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The durability of beneficial health

effects associated with expressive
writing
Denise M. Sloan

a b

, Brian A. Feinstein & Brian P. Marx

a b

National Center for PTSD, VA Boston Healthcare Systems , 150 S.

Huntington Ave, Boston, MA, 02130, USA
b

Department of Psychiatry , Boston University School of

Medicine , 85 E. Newton Street, Boston, MA, 02118, USA
Published online: 24 Aug 2009.

To cite this article: Denise M. Sloan , Brian A. Feinstein & Brian P. Marx (2009) The durability
of beneficial health effects associated with expressive writing, Anxiety, Stress, & Coping: An
International Journal, 22:5, 509-523, DOI: 10.1080/10615800902785608
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Anxiety, Stress, & Coping

Vol. 22, No. 5, October 2009, 509
523

The durability of beneficial health effects associated with expressive

writing
Denise M. Sloana,b*, Brian A. Feinsteina and Brian P. Marxa,b
a

National Center for PTSD, VA Boston Healthcare Systems, 150 S. Huntington Ave, Boston,
MA 02130, USA; bDepartment of Psychiatry, Boston University School of Medicine,
85 E. Newton Street, Boston, MA 02118, USA

Downloaded by [New York University] at 08:13 24 April 2015

(Received 12 November 2008; final version received 29 January 2009)

This study examined the durability of benefits associated with expressive writing.
Sixty-eight college undergraduates completed measures of physical and psychological health at the beginning of their first year and were then randomized to
either an expressive writing or a control writing condition. Changes in physical
health, psychological health (i.e., depression, stress, and anxiety), and academic
performance were assessed two, four, and six months later. Findings indicated
that participants assigned to the expressive writing condition reported less
depression symptom severity at the two-month follow-up assessment relative to
participants assigned to the control condition. However, these symptom reductions were not observed at any of the subsequent follow-up assessments. No
significant changes were reported for physical health complaints, stress symptoms, anxiety symptoms, or academic performance. These findings suggest that,
among first-year college students, expressive writing may provide some shortterm relief for certain symptoms.
Keywords: expressive writing; written disclosure; stress; anxiety; depression;
physical health

Over the past 20 years, a great deal of research has been conducted examining the
beneficial effects associated with expressive writing (also referred to as written
emotional disclosure). The expressive writing procedure typically requires participants to write for at least 20 minutes about a traumatic or stressful event that they
experienced, incorporating both descriptive and emotional information, on 3
5
consecutive days. The initial beneficial health findings associated with expressive
writing reported by Pennebaker and Beall (1986) have been subsequently replicated
using a variety of populations, with college students representing the sample
most frequently examined (e.g., Greenberg, Wortman, & Stone, 1996; King, 2001;
King & Miner, 2000; Klein & Boals, 2001; Lumley & Provenzano, 2003;
Pennebaker & Francis, 1996; Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Sheese,
Brown, & Granziano, 2004; Sloan & Marx, 2004a; Sloan, Marx, Epstein, &
Lexington, 2007; Ullrich & Lutgendorf, 2002). Although several studies have not
found expressive writing to be associated with health benefits (e.g., Kloss &
Lisman, 2002; see also meta-analysis by Meads & Nouwen, 2005), results from
*Corresponding author. Email: dsloan@bu.edu
ISSN 1061-5806 print/1477-2205 online
This work was authored as part of Contributors official duties as an employee of the United States Government and is
therefore a work of the United States Government. In accordance with 17 U.S.C. 105 no copyright protection is available
for such works under U.S. law.
DOI: 10.1080/10615800902785608
http://www.informaworld.com

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D.M. Sloan et al.

several meta-analyses have reported that, overall, expressive writing is associated

