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

Expressive Arts Interventions to Improve Psychosocial Well-Being in Caregivers: A Systematic Review

CONTEXT

Over 43 million caregivers provide care and support in the United States. Increased stress and burden may contribute to poor psychosocial well-being. Recently, there has been an emergence of art-based interventions to improve well-being among care receivers and caregivers. A synthesis of this literature evaluating expressive arts interventions (EAIs) with caregivers is needed.

OBJECTIVES

Identify the nature and impact of EAIs for caregivers and outline directions for future research.

METHODS

Systematic searches were conducted in PubMed/MEDLINE, CINAHL, PsychINFO, and Web of Science for relevant studies between 2001 and 2022. Inclusion criteria included EAI addressing psychosocial well-being of caregivers, quantitative and mixed methods studies, and written in English.

RESULTS

Twenty-seven studies were included (1359 participants). There was a diverse global representation of countries (n = 14). Twelve studies were randomized controlled trials. The majority (n = 11) were conducted with dementia/alzheimers caregivers and 41% (n = 11) were delivered to the caregiver/receiver dyad. Fifty-nine percent of the EAIs were music-based, 22% were visual arts, and 10% were writing. Intervention length varied from a single one-hour session to biweekly for 10-months; eight lasted two-weeks. Overall, stress improved in 80% of the studies, anxiety in 69%, caregiver burden in 57%, and depressive symptoms in 31%.

CONCLUSION

Caregivers are essential to the care of people with medically complex and life-limiting conditions. EAIs hold the potential to improve psychosocial outcomes for caregivers, are used globally, and can be culturally tailored. Future research should examine intervention duration and intensity, measures to address additional dimensions of psychsocial well-being, and implementation in additional caregiver populations.

Caring for Carers (C4C): Results from a feasibility randomised controlled trial of positive written disclosure for older adult carers of people with psychosis

Background

Older adult carers of people who experience psychosis are at increased risk of developing physical and mental health problems due to the compounding factors of supporting their care-recipient and the health changes associated with ageing. Effective interventions exist but can be difficult to access and maintain prolonged engagement. Self-directed writing therapies, frequently referred to as Written Emotional Disclosure (WED), might be a suitable alternative intervention to improve the wellbeing of carers.

Methods

This study aimed to determine the feasibility (recruitment, retention and primary outcome completion) and acceptability of a specific WED intervention known as Positive Written Disclosure (PWD). Informal carers of people with psychosis were randomised to PWD, neutral writing or no writing. Quantitative outcomes including positive and negative affect, carer wellbeing, quality of life, depression, anxiety, stress, self-efficacy, leisure time satisfaction as well as health care utilisation were collected at baseline, 1-, 3-, and 6-month assessments. Qualitative feedback was also collected via questionnaire and semi-structured interviews from those randomised to either writing group.

Results

We successfully met our progression criteria, recruiting to target and within timeframes whilst attaining 97% retention and 84% primary outcome data completed at 6 months. Carers randomised to the positive writing group described the intervention as enabling them to have a more positive attitude and focus on activities for themselves. Both writing groups described their tasks as providing distraction from caring responsibilities. However, some carers found the narrow positive emotion focus challenging.

Conclusions

PWD is a feasible and acceptable intervention for older adult carers of people with psychosis within a community setting. Further refinement of the writing protocol to include choice in type of emotion disclosed in addition to screening for some level of need may be required in future trials to reduce floor/ceiling effects of outcomes which may explain the lack of change observed.

The effect of expressive writing on wound healing: Immunohistochemistry analysis of skin tissue two weeks after punch biopsy wounding

OBJECTIVE

To investigate the effects of expressive writing and its timing (pre or post wounding) on re-epithelialisation and leucocyte subsets within healing tissue. We previously showed expressive writing pre-wounding improved re-epithelialisation. Here we investigate cellular processes in the wound.

METHODS

In a 2(writing content) x 2(writing timing) randomized trial, 122 participants were randomized to perform either expressive or control writing, before or after a 4 mm punch biopsy wound. On day 14 post-wounding, participants had a 5 mm punch biopsy of the initial wound. Seven of 16 primary registered outcomes were analysed, including re-epithelialisation from two photographs of the 4 mm biopsy (previously reported). This paper reports immunohistochemistry analysis of five primary outcomes - Langerhans cells, immune cell activation (HLA and CD3+), and macrophages (CD68 and MPO) - in the 5 mm biopsies in a random sample of 96 participants.

