The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial.

J Consult Clin Psychol. 2014 Aug;82(4):644-58. doi: 10.1037/a0036958. Epub 2014 May 26.

Lumley MA1, Keefe FJ2, Mosley-Williams A3, Rice JR2, McKee D2, Waters SJ2, Partridge RT1, Carty JN1, Coltri AM1, Kalaj A1, Cohen JL1, Neely LC1, Pahssen JK4, Connelly MA2, Bouaziz YB2, Riordan PA2.

Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.


We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.


Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.


The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Neural activity during affect labeling predicts expressive writing effects on well-being: GLM and SVM approaches.

Soc Cogn Affect Neurosci. 2017 Sep 1;12(9):1437-1447. doi: 10.1093/scan/nsx084.

Memarian N1, Torre JB1, Haltom KE1, Stanton AL1,2,3, Lieberman MD1,2.

Affect labeling (putting feelings into words) is a form of incidental emotion regulation that could underpin some benefits of expressive writing (i.e. writing about negative experiences). Here, we show that neural responses during affect labeling predicted changes in psychological and physical well-being outcome measures 3 months later. Furthermore, neural activity of specific frontal regions and amygdala predicted those outcomes as a function of expressive writing. Using supervised learning (support vector machines regression), improvements in four measures of psychological and physical health (physical symptoms, depression, anxiety and life satisfaction) after an expressive writing intervention were predicted with an average of 0.85% prediction error [root mean square error (RMSE) %]. The predictions were significantly more accurate with machine learning than with the conventional generalized linear model method (average RMSE: 1.3%). Consistent with affect labeling research, right ventrolateral prefrontal cortex (RVLPFC) and amygdalae were top predictors of improvement in the four outcomes. Moreover, RVLPFC and left amygdala predicted benefits due to expressive writing in satisfaction with life and depression outcome measures, respectively. This study demonstrates the substantial merit of supervised machine learning for real-world outcome prediction in social and affective neuroscience.


Expressive writing interventions in cancer patients: a systematic review.

Health Psychol Rev. 2014;8(3):339-61. doi: 10.1080/17437199.2014.882007. Epub 2014 Feb 18.

Merz EL1, Fox RS, Malcarne VL.

Decades of research have suggested that expressive writing produces physical and psychological benefits in controlled laboratory experiments among healthy college students. This work has been extended to clinical and medical populations, including cancer patients. Although expressive writing could be a promising and inexpensive intervention for this population, the effects have not been systematically examined in oncology samples. A systematic review using PRISMA guidelines was conducted for experimental trials of cancer patients who participated in an expressive writing intervention. PsycINFO and PubMed/Medline were searched for peer-reviewed studies. Thirteen articles met the inclusion/exclusion criteria. Although the majority of the intervention effects were null, there were several main effects for expressive writing on sleep, pain, and general physical and psychological symptoms. Several moderators were identified, suggesting that expressive writing may be more or less beneficial based on individual characteristics such as social constraints. The reviewed studies were limited due to representativeness of the samples, performance, detection and patient-reported outcomes biases, and heterogeneity of the intervention protocol and writing prompts. Future studies with rigorous designs are needed to determine whether expressive writing is therapeutically effective in cancer patients.

Relaxation training and written emotional disclosure for tension or migraine headaches: a randomized, controlled trial.

Ann Behav Med. 2008 Aug;36(1):21-32. doi: 10.1007/s12160-008-9046-7. Epub 2008 Aug 12.

D’Souza PJ1, Lumley MA, Kraft CA, Dooley JA.

Behavioral medicine interventions that directly reduce arousal and negative emotions, such as relaxation training (RT), are conceptually different from interventions that temporarily increase negative emotions, such as written emotional disclosure (WED), but no studies have directly compared their efficacy. We compared the effects of RT and WED on people with tension or migraine headaches.