with psychological and physical health benefits (Frattaroli, 2006; Frisina, Borod, &
Lepore, 2004; Smyth, 1998), with weighted mean overall effect sizes (d) ranging
from .13 to .47.
Although there has been a great deal of research investigating the benefits of
expressive writing, the durability of these benefits remains unclear. Expressive
writing studies have most often included only one follow-up assessment (e.g.,
Epstein, Sloan, & Marx, 2005; King, 2001; Park & Blumberg, 2002; Pennebaker &
Francis, 1996; Sloan & Marx, 2004a; Sloan et al., 2007; Ullrich & Lutgendorf,
2002) and the handful of studies that have assessed participants repeatedly over
time have typically collapsed the data into a single composite follow-up score (e.g.,
Greenberg et al., 1996; Sheese et al., 2004). For instance, Sheese and colleagues
(2004) conducted follow-up assessments once a week over a five-week period.
These investigators then averaged the weekly assessments to produce composite
scores that were used in their outcome analyses. Similarly, Greenberg et al. (1996)
conducted follow-up assessments once a week over a four-week period and then
used an average score (average of the four assessments) in the outcome analyses.
Other studies have included multiple assessment points but have focused their
outcome analysis on just one of the follow-up assessments (e.g., Broderick,
Junghaenel, & Schwartz, 2005; Smyth, Stone, Hurewitz, & Kaell, 1999). In using
both approaches it is not possible to determine whether beneficial outcome
associated with expressive writing is sustained. Alternatively, some outcome effects
may require a longer duration of time to be observed. If a study only includes one,
relatively short follow-up assessment, the beneficial outcome may be missed. An
example of such a scenario was reported by Smyth and colleagues (1999). These
investigators examined the effects of expressive writing on rheumatoid arthritis
symptoms. Although these investigators assessed differences in outcome at two
weeks, two months, and four months, results showed a significant difference only
at the four-month follow-up interval.
Frattaroli (2006) examined whether time to follow-up moderated the effects of
expressive writing outcome in her meta-analysis of disclosure studies. Results
revealed that time to follow-up significantly moderated psychological health
outcomes, with studies including a shorter follow-up assessment period having
larger effect sizes than studies that included a longer follow-up assessment period. In
contrast, a significant moderation effect was not observed for self-reported physical
health outcomes or academic performance outcomes. These findings suggest the
possibility that, although the psychological health benefits derived from expressive
writing may be short lived, the physical health benefits and improvements in
academic performance may be longer lasting.
Although Frattarolis results are informative, they may not provide an adequate
understanding of the durability of the expressive writing effects simply because
a direct examination of the durability of outcomes associated with expressive
writing using multiple follow-up assessments and outcome measures has not
been conducted. Frattarolis meta-analytic findings were obtained by comparing
studies with varying methodologies (e.g., participant sample, outcome measures,
time to follow-up assessment). In order to adequately examine durability of

Anxiety, Stress, & Coping

511

benefits associated with expressive writing, direct investigation of this question

is needed.

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Specific aims of the present study

The current study directly examined the durability of benefits derived from
expressive writing by including two, four, and six-month follow-up assessments. As
prior research has suggested that durability of health benefits associated with
expressive writing may differ by the type of health outcome measure, we also
investigated whether durability differed across various domains of functioning (i.e.,
psychological health, physical health, and academic performance).
Participants in this study were individuals who were beginning college. We elected
to investigate this group of individuals because transition to college is generally
regarded as a stressful period for young adults (e.g., Dyson & Renk, 2006), and other
studies have suggested that expressive writing might be helpful under such
circumstances (e.g., Cameron & Nicholls, 1998; Lumley & Provenzano, 2003;
Pennebaker & Francis, 1996). As noted earlier, there is limited information in the
literature with regard to durability of benefits associated with expressive writing
given that the majority of studies have examined only one follow-up assessment.
Thus, we based our predictions for this study largely on Frattarolis (2006) metaanalysis. We predicted that participants assigned to the expressive writing condition
would show benefits in psychological health, physical health, and academic
performance at the first (two months, first semester grade point average (GPA))
follow-up assessment compared with participants assigned to the control writing
condition. Given that we expected psychological health benefits associated with
expressive writing would be short lived, we did not expect to observe psychological
health benefits for expressive writing participants at the four and six-month followup assessments. However, improvements in health and academic performance at later
follow-up assessments were expected.
Method
Participants
During a summer student orientation fair, incoming first-year students enrolled at a
university in the northeast region of the USA were asked to provide their names and
contact information, if they were interested in potentially volunteering for a
research study examining the effects of writing on academic performance.
Individuals who provided their contact information were informed that they
would be contacted at the beginning of the fall semester to see if they were still
interested in participating and, if so, arrangements for participation would be made
at that time.
Potential participants were contacted during the first two weeks of the fall
semester and asked to volunteer for the study in exchange for financial compensation
($5 per session). The only inclusion criterion for this study was that participants
needed to be first-year university students. Among first-year university students,
there were no exclusion criteria. Participants entered the study between the third and
sixth weeks of the fall (i.e., beginning) semester. These participants were randomly

