Although activities such as journaling, diary keeping and self-expression have long been considered valuable for emotional health and personal creativity, should the oncology clinician be encouraging cancer patients to include this activity as a therapeutic strategy? Is it just a handy way to occupy oneself to prevent boredom? Does it actually do anything useful for patients? Is there an evidence base to support writing as a therapeutic activity?
At first glance, it may be tempting to consider writing as a simple activity that perhaps does not justify too much attention from health care workers, however, the benefits of writing have been investigated for decades and have produced noteworthy results.
History of expressive writing
Unstructured expressive writing has been researched by psychology since the 1980s. This approach asks individuals to choose a traumatic or upsetting experience, and, to write freely about their deepest thoughts and feelings (Pennebaker & Beall, 1986). The actual writing instructions have historically been quite general, whereby the participant can select the traumatic situation on which to focus. A typical example of an expressive writing prompt is shown below:
“…I would like you to write your very deepest thoughts and feelings about the most traumatic experience of your entire life or an extremely important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore your deepest emotions and thoughts. You might tie your topic to your relationships with others, including parents, lovers, friends or relatives; to your past, your present or your future; or to who you have been, who you would like to be or who you are now. You may write about the same general issues or experiences on all days of writing or about different topics each day. All of your writing will be completely confidential. Don’t worry about spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.” (Baike & Wilhelm, 2005, p. 338)
The original intervention, by created by Pennebaker and colleagues, involved four occasions of writing over four consecutive days, with sessions of approximately 20 minutes each (Pennebaker & Beall, 1986).
Benefits of expressive writing
Benefits of unstructured expressive writing have been broad and impressive, encompassing many physical, social and psychological areas of wellbeing (Baike & Wilhelm, 2005). In Pennebaker’s early studies with college students, he found evidence of improved grades, better health, and greater adjustment to college (Pennebaker, 1993); with benefits being maintained at the 4-month follow-up point (Pennebaker & Beall, 1986). Health-related benefits in a variety of contexts have been demonstrated, including objective measures such as improvement in blood pressure (Davidson, et al., 2002), liver function (Francis & Pennebaker, 1992), lung function (Smyth, 1998), and immune system functioning (Booth, Petrie, & Pennebaker, 1997; Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Petrie, Fontanilla, Thomas, Booth, & Pennebaker, 2004). Fewer days of hospitalisation have also been associated with expressive writing in female chronic pain populations, (Norman, Lumley, Dooley, & Diamond, 2004), as well as benefits in self-reported health outcomes, such as fewer visits to the doctor and physical symptoms (Cameron & Nicholls, 1998; Park & Blumberg, 2002). Effects of unstructured expressive writing upon physical symptoms and behavioural outcomes have been favourable, and understandably have been of interest for adoption by various settings as a patient intervention (Baike & Wilhelm, 2005).
Expressive writing in cancer populations
Increasingly the use of expressive writing is being evaluated in the field of psycho-oncology. A systematic review (Merz, Fox, & Malcarne, 2014) found 13 oncology expressive writing studies, with nine of these being breast cancer specific. The effectiveness of a single session home-based writing format has been studied with breast cancer survivors (Henry, Schlegel, Talley, Molix, & Bettencourt, 2010). A home based writing intervention has two advantages: first, to eliminate the need to travel for an intervention; and second, to provide a greater opportunity for comfort by writing in the privacy of one’s home. In the Henry study, participants were instructed to write in a single session without interruption for 20-30 minutes in a private place, using a modified Pennebaker prompt that focussed on positive outcomes of the participants’ cancer experience as below:
“What we would like you to do is write about any positive thoughts and feelings about your experience with breast cancer. We realise that women with breast cancer experience a full range of emotions, but we would like you to focus on some positive emotions, thoughts, and life changes that have come out of your experiences. For example, some women feel that they have gained important lessons out of their experience with cancer. In this writing exercise, we want you to try and write about any positive thoughts, experiences, and feelings that you have encountered over the course of your cancer, from the time you were diagnosed until now. You might also tie your positive thoughts and feelings about your experiences to other parts of your life – your childhood, people you love, who you are, or who you want to be. Ideally, we would like you to write without stopping for 20 minutes. If you run out of things to say, just repeat what you have already written until the 20 minutes are up. Don’t worry about grammar, spelling, or sentence structure. Don’t worry about erasing things or crossing things out, just write freely.” (Henry, Schlegel, Talley, Molix, & Bettencourt, 2010, p. 751)
Participants were monitored for improvements in physical health, depressive symptomatology and affect, at two time points (three and nine months), after completion of the writing activity. Henry and colleagues found that physical symptoms, depressive symptoms and overall mood were significantly improved in the experimental group at the 3-month point, compared to a control group who did not engage in a writing exercise. However, at the 9-month point both groups were the same, suggesting that benefits of the positively focussed single expressive writing session weakened somewhere between the 3-9 months post-writing. The reason for this drop-off in effect may be related to the need for more writing sessions to sustain benefits over time, or that the chronic nature of trauma in oncology (e.g. ongoing fears of reoccurrence), is different from a one-off traumatic or difficult event (such as having an accident). Henry and colleagues concluded that expressive writing at various time points during the cancer experience may be helpful to cope with the chronicity of the problems faced by breast cancer survivors.
Should therapeutic writing include self-compassion?
Historically, the traditional Pennebaker activity asks participants to write “randomly” according to the initial prompt, (Lu & Stanton, 2010). Although the prompt encourages emotional expression, it can be argued that the writer is left with little guidance in how to approach their writing topic, manage associated emotions, or process their distressing events in a therapeutic way. As such, expressive writing activities may benefit from refinement and improvement in structure to provide greater support for the writer.