College students with either tension (n = 51) or migraine (n = 90) headaches were randomized to one of three groups: RT, WED, or a neutral writing control condition; four sessions were held over 2 weeks. Mood was measured before and after each session, and outcomes (headache frequency, severity, disability, and general physical symptoms) were assessed at baseline and at 1-month and 3-month follow-ups.


As expected, RT led to an immediate increase in calmness, whereas WED led to an immediate increase in negative mood, for both headache samples. Intent-to-treat analyses showed that, for the tension headache sample, RT led to improved headache frequency and disability compared to both WED and the control group, but WED had no effect. For migraine headaches, RT improved pain severity relative to the control group, but WED again had no effect.


A brief RT protocol was effective for tension headaches, but WED had no effect on health status for either tension or migraine headaches. Modifications to WED, such as targeting people with unresolved stress, providing guidance to enhance the potency of the writing, or including additional at-home writing and exposure exercises, may improve its efficacy for people with headaches and other health problems.

Expressive writing as a presurgical stress management intervention for breast cancer patients.

J Soc Integr Oncol. 2008 Spring;6(2):59-66.

de Moor JS1, Moyé L, Low MD, Rivera E, Singletary SE, Fouladi RT, Cohen L.

This study evaluated whether expressive writing (EW) was an effective stress management intervention for breast cancer patients. Women were recruited at the end of neoadjuvant chemotherapy and 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 7-day period. Participants were reassessed approximately 3 days before and 2 weeks after surgery. The 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 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.

Writing Can Heal: Effects of Self-Compassion Writing Among Hong Kong Chinese College Students

(full text)

Asian American Journal of Psychology © 2016 American Psychological Association 2016, Vol. 7, No. 1, 74–82 1948-1985/16/$12.00

Self-compassion has been repeatedly shown to be associated with mental and physical well-being. Recent studies showed that self-compassion writing can promote mental well-being, but this has not been examined among Chinese populations. The present study examined the effectiveness of self-compassion writing among Chinese students. One hundred and twelve university students were recruited and randomly assigned into 1 of the following 2 writing conditions: self-compassion writing and control writing. Participants were asked to write according to the instruction for 3 times in a week and report their levels of positive and negative affect immediately after writing. Self-reported depressive symptoms and physical symptoms, as well as self-compassion (i.e., self-kindness, common humanity, and mindfulness) and emotion regulation capacities (i.e., attention, clarity, and repair) were assessed at baseline and 2 follow-ups (1-month, 3-month). Results showed the self-compassion writing group reported more negative affect across the 3 days of writing than the control group. No significant group differences were found in depressive symptoms, self-compassion components, or emotion regulation capacities, but the self-compassion writing group reported a significant drop in physical symptoms at the 1- and 3-month follow-up whereas the control writing group reported no significant change in physical symptoms across time. The findings suggested that self-compassion writing may benefit physical health, but further studies should be conducted to examine its underlying mechanism.

Writing content predicts benefit from written expressive disclosure: Evidence for repeated exposure and self-affirmation


Cognition and Emotion

Volume 30, 2016 – Issue 2


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Pages 258-274


Expressive disclosure regarding a stressful event improves psychological and physical health, yet predictors of these effects are not well established. The current study assessed exposure, narrative structure, affect word use, self-affirmation and discovery of meaning as predictors of anxiety, depressive and physical symptoms following expressive writing. Participants (N = 50) wrote on four occasions about a stressful event and completed self-report measures before writing and three months later. Essays were coded for stressor exposure (level of detail and whether participants remained on topic), narrative structure, self-affirmation and discovery of meaning. Linguistic Inquiry and Word Count software was used to quantify positive and negative affect word use. Controlling for baseline anxiety, more self-affirmation and detail about the event predicted lower anxiety symptoms, and more negative affect words (very high use) and more discovery of meaning predicted higher anxiety symptoms three months after writing. Findings highlight the importance of self-affirmation and exposure as predictors of benefit from expressive writing.