Implementing an Expressive Writing Study in a Cancer Clinic


Patients at a comprehensive cancer center have participated in a weekly writing program for 7 years. Anecdotal evidence following writing in this clinical setting appeared congruent with the results of expressive writing studies conducted in laboratory settings. To move expressive writing research beyond the laboratory, we evaluated the feasibility of engaging a clinical population in a structured expressive writing task while they waited for an appointment in a cancer clinic. Adult leukemia and lymphoma patients (n = 71) completed a baseline assessment, 20-minute writing task, postwriting assessment, and 3-week follow-up; 88% completed the writing task and 56% completed the follow-up. Participants reported positive responses to the writing, and immediately postwriting about half (49.1%) reported that writing resulted in changes in their thoughts about their illness, while 53.8% reported changes in their thoughts at the 3-week follow-up. Reports of changes in thoughts about illness immediately postwriting were significantly associated with better physical quality of life at follow-up, controlling for baseline quality of life. Initial qualitative analyses of the texts identified themes related to experiences of positive change/transformation following a cancer diagnosis. Findings support the feasibility of conducting expressive writing with a clinical population in a nonlaboratory setting. Cancer patients were receptive to expressive writing and reported changes in the way they thought about their illness following writing. These preliminary findings indicate that a single, brief writing exercise is related to cancer patients’ reports of improved quality of life.



The effects of guided written disclosure on psychological symptoms among parents of children with cancer.

J Fam Nurs. 2007 Aug;13(3):370-84.

Duncan E1, Gidron Y, Rabin E, Gouchberg L, Moser AM, Kapelushnik J.

This study examines whether structured writing about receiving a diagnosis and treatment for pediatric cancer reduces distress among highly distressed parents of children with cancer (PCWC). Eight PCWC completed measures of posttraumatic stress symptoms (PTSS) and depressive symptoms at two baselines, and again after writing, with 1-month gaps between assessments. Using a guided disclosure protocol (GDP), parents were asked to write about receiving the diagnosis first in a chronological manner, then to explicitly label their emotions at the time of diagnosis and explain the impact of the child’s illness on their life. Finally, they were asked to reflect on current feelings, future coping ability, and personal growth. Although symptoms of distress did not change between baselines, significant reductions were found in PTSS from the first baseline to postwriting, but not in depression. This preliminary study suggests that the GDP may reduce PTSS in distressed PCWC.

Figures of grief: metaphors from a bereavement writing group.

Omega (Westport). 2007-2008;56(4):359-67.

Young E1.

In a community-based bereavement writing group, patterns of metaphor emerged and helped the group members identify and deal with particularly challenging aspects of death and grief, including taboo subjects such as abuse and suicide. The metaphors show how a bereavement writing group functioned to address the needs of people coping with different kinds of grief effectively and efficiently. Analysis of the specific metaphors suggests why figurative language enabled the group to bond quickly and strongly, delve into the complex emotions death elicits, and integrate experiences of loss and grief safely and productively. The patterns of metaphors the group produced in their writing about death and grief are discussed in terms of bereavement processes, and the topics the group used to elicit the figures of speech are presented for further refinement and use.

Effects of written emotional expression: the role of positive expectancies.

Health Psychol. 2007 Mar;26(2):174-82.

Langens TA1, Schüler J.

Writing in an emotional way about stressful or traumatic experiences has beneficial effects on emotional well-being and physical health. Yet the mechanisms that underlie these effects still need to be explored. Integrating research on the effects of positive expectancies, the authors suggest that positive effects of written emotional expression may, in part, depend on expectancies induced by writing about emotional experiences.


Two studies were conducted to test this hypothesis. In both studies, participants wrote about either an upsetting event or trivial issues. After the writing period, participants rated their expectancies that the writing intervention would improve (or impair) their emotional well-being over time.


Study 1 assessed the emotional impact of an upsetting event, whereas Study 2 assessed subjective reports of physical symptoms. In both studies, outcome variables were collected both before and 6 weeks after the writing intervention.