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D.M. Sloan et al.

assigned to either an expressive writing condition or a control writing condition

using a computerized random number generator. A stratified randomization
procedure was used so that the two conditions would be balanced for gender.
Experimenters were aware (i.e., not blind) to condition assignment, but participants
were blind to condition assignment. That is, participants were unaware that there
was more than one condition in the study. The study was approved by the university
Institutional Review Board.
Of the 69 students (45 females) who entered the study, one dropped out after
the first writing session (expressive writing condition), three failed to return for the
two-month follow-up assessment (two from the expressive writing condition), three
failed to return for the four-month follow-up assessment (two from the expressive
writing condition), and five participants failed to return for the six-month follow-up
assessment (two from the expressive writing condition). In total, 12 students dropped
out of the study before the final follow-up assessment with seven (four females)
participants assigned to the expressive writing condition and five (four females)
assigned to the control condition, resulting in an 83% retention rate. Chi-square
(racial background, gender) and t-test (age, baseline outcome measures) analyses
indicated that participants who dropped out of the study did not significantly differ
from participants who completed the study (largest p
.40). The data for the
68 students who completed all of the writing sessions are used for the analyses
reported here. Demographic and academic characteristics of the sample as a function
of condition are shown in Table 1.
Consistent with other studies that have allowed expressive writing participants to
select the writing topic (Epstein et al., 2005; Park & Blumberg, 2002; Sloan & Marx,
2004a), there was considerable range in the types of events that participants elected
to write about. Most participants wrote about either an assault (24%) or an illness or
injury to themselves or a family member (24%). Others wrote about the end of a
close relationship (16%), a family conflict (12%), the death of a close friend or family
member (12%), or another stressful life event (10%). Although all of the participants
were starting their first-year in college, only 2% of the expressive writing participants
wrote about their transition to college.
Table 1. Demographic and academic characteristics as a function of condition.
Expressive writing condition
(n 35)

Control writing condition

(n33)

Age (in years)

Female (n)

18.8 (.6)
20

19.0 (.4)
17

Ethnicity (n)
White
African American
Other

20
10
5

19
9
5

Variable

Overall SAT score

Credits completed in fall
Credits earned in spring

1034.7 (101.4)
13.2 (3.2)
13.6 (3.6)

Note: Standard deviations are in parentheses.

1051.8 (110.8)
12.8 (3.1)
13.8 (3.6)

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Measures
Depression, Anxiety, and Stress Scale
21 item (DASS21; Lovibond & Lovibond,
1995)
The Depression, Anxiety, and Stress Scale (DASS) is a 21-item questionnaire
consisting of items relating to depression, hyperarousal, and stress. A Likert-type
scale is used to rate items according to symptoms experienced in the past week,
ranging from zero (not at all) to three (most of the time). Factor analytic studies with
both clinical and non-clinical samples have shown that the DASS21 items can be
reliably grouped into three scales: depression, anxiety, and stress (Antony, Bieling,
Cox, Enns, & Swinson, 1998) and that the measure differentiates between symptoms
of anxiety and depression, as well as between symptoms of physical arousal and
symptoms of generalized anxiety (e.g., tension; Antony et al., 1998). The depression
subscale is composed of items that measure symptoms associated with depressed
mood (e.g., sadness, worthlessness), and the anxiety subscale includes items that are
related to symptoms of physical arousal, panic attacks, and fear (e.g., trembling,
faintness). Items that measure symptoms, such as tension, irritability, and tendency
to overreact to stressful events comprise the stress subscale. Examples of items from
the depression subscale include, I felt I had nothing to look forward to and I felt
down-hearted and blue. Examples of items from the anxiety subscale include,
I experience trembling and I felt scared without any good reason. Examples of
items from the stress subscale include, I found it hard to relax and I felt that
I was using a lot of nervous energy.
The DASS21 depression subscale has been shown to provide a better separation
of the features of anxiety and depression than other existing measures of depression
and anxiety (Antony et al., 1998; Brown, Chorpita, Korotitsch, & Barlow, 1997;
Lovibond & Lovibond, 1995). Two-week retest reliabilities for the DASS21 subscales
were found to be relatively high at .71, .78, and .81, for the depression, anxiety, and
stress scales, respectively (Antony et al., 1998). In this study, Cronbachs alphas for
the baseline administration of the depression, anxiety, and stress subscales were .94,
.89, and .93, respectively. These internal consistency values are similar to those
reported by Antony and colleagues (1998).
The DASS21 was included in this study because of its strong psychometric
properties and ability to assess several areas of psychological functioning. The
DASS21 has also been used in other expressive writing studies to examine outcome in
psychological functioning (e.g., Epstein et al., 2005).
Pennebaker inventory of limbic languidness (PILL; Pennebaker, 1982)
The Pennebaker inventory of limbic languidness (PILL) is a 54-item self-report
measure that indexes the frequency of a group of common physical symptoms and
sensations. Examples of items from the PILL include, sore throat, congested
nose, upset stomach, heartburn or gas, and chills. Cronbachs alphas range
from .88 to .91 and two-month test-retest reliability ranges from .79 to .83.
Cronbachs alpha in this study was .86 for the baseline administration of the PILL.
Research indicates that high scores on the PILL are significantly associated with
a greater frequency of health center visits and a greater number of days sick and/or
work related absences (Pennebaker, 1982). The PILL is scored by summing the total

