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.

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.

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.

• 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.

• Single site
• Home
• California

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

The study was a randomized, controlled trial.

• 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

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.

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

• 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.

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.