The Gerontologist

Vol. 47, No. 3, 296306

Copyright 2007 by The Gerontological Society of America

Does Expressive Writing Reduce Stress and

Improve Health for Family Caregivers of
Older Adults?
Corey S. Mackenzie, PhD,1 Ursula J. Wiprzycka, BSc,1
Lynn Hasher, PhD,2,3 and David Goldstein, PhD2

This research was supported by Grant R37 AG 04306 from the U.S.
National Institute on Aging to Lynn Hasher, and by a fellowship from
the Canadian Institutes for Health Research to Ursula J. Wiprzycka.
We are grateful to Dr. Guy Proulx, Joyce Lagunoff, and her staff at
the Baycrest Community Day Centre for Seniors for helping to
administer this study; to those caregivers who participated under
difcult circumstances; and to Peter Vitaliano and Harvey Keselman
for their consultation and help with statistical analyses. We thank
Melina Conbren, Michel Jones, and Limor Zomer for their research
assistance.
Address correspondence to Corey Mackenzie, PhD, Department of
Psychology, University of Manitoba, P435G Duff Roblin Building, 190
Dysart Road, Winnipeg, Manitoba, Canada, R3T 2N2. E-mail:
corey_mackenzie@umanitoba.ca
1
Department of Counselling Psychology, University of Toronto,
Canada.
2
Department of Psychology, University of Toronto, Canada.
3
Rotman Research Institute of Baycrest Centre, Canada.

296

Key Words: Expressive writing, Written disclosure,

Caregiver stress, Time management, Randomized
clinical trial

Developments within clinical and health psychology, psychiatry, and psychoneuroimmunology are
providing increasingly clear evidence of the negative
impact of stress on mental and physical health
(Schneiderman, Ironson, & Siegel, 2005). There has
also been concurrent growth in interventions designed to reduce stress or treat stress-related
conditions. Two decades ago, Pennebaker and Beall
(1986) published the rst study examining the impact
of a brief writing intervention focusing on traumatic
or stressful experiences. University students who
wrote about their deepest thoughts and feelings concerning the most traumatic experience of their lives for
15 minutes on four consecutive days experienced
signicant reductions in health center visits. Since that
landmark study, an impressive body of literature has
developed with the aim of exploring the health benets of the expressive-writing paradigm. The current
study adds to this growing body of evidence by
extending expressive writing to a stressed population
that has been neglected in the written-disclosure literature: Family caregivers of physically frail and cognitively impaired older adults who are no longer able to
care for themselves independently.
Preliminary studies supported the efcacy of
expressive writing. In a meta-analysis of 13 randomized controlled trials examining its mental and physical health benets, Smyth (1998) found an overall
effect size of 0.47 (Cohens d) across studies and outcomes. This moderate effect size represented a 23%
improvement among intervention participants compared with control subjects. Larger effects were found
for studies that included greater numbers of men,
when writing sessions were spaced further apart, and
when participants wrote about current rather than
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Purpose: We examined whether written emotional

disclosure reduces stress and improves health outcomes for family caregivers of physically frail and
cognitively impaired older adults, as it has been
shown to do for certain student and clinical populations. Design and Methods: Primary caregivers of
older adults attending a day program were randomly assigned to expressive-writing (n = 14), timemanagement (n = 13), or history-writing (n = 13)
conditions. Participants wrote for 20 minutes on four
occasions over a 2-week period, and they completed
self-report measures of caregiver burden and health
prior to the intervention, immediately afterward, and
at 1-month follow-up. Results: Contrary to expectations, expressive-writing and history-writing participants performed similarly across outcomes. Only
caregiver participants in the time-management condition experienced significant mental and physical
health improvements after writing. Implications: The
results of this study add to a growing body of research
demonstrating equivocal effects of expressive writing
with clinical samples, and they suggest the potential benefit of written time management for stressed
caregivers.