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D.M. Sloan et al.

number of items on which the frequency occurs at least every month. The mean score
on the PILL is 17.9 (SD 4.5) based on a college sample (Pennebaker, 1982). The
PILL was included in this study because we were interested in examining the effect of
expressive writing on physical health outcomes and the PILL is a measure that has
been frequently used in other expressive writing studies (e.g., Epstein et al., 2005;
Sheese et al., 2004; Sloan et al., 2007).

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Grade point average (GPA)

University transcripts for participants enrolled in the study were obtained and GPA
for the fall semester (the semester in which the student participated) and the
subsequent spring semester were calculated on a .0
4.0 scale. In addition, the number
of credit hours attempted and earned for the fall and spring semesters were recorded.
Of the 68 participants in the study, only one student (expressive writing condition)
withdrew from the university. This student withdrew in the fall semester due
to medical reasons, did not return to college in the spring semester, and did
not complete any of the follow-up assessments. The GPA for this student was
recorded as .0.
Manipulation check
Using a five-point scale (1 not at all, 5 a great deal), immediately after each
writing session participants provided ratings regarding the extent to which their
narrative was meaningful, personal, and revealing of their emotions. These
ratings were used as a manipulation check of whether or not participants in the two
writing conditions followed the writing instructions that they were given.
Procedure
Participants were informed that the purpose of the study was to examine the effect of
writing on academic performance. As noted earlier, participants were not aware that
there was more than one condition in the study. Thus, all participants had similar
expectations for the study regardless of their condition assignment. Upon arrival for
the first session, participants provided written informed consent and consent to
access their academic records (for purpose of obtaining information on GPA and
Scholastic Assessment Test (SAT) score). Although consent to access their academic
record was optional, all participants provided this consent. Participants were then
asked to complete an assessment packet containing a demographics questionnaire,
the DASS21, and the PILL. Following completion of the questionnaires, participants
were given an envelope that contained the general instructions for writing and
specific instructions for the first writing session, as well as a booklet in which they
were instructed to write. Writing instructions for each writing condition and session
were replicated from the standard instructions developed by Pennebaker (1997).
Briefly, participants assigned to the expressive writing condition were asked to write
about the most stressful or traumatic experience of their lives with as much emotion
and feeling as possible. Consistent with the standard protocol, they were instructed
that they could write about the same or different events during each writing session.
Participants assigned to the control writing condition were asked to write about how