RESULTS

Participants who performed either writing task pre-wounding had greater Langerhans cell infiltration, than those who wrote post-wounding (F_(1,85) = 7.86, p = .006, η_p² = 0.08). Those who performed expressive writing also had greater Langerhans cell infiltration than those who performed control writing (F_(1,85) = 4.00, p = .049, η_p² = 0.04). There were no significant group or interaction effects on immune cell activation or macrophages. Healed wounds on day 10 had lower levels of macrophages (z = -1.96, p = .050), and CD3+ cells (z = -1.99, p = .046) than non-healed wounds.

CONCLUSION

Langerhans cells in the healing skin are affected by the timing and topic of writing. More research is needed to further explore timing and corroborate these results.

CLINICAL TRIALS REGISTRATION

Registered at https://www.anzctr.org.au/ (Trial ID: ACTRN12614000971639).

Building Resources in Caregivers: Feasibility of a Brief Writing Intervention to Increase Benefit Finding in Caregivers

The Building Resources in Caregivers (BRiC) is a pilot feasibility trial that compared the effects of a 2-week benefit finding writing expressive intervention to a control intervention, who wrote about the weather. Caregivers completed primary (benefit finding) and secondary (quality of life, depression and anxiety) outcome measures at pre (t1), immediately post-test (t2) and 1 month later (t3). They also completed measures relating to trial feasibility, difficulty, and acceptance. Using complete case analysis only, analysis revealed no effect of the intervention for primary or secondary outcomes. Despite this, there were no differences between the intervention and control groups on key feasibility measures. Caregivers in the control condition were less likely to recommend this to other caregivers. Moreover, qualitative commentary provided by caregivers suggested that not everyone enjoyed the writing, some found it stressful, offering up some explanation for our findings. Our pilot trial suggests that any future benefit-finding writing intervention would require several procedure modifications including tailoring to a specific cohort of caregivers, in particular those who like writing, before it has some utility as a psychosocial intervention.

The Impact of Written Emotional Disclosure on Cancer Caregivers' Perceptions of Burden, Stress, and Depression: A Randomized Controlled Trial

Spousal cancer caregivers' emotional and relational health can become compromised over time due to ongoing challenges related to the cancer experience. This warrants a call for the assessment of interventions aimed at improving aspects of caregiver well-being. The current study employed a randomized controlled trial to determine whether emotional disclosure via the use of expressive writing improved spousal cancer caregivers' perceived caregiver burden, stress, and depression. Participants (N = 64) were assigned to one of the two disclosure conditions: expressive disclosure or benefit finding-or to a time-management control condition. Participants completed three at-home writing sessions at one-week intervals. Results indicated that written forms of emotional disclosure might improve burden, stress, and depression contingent on writing condition. Specifically, both forms of emotional disclosure outperformed the control condition in reducing caregivers' depression. The control condition outperformed treatments in reducing caregiver stress. Finally, posttest caregiver burden was significantly lower than pretest burden across all writing conditions. This trial was registered with clinicaltrials.gov, ID: NCT02339870.

Predictors of Caregiver Burden among Mothers of Children with Chronic Conditions

Objective: The complex medical regimens of children and adolescents with chronic conditions can have a significant impact on families and households. Caregivers may experience burden, which can lead to negative health consequences and poor quality of life. The objective of this study was to determine child-related predictors and risk factors for caregiver burden among parents of children with chronic conditions. Methods: We distributed an institutional review board (IRB)-approved, online cross-sectional survey to parents of children who attended the Victory Junction therapeutic camp. Parents provided information on child demographics, disease characteristics, and healthcare utilization. Parents also answered the adapted Zarit Burden Interview, which measured caregiver burden. Children completed scales about self-management and self-efficacy. Linear regression analyses determined how children’s disease characteristics, health utilization, and self-management skills were associated with caregiver burden. Results: We enrolled 150 mother-child dyads. The mean age of child participants was 12.23 years (±2.5), with an age range of 6 to 16 years. It was determined that children’s number of medicines and injections (β = 0.161, p = 0.047), a diagnosis of attention-deficit/hyperactivity disorder (ADHD) in addition to the primary medical condition (β = 0.216, p = 0.008), frequent visits with a primary care provider (PCP) (β = 0.209, p = 0.026) and emergency room (ER) visits (β = 0.197, p = 0.038), and lower child self-efficacy (β = −0.241, p = 0.041) were predictors of increased caregiver burden. Conclusions: We identified risk factors for caregiver burden among mothers. Future studies should explore additional child-related characteristics as they relate to caregiver burden, and should determine if interventions for mothers of children with chronic conditions can lead to positive outcomes.

