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Howard Karl Butcher RN, PhD, PMHCNS-BC
is associate professor, University of Iowa
College of Nursing
26 N o v e m b e r 2 0 0 8 v o l u m e 7 n u m b e r 9 c a n c e r n u r s i n g p r a c t i c e
review
Structured written emotional expression (SWEE) is a promising low-cost and innovative
intervention. It involves asking participants to share brief written accounts to express their
deepest thoughts and feelings about a traumatic experience. Investigators and theorists have also postulated that expressing one’s emotions about a traumatic experience helps the person Let the words flow
Therapies that involve encouraging caregivers to express their feelings in writing are shown
to enhance their wellbeing and could be used with patients, says Howard Butcher
‘Even more remarkable is the body of research showing the health benefits for patients’
to organise, assimilate and give meaning to the traumatic experience. Lutgendorf and Antoni
(1997) propose that at a ‘deeper level’ SWEE acts as a motivator that helps people to ‘grapple’ with a traumatic event by trying to assimilate it in a manner that ‘may change its meaning’ and mediate cognitive and physiological changes.
Health benefits
Since 1986, Pennebaker and his colleagues have explored the health benefits to people
who write or talk about their deepest thoughts regarding traumatic or stressful experiences.
They have reported significant effects in cases where people have used 15 to 30-minute writing sessions for three to five consecutive days, with health benefits lasting as long as four to six months. There is evidence from a wide range of controlled studies to demonstrate that the robust nature of SWEE significantly enhances physical health, physiological functioning, psychological wellbeing and general functioning in healthy participants. Even more remarkable is the increasing body of research that demonstrates the health benefits of SWEE for patients with asthma, rheumatoidarthritis (Smyth et al 1999), fibromyalgia (Broderick et al 2005), HIV (Rivkin et al 2006) and patients with breast cancer (Stanton et al 2002). Investigations have shown that in comparison with controls, SWEE decreased Epstein-Barr virus (EBV) antibody titres suggestive of better immune control of the latent virus (Esterling et al 1994, Lutgendorf et al 1994); increased the proliferative response capacity of blood T-lymphocytes to phytohaemagglutinin (Pennebaker and Susman 1988); increased postinoculation antibody levels against hepatitis B, suggestive of a more adaptive antibody response (Lutgendorf et al 1994); brought about acute increases in NK cytotoxicity (Christensen et al 1996); and led to an increase in total circulating lymphocytes and CD4 (helper) T-lymphocyte levels (Petrie et al 1998). There have been a few studies testing the
SWEE intervention with cancer patients (Stanton et al 2000, Rosenberg et al 2002, Walker
et al 1999, Owen et al 2006, Zakowski et al 2004, Lieberman and Goldstein 2006). For example, Zakowski et al (2004) report that for prostate and gynaecological patients with social support systems unresponsive to the expression of problems and emotions, those asked to engage in emotionally expressive writing exhibited improvements in distress levels.
Stanton et al (2000) show that written emotional disclosure in women with breast cancer is associated with improvements inphysical symptoms. However, there have been
no studies to test SWEE with cancer family caregivers and only one by the author that
tested the SWEE intervention with Alzheimer’s disease and related dementias (ADRD) family
caregivers.
Comparison
Butcher et al (2008) conducted a study funded by the National Institutes of Nursing
Research (NINR) and the John A Hartford Foundation of 43 homebound ADRD family
caregivers (mean age=66 years) who were randomly assigned to either a comparison group
or an experimental group, both of which wrote for 20 minutes on three alternating days.
Experimental group family caregivers (n=25) wrote about their deepest thoughts and feelings
about caring for their loved one, while those in the comparison group (n=18) wrote about
non-emotional topics such as food preparation. Saliva cortisol, an indicator of caregiver stress,was measured four times a day for two days at pre-test, on the fourth and fifth, and again on the 30th and 31st days after the last day of writing. A three-level analysis was performed using HLM software (hierarchical linear and nonlinear modeling) to test the effect of the intervention on saliva cortisol levels. The experimental group participants had significantly lower saliva cortisol levels (p=0.011) on the fourth and fifth days after writing, but not on the 30th and 31st days after writing. The author is currently conducting a study
funded by the Cancer and Aging Program at the University of Iowa using the same design as that used in the study involving ADRD caregivers to test the SWEE intervention in a population of family caregivers of people in the late stages of cancer. The sample population for the study will consist of caregivers over the age of 55 years who live with a family member in the later phases of cancer and who spend at least four hours a day providing care.
Given the negative health outcomes due to the emotional and physical stress and burden in
cancer family caregivers, an easily administered and low-cost intervention that has an impact on improving the health outcomes is both significant and timely.
the Click Researcher 
