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Practice Profile

Expressive Writing Interventions for Adolescents

Evidence Ratings for Outcomes:

Effective - One Meta-Analysis Juvenile Problem & At-Risk Behaviors - Multiple juvenile problem/at-risk behaviors
Effective - One Meta-Analysis Mental Health & Behavioral Health - Internalizing behavior
Effective - One Meta-Analysis Education - School participation
Effective - One Meta-Analysis Mental Health & Behavioral Health - Somatic complaints
No Effects - One Meta-Analysis Education - Academic achievement/school performance

Practice Description

Practice Goals/Target Population
Expressive writing is a brief psychosocial intervention, also called written emotional disclosure. Expressive writing interventions are individually focused and designed to improve emotional expression and processing during adaptation to stressful situations. The goal is to improve psychological and physical health. For this iteration of expressive writing interventions, the target population was adolescents ages 10 to 18.

Practice Components
The length, spacing of sessions, and focus of the writing assignment can vary by intervention. Expressive writing interventions are usually three or four sessions, 15 to 20 minutes each, spaced 1 to 7 days apart. The focus of the writing task can also differ by intervention. Some expressive writing interventions instruct adolescents to write about a general topic (such as an upsetting or stressful event); others instruct them to write about something specific (such as the trauma of a death or an ongoing physical illness).

A writing protocol described by Pennebaker (1997) provides an example of the types of instructions that might be given to adolescents during an expressive writing intervention. The protocol is as follows: “For the next 3 days, I would like you to write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. In your writing I’d like you to really let go and explore your very deepest emotions and thoughts. You might tie your topic to your relationships with others, including parents, friends, or relatives, to your past, your present, or your future, or to whom you have been, whom you would like to be, or whom you are now. You may write about the same general issues or experiences on all days of writing or on different topics each day. All of your writing will be completely confidential. Don’t worry about spelling, sentence structure, or grammar. The only rule is that once you begin writing, continue to do so until your time is up” (Pennebaker 1997:162).

Practice Theory
There are several theories (including attentional processing, habituation, and cognitive processing) to explain how expressive writing interventions could affect adolescents and initiate emotion regulation. With attentional processing, expressive writing interventions allow adolescents to focus their attention on memories of upsetting or traumatic events (that they’re writing about) and redirect that attention toward more positive aspects of the event that may have been disregarded or forgotten. Habituation involves reducing the magnitude of a response to a specific stimulus (such as an upsetting or traumatic event) with repeated exposure to that stimulus. Writing repeatedly about a traumatic event may produce the reactivation, the habituation, and the eventual diminishing and loss of the stress-related physiological and emotional states that were brought about by the event. Finally, expressive writing interventions may help in the cognitive processing of upsetting or traumatic events, in terms of search for a meaning for the event and reappraising the situation. Writing about the event allows adolescents to look for causal explanations and interpretations about the event that can help process what happened (Travagin, Margola, and Revenson 2015).

It is believed that expressive writing can improve adolescents’ psychological and behavioral response to upsetting or traumatic events because it facilitates emotion- and self-regulation by encouraging adolescents to write about those events and their associated emotions. Adolescents can learn to regulate their emotions by directing their attention to different aspects of the event and develop alternative ways to respond (Kliewer et al. 2011; Travagin, Margola, and Revenson 2015).

Meta-Analysis Outcomes

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Effective - One Meta-Analysis Juvenile Problem & At-Risk Behaviors - Multiple juvenile problem/at-risk behaviors
Aggregating the results from seven studies, Travagin, Margola, and Revenson (2015) found a small, statistically significant mean effect size of 0.131 for problem behaviors (such as conduct problems or aggression) in favor of the treatment group. This means that adolescents who participated in expressive writing interventions displayed improvements in problem behaviors compared with adolescents in the comparison group.
Effective - One Meta-Analysis Mental Health & Behavioral Health - Internalizing behavior
Aggregating the results from 20 studies, Travagin, Margola, and Revenson (2015) found a small, statistically significant mean effect size of 0.107 for internalizing behaviors (such as depression or anxiety) in favor of the treatment group. This means that adolescents who participated in expressive writing interventions displayed improvements in internalizing behaviors compared with adolescents in the comparison group.
Effective - One Meta-Analysis Education - School participation
Aggregating the results from six studies, Travagin, Margola, and Revenson (2015) found a statistically significant mean effect size of 0.246 for school participation (such as school absences and tardiness) in favor of the treatment group. This means that adolescents who participate in expressive writing interventions displayed improvements in school participation compared with adolescents in the comparison group.
Effective - One Meta-Analysis Mental Health & Behavioral Health - Somatic complaints
Aggregating the results from nine studies, Travagin, Margola, and Revenson (2015) found a statistically significant mean effect size of 0.246 for somatic complaints (such as headaches, nausea/upset stomach, or sore muscles) in favor of the treatment group. This means that adolescents that participated in expressive writing interventions reported improvements in somatic complaints compared with adolescents in the comparison group.
No Effects - One Meta-Analysis Education - Academic achievement/school performance
Aggregating the results from six studies, Travagin, Margola, and Revenson (2015) found expressive writing interventions had no statistically significant effect on school performance (such as exam scores or grades).
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Meta-Analysis Methodology

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Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 11993 - 2011212182

Meta-Analysis 1
Travagin, Margola, and Revenson (2015) conducted a meta-analysis of studies on expressive writing interventions for adolescent populations, specifically examining whether these types of programs made an effect on well-being and physical health. A four-phase systematic literature search was conducted: 1) keyword search of four electronic databases [PsycINFO, Medline, ProQuest Digital Dissertations, and Education Resources Information Center (ERIC)] for a period between August 1986 and July 2012; 2) reference search of all publications collected through the keyword search; 3) citation search of all publications citing the studies collected through the keyword and reference searches; and 4) expert search that involved contacting several scholars who had done work on written emotional disclosure. The following inclusion criteria were used to determine which studies would be included in the meta-analysis: the study had to be original research of one or more studies of expressive writing interventions; the study had to use an experimental design with at least one posttreatment assessment of the outcome variable (or variables); the study had to include a neutral (nonemotional) writing control condition or assessment-only control condition; the instructions for participations in the treatment condition had to follow some variation of the instructions of the original expressive writing paradigm; and the sample had to be between the ages of 8 and 18.