Designing a Resilience Program for Critical Care Nurses

BACKGROUND

Workplace stress can affect job satisfaction, increase staff turnover and hospital costs, and reduce quality of patient care. Highly resilient nurses adapt to stress and use a variety of skills to cope effectively.

OBJECTIVE

To gain data on a mindfulness-based cognitive therapy resilience intervention for intensive care unit nurses to see if the intervention program would be feasible and acceptable.

METHODS

Focus-group interviews were conducted by videoconference with critical care nurses who were members of the American Association of Critical-Care Nurses. The interview questions assessed the feasibility and acceptability of a mindfulness-based cognitive therapy program to reduce burnout syndrome in intensive care unit nurses.

RESULTS

Thirty-three nurses participated in 11 focus groups. Respondents identified potential barriers to program adherence, incentives for adherence, preferred qualifications of instructors, and intensive care unit-specific issues to be addressed.

CONCLUSIONS

The mindfulness-based cognitive therapy pilot intervention was modified to incorporate thematic categories that the focus groups reported as relevant to intensive care unit nurses. Institutions that wish to design a resilience program for intensive care unit nurses to reduce burnout syndrome need an understanding of the barriers and concerns relevant to their local intensive care unit nurses.

Feasibility and Participant Experiences of a Written Emotional Disclosure Intervention for Parental Caregivers of People with Psychosis

Caregivers are at increased risk of poor health but often cannot engage with health care because of practical constraints. Writing therapies such as written emotional disclosure (WED) might represent an accessible therapy for this population. This study aimed to determine whether WED is a suitable therapy for caregivers of people with psychosis. Data were collected from a feasibility trial comparing WED with a neutral writing task. Twenty four participants completed writing tasks; the content was analysed using the Linguistic Inquiry Word Count (LIWC) programme. Twenty one participants provided feedback about the writing task, and data were analysed using Burnard's thematic content analysis. WED was feasible to implement in caregivers of people with psychosis. All participants ascribed benefit to writing tasks, the majority describing a cathartic effect, enjoying time to oneself or distraction from caregiving. Quantitative comparison indicated differences in emotional content between intervention and control writing. However, qualitative analysis showed that control participants found it challenging to write neutrally, the majority citing the care-recipient in their writing. Community-based WED is a feasible therapy for caregivers of people with psychosis. The need for refinement of the control writing task for use in caregivers is discussed. Copyright © 2015 John Wiley & Sons, Ltd.

Finding Meaning in Written Emotional Expression by Family Caregivers of Persons With Dementia

This study tested the effect of written emotional expression on the ability to find meaning in caregiving and the effects of finding meaning on emotional state and psychological burden in 91 dementia family caregivers. In a pretest-posttest design, participants were randomly assigned to either an experimental or a comparison group. Experimental caregivers (n = 57) wrote about their deepest thoughts and feelings about caring for a family member with dementia, whereas those in the comparison group (n = 34) wrote about nonemotional topics. Results showed enhanced meaning-making abilities in experimental participants relative to comparison participants, particularly for those who used more positive emotion words. Improved meaning-making ability was in turn associated with psychological benefits at posttest, but experimental participants did not show significantly more benefit than comparison participants. We explore the mediating roles of the meaning-making process as well as some of the background characteristics of the individual caregivers and their caregiving environments.

Randomized controlled expressive writing pilot in individuals with Parkinson's disease and their caregivers

Background

Individuals with Parkinson’s disease (PD) and their caregivers are at risk for emotional distress and hypercortisolism. Expressive writing is an effective complementary intervention to ameliorate the psychological and physiological effects of chronic illness. This pilot study aimed to evaluate feasibility and preliminary effectiveness of an expressive writing intervention for individuals with PD and their caregivers.

Methods

Individuals with PD (N = 27) and their caregivers (N = 14) were randomly assigned to expressive (N = 15 patients, eight caregivers) or neutral (N = 12 patients, six caregivers) writing conditions. Cortisol awakening response (CAR), non-motor functioning, quality of life, and performance on tests of cognitive functioning were assessed at baseline, immediate post, 4-month, and 10-month post intervention.

