Expressive Writing/Emotional Disclosure/Journaling

Expressive Writing/Emotional Disclosure/Journaling

PEP Topic 
Sleep-Wake Disturbances
Description 

Expressive writing/journaling is the art of putting thoughts and feelings on paper. Writing about negative emotional experiences may improve physical and psychological health, and writing about deep feeling regarding personal stressors can enhance well-being and health. Expressive writing as a form of emotional disclosure has been examined in fatigue and depression and may have relevance for pain, sleep-wake disturbances, anxiety, and caregiver strain and burden. Individuals may be counseled to write specifically about thoughts and feelings, or some other aspect of their experience.  

Effectiveness Not Established

Research Evidence Summaries

de Moor, J. S., Moyé, L., Low, M. D., Rivera, E., Singletary, S. E., Fouladi, R. T., & Cohen, L. (2008). Expressive writing as a presurgical stress management intervention for breast cancer patients. Journal of the Society for Integrative Oncology, 6, 59–66.

Print

Study Purpose:

To evaluate whether expressive writing (EW) was an effective stress management intervention for patients with breast cancer.

Intervention Characteristics/Basic Study Process:

Women were assigned to write about their cancer experience (EW group; n = 24) or neutral topics (neutral writing [NW] group; n = 25). Women were asked to write for 20 minutes a day for a total of four writing sessions that were completed over a seven-day period. Patients were reassessed approximately three days before and two weeks after surgery.

Sample Characteristics:

  • The sample was comprised of 49 women.
  • Patients were older than 18 years; mean age was 56.89 years (standard deviation = 10.79 years).
  • Women were recruited two or more months from neoadjuvant chemotherapy.
  • Of the patients, 58% were white, 13% were black, 13% were Latina, and 16% were other; 52% were college graduates or had some graduate training; 44% had an annual income of greater than $50,000, 79% were married/cohabitating; and 49% had stage II and 54% had stage III.

Setting:

  • Cancer outpatient clinic
  • MD Anderson Cancer Center, Texas

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Brief Symptom Inventory 18 (BSI 18)
  • Perceived Stress Scale (PSS)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Social Constraints Scale (SCS)
  • Brief Pain Inventory (BPI)
  • Impact of Events Scale (IES)
  • Emotional Approach Coping Scale (EACS)
  • Linguistic Inquiry and Word Count (LIWC)

Results:

The EW intervention did not significantly decrease women’s distress, perceived stress, sleep disturbance, or pain. There was some evidence that the EW group used more sleep medication at the presurgical assessment than the NW group. Social constraints moderated the effect of the intervention. Among women with high social constraints, the EW group reported lower average daily pain than the NW group. Among women with low social constraints, the EW group reported higher average daily pain than the NW group.

Conclusions:

EW was not as broadly effective as a stress management intervention for women with breast cancer.

Limitations:

  • The study had a small sample size and lacked statistical power.
  • There was high attrition and inconsistent adherence.

Nursing Implications:

These data do not support the use of EW as a presurgical mind-body complementary medicine program for this population.

de Moor, C., Sterner, J., Hall, M., Warneke, C., Gilani, Z., Amato, R., . . . Cohen, L. (2002). A pilot study of the effects of expressive writing on psychological and behavioral adjustment in patients enrolled in a Phase II trial of vaccine therapy for metastatic renal cell carcinoma. Health Psychology, 21, 615–619.

doi: 10.1037/0278-6133.21.6.615
Print

Intervention Characteristics/Basic Study Process:

The study included four weekly sessions of expressive writing associated with the first four cancer vaccines; patients were randomly assigned to neutral health issues writing or expressive writing of the group’s deepest thoughts and feelings.

Outcomes were psychological and behavioral adjustment, symptoms of distress, perceived stress, mood, and sleep.

Sample Characteristics:

  • The sample was comprised of 42 patients (85% male) with newly diagnosed stage IV metastatic renal cell carcinoma who were four to six weeks postoperative.
  • Mean age was 56.4 years.

Setting:

  • Outpatient
  • Southwestern United States

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

This was a pilot, randomized, controlled trial.