Vol. 47, No. 3, 2007

297

improve health by: (a) providing a release for previously inhibited thoughts, emotions, or behaviors; (b)
facilitating the development of organized, coherent
narratives of stress-related thoughts and memories in
order to promote cognitive adaptation to traumatic
experiences; or (c) exposing individuals to aversive
emotions that they had previously avoided so that
they habituate to them (Sloan & Marx, 2004).
Regardless of which theory or theories are correct,
they all suggest that, according to the caregiver stress
process model (Pearlin, Mullan, Semple, & Skaff,
1990), expressive writing should help caregivers cope
with the emotional impact of the various primary
stressors and secondary strains they are experiencing
in order to avoid negative physical and mental health
outcomes. Second, Sloan and Marx (2004) speculate
that expressive writing may work best for individuals with less severe psychopathology, and caregivers
have predominantly subclinical levels of distress
(Schulz et al., 2002). Third, although intensive multicomponent interventions are especially effective for
caregivers (Schulz & Martire, 2004), they may not be
available to those who do not live in large urban
centers, who cannot afford the costs involved, or
who will not commit to comprehensive programs as
a result of time-intensive caregiving responsibilities.
Because of the brevity and ease of administration of
expressive writing, it has the potential to reach those
care providers who might not otherwise access more
intensive interventions. It could also be used as a
rst-line intervention within a stepped-care model, in
which the least complex, expensive, and intrusive
treatments are attempted before proceeding to more
intensive interventions, if necessary (Haaga, 2000).
In the only examination of written disclosure with
caregivers to date, it was ineffective in reducing
depression, anxiety, and stress for 54 family caregivers
of hospitalized children (Schwartz & Drotar, 2004).
The results of that study may not generalize to
caregivers of older adults, however, because care
requirements for children and older individuals differ
considerably, and because the writing intervention in
that investigation deviated from the traditional methodology by allowing parents to write unsupervised
while in their childs room rather than in a distractionfree environment for a specic length of time.
In this study, caregivers in the expressive-writing
condition used methods (spaced writing sessions
focusing on current rather than past sources of
stress) that have been particularly effective (Smyth,
1998). Meta-analyses have reported inconsistent yet
signicant effects of writing across a variety of selfreport physical and psychological health outcomes
(Frisina et al., 2004; Smyth, 1998). As a result, we
hypothesized that individuals who write emotionally
about stressful caregiving experiences would experience reductions in perceived caregiver burden in
comparison with caregivers in time-management and
history-writing control groups. We also expected
that expressive writing would improve common

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past sources of stress. Although this meta-analysis

suggested that written disclosure effectively reduced
stress and improved health, generalizability of the
results was limited because 10 of the 13 studies
used student samples. The results of student-sample
expressive-writing interventions published since
Smyths meta-analysis have been mixed, with certain studies showing impressive benets (Epstein,
Sloan, & Marx, 2005; Schoutrop, Lange, Hanewald,
Davidovich, & Salomon, 2002), others showing null
results (Kovac & Range, 2000; Range, Kovac, &
Marion, 2000), and some nding that expressive
writing is only effective for certain subgroups
(Langens & Schuler, 2005).
More recently, the emphasis of expressive-writing
research has shifted to clinical populations. The
results of this shift have also been equivocal. A metaanalysis of nine randomized clinical trials found a
small effect size of 0.19 (Cohens d), with individual
study effect sizes ranging from
0.24 to 0.49 (Frisina,
Borod, & Lepore, 2004). Both this analysis and more
recently published studies suggest that expressive
writing is benecial for patients with high blood
pressure (McGuire, Greenberg, & Gevirtz, 2005) and
bromyalgia (Broderick, Junghaenel, & Schwartz,
2005). In contrast, largely negative ndings have
been reported with abuse and trauma survivors
(Batten, Follette, & Palm, 2002; Gidron et al., 2002;
Koopman et al., 2005), individuals with chronic pain
(Norman, Lumley, Dooley, & Diamond, 2004), and
bereaved individuals (Stroebe, Stoebe, Zech, &
Schut, 2002). Finally, contradictory ndings have
been published regarding the efcacy of expressive
writing for patients with HIV (Petrie, Fontanilla,
Thomas, Booth, & Pennebaker, 2004; Rivkin,
Gustafson, Weingarten, & Chin, 2006), cancer
(Stanton et al., 2002; Walker, Nail, & Croyle,
1999), asthma, and rheumatoid arthritis (Harris,
Thoresen, Humphreys, & Faul, 2005; Smyth, Stone,
Hurwitz, & Kaell, 1999).
Although ndings regarding the benets of written
disclosure are mixed, expressive writing does appear
to be moderately effective in reducing stress
and improving health for certain clinical populations,
or subsets of individuals within these populations. In
the current study we examined the efcacy of
this writing intervention for caregivers of physically frail and cognitively impaired older adults.
Although expressive writing has been recommended
as a method for helping dementia caregivers make
sense of their stressful situations in order to promote
health and well-being (Butcher & Buckwalter, 2002),
to our knowledge it has yet to be examined in this
population.
There are several reasons why expressive writing
is a promising intervention for caregivers of older
adults. First, although researchers are not yet clear
about why it improves physical and emotional
health, they have proposed three general theories to
explain its efcacy. Expressive writing is thought to

Table 1. Sample Characteristics by Writing Condition

Characteristics
Mean (SD) age: years
Female (%)
White race (%)
Marital status (%)
Never married
Married
Separated or divorced
Mean (SD) years of education

Expressive Writing (n 14)

Time Management (n 13)

History Writing (n 13)

61.79 (13.05)
10 (71.4)
14 (100)

63.31 (12.38)
10 (76.9)
13 (100)

59.46 (13.75)
9 (69.2)
13 (100)

0 (0.0)
13 (92.9)
1 (7.1)

2 (15.4)
10 (76.9)
1 (7.7)

1 (7.7)
12 (92.3)
0 (0.0)

14.29 (2.97)

14.15 (2.73)

16.00 (2.71)

6
4
2
2

Relationship to care recipient (%)

Spouse
Child
Other relative

5 (35.7)
9 (64.3)
0 (0.0)

Caregiving duration
Mean (SD) months
Mean (SD) hours per day
Care recipient has dementia (%)

(42.9)
(28.6)
(14.3)
(14.3)