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Anxiety, Stress, & Coping

515

they spent their time each day without any emotion or opinions. Participants in both
conditions wrote continuously for 20 minutes each session on three consecutive days.
Participants wrote alone in a private location within the laboratory. After the
participant had read their instructions, they were left alone in the room to write.
After 20 minutes, the experimenter entered the room and instructed the participant
to stop writing. Although participants were given the option of keeping their
narratives, all participants submitted their narratives by placing them back in the
envelope and dropping the envelope into a secured box located within the laboratory.
With the exception of the questionnaires, the same procedure was followed for
the writing sessions completed on the following two days. Participants returned two,
four, and six months later to complete the DASS21 and PILL. Participants were fully
debriefed at the six-month follow-up assessment. Participants who dropped out of
the study prior to the last follow-up assessment were asked to return for a debriefing.
If they did not return for an in-person debriefing, a letter was sent to them that
provided the debriefing information.
Data analysis plan
To investigate the adequacy of randomization, participants assigned to the two
writing conditions were compared on demographic and academic characteristics
using chi-squares (racial background, gender) and t tests (age, SAT total score, credit
hours earned in fall and spring semesters).
An intent-to-treat analysis approach was used to examine outcome. Participants
who did not attend one follow-up assessment session continued to be contacted for
subsequent follow-up assessment sessions. In many cases, we were successful in
participants who had missed one follow-up assessment returning for subsequent
follow-up assessments. In cases in which participants did not return, we used the last
observation carried forward approach. Hence, all 68 participants who completed the
writing sessions were included in the outcome analyses. To examine writing condition
differences on the outcome measures, a 2 (writing condition) 3 (assessment period)
repeated measures of analysis of covariance (ANCOVA) was conducted, with writing
condition as the between subjects variable, assessment period (two month, four
month, and six-month follow-up) as the within subject variable, and baseline score
used as the covariate variable, separately for each self-report outcome measure
(DASS21
depression, DASS21
anxiety, DASS21
stress, PILL). Effect sizes were
calculated using Cohens d (1988).
Results
The analyses examining adequacy of randomization revealed no significant
condition differences in demographic or academic characteristics. Demographic
and academic characteristics as a function of condition are shown in Table 1.
Manipulation check
To examine the effectiveness of writing instructions for the two conditions, ratings of
the extent to which the writing was meaningful, personal, and revealing of emotions
following each of the three writing sessions were averaged. Average ratings were then

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D.M. Sloan et al.

compared for the writing groups using a t-test. As shown in Table 2, participants
assigned to the expressive writing condition rated their narratives as significantly
more meaningful, personal, and revealing of emotions relative to average ratings of
the participants assigned to the control writing condition. These results indicate that
expressive writing participants complied with the expressive writing instructions and
were engaged in the writing assignment.
In addition to examining participant ratings of their essays, the first and third
authors read each essay to investigate whether the participant complied with the
writing instructions. This review indicated 100% compliance with the writing
instructions.

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Outcome assessment
Descriptive information for the outcome measures at baseline and at follow-up
assessments, as a function of condition, is shown in Table 3. An exploratory analysis
of each of the dependent variables was first conducted to examine whether the
assumptions of ANCOVA were met. The exploratory analyses indicated that the
depression, anxiety and stress subscale scores at each assessment period
were significantly skewed. Square root transformations corrected the skew
for each of these variables. The square root transformed variables were used in
our outcome analyses. Exploratory analyses of the PILL and GPA variables
indicated that these variables were normally distributed and therefore no transformations were conducted.
No significant main effects (largest F(2, 65) .72, p
.45, d .21) or writing
condition assessment period interaction (F(2, 65) .30, p
.70, d.14) were found
for self-reported physical health. The main effects and interaction for the stress
subscale (largest main effect F(2, 65) .21, p
.80, d.11; interaction F(2, 65) .21,
p
.75, d .11) and anxiety subscale of the DASS21 (largest main effect F(2, 65) 
.05, p
.90, d.06; interaction F(2, 65) .23, p
.75, d.12) were also not
significant. The main effects for writing condition for the depression subscale of
the DASS21 were not significant (largest F(2, 65) 2.54, p .08, d.40), however, a
significant writing conditionassessment period interaction was observed, F(2,
65) 3.60, pB.05, d.47. An ANCOVA, in which baseline depression score was
used as a covariate and Writing condition as the between subject variable, was
conducted for each assessment period to further explore the significant interaction.
As shown in Figure 1, the significant interaction was the result of writing condition
differences at the two-month follow-up assessment (F(2, 65) 3.05, p B.05, d .43).
Table 2. Manipulation check on ratings of the essays.
Expressive writing
condition
Rating
Meaningfula
Personal
Revealing
a

Control writing condition

M (SD)

M (SD)

t(66)

3.97 (1.21)
4.25 (.78)
4.08 (.89)

1.28 (.44)
2.56 (1.17)
2.28 (.97)

5.24
7.06
8.00

.001
.001
.001

Rating scale for all three ratings ranged from one (not at all) to five (a great deal).

