Are Art-Based Interventions Effective in Improving Psychological Well-Being Among Informal Caregivers of Cancer Patients? A Systematic Review

Objectives: To systematically synthesize the current evidence on the effects of art-based interventions on improving anxiety, depression, stress, sleep, and well-being of cancer caregivers. Design: A systematic review. Methods: We searched PubMed, EMBASE, Web of Science, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials databases from their inception up to April 2024. Studies exploring the effects of art-based interventions on the psychological symptoms of cancer caregivers were included. We did not restrict the publication to the particular study designs, including randomized controlled trials, quasiexperimental studies, and qualitative studies. Results: Fifteen studies of 607 participants were identified in this systematic review. Overall, the existing studies provided preliminary evidence to suggest that art-based interventions may benefit cancer caregivers in improving anxiety, depression, stress, caregiver burden, and quality of life. However, the relatively low quality of the current evidence limits the efficacy of these findings. Conclusions: According to the existing evidence, the therapeutic benefits of using art-based interventions for improving the psychological well-being of cancer caregivers are uncertain. More high-quality and well-designed studies are still required to confirm the psychological effectiveness of art-based interventions for cancer caregivers in the future.

Narrative identity in addictive disorders: a conceptual review

Narrative identity allows individuals to integrate their personal experiences into a coherent and meaningful life story. Addictive disorders appear to be associated with a disturbed sense of self, reflected in problematic and disorganized self-narratives. In recent literature, a growing body of research has highlighted how narrative approaches can make a dual contribution to the understanding of addiction: on the one hand, by revealing crucial aspects of self structure, and, on the other, by supporting the idea that addiction is a disorder related to unintegrated self-states in which dissociative phenomena and the resulting sense of 'loss of self' are maladaptive strategies for coping with distress. This conceptual review identified the main measures of narrative identity, i.e., narrative coherence and complexity, agency, and emotions, and critically examines 9 quantitative and qualitative studies (out of 18 identified in literature), that have investigated the narrative dimension in people with an addictive disorder in order to provide a synthesis of the relationship between self, narrative and addiction. These studies revealed a difficulty in the organization of narrative identity of people with an addictive disorder, which is reflected in less coherent and less complex autobiographical narratives, in a prevalence of passivity and negative emotions, and in a widespread presence of themes related to a lack of self-efficacy. This review points out important conceptual, methodological and clinical implications encouraging further investigation of narrative dimension in addiction.

Promoting post-traumatic growth in cancer patients: a randomized controlled trial of guided written disclosure

Background

Cancer is a life-threatening disease that triggers not only vulnerability to distressing symptoms but also a meaning-making process that may lead to post-traumatic growth. As people often struggle to integrate cancer illness into their meaning system to reach an adaptive meaning, psychological interventions focused on a reappraisal of the illness experience can facilitate this process. This multicenter randomized controlled trial (RCT) was primarily aimed at assessing the efficacy of a writing intervention known as a guided disclosure protocol (GDP), compared to a generic writing intervention, in promoting post-traumatic growth in stage I-III breast and colon cancer patients at the end of their adjuvant chemotherapy.

Methods

Between January 2016 and August 2020 recruitment of eligible subjects took place during follow-up clinical consultations. Assessment occurred at baseline (T0), after the intervention (T1, 3 months from baseline), and at 6 months from baseline (T2). Both interventions consisted of three 20-min writing sessions to be performed once every two weeks. Change in post-traumatic growth was assessed using the Posttraumatic Growth Inventory, meaning with the Constructed Meaning Scale, and psychological distress with the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

Results

In the five participating centers, 102 eligible patients were randomized and 72 participants completed follow-up evaluation. Most patients were women (79.4%), had breast cancer (68.6%), and stage I (27.5%), or stage II (44.1%) disease. Mean differences did not reach statistical significance for any of the dependent variables. However, an effect of the GDP, although not statistically relevant, was observed after the intervention in terms of enhanced post-traumatic growth and increased distress measured with the Impact of Event Scale.