4
2
0
7

(30.8)
(15.4)
(0.0)
(53.8)

4 (30.8)
7 (53.9)
2 (15.4)

6
3
2
2

(46.2)
(23.1)
(15.4)
(15.4)

4 (30.8)
9 (69.2)
0 (0.0)

44.71 (32.01)
8.54 (9.79)

55.15 (48.20)
9.40 (10.39)

60.62 (71.90)
7.25 (9.77)

8 (57)

6 (46)

8 (62)

Note: SD = standard deviation.

distressing reactions to stressful events, including

intrusive thinking and avoidance, as well as selfreported physical health and key indicators of mental
health, including depression, social dysfunction,
anxiety, and sleep problems. We included the historywriting condition because of the possibility that time
management, the most common control condition in
the written-disclosure literature, might be benecial
for caregivers for two reasons. First, caregivers often
list time pressure as a signicant source of stress
(Jones & Jones, 1994). Second, time management
requires individuals to write about how they spend
their time in an objective manner. Caregivers in this
condition may experience health benets, considering
that suppressing emotional expression (e.g., writing
objectively about emotional caregiving experiences)
has been shown to be an adaptive and healthy coping
strategy for highly stressed older adults (Consedine,
Magai, & Bonanno, 2002; Leventhal, Patrick-Miller,
Leventhal, & Burns, 1998).
Methods
Participants
Participants were family caregivers of older adult
members of the Community Day Centre for Seniors at
Baycrest, a geriatric teaching hospital afliated with
the University of Toronto. The Day Centre has two
programs that provide supportive and recreational
services to older adults 2 days per week. One program
is located in a locked area designated for members
diagnosed with dementia, and the other is located in

an open area designated for physically frail or mildly

cognitively impaired members. We recruited participants from both programs because caregiver stress is
associated with caring for both physically frail and
cognitively impaired older adults (Pinquart & Sorensen, 2003). Criteria for entrance into the study
included the following: (a) the participant was
identied as a primary family caregiver of a day
program member for at least 6 months; (b) the
participant was uent in written and spoken English;
(c) the participant had not used a personal diary for
the past 12 months; and (d) the participant had no
known neurological or incapacitating health problems. Of the 209 participants contacted to participate
in the study, 69 did not meet inclusion criteria and 94
declined participation. Six participants dropped out of
the study, resulting in a nal sample of 40 caregivers.
Overall, these participants were 61.53 years of age (SD
= 12.83), with an average of 14.80 years of education
(SD = 2.87). The majority were female (72.5%) and
working full or part time (62.5%). Most caregivers
were either children of the care recipient (62.5%) or
spouses of the care recipient (32.5%), and 87.5% were
married. Just over half of the participants (55%) were
caring for family members with diagnosed dementia.
Table 1 provides demographic information for caregivers assigned to the three experimental groups.

298

Measures
Demographic Questionnaire.Participants provided basic demographic information about their
age, gender, marital status, education, occupation,
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Work status (%)

Full time
Part time
Homemaker
Retired

and race or ethnicity. They also indicated their

relationship to the care recipient, number of months
as a caregiver, and the average daily hours spent
caregiving.
Manipulation Check Questionnaire.At the
follow-up assessment, participants rated their essays
on a 7-point scale ranging from 1 (not at all) to 7 (a
great deal) in terms of how emotional and personal
they were, as well as the extent to which the writing
was difcult to do, had a lasting positive effect, had
a lasting negative effect, and was valuable.

Caregiver Burden.The short form of the Zarit

Burden Interview (ZBI; Bedard et al., 2001) is a 12item questionnaire measuring perceived burden associated with caring for individuals with dementia.
Participants rate each item on a 5-point scale ranging
from 0 (never) to 4 (nearly always) so that the range
of possible scores is 0 to 48. According to Bedard and
colleagues, scores above 16 suggest clinically significant burden, although lower cut scores might be
more appropriate (ORourke & Tuokko, 2003). A
great deal of support exists for the reliability and
validity of the original 22- and 29-item versions of
the questionnaire (Hebert, Bravo, & Preville, 2000).
The short form used in this study correlates between
.92 and .97 with the 22-item ZBI, and it exhibits
similarly strong psychometric properties.
Intrusive Thinking and Avoidance.The 15-item
Impact of Events Scale (IES; Horowitz, Wilner, &
Alvarez, 1979) is frequently used in expressivewriting studies to assess the impact of writing on
psychological distress caused by stressful events. It
consists of 7 items measuring intrusive symptoms
(thoughts, nightmares, feelings, and imagery) and 8
items measuring avoidance symptoms (numbing of
responsiveness, and avoidance of feelings, situations,
ideas) related to stressful events. Participants rate
items on a 4-point scale scored as 0 (not at all), 1
(rarely), 3 (sometimes), or 5 (often). Total scores can
range from 0 to 75, with 8.5 and below representing
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299