Evidence indicates that approaches which combine emotional acceptance with derivation of new meaning may be particularly effective (North, Meyerson, Brown, & Holahan, 2012). Using such an approach, individuals are encouraged to have a willingness to experience all emotions without trying to change, avoid or control them (Hayes, 1994), while also deriving a new meaning, perspective or outlook from their negative experiences (Folkman, 2008). There is evidence that writing interventions which integrate acceptance and provide explicit permission to express difficult emotions, while also encouraging individuals to review their negative experiences, may be more effective than either strategy alone. It appears that both these aspects may be essential to decrease distress, and, facilitate a change in thinking (North, Meyerson, Brown, & Holahan, 2012). As such, conducting writing in the context of warmth, kindness and compassion, may further facilitate the effectiveness of this process.
Existing self-compassion based writing activities for general populations
A variety of different methods to undertake compassionate writing exist, including writing from the “compassionate part of self”, writing compassionately to someone else who they imagine is going through the same difficulties, or, writing a dialogue that they might imagine coming from their ideal compassionate image (Gilbert, 2009; Gilbert & Procter, 2006). As such, there are a variety of explanations, directions, and prompts available for participants who undertake compassion focused writing. An example of self-compassion based writing has been developed by Dr Kristen Neff using a three part format as part of her Mindful Self-Compassion (MSC) group intervention, as shown below:
Part One: Which imperfections make you feel inadequate?
Everybody has something about themselves that they don’t like; something that causes them to feel shame, to feel insecure, or not “good enough.” It is the human condition to be imperfect, and feelings of failure and inadequacy are part of the experience of living a human life. Try writing about an issue you have that tends to make you feel inadequate or bad about yourself (physical appearance, work or relationship issues…) What emotions come up for you when you think about this aspect of yourself? Try to just feel your emotions exactly as they are – no more, no less – and then write about them.
Part Two: Write a letter to yourself from the perspective of an unconditionally loving imaginary friend
Now think about an imaginary friend who is unconditionally loving, accepting, kind and compassionate. Imagine that this friend can see all your strengths and all your weaknesses, including the aspect of yourself you have just been writing about. Reflect upon what this friend feels towards you, and how you are loved and accepted exactly as you are, with all your very human imperfections. This friend recognizes the limits of human nature, and is kind and forgiving towards you. In his/her great wisdom this friend understands your life history and the millions of things that have happened in your life to create you as you are in this moment. Your particular inadequacy is connected to so many things you didn’t necessarily choose: your genes, your family history, life circumstances – things that were outside of your control.
Write a letter to yourself from the perspective of this imaginary friend – focusing on the perceived inadequacy you tend to judge yourself for. What would this friend say to you about your “flaw” from the perspective of unlimited compassion? How would this friend convey the deep compassion he/she feels for you, especially for the pain you feel when you judge yourself so harshly? What would this friend write in order to remind you that you are only human, that all people have both strengths and weaknesses? And if you think this friend would suggest possible changes you should make, how would these suggestions embody feelings of unconditional understanding and compassion? As you write to yourself from the perspective of this imaginary friend, try to infuse your letter with a strong sense of his/her acceptance, kindness, caring, and desire for your health and happiness.
Part Three: Feel the compassion as it soothes and comforts you
After writing the letter, put it down for a little while. Then come back and read it again, really letting the words sink in. Feel the compassion as it pours into you, soothing and comforting you like a cool breeze on a hot day. Love, connection and acceptance are your birthright. To claim them you need only look within yourself.
Emergence of self-compassion based writing for oncology populations
Self-compassionate writing adapted for the oncology patient is in its early days, and, evidence for this intervention is still emerging. However, potential applications with a variety of issues are being investigated. Self-compassion based writing is being included as a component in supporting parents of children with cancer to decrease stress and enhance adaptation (Cernvall, Calbring, Ljungman & Von Essen, 2013) https://www.tandfonline.com/doi/full/10.1080/07347332.2012.741095. Self-compassion based writing is also being developed as an intervention to assist with body image difficulties after treatment for breast cancer (Przezdziecki, Alcorso & Sherman, 2016), and, is showing effectiveness in decreasing psychological distress (Sherman et al. 2018).
The take home message
Therapeutic writing does have a scientific evidence base, and, has shown benefits for both general and oncology populations. It is a low cost, easy to administer intervention that does not demand intense use of clinical resources. Furthermore, research suggests that addition of self-compassion based approaches may further enhance its effectiveness.
Tips for the clinician
- Writing can assist with expression, meaning making and reframing past experiences.
- Discuss the benefits of self-expression, through writing, with your patients. This approach may be of particular interest to individuals who are creative, or, who wish to undertake self-help activities in the home environment.
- Therapeutic writing can take many forms, and can include diary keeping, journaling, formal structured writing activities, or, blogs especially designed for survivors to write about their experiences, (for example, https://www.cancer.net/blog/2017-06/3-tips-writing-about-your-cancer-experience).
- For cancer patients who wish to leave a written legacy for their families, there are services that can assist in putting together books using the individual’s words and pictures, http://www.itsaboutus.com.au/ . Such activities can have a profound impact, and, provide longstanding benefits for family and friends (e.g. https://www.ted.com/talks/lakshmi_pratury_on_letter_writing)
- For individuals with literacy challenges, an alternative may be to keep an audio or video diary
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