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Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism among Autistic-LGBQ+ Individuals

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Title: Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism among Autistic-LGBQ+ Individuals
Language: English
Authors: Meredith R. Maroney (ORCID 0000-0002-4622-2683), Heidi M. Levitt, Sharon G. Horne
Source: Journal of Autism and Developmental Disorders. 2024 54(8):2946-2959.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 14
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Descriptors: LGBTQ People, Autism Spectrum Disorders, Sexual Orientation, Gender Bias, Intervention, Computer Mediated Communication, Expressive Language, Writing Exercises, Psychological Patterns, Depression (Psychology), Trauma, Stress Variables, Symptoms (Individual Disorders), Response to Intervention, Program Effectiveness, Coping
DOI: 10.1007/s10803-023-06027-1
ISSN: 0162-3257
1573-3432
Abstract: This experimental study explored the use of online expressive writing interventions to cope with distress from heterosexist events among a sample of autistic-LBGQ + individuals. This study included an open writing condition and an emotion focused therapy guided writing condition. Over 89% of the participants indicated that the writing exercises were helpful in processing the event, with significant decreases for measures of depressive and trauma/stressor symptoms. A thematic analysis identified specific aspects of each condition that were helpful for participants in coping with heterosexist distress, such as the development of insight through the emotion-focused exercises. This low-demand exercise is promising as a solo exercise or as a therapy homework assignment, especially given the accessibility of this online intervention for autistic-LGBQ + people.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1434178
Database: ERIC
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  Value: <anid>AN0178836269;aut01aug.24;2024Aug09.07:59;v2.2.500</anid> <title id="AN0178836269-1">Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism Among Autistic-LGBQ + Individuals </title> <p>This experimental study explored the use of online expressive writing interventions to cope with distress from heterosexist events among a sample of autistic-LBGQ + individuals. This study included an open writing condition and an emotion focused therapy guided writing condition. Over 89% of the participants indicated that the writing exercises were helpful in processing the event, with significant decreases for measures of depressive and trauma/stressor symptoms. A thematic analysis identified specific aspects of each condition that were helpful for participants in coping with heterosexist distress, such as the development of insight through the emotion-focused exercises. This low-demand exercise is promising as a solo exercise or as a therapy homework assignment, especially given the accessibility of this online intervention for autistic-LGBQ + people.</p> <p>Keywords: Expressive writing; Sexual minority; Autism; Mixed methods; Emotion focused therapy</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <p>In comparison to heterosexual individuals, lesbian, gay, bisexual, and queer (LGBQ+) people are at greater risk for physical and mental health problems as a result of chronic stressors related to their sexual orientation (Meyer, [<reflink idref="bib40" id="ref1">40</reflink>]). Minority stress theory has been widely utilized to describe the multiple social stressors experienced by sexual minority individuals as a result of both external (e.g., harassment, prejudice-events) and internal (e.g., identity concealment, internalized heterosexism) events (Meyer, [<reflink idref="bib41" id="ref2">41</reflink>]; Hatzenbuehler & Pachankis, [<reflink idref="bib29" id="ref3">29</reflink>]), and has been extended to the experiences of autistic adults (Botha & Frost, [<reflink idref="bib8" id="ref4">8</reflink>]). Specifically, finding that discrimination, internalized stigma, and concealment of identity predicts worse mental health outcomes among autistic adults, which may explain mental health disparities (Botha & Frost, [<reflink idref="bib8" id="ref5">8</reflink>]). Preliminary research has highlighted that autistic adults face greater exposure to stigma (Hall, et al., [<reflink idref="bib27" id="ref6">27</reflink>]; Strauss, et al., [<reflink idref="bib61" id="ref7">61</reflink>]), yet there has been limited research on the impact of distal stressors (i.e., prejudice-events) among LGBQ + autistic people.</p> <p>A growing body of research has documented the high prevalence of gender minority (Dewinter, et al., [<reflink idref="bib16" id="ref8">16</reflink>]; George & Stokes, [<reflink idref="bib22" id="ref9">22</reflink>]; Strang, et al., [<reflink idref="bib59" id="ref10">59</reflink>]; Strang, et al., [<reflink idref="bib60" id="ref11">60</reflink>]; van der Miesen, et al., [<reflink idref="bib64" id="ref12">64</reflink>]; Warrier, et al., [<reflink idref="bib65" id="ref13">65</reflink>]) and sexual minority (Gilmour, et al., [<reflink idref="bib24" id="ref14">24</reflink>]; Øien, et al., [<reflink idref="bib44" id="ref15">44</reflink>]; Pecora, et al., [<reflink idref="bib47" id="ref16">47</reflink>]; Rudolph, et al., [<reflink idref="bib54" id="ref17">54</reflink>]) identities among autistic adults and adolescents. Stigma or prejudicial events differentially impact the mental health of individuals with multiple marginalized identities (Balsam, et al., [<reflink idref="bib7" id="ref18">7</reflink>]), which points the importance of better understanding the high co-occurrence of comorbid diagnoses and concerns among this population (Strang, et al., [<reflink idref="bib59" id="ref19">59</reflink>]). For instance, research on autistic transgender autistic people has documented worse mental health outcomes as compared to transgender autistic people, including lower well-being, higher stress, (George & Stokes, [<reflink idref="bib22" id="ref20">22</reflink>]), as well as higher depression and anxiety (Strauss, et al., [<reflink idref="bib61" id="ref21">61</reflink>]). Relatedly, autistic-transgender adolescents have been found to have higher rates of emotional internalizing symptoms when compared to autistic-cisgender and allistic-transgender (i.e., neurotypical) individuals (Strang, et al., [<reflink idref="bib58" id="ref22">58</reflink>]). Both LGBQ + and autistic people experience barriers to mental health treatment and providers that are knowledgeable, free of stigma, and integrate an understanding of identity-specific challenges (Foy, et al., [<reflink idref="bib20" id="ref23">20</reflink>]: Lewis, [<reflink idref="bib37" id="ref24">37</reflink>]; Strang, et al., [<reflink idref="bib60" id="ref25">60</reflink>]). The current study examines the use of expressive writing as an intervention to assist autistic-LGBQ + people (of any gender) to process heterosexist experiences, which responds to calls for interventions focused on the needs of autistic people with diverse sexual identities and experiences (Dewinter, et al., [<reflink idref="bib17" id="ref26">17</reflink>]).</p> <hd id="AN0178836269-2">Expressive Writing for Heterosexist Distress</hd> <p>Expressive writing interventions have been found to effectively reduce symptoms of psychological distress (i.e., depression and post-traumatic stress disorder) in a wide range of individuals and concerns (Kaufka, [<reflink idref="bib33" id="ref27">33</reflink>]; Hirai, et al., [<reflink idref="bib31" id="ref28">31</reflink>]; Pennebaker, [<reflink idref="bib50" id="ref29">50</reflink>]; Pennebaker, [<reflink idref="bib49" id="ref30">49</reflink>]). A meta-analysis of 146 randomized studies found expressive writing interventions to have beneficial effects for participants, when used for a minimum of three consecutive days of writing for at least 15 min (Frattaroli, [<reflink idref="bib21" id="ref31">21</reflink>]). The use of expressive writing interventions has been explored among LGBQ populations, such as coping with stress related to LGB identity (Lewis, [<reflink idref="bib37" id="ref32">37</reflink>]; Pachankis and Goldfried, [<reflink idref="bib45" id="ref33">45</reflink>]; Swabon, et al., [<reflink idref="bib62" id="ref34">62</reflink>]), perceived stress (Pachankis, et al., [<reflink idref="bib46" id="ref35">46</reflink>]), and hate speech among LGBQ individuals (Crowley, [<reflink idref="bib15" id="ref36">15</reflink>]). In prior work by the authors, we found these exercises to be beneficial for processing challenging and stressful events with a neurotypical (i.e., non-autistic) population (Collins et al., [<reflink idref="bib11" id="ref37">11</reflink>]), and that engagement promoted self-awareness and understanding of the impact of heterosexist events (Collins et al., [<reflink idref="bib12" id="ref38">12</reflink>]).