The results showed that (a) writing about upsetting experiences induced higher positive expectancies than writing about trivial issues and (b) expectancies associated with written emotional expression were related to a reduction in the emotional impact of an upsetting event (Study 1) and to a reduction in physical symptoms (Study 2).


There may be 2 alternative ways to render written emotional expression effective in reducing negative emotions: (a) by rendering an emotional experience more meaningful and (b) by inducing positive affect regulation expectancies.

Does expressive writing reduce stress and improve health for family caregivers of older adults?

Gerontologist. 2007 Jun;47(3):296-306.

Mackenzie CS1, Wiprzycka UJ, Hasher L, Goldstein D.

We examined whether written emotional disclosure reduces stress and improves health outcomes for family caregivers of physically frail and cognitively impaired older adults, as it has been shown to do for certain student and clinical populations.


Primary caregivers of older adults attending a day program were randomly assigned to expressive-writing (n = 14), time-management (n = 13), or history-writing (n = 13) conditions. Participants wrote for 20 minutes on four occasions over a 2-week period, and they completed self-report measures of caregiver burden and health prior to the intervention, immediately afterward, and at 1-month follow-up.


Contrary to expectations, expressive-writing and history-writing participants performed similarly across outcomes. Only caregiver participants in the time-management condition experienced significant mental and physical health improvements after writing.


The results of this study add to a growing body of research demonstrating equivocal effects of expressive writing with clinical samples, and they suggest the potential benefit of written time management for stressed caregivers.

Does altering the writing instructions influence outcome associated with written disclosure?

Behav Ther. 2007 Jun;38(2):155-68. Epub 2007 Jan 18.

Sloan DM1, Marx BP, Epstein EM, Lexington JM.

This study examined the effect of changing the instructional set for written disclosure on psychological and physical health reports among traumatized college students with current posttraumatic stress symptoms. Eighty-two participants were randomly assigned to one of three writing conditions that focused on emotional expression (EE), insight and cognitive assimilation, or to a control condition. Participants assigned to the EE condition reported significant improvements in psychological and physical health 1 month following the writing sessions relative to the other two conditions. The EE participants also reported and displayed significantly greater initial psychophysiological reactivity and subsequent habituation compared with the other two conditions. These findings suggest the importance of emphasizing emotional expression during written disclosure and underscore the importance of examining how modifying the written disclosure protocol can affect outcome.

Writing assignments about stressful and/or traumatic events do not benefit patients with anxiety disorders

Tijdschr Psychiatr. 2007;49(2):75-84.

Lammerts van Bueren N1.

Several studies have indicated that patients with mild anxiety symptoms may benefit from writing about life events that they have found stressful. However, there is very little research done into the effects of this technique.


To find out whether writing about stressful and/or traumatic events would also benefit patients with severe anxiety disorders.


Our sample consisted of 32 patients (24 women and 8 men) with anxiety disorders. They were randomly assigned to 2 groups, one being an experimental group, the other a control group. Eighteen patients were asked to write about the most stressful events they had experienced and 14 were asked to write about trivial topics. Each patient completed 4 writing sessions over a 2-week period. A follow-up writing session took place six weeks later. Anxiety symptoms and mood were measured by means of the Symptom Check List, the Penn State Worry Questionnaire, the Impact of Event Scale and the Profile of Mood State. The immediate effect of writing on mood was scored by means of a simple questionnaire.


The mood of the patients in the experimental writing group deteriorated markedly during a short time. Multivariate analyses conducted on repeated measurements did not reveal any significant effects. The interaction between the experimental group and the test scores was not significant either. At follow-up psychic functioning and mood in the experimental group were no better that in the control group.


Writing about stressful and/or traumatic events is a very taxing activity for patients (pain). This has often been demonstrated in the past. The results show that simply writing about stressful events is definitely not a successful way of reducing anxiety symptoms (no gain).