening for mental health and trauma-related symptoms, difficulty engaging families (Burke, Mulvey, Schubert, & Garbin, 2014; Justice for Families, 2012), insufficient clinical resources for intervention delivery (Sedlak & Bruce, 2010), and inadequate collaboration among systems (Huang, Ryan, & Herz, 2012). Further, many extant programs have low levels of youth engagement (Sedlak & McPherson, 2010) and retention (Gaarder, Rodriguez, & Zatz, 2004). Lastly, by nature of the detention facilities in several cities, youth placed in non-secure and residential facilities must travel to secure detention facilities in order to receive medical and mental health care. Such removal from their facilities and transport to secure detention centers are effortful, disruptive, and potentially traumatic, as all youth entering secure detention centers must be strip searched upon arrival. Taken together, the literature exposes a profound need for trauma-informed and youth-centered mental health treatment that is clinically feasible in under-resourced juvenile justice-related settings. Given its brief and low-cost nature coupled with its demonstrated effectiveness, expressive writing (EW) may have utility within this population.

1999), are more inhibited (Smyth, 1998), have less opportunity for confiding, or belong to a stigmatized social group (Richards, Beal, Seagal, & Pennebaker, 2000). In addition, studies (e.g., Smyth, True, & Souto, 2001) have revealed that individuals improved most when they constructed narratives and made meaning out of negative life events, rather than merely recounting them in list format. Potential mechanisms underlying these changes are the schematic restructuring of traumatic memories (Smyth et al., 2001) and desensitization to trauma-related stimuli (Lepore & Greenberg, 2002). Although there is a paucity of expressive writing research on at-risk youth, expressive writing may be an effective form of therapy for adolescents. To our knowledge, only five expressive writing studies have been conducted with at-risk youth (Evans, 2000; Muris, Meesters, & van Melick, 2002; OʼHeeron, 1993; Stice, Burton, et al., 2006; Stice, Shaw, et al., 2006), and none has been conducted with juvenile justice-involved youth. The most robust evidence for the potential utility of expressive writing interventions for adolescents comes from a recent meta-analysis on this topic that is inclusive of 21 independent studies with youth (though their study is not focused on at-risk youth in particular). Specifically, Travagin, Margola, and Revenson (2015) conducted a meta-analysis evaluating the effects of EW interventions among adolescents aged 10–18 years. The overall adjusted effect size was significant yet relatively small (g = 0.13), with significant effects for the individual domains of internalizing problems, social adjustment, problem behaviors, and school participation. Gender did not moderate the effects of EW, but adolescents with high levels of emotional problems at baseline exhibited greater improvements in school participation. Moreover, in one study youth who reported the highest levels of community violence exposure displayed the greatest changes in lability (Kliewer et al., 2011). Relatedly, the use of trauma narratives, a central component of EW, is also integral to trauma-focused cognitive behavior therapy (TFCBT), which has demonstrated effectiveness at reducing symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, and behavior problems in children and adolescents participating in randomized controlled trials (e.g., Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011). Moreover, adolescents who are wary of adult and authority figures may respond better to creative approaches than traditional psychotherapy (Utley & Garza, 2011). Despite the brevity, ease of delivery, and demonstrated effectiveness of EW interventions, none has been implemented or evaluated in juvenile justice settings. An exhaustive search of the literature revealed that there is currently one manualized writing-based intervention for incarcerated youth, Writing Our Stories (Smitherman & Thompson, 2002). Although the program's evaluation comprised anecdotal data and subjectively scored tests and lacked a control comparison group, data indicated that youth who completed the program demonstrated greater emotional awareness and understanding of their placement in the juvenile justice system. Collectively, the literature suggests that written selfexpression may be a compelling treatment for adolescents with histories of trauma exposure who reside in underserved settings.

1.2. Expressive writing interventions

1.3. Intervention development

Though it has not been systematically implemented or evaluated in juvenile justice populations, regular written self-disclosure has been linked with improvements in psychological outcomes in clinical and nonclinical samples (e.g., Pennebaker & Chung, 2011). The first study on EW demonstrated that university students experienced lasting improvements in their mental health when instructed to write, three separate times, about the most traumatic event of their lives (Pennebaker & Beall, 1986). Since its conception, hundreds of studies have implemented the intervention with adults, and the largest and most recent metaanalysis on EW interventions (Frattaroli, 2006) revealed an overall small, yet significant, effect size (d = 0.15). Across EW studies, mental health benefits after writing seem to be greater for those who wrote about a previously undisclosed trauma (Páez, Velasco, & González,

In light of these considerations, our research team collaborated with the juvenile justice subsection of a large American city's child welfare system with the goal of creating an intervention tailored to the needs of underserved system-involved youth. The product of this work was the development of a writing-based intervention named WRITE ON, an acronym for Writing and Reflecting on Identity To Empower Ourselves as Narrators. Particularly novel aspects of WRITE ON include that it 1) uses a youth-centered and trauma-informed manualized curriculum, 2) is based on empirically supported therapeutic paradigms, and 3) is the first implementation of the EW paradigm in a juvenile justice-involved sample. WRITE ON operates within a framework of trauma-informed treatment and its development was influenced by the Substance Abuse and

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Mental Health Services Administration's (SAMHSA) six key principles of a trauma-informed approach: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and cultural, historical, and gender issues (SAMHSA, 2015). WRITE ON is strength-based in that it seeks to foster youth dignity, autonomy, and resilience over and above “fixing” pathologies, an aim in line with Larson's (2000) Positive Youth Development approach to treating juvenile justice-involved youth.

trauma writing after four sessions focused on relationship-building and by succeeding trauma writing with group mindfulness activities. The inclusion of these activities derived from the clinical literature highlighting the importance of incorporating coping skills into trauma treatments (e.g., Salloum & Overstreet, 2012).