Results

Attrition was a challenge as eight patients (29.62 %) and four caregivers (28.57 %) chose to discontinue before beginning the intervention or were lost to follow up prior to completing the intervention or the first follow up visit. Significant reduction in anxiety, marginally significant improvement in depression and caregiver burden, and significant improvements in performance on tests of learning and memory were observed, but these changes did not differ by writing condition. CAR significantly differed over time between patients and caregivers and writing conditions.

Conclusions

Some evidence for the feasibility and effectiveness of writing to alleviate hypercortisolism was demonstrated in a small sample of PD patients; however, relatively high attrition rates and the lack of difference between expressive and neutral writing conditions on emotional and neurocognitive outcomes suggests expressive writing procedure modifications may be needed to obtain optimal results for this population.

Trial registration

ClinicalTrials.gov, NCT02217735, Study Start Date: August 30, 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s40359-015-0101-4) contains supplementary material, which is available to authorized users.

Caregiving and Family Support Interventions: Crossing Networks of Aging and Developmental Disabilities

This scoping review addressed the following questions: (a) What types of caregiver interventions are being done in both aging and developmental disability research? (b) How are these interventions similar and different? (c) What kinds of outcomes do these interventions have? (d) What innovative approaches are these interventions using? and (e) What can each field (developmental disabilities and gerontology) learn from the other based on this review? The disability review spanned 20 years (1992-2012), resulting in 14 studies; the aging review spanned 5 years (2008-2012), resulting in 55 studies. Data from the final selected studies were then extracted and compared on research design, type of intervention (governmental programs, small-group psychosocial, and other), and outcomes. Generally, in both fields, family-support interventions benefited participants' well-being and improved service access and satisfaction. Increased partnership between the fields of aging and developmental disabilities is critical to future scholarship in caregiving for both populations.

Expressive writing and wound healing in older adults: a randomized controlled trial

OBJECTIVE

To investigate whether expressive writing could speed wound reepithelialization in healthy, older adults.

METHODS

In this randomized controlled trial, 49 healthy older adults aged 64 to 97 years were assigned to write for 20 minutes a day either about upsetting life events (Expressive Writing) or about daily activities (Time Management) for 3 consecutive days. Two weeks postwriting, 4-mm punch biopsy wounds were created on the inner, upper arm. Wounds were photographed routinely for 21 days to monitor wound reepithelialization. Perceived stress, depressive symptoms, health-related behaviors, number of doctor visits, and lipopolysaccharide-stimulated proinflammatory cytokine production were also measured throughout the study.

RESULTS

Participants in the Expressive Writing group had a greater proportion of fully reepithelialized wounds at Day 11 postbiopsy compared with the Time Management group, with 76.2% versus 42.1% healed, χ(2)(1, n = 40) = 4.83, p = .028. Ordinal logistic regression showed more sleep in the week before wounding also predicted faster healing wounds. There were no significant group differences in changes to perceived stress, depressive symptoms, health-related behaviors, lipopolysaccharide-induced proinflammatory cytokine production, or number of doctor visits over the study period.

CONCLUSIONS

This study extends previous research by showing that expressive writing can improve wound healing in older adults and women. Future research is needed to better understand the underlying cognitive, psychosocial, and biological mechanisms contributing to improved wound healing from these simple, yet effective, writing exercises.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (trial number 343095).

Optimizing the perceived benefits and health outcomes of writing about traumatic life events

Expressive writing, which involves disclosing one's deepest thoughts and feelings about a stressful life event by using a first-person perspective, has been linked to gains in health and well-being, though effect sizes range widely. Assuming a third-person perspective is a natural and effective way of coping with highly distressing events. Therefore, the current study examined whether a distanced, third-person approach to expressive writing might be more beneficial than a traditional, first-person intervention for high baseline levels of event-linked intrusive thinking. Randomly assigned participants wrote expressively about traumatic life events by using a first-person or third-person-singular perspective. Linguistic analyses showed that assuming a first-person perspective is linked to higher levels of in-text cognitive engagement, whereas a third-person perspective is linked to lower cognitive engagement. However, in a context of higher levels of intrusive thinking, third-person expressive writing, relative to a traditional first-person approach, yielded (1) greater perceived benefits and positive, long-lasting effects as well as (2) fewer days of activity restriction due to illness. Although more research is needed, these results suggest that third-person expressive writing may be an especially fitting technique for recovering from traumatic or highly stressful life events.