Caregiver Health.The 28-item General Health

Questionnaire (GHQ; Goldberg & Williams, 1988)
is a self-report measure of mental and physical health
that is composed of four subscales: Anxiety and
Insomnia, Somatic Complaints, Social Dysfunction,
and Severe Depression. Participants rate each item
on a 4-point scale ranging from 0 (e.g., not at all) to 3
(e.g., much more than usual). Total scores can range
from 0 to 84, and subtest scores can range from 0 to
21. The GHQ has proven to be a reliable and valid
measure, with full-scale values of 24 or higher
indicating clinically signicant levels of distress
(Goldberg et al., 1997).
Procedures
Participants identied by day program social
workers as primary caregivers were recruited by
telephone, matched according to age and gender, and
randomly assigned to one of the three writing
groups. We replaced participants who dropped out
of the study with the next available participant.
This study followed standard procedures for
writing interventions (Pennebaker, 1997). Briey,
participants wrote about an assigned topic for 20
minutes on four occasions within a 2-week period.
We used spaced, rather than consecutive, writing
sessions because they are associated with larger effect
sizes (Smyth, 1998). For each writing session, research assistants provided participants with an
envelope containing the writing instructions and
paper. The assistants instructed the participants to
begin writing once they were alone in a small, quiet,
laboratory room. Twenty minutes later, participants
nished writing and sealed their essays in an envelope
to emphasize the condential nature of the study.
In addition to four writing sessions, participants
completed a battery of questionnaires immediately
prior to the rst writing session, immediately following the fourth writing session, and 1 month later.
During the follow-up assessment, participants also
completed the manipulation check questionnaire and
received information about the study and a package
of caregiving material.
Writing Conditions and Instructions.Participants in the expressive-writing condition wrote about
caregiver stress and burden because current, rather
than past, stressors are associated with larger effect

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Essay Characteristics.We analyzed participants transcribed essays with the Linguistic Inquiry
and Word Count Program (Pennebaker & Francis,
1999), which reliably searches text for over 2,300
words or word stems and converts them to a percentage of total words to correct for differences in
text length. We compared participants use of rst
person words (e.g., I, me), positive and negative
affect words (e.g., love, sad, afraid), and cognitive
words (e.g., think, know, because), because these
categories are thought to distinguish expressive and
control writing (Pennebaker, 1997) and should therefore vary in expected ways across the three writing
conditions (e.g., expressive writing should include
rst person, affective, and cognitive language).

low levels of clinical concern, 8.6 to 19 representing

medium levels, and above 19 representing high levels
of distress. Support exists for the reliability, validity,
and factor structure of the IES in general (Joseph,
2000), and for both chronic and acute stressful events
(Thewes, Meiser, & Hickie, 2001). As is commonly
done in studies of chronic stress, we modied the IES
to refer to current caregiver stress rather than a prior
traumatic event.

sizes (Smyth, 1998). As is the norm in the writtendisclosure literature, time-management participants
wrote objectively about how they spend their time.
Because of our concerns that doing so might benet
caregivers, we developed a history-writing condition,
in which participants wrote objectively about significant 20th-century Canadian or world events that did
not affect them personally. Session 1 instructions for
each writing condition are provided in Appendix A;
instructions for the three remaining sessions are
available from us upon request.
Analyses

Results
Participant Attrition and Baseline Characteristics
Of the 46 caregivers who began the study, 6
dropped out, all from the expressive-writing group: 1
dropped out prior to beginning the intervention
during the baseline assessment, 2 dropped out during
the intervention, and 3 dropped out after the
intervention but prior to the 1-month follow-up.
According to the clinical cutoff information provided
in the Measures section, at baseline caregivers met or
exceeded the rounded ZBI criterion for clinically
signicant burden, they had medium to high levels of
300

Manipulation Checks
Participants responses to the manipulation check
questionnaire provided a rst test of the experimental
manipulation. Only expressive-writing participants
were instructed to write emotionally; Table 2 shows
the anticipated group differences in the emotion
category. Follow-up pairwise comparisons demonstrated that ratings of emotion were higher for the
expressive-writing group than for the time-management and history-writing groups (ps , .01). They
were also higher for the time-management group
than for the history-writing group (p = .03). As we
expected, signicant differences also emerged with
respect to how personal the writing was. Essays were
rated as more personal by participants in both the
expressive-writing and time-management groups
than by participants in the history-writing group
(ps , .01), and the expressive-writing groups essays
were also nearly signicantly more personal than the
time-management groups essays (p = .07). Finally,
although differences between the three groups
ratings of the value of the intervention only
approached signicance (p = .07), exploratory
follow-up tests revealed that history writing was
signicantly less valuable than time management
(p = .03), and nearly signicantly less valuable than
expressive writing (p = .07).
A second check on the validity of the experimental
manipulation involved analyses of the language that
participants used in their essays (Pennebaker &
Francis, 1999). Table 2 shows differences, which we
expected, in the percentage of rst-person words
used in essays between groups, with history-writing
participants using far fewer rst-person words than
time-management and expressive-writing participants (ps , .01), who did not differ from each
another. The number of affect words also varied by
group. Expressive-writing participants wrote more
affectively than did history-writing participants
(p , .01), who used more affect than time-management participants did (p , .01). Interestingly, despite
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We compared participants demographic and

