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Expressive writing interventions incancer patients: a systematic reviewErin L. Merza, Rina S. Foxa & Vanessa L. Malcarneaa SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 6363Alvarado Court, Suite 103, San Diego, CA 92120-4913, USAAccepted author version posted online: 05 Feb 2014.Publishedonline: 18 Feb 2014.

To cite this article: Erin L. Merz, Rina S. Fox & Vanessa L. Malcarne (2014) Expressive writinginterventions in cancer patients: a systematic review, Health Psychology Review, 8:3, 339-361, DOI:10.1080/17437199.2014.882007

To link to this article: http://dx.doi.org/10.1080/17437199.2014.882007

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Expressive writing interventions in cancer patients:a systematic review

Erin L. Merz*, Rina S. Fox and Vanessa L. Malcarne

SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103,San Diego, CA 92120-4913, USA

(Received 16 May 2013; accepted 8 January 2014)

Decades of research have suggested that expressive writing produces physical andpsychological benefits in controlled laboratory experiments among healthy collegestudents. This work has been extended to clinical and medical populations, includingcancer patients. Although expressive writing could be a promising and inexpensiveintervention for this population, the effects have not been systematically examined inoncology samples. A systematic review using PRISMA guidelines was conducted forexperimental trials of cancer patients who participated in an expressive writingintervention. PsycINFO and PubMed/Medline were searched for peer-reviewedstudies. Thirteen articles met the inclusion/exclusion criteria. Although the majorityof the intervention effects were null, there were several main effects for expressivewriting on sleep, pain, and general physical and psychological symptoms. Severalmoderators were identified, suggesting that expressive writing may be more or lessbeneficial based on individual characteristics such as social constraints. The reviewedstudies were limited due to representativeness of the samples, performance, detectionand patient-reported outcomes biases, and heterogeneity of the intervention protocoland writing prompts. Future studies with rigorous designs are needed to determinewhether expressive writing is therapeutically effective in cancer patients.

Keywords: expressive writing; cancer; adjustment; coping; emotional disclosure;oncology

I write about illness to work out some terms in which it can be acceptedSeizing theopportunity means experiencing it fully, then letting go and moving on.

- Sociologist Arthur W. Frank (1991, p. 3) on writing about his cancer

Cancer can be an overwhelming and traumatic event in a persons life, impacting not onlyphysical health but also emotional, social and spiritual functioning. Over the past severaldecades, much attention has been paid to how cancer affects the whole person, andparticularly how to promote psychosocial adjustment to the disease. Interventionsincluding psychotherapy (Hart et al., 2012), peer groups (Hoey, Ieropoli, White, &Jefford, 2008) and Internet-based support (Hybye et al., 2010) have been used in cancerpatients with some benefits. Another complementary intervention that has gainedsubstantial interest among psycho-oncology clinicians is expressive writing (EW), an

*Corresponding author. Email: emerz@ucsd.edu

Health Psychology Review, 2014Vol. 8, No. 3, 339361, http://dx.doi.org/10.1080/17437199.2014.882007

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emotional disclosure technique wherein a person writes about a major life event ortrauma.

The first standardised EW prompt, developed in 1986 by Pennebaker and Beall,instructed respondents to write for approximately 20 minutes over four consecutive daysabout their deepest emotions and thoughts regarding traumatic/upsetting experiences.Early studies reported that, compared to control participants who wrote factual essaysabout superficial (i.e., non-traumatic) topics, those who wrote expressively gainedphysical and psychological health benefits over time (e.g., Pennebaker, 1993), suggestingthat a simple writing exercise can improve health. These findings have been supported byFrattarolis (2006) meta-analysis, which reported a small health-enhancing effect ofwritten or spoken emotional disclosure across 10,994 people (unweighted mean effectsize = .075; d = .15).

How does expressive writing work?

Several theoretical frameworks have been proposed to explain the mechanismsunderlying the benefits of EW. There is likely no single explanatory route, but rather acomplex combination of interconnected and mutually influential processes. It is possiblethat EW serves a cathartic function, allowing the writer to express and release theiremotions, which in turn improves their well-being (Pennebaker & Chung, 2007).Cognitive restructuring of a trauma and habituation to the emotions associated with thattrauma may also facilitate the effectiveness of EW (Pennebaker & Chung, 2011). That is,repeatedly writing about ones experience with cancer may serve an exposure function.Writing may lead to initial distress, but it also enables the writer to process, reflect andreframe their experience, extinguishing the connection between the event and theiremotional reaction to it, and assimilating it into their self-schema (Low, Stanton, &Danoff-Burg, 2006; Pennebaker & Chung, 2011). Another explanation is that EW offersan opportunity for personal mastery and self-regulation (Creswell et al., 2007; Lepore,Greenberg, Bruno, & Smyth, 2002). EW may enable people to step back and observehow they handled their cancer experience, increasing their confidence to manage stressand regulate their emotions, thoughts and behaviours. It is also possible that EW serves torestore a sense of perceived control, which can be lost or diminished in the context of aserious illness (Andersson & Conley, 2008).

Written content

The linguistic characteristics of EW passages provide information regarding whether theintervention was followed (i.e., manipulation check) and the emotional processing of thewriter, which can provide insight into the mechanisms underlying the impact of EW.However, reliably and validly evaluating written content is challenging. Computer textanalysis programs have been developed, including the Linguistic Inquiry Word Countprogram (LIWC; Pennebaker, Booth, & Francis, 2007), which calculates the frequencyand percentage of words in 74 content categories. Using LIWC, researchers havedemonstrated that emotional (e.g., happy and depressed) and cognitive mechanism (e.g.,because and realise) words predict changes in physical and psychological health afterEW (Pennebaker, Mayne, & Francis, 1997). Although such programs offer quick,inexpensive and reliable assessment, they are not sensitive to contextual aspects oflanguage (e.g., tone, cultural jargon and abstraction; Tausczik & Pennebaker, 2010).

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Trained independent judges and self-ratings have also been widely adopted toappraise aspects of written passages (e.g., degree of emotionality, personal meaning andnarrative structure) that are not detected by computers. Both methods have advantagesand shortcomings. Judges are more objective than self-rating, but they are timeconsuming and costly, and inter-rater reliability can be problematic (Tausczik &Pennebaker, 2010). Although self-rating is easier to implement, it assumes a sophisticatedlevel of evaluation on behalf of the writer, and ratings may be influenced by recognitionof condition assignment (i.e., expectation/performance bias from the informed consentprocess and knowledge of the prompt). However, both methods have been shown tosufficiently analyse text characteristics (e.g., Danoff-Burg, Mosher, Seawell, & Agee,2010; Smyth, True, & Souto, 2001).

