Cancer is a top leading cause of death in the world. A person that had been diagnosed with cancer will eventually develop a negative emotion. It is important for cancer patients to have a positive emotion, as they need to have the motivation to survive. Positive emotion helps them to go through the treatment and continue with their life despite the difficult situation. Thus, as a nurse, what could we do to help them develop the positive emotion?
Putting your negative thoughts into writing has been found to improve physical and mental health. According to Pennebaker (1986), expressive writing (EW) is a therapeutic method that is designed to aid in working through traumatic life experiences. The EW paradigm is designed to help the writer to organize their thoughts. Typically, the participants will be instructed to briefly write about their deepest thoughts and feelings regarding the experience for 20 minutes on four occasions.
As a student nurse and a novice researcher, my main concern is on how to help cancer patients to change their negative emotion into a positive emotion. Therefore, I had collected some literature related to EW implementation in cancer patients. There is various literature that supports the benefit of EW and some are not. Thus, I am going to review some of this literature to determine if there is any benefit of EW in helping a cancer patient.
To begin with, the purpose of this literature review is to investigate previous research and find out what has been done before regarding EW for a cancer patient. There are few articles that agree and disagree on this matter. Let us take a closer look at each category.
Getting closer to our main sample, cancer patients, there are many of the articles that focused on breast cancer patients. EW has been shown to improve the quality of life among breast cancer patients. Gripsrud et al. (2016) did a research with the aim to explore and describe the experience and feasibility of expressive writing among women with breast cancer following mastectomy. The enrollment criteria are women diagnosed with breast cancer and had a mastectomy, aged 18 and older, and who read and wrote English. Seven participants enrolled to undertake 4 episodes of expressive writing at home, with semi-structured interviews conducted afterward.
Through this longitudinal study, three themes of writing have emerged: writing as a process, writing as therapeutic, and writing as a means to help others. Despite going through a difficult situation, the participants still have the thought of motivating others through writing. They were performing for an imagined readership of breast cancer women, suggesting a wish to contribute to peer-support, in which the newly diagnosed woman can seek out and benefit from the narrative wisdom of the veteran patients.
Therefore, Gripsurd et al. (2016), found that EW is a strong evidence-based intervention, not only from the perspective of measurable outcomes but also from the patients’ own perspectives’
In breast cancer case, there is a limitation in this study whereby the sample population is only focused on women. Therefore, Milbury et al. (2014) conducted a randomized controlled trial (RCT) with a longer follow-up period to evaluated the benefits of EW in a non–sex-specific cancer, renal cell carcinoma (RCC). The trial was conducted at MD Anderson Cancer Center (MDACC) between 2006 and 2009. Criteria for participants in this study are newly diagnosed patients with stage I to IV renal cell carcinoma, a Zubrod performance status of ? 2, and no serious intercurrent medical illness requiring hospitalization and who were at least 18 years old and able to read, write, and speak English. After providing consent letter, participants in the EW group were asked to write about their deepest emotions and thoughts regarding their cancer experience with slightly different topics at each session. They were asked to complete four 20-minute writing assignments in their home over a 10-day period, with at least 1 day and no more than 3 days between sessions. A research assistant will give them a phone call on when to begin and stop writing. Participants were provided with envelopes for mailing each writing sample as soon as it was completed.
After the data analysis, this RCT found that EW is a safe, brief, and cost-effective therapeutic approach that may improve cancer-related symptoms and physical functioning, with benefits emerging 10 months after EW.
Until this point, we have found that EW has a benefit for a cancer patient. However, there is some limitation for those study above, both of them were conducted in the United States, whereby the participants are fluent in English. Little attention has been focused on Asian American breast cancer survivor’s psychological needs. Thus, this pilot study aimed to test the cultural sensitivity, feasibility, and potential health benefits of an expressive writing intervention among Chinese-speaking breast cancer survivors (Lu, Zheng, Young, Kagawa-Singer, & Loh, 2012).
To summarize, this pilot study showed that Asian cancer survivors experience increased benefits from expressive writing. Expressive writing interventions may have the potential to be utilized by other populations with limited English fluency and cultural backgrounds that differ from non-Hispanic white groups.
Baikie & Wilhelm (2005) tried to apply EW in psychiatric treatment. They found that there is immediate impact where there will be a short-term increase distress and negative mood. However, at longer-term follow-up, many studies have continued to find evidence of health benefits in terms of objectively assessed outcomes, self-reported physical health outcomes (such as fewer stress-related visits to the doctor, and reduced depressive symptoms before examinations) and self-reported emotional health outcomes. Although they believed that there are benefits in EW, Baikie and Wilhelm stated that EW should not replace appropriate medical or psychological treatment in clinical populations; it should be used as an adjunct to standard treatment while further research is being conducted.
Move on to this randomized trial, whereby women with metastatic breast cancer and significant psychological distress were assigned randomly to engage in four home-based sessions of expressive writing (EW) or neutral writing (NW). Women in the EW group wrote about their deepest thoughts and feelings regarding their cancer, whereas women in the NW group wrote about their daily activities (Mosher et al., 2012).
In this trial, EW did not result in better existential and psychological well-being, reduced fatigue, or enhanced sleep quality as compared to neutral writing. However, there are some limitations in this trial that should be noted, such as findings cannot be generalized to men, diverse ethnic & socioeconomic backgrounds, unable to detect small effect sizes due to limited power, and also it relied on self-reported outcome measures at 1 follow-up assessment. Administering self-reported health assessments over a longer period of time would provide a more comprehensive evaluation of expressive writing’s health effects.
In conclusion, my final summary of this review is that expressive writing indeed plays a role in helping cancer patients to improve their emotional health. With a positive emotion, they could help themselves to improve their physical and psychosocial health, in addition to that, they could also share their thought with the other newly diagnosed patient about their experienced. Hence expressive writing does not only benefit the writer itself, it also benefits other patients. Furthermore, it is a valuable tool for healthcare providers, including nurses, to introduce the patient to the plan of care for cancer patient groups. However, EW required a good cooperation from the patient and also enough power from the research group and enough observation time to analyze the data findings.
In addition to this review, I and my research group would like to propose a study regarding expressive writing for a cancer patient in Singapore. The purpose of our study is to determine if there is any benefit of EW in the cancer patient. Participants criteria for our study are patient with any type of cancer in stage 2-3, not suffering any psychiatric disorder, able to communicate and write English and at least 21 years old. Regarding patient’s safety, before we start our study we will obtain a consent form. This study will be a combination of qualitative and quantitative study. Our plan for study methods are:
1. Each participant will initially have 1 round of interviews to establish their baseline mental and emotional state.
2. Participants will then write down their emotions and feelings once a week for 20 minutes. The written document will be taken for analysis. the study will run for 4 weeks. All written emotions by patients are confidential, and will not be shared with any healthcare organization or worker without the consent of the participant or if it is deemed necessary to ensure the patient’s safety.
3. At the end of the study, the participants will have another round of interviews to find out if there have been any changes to their mental state. Follow-up interviews at 6 months and 12 months after last writing.
To sum it all, as a student nurse, expressive writing is a good and effective therapeutic approach that may help a cancer patient. However, most of the RCT that has been published was conducted in the USA. As a novice researcher, it would be interesting to conduct a study in this field in Singapore, to observe if there is any benefit in expressive writing.