</p> <p>One condition in the present study utilized guided expressive writing questions to explore heterosexist events, drawing from emotion focused therapy (EFT) theory, which suggests that individuals change through exploring emotional experiences and processing the needs that emotions signify (Elliot & Greenberg, [<reflink idref="bib19" id="ref39">19</reflink>]). EFT has been effectively used for LGBTQ + individuals and has specifically focused on coping with stressors related to LGBQ identity (Hardtke, et al., [<reflink idref="bib28" id="ref40">28</reflink>]), and to cope with minority stress among transgender and gender diverse individuals (Westmacott & Edmonstone, [<reflink idref="bib68" id="ref41">68</reflink>]). Relatedly, in prior research on this online EFT expressive writing intervention, authors utilized a task analysis to examine processes of change among LGB + participants in an online writing emotion-focused intervention, in which participants were able to reduce distress and work towards resolution by moving through four stages and work towards an empowered self (Levitt et al., [<reflink idref="bib36" id="ref42">36</reflink>]). Research has demonstrated the productive use of EFT with autistic individuals in working through traumatic events in a group setting, which facilitated the transformation of emotional pain into a more adaptive emotions (Robinson & Elliott, [<reflink idref="bib53" id="ref43">53</reflink>]; Robinson, [<reflink idref="bib52" id="ref44">52</reflink>]). The study of both open expressive writing and EFT-informed interventions to process experiences of heterosexism with autistic-LGBQ + adults provides a structure in which autistic participants can use their own ways of making meaning and languaging experience to come to terms with troubling experiences.</p> <hd id="AN0178836269-3">The Present Study</hd> <p>The present study advanced the understanding of events of heterosexism, by exploring the efficacy of an intervention among a sample of autistic-LGBQ individuals using a convergent mixed methods design. This study extends prior work (Levitt et al., [<reflink idref="bib36" id="ref45">36</reflink>], Collins et al., [<reflink idref="bib12" id="ref46">12</reflink>], [<reflink idref="bib11" id="ref47">11</reflink>]), that developed an EFT-based expressive writing intervention to cope with experiences of heterosexism with a general LGBQ + sample, to assess the suitability of expressive writing for autistic-LGBQ + individuals. This study examined stressors and coping experiences through a minority stress framework to extend the literature on possible means of coping with psychological distress related to living in a heterosexist, cissexist, and neurotypical society. Given findings from past research (e.g., Collins et al., [<reflink idref="bib11" id="ref48">11</reflink>]), we hypothesized that the EFT condition would be equivalent to open expressive writing condition in decreasing symptoms of psychological distress, but that it would lead to explore more nuanced insights.</p> <hd id="AN0178836269-4">Study 1</hd> <p></p> <hd id="AN0178836269-5">Quantitative Methods</hd> <p></p> <hd id="AN0178836269-6">Study Flow</hd> <p>To be sure that participants understood the research study and that it was appropriate for them, the first author conducted screenings prior to any involvement in study activities. The screener included a brief online survey and phone call with questions about their country of origin, age, language used to describe being autistic, phone number, and heterosexist event. Participants who indicated they were less comfortable speaking on the phone (<emph>N</emph> = 6) were provided with several options to complete the screening questions: (<reflink idref="bib1" id="ref49">1</reflink>) web conferencing, (<reflink idref="bib2" id="ref50">2</reflink>) online chat or (<reflink idref="bib3" id="ref51">3</reflink>) email. During the screening, the first author reviewed criteria for participation, provided additional information about the nature of the study and consent, and answered any questions.</p> <p>During several screenings some participants inquired about the first author's identities and interest in this area, and she disclosed that she is researcher who is a neurotypical, sexual minority woman. Several participants also asked about the framework of this intervention, specifically, if this intervention was informed by Applied Behavior Analysis (ABA), due to self-reported harm and research linking ABA treatment to posttraumatic stress symptoms (Kupferstein, [<reflink idref="bib34" id="ref52">34</reflink>]), and the harm caused by ABA (Sanvodal- Norton & Shkedy, [<reflink idref="bib56" id="ref53">56</reflink>]). Autistic adults and advocates condemned ABA International's (ABAI) decision to feature the Judge Rotenberg Center at a [<reflink idref="bib5" id="ref54">5</reflink>] conference, noting that this reflects an endorsement of electrical aversive therapy, and called for ABAI to examine ways they have contributed to the abuse of autistics (Autistic Self Advocacy Network, [<reflink idref="bib5" id="ref55">5</reflink>]). The investigation of ABA-related harm has generated much discussion, although a full review of the controversial nature of such findings is beyond the score of this manuscript. Instead, we direct interested readers to critiques of the aforementioned articles (e.g., Leaf, et al., [<reflink idref="bib35" id="ref56">35</reflink>]; Gorycki, et al., [<reflink idref="bib26" id="ref57">26</reflink>]) and responses to the critiques (e.g., Chown, et al., [<reflink idref="bib10" id="ref58">10</reflink>]; Shkedy, et al., [<reflink idref="bib57" id="ref59">57</reflink>]). In these instances, the first author described that this study used open-ended and emotion focused interventions with autistic adults (rather than behavioral modification), which seek to empower participants to develop solutions that work in their own lives.</p> <p>After completing all pre-intervention measures and questions, participants were randomly assigned to one of two groups, (<reflink idref="bib1" id="ref60">1</reflink>) the Emotion Focused Therapy (EFT) guided writing condition, or (<reflink idref="bib2" id="ref61">2</reflink>) open writing condition. Participants in both conditions engaged in three consecutive days of writing through Qualtrics. All participants were asked to briefly describe their heterosexist event, before engaging in the intervention and to respond to questions on exercise effectiveness after completing the intervention. Participants were sent a follow up survey approximately 28 days following completion of the writing exercises, which included questions focused on their experience engaging in the study, as well as post-intervention measures of psychological distress. Participants who completed the follow up survey received a $50 gift card as compensation and all participants were entered into a raffle for a $100 gift card.</p> <p> <bold>Participants</bold>. In total, 56 participants, ages ranging from 18 to 56 (<emph>M</emph> = 27.8, <emph>SD</emph> = 8.74), completed pre-intervention measures. More than half of the total sample identified as transgender, nonbinary, or gender diverse (58.9%; <emph>n</emph> = 33), while the rest of the sample identified as cisgender (41.1%; <emph>n</emph> = 23). Approximately 68% of the sample reported having a diagnosis of ASD, while 89.3% (<emph>n</emph> = 50) participants met clinical significance for autistic traits (six or more on AQ-10; <emph>M</emph> = 8.3), with 75% self-reporting traits of eight or more (on the AQ-10). Table 1 provides an overview of all participant demographics, stratified by condition.</p> <p>Table 1 All participant demographic information, by condition</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Characteristic</p></th><th align="left"><p>Total Sample</p><p>(<italic>N</italic> = 56)</p></th><th align="left"><p>EFT</p><p>(<italic>n</italic> = 30)</p></th><th align="left"><p>Open</p><p>(<italic>n</italic> = 26)</p></th></tr></thead><tbody><tr><td align="left"><p>Age, Mean (SD)</p></td><td char="." align="char"><p>27.8 (8.74)</p></td><td align="left"><p>29.3 (10.01)</p></td><td align="left"><p>26.0 (6.76)</p></td></tr><tr><td align="left"><p><bold>Gender</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Male</p></td><td char="." align="char"><p>6 (10.7%)</p></td><td align="left"><p>2 (6.7%)</p></td><td align="left"><p>4 (15.4%)</p></td></tr><tr><td align="left"><p>Female</p></td><td char="." align="char"><p>19 (33.9%)</p></td><td align="left"><p>12 (40.0%)</p></td><td align="left"><p>7 (26.9%)</p></td></tr><tr><td align="left"><p>Genderqueer</p></td><td char="." align="char"><p>12 (21.4%)</p></td><td align="left"><p>6 (20.0%)</p></td><td align="left"><p>6 (23.1%)</p></td></tr><tr><td align="left"><p>Transgender</p></td><td char="." align="char"><p>3(5.4%)</p></td><td align="left"><p>2 (6.7%)</p></td><td align="left"><p>1 (3.8%)</p></td></tr><tr><td align="left"><p>Self-identified</p></td><td char="." align="char"><p>16 (28.6%)</p></td><td align="left"><p>8(26.7%)</p></td><td align="left"><p>8 (30.8%)</p></td></tr><tr><td align="left"><p><bold>Sexual Orientation</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Gay</p></td><td char="." align="char"><p>8 (14.3%)</p></td><td align="left"><p>2 (6.66%)</p></td><td align="left"><p>6 (23.1%)</p></td></tr><tr><td align="left"><p>Lesbian</p></td><td char="." align="char"><p>15 (26.8%)</p></td><td align="left"><p>9 (30.0%)</p></td><td align="left"><p>6 (23.1%)</p></td></tr><tr><td align="left"><p>Bisexual</p></td><td char="." align="char"><p>10 (17.9%)</p></td><td