Expressive writing and cancer

Given that EW has been shown to promote health in relatively healthy people, there hasbeen an increasing interest in its therapeutic potential. As such, Pennebaker and Bealls(1986) prompt has been tailored to accommodate clinical populations. EW has beeninvestigated as a potentially useful intervention for psychosocial adjustment to medicalillness in numerous disease groups, including rheumatoid arthritis (Broderick, Stone,Smyth, & Kaell, 2004), asthma (Harris, Thoresen, Humphreys, & Faul, 2005), HIV(Rivkin, Gustafson, Weingarten, & Chin, 2006) and cardiovascular disease (Manzoni,Castelnuovo, & Molinari, 2011). There have also been a number of recent studies on EWin cancer (e.g., Kallay & Baban, 2008; Laccetti, 2007; Lu, Zheng, Young, Kagawa-Singer, & Loh, 2012; Owen et al., 2006; Smith, Anderson-Hanley, Langrock, & Compas,2005; Zakowski, Herzer, Barrett, Milligan, & Beckman, 2011). Because many cancerpatients report feeling emotionally inhibited (Servaes, Vingerhoets, Vreugdenhil, Keun-ing, & Broekhuijsen, 1999; Zakowski et al., 2003), and because emotional inhibition hasbeen linked with poorer psychological functioning (Tamagawa et al., 2013), EW mayoffer an outlet for patients to express their feelings related to cancer.

EW is time- and cost-effective, can be easily self-administered, and people generallyreport a high level of satisfaction with it (Frattaroli, 2006). Given this, it is not surprisingthat EW has already been employed at cancer centres around the world. However, thecumulative evidence of EW in cancer has not yet been systematically examined,suggesting that such wide dissemination could be premature. Therefore, the primaryobjective of the present study was to examine the efficacy of EW on physical and mentalhealth in cancer patients. A second, exploratory aim was to identify the text analysismethods used in each study, determine the purpose of this analysis and evaluate therelated findings.

Methods

Search strategy

The search was limited to peer-reviewed articles1 published in English after 1986, as thiswas the year that the first EW study using Pennebakers prompt was published. Articleswere identified via a search of PsycINFO (1986 to November 2012) and PubMed/Medline (1986 to November 2012) using combinations of expressive writing (expressivewriting OR emotional disclosure OR written emotional disclosure OR emotionalexpression OR creative writing OR Pennebaker OR self-disclosure OR cancer narrative

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OR illness narrative OR reflective writing OR writing cure) and cancer (cancer ORoncology OR breast cancer OR prostate cancer OR neoplasm OR metastatic ORleukaemia OR lymphoma OR lung cancer OR cancer clinic OR tumour OR oncology ORoncologist OR malignant OR malignancy OR chemotherapy OR radiation) terms foundanywhere in the text. Backward (examining references of articles found in the keywordsearch) and forward (examining articles cited by those in the keyword/backwardsearches) searches were subsequently conducted.

Study selection

Supplemental Figure 1 illustrates the selection process. One-hundred sixty articles werescreened for inclusion, with four studies added from the backward/forward searches.Studies were independently screened by the first (E.M.) and second (R.F.) authors.Disagreements were resolved by collaborative reanalysis of the studies in question. To beincluded, a study was required to have an experimental design with an EW group[expressive writing for at least a single 20-minute session using the Pennebaker and Beall(1986) paradigm] and a control group for comparison. Studies needed to measure aphysical and/or mental health outcome. Participants needed to (i) have any cancerdiagnosis; and (ii) be undergoing or have undergone medical treatment for their cancer(e.g., surgery, radiation and chemotherapy). To avoid drawing omnibus conclusions frommultiple publications that reported findings from the same sample, articles that presentedresults from a previously published study were excluded. Studies without quantitativeanalysis were also excluded.

Data extraction

Information from the 13 included articles was recorded in an electronic spreadsheetdesigned by the first author. Data were collected on (i) participant characteristics (i.e.,sample size, demographics and disease); (ii) study characteristics (i.e., design, andexperimental and control group details); (iii) session dosing (i.e., number, spacing andduration); (iv) text analysis details; (v) health outcomes; (vi) statistical values for EWeffects; (vii) participant feedback; and (viii) risk of bias. Standardised effect sizes(Cohens d) were calculated for the standardised mean difference between theintervention and control groups based on statistical values and descriptive statisticsprovided in the original manuscripts. For mediation and moderation analyses, p-valueswere listed in the final table.

The Cochrane Collaborations tool for assessing risk of bias was used. Randomsequence generation (i.e., selection bias) was rated as low risk if participants had equalpossibility of being assigned to either the treatment or control group, and allocation foreach participant could not be predicted by the investigator (e.g., computer-generatedrandomisation schedule); high risk if group assignment could be predicted by theinvestigator (e.g., sequential assignment); and unclear risk if no details regarding groupassignment or the method of random assignment were reported. Allocation concealment(i.e., selection bias) was rated as low risk if authors reported that allocations wereconcealed such that investigators or participants could not possibly foresee groupassignment (e.g., central allocation or sequentially numbered, opaque and sealedenvelopes); high risk if allocation could be foreseen (e.g., based on case record numberand sequential by admission into the study); and unclear risk if authors did not reportconcealment or describe the method used. Blinding of participants and personnel

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(i.e., performance bias) is problematic in all EW studies because a true double-blinddesign is not possible given the nature of EW tasks. Although all EW studies are high riskbecause participants will be aware of group assignment upon receiving their instructions,blindness and/or awareness of study hypotheses of personnel who interacted withparticipants during the intervention was noted. Blinding of outcome assessment (i.e.,detection bias and patient-reported outcomes) was rated as low risk under the followingconditions: for interviews, personnel were blind to group assignment and efforts weremade to mask the purpose of the study for the participants; for written self-reportassessments, efforts were made to mask the purpose of the study for the participants; formedical/biological assessments, personnel were blind to group assignment or assessmentswere made via chart review. Blinding of outcome assessment was rated as high risk ifpersonnel were not blind to group assignment or there was evidence that participants wereaware of the study purpose; and unclear risk if there were insufficient details to determinewhether there were efforts to mask participant knowledge of the studys purpose.Incomplete outcome data (i.e., attrition bias) was rated as low risk if 30% of patientswere lost to follow-up, and rates and reasons for attrition were similar across studygroups; high risk if > 30% of patients were lost to follow-up, and rates and reasons forattrition across study groups were different or were not reported; and unclear risk if nodetails regarding loss to follow-up were reported. Selective reporting (i.e., reporting bias)was rated as low risk if all outcomes listed in the Methods section were reported on, andthere was no other suggestion of selective outcome reporting; and high risk if there wasevidence that not all outcomes were reported or suggestion of selective outcomereporting.

Results

Study characteristics

Descriptions of the samples and studies are presented in Table 1. Sample sizes rangedfrom 30 to 507. A variety of cancers of all stages were represented, with breast cancerbeing the most common (9 of the 13 samples). Average age ranged from 49.5 to 70.4years, with the majority of studies reporting a mean age in the 50s. Most samples werepredominantly female given the cancer diagnoses being studied (e.g., breast andgynaecological). Five studies did not describe the ethnic composition of the sample.Although Cepeda et al. (2008) did not report ethnicity, the patients were recruited fromoncology clinics in Bogot, Colombia, and were presumably of Latino background. In theeight studies that reported ethnicity, participants were predominantly White, with theexception of the study by deMoor et al. (2008), which was 17% Latina, 10% AfricanAmerican and 10% other.