1.4. Intervention Design

The present study was the first to implement and systematically evaluate a trauma-informed writing-based intervention for youth in detention employing an experimental design. An overall aim of this pilot study was to assess fidelity of intervention delivery, including participant satisfaction, in a sampling of urban detention centers. Second, we compared the mental health outcomes of youth receiving WRITE ON to those in a comparison support group (CSG) by analyzing quantitative outcome data informing positive and negative mental health outcomes. Based on previous research (Pennebaker & Chung, 2011; Travagin et al., 2015), we operationalized psychological health as encompassing a number of measurable constructs, focusing on both protective (e.g., resilience) and risky (e.g., negative affect) mental health experiences given research suggesting that mental health and illness represent distinct constructs (Keyes, 2005). We hypothesized that WRITE ON would reduce negative mental health outcomes and improve positive mental health outcomes.

1.4.1. Structure In their meta-analysis on expressive writing in youth, Travagin et al. (2015) reported that larger effect sizes were found in interventions with more than three sessions than in interventions with three or fewer sessions, as well as in studies with writing sessions spaced more than one day apart as opposed to interventions with sessions on consecutive days. WRITE ON was accordingly designed to be a six-week-long group-based intervention, with sessions taking place twice a week, for 1.5 h at a time, for a total of 18 h of intervention. 1.4.2. Content Each WRITE ON intervention session followed a fixed structure, in line with findings that the most effective programs for juvenile justice-involved youth are highly structured (Altschuler, 1998). Weekly themes (i.e., emotions, self-expression, relationships, past self, present self, future self) were selected based on anecdotal data collected from interventionists involved in three programs across the country (i.e., The Beat Within, Youth Arts Alliance, Telling My Story) regarding youth's preferred writing topics. Sessions began with the collaborative creation and review of a community agreement (i.e., set of rules), emphasizing safety and respect. Next, community-building activities aimed to increase group members' comfort with and trust in each other. A choice of two writing prompts was administered to youth at each session. Writing prompts encouraged emotional and cognitive reflection in the context of narrative construction (e.g., Imagine you wrote an autobiography of your life up to this point in time, and then you opened the book to a random page. Write that page.), in accordance with studies demonstrating the beneficial effects of emotional and cognitive processing and narrative creation (e.g., Ullrich & Lutgendorf, 2002). Writing prompts were designed to be culturally relevant and sensitive (e.g., “Write about a community you are part of. How might that community help you? How might it hurt you?”). If they elected not to respond to either writing prompt, youth were offered Pongo (http://www. pongoteenwriting.org/introduction-to-writing-activities.html?) worksheets (i.e., fill-in-the-blank poems), and if they declined writing, they were provided with word searches. Following the writing activities, youth were given the opportunity to verbally share their writing with the group and receive semi-structured strength-based feedback from their peers. Youth also had the options of receiving individual written feedback from the facilitator or keeping their writing entirely private. This array of options for writing, sharing, and receiving feedback was created to foster youth empowerment and choice. Groups culminated with a collaborative closing activity (e.g., creating a group poem wherein each member contributed one line). Each participant was supplied with a journal to use between groups, though no homework was assigned. In three separate sessions, Pennebaker's expressive writing prompt (i.e., trauma narrative; see Pennebaker & Beall, 1986) was administered as a second writing activity. Youth were given envelopes in which to deposit their trauma writing, and this writing was not shared with the group or facilitator. The spacing of these trauma prompts throughout the six weeks was based on the finding that the effects of writing are greatest when individuals have the opportunity to habituate to traumatic memories over multiple writing sessions (Smyth et al., 2001). Additionally, youth safety and trust were maintained by introducing

1.5. The present study

2. Method 2.1. Settings and participants WRITE ON was piloted in the summer of 2014 within short-term detention facilities (STDFs) in a large American city. This city is one of several nationwide to have merged their child welfare and juvenile justice systems in response to the exigent need for inter-system collaboration (Ryan, Herz, Hernandez, & Marshall, 2007). These STDFs function as short-term residential facilities that house adolescents while they await Family Court decisions regarding long-term housing (e.g., foster care) or sentences for violent and non-violent juvenile offenses. Out of three possible boys' and three possible girls' STDFs, two facilities housing each gender were randomly selected by the second author, through the use of a random number generator, to be included in the study. Randomization occurred at the site level because it was not possible to randomize individual youth to condition since youth had already been placed in particular detention facilities prior to their enrollment in the study. All youth in participating facilities were invited to participate, regardless of trauma history or mental health symptoms. Given incarcerated youth's disproportionately high rates of trauma and mental health challenges, this program may be framed as a targeted prevention model. Fifty-three detained adolescents (N = 31 girls) between the ages of 12 and 17 (M = 14.72, SD = 1.16) participated in the present study (see Table 1 for participants' demographic information). Thirty adolescents (N = 18 girls) participated in the WRITE ON condition and 23 youth (N = 13 girls) participated in the CSG. Given the high turnover rates inherent to STDFs, 18 youth completed at least two assessments and comprise the evaluation sample for this study (WRITE ON N = 9; CSG N = 9). There were no significant differences in any of the outcome variables at baseline between the full and evaluation samples, with the exception of positive affect, which was significantly higher in the evaluation sample (M = 4.31, SD = 1.20) than in the full sample (M = 3.56, SD = 0.92), t(45) = −2.24, p = 0.03. Within the evaluation sample, there were no significant differences in any of the outcome variables at baseline between the WRITE ON and CSG groups or between boys and girls. Thus, there is adequate support for meeting requirements regarding the establishment of baseline equivalence.