health characteristics at baseline using analyses of
variance (ANOVAs) with continuous variables and
Pearson chi-square analyses with categorical variables. We then examined the validity of the experimental manipulation by comparing the three
experimental groups essay ratings and linguistic
indicators using ANOVAs. As is typically done in the
written-expression literature, our examination of the
efcacy of expressive writing focused on change
from preintervention to follow-up because shortterm worsening of symptoms is often found immediately after writing (Smyth, 1998). We examined
changes in perceived caregiver burden, mental
health, and physical health from before to 1 month
following writing by using 3 (groups: expressive
writing, time management, and history writing) 3 2
(times: pretest, follow-up) repeated measures
ANOVAs with follow-up pairwise comparisons.
To indicate effect sizes, we report partial eta squared
(g2p ) for the overall group by time interactions, and
Cohens d for specic comparisons within group
across time (with pretest standard deviations as the
standardizer) and between two groups at follow-up
(with pooled pretest standard deviations as the standardizer). Small, medium, and large effect sizes are
associated with g2p values of 0.01, 0.06, and 0.14,
respectively, and with Cohens d values of 0.20, 0.50,
and 0.80, respectively (Olejnik & Algina, 2000). We
analyzed the data by using SPSS 14.0.1 software
(SPSS, 2005).

intrusive and avoidant symptoms, and their GHQ

total scores fell just below the clinical cutpoint,
indicating subclinical physical and mental health
problems. The only signicant difference between
dropouts and completers was that prior to beginning
the intervention, participants who dropped out
exhibited higher levels of intrusive and avoidant
thinking than did participants who remained in the
study; this is according to the IES total score, t(43) =

2.30, p = .03, and the IES Avoidance subscale,
t(43) =
2.40, p = .02. We also compared the baseline demographic characteristics and health of
expressive-writing, time-management, and historywriting participants to determine the success of
randomization. The groups did not differ signicantly on any demographic (all ps . .19) or preintervention health outcomes (all ps . .10).

Table 2. Mean (SD) Essay Ratings and Percentages of Words Used by Writing-Condition Groups

Outcome Measure

Expressive Writing
(n 14)

Time Management
(n 13)

History Writing
(n 13)

Group F

Essay ratings
Writing was emotional
Writing was personal
Writing was difcult to do
Writing had a lasting positive effect
Writing had a lasting negative effect
Writing was valuable

5.71
5.86
3.14
3.28
1.57
3.64

(1.20)
(1.10)
(1.99)
(2.09)
(1.40)
(1.60)

3.62
4.62
1.85
3.46
1.54
4.00

(2.26)
(2.18)
(1.46)
(1.98)
(1.13)
(2.24)

2.15
2.62
3.00
2.54
1.46
2.31

(1.34)
(1.80)
(2.31)
(2.30)
(1.66)
(1.80)

15.79**
11.86**
1.75
0.70
0.98
2.91

Linguistic indicators
% total words that are rst person
% total words that are affective
% affect words that are positive
% total words that are cognitive

8.55
4.82
55.14
6.98

(2.42)
(1.34)
(13.10)
(1.79)

8.27
1.56
76.45
3.11

(3.25)
(0.83)
(22.62)
(0.86)

1.42
3.35
54.20
4.87

(2.09)
(0.96)
(16.04)
(1.57)

29.14**
30.75**
6.60**
23.54**

using the fewest affect words, the time-management

group used a signicantly greater proportion of
positive affect words in their essays than did the
other groups (ps , .01), who did not differ from one
another. Finally, the three writing groups differed
with respect to their use of cognitive words that are
considered reective of the development of meaningful narrative (Pennebaker, 1997). Expressive-writing
participants used more of these words than did
history-writing participants (p , .01), who used
more cognitive words than did time-management
participants (p , .01).
To summarize, both questionnaire responses and
linguistic indicators supported the validity of the
experimental manipulation. Individuals in the expressive-writing condition wrote more personally,
emotionally, and cognitively than did participants in
the other two conditions. We also found that timemanagement participants wrote more personally and
emotionally than did those in the history-writing
group. Finally, time-management participants judged
the intervention to be more valuable than did
participants in the other groups, signicantly more
so than the history-writing participants.

Effects of Writing on Mental and Physical Health

Although our analyses of the efcacy of expressive
writing focused on changes from preintervention to
follow-up, mean scores from Table 3 (and analyses
available from us upon request) indicate that only
expressive-writing participants experienced nonsignicant worsening ZBI and IES total scores immediately following the intervention. At 1-month
follow-up, written disclosure did not have the
hypothesized effect on perceived burden. As shown
in Table 3, the Group 3 Time interaction for the ZBI
was not signicant, and the groups did not improve
signicantly over time. Furthermore, an examination
of mean scores shows that, contrary to our hypoVol. 47, No. 3, 2007