The EW interventions were heterogeneous. Dosing varied from one to four writingsessions. Gaps between sessions ranged from consecutive days to several weeks. Theemotional prompt specific to cancer (in which participants write about their deepestthoughts and feelings/emotions) was the most widely used, although variations werenoted. One study (Jensen-Johansen et al., 2012) used the emotional prompt but allowedparticipants to write about either their cancer or any trauma [56% of patients wrote abouttheir cancer at least once (n = 108), 44% of patients always wrote about another trauma(n = 85)]. The authors also reported varying the instructions slightly between sessions toavoid uniformity (Jensen-Johansen et al., 2012, p. 1494). Craft, Davis, and Paulson(2013) used the emotional prompt for two experimental groups: one group wrote

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Table 1. Studies (N = 13) reporting experimental trials of expressive writing interventions in cancer patients.

Study and sample Task and follow-up Results; (Cohens d) for main effects

Cepeda et al. (2008)N = 198 patientsAny cancerstages 14Race: NRMage = 48.5 12.464.0% female

EW: STORY (n = 65)Control: SURVEY (n = 67)

USUAL (n = 66)Three sessions over 3 weeksFollow-up at weeks 18; first 3 follow-upstook place during the 3 EW weeks

Over 8 weeks, EW did not directly improve pain or well-being (insufficient informationto calculate ds; ps > .05).

Emotional disclosure interacted with EW to predict pain and well-being over time.Respondents with at least one essay rated as very much disclosure (vs. respondentswith no essays rated as very much disclosure) reported improved pain (2.5difference; 95% CI: 4.2 to 0.9) and well-being (+1.37 difference; 95% CI: 1 to 1.7).

Craft et al. (2013)N = 97Breast cancerstages 03Race: 92.8% WhiteMage = 56 10.5All female

EW: EMO (n =26)EMO (n = 19)

Control: NWc (n = 22)USUAL (n = 30)

Four sessions, consecutive daysFollow-up at 1, 6 months

At 1 and 6 months, EMO did not significantly improve quality of life compared to NWc(ds = .40, .06) or USUAL (ds = .62, .56). At 1 and 6 months, EMO did notsignificantly improve quality of life compared to NWc (ds = .62, .48) or USUAL (ds =.34, .25).

For EMO, quality of life increased from baseline to 1 and 6 months (ps < .05). For NWc,quality of life increased from baseline to 1 month (p < .05).

deMoor et al. (2002)N = 42Renal cell carcinomastage 4Race: NRMage = 56.4 NR85.7% male

EW: EMO (n = 21)Control: NWb (n = 21)Four sessions over 4 weeksFollow-up immediately after last writingsession, 4, 6, 8, 10 weeks

Scores were pooled across the five follow-ups. Over time, EW did not significantlyimprove distress (d = .35), perceived stress (d = .17) or overall mood disturbance (d =.18) excepting the vigour subscale (d = .64). EW significantly improved overall sleepdisturbance (d = .64), sleep quality (d = 1.3), sleep duration (d = .87), daytimedysfunction (d = .87); however, sleep latency (d = .65), sleep efficiency (d = .11),sleep disturbances (d = .44), sleep medications (d = .09) not significantly changed.

deMoor et al. (2008)N = 49Breast cancerstages 2 and 3Race: 63% WhiteMage = 53.5 10.4All female

EW: EMO (n = 24)Control: NWb (n = 25)Four sessions over 7 days, 3 weeks prior tosurgeryFollow-up at 3 days pre-surgery and 2weeks post-surgery

At 3 days pre-surgery and 2 weeks post-surgery, EW did not directly improve distress (ds= .07, .01), perceived stress (ds = .24, .16), sleep disturbance (ds = .13, .33), worstpain (ds = .10, .67), least pain (ds = .28, .45), average pain (ds = .05, .40) or paininterference (ds = .23, .54). EW reported increased sleep medication use 3 days beforesurgery (d = .57); group differences at baseline were not reported.

Social constraints interacted with EW to predict pre-surgery (p = .05) and post-surgery (p= .05) average pain. High social constraints in EW associated with less pain; lowsocial constraints in EW associated with more pain.

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Table 1 (Continued)

Study and sample Task and follow-up Results; (Cohens d) for main effects

Gellaitry et al.(2010)N = 80Breast cancerstages 12Race: NRMage = 57.9 9.9All female

EW: MULTIPLE (n = 38)Control: USUAL (n = 42)Four sessions, consecutive days (differentprompt each day)Follow-up at 1, 3, 6 months

At 1, 3 and 6 months, EW did not directly improve quality of life (ds = .16, .00, .07),mood disturbance (ds = .15, .07, .10), healthcare utilisation or satisfaction withperceived practical support (insufficient information to calculate latter ds; ps > .05).EW directly improved perceived emotional support (ds = .36, .48, .50; overall d overtime = .47) at all three follow-ups.

Henry et al. (2010)N = 80Breast cancerstages 14Race: NRMage = 58.9 NRAll female

EW: BEN (n = 40)Control: USUAL (n = 40)One sessionFollow-up at 3, 9 months

At 3 and 9 months, EW did not directly improve somatisation or retarded activity(insufficient information to calculate ds; ps > .05). EW directly improved depressivesymptoms (d = .76), physical symptoms (d = .76), mood disturbance (d = .58) at 3months, but not 9 months (depressive d = .18, physical d = .04, mood disturbance d =.21).

Location (rural vs. urban) did not interact with EW (p > .05).

Jensen-Johansenet al. (2012)N = 507Breast cancerstages 1-2Race: NRMage = 53.6 9.1All female

EW: EMO (n = 253)Control: NW (n = 254)Three sessions over 3 weeksFollow-up at 3, 9 months

At 3 and 9 months, EW did not directly improve distress (ds = .15, .04), intrusivethoughts (ds =.07, .03), avoidance (ds = .18, .08), depression (ds = .12, .07), negativemood (ds = .04, .10) or positive mood (ds =.06, .01).

Externally oriented thinking interacted with EW to predict distress at 3 months (p =.021). In EW (vs. NW), lower external orientation predicted less distress. Difficultiesdescribing feelings interacted with EW to predict positive mood at 3 months (p =.049). In NW (vs. EW), greater difficulties describing feelings predicted better mood.Writing topic (cancer vs. another trauma) moderated the effects of EW to predictavoidance (p < .05), depression (p = .013), negative mood (p = .052), positive mood (p= .014). Writing about another trauma (vs. cancer) predicted less avoidance. Writingabout cancer (vs. NW) improved depression and mood. Number of essays written,social constraints, other alexithymia variables did not interact with EW (ps > .05).

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Table 1 (Continued)

Study and sample Task and follow-up Results; (Cohens d) for main effects

Low et al. (2010)N = 62Breast cancerstage 4Race: 87% WhiteMage = 53.8 10.3All female

EW: EMO (n = 31)Control: NWc (n = 31)Four sessions over 3 weeksFollow-up at 3 months

At 3 months, EW did not directly improve depression (d = .05), intrusive thoughts (d =.26), somatic symptoms (d = .09) or sleep disturbances (d = .18).

Emotional support interacted with EW to predict intrusive thoughts (p = .001). Low (vs.high) support in EW had fewer intrusions. Emotional support interaction with EW topredict somatic symptoms (trend; p = .08); same pattern. Time since diagnosisinteracted with EW to predict somatic symptoms (p = .034), sleep quality (p = .023).Diagnosis < 20 months ago (vs. > 20 months) in EW reported fewer symptoms (p =.048). Diagnosis > 20 months ago (vs. < 20 months) in EW reported more sleepdisturbances (p = .025).