C.A. Greenbaum, S. Javdani / Children and Youth Services Review 73 (2017) 220–229 Table 1 Demographic information of full sample (N = 53) and evaluation sample (N = 18).

Gender N (%) Female Male Age M (SD) Race N (%) Black/African American Biracial/Multiracial White Hawaiian/Pacific Islander Asian/Asian American Ethnicity N (%) Hispanic Non-Hispanic Sexual orientation N (%) Heterosexual Homosexual Bisexual Education level In middle school N (%) In high school N (%) Highest grade completed M (SD) Juvenile justice involvement History of probation N (%) History of treatment program N (%) Times incarcerated M (SD)

Full sample (N = 53)

Evaluation sample (N = 18)

31 (58.4) 22 (41.5) 14.72 (1.16)

7 (38.9) 11 (61.1) 14.89 (1.08)

33 (71.7) 7 (15.2) 3 (6.5) 1 (2.2) 2 (4.3)

12 (75.0) 2 (12.5) 1 (6.3) 0 (0) 1 (6.3)

22 (52.4) 20 (47.6)

8 (53.3) 7 (46.7)

30 (65.2) 5 (10.9) 9 (19.6)

11 (64.7) 3 (17.6) 3 (17.6)

20 (45.5) 24 (54.5) 8.83 (1.23)

8 (50.0) 8 (50.0) 8.77 (0.83)

28 (68.3) 16 (40.0) 2.05 (1.22)

10 (66.7) 7 (46.7) 2.31 (1.25)

Note. The full sample comprises all participants who completed assessments at Time 1. The evaluation sample comprises participants who completed assessments at Time 1 and Time 2. The significant attrition rate is due to the high turnover rate inherent to non-secure detention facilities.

2.2. Intervention method 2.2.1. Training of facilitators Intervention facilitators were four female graduate students enrolled in psychology programs and were of varying racial and ethnic backgrounds. Every facilitator attended 9 h of training focused on the characteristics and needs of system-involved youth, trauma-informed group counseling techniques, crisis response skills, mandatory reporting, and intervention components. For the duration of the six-week-long intervention, all facilitators, across both conditions, received supervision through participation in weekly group supervision sessions, individual supervision following each session from the doctoral student supervisor [the first author], and supervision from and continuous access to a PhDlevel supervisor [the second author] with expertise in adolescent mental health treatment.

2.2.2. Intervention procedures The WRITE ON intervention comprised six weeks of intervention, with sessions designed to be 90 min long and take place twice a week, for a total of 12 sessions. Due to the variable turnover rate of residents in these facilities, youth who were new to the facility were invited to join throughout the intervention. The number of participants in each group ranged from two to 10 (M = 5.53, SD = 1.91). Groups took place within common areas of STDFs. The CSG condition was an active treatment designed in collaboration with directors of STDFs, who advocated for a program including supportive group dynamics and regular contact with a facilitator. With these considerations in mind, our team designed the content and activity structure of the CSG condition to mirror that of the WRITE ON condition in order to provide a comparable control. The CSG entailed four sessions, each intended to be 1 h long, over the course of six weeks. CSG participants partook in similar activities as in the WRITE ON condition; the critical exception was that in the CSG condition, youth did not engage in writing activities that promoted reflection and emotional selfexpression. For example, a writing prompt for WRITE ON was “Write a