align="left"><p>6 (20.0%)</p></td><td align="left"><p>4 (15.4%)</p></td></tr><tr><td align="left"><p>Queer</p></td><td char="." align="char"><p>13 (23.2%)</p></td><td align="left"><p>7 (23.3%)</p></td><td align="left"><p>6 (23.1%)</p></td></tr><tr><td align="left"><p>Questioning</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>Asexual</p></td><td char="." align="char"><p>6 (10.7%)</p></td><td align="left"><p>2 (6.7%)</p></td><td align="left"><p>4 (15.4%)</p></td></tr><tr><td align="left"><p>Self-identified</p></td><td char="." align="char"><p>3 (5.4%)</p></td><td align="left"><p>3 (10.0%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p><bold>Race/Ethnicity</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Alaskan Native/Native American/Indigenous</p></td><td char="." align="char"><p>4 (7.1%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>3 (11.5%)</p></td></tr><tr><td align="left"><p>Latinx/Hispanic (White)</p></td><td char="." align="char"><p>2 (3.6%)</p></td><td align="left"><p>2 (6.7%)</p></td><td align="left"><p>0-</p></td></tr><tr><td align="left"><p>Latinx/Hispanic (Non-White)</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0-</p></td></tr><tr><td align="left"><p>Asian & White</p></td><td char="." align="char"><p>2 (3.6%)</p></td><td align="left"><p>0 -</p></td><td align="left"><p>2 (7.7%)</p></td></tr><tr><td align="left"><p>White</p></td><td char="." align="char"><p>36 (64.3%)</p></td><td align="left"><p>20 (66.7%)</p></td><td align="left"><p>16 (61.5%)</p></td></tr><tr><td align="left"><p>Black/African American</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left" /></tr><tr><td align="left"><p>Multiracial/Multiethnic</p></td><td char="." align="char"><p>9 (16.1%)</p></td><td align="left"><p>4 (13.3%)</p></td><td align="left"><p>5 (19.2%)</p></td></tr><tr><td align="left"><p>Self-identified</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left" /></tr><tr><td align="left"><p><bold>Country of Origin</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>United States</p></td><td char="." align="char"><p>46 (82.14%)</p></td><td align="left"><p>22 (73.3%)</p></td><td align="left"><p>24 (92.3%)</p></td></tr><tr><td align="left"><p>Canada</p></td><td char="." align="char"><p>3 (5.4%)</p></td><td align="left"><p>3 (10.0%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>Germany</p></td><td char="." align="char"><p>3 (5.4%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>2 (7.7%)</p></td></tr><tr><td align="left"><p>Ecuador</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>South Africa</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>The Netherlands</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>United Kingdom</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p><bold>Education Level</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Some High School</p></td><td char="." align="char"><p>17 (30.4%)</p></td><td align="left"><p>10 (33.3%)</p></td><td align="left"><p>7 (26.9%)</p></td></tr><tr><td align="left"><p>High School Grad/GED</p></td><td char="." align="char"><p>8 (14.3%)</p></td><td align="left"><p>3 (10.0%)</p></td><td align="left"><p>5 (19.2%)</p></td></tr><tr><td align="left"><p>Some College</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>1(3.3%)</p></td><td align="left"><p>0 -</p></td></tr><tr><td align="left"><p>Associate's Degree</p></td><td char="." align="char"><p>4 (7.14%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>3 (11.5%)</p></td></tr><tr><td align="left"><p>Bachelor's Degree</p></td><td char="." align="char"><p>16 (28.6%)</p></td><td align="left"><p>9 (30.0%)</p></td><td align="left"><p>7 (26.9%)</p></td></tr><tr><td align="left"><p>Master's Degree</p></td><td char="." align="char"><p>9 (16.1%)</p></td><td align="left"><p>6 (20.0%)</p></td><td align="left"><p>3 (11.5%)</p></td></tr><tr><td align="left"><p>Doctoral/Professional</p></td><td char="." align="char"><p>1 (1.8%)</p></td><td align="left"><p>0 -</p></td><td align="left"><p>1 (3.8%)</p></td></tr><tr><td align="left"><p><bold>Autism Diagnosis</bold></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Autism Spectrum Disorder</p></td><td char="." align="char"><p>21 (37.5%)</p></td><td align="left"><p>11 (36.7%)</p></td><td align="left"><p>10 (38.5%)</p></td></tr><tr><td align="left"><p>Asperger's Syndrome</p></td><td char="." align="char"><p>14 (25.0%)</p></td><td align="left"><p>5 (16.7%)</p></td><td align="left"><p>9 (34.6%)</p></td></tr><tr><td align="left"><p>PDD-NOS</p></td><td char="." align="char"><p>3 (5.3%)</p></td><td align="left"><p>1 (3.3%)</p></td><td align="left"><p>2 (7.7%)</p></td></tr><tr><td align="left"><p>Self-identified</p></td><td char="." align="char"><p>18 (32.1%)</p></td><td align="left"><p>13 (43.3%)</p></td><td align="left"><p>4 (15.4%)</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. PDD-NOS = Pervasive Developmental Disorder- Not Otherwise Specified</p> <hd id="AN0178836269-7">Procedures</hd> <p></p> <hd id="AN0178836269-8">Recruitment</hd> <p>University Institutional Review Board (IRB) approval was granted. Recruitment flyers were sent to relevant groups, listservs, organizations, and posted to online communities (e.g., Facebook, Reddit) for individuals who identify as autistic and/or LGBQ.</p> <hd id="AN0178836269-9">Interventions</hd> <p>Participants in both conditions were prompted to complete the intervention in a quiet space with minimal distractions. They were also encouraged to prioritize exercise instructions over spelling or grammar and reminded of confidentiality before starting the intervention. Participants in both conditions responded to the same prompts for three days in a row, for at least 15 min each, informed by prior research on expressive writing (Fratttaroli, [<reflink idref="bib21" id="ref62">21</reflink>]).</p> <hd id="AN0178836269-10">Open Writing Intervention</hd> <p>Participants in the open writing condition were directed to write freely about their deepest thoughts and feelings related to the heterosexist event. There was no structure provided to guide their processing other than the initial instruction. This prompt was repeated across the three days of the intervention.</p> <hd id="AN0178836269-11">Emotion Focused Therapy (EFT) Guided Writing Intervention</hd> <p>In the EFT condition, participants were asked to spend five minutes writing about their feelings about the heterosexist event; then, they wrote for five minutes on the needs that they could identify as emerging from considering those feelings; and, finally, they spent five minutes identifying ways they could try to meet those needs. These three prompts were repeated across the three days of the intervention.</p> <hd id="AN0178836269-12">Measures</hd> <p></p> <hd id="AN0178836269-13">Demographic Questionnaire</hd> <p>Participants reported their age, country of origin, sexual orientation, gender identity, race, ethnicity, income level, involvement in LGBTQ community, outness, previous diagnoses, suspected diagnoses, neurodivergent identity, and treatment history.</p> <hd id="AN0178836269-14">Autistic Traits</hd> <p>The AQ-10 (Allison, et al., [<reflink idref="bib2" id="ref63">2</reflink>]) is a 10-item measure that assesses for the presence of traits often found in individuals on the autism spectrum, and is limited to use with adults who do not have a co-occurring learning disability. Participants rated statements which were then coded or reverse coded as they relate to ASD criteria. The Cronbach's alpha for the present study was 0.63.</p> <hd id="AN0178836269-15">Depressive Symptoms</hd> <p>The Center of Epidemiology Scale for Depression-10 (CESD-10); Andresen, et al., [<reflink idref="bib3" id="ref64">3</reflink>]) is a ten-item measure that assesses the presence of depressive symptom during the past week, and is the short form of the CES-D (Radloff, [<reflink idref="bib51" id="ref65">51</reflink>]). Participants rated statements on a scale of 1 (<emph>rarely or none of the time</emph>) to 4 (<emph>most or all of the time</emph>). The CESD-10 has been used among diverse samples (e.g., González, et al., [<reflink idref="bib25" id="ref66">25</reflink>]), including autistic young adults (Pelton & Cassidy, [<reflink idref="bib48" id="ref67">48</reflink>]), and has demonstrated high internal consistency in prior studies (Cronbach's alpha: 0.80-0.86; González, et al., [<reflink idref="bib25" id="ref68">25</reflink>]). The Cronbach's alpha in this study was 0.82.</p> <hd id="AN0178836269-16">Event-Related Distress</hd> <p>The Impact of Event Scale-Revised (IES-R; Weiss, [<reflink idref="bib66" id="ref69">66</reflink>]<bold>)</bold> is a 22-item measure, which ask participants to reflect on the presence of difficulties that often appear after stressful life events. Scores reflect symptoms of trauma and stress related disorders, such as Post Traumatic Stress Disorder (PTSD). In this case, participants were asked to rate items from 0 (<emph>not at all</emph>) to 4 (<emph>extremely</emph>), reflecting on occurrences over the course of the past seven days. This scale has been previously used with adults diagnosed with ASD (Nisticò et al. [<reflink idref="bib43" id="ref70">43</reflink>]). Previous studies have reported high levels of internal consistency (Cronbach's alphas: Intrusion = 0.87 – 0.94, Avoidance = 0.84 – 0.87, Hyperarousal = 0.79 – 0.91) (Creamer, et al., [<reflink idref="bib14" id="ref71">14</reflink>]; Weiss et al., [<reflink idref="bib67" id="ref72">67</reflink>]). The Cronbach's alpha in the current study was 0.93.