301

thesis, participants in the expressive-writing group

showed less improvement in caregiver burden than
did those in the other two groups.
Written emotional disclosure was also ineffective
in reducing intrusive thinking and avoidance. For the
full-scale IES, as well as for the Intrusion subscale,
the Group 3 Time interactions were not signicant,
although in both instances, the main effect of time
was, F(1, 37) = 4.42, p = .04, F(1, 37) = 9.12, p =
.005, respectively. There were no signicant main
effects or interactions for the Avoidance subscale. As
we can see from the mean scores in Table 3, there
was no suggestion that expressive writing had a benecial inuence on this outcome measure.
With respect to the impact of the intervention on
mental and physical health, our hypothesis about
expressive writing was again disconrmed. For the
full-scale GHQ there was a signicant effect of time,
F(1, 37) = 10.31, p = .003, and a Group 3 Time
interaction. The direction of this interaction was
opposite to what we expected, with all three groups
improving but only the time-management group
experiencing signicant benet (p , .001). As shown
in Table 3, the amount of change on the full-scale
GHQ among expressive-writing and history-writing
participants was modest and virtually identical.
Because time-management participants exhibited
a trend toward poorer self-rated health prior to
writing, the magnitude of their improvement from
preintervention to follow-up was large (Cohens d =
0.89), whereas differences between time management
and expressive writing (d = 0.17) and time
management and history writing (d = 0.24) at
follow-up were small. This large change in overall
physical and mental health among time-management
participants could reect a clinically meaningful
improvement, regression toward the mean, or
a combination of the two. The same pattern emerged
for the Anxiety and Insomnia subscale, including
a main effect of time, F(1, 37) = 13.62, p = .001, and
a Group 3 Time interaction. Follow-up comparisons

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Notes: Essay items are rated on a 7-point scale ranging from 1 (not at all) to 7 (a great deal). SD = standard deviation.
*p , .05; **p , .01.

Table 3. Comparison of Writing-Condition Groups on Mental and Physical Health Outcomes

Time Management
(n 13)

History Writing
(n 13)

Group 3 Time F

Effect Size
(g2p )

ZBI total
Pretest
Post-test
Follow-up

15.50 (9.55)
16.86 (8.71)
15.21 (7.63)

18.77 (8.01)
18.62 (6.36)
16.38 (7.18)

19.55 (9.13)
18.46 (9.54)
17.31 (9.60)

0.41

0.02

IES total
Pretest
Post-test
Follow-up

14.79 (14.11)
16.86 (15.36)
13.93 (14.57)

18.85 (9.73)
17.46 (10.02)
12.08 (10.07)

20.92 (19.89)
19.46 (15.32)
17.38 (15.13)

0.94

0.05

IES intrusions
Pretest
Post-test
Follow-up

8.21 (8.82)
7.93 (7.83)
6.00 (6.62)

10.15 (6.45)
10.31 (7.66)
4.77 (4.06)

9.85 (10.09)
10.31 (7.89)
7.54 (7.07)

0.90

0.05

IES avoidance
Pretest
Post-test
Follow-up

6.57 (7.77)
8.93 (8.32)
7.93 (8.38)

8.69 (5.71)
7.15 (3.91)
7.31 (6.92)

11.08 (10.92)
9.15 (7.98)
9.85 (8.48)

0.41

0.05

GHQ total
Pretest
Post-test
Follow-up

20.14 (11.42)
20.07 (9.55)
17.93 (8.50)

24.85 (9.81)
20.31 (9.30)
16.08 (8.39)

19.46 (5.42)
18.38 (7.16)
18.00 (7.11)

3.18*

0.15

GHQ anxiety and insomnia

Pretest
Post-test
Follow-up

6.64 (5.21)
6.36 (4.25)
5.64 (5.05)

8.23 (2.74)
6.38 (3.30)
4.31 (2.14)

6.38 (2.99)
6.00 (3.49)
5.38 (3.50)

3.28*

0.15

GHQ somatic complaints

Pretest
Post-test
Follow-up

4.29 (3.47)
4.79 (2.78)
3.86 (2.63)

6.92 (3.71)
4.54 (2.82)
4.62 (2.72)

4.54 (2.85)
4.46 (3.04)
4.85 (3.08)

1.56

0.08

GHQ social dysfunction

Pretest
Post-test
Follow-up

7.86 (2.18)
7.50 (1.70)
7.14 (2.14)

7.77 (3.19)
7.23 (1.74)
6.15 (3.39)

7.38 (1.76)
7.15 (1.68)
7.23 (1.59)

0.94

0.05

GHQ severe depression

Pretest
Post-test
Follow-up

1.36 (2.65)
1.43 (2.77)
1.29 (3.29)

1.92 (3.04)
2.15 (4.26)
1.00 (2.27)

1.15 (1.68)
0.77 (1.09)
0.54 (0.88)

1.40

0.07

Notes: ZBI = Zarit Burden Interview; IES = Impact of Events Scale; GHQ = General Health Questionnaire. Higher outcome
scores represent poorer functioning.
*p , .05.