Mosher et al. (2012)N = 86Breast cancerstage 4Race: 81% WhiteMage = 57.9 12.1All female

EW: EMO (n = 44)Control: NW (n = 42)Four sessions over 4-7 weeksFollow-up at 8 weeks

At 8 weeks, EW did not directly improve existential well-being (meaning/peace d = .25,demoralisation d = .14), distress (d = .07), depressive symptoms (d = .01), anxiety (d =.23), sleep (d = .23) or fatigue (d = .28). EW directly increased uptake of mental healthservices (d = 1.01), as compared to NW, at 8 weeks.

Rosenberg et al.(2002)N = 30Prostate cancerstage NRRace: 97% WhiteMage = 70.4 5.4All male

EW: EMO (n = 16)Control: USUAL (n = 14)Four sessions, consecutive daysFollow-up at 3, 6 months

At 6 months, EW did not directly improve immune-directed cancer activity markers[PSA-specific CD4 helper cells (d = .00), PSA-specific CD8 cytolytic cells (d = .36),IL-10 (d = .52), IL-4, TNF (insufficient information to calculate ds)], psychologicalsymptoms, quality of life or coping (insufficient information to calculate ds; ps > .05).At 3 and 6 months, EW directly improved pain (ds = .57, .98); significant trends forEW on decreased healthcare utilisation (ds = .13, .51), decreased medication use (ds =.62, .29).

Stanton et al. (2002)N = 60Breast cancer

EW: EMO (n = 21)BEN (n = 21)

Control: NWc (n = 18)

Neither EW group directly improved distress, vigour or quality of life (insufficientinformation to calculate ds; ps > .05) at 1 or 3 months, or somatic symptoms at 1month (EMO d = .58, BEN d = .10). EW directly improved somatic symptoms at 3

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Table 1 (Continued)

Study and sample Task and follow-up Results; (Cohens d) for main effects

stages 12Race: 93% WhiteMage = 49.5 12.2All female

Four sessions over 3 weeksFollow-up at 1, 3 months

months (EMO d = .89, BEN d = .55). EW predicted fewer cancer-related (EMO d =.94, BEN d = .70) but not other medical appointments (EMO d =.19, BEN d =.16) at3 months.

Cancer-related avoidance interacted with EW to predict distress (1 month p = .0015, 3month p = .0148). EMO with low (vs. high) avoidance and BEN with high (vs. low)avoidance predicted less distress. No interaction for vigour, quality of life, somaticsymptoms, medical appointments (ps > .05).

Walker et al. (1999)N = 39Breast cancerstages 12Race: 95% WhiteMage = 53.6, range:

2976All female

EW: 1 dose EMO (n = 11)3 dose EMO (n = 14)

Control: ATT (n = 14)One or three sessions over 14 daysFollow-up at 1, 4-6, 16, 28 weeks

At the four follow-ups, EW (1 and 3 doses) did not directly improve (p > .0125) negativeaffect (1 dose ds = .22, .53, .64, .49; 3 dose ds = .11, .32, .48, .49), positive affect (1dose ds = .79, .31, .49, .66; 3 dose ds = .40, .43, .05, .25), avoidance of cancerreminders (1 dose ds = .04, .48, .35, .15; 3 dose ds = .00, .20, .01, .02) or intrusivenessof thoughts (1 dose ds = .15, .13, .39, .60; 3 dose ds = .01, .18, .04, .34).

Zakowski et al.(2004)N = 104Prostate,gynaecological

stages 14Race: 95.2% WhiteMage = 59.8 11.151.9% female

EW: EMO (n = 62)Control: NW (n = 42)Three sessions, consecutive daysFollow-up at 6 months

At 6 months, EW did not directly improve distress (d = .03), avoidance (d = .08) orintrusive thoughts (d = .23).

Social constraints interacted with EW to predict distress (p < .04) and avoidance (p .05).

ATT = non-cancer attention; BEN = benefit-finding (cancer) prompt; EMO = emotional (cancer) prompt; EMO = emotional (any trauma) prompt; MULTIPLE= emotional, benefit-finding, cognitive-appraisal, coping prompts; NR = not reported; NW = neutral writing (trivial); NWc = neutral writing (cancer); NWb = neutral writing (health behaviour); STORY =cancer story; SURVEY = took survey; USUAL = usual care

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0

1

5

emotionally about cancer, the other wrote emotionally about any trauma (the authors didnot report whether any patients in the latter group chose to write about cancer). Stantonet al. (2002) used two experimental groups: one wrote emotionally about cancer, the otherwrote about their positive thoughts and feelings related to cancer (i.e., benefit-finding).Henry, Schlegel, Talley, Molix, and Bettencourt (2010) used the benefit-finding promptonly. Alternatively, the study by Gellaitry, Peters, Bloomfield, and Home (2010) used adifferent topic for each of the four writing sessions (emotional, benefit-finding, cognitiveappraisals of cancer and coping strategies); and the study by Cepeda et al. (2008)prompted patients to write a story about how cancer affected their lives (p. 625).

The majority of control conditions instructed participants to engage in writing. Thestudies by Low, Stanton, Bower, and Gyllenhammer (2010) and Stanton et al. (2002)used a neutral prompt regarding the facts of their cancer (e.g., number of chemotherapysessions, oncologists name and medication). Alternatively, deMoor et al.s (2002, 2008)neutral prompt asked participants to write factually about health behaviours (e.g., diet andsleep). Three studies used a neutral prompt to write about the facts of a trivial/everydaytopic (e.g., daily activities; Jensen-Johansen et al., 2012; Mosher et al., 2012; Zakowski,Ramati, Morton, Johnson, & Flanigan, 2004). Craft et al. (2013) had two controlconditions: neutral writing about the facts of their cancer2 and usual care (with nowriting). Cepeda et al. (2008) had two conditions: usual care and completing a painquestionnaire. Usual care was the only control condition in three studies (Gellaitry et al.,2010; Henry et al., 2010; Rosenberg et al., 2002). One study used an attentional controlwherein patients met with a researcher to discuss non-cancer life events (Walker, Nail, &Croyle, 1999).

Effects of expressive writing on physical and mental health

The effects of EW on physical and mental health outcomes are presented in Table 1. All13 studies reported some null effects of experimental condition on the outcomes ofgeneral or existential well-being, quality of life, social support satisfaction, coping,distress, stress, affect, mood, depression, intrusive thoughts, avoidance, somatisation,vigour, pain, sleep characteristics, healthcare utilisation and cancer-related immunefunctioning. Six studies reported some significant benefits for EW. Standardised effectsizes for statistically significant main effects indicating that EW improved physical and/ormental health were small (d = .20) to large (d = 1.21) in magnitude, with the majoritybeing in the moderate range (ds = .54 to .76). Improvements were noted in energy andsleep characteristics (deMoor et al., 2002), depressive (Henry et al., 2010) and physicalsymptoms (Henry et al., 2010; Stanton et al., 2002), emotional support (Gellaitry et al.,2010), pain (Rosenberg et al., 2002), uptake of mental health services (Mosher et al.,2012) and healthcare utilisation (Stanton et al., 2002).