Twenty-one studies (providing 24 effect sizes) met the inclusion criteria. All 21 studies were randomized controlled trials. Fourteen studies used neutral writing as the control condition, and seven studies used a no-writing control condition. Across the 21 studies there was a total sample size of 2,182 youths. The age of study participants ranged from 10 to 18 years. Most studies included mixed-gender samples; 14 studies were predominately female, 5 studies were predominately male, and 2 studies were all-female study participants. With regard to risk status, 11 studies involved healthy adolescents, 7 studies involved adolescents with psychological problems (such as depression), 3 studies involved adolescents with physical illnesses (such as asthma), 2 studies targeted adolescents at risk for physical victimization, and in 1 study the parents were alcoholics. Information about race/ethnicity of study participants was not provided.

With regard to characteristics of the expressive writing interventions, the number of writing sessions ranged from 1 to 12. Thirteen studies included three or fewer sessions, and eight studies included more than three sessions. The length of the writing sessions ranged from 10 to 45 minutes. Nineteen studies used the traditional expressive writing paradigm, which asked adolescents to write about a stressful or upsetting experience of their choosing (13 studies) or about a specific negative topic such as an experienced peer problem or ongoing illness (6 studies). The remaining two studies used other writing instructions not solely focused on negative experiences (one study asked students to write about both positive and negative aspects of school participation, and the other studies asked students to write about hobbies or a vacation that could be either positive or negative).

The outcome variables of interest for the meta-analysis included problem behaviors (such as externalizing-conduct problems or problems related to aggression), internalizing problems (such as symptoms of depression, anxiety, and other measures of emotional distress), school performance (which included indicators of academic achievement such as exam results or school grades), school participation (which included school absences and tardiness), and somatic complaints (which included self-report measures of symptoms such as the Children’s Somatization Inventory and the Somatization Scale of the Child Behavior Checklist).

The Hedge’s g effect size was estimated as the difference between the standardized mean change for the treatment and control conditions. The values of the effect sizes were scaled so that positive values represented a positive effect. The mean effect sizes were estimated using a random e?ects model.
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Cost

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There is no cost information available for this practice.
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Other Information

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Travagin, Margola, and Revenson (2015) conducted moderator analyses, to see whether any factors strengthened the likelihood that expressive writing interventions improved outcomes (specifically, school performance and somatic complaints).

For participant characteristics, expressive writing interventions that included participants at risk for psychological problems had a statistically significant larger effect than interventions with healthy participants on measures of somatic complaints (meaning adolescents at risk for psychological problems saw a larger decrease in somatic complaints than healthy adolescents did). There were no other statistically significant effect sizes for somatic complaints related to other participant characteristics (such as gender and age). There were no statistically significant effect sizes for school performance related to any participant characteristics.

For intervention characteristics, expressive writing interventions with more than three sessions had a statistically significant larger effect than interventions with a maximum of three sessions on measures of somatic complaints (meaning adolescents who participated in interventions with more than three sessions saw a larger decrease in somatic complaints than did adolescents who participated in interventions with three or fewer sessions). Similarly, interventions that had writing sessions spaced more than 1 day apart had a statistically significant larger effect for somatic complaints than interventions with writing sessions on consecutive days. There were no statistically significant effects for somatic complaints pertaining to other intervention characteristics (such as focus of the writing or length of sessions). There was no statistically significant effect for school performance related to any intervention characteristics.
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Evidence-Base (Meta-Analyses Reviewed)

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These sources were used in the development of the practice profile:

Meta-Analysis 1
Travagin, Gabriele, Davide Margola, and Tracey A. Revenson. 2015. “How Effective Are Expressive Writing Interventions for Adolescents? A Meta-Analytic Review.” Clinical Psychology Review 36:42–55.
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Additional References

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These sources were used in the development of the practice profile:

Pennebaker, James W. 1997. “Writing About Emotional Experiences as a Therapeutic Process.” Psychological Science 8(3):162–66.

Kliewer, Wendy, Stephen J. Lepore, Albert D. Farrell, Kevin W. Allison, Aleta L. Meyer, Terri N. Sullivan, and Anne Y. Greene. 2011. “A School-Based Expressive Writing Intervention for At-Risk Urban Adolescents’ Aggressive Behavior and Emotional Lability.” Journal of Clinical Child & Adolescent Psychology 40(5):693–705.
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Related Programs

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Following are CrimeSolutions.gov-rated programs that are related to this practice:

School-Based Expressive Writing Intervention for At-Risk Urban Adolescents No Effects - One study
This was a school-based intervention targeting at-risk, seventh-grade students. The intervention included either a standard expressive-writing condition or an enhanced expressive-writing condition. The program is rated No Effects. No significant differences were found between the standard writing condition and the control condition, or between the enhanced writing condition and the control condition, on self- and teacher-reported measures of aggression and emotion regulation.
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Practice Snapshot

Age: 10 - 18

Gender: Both

Settings: School

Practice Type: Academic Skills Enhancement, Classroom Curricula, Conflict Resolution/Interpersonal Skills, Leadership and Youth Development

Unit of Analysis: Persons