Variations in the spacing of expressive writing sessions

Testing the efficacy of a brief online writing intervention on body image and distress in female cancer survivors

OBJECTIVE

This study tested the feasibility and efficacy of two iterations of a low-intensity online writing intervention, Expand Your Horizon (EYH), in improving body image and distress in a cancer population.

METHODS

In study 1 (3-session version of EYH), adult female cancer survivors (N = 201) were randomised to EYH, where they described their body functionality, or a creative writing control. Outcomes assessed at baseline and one-week follow-up included body appreciation, body dissatisfaction, and distress. In study 2 (1 session version of EYH), adult female cancer survivors (N = 65) were randomised to EYH or a neutral writing control. Outcomes (assessed at baseline, immediately post-intervention and one-week follow-up) included body appreciation, body functionality appreciation, body dissatisfaction and distress.

RESULTS

Study 1 experienced severe attrition; only 14 participants (7 %) completed the intervention and follow-up. Study 2 had higher retention, with 74 % completing the study. In study 2, while no significant differences emerged between EYH or control, both groups significantly improved immediately post-intervention across all outcomes. No differences were found at follow-up.

CONCLUSIONS

A single-session online writing intervention for cancer survivors appears to be more feasible than multi-session, however the efficacy of EYH for this population remains to be established.

The delayed, durable effect of expressive writing on depression, anxiety and stress: A meta-analytic review of studies with long-term follow-ups

BACKGROUND

Expressive writing is a promising tool to heal the wounds with words.

AIMS

This meta-analysis evaluated the current state of efficacy of expressive writing on depression, anxiety and stress symptoms among healthy and subclinical samples.

MATERIALS AND METHODS

Thirty-one experimental studies (N = 4012) with randomized controlled trials and follow-up assessments were analysed.

RESULTS

Results showed that expressive writing had an overall small but significant effect (Hedges' g = -0.12, 95% CI [-0.21, -0.04]) on reducing symptoms of depression, anxiety and stress. Change score analyses suggested that the intervention effect emerged after a delay, as evidenced by assessments at follow-up periods. Moderator analyses indicated that the effect sizes varied as a function of one intervention feature: interval. Studies that implemented short intervals (1-3 days) between writing sessions yielded stronger effects (G_diff  = -0.18, p = .01) relative to studies that implemented medium intervals (4-7 days) or long intervals (>7 days). The effects of expressive writing remained consistent across other intervention features including focus, instruction, number of sessions, topic repetition and delivery mode.

DISCUSSION

Together, these findings provide evidence for the delayed, durable effect of expressive writing and underscore the importance of scheduling writing sessions at short intervals.

CONCLUSION

Implications for incorporating expressive writing into clinical practice and daily life are discussed.

Pilot Randomized Trial of an Expressive Writing Intervention to Reduce Sexual HIV-Transmission Risk and Substance Use Among Emerging Adult Gay and Bisexual Men

This pilot randomized controlled trial evaluated the feasibility, acceptability, and preliminary efficacy of expressive writing to reduce HIV-related sexual risk taking and symptoms of drug dependence among emerging adult gay and bisexual men (EAGBM) through linguistic mechanisms involving use of words associated with cognitive processing (e.g., think, cause), positive emotion (e.g., love, nice), and negative emotion (e.g., hurt, shame). Between 2014 and 2015, EAGBM (n = 78; aged 18-29) completed a baseline survey and were randomized to complete three 15-min expressive writing or equivalent control-group writing sessions and follow-up assessments 2 months post-baseline. EAGBM in the expressive writing condition utilized significantly more positive emotion, negative emotion, and cognitive processing words. Path model results indicated the intervention condition resulted in significant reductions in symptoms of drug dependence and frequency of condomless anal sex (CAS) through paths mediated by positive emotion words, and significant increases in CAS through a path mediated by negative emotion words.

Comparing the effects of emotional disclosure and peer helping writing on psychological distress among Chinese international students: The moderating role of rumination

OBJECTIVES

This study tested the effects of emotional disclosure writing and peer helping writing in reducing psychological distress among Chinese international students. This study also examined whether rumination and ambivalence over emotion expression moderated the effects of emotional disclosure and peer helping writing.