</p> <hd id="AN0178836269-17">Expectancy Question</hd> <p>For each condition, participants were given a rationale specific to the process of change so that expectancy effects could be evaluated. For instance, the open writing condition focused on the impact of deeply processing emotions and feelings, while the EFT condition focused on the benefit of recognizing new options and responses through guided questions. Participants were asked to rate a rationale for the intervention assess their expectations about potential for change prior to their first day of writing. After being provided a rationale for the condition they were randomly assigned to, they answered the following question: "Do you think there is a good rationale for this exercise?" Participants provided these ratings on a scale Likert scale of 1 (<emph>very little</emph>) to 5 (<emph>very much</emph>).</p> <hd id="AN0178836269-18">Self-Assessment of Progress</hd> <p>Participants responded to three statements to rate their overall experiences engaging in the expressive writing intervention: (<reflink idref="bib1" id="ref73">1</reflink>) How much progress do you feel you made in dealing with this event in this exercise? (<reflink idref="bib2" id="ref74">2</reflink>) How helpful do you feel the exercise was? (<reflink idref="bib3" id="ref75">3</reflink>) How do you feel about the exercise you have just completed? Participants rated the three statements using a Likert-style anchors adapted for each question with 1 = <emph>made things worse</emph> and 7 = <emph>a great deal of progress</emph>. These questions were repeated on the final day of writing and the follow up survey. Participant responses were averaged to create a total self-assessment of progress score. The Cronbach's alpha was excellent for the final day of writing (day 4; 0.967) and follow up (day 5; 0.915), which indicated high internal consistency of the three items.</p> <hd id="AN0178836269-19">Positive Therapeutic Outcomes</hd> <p>Participants were asked a series of questions created for this study about possible therapeutic outcomes that indicate positive therapeutic change. Questions focused on distress tolerance, feelings awareness, identification of needs, acceptance, understanding of others, understanding of event, empathy, and insights about interpersonal dynamics. An example question was: "I thought of new ways of responding to others." These items were rated on a Likert scale of 1 (<emph>strongly disagree</emph>) to 7 (<emph>strongly agree</emph>).</p> <hd id="AN0178836269-20">Analytic Plan</hd> <p>Data were analyzed using R Studio. Preliminary data analyses were conducted to examine the data outlying values, screen for missing data, and to screen data for normality. Duplicated responses (<emph>n</emph> = 5) and responses that did not go through the screening first (<emph>n</emph> = 12; possibly fraudulent attempts to obtain payment) were removed in the process of data cleaning. First, we analyzed descriptive statistics of the overall sample, including those that dropped out, for participants who completed all parts of the study. We calculated zero-order correlations to understand associations between variables of interest. Next, we used repeated measures analysis of variance (RM-ANOVAs) to examine differences by time and by condition for depressive symptoms and event-related distress scores. Mauchly's test was utilized to test for violations of the assumption of sphericity. Finally, we conducted chi-square analyses on therapeutic outcomes to further understand possible differences between the two conditions.</p> <hd id="AN0178836269-21">Quantitative Results</hd> <p>Of the total sample, approximately 34 individuals (60.7%) completed all parts of the study. We used unpaired t-tests to explore differences between baseline scores of outcome participants and demographic characteristics to determine if participants were randomized equally across conditions. There were no significant differences between those who completed the intervention and those who dropped out in terms of autistic traits (<emph>t</emph>(<reflink idref="bib54" id="ref76">54</reflink>) = 0.4702, <emph>p</emph> = 0.64), depressive symptoms (<emph>t</emph>(<reflink idref="bib54" id="ref77">54</reflink>) = 0.4905, <emph>p</emph> = 0.49), trauma/stress related symptoms (<emph>t</emph>(<reflink idref="bib54" id="ref78">54</reflink>) = − 0.0965, <emph>p</emph> = 0.34), rating of heterosexist distress (<emph>t</emph>(<reflink idref="bib54" id="ref79">54</reflink>) = 0.8817, <emph>p</emph> = 0.88), age (<emph>t</emph>(<reflink idref="bib54" id="ref80">54</reflink>) = 1.51, <emph>p</emph> = 0.14), or gender identity (i.e., transgender or cisgender; (<emph>t</emph>(<reflink idref="bib54" id="ref81">54</reflink>) = -0.5673, <emph>p</emph> = 0.57). Table 2 provides Pearson correlations among study outcome variables of interest, means and standard deviations.</p> <p>Table 2 Correlations among symptom outcome variables</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>1.</p></th><th align="left"><p>2.</p></th><th align="left"><p>3.</p></th><th align="left"><p>4.</p></th><th align="left"><p>5.</p></th><th align="left"><p>6.</p></th><th align="left"><p>7.</p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th></tr></thead><tbody><tr><td align="left"><p>1. ASQ-10</p></td><td align="left"><p>-</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td char="." align="char"><p>8.16</p></td><td char="." align="char"><p>2.04</p></td></tr><tr><td align="left"><p>2. CESD-10 (D1)</p></td><td align="left"><p>-0.01</p></td><td align="left"><p>-</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td char="." align="char"><p>15.53</p></td><td char="." align="char"><p>6.51</p></td></tr><tr><td align="left"><p>3. CESD-10 (D4)</p></td><td align="left"><p>0.06</p></td><td align="left"><p>0.73**</p></td><td align="left"><p>-</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td char="." align="char"><p>12.91</p></td><td char="." align="char"><p>5.26</p></td></tr><tr><td align="left"><p>4. CESD-10 (D5)</p></td><td align="left"><p>0.25</p></td><td align="left"><p>0.56**</p></td><td align="left"><p>0.67**</p></td><td align="left"><p>-</p></td><td align="left" /><td align="left" /><td align="left" /><td char="." align="char"><p>12.56</p></td><td char="." align="char"><p>6.36</p></td></tr><tr><td align="left"><p>5. IES-R (D1)</p></td><td align="left"><p>-0.05</p></td><td align="left"><p>0.43**</p></td><td align="left"><p>0.56**</p></td><td align="left"><p>0.36**</p></td><td align="left"><p>-</p></td><td align="left" /><td align="left" /><td char="." align="char"><p>21.88</p></td><td char="." align="char"><p>14.36</p></td></tr><tr><td align="left"><p>6. IES-R (D4)</p></td><td align="left"><p>0.02</p></td><td align="left"><p>0.30*</p></td><td align="left"><p>0.55**</p></td><td align="left"><p>0.38**</p></td><td align="left"><p>0.85**</p></td><td align="left"><p>-</p></td><td align="left" /><td char="." align="char"><p>22.79</p></td><td char="." align="char"><p>15.76</p></td></tr><tr><td align="left"><p>7. IES-R (D5)</p></td><td align="left"><p>-0.06</p></td><td align="left"><p>0.26</p></td><td align="left"><p>0.42**</p></td><td align="left"><p>0.47**</p></td><td align="left"><p>0.72**</p></td><td align="left"><p>0.74**</p></td><td align="left"><p>-</p></td><td char="." align="char"><p>14.12</p></td><td char="." align="char"><p>14.45</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. * <emph>p</emph> < 0.05; ** <emph>p</emph> < 0.01. D1, D4, D5 refers to the day of assessment in the intervention; D1 = pre-intervention, D4 = post-intervention, D5 = one month follow up. ASQ-10 = Autism Spectrum Quotient-10, CESD-10 = Center of Epidemiology Scale for Depression-10, IES-R = Impact of Event Scale-Revised. All participants who participated in this study (<emph>N</emph> = 56) are included in this table</p> <hd id="AN0178836269-22">Expectancy Effects</hd> <p>As expectancy effects have been found to be an important influence on change within psychotherapy (Tambling, [<reflink idref="bib63" id="ref82">63</reflink>]), this was assessed. Overall, participants reported high agreement with the rationale for interventions in the study. Specifically, 90.5% indicated high agreement with the provided rationale, with 54.3% reported (<reflink idref="bib5" id="ref83">5</reflink>) "very much" while 32.6% reported agreement (<reflink idref="bib4" id="ref84">4</reflink>, on a scale of 1–5). Two participants (4.3%) reported little or very little agreement (1 or 2). There were no significant differences in agreement across conditions (<emph>t</emph>(<reflink idref="bib44" id="ref85">44</reflink>) = -0.0142, <emph>p</emph> = 0.9887); and both conditions had high agreement with the provided rationale (i.e., EFT <emph>M</emph> = 4.346, open writing <emph>M</emph> = 4.35), suggesting that there were not differences in expectancy of change between the conditions.