Six studies reported significant moderators of EW. The extent of perceived socialconstraints (i.e., inhibition from expressing thoughts/feelings due to social restrictions ornorms) affected the impact of the intervention in two studies (deMoor et al., 2008;Zakowski et al., 2004). deMoor et al. (2008) found that patients with high levels of socialconstraints who wrote expressively had lower average daily pain before and after surgerycompared to high-constraint patients who wrote about health behaviours. The painreported by the EW group actually paralleled all patients who reported low socialconstraints, suggesting that EW buffers the deleterious effects of inhibition. Similarly,Zakowski et al. (2004) reported that patients with high social constraints who wrote

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expressively had lower distress and avoidance of cancer-related thoughts compared tohigh-social-constraint controls who wrote about trivial topics. Again, the levels of distressand avoidance reported by the EW group paralleled patients with few social constraints.

Other studies found evidence that individual differences including emotional support,time since diagnosis, intentional avoidance of cancer-related thoughts/feelings andalexithymia (i.e., inability to identify and describe ones emotions) moderated theeffectiveness of EW in patients with breast cancer. Low et al. (2010) found that womenwith poor emotional support at baseline were benefited by EW such that they had fewerintrusive thoughts and somatic symptoms (trend only; p = .08) at follow-up, whereaswomen with greater support were not impacted by EW. In this same study, women whowere diagnosed recently and wrote expressively reported fewer somatic symptoms atfollow-up, whereas women who had been diagnosed for more than 20 months were notbenefited by EW. This study also revealed a potentially harmful result of EW for womenwho had been living with cancer for a longer time: women in the EW condition who werediagnosed more than 4.7 years prior to the study reported increased sleep disturbances. InStanton et al.s (2002) sample, women who reported low levels of avoidance and used theemotional prompt (but not the benefit-finding prompt) reported lower distress thanwomen with high avoidance. There was also a trend in the opposite direction for thebenefit-finding prompt: women with high avoidance who wrote about benefit-findingreported less distress than women who were less avoidant (Stanton et al., 2002). In thestudy by Jensen-Johansen et al. (2012), two aspects of alexithymia (i.e., externallyoriented thinking and difficulty describing feelings) moderated the effectiveness of EW.Women who reported a higher cognitive focus on inner experiences who wroteexpressively reported lower distress; women with difficulty describing their feelingswho wrote expressively reported a more positive mood (Jensen-Johansen et al., 2012).

Writing topic and level of emotional disclosure within writing passages were alsosignificant moderators. In Jensen-Johansens (2012) study, wherein patients could choosetheir EW topic (cancer vs. another trauma), women who wrote about another traumareported lower avoidance, whereas women who wrote about cancer reported decreaseddepression and improved mood. Notably, patients who wrote about cancer were morelikely to have a history of critical medical interventions (e.g., mastectomy andchemotherapy), pain medication usage and psychotherapy (Jensen-Johansen et al.,2012). Only Cepeda et al. (2008) examined the influence of linguistic characteristics inEW texts; these findings are discussed in the Measurement of Written Content section.

Several studies reported qualitative feedback regarding patient experiences with EW.Gellaitry et al. (2010) noted that EW gave participants the opportunity to disclosefeelings they found difficult to share with those closest with them because they did notwant to cause them more worry (p. 82). Craft and colleagues (2013) also publishedpositive written reflections suggesting that the patients listening to themselves led toperceptions of increased quality of life (p. 312). Similarly, Walker and colleagues (1999)found that many women described the exercise as helpful with regard to their end-of-treatment concerns, expression of their emotions and consolidation of their thoughtswithout burdening their loved ones. deMoor et al. (2002) found comparably favourableresults; over 80% of the sample reported that they would like to participate again, and90% reported that they would recommend EW to a friend. In another sample, the majorityof women (59%) stated that they felt positively about writing, while 34% felt neutrally(Henry et al., 2010). A number of these participants also indicated that the interventionaided in their coping efforts, although some expressed that they did have difficulty

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writing (Henry et al., 2010). Stanton et al. (2002) also reported that respondents foundEW to be a valuable/meaningful experience that provided them with positive, long-lastingeffects, and did not elicit negative effects.

Measurement of written content

Five studies (Craft et al. 2013; Gellaitry et al., 2010; Henry et al., 2010; Jensen-Johansenet al., 2012; Rosenberg et al., 2002) did not evaluate written content. Of the eight studiesthat used a method of text analysis, seven used written characteristics solely as amanipulation check.3 Three studies used the LIWC program as a manipulation check,finding that respondents in the experimental conditions used greater numbers of emot-ional and cognitive words compared to those in the control conditions [deMoor et al.,2002 (32 categories evaluated, significant differences in 24 categories); deMooret al., 2008 (10 categories evaluated, significant differences in nine categories); Mosheret al., 2012 (two categories evaluated, significant differences in both)], indicatingcompliance with the writing instructions. One study (Walker et al., 1999) used the LIWCprogram for a substantive question, finding that patients who were assigned to have threedoses of writing (vs. one dose) used more positive emotion words, and wrote moreabout the present and future and less about the past in their third essay than their firstessay.

Trained judges were used to code written content as a manipulation check in fourstudies [Low et al., 2010 (one judge, 94% accuracy); Mosher et al., 2012 (one judge, 99%accuracy); Stanton et al., 2002 (one judge, 95% accuracy); Walker et al., 1999 (fourjudges, accuracy not reported)] and as a process variable in one study (Cepeda et al.,2008; 2 judges, k = .8, p = .0001). Across these studies, judge ratings suggested thatnarratives from the experimental group were more personal and revealing compared tonarratives from the control conditions. The study by Cepeda et al. (2008), which was theonly study in the current review to evaluate whether the written content was related tohealth outcomes, reported that individuals who wrote at least one essay with very muchdisclosure reported less pain and greater well-being over eight weeks compared to thosewho never had an essay rated as very much disclosure (disclosure was rated on a six-point scale ranging from none to very much). This suggests that exposure to onescancer-related emotions engendered the effectiveness of EW in this study. However, thecategorisation of emotional disclosure by dichotomising the blind judges ratings in thisstudy was unconventional; given that the authors reported that no other categorisationshad produced statistically significant results, these findings may represent a reportingbias. Three studies (Mosher et al., 2012, Stanton et al., 2002, Zakowski et al., 2004) usedself-rating as a manipulation check; EW participants rated their essays as more personaland revealing.

Risk of bias within studies

Table 2 provides a summary of risk of bias in the current review. Eight studies wereconsidered low risk of selection bias due to random sequence generation. Four studiesused a computerised random number generator, conferring the absolute lowest risk(Cepeda et al., 2008; Gellaitry et al., 2010; Low et al., 2010; Stanton et al., 2002) andfour studies used restricted randomisation procedures that balance characteristics betweengroups but can increase the predictability of group assignment by the investigator (e.g.,minimisation, random permuted block; deMoor et al., 2002; deMoor et al., 2008; Jensen

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Johansen et al., 2012; Mosher et al., 2012). Two studies did not indicate the method ofrandom assignment (Rosenberg et al., 2002; Zakowski et al., 2004). The three studieswith the most significant risk used sequential assignment (Craft et al., 2013; Walker et al.,1999) or matched controls (Henry et al., 2010).