Measurement Instruments/Methods:

Pittsburgh Sleep Quality Index (PSQI)

Results:

Statistically significant improvements in the expressive writing group were found for four of the sleep disturbance measures on the PSQI (total score and subscales of Sleep Quality, Sleep Duration, and Daytime Dysfunction).

Limitations:

  • The study had a small sample size.
  • Generalizability was questionable because of the nature of the illness.
  • Space is needed for the writing to occur, prior to the injection.

Low, C. A., Stanton, A. L., Bower, J. E., & Gyllenhammer, L. (2010). A randomized controlled trial of emotionally expressive writing for women with metastatic breast cancer. Health Psychology, 29, 460–466.

doi: 10.1037/a0020153
Print

Study Purpose:

To test the effect of emotionally expressive writing in a randomized, controlled trial of patients with metastatic breast cancer (MBC) and to determine whether the effects of the intervention varied as a function of perceived social support or time since metastatic diagnosis.

Intervention Characteristics/Basic Study Process:

The sample was recruited from several sources; all contact occurred via telephone, mail, or email. Patients were randomized to either an emotional or control writing condition and were mailed a packet of sealed envelopes. Trained research assistants telephoned women at the beginning of each of the four writing sessions within a three-week interval to read instructions and called back 20 minutes later to ask the women to stop writing. The women mailed the essays to the research office at the end of each session for analysis. Outcomes were measured three months after the final writing.

Sample Characteristics:

  • The sample was comprised of 62 women.
  • Mean age was 53.8 years (standard deviation = 10.3 years; range 29–78).
  • Patients had stage IV MBC.
  • Patients could be on or off treatment.

Setting:

  • Single site
  • Home
  • California

Phase of Care and Clinical Applications:

  • Patients were undergoing the long-term follow-up phase of care.
  • The study has clinical applicability for end of life and palliative care.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Center for Epidemiologic Studies Depression Scale (CESD)    
  • 7-Item Intrusion Scale
  • Impact of Events Scale (IES)
  • Negative Somatic Symptoms (Pennebaker 1982)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Demographic/medical variables
  • Questionnaire reactions to participation at three months

Results:

No significant differences existed between the two experimental conditions on demographic/medical variables, depression, intrusive thoughts, or sleep disturbances. There were no main effects for the experimental condition to predict intrusive thoughts. Perceived emotional support at study entry interacted with the experimental condition to predict IES-Intrusion (F [1, 56] = 11.61; p = 0.001). For women with a decreased level of emotional support at entry, the effect of the experimental condition was significant (p = 0.002). There was no effect on sleep in newly diagnosed patients but increased sleep disturbances for women who had been diagnosed more than 4.7 years.

Conclusions:

Contrary to the hypothesis, expressive writing did not reduce psychological distress or improve physical health as quantified by fewer sleep disturbances and somatic symptoms.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • The study lacked heterogeneity and was white.
  • Physical health measures relied on self-reports.
  • The study was underpowered to detect an effect in the subset of women who had not previously participated in a cancer support group or talked with a mental health professional about cancer.

Nursing Implications:

Expressive writing may be helpful for a subset of patients with MBC (those with low levels of social support and recently diagnosed) and contraindicated for others (those living longer with the diagnosis). Further studies should explore alternative writing topics, such as perceived benefits of the cancer experience.

Mosher, C. E., Duhamel, K. N., Lam, J., Dickler, M., Li, Y., Massie, M. J., & Norton, L. (2012). Randomised trial of expressive writing for distressed metastatic breast cancer patients. Psychology and Health, 27, 88–100.

doi: 10.1080/08870446.2010.551212
Print

Study Purpose:

To examine the health effects—on existential and psychological well-being, fatigue, and sleep—of writing about the deepest cancer-related thoughts and feelings in patients with advanced breast cancer.