</p> <hd id="AN0178836269-23">Comparing Participants' Characteristics in Expressive Writing Conditions</hd> <p>Participants were randomized into one of two conditions: EFT condition (<emph>n</emph> = 30) and open writing (<emph>n</emph> = 26). In total, 19 participants completed the EFT intervention and 15 participants finished the open writing intervention.</p> <hd id="AN0178836269-24">Effects of Expressive Writing on Heterosexist Distress</hd> <p>Symptom outcomes were collected at the following points: pre-intervention, post-intervention and at follow-up. Generalized eta squared (η<sups>2</sups><subs><emph>G</emph></subs>) were calculated so that effect size statistics could be used to inform the clinical implications of this pilot study. Prior research has found η<sups>2</sups> to be more useful in making comparisons across between and within-subject design, thus it was used here (Bakeman, [<reflink idref="bib6" id="ref86">6</reflink>]). See summary of findings in Table 3 and changes in depression and event-relates distress in Figs. 1 and 2.</p> <p>Table 3 Results of repeated measures analysis of variance, efficacy analyses</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Outcome</p></th><th align="left" colspan="3"><p>Condition</p></th><th align="left" colspan="3"><p>Time</p></th><th align="left" colspan="3"><p>Condition x Time Interaction</p></th></tr></thead><tbody><tr><td align="left" /><td align="left"><p><italic>F(df)</italic></p></td><td align="left"><p><italic>P</italic></p></td><td align="left"><p>η<sup>2</sup><sub><italic>G</italic></sub></p></td><td align="left"><p><italic>F(df)</italic></p></td><td align="left"><p><italic>P</italic></p></td><td align="left"><p>η<sup>2</sup><sub><italic>G</italic></sub></p></td><td align="left"><p><italic>F(df)</italic></p></td><td align="left"><p><italic>p</italic></p></td><td align="left"><p>η<sup>2</sup><sub><italic>G</italic></sub></p></td></tr><tr><td align="left"><p>Depress</p></td><td align="left"><p>1.394(1,32)</p></td><td align="left"><p>0.247</p></td><td align="left"><p>0.026</p></td><td align="left"><p>4.431(2,64)</p></td><td align="left"><p>0.016*</p></td><td align="left"><p>0.051</p></td><td align="left"><p>0.139(2,64)</p></td><td align="left"><p>0.870</p></td><td align="left"><p>0.002</p></td></tr><tr><td align="left"><p>Trauma</p></td><td align="left"><p>0.305(1, 32)</p></td><td align="left"><p>0.584</p></td><td align="left"><p>0.007</p></td><td align="left"><p>7.826(2,64)</p></td><td align="left"><p>< 0.001**</p></td><td align="left"><p>0.068</p></td><td align="left"><p>1.402(2,64)</p></td><td align="left"><p>0.254</p></td><td align="left"><p>0.013</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. * <emph>p</emph> < 0.05; ** <emph>p</emph> < 0.01. These data include only participants who completed the study(<emph>N</emph> = 34). Depress refers to depressive symptoms, while trauma refers to event-related distress</p> <p>Graph: Fig. 1 Depressive Symptoms x Condition x Time. (Note. EFT = Emotion Focused Therapy, Writing = Open writing)</p> <p>Graph: Fig. 2 Event-Related Distress x Condition x Time. (Note. EFT = Emotion Focused Therapy, Writing = Open writing)</p> <hd id="AN0178836269-25">Effects on Depressive Symptoms</hd> <p>This RM-ANOVA did not reveal a significant condition by time interaction (<emph>F</emph>[<reflink idref="bib2" id="ref87">2</reflink>,<reflink idref="bib108" id="ref88">108</reflink>] = 0.165, <emph>p</emph> = 0.848, η<sups>2</sups><subs><emph>G</emph></subs> = < 0.001), meaning there were not significant differences between the two conditions. Results revealed a significant reduction in depressive symptoms across groups, with a small effect (<emph>F</emph>[<reflink idref="bib2" id="ref89">2</reflink>,<reflink idref="bib108" id="ref90">108</reflink>] = 5.527, <emph>p</emph> = 0.005, η<sups>2</sups><subs><emph>G</emph></subs> = 0.023) both at the time when the writing was completed and in the one-month follow up.</p> <hd id="AN0178836269-26">Event-Related Stress</hd> <p>This RM-ANOVA did not reveal significant differences by condition (<emph>F</emph>[<reflink idref="bib2" id="ref91">2</reflink>,<reflink idref="bib108" id="ref92">108</reflink>] = 0.980, <emph>p</emph> = 0.379, η<sups>2</sups><subs><emph>G</emph></subs> = 0.003). Across groups, there was a statistically significant decrease in event-related stress/trauma symptoms, indicating a small effect (<emph>F</emph>[<reflink idref="bib2" id="ref93">2</reflink>,<reflink idref="bib108" id="ref94">108</reflink>] = 7.763, <emph>p</emph> = 0.0007, η<sups>2</sups><subs><emph>G</emph></subs> = 0.021) both at the time when the writing was completed and in the one-month follow up. Additionally, it appears that the event-related distress from contact with the emotion was more moderate in the EFT condition than in the open writing condition, as shown in Fig. 2.</p> <hd id="AN0178836269-27">Self-Assessment of Progress</hd> <p>We examined descriptive statistics to assess self-reported changes. 89% (<emph>n</emph> = 34) of participants who completed this study felt that they had made progress in dealing with the heterosexist event, with 75% reporting they made <emph>moderate</emph> to <emph>considerable</emph> progress. The average score was 4.36 (<emph>SD</emph> = 1.12), and the range was 2.16–6.67. There were no significant differences between the two conditions in terms of progress made dealing with heterosexist events (<emph>t</emph>(34.99) = -1.0313, <emph>p</emph> = 0.31) both at the time when the writing was completed and in the one-month follow up.</p> <hd id="AN0178836269-28">Positive Therapeutic Outcomes</hd> <p>The chi-square test of independence revealed a significant difference between the two conditions, a <emph>X</emph><sups>2</sups>(<reflink idref="bib6" id="ref95">6</reflink>, _I_N_i_ 34) = 12.521, <emph>p</emph> = 0.051, with participants in the EFT condition reporting they were more likely than those in the open writing condition to develop empathy or patience towards others after participating in this intervention.</p> <hd id="AN0178836269-29">Study 2</hd> <p></p> <hd id="AN0178836269-30">Qualitative Methods</hd> <p></p> <hd id="AN0178836269-31">Participants</hd> <p>All participants who completed the study were included in the analyses, as the qualitative item was embedded in the follow up survey. A total of 14 participants in the open writing condition and 17 in the EFT condition responded to this qualitative open-ended question. Demographics were consistent with those presented in Table 1.</p> <hd id="AN0178836269-32">Thematic Analysis</hd> <p>All participants who completed the study answered open-ended questions on their experience participating in the expressive writing interventions. This study analyzed responses from participants for the following prompt: "Please take some time to write a description of what was most helpful about the study at this time." We used reflexive thematic analysis (Braun & Clarke, [<reflink idref="bib9" id="ref96">9</reflink>]) to explore how participants changed. Data were coded by the first author and then reviewed by the second author, who provided feedback and engaged in discussion until authors reached consensus on themes. After categorizing text, we examined trends across conditions. Themes were identified across both conditions, highlighting the ways aspects of the intervention facilitated change in coping with heterosexist distress.</p> <hd id="AN0178836269-33">Qualitative Results</hd> <p>We begin by presenting themes that were common across both conditions (open and EFT), followed by themes that were condition specific. See Table 4 for frequencies that represent the number of times a theme appeared across participant responses; higher frequencies are not reflective of greater importance because the themes emerged in the context of the open-ended question and many more people might have agreed with each theme if asked directly.</p> <p>Table 4 Qualitative themes by condition</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Themes</p></th><th align="left"><p>Open</p></th><th align="left"><p>EFT</p></th></tr><tr><th align="left"><p>Relevant Across Both Conditions</p></th><th align="left" /><th align="left" /></tr></thead><tbody><tr><td align="left"><p>Facilitating next actions and self-advocacy to meet needs</p></td><td char="." align="char"><p>1</p></td><td char="." align="char"><p>3</p></td></tr><tr><td align="left"><p>Considering increased connection to community</p></td><td char="." align="char"><p>2</p></td><td char="." align="char"><p>3</p></td></tr><tr><td align="left"><p>Structure of the exercises</p></td><td char="." align="char"><p>3</p></td><td char="." align="char"><p>5</p></td></tr><tr><td align="left"><p><bold>Unique Gains from One Condition</bold></p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p><italic>Open Writing</italic></p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Identification and differentiation of emotions</p></td><td char="." align="char"><p>17</p></td><td align="left" /></tr><tr><td align="left"><p>Unbottling emotions but difficulty containing them</p></td><td char="." align="char"><p>4</p></td><td align="left" /></tr><tr><td align="left"><p>Time to think about the issue</p></td><td char="." align="char"><p>8</p></td><td align="left" /></tr><tr><td align="left"><p>Knowing someone would read my writing</p></td><td char="." align="char"><p>1</p></td><td