Conclusion

This is the first RCT investigating the efficacy of a GDP in cancer patients having post-traumatic growth as the primary aim. Though GDP is a promising intervention in promoting post-traumatic growth, the lack of statistical significance of our findings may be due to the study being underpowered, hence this trial should be replicated with an adequate sample size, paying attention to supporting recruitment.

Clinical trial registration: ClinicalTrials.gov, identifier: 2015/0024360.

Sex differences in the outcome of expressive writing in parents of children with leukaemia

Background

Sex differences are widely reported in clinical psychology but are rarely examined in interventions.

Method

This mixed-method explorative study examined sex differences in 13 mothers and 10 fathers of children in the off-therapy phase of acute lymphoblastic leukaemia. Parents underwent an expressive writing intervention using the guided written disclosure protocol (GWDP).

Results

Mothers had more negative mood profiles than fathers but improved more during the intervention.

Conclusion

Though preliminary, our findings highlight the importance of sex as a potential moderator of intervention and treatment outcome that could be of great clinical significance.

Parents of children in remission from cancer can benefit from expressive writing.

Expressive writing can improve mood states.

Mothers may benefit more than fathers.

More research on gender differences in outcomes is needed.

Does Guided Written Disclosure Reduce Distress and Improve Psychological Functioning in Patients with Skin Diseases?

Background. Skin diseases (e.g., psoriasis and systemic sclerosis) are generally associated with negative psychosocial outcomes. Although different psychological interventions have been used to improve the quality of life of dermatological patients, the effects of the guided written disclosure (GWD) protocol have not been previously examined in these patients. Moreover, little attention has been paid to positive psychology constructs. Methods. This study investigates the effectiveness of GWD on positive and negative functioning in dermatological patients. Pre- and 1-month post-intervention measures included emotion regulation, sense of inner peace, skin-related symptoms and functioning, sense of coherence, and psychological distress. Results. A total of 196 consecutive outpatients were randomly assigned to GWD and active control groups, of whom 60 (30.6%) completed the study and 45 (GWD: n = 24; AC: n = 21) provided complete data. Our results did not show any significant difference between the experimental and control groups in the outcome variables, whereas non-completers reported higher levels of distress, unpleasant skin-related emotions, and lower cognitive reappraisal compared to completers. Conclusions. These findings show a poor compliance, and suggest that expressive writing is not well accepted by patients and is not effective in improving positive and negative psychological functioning in dermatological patients.

Written benefit finding for improving psychological health during the Covid-19 pandemic first wave lockdown

Objectives. Written benefit finding is known to improve psychological and physical health in a range of patient groups. Here, we tested the efficacy of written benefit finding, delivered online during the Covid-19 pandemic lockdown, on mood and physical symptoms. We also investigated perseverative thinking as a moderator of these effects. Design. A quantitative longitudinal design was employed. Main Outcome Measures. Participants (n = 91) completed self-report measures of anxiety, depression, stress and physical symptoms at baseline, and two weeks after being randomised to complete three consecutive days of writing about the positive thoughts and feelings they experienced during the pandemic (written benefit finding) or to unemotively describe the events of the previous day (control). State anxiety was measured immediately before and after writing. Perseverative thinking was measured at baseline. Results. Anxiety and depression symptoms decreased between baseline and the two week follow-up, but did not differ significantly between the two conditions. Perseverative thinking was negatively associated with changes in symptoms of anxiety, depression and stress, but did not moderate any writing effects. There was a significant reduction in state anxiety in the written benefit finding condition. Conclusions. Written benefit finding may be a useful intervention for short-term improvements in wellbeing.

Kellner's Symptom Questionnaire, a Highly Sensitive Patient-Reported Outcome Measure: Systematic Review of Clinimetric Properties

INTRODUCTION

Patient-reported outcomes (PROs) are of increasing importance in clinical medicine. However, their evaluation by classic psychometric methods carries considerable limitations. The clinimetric approach provides a viable framework for their assessment.

OBJECTIVE

The aim of this paper was to provide a systematic review of clinimetric properties of the Symptom Questionnaire (SQ), a simple, self-rated instrument for the assessment of psychological symptoms (depression, anxiety, hostility, and somatization) and well-being (contentment, relaxation, friendliness, and physical well-being).

