Cummings, J. A., Hayes, A. M., Saint, D. S., & Park, J. (2014). Expressive writing in psychotherapy: A tool to promote and track therapeutic change. Professional Psychology: Research and Practice, 45(5), 378-386.
Expressive writing (EW) can be a useful supplement to psychotherapy, regardless of therapeutic orientation. In an open trial of exposure-based cognitive therapy for depression, 43 participants used EW before each session, producing 928 EW samples. Using examples from these, we discuss how EW can be used to both promote and track therapeutic change. Specifically, we review the impact of EW on therapeutic growth, via self-monitoring, increased awareness, and exposure/emotional processing. We then discuss how EW can be used to track important predictors of change such as symptoms, therapeutic alliance, social support, avoidance, and hopelessness. We conclude by discussing potential limitations to the use of EW in therapy and by recommending specific strategies for incorporating EW into clinical practice.
Psychol Health. 2017 Jul;32(7):826-842. doi: 10.1080/08870446.2017.1307372. Epub 2017 Mar 30.
Sohl SJ1, Dietrich MS2, Wallston KA2, Ridner SH2.
Breast cancer survivors who develop lymphedema report poorer quality of life (QoL) than those without lymphedema. Expressive writing is a potential intervention to address QoL.
Adult women (N = 107) with breast cancer and chronic Stage II lymphedema were randomised to writing about thoughts and feelings specific to lymphedema and its treatment (intervention) or about daily activities (control) for four, 20-min sessions.
MAIN OUTCOME MEASURES:
Outcome measures were several indicators of QoL assessed at baseline, one, three, and six months post-intervention (total scores and subscales of Upper Limb Lymphedema 27 and Functional Assessment of Cancer Therapy-Breast). Hypothesised moderators of change in QoL were dispositional optimism, avoidant behaviours, and time since lymphedema diagnosis.
There was no statistically significant intent-to-treat main effects of expressive writing on QoL. Statistically significant moderating effects on change in different indicators of QoL were observed for all three moderators. Expressive writing was more effective for improving QoL in women who were higher on optimism, lower on avoidance and had less time since a lymphedema diagnosis.
These results provide further evidence that there are subsets of individuals for whom expressive writing is more effective. Future research may investigate targeting expressive writing based on identified moderators.
J Clin Psychol. 2009 Sep;65(9):971-88. doi: 10.1002/jclp.20600.
Moore SD1, Brody LR, Dierberger AE.
This randomized study examined whether narrative emotional disclosure improves mindfulness, experiential avoidance, and mental health, and how baseline levels of and changes in mindfulness and experiential avoidance relate to mental health. Participants (N=233) wrote repeated traumatic (experimental condition) or unemotional daily events narratives (control condition). Regression analyses showed neither condition nor gender effects on mental health or experiential avoidance at a 1-month follow-up, although the control condition significantly increased in one component of mindfulness. Decreased experiential avoidance (across conditions) and increased mindfulness (in the experimental condition) significantly predicted improved mental health. Narrative disclosure thus did not improve outcomes measured here. However, increasing mindfulness when writing narratives with traumatic content, and decreasing experiential avoidance regardless of writing content, was associated with improved mental health.
J Pers Soc Psychol. 1996 Sep;71(3):588-602.
Greenberg MA1, Wortman CB, Stone AA.
Health benefits derived from personal trauma disclosure are well established. This study examined whether disclosing emotions generated by imaginative immersion in a novel traumatic event would similarly enhance health and adjustment. College women, preselected for trauma presence, were randomly assigned to write about real traumas, imaginary traumas, or trivial events. Yoked real-trauma and imaginary-trauma participants wrote about real-trauma participants’ experiences. Imaginary-trauma participants were significantly less depressed than real-trauma participants at immediate posttest, but they were similarly angry, fearful, and happy. Compared with control group participants, both trauma groups made significantly fewer illness visits at 1-month follow-up; however, real-trauma participants reported more fatigue and avoidance than did the other groups. Imaginary-trauma group effects could reflect catharsis, emotional regulation, or construction of resilient possible selves.
J Soc Clin Psychol. 2010 May 1;26(3):362-384.
Radcliffe AM1, Lumley MA, Kendall J, Stevenson JK, Beltran J.
Studies suggest that written emotional disclosure can improve health. Unknown, however, is whether the presence or absence of an audience for one’s disclosure matters, and whether time management control writing has any effects. Undergraduates (N = 165) with unresolved stress were randomized to 1 of 3 groups that wrote for 4 sessions: shared written disclosure (submitted to researchers), private written disclosure (not submitted), or time management control writing; or to a fourth group (no-writing control). At 3-month follow-up, the two control groups were equivalent on outcomes. Both shared and private disclosure resulted in less cognitive intrusion and avoidance than the combined control groups. Yet, shared disclosure reduced depression and interpersonal sensitivity more than either private disclosure or the control groups, and only shared disclosure reduced physical symptoms. Although truly private writing improves cognitive stress effects, shared writing has broader benefits, suggesting that social disclosure for one’s writing matters.
Transl Behav Med. 2012 Mar;2(1):73-81. doi: 10.1007/s13142-011-0085-4.
Lumley MA1, Sklar ER, Carty JN.
Life stress and the avoidance of negative emotions may contribute to chronic pain. The technique of written or spoken emotional disclosure can reverse emotional avoidance and improve health, and 18 randomized studies have tested it among people with chronic pain. We review these studies to provide guidance for the clinical use of this technique. The benefits of emotional disclosure for chronic pain are quite modest overall. Studies in rheumatoid arthritis show very limited effects, but two studies in fibromyalgia suggest that disclosure may be beneficial. Effects in other populations (headaches, cancer pain, pelvic pain, abdominal pain) are mixed. Moderator findings suggest that some patients are more likely to benefit than others. Emotional disclosure has been tested in well-controlled efficacy trials, leaving many unanswered questions related to translating this technique to practice. Issues needing further study include determining disclosure’s effects outside of randomized controlled trials, identifying the optimal pain populations and specific individuals to target for disclosure, presenting a valid rationale for disclosure, selecting the location and method of disclosure, and choosing between cognitive-behavioral or emotional disclosure techniques.
Br J Health Psychol. 2008 Feb;13(Pt 1):53-6. doi: 10.1348/135910707X251180.
Swanbon T1, Boyce L, Greenberg MA.
This experimental study examined expressive writing (EW) in a community sample with social constraints on self-expression. Gay men (N=62) were assigned randomly to describe gay-related thoughts and feelings (EW) or to write objectively (CTRL). Self-reported symptoms and physician visits were assessed at baseline and 1- and 2-month follow-ups.
Significant GroupxTime interaction for somatic symptoms indicated buffering effect of EW. EW reduced gay-related avoidance, relative to CTRL. Avoidance and symptom changes were significantly, positively associated.
Consistent with inhibition theory, EW reduces chronic avoidance and buffers stress-related physical symptoms in stigmatized groups.