Anxiety, Stress, & Coping

517

Table 3. Means (and SD) at baseline and follow-up assessments as a function of condition.
Disclosure

Control

GPA fall semester

GPA spring semester

2.77 (.71)
2.79 (.65)

2.93 (.74)
3.03 (.64)

DASS21
depression
Baseline
Two months
Four months
Six months

9.50
4.24
8.60
9.35

(8.3)
(9.2)
(9.8)
(8.6)

8.43
8.76
8.20
8.07

DASS21
anxiety
Baseline
Two months
Four months
Six months

3.78
4.00
5.46
6.72

(3.9)
(5.7)
(6.8)
(5.7)

4.38 (5.1)
4.9 (4.8)
6.27 (7.4)
5.70 (7.1)

DASS21
stress
Baseline
Two months
Four months
Six months

9.42
8.18
8.32
8.78

(7.8)
(8.7)
(8.5)
(8.7)

9.62
9.41
8.45
9.62

(7.4)
(8.2)
(7.4)
(9.3)

PILL
Baseline
Two months
Four months
Six months

15.77
15.14
14.77
14.14

(8.3)
(9.9)
(9.7)
(9.8)

16.62
16.19
15.74
16.14

(8.8)
(8.9)
(10.3)
(10.4)

(7.9)
(6.4)
(8.1)
(8.3)

Note: GPA grade point average; DASS21 Depression, Anxiety, and Stress Scale; PILLPennebaker
inventory of limbic languidness.

Specifically, participants assigned to the expressive writing condition reported

significantly fewer depression symptoms compared with participants assigned to
the control writing condition. This significant decrease in depression symptom
severity for the expressive writing participants was not sustained, however, as
20
18
Average depression score

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Outcome measure

16
14
12
*p <.05

10
8
6
4

Disclosure
Control

2
0
Baseline

2 month
4 month
Assessment period

6 month

Figure 1. Mean depression symptom severity as a function of time of assessment and

condition assignment.

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D.M. Sloan et al.

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indicated by the non-significant writing condition difference in depression scores

at the four-month (F(2, 65) 2.10, p
.15, d .36) and six-month (F(2, 65) .98,
p
.30, d.24) follow-up assessments.
To investigate whether the participants assigned to the two writing conditions
differed in GPA, a 2 (writing condition) 2 (fall semester, spring semester) repeated
measures ANCOVA was conducted, using GPA as the dependent variable and SAT
total score as a covariate. In contrast to the findings of Lumley and Provenzano
(2003) and Pennebaker and Francis (1996), the main effect and the interaction for
GPA were not significant for either the fall (F(1, 66) .64, p
.20, d.19) or spring
semesters (largest F(1, 66) .41, p
.30, d .15). The findings remained unchanged
when the one student who dropped out of college was removed and the data were
reanalyzed.
Discussion
We predicted that psychological health benefits associated with expressive writing
would be short lived, whereas physical health benefits and improvements in academic
performance associated with expressive writing would be sustained for a longer
period of time. Consistent with our first prediction, expressive writing participants
displayed decreased depression symptom severity relative to control participants at
the first (two months) assessment, but this benefit was not sustained at the
subsequent follow-up assessments. However, in contrast to our predictions, no other
group differences were found any of the follow-up assessments for self-reported
physical health, academic performance, and other areas of psychological health (i.e.,
stress and anxiety). These findings were somewhat surprising given that prior studies
have reported psychological and physical health benefits associated with expressive
writing, and Frattarolis meta-analysis indicated significant effect sizes for selfreported physical health, psychological health, and academic outcomes.
There are a number of explanations that might account for the results obtained
in this study. First, when psychological health has been used as an outcome measure
in other expressive writing studies, investigators have typically examined depression
(e.g., Batten, Follette, Hall, & Palm, 2002; Lepore, 1997; Sloan & Marx, 2004a). In
Frattarolis (2006) meta-analysis, depression was one of three psychological health
subcategories (among a total of 13 subcategories) that had a significant effect size
(r.07, p.04), with distress and psychological functioning representing the other
two subcategories. Consequently, it may be the case that psychological benefits
derived from expressive writing are limited to a handful of psychological health
variables, which include depression.
Our null findings for self-reported physical health were somewhat surprising given
that numerous studies have reported self-reported physical health benefits associated
with expressive writing (e.g., Greenberg et al., 1996; Norman, Lumley, Dooley, &
Diamond, 2004; Pennebaker, Colder, & Sharp, 1990; Pennebaker & Francis, 1996;
Radcliffe, Lumley, Kendall, Stevenson, & Beltran, 2007; Sheese et al., 2004), and
Frattarolis (2006) meta-analysis indicated a significant effect size for self-reported
physical health (r.056). Several possible factors might account for the null findings
observed for physical health. First, our first follow-up session occurred two months
following the writing sessions. Expressive writing studies have substantially varied in
the time to follow-up assessment (see Sloan & Marx, 2004b, for a review), and it is