METHODS

The PRISMA guidelines were used. Electronic databases were searched from inception up to March 2019. Only original research articles, published in English, reporting data about the clinimetric properties of the SQ, were included.

RESULTS

A total of 284 studies was selected. The SQ has been used in populations of adults, adolescents, and older individuals. The scale significantly discriminated between subgroups of subjects in both clinical and nonclinical settings, and differentiated medical and psychiatric patients from healthy controls. In longitudinal studies and in controlled pharmacological and psychotherapy trials, it was highly sensitive to symptoms and well-being changes and discriminated between the effects of psychotropic drugs and placebo.

CONCLUSIONS

The SQ is a highly sensitive clinimetric index. It may yield clinical information that similar scales would fail to provide and has a unique position among the PROs that are available. Its use in clinical trials is strongly recommended.

Feasibility and effect of a guided self-disclosure intervention designed to facilitate benefit finding in breast cancer patients: A pilot study

PURPOSE

This pilot study aimed to evaluate the feasibility and effect of a guided self-disclosure intervention (GSDI) promoting benefit finding (BF) for breast cancer patients.

METHODS

A total of 40 women with breast cancer were randomized either to a GSDI group, which included a 6-session face-to-face self-disclosure intervention, or to a control group. The Benefit Finding Scale (BFS) was used to measure BF, the Distress Disclosure Index (DDI) was used to measure self-disclosure, and the Impact of Event Scale-Revised (IES-R) was used to measure cognitive reappraisal. The outcomes were evaluated at baseline and the 3rd and 6th months.

RESULTS

The GSDI group had more satisfaction (t = 2.35, P = .02) than the control group and had significant group effects of higher BF (t = 2.214, P = .03) and a lower avoidance of the IES-R (t = -2.353, P = .024) at the 3rd month. There was a significant difference of BF (t = 2.036, P = .049) between the two groups at the 6th month, and other outcomes were not significant (P > .05). Intention-to treat (ITT) analysis showed significant time effects for all outcomes (P < .05); there were slightly significant time × group effects for BF (F = 4.15, P = .052) and disclosure (F = 2.719, P = .090). There were no time × group effects for the other outcomes (all P > .05).

CONCLUSION

This study suggests that the GSDI intervention may be feasible in the clinic and might improve BF for breast cancer patients. However, future research needs to further refine the intervention and expand the sample to carry out a full-scale randomized controlled trial.

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.

Promoting post-traumatic growth in cancer patients: A study protocol for a randomized controlled trial of guided written disclosure

This multicenter study investigates the efficacy of the guided disclosure protocol in promoting post-traumatic growth, through meaning reconstruction, in cancer patients after adjuvant chemotherapy. Participants will be randomized to guided disclosure protocol or to an active control condition. Both conditions consist of three 20-minute writing sessions. Experimental participants verbalize emotions, describe events, and reflect on trauma effects. Control participants write about their past week’s daily routine. Patients, blinded to treatment assignment, will complete questionnaires at pre-intervention, post-intervention, and 6-month follow-up. This study will improve knowledge concerning the effects of writing interventions on psychological health and well-being in cancer patients.

Linguistic Markers of Processing Trauma Experience in Women's Written Narratives During Different Breast Cancer Phases: Implications for Clinical Interventions

Research into the change processes underlying the benefits of expressive writing is still incomplete. To fill this gap, we investigated the linguistic markers of change in cognitive and emotional processing among women with breast cancer, highlighting the differences and peculiarities during different treatment phases. A total of 60 writings were collected from 20 women: 10 receiving chemotherapy and 10 receiving biological therapy. We performed a series of repeated measures ANOVA for the most meaningful LIWC linguistic categories, including positive/negative emotions and cognitive processes, to assess change over three sessions. Results demonstrated a significant increase in the positive emotions category for the entire group of women, with particular relevance for the biological therapy group of women, and a marginally significant (p = .07) greater use of words indicating cognitive processes for women receiving biological therapy. For the negative emotions category time was significant for the whole group of women, showing a peak of use in the second session of writing. Peculiar differences in the linguistic markers of processing trauma were observed between the two groups. Although the writing intervention is a support for both groups of women, it seems to be beneficial when there is a large time gap since the administration of chemotherapy and, thus, when the patient can revisit the experience. The relationship of the illness with life can be rearticulated, and the writing becomes a space for resignifying the traumatic cancer experience.

