Expressive writing, such as journaling, involves writing about one’s deepest thoughts and feelings, often regarding stressful or traumatic experiences. This emotional disclosure process may help individuals process and make sense of their experiences, leading to reduced feelings of anxiety.
While some studies suggest immediate benefits, others indicate that the positive effects on anxiety may emerge after a delay, suggesting that expressive writing could potentially provide both short-term and long-term relief from anxiety symptoms.
Guo, L. (2023). The delayed, durable effect of expressive writing on depression, anxiety and stress: A meta‐analytic review of studies with long‐term follow‐ups. British Journal of Clinical Psychology, 62(1), 272-297. https://doi.org/10.1111/bjc.12408
Key Points
- Expressive writing had an overall small but significant effect (Hedges’ g = −0.12) on reducing symptoms of depression, anxiety and stress in healthy and subclinical samples.
- The intervention effect emerged after a delay, as evidenced by assessments at follow-up periods rather than immediately post-intervention.
- Studies that implemented short intervals (1–3 days) between writing sessions yielded stronger effects compared to medium (4-7 days) or long intervals (>7 days).
- The effects were consistent across other intervention features like focus, instructions, number of sessions, topic repetition, and delivery mode.
Rationale
Expressive writing, which involves expressing one’s deepest thoughts and feelings about emotionally-charged events, is a promising intervention for healing psychological wounds (White & Epston, 1990; Smyth & Pennebaker, 2008).
However, its efficacy has not been firmly established, with some meta-analyses finding benefits (Frattaroli, 2006; Frisina et al., 2004; Pavlacic et al., 2019; Travagin et al., 2015) and others reporting no improvement in psychological outcomes (Meads & Nouwen, 2005; Reinhold et al., 2018).
There is also a lack of clarity on the boundary conditions influencing the effectiveness of expressive writing, especially for prevalent psychological symptoms like depression, anxiety, and stress. Examining this has implications for emotionally vulnerable and at-risk individuals.
Additionally, recent studies modifying the standard expressive writing protocol necessitate an updated systematic review and meta-analysis to determine the significance, strength, and moderators of expressive writing’s effects.
A meta-analysis can summarize diverse findings, overcome the limitations of small sample sizes, and identify variables contributing to variations between studies (Lipsey & Wilson, 2001).
Therefore, this meta-analysis aimed to examine the direction, magnitude, and moderators of expressive writing’s effects on depression, anxiety, and stress symptoms.
Method
The meta-analysis included thirty-one randomized controlled trials (N = 4012) examining expressive writing’s effects on depression, anxiety, and stress symptoms in healthy and subclinical samples were included. Studies required at least one follow-up assessment.
Data were extracted on study characteristics, sample demographics, intervention features, and outcome measures. Effect sizes were calculated using Hedges’ g.
Random-effects models were used to compute overall effect sizes and moderator analyses were conducted for intervention features such as writing focus, instructions, number and spacing of sessions, topic repetition, and delivery mode. Risk of bias and publication bias were assessed.
Results
The meta-analysis found 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 in healthy and subclinical samples.
Change score analyses indicated that the intervention effect emerged after a delay, as evidenced by significant effects at follow-up assessments but not immediately post-intervention.
Moderator analyses revealed that the interval between writing sessions significantly influenced the effect sizes.
Studies with short intervals (1–3 days) between sessions yielded stronger effects (Gdiff = −0.18, p = .01) compared to studies with medium intervals (4–7 days) or long intervals (>7 days).
The effects of expressive writing did not significantly differ across other examined intervention features, including the writing focus, instructions provided, number of sessions, topic repetition across sessions, and delivery mode (handwritten vs typed).
Together, these findings provide meta-analytic evidence for a delayed yet durable beneficial effect of expressive writing on depression, anxiety and stress symptoms. The results underscore the importance of scheduling expressive writing sessions at short intervals of 1-3 days for optimal effectiveness.
The consistency of effects across most intervention features suggests expressive writing is a robust and flexible intervention.
Insight
This meta-analysis provides compelling evidence that expressive writing is a beneficial intervention for reducing symptoms of depression, anxiety, and stress, with effects that emerge sometime after the intervention rather than immediately.
This delayed effect is intriguing and suggests that expressive writing may initiate a gradual process of emotional processing and meaning-making that reduces distress over time. The finding that spacing writing sessions 1-3 days apart strengthens the effects is a valuable insight for designing maximally effective expressive writing interventions.