METHOD

One hundred forty-four Chinese international students were randomly assigned to one of three conditions: emotional disclosure, peer helping, or neutral control writing. Participants completed two 20-min writing sessions and questionnaires at baseline, 2-month follow-up, and 4-month follow-up.

RESULTS

We found no significant differences across the three writing conditions in levels of psychological distress over time. However, rumination emerged as a significant moderator in both emotional disclosure and peer helping intervention conditions. High ruminators generally experienced significant reductions in depressive symptoms, whereas low ruminators experienced increased depressive symptoms.

CONCLUSIONS

These findings demonstrate that the benefits of writing interventions may vary as a function of rumination.

A systematic review of psychotherapy research topics (2000-2016): a computer-assisted approach

The present work aims to empirically map what has been investigated and which issues (i.e. topics) characterize the debates of psychotherapy research, using a computer-assisted, bottom-up method of content analysis. The abstract of papers (N=13,499), published between 2000-2016 and retrieved from a sample of 10 journals selected as representing the field of psychotherapy research, were subjected to a method of automated content analysis. Five different research topics were identified (clinical relationship, clinical efficacy, clinical practice and research, psychopathology, and neuroscientific approaches to mental disorders) and each abstract was labeled according to the retrieved research topic. Two different Chi-square analyses investigated the distributions of research topics over time and among the selected journals. Results concerning the distribution over time highlighted an increase in the clinical relationship and clinical efficacy topics and a decrease in the others. An examination of the distribution among journals showed that psychopathology and neuroscientific approaches to mental disorders were associated with psychiatric journals, while the others were associated with non-psychiatric journals. The findings are discussed in light of the theoretical, methodological, and practical implications offering pointers for a critical understanding of the current psychotherapy research domain.

My Sadness - Our Happiness: Writing About Positive, Negative, and Neutral Autobiographical Life Events Reveals Linguistic Markers of Self-Positivity and Individual Well-Being

Objective: Narratives of autobiographical events contain rich information about an individual's private experience, his/her deepest thoughts, feelings, and emotions. The present study investigates linguistic markers of emotion expression and subjective well-being in adults during one session of positive, negative, and neutral expressive writing. Participants (N = 28 healthy participants, N = 7 adults with depressive symptoms), all native speakers of German were instructed to write expressively about personally relevant autobiographical life events of negative, positive, and neutral content. Methods: Quantitative text analysis was performed to determine the amount of emotional words, first person pronouns (singular vs. plural), and cognitive function words used in positive, negative, and neutral narratives and to examine the potency of these classes of words as linguistic markers of positivity/negativity, self-reference, and cognitive reappraisal. Additionally, the relationship between expressive writing and subjective well-being was explored by assessing changes in self-reported psychosomatic symptoms and in bodily and emotional awareness immediately after positive, negative, and neutral writing. Results: Regarding healthy participants, negative narratives contained significantly more negative emotional words than positive or neutral narratives. However, negative narratives also contained more positive emotional words compared to negative emotional words in positive narratives. Moreover, negative narratives contained more cognitive function words than positive narratives, suggesting that healthy participants tried to reappraise negative experiences while writing about negative personal life events. Positive narratives were characterized by an increased use of positive words and of pronouns of the first person plural ("we"), supporting a positivity bias and an extension of self-reference from first person singular to plural (we-reference) during positive expressive writing. Similarly, writing about neutral events was characterized by a positivity bias. Although based on descriptive analysis only, preferential use of positive words and cognitive function words in negative narratives was absent in participants reporting depressive symptoms. Positive, negative, and neutral expressive writing was accompanied by differential changes in bodily sensations, emotional awareness, and self-reported psychosomatic symptoms in all participants. Discussion: The findings are discussed with respect to previous research, a self-positivity bias, and a universal positivity bias in language use highlighting the relevance of these biases as markers of subjective well-being.

How should a virtual agent present psychoeducation? Influence of verbal and textual presentation on adherence

BACKGROUND AND OBJECTIVE

With the rise of autonomous e-mental health applications, virtual agents can play a major role in improving trustworthiness, therapy outcome and adherence. In these applications, it is important that patients adhere in the sense that they perform the tasks, but also that they adhere to the specific recommendations on how to do them well. One important construct in improving adherence is psychoeducation, information on the why and how of therapeutic interventions. In an e-mental health context, this can be delivered in two different ways: verbally by a (virtual) embodied conversational agent or just via text on the screen. The aim of this research is to study which presentation mode is preferable for improving adherence.