Intervention Characteristics/Basic Study Process:

  • By telephone, one week after the screening assessment, investigators conducted a baseline interview of patients who met the criteria. Investigators obtained consents.
  • At random, a computer assigned patients to the expressive writing or neutral writing group. Patients were stratified by ethnicity and age.
  • Patients received four sets of writing instructions, lined paper, forms for rating the essays, and envelopes for returning the materials by postal mail.
  • Study design called for each patient to complete four writing sessions over a period of four to seven weeks, with instructions for each session provided by telephone by the study staff. Intervention and control groups were to begin writing immediately after the instruction telephone call. All patients were to write for 20 minutes continuously. At the 20-minute mark, a telephone call from staff collected patients' assessments of the quality of the writing time; adjustments were made for interruptions. Staff told patients to rate their essays on a scale of one to seven and asked patients to mail their essays to the investigators.

Sample Characteristics:

  • The study reported a sample of 86 females with stage IV breast cancer.
  • Mean age was 57.4 years (standard deviation [SD] = 12.5 years) in the expressive writing group and 58.5 years (SD = 11.7 years) in  the neutral writing group.
  • Patients were included if they had clinically elevated distress, as indicated by scores greater than four on the Distress Thermometer, were fluent in English, and were 18 years or older.
  • Patients were excluded from the study if they had severe cognitive impairment, as assessed by the Short Portable Mental Status Questionnaire, or if they were already engaged in expressive writing on a daily basis.
  • Average range of time since diagnosis was 4.2 to 4.7 years in the expressive writing group and 3 to 3.5 years in the neutral writing group. Most patients had received chemotherapy or hormone therapy.
  • Of the patients in the expressive writing group, 40.9% were using mental health services at baseline.

Setting:

  • Single site
  • Outpatient setting
  • Comprehensive cancer center in New York City

Phase of Care and Clinical Applications:

  • Patients were undergoing the active treatment phase of care.
  • The study has clinical applicability for late effects and survivorship and end-of-life and palliative care.

Study Design:

The study was a randomized trial, with interviewers blinded in regard to the group they were interviewing.

Measurement Instruments/Methods:

  • Meaning/Peace subscale of the Functional Assessment of Chronic Illness Therapy (FACIT)–Spiritual Well-Being Scale, to assess existential well-being. This measure reflected patients’ degree of purpose in life and inner peace.
  • A measure of demoralization, or existential despair and distress
  • Distress Thermometer, to measure psychological well-being and general distress
  • Center for Epidemiologic Studies Depression (CESD) Scale, to assess symptoms of depression
  • Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS), to measure anxiety
  • Pittsburgh Sleep Quality Index (PSQI), to measure habitual sleep disturbance and fatigue over one month. This study used the total global sleep-quality score.
  • Fatigue subscale of the FACIT, to measure fatigue during the past seven days 
  • Australia-modified Karnofsky Performance Status (KPS) Score, to measure sociodemographic and medical variables and functional impairment at baseline. Trained interviewers administered this instrument.
  • Manipulation check and essay ratings, gathered by an independent rater blinded to the group assignment, to assess the writing instructions for each essay
  • Seven-point scale, used by each patient, to rate how personal the patient's essays were and how much essays revealed of emotions
  • Linguistic Inquiry and Word Count, a computerized text-analysis program, to report the percentage of position and negative-emotion words in each essay

Results:

In this sample, expressive writing—compared to neutral writing—did not result in better existential and psychological well-being, reduced fatigue, or enhanced sleep quality. Although both writing groups showed little change in their distress over time, during the study, patients in the expressive writing group reported more than double the rate of mental health service use than did patients in the neutral writing group.

Conclusions:

Expressive writing may have increased patients’ awareness of their distress and challenging circumstances, prompting the patients to seek mental health services. Further research is needed.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • Patients who were younger and closer to diagnosis were more likely to participate; however, these response biases were relatively small.
  • Whether results are generalizable to men and patients with diverse ethnic and socioeconomic backgrounds are points that warrant examination.
  • The study relied on self-reported outcome measures administered at one follow-up assessment.

Nursing Implications:

Expressive writing may increase use of psychological support services by distressed patients, without increasing symptom severity. Expressive writing may help keep patients in touch with their emotions, whether negative or positive. When patients are in touch with their emotions, they may be more likely to reach out for help, if they recognize negative emotions that they are not resolving on their own. However, this intervention did not result in differences in patient symptoms or outcomes.

Menu