Three studies were considered low risk of selection bias due to allocationconcealment (Cepeda et al., 2008; Low et al., 2010; Stanton et al., 2002) and threestudies were considered high risk (Craft et al., 2013; Henry et al., 2010; Walker et al.,1999). The remaining studies did not provide sufficient details to draw a conclusion,although Jensen-Johansen et al. (2012) did indicate that allocation was concealed prior togroup assignment without specifying the method.

As in any EW study, the risk of performance bias in the reviewed papers was highoverall. It is not possible to fully blind participants to condition assignment, as awarenessof the prompt is required to complete the task. Only one study described efforts to

Table 2. Risk of bias in studies reporting experimental trials of expressive writing interventions incancer patients.

Randomsequencegeneration

Allocationconcealment

Blinding ofparticipants

andpersonnel

Blindingof

outcomeassessment

Incompleteoutcomedata

addressedSelectivereporting

Cepedaet al. (2008)

+ + ? +

Craftet al. (2013)

+ +

deMooret al. (2002)

+ ? ? + +

deMooret al. (2008)

+ ? ? +

Gellaitryet al. (2010)

+ ? ? + +

Henryet al. (2010)

+ +

Jensen-Johansenet al. (2012)

+ ? + ? +

Lowet al. (2010)

+ + ? + +

Mosheret al. (2012)

+ ? ? + +

Rosenberget al. (2002)

? ? ? + +

Stantonet al. (2002)

+ + + + +

Walkeret al. (1999)

? + +

Zakowskiet al. (2004)

? ? ? + +

Note: low risk of bias: +, high risk of bias: , unclear risk of bias: ?

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attenuate performance bias by blinding personnel to study purpose/hypotheses during theintervention (Stanton et al., 2002).

Evidence of detection bias was largely unclear given that most studies used writtenself-report measures for the primary study outcomes but did not provide details regardingparticipant knowledge of the study purpose and hypotheses (n = 9). Three studies thatused written self-report were considered low risk because some efforts to obscure thestudy purpose were described (Craft et al., 2013; Jensen-Johansen et al., 2012; Stantonet al., 2002). One study was considered high risk because the nurse interviewers whoconducted the baseline assessment were not blind to allocation (Henry et al., 2010).

There was a relatively low attrition bias, with most studies reporting participantretention rates in excess of 80%. Both samples with significant attrition comprised breastcancer patients at different points in their treatment [i.e., definitive treatment had beencompleted within the past two years (Craft et al., 2013); immediately prior to surgeryafter completing neoadjuvant chemotherapy (deMoor et al., 2008)]. Notably, Craft et al.(2013) used intent-to-treat analyses to attenuate the potential for misleading results fromtheir data. One study (Jensen-Johansen et al., 2012) did not describe the reasons forattrition and was therefore considered an unclear risk.

Overall it appeared there was a low risk for reporting bias. However, Cepeda et al.(2008) noted that while multiple categorisations of the emotional disclosure variable hadbeen tested, only the one that emerged as significant was presented; therefore, it is likelythat some amount of reporting bias was conferred. It is also worth mentioning that threestudies reported non-statistically significant trends (Craft et al., 2013, Low et al., 2010,Rosenberg et al., 2002). While this does not formally constitute reporting bias, this cancreate the appearance of greater significance than was evident in the data.

Discussion

This review summarised 13 experimental trials of EW in cancer. The samples were notrepresentative of the cancer population at large in terms of ethnicity or age, with anoverwhelming majority of participants being White and also younger than the overallcancer population (median age of onset is 66; Horner et al., 2009). The younger age maybe due in part to the overrepresentation of breast cancer, which has a somewhat earlierage of onset (median age of onset is 61years; Horner et al., 2009). Thus, the conclusionsdrawn are limited in generalisability.

Findings from the reviewed studies were mixed, with some main effects reported forsleep, pain, physical and mental health, and healthcare utilisation. The sizes of thesignificant main effects varied widely, although the majority suggested a small tomoderate impact. This corroborates Frattarolis (2006) analysis of written and spokenemotional disclosure, as well as meta-analyses by Frisina, Borod, and Lepore (2004) whofound an overall effect size of .084 (d = .19) in nine clinical samples, and Smyth (1998)who found an overall effect size of .230 (d = .47) in 13 non-clinical samples. However, inthe present review there were few similarities in the designs of the six studies withsignificant benefits. All but one (Henry et al., 2010) had participants complete four EWsessions, although the time between sessions ranged widely. There was also greatvariability in prompts [emotional (deMoor et al., 2002; Mosher et al., 2012; Stanton et al.,2002; Rosenberg et al., 2002) vs. benefit-finding (Henry et al., 2010; Stanton et al., 2002)vs. different prompts (Gellaitry et al., 2010)] and controls [usual care (Gellaitry et al.,2010; Henry et al., 2010; Rosenberg et al., 2002) vs. neutral writing about trivial topics

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(Mosher et al., 2012), health behaviours (deMoor et al., 2002) or cancer facts (Stantonet al., 2002)], making it difficult to ascertain which aspects of EW are therapeutic, if any.

The implications of the demonstrated benefits of EW should also be consideredwithin the context of potential threats to the validity of these findings. Risk of biasesvaried across the studies in the current review, although several trends were observed. Ingeneral, there was little risk of biased findings due to selection, attrition or reporting bias.Among the studies with significant main effects, Henry et al. 2010) conferred the greatestamount of risk mainly because the matched groups design increased selection bias.

All EW studies carry a high risk of performance and detection biases. As part of theinformed consent process, experimenters warn participants about the risks and benefits ofthe study and that they may be asked to write about their emotional experience withcancer, which could be upsetting. Upon receiving instructions, participants become awareof which condition they were assigned to, potentially creating different emotional andbehavioural reactions between the groups. One consequence of performance anddetection biases is that individuals in the experimental condition may experience (i.e.,performance bias) or report (i.e., detection bias) improvements that are due to theirexpectations about EW, rather than the actual EW task. The highest risk for this is instudies where non-writing controls are used (e.g., usual care or attentional control; sixstudies in the current review), because allocation is more obvious than in studies thatemploy some type of neutral writing. Three of these non-writing control studies yieldedmain effects (Gellaitry et al., 2010; Henry et al., 2010; Rosenberg et al., 2002), which isnoteworthy given that these represent half of the studies in the review with significantresults of experimental condition.

Although performance and detection biases cannot be totally eliminated given thenature of the EW task, they can be attenuated by blinding study personnel to condition orto purpose/hypotheses during all parts of the study that require participant contact. Somestudies reported efforts within the early stages of a participants protocol [e.g.,interviewers in Rosenberg et al.s (2002) study were blind to condition before thebaseline assessment], during the intervention (Stanton et al., 2002) and during outcomeassessment (Cepeda et al., 2008; Mosher et al., 2012; Walker et al., 1999). However, itshould be noted that even in studies that did not report these efforts, contact betweenresearchers and participants was typically minimal after the instructions wereadministered.