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possible that the self-reported physical health benefit derived from expressive writing
may have dissipated prior to our first follow-up assessment.
Another possible explanation for our null physical health findings is that our
sample was comprised of healthy young adults. Frattarolis meta-analysis findings
suggest that individuals in poorer physical health reap greater physical health
benefits from expressive writing. If someone is already in good physical health, such
as the sample examined in this study, there is little room for improvement and
therefore it is more difficult to observe beneficial outcome. This ceiling effect
explanation would also apply to the null findings observed for stress and anxiety
outcomes. That is, Frattaroli found that individuals with greater stress levels were
more likely to experience improvements in psychological health. Although our
sample consisted of individuals who were transitioning to college, a period of
elevated stress (Dyson & Renk, 2006), their stress levels may not have been
sufficiently high enough to glean any of the previously noted psychological health
benefits associated with expressive writing, and we did not specifically pre-select
individuals for high levels of stress. In some ways, the fact that we observed a
significant between condition difference for depression symptom severity at the twomonth follow-up assessment is remarkable given that the mean score for depression
symptom severity at baseline was 7.2 for all participants and the range of scores for
both conditions at the two-month follow-up assessment was restricted with the mean
score within normal range (7.9).
Although, some expressive writing studies have found improved GPA to be
associated with expressive writing (Cameron & Nicholls, 1998; Lumley & Provenzano, 2003; Pennebaker & Francis, 1996; Pennebaker et al., 1990), other studies have
found no improvement in GPA (Klein & Boals, 2001; Pennebaker & Beall, 1986).
Moreover, two of the studies that showed improved GPA associated with expressive
writing reported a marginal effect only (Pennebaker & Francis, 1996; Pennebaker
et al., 1990). Frattarolis (2006) meta-analysis revealed a significant but small effect
size for academic outcomes (r.038). Thus, a large sample size may be needed in
order to observe improvements in GPA associated with expressive writing. Although,
the sample size included in our study is consistent with the sample size of other
expressive writing studies (see Frattaroli, 2006), we may not have been sufficiently
powered to find a significant group effect for GPA outcome.
Related to the sample examined in this study, investigators have suggested that
sample characteristics (e.g., college students versus clinical samples) may influence
expressive writing outcome. Smyths (1998) meta-analysis found that expressive
writing studies that used college students had significantly larger psychological
health effect sizes than studies that used non-student populations. In contrast, a
more recent meta-analysis (Frattaroli, 2006) found that studies that used nonstudent populations had marginally larger psychological health effect sizes than
studies that used student populations. Frattaroli (2006) noted that this discrepancy
might be due to another, third variable, location of the writing sessions. That is,
studies that examined student samples were more likely to be conducted in a
controlled setting, such as a laboratory. When location of writing session was used as
a covariate, sample no longer served as a significant moderator of outcome. Taken
together, there is not convincing evidence that the expressive writing procedure is
more or less effective for student versus non-student populations. However, a more
critical issue may relate to individual differences serving as a moderator of expressive

