Expressive Writing/Emotional Disclosure/Journaling

Expressive Writing/Emotional Disclosure/Journaling

PEP Topic 
Chronic Pain

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

Cepeda, M.S., Chapman, C.R., Miranda, N., Sanchez, R., Rodriguez, C.H., Restrepo, A.E., . . . Carr, D.B. (2008). Emotional disclosure through patient narrative may improve pain and well-being: Results of a randomized controlled trial in patients with cancer pain. Journal of Pain and Symptom Management, 35, 623–631.

doi: 10.1016/j.jpainsymman.2007.08.011

Study Purpose:

To determine if a structured approach using patient narrative in patients with advanced cancer decreases pain and improves sense of well-being

Intervention Characteristics/Basic Study Process:

Patients were randomized into one of three groups: (1) narrative group, (2) questionnaire group, or (3) control group. Patients in the narrative group were asked to write about how cancer affected their lives, calling upon their deepest thoughts, feeling, and fears, and to write for at least 20 minutes once a week. Patients in the questionnaire group were asked to complete a pain questionnaire as an attentional control. Patients in the control group were asked to attend weekly medical follow-up visits and receive usual care. All patients were seen weekly in the clinic for eight weeks. Three weeks after randomization, research personnel called patients to remind them about completing narratives, filling out the questionnaire, and coming to the office for follow-up. Research personnel who collected data were blinded to group assignment. Patients rated their average pain intensity during the prior week in clinic visits. Investigators rated emotional content of the narratives.

Sample Characteristics:

  • The study reported on 234 patients.
  • Mean patient age across groups ranged from 46.2 (SD = 12.6) to 50.2 (SD = 10.5) years.
  • The sample was 64% female and 48% male.
  • Patients had a broad variety of cancer diagnoses, with breast cancer being the most prevalent (23.5%).
  • All patients had a Karnofsky Performance Status score of less than 50%.
  • All patients had an average pain intensity score of at least 5 on a 10-point scale, and average baseline intensity was at least 7.2 (SD = 1.8).
  • The majority of patients had pain duration of less than six months.


  • Single site
  • Outpatient setting
  • University cancer center in Bogota, Colombia

Study Design:

The study was a randomized, single-blinded, controlled trial.

Measurement Instruments/Methods:

  • Numeric pain rating scale (0–10)
  • Seven-point Likert-type scale for well-being


There were no differences between groups in outcomes measured. More than half (53%) of patients in the narrative group completed narratives as requested, 86% of patients in the questionnaire group completed the questionnaire, and 90% of patients in the control group kept all clinic appointments. Twenty patients did not demonstrate any emotional disclosure in narratives. Five patients had strong emotional content of narratives, and these patients had lower pain intensity scores.


Participation in writing narratives as structured in this study did not have any impact on pain or well-being. Only half of the patients fully participated in the narrative writing as designed.


  • Methods for qualitative analysis of the emotional content of narratives were not described, and methods to ensure reliability were not stated.
  • The observation that most narratives were not very emotional suggests that the impact of actual emotional disclosure cannot be evaluated from this study.

Nursing Implications:

Study findings suggest that having patients write narratives for emotional disclosure to reduce pain is not effective. The apparent lack of actual emotional content in the majority of narratives reviewed in this study suggests that patients need assistance to identify and disclose these aspects of their experience. It is not clear whether patients may have concerns about privacy in terms of what content they provided in this research.