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letter to your 10-year-old self, detailing what you wish you had known at that time,” whereas the corresponding CSG prompt was “Write a letter to your favorite celebrity.” In line with WRITE ON procedures, CSG participants also received journals to use between sessions if they so chose. By maintaining controls between the WRITE ON and CSG curricula, we minimized the probability that gains from WRITE ON would be based on non-writing-specific features such as regular contact with a facilitator. Thus, the CSG condition is considered an active treatment comparison condition. 2.3. Research procedures The WRITE ON intervention was evaluated using an experimental multi-site research design. The Principal Investigator and facilitators/assessors were privy to condition among the four sites, but site directors and staff were blind to condition. This study employs a cross-sectional design and constitutes a secondary analysis of de-identified assessment data in aggregate, originally collected to track individual youth's progress in this pilot group therapy program. The research protocol was reviewed and deemed exempt by the New York University Institutional Review Board, and the collaborating government agency granted permission for the team to invite residents at participating facilities to enroll in the intervention and assessments. The assessment team included four female graduate students, all of whom received training and supervision on assessment, comprehensible consent scripts, and safety protocols (e.g., in the event that youth indicated suicidal ideation on a survey). Assessment team members informed youth and facility staff that participation was voluntary, non-participation would not adversely impact youth's relationship with facility staff, and that youth could choose to stop participating at any time or participate at a later date. Interested youth then completed assent forms that explained that responses were confidential and would be used to monitor each youth's progress through treatment, and that no identifying information would be shared with anyone outside of the research team. Outcome data were collected at two-week intervals. Youth who consented to participate completed assessments no more than one week prior to their enrollment in the intervention (T1). Due to the variability in youth's length of detention, a rolling assessment schedule was implemented that allowed new youth entering a STDF to complete baseline assessments prior to their starting the intervention. Thus, we employed a multiple-baseline research approach by conducting baseline (T1) assessments as youth joined the groups. Though the assessment protocol was designed to include four time points (i.e., T1, T2, T3, T4), data from this study inform a two-week intervention period, since only seven youth completed three or more assessments. This two-week period of assessment is ecologically valid given the shortterm nature of STDFs. All assessments were conducted in group settings, with WRITE ON assessment team members and facility staff present. To respect youth's privacy and ensure their confidentiality, participants were asked to sit apart from one another. Each assessment session lasted between 30 and 90 min, depending on the number of youth present and their sustained attention. Snacks were provided to all youth in the facilities regardless of participation, and alternative materials (i.e., word searches) were offered to individuals who declined survey participation. 2.4. Measures 2.4.1. Intervention Fidelity Fidelity was conceptualized and measured across three core components of intervention fidelity (Gearing et al., 2011): design, training, and monitoring of delivery. First, intervention design and procedures were outlined in separate manuals for each condition to promote treatment differentiation. The extent to which these manuals contained well-defined sets of procedures was assessed through facilitators' responses at

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the end of the intervention to the question “Do you feel that the written procedures were helpful?” which was rated on a Likert scale (e.g., 1 = not at all, 5 = very). Second, training was standardized for all practitioners and accommodated provider differences in education and expertise. The Principal Investigator recorded facilitators' attendance and hours of training devoted to manual review, didactic sessions, and role play. Ongoing supervision and consultation were provided by the Principal Investigator and doctoral student supervisor over the course of the intervention to monitor drift, provide corrective feedback as needed, and promote adherence to the model. This supervision entailed a process by which facilitators completed semi-structured intervention logs following every session, supervisors reviewed these logs on a weekly basis, and all facilitators and supervisors met in person for weekly group supervision. Third, intervention delivery was monitored through review of facilitators' logs to assess frequency and length of sessions. This self-report method was selected because it was feasible and ecologically valid given the security protocols inherent to the study settings. To assess participant engagement (i.e., a vital element of intervention delivery; Duwe & Clark, 2015), we created an eight-item satisfaction survey that participants anonymously completed at the culmination of each session. The survey's items assessed respondents' overall satisfaction with the sessions, level of liking, amount they learned, and fun they had, each of which was rated on a Likert scale (e.g., 1 = very satisfied, 5 = very dissatisfied). Satisfaction surveys were internally consistent (α = 0.85).

2.4.2. Resilience At T1, T2, T3, and T4, we administered the Brief Resilience Scale (BRS; Smith et al., 2008), a six-item self-report scale designed to measure respondents' ability to “bounce back or recover from stress” (p. 194). Items are statements about responses to stress (e.g., “It is hard for me to snap back when something bad happens”), each of which is rated on a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). As recommended for scale scoring (Smith et al., 2008), half of the items are reverse-coded and then scores are totaled. Higher scores reflect higher resilience. Across four samples tested, including college students and medical patients, Cronbach's alpha for the BRS ranged from 0.80 to 0.91 (Smith et al., 2008). The BRS had acceptable reliability within our evaluation sample at baseline (α = 0.71). Convergent validity was established between the BRS and the Connor-Davidson Resilience Scale and the Ego Resilience Scale (Smith et al., 2008). Though the measure has not been employed with children, its readability, as measured by the Flesch-Kincaid index, is at grade level 5.1.

2.4.3. Affect At T1, T2, T3, and T4, we used the Positive and Negative Affect Schedule – Short Form (PANAS-SF; Kercher, 1992), a 10-item self-report scale, to assess respondents' psychological well-being by capturing their emotional states, operationalized as positive and negative affect. Items consist of single words describing positive (e.g., “Alert”) and negative (e.g., “Ashamed”) emotions; respondents are asked to rate the extent to which they feel each emotion on a Likert scale ranging from 1 (very slightly or not at all) to 5 (extremely). As recommended by the scale developers (Kercher, 1992), responses are summed to yield two separate subscales: total positive and negative affect scores. Among adult samples, Cronbach's alpha ranged from 0.86 to 0.90 for positive affect and from 0.84 to 0.87 for negative affect (Huebner & Dew, 1995; Mackinnon et al., 1999). Within our evaluation sample, the positive affect subscale had excellent reliability (α = 0.91), and the negative affect subscale had good reliability (α = 0.81) at baseline. The PANAS-SF was found to have high convergent validity with the Depression Anxiety and Stress Scale (Crawford & Henry, 2004). Though the PANAS-SF has not been employed in youth samples, the measure's readability, as measured by the Flesch-Kincaid Index, is at grade level 7.