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writing outcome (e.g., Norman et al., 2004; Sloan, Marx, Epstein, & Dobbs, 2008).
Future studies examining expressive writing outcome should include an examination
of moderators of expressive writing. Although the findings from Frattarolis metaanalysis provide some important information on this topic, it is best to directly
examine moderators of expressive writing outcome so that the influence of
third variables can be controlled. There is also some evidence that altering
the instructional set may lead to greater expressive writing benefits (e.g., Sloan
et al., 2007).
As noted earlier, our study may not have been able to detect between group
differences at follow-up assessments due to low power. Although, Frattaroli (2006)
reported significant effect sizes across a variety of outcome measures, the reffect size for
each outcome category was relatively small (e.g., .056, .054, and .036 for
psychological health, self-reported physical health, and general functioning,
respectively). These relatively small weighted mean effect sizes suggest the need to
include larger sample sizes to detect between group differences in outcome effects. To
investigate whether our study was underpowered to detect between group effects, we
conducted a post hoc power analysis using G*power software (Faul, Erdfelder,
Lang, & Buchner, 2007). Findings indicated that power for the between group
difference of GPA for the fall semester was .26. Thus, we were underpowered to
detect between group effects on GPA. However, post hoc power analyses of our other
outcome variables indicated power was at least .80 (e.g., .86 for the PILL and .92 for
anxiety), which is sufficient to detect between group differences.
Although, there is not clear evidence as to the underlying mechanism for the
health benefits associated with expressive writing, there is growing evidence that the
expressive writing intervention allows individuals the opportunity to express
emotions and feelings surrounding current stressful experiences that they might
not otherwise express (for a review see, Sloan & Marx, 2004b). Therefore, the
intervention should primarily be associated with psychological health benefits.
However, as the mind affects the body (e.g., Irwin, 2008; Kiecolt-Glaser, McGuire,
Robles, & Glaser, 2002; Lutgendorf & Costanzo, 2003), it is reasonable to assume
that other benefits would also be observed. For example, reductions in psychological
stress levels may lead to improvements in physical health (Lovallo, 2005). Thus, if
expressive writing is associated with decreased stress then one would expect to find
decreased physical health problems to follow. Given that we did not find any
improvements in stress levels associated with expressive writing in this study, it is not
surprising that physical health benefits were also not observed. Similarly, if a person
is in good physical and psychological health they will be better able to focus on their
school work as they will not be distracted by physical and psychological health
problems. Consequently, we would expect improvement in academic performance to
follow improvements in psychological and physical health. As we found no benefits
in anxiety, stress or physical health associated with expressive writing, it is not
surprising that we did not observe improvements in academic performance (as
indexed by GPA). In addition, the short-lived reductions in depression symptoms
would not promote longer term additional benefits, such as improved scholastic
performance.
One of the main findings of this study is the short duration of the derived benefits
associated with expressive writing. This finding raises questions regarding whether
expressive writing can be useful as an intervention. On the other hand, it may be

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necessary to conduct writing sessions on a periodic basis (e.g., every few weeks) in
order to reap the greatest benefit from the expressive writing procedure. As
Pennebaker (1997) has noted, because new stressors occur over time, the expressive
writing intervention might be best implemented by individuals who complete writing
sessions at regular intervals, similar to booster sessions that are commonly used in
psychotherapy (e.g., Baggs & Spence, 1990; Braukhaus, Hahlweg, Kroeger, Groth, &
Fehm-Wolfsdorf, 2003; Clarke, Rohde, Lewinsohn, Hops, & Seeley, 1999; Connors &
Walitzer, 2001), and booster sessions might be particularly useful for relatively
healthy individuals. Gortner, Rude, and Pennebaker (2006) investigated whether a
booster writing session enhanced expressive writing outcome with a college student
sample. No benefit was observed by adding a booster session. It should be noted that
these investigators used only a single booster writing session that occurred five weeks
after the initial expressive writing sessions. Given that follow-up was assessed six
months following the initial writing sessions, the single booster writing session may
have been insufficient to enhance lasting benefits derived from the expressive writing
procedure. Overall, it will be important for investigators to continue to examine
whether booster writing sessions enhance the efficacy of expressive writing.
Taken together, the results of this study add to the large body of research
indicating that expressive writing can be associated with beneficial outcome, at least
in the short term. However, it appears that beneficial outcome may be observed for
some areas of functioning but not others. It is likely that the benefits derived from
the expressive writing task may vary by the sample that is being studied. Durability
of any observed benefit might also vary as a function of domain of assessment. In
order to continue to further our knowledge on how expressive writing is best used, it
will be important for investigators to include multiple assessments over time and to
investigate a variety of health outcomes with different populations. Investigation of
the potential benefit of booster writing sessions should also be pursued.

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