An organizing framework for informal caregiver interventions: detailing caregiving activities and caregiver and care recipient outcomes to optimize evaluation efforts

Background

Caregiver interventions may help improve the quality of informal care. Yet the lack of a systematic framework specifying the targets and outcomes of caregiver interventions hampers our ability to understand what has been studied, to evaluate existing programs, and to inform the design of future programs. Our goal was to develop an organizing framework detailing the components of the caregiving activities and the caregiver and care recipient outcomes that should be affected by an intervention. In so doing, we characterize what has been measured in the published literature to date and what should be measured in future studies to enable comparisons across interventions and across time.

Methods

Our data set comprises 121 reports of caregiver interventions conducted in the United States and published between 2000 and 2009. We extracted information on variables that have been examined as primary and secondary outcomes. These variables were grouped into categories, which then informed the organizing framework. We calculated the frequency with which the interventions examined each framework component to identify areas about which we have the most knowledge and under-studied areas that deserve attention in future research.

Results

The framework stipulates that caregiver interventions seek to change caregiving activities, which in turn affect caregiver and care recipient outcomes. The most frequently assessed variables have been caregiver psychological outcomes (especially depression and burden) and care recipient physical and health care use outcomes.

Conclusions

Based on the organizing framework, we make three key recommendations to guide interventions and inform research and policy. First, all intervention studies should assess quality and/or quantity of caregiving activities to help understand to what extent and how well the intervention worked. Second, intervention studies should assess a broad range of caregiver and care recipient outcomes, including considering whether expanding to economic status and health care use of the caregiver can be accommodated, to ease subsequent economic evaluations of caregiving. Third, intervention studies should measure a common set of outcomes to facilitate cross-time and cross-study comparisons of effectiveness.

Benefits of a poetry writing intervention for family caregivers of elders with dementia

This pilot clinical trial tested effectiveness of a poetry writing intervention for family caregivers of elders with dementia. This paper presents findings from a larger study using mixed methods to examine outcome variables of self-transcendence, resilience, depressive symptoms, and subjective caregiver burden. Findings reported here focus on qualitative analysis of in-depth interviews conducted with participants following their poetry writing experience. A grounded theory approach was used. Themes that arose from the data support a mid-range theory of self-affirmation in caregivers with subthemes of achievement, catharsis, greater acceptance, empathy, self-awareness, reflection, creative and fun, positive challenge, and helping others.

Caring and Retirement: Crossroads and Consequences

As older workers move closer to retirement, they are more likely to take on caring roles. This may affect their health, retirement plans, and income security. Retired men and women experience the caring role differently, with men less likely to be adversely affected and more likely to accept services and to derive satisfaction from caring. Carers make an important contribution to the lives of the people they care for and to the community. Caring is a productive role that can be sustained into older age, as long as the carer's health and well-being are maintained. More research is needed on the relationship between retirement and caring, to explore the extent of caring and its impact on retirement plans, income, and the physical and mental health of retired carers. This information could then be built into retirement planning to better prepare older workers for this important role. Caring roles and retirement intersect in several ways. About 6 million Americans, 2.6 million Australians, and 6 million people in the United Kingdom are informal carers. People (especially men) are more likely to take on caring roles as they get older and leave the paid workforce. The need to care for a spouse or older relative can be an unanticipated outcome or a precipitator of retirement. Retirement may coincide with illness or disability of a parent or spouse, or may be forced by the demands of caring. Caring may bring about major changes to retirement plans. The financial impact of having been a carer during one's working life may also be felt most keenly on retirement, through the lack of opportunities for savings and retirement fund co-contributions.

Associations between psychological distress, learning, and memory in spouse caregivers of older adults

Family caregivers of older adults experience high levels of chronic stress and psychological distress, which are known to impair cognition. Very little research, however, has assessed the impact of caregiving on key cognitive outcomes such as learning and memory. This study compared 16 spouse caregivers with 16 matched controls using standardized neuropsychological measures of learning, episodic memory, and working memory. Analyses compared groups on these cognitive outcomes and examined whether psychological distress mediated group differences in cognition. Results indicated that caregivers were significantly more distressed than non-caregivers and exhibited deficits in learning, recall of episodic information after short and long delays, and working memory. Furthermore, the majority of group differences in cognitive outcomes were mediated by psychological distress. This study adds to a small body of literature demonstrating impaired cognitive functioning among family caregivers. It also suggests that distress is one of a number of possible underlying mechanisms leading to disruptions in learning and memory in this population.