A number of methodological issues should also be considered when appraising thequality of the evidence in the reviewed studies. Variability in the experimental and controlconditions may have impacted the findings. Most studies used a uniform EW promptacross administrations, although Gellaitry et al., (2010) used different prompts acrosssessions, and Jensen-Johansen et al. (2012) varied the instructions, threatening theconsistency (and thus the internal validity) of the study. Emotional, benefit-finding andmultiple-prompt writing instructions all elicited significant and null main effects across amyriad of outcomes. Control conditions also ranged from usual care, to receivingattention, to neutral writing about non-cancer topics, to cancer facts, which morestringently controls for mere exposure to cancer-related content. Thus, the mixed resultsproduced by the included studies may not be due entirely to EW being ineffective in thispopulation, but rather an artefact of comparing apples with oranges. The specific featuresof EW that are effective in cancer populations are clearly not well understood.

It is interesting that most EW protocols instructed participants to write expressivelyabout their cancer. Although it is reasonable to assume that a cancer diagnosis is the most

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central traumatic issue in ones life, this is not necessarily the case. For example, thestudy by Jensen-Johansen et al. (2012), which allowed participants to self-modify theexpressive writing topic, found no main effects for EW. However, chosen topic (cancervs. other) moderated the efficacy of EW, with each group reporting different benefits(Jensen-Johansen et al., 2012). This raises an interesting point: in healthy populations, forwhich EW effects have been greater, participants can write about any trauma; in cancer,researchers have generally tailored the prompt to be cancer specific. In doing so, thepossibility that some patients may be even more distressed by other issues in their livesmay have been overlooked. In allowing for a choice, Jensen-Johansen et al. (2012)provided the opportunity for participants to tailor the intervention, leading to improvedoutcomes for both topics. Such flexibility in clinical settings has also been generallyrecommended by Pennebaker (2010) who wrote, Encourage people to write about whatis bothering them, rather than what you think is bothering them (p. 24). Interestingly,Craft et al. (2013) also included a condition wherein patients were instructed to writeabout any trauma (the nature of the chosen topics was not reported; therefore, it isunknown whether any of these patients wrote about cancer) in addition to the cancertrauma EW group. All of the writing groups in Crafts study (i.e., emotional writing aboutcancer, emotional writing about any trauma, neutral writing about cancer) had an increasein quality of life from baseline to the first follow-up, whereas the usual care group didnot. However, when all four groups were compared against one another, the onlysignificant group difference that emerged was between those who wrote neutrally aboutcancer and those who received usual care and therefore did not write anything.

Threats to internal validity due to lower control in clinical studies are also relevant.Given the challenges of recruiting and retaining medical patients, location of settingsvaried (e.g., home and waiting rooms) and participants often completed writing sessionsover periods that were longer than the original recommendation of four consecutive days.The extent to which these differences influenced outcomes is unclear; however, it isimportant to recognise that the many differences between the clinic and highly controlledlaboratory settings may be important.

Differences in the timing of follow-up assessments should also be considered. In thestudy by deMoor et al. (2002), the first follow-up assessment was conducted immediatelyfollowing the intervention, which may have affected the pooled estimates of theoutcomes. People typically feel somewhat worse after EW (Pennebaker & Beall, 1986;Smyth, 1998); thus, the observed effects for EW on distress, stress and mood may havebeen diminished in this study. In addition, Cepeda et al. (2008) conducted the first threeassessments (out of eight) during the same weeks that patients engaged in EW. Althoughno main effects for EW on pain or quality of life emerged even by the eighth week of thestudy, it is possible that the immediacy of the first several follow-ups contaminated theoutcome measurements.

Another possibility is that the EW protocols (whether one session of writing ormultiple sessions) were considered single interventions. Health-promoting therapies arenot generally administered once and then expected to provide benefits into the futurewithout repetition. Perhaps EW should be considered a repeatable exercise, or part of alarger therapeutic programme that includes other components such as psychoeducationand group therapy, as was recently demonstrated in patients with colorectal cancer(Carmack et al., 2011).

A wide array of dependent variables was evaluated in the included studies, increasingthe possibility of chance findings. Also, p-value corrections were not typically applied,

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including in studies that evaluated a variety of outcomes from the same domain [e.g.,deMoor et al. (2002) evaluated 19 outcomes of stress, mood and sleep; and Craft et al.(2013) analysed the same quality of life variable in several ways with alphas set at .05].The reviewed studies included outcomes ranging from affect and cognitions, to sleep andpain, to disease markers and immune functioning. It seems that a kitchen sink ofoutcomes has been evaluated, rather than identifying key areas of change expected fromEW in the context of cancer.

Alternatively, the effectiveness of EW could be dependent upon individual differences(e.g., social constraints, alexithymia, avoidance, emotional support and time sincediagnosis) and thus the effects of the intervention may not be detectable until thesefeatures are partialed out. Several studies evaluated potential moderators to this end;however, more research on moderators is warranted as these findings were derived fromsingle studies, except those regarding social constraints.

Another potential explanation is that the effect size for EW is simply smaller forclinical samples as compared to healthy samples (Frisina et al., 2004). Perhaps clearreductions in pathology are more than should be expected from EW in the context of alife-altering and potentially life-ending disease. Even when EW did not elicit changes inthe presence or absence of symptoms, participant feedback was overwhelmingly positiveand patients generally reported appreciating the exercise. Researchers and clinicians maywant to consider the possibility that EW provides benefits that are more existential innature. Notably, one of the reviewed studies (Mosher et al., 2012) investigated thepossibility of existential gains using standardised self-report tools, without significantfindings. Nevertheless, there is merit in continuing to explore this possibility.

Use of written content

This review found that text analysis is used primarily as a manipulation check and isgreatly underused as a process variable within experimental trials of cancer patients. Thisis unfortunate given that linguistic information could enhance theoretical understandingof why EW works and for whom, within this population. Such information could alsoserve as an aid in decision-making with regard to intervention design (e.g., how manysessions to prescribe). For example, Walker et al. (1999) evaluated written content in theirsubstantive analyses, finding that emotional disclosure and present/future orientationwords increased from the first essay to the third. The authors concluded that the practicalimplication of this finding is that greater doses of EW in clinical settings encouragemore disclosure, although notably this did not elicit differences on the studied outcomes(Walker et al., 1999). The only study from the current review to investigate linguisticcharacteristics as a process variable found that greater disclosure (i.e., exposure to onesemotions) predicted reduced pain, suggesting that disclosure may be the key mechanismthrough which EW is effective (Cepeda et al., 2008). However, caution regarding thisfinding is warranted given the evidence for selective reporting bias in this study.

Other studies have analysed text in cancer studies with promising results. In a re-analysis of Stanton et al.s (2002) data, a greater number of negative emotion words wasassociated with fewer somatic symptoms, suggesting that the positive effects of EW arecontingent on habituation to an emotional reaction to cancer through the writing process(Low et al., 2006). That is, it may be necessary to expose the writer to their emotionsrelated to cancer, rather than the facts of the event itself, for EW to be effective (Lowet al., 2006). In a correlational study of women with metastatic breast cancer, Laccetti

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(2007) found that more positive words were associated with better emotional well-being.Smith et al. (2005) also found that greater negative emotion words predicted higheranxiety and depression after adjusting for baseline mood in a prepost study of newlydiagnosed breast cancer patients. In contrast, Morgan, Graves, Pogi, and Cheson (2008)found that while greater use of affect, positive emotion and anxious words correlated withbetter physical health-related quality of life in leukaemia and lymphoma patients, andusing more sad and anxious words correlated with poorer mental health-related quality oflife, the relationship was explained by pre-intervention quality of life.