align="left" /></tr><tr><td align="left"><p><italic>Emotion Focused Therapy</italic></p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Deeper contact with emotion lead to language and then an awareness of needs</p></td><td align="left" /><td char="." align="char"><p>10</p></td></tr><tr><td align="left"><p>Deeper understanding of feelings led to greater clarity moved to beginning stages of processing and making meaning</p></td><td align="left" /><td char="." align="char"><p>12</p></td></tr><tr><td align="left"><p>Helpful to unbottle suppressed emotions, leading to a shift</p></td><td align="left" /><td char="." align="char"><p>3</p></td></tr><tr><td align="left"><p>Forgiveness</p></td><td align="left" /><td char="." align="char"><p>2</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0178836269-34">Themes Across Both Conditions</hd> <p></p> <hd id="AN0178836269-35">Facilitating Next Actions and Self-Advocacy to Meet Needs</hd> <p>Participants across both conditions reflected on new insights and actions they could take to continue to work towards well-being. For instance, the exercises helped one participant to identify "how [they] might handle that better in the future" (Participant 14, open) when faced with heterosexism. Several participants identified the importance of ongoing therapeutic support and noted they were planning to reach out to a therapist to continue the exploration they started through expressive writing (EFT & open). Some participants in the EFT condition reflected on self-advocacy intentions to better meet their health and interpersonal needs, rather than simply accepting the ways others treated to them.</p> <p>This made me realise that it was within my own power to change how I react and behave, that I wasn't entirely powerless. Having thought that seeking to change people's opinions about me was a losing battle that left me powerless, this was a welcome realisation. (Participant 37, EFT).</p> <p>In one instance, a participant had already reached out for medical referrals prior to the follow up survey. Finally, another participant identified a hope for collectively moving beyond discussion of these ideas and working an application "within society, communities, or the heterosexist contexts within which LGBT people live" (Participant 22, EFT).</p> <hd id="AN0178836269-36">Considering Increased Connection to Community</hd> <p>Through writing, a commonly identified action identified across conditions was the importance of greater community connection. Participants reflected on themselves in the context of their current communities, nature of relationships, and possible new ways of relating to others. Some identified unmet needs for community with shared identities; "For someone like me, I really just need a local tribe of people who can easily relate (both gay and on the autism spectrum). Everyday support is what is missing in my equation" (Participant 18, EFT). Several individuals reported a recognition of the importance of addressing underlying feelings with friends, and new insights about their interpersonal needs.</p> <hd id="AN0178836269-37">Structure of the Exercises</hd> <p>Across both conditions participants noted structured aspects of the survey that were beneficial in reducing heterosexist distress. Specifically, they noted repetition across three days of writing was helpful for in experiencing new things each day, while three additional participants found that the semi-structured questions helped to facilitate exploration of the event through a new lens. In addition, participants found it helpful to have a guide on what they should focus on during their allotted time.</p> <hd id="AN0178836269-38">Unique Gains from Open Writing Condition</hd> <p>The open writing condition was helpful in labeling and sitting with uncomfortable feelings related to the heterosexist event, which was facilitated by structured time to reflect. These unique gains are detailed below.</p> <hd id="AN0178836269-39">Identification and Differentiation of Emotions</hd> <p>Participants in the open condition noted that the writing exercises prompted deeper "inquiry" and "reflection" on their emotions related to the heterosexist event. Specifically, writing helped them to better identify and verbalize their feelings by working through the "stress and confusion." They were able to differentiate and "tease out" feelings, prompting a focus on painful topics they had previously avoided. This resulted in an awareness of new insights and in one case awareness of their own resilience. Participants also reported an ability to identify parts of the heterosexist event that impacted their feelings and their behavior, as articulated in the following quote, "identifying what and why that event caused such emotion, and identifying it as the reason why certain behaviors developed, helped me realize how far I've come and how much I've learned" (Participant 29, open). Although there was a focus on understanding emotion, they did not describe learning to make new meanings from the emotions.</p> <hd id="AN0178836269-40">Unbottling Emotions but Difficulty Containing Them</hd> <p>The open writing condition facilitated an unbottling of emotions that were previously suppressed, which in some cases was difficult as it "stirred everything up." For instance, several participants reported an awareness of unresolved or uncomfortable emotions but were unsure what to do with these new insights. Others noted it was challenging to cope with the aftereffects. One participant in the writing condition reported increased hypervigilance and distractibility, while another noted it was painful to "drudge up again." This unveiling made it difficult continue using avoidance strategies, as shared here: "I do feel like teasing out my depression has made it more difficult to ignore it. I have pretended that it was not there for so long and now, talking through it, I realize just how depressed I was, am, and continue to be" (Participant 28, open).</p> <hd id="AN0178836269-41">Time to Think About the Issue</hd> <p>Participants in the writing condition reported that having time (i.e., 15 min each day) to intentionally think about their chosen heterosexist event was helpful in their coping processes. This included "structured" time to "chase my thoughts" and intentionally focus on and think more critically about the heterosexist event. Participants noted as they coped with heterosexism in real time, this often meant finding ways to distance themselves from the event and the painful realities they'd experienced. As stated by one participant, "at the time the event occurred, I really didn't give myself time to sit and think about it or analyze what was so upsetting to me" (Participant 42, open). By turning inward, they were able to confront some of things they'd pushed away.</p> <hd id="AN0178836269-42">Knowing Someone Would Read my Writing</hd> <p>The design of the study was noted to be effective for one participant in the writing condition who reported that it was more powerful to be able to write to another person. This participant noted "I guess I liked being able to write my feelings out knowing someone would read it" (Participant 50, open). Although there was no response back to their writing, this was still beneficial for this individual.</p> <hd id="AN0178836269-43">Unique Gains from EFT Condition</hd> <p>The themes within the EFT condition expressed the helpfulness of emotional expression, but as also tied to a shift toward new insights, understandings, and identification of unmet needs. In contrast to the open writing condition, participants spoke of resolution which was facilitated by a transformation of emotions. Themes from this condition are presented in detail below.</p> <hd id="AN0178836269-44">Deeper Contact with Emotion, Lead to Language and Then an Awareness of Needs</hd> <p>Similarly, participants in the EFT condition also reported deeper reflection and contact with their emotions which facilitated new insights about themselves. Specifically, they reported an ability to sit with negative thoughts and feelings and make sense of their feelings, as shown in the following quote, "Often, emotions overwhelm me pretty easily because I struggle to make sense of them. But doing the same thing each day allowed me to delve in more deeply and extract more information from the confusing mass of emotion I was experiencing" (Participant 13, EFT). A unique aspect for the EFT condition was a more action-oriented focus after contact with feelings. "It reminded me that I can do this at other points in my life as well so that coping can involve getting some of those needs met rather than having to just accept them not being met" (Participant 13, EFT). Participants reported a focus on their emerging needs, the importance of meeting those needs, as well as specific ways to meet these needs (e.g., community connection).</p> <hd id="AN0178836269-45">Deeper Understanding of Emotions Resulted in Greater Clarity and Initiated Processing and Mea...