2.4.4. Self-esteem At T1, T2, T3, and T4 we measured youth's self-esteem using the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965). The RSES is a 10item self-report scale that measures global self-worth by inquiring about respondents' positive and negative feelings about themselves. Items such as “On the whole, I am satisfied with myself” are scored on a 4-point Likert Scale ranging from 0 (strongly disagree) to 3 (strongly agree). As recommended by the scale developer (Rosenberg, 1965), half of the items are reverse-coded and responses are summed, with higher scores indicating higher self-esteem. In samples of high school and college students, Cronbach's alpha has ranged from 0.72 to 0.88 (Robins, Hendin, & Trzesniewski, 2001), but the measure had less than optimal reliability within our evaluation sample at baseline (α = 0.59). The RSES has been shown to correlate with other measures of self-esteem such as the Coopersmith Self-Esteem Inventory (Demo, 1985). 2.4.5. Shame and guilt At T1, T2, T3, and T4 we collected data on youth's feelings of shame and guilt using the shame and guilt subscales of the State Shame and Guilt Scale-Revised (SSGS-R; Marschall, Sanftner, & Tangney, 1994). Items of these subscales measure the extent to which participants feel shame (e.g., “I want to sink into the floor and disappear”) and guilt (e.g., “I feel remorse, regret”), and the scale's 15 items are rated by respondents on a 5-point Likert scale ranging from 1 (not feeling this way at all) to 5 (feeling this way strongly). As recommended by scale developers (Marschall et al., 1994), responses are summed to create subscales assessing Shame and Guilt, with higher scores indicating higher shame and guilt. A Cronbach's alpha of 0.83 was found for both the shame and guilt subscales in middle school and high school samples, and convergent validity was established with the Children's Depression Inventory and the Depression Scale for Children (Tilghman-Osborne, Cole, Felton, & Ciesla, 2008). The shame and guilt subscales had good reliability within our evaluation sample at baseline (αs = 0.85 and 0.83, respectively). 2.5. Data analytic plan Descriptive analyses were employed to characterize the sample and report program fidelity and satisfaction within the full sample. Our substantive outcome analyses were informed by the evaluation sample and sought to assess the extent to which youth receiving the WRITE ON intervention demonstrated changes in mental health outcomes from T1 to T2, as compared to youth in the CSG condition. Notably, while the actual two-week period of assessment varied among youth (e.g., some participants' data derived from weeks 1–3, while others derived from weeks 3–5), all WRITE ON participants who completed two assessments received an average of 5.90 intervention hours between them, a relatively high dose of treatment for a two-week period (Hansen, Lambert, & Forman, 2002). CSG participants who completed two assessments received an average of 2.13 intervention hours between them. Repeated-measures MANCOVA tests, using age as a covariate, were conducted to examine the extent to which the WRITE ON intervention had a holistic impact on a set of key outcomes as compared to the CSG condition. MANCOVAs were used to minimize the likelihood of Type I error while measuring multiple dependent variables that refer to the same concept, in line with methods commonly employed in intervention research (e.g., Hovland et al., 2013; Jafar, Salabifard, Mousavi, & Sobhani, 2015). Two sets of MANCOVA analyses were conducted: (a) one on positive mental health outcomes (i.e., resilience, self-esteem, and positive affect), and (b) one on negative mental health outcomes (i.e., shame, guilt, and negative affect). To control for multiple comparisons (i.e., examination of two sets of MANCOVAS), the significance level for MANCOVA analyses was set at p = 0.25. Follow-up univariate tests of individual outcome variables (i.e., ANCOVA analyses) were performed to discern specific domains of impact. These ANCOVAs represent posthoc tests and were only performed in instances where the overall F-


test for the MANCOVA was significant. Finally, to account for the fact that the WRITE ON condition included a higher treatment dosage compared to the CSG condition, a “number of treatment minutes” variable was calculated to assess the total number of minutes a participant received treatment in either condition. This variable was calculated using facilitators' intervention logs, in which they recorded youth in attendance and the exact number of minutes per intervention session. This variable was used as a covariate to examine whether treatment dosage accounted for treatment effects. 3. Results

3.2.2. Positive mental health outcomes WRITE ON participants reported a significant increase in positive mental health attributes compared to CSG participants, F(3,15) = 6.46, p b 0.01. Univariate analyses suggested that this overall increase was driven by a significant increase in resilience, F(18,1) = 5.64, p b 0.05, η2p = 0.27, but not self-esteem, F(18,1) = 0.81, p = 0.36 or positive affect, F(18,1) = 1.4, p = 0.26; see Fig. 1. Results demonstrated that all substantive findings remained the same when “number of treatment minutes” was entered as a covariate, suggesting that youth in the WRITE ON condition demonstrated increased resilience compared to the CSG condition above the influence of treatment dosage.

3.1. Intervention fidelity

4. Discussion

Facilitators reported that the intervention protocols detailed in the manual were both feasible and conducive to implementation of therapy protocols, with 100% reporting that the written procedures were very helpful in implementing the intervention (M = 5, SD = 0). Each facilitator attended all 9 h of training, four of which were devoted to didactic instruction, three to manual review, and two to supervised practice of facilitation (e.g., role plays). Across both conditions, the interventions were delivered according to the intended amount of sessions (WRITE ON = 12; CSG = 4) and conformed to their intended length of sessions (WRITE ON M = 88.55 min, SD = 20.72; CSG M = 64.29, SD = 6.07; see Table 2). These results indicate that the intervention was delivered with the intended degree of dosage. Additionally, participants reported high levels of program satisfaction across sessions, with 82.4% reporting overall program satisfaction, 85.5% reporting that they liked the sessions, 85.4% reporting that they had more fun than average, and 82.9% reporting that they learned more than average (see Table 2). Program satisfaction did not significantly vary between treatment and control groups (p = 0.25) or between genders (p = 0.09).