revealed signicant improvement for time-management participants (p , .001) but not for participants
in the other groups (ps = .28
.29). Once again, the
magnitude of improvement for time management
was very large (d = 1.43), whereas differences
between time management and expressive writing
(d = 0.32) and time management and history writing
(d = 0.37) at follow-up were small. No other
signicant differences emerged for the remaining
three GHQ subscales with the exception of a main
effect of time on the Severe Depression subscale,
F(1, 37) = 6.36, p = .02.
We examined whether the results of the analyses
in this section reected general trends, or the inuence of outliers, by identifying dependent variable
scores, at pretest and follow-up, that were greater
302

than 3 SD from their scale mean. Only three scores

met this criterion, and analysis results were similar
with them included and removed.
Follow-Up Exploratory Analyses
Contrary to our a priori hypotheses that expressive writing would result in signicantly greater
improvement in outcomes compared with the other
groups, time management signicantly outperformed
the other two conditions on the overall GHQ and its
Anxiety and Insomnia subscale. Further, although
we found main effects of time but not Group 3 Time
interactions for the IES total score, IES Intrusion
subscale, and GHQ Depression subscale, mean
scores from Table 3 suggested that time management
The Gerontologist

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Expressive Writing
(n 14)

Outcome Measure

Discussion
There are two major outcomes of this caregiver
intervention study. The rst is a null nding: expressive writing neither reduced the subjective burden of
caregivers nor improved their mental or physical
health. The second is positive: time management
appears to have health benets for stressed caregivers.
With respect to the primary null outcome, the
current study, together with that of Schwartz and
Drotar (2004), suggests that writing emotionally
about stressful caregiving experiences does not
reduce this kind of stress or improve caregivers
mental or physical health. As is common in the
expressive-writing literature, participants in this
study experienced small, nonsignicant increases in
stress and symptoms of avoidance, somatic disturbance, and depression immediately following the
writing intervention. In addition to experiencing
mild short-term distress, however, written-disclosure
participants experienced no greater health benets at
1-month follow-up than did participants who wrote
objectively about historical events, and they often
showed fewer benets than participants in the timemanagement condition. The increased distress while
writing and failure to improve afterward may
underlie the higher likelihood of dropout associated
with expressive writing.
We note that our instantiation of the writtendisclosure protocol was successful. Expressive-writing
participants produced essays that were more
emotional, personal, and cognitive than the essays
of participants in the other two conditions. The null
ndings regarding the impact of expressive writing
also do not appear to be the result of our modest
sample size. Participants in the emotional-writing
condition failed to show trends toward superior
performance compared with control participants on
any of the study outcomes, suggesting that, if anything, larger numbers of participants would have
Vol. 47, No. 3, 2007

303

emphasized how poorly caregivers in the expressivewriting condition faired, at least in comparison with
those in the time-management group. Finally, the
lack of expected improvement for expressive-writing
participants was not due to unreliable outcome measures that are often used in the written-disclosure
literature, such as the frequency of physician visits.
Consistent with the suggestion by Sloan and Marx
(2004), we used psychometrically sound self-report
health outcomes, although future studies should also
consider measuring reliable objective health indicators such as cortisol levels.
It might be argued that our single 1-month followup assessment was insufcient to detect the longterm effects of writing given the curious nding by
several groups that the physiological effects of
writing do not emerge until several months following
expressive writing (Petrie, Booth, Pennebaker, Davison, & Thomas, 1995; Smyth et al., 1999). Although
this long-term delayed effect does not appear to hold
for self-reported health (Epstein et al., 2005;
McGuire et al., 2005; Petrie et al., 2004; Schoutrop
et al., 2002), future research with chronically stressed
populations might consider a 3 or 6-month follow-up
assessment. Such research should also assess supportive interventions or major life events experienced
during chronically stressful periods that may affect
perceived burden and health.
There are a number of potential explanations
for why caregivers in this study did not benet
from written emotional disclosure. Demographic
factors may be partly responsible; roughly 70% of
the participants were women, reecting the ratio of
female caregivers in the population (Montgomery &
Kosloski, 2000). Smyths (1998) meta-analysis found
higher effect sizes in studies with larger numbers of
male participants, although this gender effect has not
been reliably replicated (Epstein et al., 2005; Koopman
et al., 2005). In addition to being predominantly
female, our participants were, on average, 62 years
of age and therefore considerably older than those in
most other written disclosure studies. Perhaps students and other younger adults are better able to
perform in situations requiring emotional processing
while writing under time pressure compared with
older adults who are further removed from experiences at school or work that require written
disclosure. Our data provide partial support for
this hypothesis, with nonsignicant negative correlations between age and improvement among
expressive-writing participants from preintervention
to follow-up on the ZBI, IES, and GHQ (r =
.14,

.17,
.32, respectively). Alternatively, there may be
developmental factors that reduce the effectiveness
of this intervention for older individuals. According
to socioemotional selectivity theory, as we age we
are increasingly likely to regulate emotion by selectively attending to positive information (Carstensen,
Mikels, & Mather, 2006). The instructions for
expressive writing prevent participants from doing

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was outperforming the other groups on these outcomes as well. We examined whether this was true
by conducting additional post hoc pairwise comparisons of change across time for each group on the IES
total score, the IES Intrusion subscale, and the GHQ
Depression subscale. Using this liberal exploratory
approach, we found that caregivers who wrote about
time management improved signicantly from pretest to 1 month after writing on each of these
outcomes (ps , .04), whereas caregivers in the other
groups did not (ps . .10). The magnitude of change
for time-management participants was large for the
IES total score (d = 0.70) and Intrusion subscale
(d = 0.83), and small for the Depression subscale (d =
0.30). These exploratory analyses suggest that, with
additional statistical power, Group 3 Time interactions favoring time management would also likely
have emerged for intrusive thinking and depression.