</hd> <p>Participants in the EFT condition reported gaining a deeper understanding of their heterosexist event aby taking a deeper look at their emotions. This was exemplified by one participant who stated responding to guided prompts allowed them to "delve in more deeply and extract more information from the confusing mass of emotion I was experiencing" (Participant 13, EFT). These processes also facilitated more internal reflection and an opportunity to "let my feelings out", which was labeled as "emotionally freeing" and often led to increased awareness of what they needed to move forward. As stated by one participant, "I think that the study was useful as it allowed me to think of my experiences from different angles which I hadn't considered before such as what I need to overcome my feelings related to that" (Participant 45, EFT). By examining the event through different angles participants were able to examine different perspectives they had not previously considered, including what was unresolved from event and truth about themselves. This sentiment was illustrated by one participant one shared, "this survey helped me discover more roots to my queer autistic femme identity" (Participant 44, EFT), and others who made connections with their trauma history and coping patterns.</p> <hd id="AN0178836269-46">Helpful to Unbottle Suppressed Emotions, Leading to a Shift</hd> <p>Many participants in the EFT condition reported it was helpful to unbottle previously suppressed emotions, describing it as "emotionally freeing" often leading to "resolution." They noted a reduced intensity of painful emotions and feeling as if they were able to "overcome my feelings related to [heterosexist event]." Several endorsed feeling less ruminative about the event, while another noted an ability to "pause and check in with myself more." This shift was noted by one participant, who stated, "The way I was thinking about the event shifted from being ruminative, which in itself is great (Participant 39, EFT). It appeared that participants in the EFT condition experienced more of a change in how they experienced their emotions, beyond just noticing them, which allowed them to cope more easily.</p> <hd id="AN0178836269-47">Forgiveness</hd> <p>Participants in the EFT condition reported shifting from blame to forgiveness, both related to themselves and others. One participant reflected that they had been able to forgive themself for taking a protective stance when experiencing heterosexism, "rather than berate myself for being weak" (Participant 37, EFT). Another participant reported that as a result of greater understanding, they were beginning to imagine a future where they could one day forgive their aunt for her heterosexist "unkindness" (Participant 17, EFT). By making steps towards forgiveness, participants demonstrated a transformation of painful feelings.</p> <hd id="AN0178836269-48">Discussion</hd> <p>This study replicated the use of an online expressive writing intervention, found to be effective in reducing depressive symptoms and the event-related distress for LGBQ people (Collins et al., [<reflink idref="bib11" id="ref97">11</reflink>]), with a new population of study. We hypothesized that the EFT intervention would be equivalent to open writing on decreasing scores for both depression and event-related distress and found this to be so. Furthermore, results of the expectancy questions shows that participants felt there was a strong rationale for both interventions, which suggests that expectancy effects did not contribute disproportionately to either condition (Constantino, et al., [<reflink idref="bib13" id="ref98">13</reflink>]). When comparing conditions, the quantitative results of this pilot study did not find significant differences in self-reported change, depressive symptoms, or event-related stress across conditions. It is notable that participants in both the EFT condition and the open writing condition showed continued reductions in depressive symptoms and event-related distress between pre-intervention and the one month follow up, with significant reductions across time. Distinct differences were evident when quantitatively examining positive therapeutic changes, as participants in the EFT condition reported having developed significantly more empathy and patience towards others at the post-study evaluation. In addition, participants in the EFT condition appeared to have more moderate distress when processing their event, perhaps because of the structure that guided participants to think about their emotions, work through what they needed and consider how they might meet those needs.</p> <p>The qualitative experience of participating in the EFT condition was characterized by deeper contact with emotions which led to identification of needs and transformation of feelings. Participating in the open writing condition facilitated the labeling of emotions, although it presented participants with some challenges regulating uncomfortable feelings, when event-related stress rose immediately the writing exercises were completed. Overall, the results of this pilot study are encouraging across both conditions and indicate that these approaches may be a helpful way for many autistic-LGBTQ individuals to address heterosexist events.</p> <p>It is important to note that four participants reported that they did not make any progress in dealing with the event. Of these four, three of these participants reported engagement in the exercises made things worse. Two participants in the open writing condition reported that the exercises "stirred everything up". These participants noted increased hypervigilance (i.e., vivid dreams, feeling jumpy and on edge, problems concentrating) and difficulty sleeping. The participant in the EFT condition expressed frustration at the focus on coping with internal heterosexist distress rather than working to change heterosexist contexts and society. From examining their written responses, it seemed that these participants would have rather had someone to talk with in person about their issues as they wanted more personalized support (helpline information was provided to all participants). These findings suggest that this intervention may not be the preferred way of dealing with troubling events of heterosexism for all LGBTQ people on the autism spectrum, however this would need to be the focus of further research for a clear conclusion to be drawn.</p> <hd id="AN0178836269-49">Clinical Implications</hd> <p>This study has many implications for understanding and working with autistic-LGBTQ individuals, as well as on the development of interventions that may be helpful for this population. Based on the findings in this study, autistic-LGBTQ + individuals report experiencing distress related to heterosexist events and the vast majority (89%) reported making gains in processing this event. Autistic-LGBQ + people have difficulty finding a provider who is knowledgeable about their intersecting identities and experiences (Hillier, et al., [<reflink idref="bib30" id="ref99">30</reflink>]; Mendes & Maroney, [<reflink idref="bib39" id="ref100">39</reflink>]). Even participants living in urban areas, may find it difficult to find a provider who is both LGBTQ affirmative and knowledgeable about autism in adults (Maroney & Horne, [<reflink idref="bib38" id="ref101">38</reflink>]). The use of an online intervention such as this may be preferable over an in-person session (Gillespie-Lynch, et al., [<reflink idref="bib23" id="ref102">23</reflink>]), or may even complement ongoing therapy. A recent content analysis found that there were no intervention studies in counseling psychology, prompting a call for interventions to support and empower diverse LGBTQ + individuals (Abreu, et al., [<reflink idref="bib1" id="ref103">1</reflink>]). Given the relatively small demands of this exercise (approximately 3 h in total) and the accessibility of this online exercise, this intervention appears quite promising as even small gains can be seen as worthwhile and warrant further study.</p> <p>The use of Emotion Focused Therapy (EFT) to inform this intervention appears to be a promising approach for use with autistic-LGBTQ adults given the similar outcomes to the open writing condition. This is consistent with prior research, which piloted the use of EFT as a helpful approach for autistic individuals in processing traumatic experiences in a group therapy format (Robinson, [<reflink idref="bib52" id="ref104">52</reflink>]). This study helps to expand the understanding of therapeutic approaches that are possible for use with autistic individuals beyond behavioral approaches; an evidenced-based practice report identified predominantly behaviorally oriented approaches for use with autism (Wong, et al., [<reflink idref="bib69" id="ref105">69</reflink>]). The EFT intervention piloted in this study, and in Authors' 2021 study with LGBQ people generally, are the first times EFT strategies have been extended to an online platform (Authors, 2021), which is a promising next step for a therapeutic approach that has been found to be widely helpful in promoting change through emotional processing (Angus, et al., [<reflink idref="bib4" id="ref106">4</reflink>]). Finally, the use of EFT provides an important contribution to therapeutic interventions, particularly when contrasted with the controversy around ABA. Autistic people, given a supportive structure, were able to make meaning of their experiences in creative and beneficial manner. We encourage the field to use similar strategies that empower autistic-LGBQ + people to develop solutions to their problems, rather than to assume that they are not capable or interested in engaging in this form of processing.