4.1. Conclusions

3.2. Mental health outcomes In order to examine substantive research questions, we conducted two sets of repeated-measures MANCOVA analyses (see Table 3 for results). 3.2.1. Negative mental health outcomes Overall, negative mental health outcomes of shame, guilt, and negative affect did not significantly change over time across or within groups, F(3,15) = 1.35, p = 0.31. A closer examination of univariate tests indicated that there was a marginally significant increase in shame for individuals receiving the WRITE ON intervention as compared to those in the CSG, F(18,1) = 4.37, p = 0.06,η2p = 0.20 (Table 4). Table 2 Program fidelity and youth satisfaction.

Program fidelity Total sessions for each treatment group Total sessions for each control group Average length of sessions for Tx group (minutes) Average length of sessions for Ctl group (minutes) Facilitator-rated participant satisfaction Program satisfaction Overall satisfaction Overall liking Amount of fun Amount learned

M

SD

Range

12.00 4.00 88.55

0.00 0.00 20.72

12.00–12.00 4.00–4.00 50.00–140.00

64.29

6.07

60.00–75.00

7.31

1.65

1.00–10.00

1.63 1.49 8.24 7.78

0.93 0.89 2.28 2.24

1.00–5.00 1.00–5.00 1.00–10.00 1.00–10.00

Note: facilitator-rated participant satisfaction range from 1 = did not enjoy to 10 = enjoyed a lot. Program satisfaction and liking range from 1 = yes, definitely to 5 = not at all; amount of fun and amount learned range from 1 = the most to 10 = the least. Tx = treatment (WRITE ON); Ctl = control (CSG).

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In this pilot study we developed, implemented, and evaluated the WRITE ON intervention, which is intended to improve the psychological well-being of underserved youth in confinement. As the first study to implement and assess such an intervention in this population with an experimental design, our aims were to: 1) assess intervention implementation fidelity, including participant satisfaction, and 2) evaluate the mental health outcomes of youth receiving WRITE ON compared to those of a comparison group. Results indicated that: 1) the intervention was delivered with good fidelity and participants reported high levels of satisfaction, and 2) WRITE ON participants endorsed nonsignificant increases in shame and significant increases in resilience as compared to their CSG counterparts. Findings, theorized mechanisms of change, study contributions, limitations, and future directions are discussed below. 4.2. Discussion of findings Evaluation of fidelity indicated that the intervention was delivered with the intended degree of dosage across all groups, pointing to the overall feasibility of WRITE ON delivery. However, given youth's short lengths of stay within these facilities, not all participants received all delivered intervention sessions. This feasibility finding is nonetheless promising, as it suggests that the intervention may be successfully adapted for longer term placement facilities. Encouragingly, participants reported high levels of program satisfaction across all intervention sessions. This finding contrasts with high rates of disengagement among incarcerated youth that have been reported by frontline service providers (Gaarder et al., 2004). Moreover, detention programs are reported to have the highest percentage of residents stating that their counseling is “not very helpful” as compared to other court-mandated placements (e.g., group homes; Sedlak & McPherson, 2010). Thus, WRITE ON may be more engaging than other available programs, which may in turn foster greater therapeutic outcomes. We detected a nonsignificant trend of increased shame for individuals receiving the WRITE ON intervention as compared to those in the CSG. This may be due to the fact that WRITE ON participants wrote trauma narratives while CSG participants did not. The literature on traumafocused therapies suggests that this type of exposure-based treatment may temporarily increase mental health symptoms, including shame (e.g., Cloitre et al., 2010). Interestingly, participants who endorse symptom exacerbation may benefit comparably from treatment as those who do not (Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002). Thus, symptom worsening may be unrelated to positive outcomes and may in fact be part of the recovery process. In light of this, we do not foreclose the chance that youth who reported increased shame simultaneously experienced therapeutic gains. Indeed, this speculation was supported by our findings on positive mental health-related outcomes. WRITE ON participants reported a significant increase in resilience, or perceived ability to bounce back, as compared to CSG participants. Resilience refers to the processes and mechanisms that promote

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Table 3 Descriptive statistics of mental health constructs at baseline (Time 1; n = 49). Outcome

M (SD)

Resilience

Resilience Self-esteem PANAS PA SGSS shame SGSS guilt PANAS NA

3.18 (0.72) 21.24 (5.90) 3.83 (1.15) 1.67 (0.77) 2.34 (1.12) 1.80 (0.84)

⁎ 0.14 0.14 −0.50* −0.30* −0.40*

Self-esteem

PANAS PA

SGSS shame

SGSS guilt

⁎ 0.51⁎ −0.53⁎ −0.13 −0.41⁎

⁎ −0.27 0.15 −0.16

⁎ 0.46⁎ 0.67⁎

⁎ 0.48⁎

Note. PANAS = Positive and Negative Affect Schedule-Short Form. PA = positive affect. NA = negative affect. SGSS = State Shame and Guilt Scale. ⁎ p b 0.05.