METHODS

This study takes the approach of evaluating a specific part of a therapy, namely psychoeducation. This was done in a non-clinical sample, to first test the general constructs of the human-computer interaction. We performed an experimental study on the effect of presentation mode of psychoeducation on adherence. In this study, we took into account the moderating effects of attitude towards the virtual agent and recollection of the information. Within the paradigm of expressive writing, we asked participants (n= 46) to pick one of their worst memories to describe in a digital diary after receiving verbal or textual psychoeducation.

RESULTS AND CONCLUSION

We found that both the attitude towards the virtual agent and how well the psychoeducation was recollected were positively related to adherence in the form of task execution. Moreover, after controlling for the attitude to the agent and recollection, presentation of psychoeducation via text resulted in higher adherence than verbal presentation by the virtual agent did.

The impact of an emotionally expressive writing intervention on eating pathology in female students

Introduction: Previous research demonstrating emotional influences on eating and weight suggest that emotionally expressive writing may have a significant impact on reducing risk of eating pathology. This study examined the effects of writing about Intensely Positive Experiences on weight and disordered eating during a naturalistic stressor.

Method: Seventy-one female students completed an expressive or a control writing task before a period of exams. Both groups were compared on BMI (kg/m²) and the Eating Disorder Examination – Questionnaire (EDE-Q) before the writing task and at 8-week follow-up. A number of secondary analyses were also examined (to identify potential mediators) including measures of attachment, social rank, self-criticism and self-reassurance, stress and mood.

Results: There was a significant effect of intervention on changes in the subscales of the EDE-Q (p = .03). Specifically, expressive writers significantly reduced their dietary restraint while those in the control group did not. There was no significant effect of the intervention on changes in BMI or the other subscales of the EDE-Q (Eating, Weight and Shape Concern). There was also no effect of writing on any of the potential mediators in the secondary analyses.

Discussion: Emotionally expressive writing may reduce the risk of dietary restraint in women but these findings should be accepted with caution. It is a simple and light touch intervention that has the potential to be widely applied. However, it remains for future research to replicate these results and to identify the mechanisms of action.

A Machine Learning Approach to Evaluating Illness-Induced Religious Struggle

Religious or spiritual struggles are clinically important to health care chaplains because they are related to poorer health outcomes, involving both mental and physical health problems. Identifying persons experiencing religious struggle poses a challenge for chaplains. One potentially underappreciated means of triaging chaplaincy effort are prayers written in chapel notebooks. We show that religious struggle can be identified in these notebooks through instances of negative religious coping, such as feeling anger or abandonment toward God. We built a data set of entries in chapel notebooks and classified them as showing religious struggle, or not. We show that natural language processing techniques can be used to automatically classify the entries with respect to whether or not they reflect religious struggle with as much accuracy as humans. The work has potential applications to triaging chapel notebook entries for further attention from pastoral care staff.

How effective are expressive writing interventions for adolescents? A meta-analytic review

This meta-analysis evaluated the effects of the expressive writing intervention (EW; Pennebaker & Beall, 1986) among adolescents. Twenty-one independent studies that assessed the efficacy of expressive writing on youth samples aged 10-18 ears were collected and analyzed. Results indicated an overall mean g-effect size that was positive in direction but relatively small (0.127), as well as significant g-effect sizes ranging from 0.107 to 0.246 for the outcome domains of Emotional Distress, Problem Behavior, Social Adjustment, and School Participation. Few significant effects were found within specific outcome domains for putative moderator variables that included characteristics of the participants, intervention instructions, or research design. Studies involving adolescents with high levels of emotional problems at baseline reported larger effects on school performance. Studies that implemented a higher dosage intervention (i.e., greater number and, to some extent, greater spacing of sessions) reported larger effects on somatic complaints. Overall, the findings suggest that expressive writing tends to produce small yet significant improvements on adolescents' well-being. The findings highlight the importance of modifying the traditional expressive writing protocol to enhance its efficacy and reduce potential detrimental effects. At this stage of research the evidence on expressive writing as a viable intervention for adolescents is promising but not decisive.