Identifying attentional deployment tactics in older adults' written narratives about emotionally upsetting events

Essays about distressing events written by 58 older adults on three occasions (n = 174) were coded to identify how older adults responded when confronting an emotionally upsetting event. Participants limited the experience of negative emotion by transitioning from negative to positive aspects of the event within a writing session, and across sessions, switched writing topics and moved from writing about past events to current problems. The use of attentional deployment tactics was associated with lower negative affect. This study confirms results found in quantitative studies and uncovers new processes that promote emotion regulation.

Health and writing: meaning-making processes in the narratives of parents of children with leukemia

There is literary evidence stating that expressive writing affects health outcomes. Nevertheless, the processes underlying its benefits remain unclear. In our previous article, we described the benefits of writing; in this article, we investigate the meaning-making processes underlying the traumatic experiences of parents of children with leukemia in off-therapy. We collected the writings of 23 parents and grouped them according to the parents' psychological outcome (low/good/high) with respect to anxiety, as assessed during a follow-up. We qualitatively analyzed the texts written by parents with good psychological outcomes to highlight their main meaning-making processes, that is, how they put into words the shattering experience, reordered the events, connected their emotions and the events, reevaluated the event, and reconstructed the time process. We found that parents with low/high outcomes articulated these processes differently. Furthermore, we discussed the uses and functions of written narration for each group.

Promoting Mentalization in Clinical Psychology at Universities: A Linguistic Analysis of Student Accounts

This study investigated the structure of mentalization (Bateman & Fonagy, 2012) in a training context. The dual purpose was to evaluate the effectiveness of practicum student training and whether the Linguistic Inquiry method (Pennebaker, 2000) could be used to evaluate the three dimensions of mentalization — relational, cognitive, and emotional. The training utilized the groups and their accounts as devices and mediators to conceptualize the relationship between self-mentalizing training, the academic context and the practicum experience. Accounts from 38 Italian students pursuing master degree in Clinical, Dynamic, and Community Psychology were analyzed by LIWC software. The Wilcoxon test showed a significant increase in mentalizing words during the middle and end of the term, as compared with the beginning. The results displayed a need to promote mentalization within academic settings and indicated the value of this competence for clinical psychology.

Processing coping methods in expressive essays about stressful experiences: Predictors of health benefit

This study distinguished constructive (e.g. planning/problem-solving) and unconstructive (e.g. worry) processing in expressive essays and their impact on depressive symptoms, healthcare visits, and physical symptoms. Affect labeling, achievement orientation, and insight utilization were examined as mediators. Essays from 43 medical students were coded; mediators were identified through linguistic text analysis. Outcomes were assessed at baseline and 3 months. Constructive processing predicted declining depressive symptoms (β = −.33, p < .05) and healthcare visits (β = −.61, p < .01). Unconstructive processing predicted increasing healthcare visits (β = .42, p < .05). Higher affect labeling mediated the effect of constructive processing, and lower achievement orientation mediated the effect of unconstructive processing.

Vision for improvement: Expressive writing as an intervention for people with Stargardt's disease, a rare eye disease

This study implemented and evaluated the effectiveness of an expressive writing intervention among patients with Stargardt's disease, a rare disease due to macular degeneration. Participants were randomly assigned to either an expressive writing intervention or a neutral writing condition. Participants completed measures at three time points: baseline, 3 weeks, and 6 weeks post-intervention. Psychological health outcomes improved at the 3-week follow-up for the intervention condition compared to control. Self-reported physical health improved at the 6-week follow-up in the intervention condition compared to control. These results suggest that expressive writing may be an effective, practical, and low-cost intervention for those with Stargardt's disease.