304

management showed immediate improvements in

health. One month following the intervention, timemanagement participants exhibited signicantly
greater improvements on the full-scale GHQ and
its Anxiety and Insomnia subscale than did caregivers in the expressive-writing and history-writing
conditions. In addition, exploratory follow-up analyses revealed that only time-management participants also showed lasting improvement in intrusive
thinking and depression. Importantly, g2p effect sizes
for the Group 3 Time interactions at follow-up,
which provide an indication of the effectiveness of
writing that is unaffected by sample size, averaged
0.07 (a medium effect) across the nine outcomes
listed in Table 3. Furthermore, the magnitude of
improvement in anxiety, insomnia, and intrusive
thinking from before to 1 month after writing was
large for time-management participants. These effect
size measures suggest that additional Group 3 Time
interactions favoring time management would likely
have emerged with a larger group of participants.
The positive impact of time management was also
evident in participants feedback about the writing
intervention; they rated their writing experience as
being more valuable than did caregivers in the
expressive-writing and history-writing groups.
The positive inuence of time management for
caregivers requires replication and exploration of
mechanisms for its effectiveness. It is possible that
busy and overloaded caregivers benet, in a relatively
straightforward way, from thinking objectively about
how to make better use of their time. Alternatively,
writing in a purposefully unemotional way about
stressful caregiving tasks may promote health because
it enables older adults to inhibit emotional expression,
and this is thought to be an especially important
coping mechanism for older individuals experiencing
high levels of chronic stress (Leventhal et al., 1998).
In conclusion, our purpose in the present study was
to address the need to reduce the emotional and physical costs associated with providing care for growing
numbers of older adults with an easily implemented
and inexpensive treatment that could be used as an
adjunct to more intensive services. This goal may be
particularly important for those caregivers who lack
access to intensive interventions, or who are unwilling
to use them. Although our study suggests that expressive writing, as it is traditionally provided, holds little
promise for addressing this need, it does highlight the
potential benets of written time management, and of
the need to consider theoretically guided modications of expressive writing for clinical populations
with complex coping needs.

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Appendix A: Instruction for the First Writing

Session
Expressive Writing

Time Management
Today and for the next four sessions we would
like you to write about how you, as a caregiver, use
your time. Each session we will give you a different
writing assignment relating to the way you spend
your time. In your writing, we want you to be as
objective as possible. We are not interested in your
emotions or opinions. Rather, we want you to try to

306

History Writing
Today and for the next four sessions we would
like you to write about any signicant Canadian or
world event that happened prior to 2000 that
affected the world in general, not you or your family
in particular (e.g., either World War, the development of Universal Health Care, the Cuban Missile
Crisis, invention of the World Wide Web). We want
you to try to be completely objective about the topic.
We are not interested in your emotions or opinions.
Rather, we want you to write objectively about facts
and events. Feel free to make your description of the
topic as detailed as possible. You can write about the
specics of the event, the impact of the event, or
whatever other aspect interests you about the event
as long as your writing is objective rather than
emotional. Please begin writing and try not to stop
until we tell you 20 minutes have passed and we
knock on the door. If you run out of things to say,
just repeat what youve already written. Dont worry
about grammar or spelling.

The Gerontologist

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Today and for the next four sessions we would

like you to write about the most stressful, upsetting,
and distressing aspect of being a caregiver and
having to provide care for your elderly family
member. In your writing, we want you to really let
go and explore your very deepest emotions and
thoughts. You can write about the same topic during
each of the four sessions or about different topics
each session. Whatever you choose to write,
however, it is critical that you really delve into
your deepest emotions and thoughts. Ideally, we
would also like you to write about signicant
experiences or conicts that you have not discussed
in great detail with others. Remember that you have
four sessions to write. You might tie your personal
experiences to other parts of your life, such as how
they are related to your childhood, your parents,
people you love, who you are, or who you want to
be. Again, in your writing, examine your deepest
emotions and thoughts. Please begin writing and try
not to stop until we tell you 20 minutes have passed
and we knock on the door. If you run out of things
to say, just repeat what youve already written.
Dont worry about grammar or spelling.

be completely objective. Feel free to be as detailed as

possible. In todays writing session, we want you to
describe what you did yesterday from the time you
got up until the time you went to bed. For example,
you might start when your alarm went off and you
got out of bed. You could include the things you ate,
where you went, and which buildings or objects you
passed by as you walked from place to place. The
most important thing in your writing, however, is for
you to describe your days as accurately and as
objectively as possible. Please begin writing and try
not to stop until 20 minutes have passed and we
knock on the door. If you run out of things to say,
just repeat what youve already written. Dont worry
about grammar or spelling.