Does emotional disclosure about stress improve health in rheumatoid arthritis? Randomized, controlled trials of written and spoken disclosure.

Pain. 2011 Apr;152(4):866-77. doi: 10.1016/j.pain.2011.01.003.

Lumley MA1, Leisen JC, Partridge RT, Meyer TM, Radcliffe AM, Macklem DJ, Naoum LA, Cohen JL, Lasichak LM, Lubetsky MR, Mosley-Williams AD, Granda JL.

Studies of the effects of disclosing stressful experiences among patients with rheumatoid arthritis (RA) have yielded inconsistent findings, perhaps due to different disclosure methods–writing or speaking–and various methodological limitations. We randomized adults with RA to a writing (n=88) or speaking (to a recorder) sample (n=93), and within each sample, to either disclosure or 1 of 2 control groups (positive or neutral events), which conducted four 20-minute, at-home sessions. Follow-up evaluations at 1, 3, and 6 months included self-reported, behavioral, physiological, and blinded physician-assessed outcomes. In both writing and speaking samples, the disclosure and control groups were comparably credible, and the linguistic content differed as expected. Covariance analyses at each follow-up point indicated that written disclosure had minimal effects compared with combined controls–only pain was reduced at 1 and 6 months, but no other outcomes improved. Spoken disclosure led to faster walking speed at 3 months, and reduced pain, swollen joints, and physician-rated disease activity at 6 months, but there were no effects on other outcomes. Latent growth curve modeling examined differences in the trajectory of change over follow-up. Written disclosure improved affective pain and walking speed; spoken disclosure showed only a marginal benefit on sensory pain. In both analyses, the few benefits of disclosure occurred relative to both positive and neutral control groups. We conclude that both written and spoken disclosure have modest benefits for patients with RA, particularly at 6 months, but these effects are limited in scope and consistency.


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Emotional disclosure interventions for chronic pain: from the laboratory to the clinic.

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.

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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 √ó 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.

Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations.

Health Technol Assess. 2016 Apr;20(27):vii-xxxvii, 1-367. doi: 10.3310/hta20270.

Nyssen OP1, Taylor SJ2, Wong G3, Steed E2, Bourke L4, Lord J5, Ross CA6, Hayman S7, Field V8, Higgins A9, Greenhalgh T3, Meads C10.


Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.


Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).


Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.


To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.


From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.


Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.


Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.


This study is registered as PROSPERO CRD42012003343.


The National Institute for Health Research Health Technology Assessment programme.

Benefit finding and expressive writing in adults with lupus or rheumatoid arthritis

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Psychology & Health

Volume 21, 2006 – Issue 5


Pages 651-665


An intriguing question within the expressive writing literature is whether writing interventions that focus on positive aspects of adverse experiences can produce health benefits, particularly among individuals with serious physical illness. Seventy-five adults with lupus or rheumatoid arthritis were randomly assigned to one of three 4-session writing interventions: benefit finding (BF), standard expressive writing (EW), or a control group. Follow-up questionnaires were completed one and three months later. At three months, fatigue was lower in the BF and EW groups than in the control group. BF appeared effective in reducing pain levels for participants with high trait anxiety, whereas EW appeared effective for participants with low trait anxiety. No significant group effects were found for psychological functioning or disability. Results are discussed with regard to the literature on BF and EW among medical patients.



Emotional and physical health benefits of expressive writing

Karen A. Baikie, Kay Wilhelm

Medical conditions that might benefit from expressive writing programmes

  • Lung functioning in asthma

  • Disease severity in rheumatoid arthritis

  • Pain and physical health in cancer

  • Immune response in HIV infection

  • Hospitalisations for cystic fibrosis

  • Pain intensity in women with chronic pelvic pain

  • Sleep-onset latency in poor sleepers

  • Post-operative course