Limitations of the review

There were several limitations to the current review. The search was limited topublications in English, thus excluding at least one relevant study [e.g., Park and Yi(2012) is published in Korean]. Further, because grey literature was excluded, the currentreview may not be fully inclusive of all research conducted on EW in cancer. The reviewwas unable to account for publication bias and the potential of incomplete reporting of allnull findings. In addition, a pooled quantitative analysis of the findings was notperformed given the diversity of study conditions and outcomes.

Future research

The extant literature limits the ability to draw definitive conclusions about EW as aneffective intervention for cancer patients. Given the heterogeneity of studies and results,further investigation is warranted, with specific recommendations. Recruitment ofpatients with other common cancers, men and ethnically diverse samples is encouragedto increase generalisability. It is also recommended that researchers adhere to Pennebakerand Bealls (1986) original design of using four writing administrations to enhancestandardisation within cancer samples and comparability to other EW literature, unlessthe question being asked warrants a variation (e.g., dosing). As much as possible,researchers are encouraged to blind personnel to study condition and study hypotheses, tomask the purpose of the study to participants, and to articulate these efforts in their finalpublications.

Researchers should build upon the strongest studies in the current review and designprotocols with respect to both basic and clinical research questions specific to cancer.Tasks should be designed to systematically explicate the components of writing that arepotentially efficacious (e.g., neutral writing about anything vs. neutral writing aboutcancer vs. emotional writing about cancer vs. benefit-finding about cancer vs. emotionalwriting about anything), and also explore the advantages and disadvantages of thesedifferent prompts. Text analysis should also be utilised to test and refine the explanatorymodels of the mechanisms underlying EW-based changes in cancer patients.

Moderators examined in the current review also need to be replicated, and possibleinteractions with gender (e.g., Range & Jenkins, 2010), personality (e.g., Zakowski et al.,2011) and other individual differences (e.g., type of cancer diagnosis, stage, treatment,age and education) should also be considered. It is also worth exploring whetherindividual differences may be used to maximise the effectiveness of EW interventions bymatching individuals with prompts. For example, Stanton et al. (2002) found that lowavoidance individuals benefit from the emotional prompt, whereas high avoidanceindividuals benefit from the benefit-finding prompt. Multiplicative interactions may alsobe important to consider given Zakowski et al.s (2003) finding that male cancer patients

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who are inhibited from expressing their emotions to their spouses suffer more problems inmood and intrusive thoughts than female cancer patients with similar levels of inhibition.This recommendation has both theoretical and practical advantages because furtheranalysis of moderators may enhance understanding of the fundamental bases of how EWworks within the context of cancer, and also may inform the identification of individualsin cancer clinics who may benefit from or be injured by EW.

More practical questions should focus on feasibility and effectiveness in clinicalsettings. Great efforts were taken in the current studies to encourage task compliance, butclinical researchers may want to design studies wherein these contingencies are not inplace to determine how viable EW is in real-world settings. It is also notable that therewas significant attrition among the pre-surgical patients in the study by deMoor et al.(2008), whereas there was less attrition in studies that enrolled patients at other points intheir cancer treatment. At least one other published study has also reported completionissues, with only two of the 24 participants in palliative care for advanced cancercompleting all four sessions (Bruera, Willey, Cohen, & Palmer, 2008). It is possible thatwriting during a trauma or immediately afterwards could cause more harm than good(Pennebaker, 2010), potentially explaining this high level of dropout. Thus, it may beworthwhile to determine whether there is an optimal time or condition for EWinterventions.

In addition, while symptomatology relevant to cancer patients (e.g., physical health,affect, mood and fatigue) should continue to be assessed in EW studies, qualitative anddescriptive outcome assessments should also be considered. Pennebaker and Beall (1986)suggested that EW improves physical health (e.g., number of illnesses and number ofdays one is restricted due to illness), which may be more relevant in healthy populations.For cancer patients, EW may have a less obvious effect on health; rather, it may providecomfort in other ways, such as with existential concerns, personal growth or meaning-making.

Finally, it is also recommended that researchers expand their use of text analysis. Inparticular, LIWC and trained judges (whenever possible, given time and cost constraints)are recommended. The LIWC program appears to have many potential benefits, includingdemonstrated sensitivity, convergent validity and discriminant validity for identifyingemotional expression in cancer patients (Bantum & Owen, 2009). It has also been used todemonstrate how cognitive and affective word choice in EW passages predicts quality oflife outcomes in cancer studies that did not meet the current reviews inclusion criteria.

Conclusions

Taken together, EW appears to be generally feasible for cancer patients, and there weresome positive outcomes. Given the current findings, a reliable recommendation cannot bemade, and healthcare providers should recognise that the evidence is not clear about thetherapeutic value of EW in cancer. There were generally no adverse consequences, withthe exception of increased sleep disturbance among patients who had been living withbreast cancer for more than 4.7 years (Low et al., 2010) and increased sleep medicationusage in breast cancer patients three days prior to surgery (although it is unknown whatthe mechanism for the uptake of these hypnotics was; deMoor et al., 2008). This isconsistent with other EW studies, suggesting that EW is likely safe to use with thispopulation, even if the measured gains are not remarkable (Baikie & Wilhelm, 2005).Many participants reported enjoying the intervention, and thus, for cancer patients who

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are interested in EW as a complementary health promotion/coping strategy, EW couldrepresent a simple, accessible, inexpensive exercise that may offer some relief.

AcknowledgementsWe are grateful to Linda C. Gallo, PhD for helpful comments on an earlier version of this paper. Wethank Scott C. Roesch, PhD and Sharon Danoff-Burg, PhD for providing additional guidance andclarification. We thank three anonymous reviewers for their constructive comments whichcontributed to improving the final version of this paper.

Supplemental materialSupplemental material for this article can be accessed here: http://dx.doi.org/10.1080/17437199.2014.882007

Notes1. Although including grey literature may attenuate publication bias, given that published studies

generally have larger treatment effects than unpublished studies (Hopewell, McDonald, Clarke,& Egger, 2007), grey literature can also introduce bias due to poorer methodological quality(Egger, Juni, Barlett, Holenstein, & Sterne, 2003) and comprehensiveness of locatable greyliterature (Sterne, Egger, & Moher, 2011). Given that reviews that include grey literature producesimilar results to those that do not (Egger et al., 2003), it was decided to restrict the search topublished findings.

2. The authors described the neutral writing condition as an experimental group; however, forconsistency across studies it was categorized as a control condition for the purpose of thisreview.

3. Jensen-Johansen and colleagues (2012) performed their manipulation check by evaluatingparticipants mood immediately following the EW intervention, rather than assessing thelinguistic characteristics of the essays.

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AbstractHow does expressive writing work?Written contentExpressive writing and cancerMethodsSearch strategyStudy selectionData extraction

ResultsStudy characteristicsEffects of expressive writing on physical and mental healthMeasurement of written contentRisk of bias within studies

DiscussionUse of written contentLimitations of the reviewFuture researchConclusions

AcknowledgementsSupplemental materialNotesReferences