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.
Jensen-Johansen, M.B., Christensen, S., Valdimarsdottir, H., Zakowski, S., Jensen, A.B., Bovbjerg, D.H., & Zachariae, R. (2012). Effects of an expressive writing intervention on cancer-related distress in Danish breast cancer survivors—Results from a nationwide randomized clinical trial. Psycho-Oncology, 22, 1492–1500.
To examine the effects of an expressive writing intervention on cancer-related distress, symptoms of depression, and mood in women with early-stage breast cancer
Women were randomized to an expressive writing group or a control group. Both groups were instructed to write for 20 minutes once a week over a three-week period. On each writing day, patients were contacted by telephone to initiate the writing session and contacted again after 20 minutes to terminate writing. Patients in the expressive writing group were instructed to write about a distressing event and to explore their deepest emotions and feelings about the experience. Control group patients were asked to write about their daily activities in a detailed and objective manner. Study questionnaires were completed at baseline and at three and nine months postintervention.
Single-blind, randomized controlled trial with an active control group
The expressive writing group showed significant changes in negative and positive mood immediately after the writing sessions (d = 0.84–1.04, p < 0.001). When age and baseline measures were included in analysis as covariates, there were no significant effects or group-by-time interactions.
Investigators could not confirm the hypothesis that, compared to patients in an active control group, patients in an expressive writing group experience less cancer-related distress.
This study does not provide evidence to support expressive writing as an intervention to reduce anxiety and symptoms of depression in women with breast cancer.
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(4), 460–466.
To test the effects of emotionally expressive writing versus disease-related writing on patients with metastatic breast cancer; to determine whether the effects of expressive writing vary as a function of perceived social support or time since diagnosis of metastasis
Investigators used three sources of recruitment: a larger study, flyers, and advertising on a website and Listserv. All contact with patients was via telephone, postal mail, or email. Participants completed baseline assessments, which gathered data about demographics and emotional support. Investigators collected saliva samples. Patients were randomized to either the emotional or control writing condition, and patients received information about the exercises. Patients were scheduled to participate in four 20-minute sessions that occurred at patients' convenience within a three-week interval. A research assistant monitored compliance. After each session, a patient mailed her writing to the research office. At study entry and three months after the final writing session, a by-mail questionnaire measured outcomes according to stated instruments.
Randomized controlled trial
Expressive writing did not produce reduction in psychological distress or improvement in physical health. The intervention may be beneficial for a subset of patients with metastasis and contraindicated for other patients.
Expressive writing may be of benefit to a certain subset of patients. The intervention is cost-effective and an activity that patients with low levels of social support can do. Future study should apply the expressive-writing approach to vulnerable, underserved, and understudied populations and offer broader topics for expressive writing (e.g., benefits of the cancer experience, a topic unrelated to cancer). Investigators should provide writing supplies. Future research should consider privacy protections (possibly from family members), especially in cultures that place great value on the privacy of written material.
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.
Rodriguez Vega, B., Palao, A., Torres, G., Hospital, A., Benito, G., Perez, E., . . . Bayon, C. (2011). Combined therapy versus usual care for the treatment of depression in oncologic patients: A randomized controlled trial. Psycho-Oncology, 20(9), 943–952.
To compare the effects—on quality of life and symptoms of depression—of an intervention consisting of a psychotherapeutic intervention, narrative therapy, plus escitalopram to the effects of usual care plus escitalopram
The initial sample was composed of 1,026 patients, between March 2006 and June 2008, with a diagnosis of breast, lung, or colorectal nonmetastatic cancer, three months after cancer diagnosis and no later than two years after diagnosis. Investigators used the Hospital and Anxiety Depression Scale (HADS) to screen participants for depression. A total of 150 had depressive disorder according to DSM-IV-TR criteria. The study contained 72 participants, 33 in usual care and 39 in combined care. Escitalopram was administered on a fixed-flexible schedule in both groups, beginning with 10 mg per day and adjusted up to 20 mg per day by week 8. A minimum of six months treatment was established for both groups. The narrative intervention was carried out individually during 12 weekly sessions, each 45 minutes long, and was guided by a treatment manual. Of the sessions, 10% were videotaped to help ensure adherence. Usual care consisted of oncologist-adminstered antidepressant. The oncologist followed a protocol and reported side effects of the medication. The follow-up of patients in the usual-care group was similar to that of patients in the treatment group. Investigators assessed depression-related outcome at weeks 12 and 24.
Two-center randomized controlled trial
Demographic variables did not differ significantly between the two groups. Gender and age were unbalanced because of cancer types. At 12 and 24 weeks, the combined-therapy group showed significantly greater improvement in all the dimensions of function (p < 0.01), pain scale (p = 0.02), global health (p = 0.02), and global quality of life (p = 0.007). Between groups there were no statistically significant differences in symptoms of depression. From week 12 to 24, study retention was higher in the combined-treatment group (p = 0.01).
Using combined therapy for major depression in patients with cancer results in significant improvements in quality of life but does not result in a significant reduction in symptoms of depression. Narrative therapy is an integrative intervention designed to address components of critical importance in patients with depression. The therapy may have a positive impact on patient’s fears and worries about medication interactions and side effects.
The interventions proved to be acceptable to patients. The intervention shows good potential for dissemination, is relatively easy to implement, and improved compliance. The intervention may be a low-cost means of improving the quality of life of patients with cancer.