</p> <hd id="AN0178836269-50">Strengths and Limitations</hd> <p>Results of this study should be interpreted cautiously in light of a number of limitations. First, there was attrition throughout the study with 39% (<emph>n</emph> = 22) of the total sample dropping out and failing to complete the study as directed, including the post-study survey. It is interesting to note that the majority of participants who completed the final day of writing (Day 4) also completed the one month follow up (Day 5), suggesting drop out tended to happen in between the writing days. Further research may explore these trends. The small sample size and low power limited the choice of more complex analyses to examine the data, although the small main effects of these analyses are notable. It is important to note that this sample was predominantly White, despite efforts to recruit in a variety of spaces. This limits the ability to generalize to racial and ethnic minorities who are also autistic and LGBTQ. This is consistent across research with LGBTQ individuals, trends in online research recruiting for LGBTQ populations, as well as racial diversity in autistic individuals (Durkin, et al., [<reflink idref="bib18" id="ref107">18</reflink>]).</p> <p>There are a number of strengths to the present study. These results of this study highlight the unique stressors autistic-LGBTQ individuals face, and the level of distress surrounding experiences of heterosexism. Given the elevated rates of depression and anxiety among autistic individuals (Hollocks, et al., [<reflink idref="bib32" id="ref108">32</reflink>]), and the event-related distress reported by this sample, it is essential that interventions are developed to address the complex needs of this population. Most participants appeared to feel very positive about having access to this study, and often expressed gratitude, appreciation, or interest during the screening process at having found a study that addressed their experiences as autistic-LGBTQ individuals. This points to the importance of future research in this area to continue to understand ways to better support this understudied population. It will benefit from continuing to be refined based on the feedback from autistic-LGBQ participants, or with the inclusion of autistic-LGBQ + adults as co-researchers, which is aligned with recent practice-based guidelines (Nicolaidis, et al., [<reflink idref="bib42" id="ref109">42</reflink>]).</p> <p>It is important to note that the sample had high levels of distress, including clinically significant depressive symptoms among 75% of the sample, and PTSD symptoms of clinical concern among 62% of this sample. This finding is notable because participants were recruited based on their autistic-LGBTQ status and the presence of a troubling heterosexist event, rather than for elevated scores on measures of depression or trauma. Prior research has found higher rates of depression (37% of sample; Hollocks, et al., [<reflink idref="bib32" id="ref110">32</reflink>]) and PTSD (45% of the sample; Rumball, et al., [<reflink idref="bib55" id="ref111">55</reflink>]) among autistic adults as well. Interestingly the percentages of clinically significant depression or trauma scores in the present study are higher, which may be reflective of intersectional stigma (i.e., being LGBQ + and autistic), and warrants future research.</p> <p>Although small, these effects in treating depression and event-related distress are impressive given the brevity of time and commitment that this study required. The study took only approximately three to four hours in total, was free, could be conducted in the privacy of participants' home, did not require insurance, and did not require time and energy in finding an LGBTQ + affirmative therapist who also has experience working with autistic individuals. As highlighted by prior literature, provider competence and mental health care that is responsive to both autistic and LGBTQ + identities is often a barrier for those who hold both identities (Maroney & Horne, [<reflink idref="bib38" id="ref112">38</reflink>]; Mendes & Maroney, [<reflink idref="bib39" id="ref113">39</reflink>]). The exercises can be especially helpful for autistic people who feel uncomfortable speaking with therapists or speaking about their sexuality or stigma-related experiences. Furthermore, this intervention may be beneficial for individuals who are questioning their identity or do not feel comfortable verbalizing their experience. In fact, several participants reported wanting to share their experiences with a therapist after engaging in the writing exercises, with some taking steps to request referrals and begin to search for a therapist. These exercises can be assigned as therapy homework as well to create a bridge toward addressing about these issues (see LGBTQmentalhealth.com). This study highlights the potential of online writing-related interventions for autistic-LGBTQ people who are coping with heterosexist distress, and the value of providing a space and structure for autistic-LGBTQ + people in which to process their own experiences and come to solutions that make sense in their lives.</p> <hd id="AN0178836269-51">Funding Acknowledgement</hd> <p>This project was funded by the Craig R. Bollinger Dissertation Research Grant at the University of Massachusetts Boston.</p> <hd id="AN0178836269-52">Declarations</hd> <p></p> <hd id="AN0178836269-53">Conflict of interest</hd> <p>We have no known conflict of interest to disclose.</p> <hd id="AN0178836269-54">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0178836269-55"> <title> References </title> <blist> <bibl id="bib1" idref="ref49" type="bt">1</bibl> <bibtext> Abreu RL, Townsend D, Mitchell YL, Ward J, Audette L, Gonzalez KA. LGBTQ qualitative and mixed methods research in counseling psychology: A content analysis. The Counseling Psychologist. 2022; 50; 5: 708-737. 10.1177/00110000221092481</bibtext> </blist> <blist> <bibl id="bib2" idref="ref50" type="bt">2</bibl> <bibtext> Allison C, Auyeung B, Baron-Cohen S. 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  Data: Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism among Autistic-LGBQ+ Individuals
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  Data: <searchLink fieldCode="AR" term="%22Meredith+R%2E+Maroney%22">Meredith R. Maroney</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-4622-2683">0000-0002-4622-2683</externalLink>)<br /><searchLink fieldCode="AR" term="%22Heidi+M%2E+Levitt%22">Heidi M. Levitt</searchLink><br /><searchLink fieldCode="AR" term="%22Sharon+G%2E+Horne%22">Sharon G. Horne</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2024 54(8):2946-2959.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: 14
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  Data: Journal Articles<br />Reports - Research
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  Data: <searchLink fieldCode="DE" term="%22LGBTQ+People%22">LGBTQ People</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Sexual+Orientation%22">Sexual Orientation</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Bias%22">Gender Bias</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Mediated+Communication%22">Computer Mediated Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Expressive+Language%22">Expressive Language</searchLink><br /><searchLink fieldCode="DE" term="%22Writing+Exercises%22">Writing Exercises</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Patterns%22">Psychological Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Trauma%22">Trauma</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Response+to+Intervention%22">Response to Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Coping%22">Coping</searchLink>
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  Data: 10.1007/s10803-023-06027-1
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  Data: 0162-3257<br />1573-3432
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  Data: This experimental study explored the use of online expressive writing interventions to cope with distress from heterosexist events among a sample of autistic-LBGQ + individuals. This study included an open writing condition and an emotion focused therapy guided writing condition. Over 89% of the participants indicated that the writing exercises were helpful in processing the event, with significant decreases for measures of depressive and trauma/stressor symptoms. A thematic analysis identified specific aspects of each condition that were helpful for participants in coping with heterosexist distress, such as the development of insight through the emotion-focused exercises. This low-demand exercise is promising as a solo exercise or as a therapy homework assignment, especially given the accessibility of this online intervention for autistic-LGBQ + people.
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    Subjects:
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        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Sexual Orientation
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