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.
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.
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.
Patients were undergoing the active treatment phase of care.
This was a pilot, randomized, controlled trial.
Pittsburgh Sleep Quality Index (PSQI)
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).
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.
To evaluate whether expressive writing (EW) was an effective stress management intervention for patients with breast cancer.
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.
Patients were undergoing the active treatment phase of care.
The study was a randomized, controlled trial.
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.
EW was not as broadly effective as a stress management intervention for women with breast cancer.
These data do not support the use of EW as a presurgical mind-body complementary medicine program for this population.
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 study was a randomized, controlled trial.
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.
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.
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.
The study was a randomized trial, with interviewers blinded in regard to the group they were interviewing.
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.
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.
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.