Notably, the benefits of expressive writing were consistent regardless of the specific writing instructions, number of sessions, topic repetition, and writing medium. This suggests expressive writing is a flexible intervention that can be adapted to individual preferences while still maintaining its therapeutic effects.
However, questions remain about the mechanisms underlying expressive writing’s benefits and its boundary conditions.
Future research could further examine factors like writing skill, use of emotion words, narrative structure, and participant motivation as potential moderators. Studies should also test expressive writing in clinical samples and as an adjunct to other therapies.
Overall, this meta-analysis positions expressive writing as an evidence-based intervention that can be widely implemented in clinical practice and as a self-help tool.
Its simplicity, flexibility, and durability of effects make expressive writing a highly promising intervention for promoting mental health. More research is still needed to optimize its delivery and uncover its mechanisms of action.
Strengths
This study had several strengths:
- Focused specifically on symptoms of depression, anxiety and stress
- Included only randomized controlled trials with follow-up assessments
- Analyzed a large total sample size (N=4012)
- Conducted moderator analyses on multiple intervention features
- Provides clear recommendations for optimal interval between sessions
Limitations
However, there were also some limitations with this study:
- Included only healthy and subclinical samples, limiting generalizability to clinical populations
- Did not examine measures of writing content or skill as potential moderators
- Some moderator analyses may have been underpowered due to categorizing continuous variables
- Potential bias from unmeasured moderators like participant expectations and motivation
- Unable to make strong causal claims due to lack of temporal precedence and third variable concerns
Implications
- Expressive writing is an effective intervention for reducing depression, anxiety and stress symptoms, with small but durable effects.
- Expressive writing sessions are optimally spaced 1-3 days apart rather than at longer intervals.
- Expressive writing is a flexible intervention that is effective across variations in writing instructions, dosage, topic repetition, and medium.
- Expressive writing may be incorporated into therapeutic practices as a homework exercise or used as a self-administered intervention.
- The delayed emergence of effects suggests expressive writing initiates a gradual process of adaptive emotional processing and coping.
- More research is needed in clinical samples and to uncover expressive writing’s mechanisms of action.
References
Primary reference
Guo, L. (2023). The delayed, durable effect of expressive writing on depression, anxiety and stress: A meta‐analytic review of studies with long‐term follow‐ups. British Journal of Clinical Psychology, 62(1), 272-297. https://doi.org/10.1111/bjc.12408
Other references
Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin, 132(6), 823–865. https://doi.org/10.1037/0033-2909.132.6.823
Frisina, P. G., Borod, J. C., & Lepore, S. J. (2004). A meta-analysis of the effects of written emotional disclosure on the health outcomes of clinical populations. The Journal of Nervous and Mental Disease, 192(9), 629–634. https://doi.org/10.1097/01.nmd.0000138317.30764.63
Lipsey, M. W., & Wilson, D. (2001). Practical meta-analysis. Sage.
Meads, C., & Nouwen, A. (2005). Does emotional disclosure have any effects? A systematic review of the literature with meta-analyses. International Journal of Technology Assessment in Health Care, 21(2), 153–164. https://doi.org/10.1017/S026646230505021X
Pavlacic, J. M., Buchanan, E. M., Maxwell, N. P., Hopke, T. G., & Schulenberg, S. E. (2019). A meta-analysis of expressive writing on posttraumatic stress, posttraumatic growth, and quality of life. Review of General Psychology, 23(2), 230–250. https://doi.org/10.1177/1089268019831645
Smyth, J. M., & Pennebaker, J. W. (2008). Exploring the boundary conditions of expressive writing: In search of the right recipe. British Journal of Health Psychology, 13(1), 1–7. https://doi.org/10.1348/135910707X260117
Travagin, G., Margola, D., & Revenson, T. A. (2015). How effective are expressive writing interventions for adolescents? A meta-analytic review. Clinical Psychology Review, 36, 42–55. https://doi.org/10.1016/j.cpr.2015.01.003
White, M., & Epston, D. (1990). Narrative means to therapeutic ends ( 1st ed.). Norton.
Keep Learning
Here are some reflective questions related to this study that could prompt further discussion:
- What psychological theories or frameworks might explain why expressive writing reduces distress? What are the “active ingredients”?
- How might you design a study to uncover the mechanisms driving expressive writing’s effects? What mediating variables would you examine?
- What populations or mental health conditions do you think expressive writing could be most beneficial for? How would you adapt the intervention for these groups?
- How would you scale up expressive writing to be widely accessible as a public health intervention? What barriers need to be addressed?
- Do you think expressive writing could have any negative effects for certain people? How would you identify and mitigate these risks?