relatively positive outcomes despite adverse or traumatic experiences (Masten, 2001) and is related to a multitude of protective factors, including problem-solving coping strategies (Dumont & Provost, 1999) and self-efficacy (Wyman, Sandler, Wolchick, & Nelson, 2000). Conversely, resilience is negatively associated with anxiety, depression (Smith et al., 2008), engagement in life-threatening behaviors (Rew, Taylor-Seehafer, Thomas, & Yockey, 2001), and illegal activities (Dumont & Provost, 1999). It is well established that juvenile justice-involved youth are disproportionately exposed to both adverse life situations (e.g., low socioeconomic status) as well as specific negative life events (e.g., maltreatment, incarceration), which, in tandem, confer risk for psychopathology. However, given that these vulnerabilities do not inevitably or universally lead to poor outcomes, it is essential to examine protective factors to clarify individual differences in responses to stressors. Our finding that WRITE ON participants endorsed significant gains in resilience after just two weeks is promising and suggests that WRITE ON may furnish youth with psychological resources to buffer against, or modify the impact of, adversities they face on an ongoing basis. 4.3. Hypothesized processes Although we did not statistically model any process-oriented mechanisms, we hypothesize a conceptual framework to inform future investigation. Nonspecific, or common, factors such as development of a therapeutic alliance with facilitators, likely contributed to WRITE ON participants' positive subjective experiences and mental health outcomes. However, the change in resilience as a function of WRITE ON participation may be ascribed to more unique mechanisms. Specifically, we hypothesize that WRITE ON enabled youth to engage in narrative construction, which may be particularly salient during this developmental period characterized by identity exploration and development (Erikson, 1993). Such exploration may be even more important for youth whose identities have been fragmented due to traumas (Berntsen & Rubin, 2006). In writing about negative life events, participants may have engaged in meaning-making processes that allowed them to acknowledge and process their experiences, and, importantly,

move forward from them. This experience of future-oriented growth may be at the root of youth's heightened resilience. These hypothesized mechanisms are reinforced by previous research demonstrating that the strongest indicators of resilience in adolescents transitioning from correctional facilities to the community were their willingness to confront problems, ability to cope with negative events, greater reflective skills, and strong future orientation replete with goals (Todis, Bullis, Waintrup, Schultz, & D'Ambrosio, 2001). WRITE ON affords participants the opportunity to develop this array of capacities within an environment of supported vulnerability and motivational support.

4.4. Contributions Our pilot evaluation provides preliminary support for WRITE ON's potential to occupy the void of available and evidence-based programming for juvenile justice-involved youth in several critical ways. WRITE ON is grounded in a youth-centered, culturally sensitive approach to treatment to ensure that system-involved adolescents' unique needs are met. Writing enables youth to choose what to express and how to do so. In this way, youth are able to cope with their experiences in ways that are not prescribed or filtered through others' cultural lenses. Further, by incorporating principles of trauma-informed care, this intervention is positioned not only to serve the needs of adjudicated adolescents, but also a broader population of youth involved in multiple systems in which trauma is prevalent (e.g., child welfare). Another intrinsic strength of WRITE ON is its potential for sustainability, which is promoted by three factors. First, our partnership with the local child welfare/juvenile justice system reflects key practice recommendations that juvenile justice-focused interventions be developed and implemented in conjunction with stakeholders. Next, this implementation of WRITE ON was supported by university resources and connected a university to a community in a sustainable manner. Finally, it is a brief, cost-effective intervention that can be implemented by unlicensed mental health professionals and therefore has potential for scalability.

Table 4 Mental health outcomes pre-intervention and at two-week follow-up. Positive mental health outcomes

Multivariate F(3, 15) = 6.46, p = 0.008 WRITE ON

Outcome Resilience Self-esteem PANAS PA Negative mental health outcomes

Time 1, M (SD) 2.98 (0.65) 20.88 (6.09) 4.09 (1.11)

CSG Time 2, M (SD) 3.65 (0.82) 22.44 (6.19) 3.33 (1.37)

Time 2, M (SD) 3.33 (0.63) 21.22 (3.87) 4.62 (0.44)

Univariate test F(18,1) = 5.64, p b 0.05 F(18,1) = 0.81, p = 0.36 F(18,1) = 1.4, p = 0.26

Time 2, M (SD) 1.64 (0.80) 2.27 (1.16) 1.44 (0.47)

Univariate test F(18,1) = 4.37, p = 0.06 F(18,1) = 0.04, p = 0.85 F(18,1) = 0.25, p = 0.62

Multivariate F(3, 15) = 1.35, p = 0.31 WRITE ON

Outcome SGSS shame SGSS guilt PANAS NA

Time 1, M (SD) 3.50 (0.39) 23.25 (2.81) 4.55 (0.63)

Time 1, M (SD) 1.51 (0.81) 2.64 (1.01) 1.80 (0.76)

CSG Time 2, M (SD) 1.98 (0.81) 2.97 (0.67) 2.15 (1.12)

Time 1, M (SD) 1.37 (0.57) 1.90 (1.37) 1.33 (0.45)

Note. CSG = comparison support group. PANAS = Positive and Negative Affect Schedule-Short Form. PA = positive affect. NA = negative affect. SGSS = State Shame and Guilt Scale.