A pilot study on the effects and feasibility of compassion-focused expressive writing in Day Hospice patients

OBJECTIVE

Research has found that writing about stress can confer physical and psychological health benefits on participants and that adopting a self-compassionate stance may have additional benefits. This pilot study evaluated a self-compassionate expressive writing intervention in a Day Hospice setting.

METHOD

Thirteen patients with life-limiting illnesses wrote on two occasions about recent stressful experiences. Half also received a self-compassion instruction for their writing. Outcome measures were taken at baseline and one week after the second writing session, and text analysis was used to identify changes in the types of words used, reflecting changes in psychological processes.

RESULTS

Patients given the self-compassion instruction increased in their self-soothing and self-esteem in contrast to patients in the stress-only condition. Happiness broadly increased in both groups although reported levels of stress generally increased in patients given the self-compassion instruction but decreased in patients in the stress-only condition. Those given the self-compassion instruction also increased in their use of causal reasoning words across the two writing sessions compared with those in the stress-only condition.

SIGNIFICANCE OF RESULTS

Expressive writing appears to be beneficial in patients at a hospice and was viewed as valuable by participants. The inclusion of a self-compassion instruction may have additional benefits and a discussion of the feasibility of implementing expressive writing sessions in a Day Hospice is offered.

Expressive writing, self-criticism, and self-reassurance

OBJECTIVES

Self-criticism and reassurance are important mechanisms for regulating negative emotions but relatively little attention has been paid to interventions aimed at improving them.

DESIGN

This study explored the use of an expressive writing task to increase self-reassurance and reduce self-criticism using a randomized controlled design.

METHOD

A total of 46 participants wrote either about life goals (the expressive writing task, n= 23) or a control topic (a review of a recent book or film, n= 23) for 15 min, three times within an hour. Measures of self-criticism/self-reassurance, stress, and positive affect were completed at baseline and at 2-week follow-up. The Linguistic Inquiry and Word Count (LIWC) was used to analyse the writing of participants in the 'life goals' condition to identify psychological processes that might differentiate those who improved and those who did not.

RESULTS

While there were no significant changes in self-reported stress or positive affect, participants writing about life goals decreased in their levels of self-criticism at 2-week follow-up relative to participants writing about control topics. Text analysis showed that experimental participants using words that imply the possibility of doubt or failure, including use of the subjunctive tense (e.g., could, would, should), were least likely to decrease their self-criticism. CONCLUSION. Expressive writing shows promise as a means by which people may decrease in their self-criticism. Future research should determine whether such experimentally induced changes in self-criticism lead to the improvements in psychological health that is implied by previous cross-sectional research.

An investigation of the efficacy of online expressive writing for trauma-related psychological distress in Hispanic individuals

This study compared the efficacy of 2 online expressive writing protocols for a traumatic/stressful life event in a Hispanic student sample. Participants who had reported a traumatic event were randomly assigned to either the emotion-focused group or the fact-focused group. The emotion-focused group focused their written accounts on emotions and feelings as well as facts about a stressful/traumatic experience, whereas the fact-focused group focused on facts of a stressful/traumatic event. Both groups completed 3 online writing sessions scheduled for 3 consecutive days, a 1-week online follow-up assessment, and a 5-week online follow-up assessment. Both groups statistically significantly reduced trauma symptoms over time with the emotion-focused group demonstrating statistically significantly greater trauma symptom reductions than the fact-focused group at the 5-week follow-up assessment.

Experimental manipulations of perspective taking and perspective switching in expressive writing

Previous studies suggest that those who naturally vary their pronoun use over the course of expressive writing subsequently report the greatest improvements in physical and mental health. To explore possible perspective taking or perspective switching effects, two studies manipulated writing perspectives about emotional events from either a first-person, second-person, or third-person perspective. In Study 1, 55 students were randomly assigned to one of the three writing perspectives and were asked to write from the same perspective for three 5-minute writing sessions. In Study 2, 129 students wrote for three 5-minute sessions, one from each perspective in a counterbalanced order. The results showed that writing from a first-person perspective conferred more perceived benefits and was associated with using more cognitive mechanism words, whether engaged in perspective taking or perspective switching.