Fig. 1. Resilience as a function of WRITE ON participation. This figure illustrates that youth who participated in the WRITE ON intervention experienced significant gains in resilience from T1 (baseline) to T2 (two-week follow-up) compared to their counterparts in the Comparison Support Group (CSG) condition.

4.5. Limitations Several limitations warrant consideration. First, this pilot study is informed by a small sample size due to a relatively low retention rate. Our low retention rate is wholly attributable to the high turnover inherent to STDFs, which house youth for short periods of time while they await sentencing or placement. In fact, we did not experience any attrition (i.e., dropout) from youth who remained in the facilities for the duration of the intervention. That is, all WRITE ON participants voluntarily participated for the duration of their stays. The ramifications of retention rate on effect size are important to note, as previous expressive writing studies have had larger mean effect sizes when attrition rates were low (Travagin et al., 2015). However, these pilot analyses add important data to a sparse literature on the impact of short-term treatment on youth in residential facilities. Second, we analyzed data from two time points spaced two weeks apart, despite the six-week length of the intervention. It is therefore possible that participants' gains would have become more pronounced with additional participation, or alternatively that positive outcomes would emerge early in treatment and then level out or decline. Our low power precluded the option to compare mental health outcomes between genders, but our finding that girls and boys reported no significant differences in program satisfaction is encouraging. Moreover, our small sample size undoubtedly limited our statistical power and ability to detect effects where they may have been present. However, our results indicate a high effect size for resilience, suggesting a robust effect. In addition, we did not have the capacity to investigate other important constructs, including emotional control. Gold standard measures of this construct require multiple informants (e.g., Emotion Regulation Checklist; Shields & Cicchetti, 1997). Due to the limitations of our sample of youth in residential facilities, it was not possible to obtain multiple informants. However, we note this is a key are for future research, particularly because EW interventions may impact aspects of emotional control. In addition, youth in the CSG condition received a lower frequency of intervention sessions as compared to youth in the WRITE ON condition. This is an important limitation and highlights the need to compare equal doses of intervention across comparison and WRITE ON conditions in future research. That said, there are important steps taken in the current study to reduce the likelihood that intervention dosage accounted for the study findings. First, a “number of treatment minutes”

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variable was calculated to assess the total number of minutes a youth received treatment in either condition. This variable was used as a covariate to examine whether treatment dosage accounted for treatment effects. Results demonstrated that all substantive findings remained the same, even when treatment minutes was entered as a covariate, suggesting that youth in the WRITE ON condition demonstrated increased resilience compared to the CSG condition above the influence of treatment dosage. Second, youth across conditions received at least one hour of in-person contact from the treatment team each week, leading us to conclude that differences between groups were not solely a byproduct of non-specific factors. Further, our inclusion of a neutral writing control condition may have weakened our effect size, as expressive writing studies with an assessment-only control condition have larger mean effect sizes than studies using a neutral writing control condition (Travagin et al., 2015). However, our inclusion of a neutral writing control condition minimized the chances that significant differences would be attributable to non-writing-specific factors such as regular contact with a facilitator. Finally, it is notable that one-third of EW studies with youth have not employed a comparison treatment condition (Travagin et al., 2015). Thus, while the CSG condition did not match the WRITE ON condition in dosage, the inclusion of an active comparison group is an important feature of the current study and lends credit to the emerging body of research suggesting the utility of EW for at-risk youth. The data reported in this paper are subject to the limitations of selfreporting. However, our assessment team took actions to combat threats to honest reporting, including through reinforcing youth's rights to confidentiality. Additionally, in this pilot evaluation each site received only one condition, thereby limiting our ability to control for settingspecific effects. However, given that all included sites are part of the city detention program and staff receive similar training and because and we randomly assigned each site to condition, we have reason to believe that setting-specific effects are minimal. In relation to this, random assignment of settings to condition minimized confounds related to selection bias; however, youth within each facility were able to voluntarily accept or decline participation. Thus, self-selection bias may have operated at the individual level, though there is little reason to believe that youth in the treatment condition would be more or less likely to accept or decline participation. Lastly, the generalizability of our findings may be limited given that our study sites were geographically confined to one city and we only delivered the program in one type of detention facility. However, our sample is demographically representative of juveniles arrested in the local jurisdiction, and its high proportion of racial and ethnic minorities reflects national demographics of youth involved in child welfare and juvenile justice systems. We also note the high proportion of sexual minority youth in this sample, a group generating increasing concern for researchers, policymakers, and practitioners throughout the child welfare system. 4.6. Future directions Future research on WRITE ON would be maximally impactful with a larger sample of youth present for a greater portion of the intervention. Expansion of WRITE ON to other types of settings that house youth for longer periods of time (e.g., juvenile justice placement facilities, group homes) would provide youth with a greater dosage of treatment and would also allow the assessment of diagnostic outcomes, including trauma-related symptoms, over time. Further, a larger sample size would equip researchers to examine the effects of dosage and various mediators and moderators on treatment outcomes. A study of this nature would provide much needed data regarding the implementation of mental health services for system-involved youth. Lastly, future research should include qualitative inquiry, through participant interviews and writing analysis. In order to foster a trauma-informed therapeutic space, we did not collect participants' trauma writing. Service organizations, such as the Beat Within, have compiled writing

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