Does written emotional disclosure improve the psychological and physical health of caregivers? A systematic review and meta-analysis

doi:10.1016/j.brat.2016.03.004

Behaviour Research and Therapy

Volume 80, May 2016, Pages 23-32

https://doi.org/10.1016/j.brat.2016.03.004 Get rights and content

Highlights

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This study aimed to establish if written emotional disclosure (WED) improves caregiver psychological and physical health.
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WED was found to reduce symptoms of trauma and improve general psychological health of informal caregivers.
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There was no effect of WED on depression, anxiety, somatic symptoms, quality of life or caregiver burden.
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WED appears to be more effective for caregivers of less than five years.
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More rigorous RCTs with clearly described interventions and standardised outcome measures are required.

Abstract

There are 5.8 million caregivers providing support to the infirm, disabled or elderly in the United Kingdom. Caregivers experience adverse physical and mental health outcomes and increased mortality. Low cost, effective interventions are needed to increase the wellbeing of caregivers. Written emotional disclosure (WED) has been shown to improve health in a range of populations. This systematic review and meta-analysis aimed to establish whether WED improves the psychological and physical health of caregivers. Searches were conducted in Medline, EMBASE, CINAHL, BNI, PsycINFO, Cochrane Library from 1986 to 2015. Ten trials investigating WED (625 participants) met the inclusion criteria. Results from four studies (n = 118) indicated that WED reduces trauma (SMD = −0.46, 95% CI -0.82, -0.09). Data from three studies (n = 102) suggest that WED improves general psychological health (SMD = −0.46, 95% CI -0.86, -0.06). There was no evidence that WED improves depression, anxiety, physical symptoms, quality of life or burden. Observations suggest WED may be more effective for caregivers of less than 5 years. Studies were highly heterogeneous in regards to caregiver age, relationship to care recipient, impairment of care recipient, follow up period and outcome measures, with high or unclear bias often observed. More rigorous RCTs, with clearly described interventions and standardised outcome measures, are needed to confirm these findings.

Section snippets

Background

A caregiver is an unpaid individual who assists another person with day-to-day activities including eating, personal hygiene and other essential tasks (Care Act, 2014). In the United Kingdom (UK), there are approximately 5.8 million caregivers (1 in 10 adults) providing support to the infirm, disabled or very elderly (Office for National Statistics, 2013). The caregiving role can lead to increased depression, anxiety, burden, post-traumatic stress and decreased self-efficacy (Bandeira et al.,

Methods

This systematic review and meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (PRISMA) (Moher, Liberatti, Tetzlaff, & Altman, 2009).

Study selection

The search strategy identified 2287 studies for possible inclusion, 2267 were excluded after reading the title or abstract. The full texts of 20 studies were accessed to determine eligibility and ten met the inclusion criteria (Fig. 1). These ten were reviewed for study design, participant characteristics, intervention and outcomes and the relevant data were entered into Review Manager (RevMan, 2012).

Study characteristics

Eight studies measured seven outcomes and supplied data suitable for meta-analysis (Ashley

Discussion

This review and meta-analysis investigated the effect of written emotional disclosure (WED), a form of writing therapy, on the mental and physical health of informal caregivers. Meta-analysis demonstrated that WED alleviates symptoms of trauma and avoidance (a subscale of trauma) and can significantly improve general psychological health in caregivers. Our meta-analysis found no evidence of efficacy on outcomes of depression, anxiety, burden, intrusion, somatic symptoms/physical health,

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It is important for an individual to be aware of and express their emotions, and writing about these emotions is an appropriate method of expressing them [40]. This method has been widely used in various populations including family caregivers, and appears to offer psychological and physical health benefits [41]. Furthermore, it has been shown that, compared with people with low emotional competence, those with high emotional competence can manage their emotions more effectively and may be more successful at solving emotional problems and managing stress; as a result, they may be more productive and positive in their family and social relationships [42].
There are many effective palliative care programs for patients with advanced cancer. However, little is known about effective programs for family caregivers of patients with advanced cancer, especially in home-based palliative care settings. This study aimed to determine the effect of the Online Daily Diary (ONDIARY) program on the quality of life (QOL) of family caregivers of patients with advanced cancer in home-based palliative care settings.
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Writing about emotional experiences has been found to have a positive effect on psychological wellbeing through the development of insight about the experience, and the disclosure of emotions (Pennebaker, 1997). Written emotional exposure has been found to support the psychological wellbeing of caregivers in other settings (Riddle et al., 2016). Diaries written exclusively by relatives raises the question about who the diary is for and limits the ability for the diary to provide a source of medical information which may need to be met in another way as information is one of the key needs for relatives during an ICU admission (Bijttebier et al., 2001; Verhaeghe et al., 2005).
Intensive care patient diaries written by staff and/or relatives are widely used in intensive care units (ICUs) across the world. Although the original aim of the diaries was to support patients in their recovery from ICU, a more recent focus of the literature has been the potential benefit of the diaries to the relatives of patients. Meta-analyzes of quantitative studies looking at the impact on the psychological wellbeing of relatives have not consistently found an effect of the diaries, even though qualitative studies suggest that relatives find the diaries to be a useful coping strategy.
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A systematic review and qualitative synthesis.
A structured search using CINAHL, MEDLINE, PsycInfo, Cochrane Central Register of Controlled Trials (CENTRAL), PTSDHubs and Published International Literature Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities was conducted.
All studies published at any time that included qualitative data (including mixed methods studies) about the perceptions of relatives using ICU patient diaries were included. Themes and narrative statements were extracted from included articles and synthesised. Articles were quality assessed using the Critical Appraisal Skills Programme (CASP) qualitative checklist and Mixed Methods Appraisal Tool (MMAT).
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Relatives use the diaries in a variety of ways including as a means of coping, a way of staying connected, as a tool to understand and develop a narrative about the experience. These findings link the use of ICU diaries with literature on written emotional exposure, post-traumatic growth and meaning making. The relationship between a relative's use of the ICU diary, coping strategies and/or post-traumatic growth could be a focus for future quantitative trials.
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Another language-based coping strategy is emotion disclosure, sometimes referred to as expressive writing. Verbal disclosure of traumatic experience, such as simply writing about the experience for 20 min, can improve physical and psychological well-being in the long-term (reviewed in Frattaroli, 2006; Hemenover, 2003; Pennebaker, 1997), including psychological health benefits among individuals with major depression (Krpan et al., 2013) and among caregivers (reviewed in Riddle et al., 2016). The mechanisms underlying the benefits of disclosure are complex and varied, but they include promotion of self-efficacy (Hemenover, 2003) and self-distancing (Park et al., 2016) (see Sections 4.2.3.
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View all citing articles on Scopus

View full text

Does written emotional disclosure improve the psychological and physical health of caregivers? A systematic review and meta-analysis

Highlights

Abstract

Section snippets

Background

Methods

Study selection

Study characteristics

Discussion

Journal of Psychosomatic Research

Effects of emotional disclosure in caregivers: moderating role of alexithymia

Stress and Health

Psychological distress in Brazilian caregivers of relatives with dementia

Aging & Mental Health

Reducing maternal psychological distress after the NICU experience through journal writing

Journal of Early Intervention

Reducing symptoms of trauma among carers of people with psychosis: pilot study examining the impact of writing about caregiving experiences

Australian and New Zealand Journal of Psychiatry

The effects of guided written disclosure on psychological symptoms among parents of children with cancer

Journal of Family Nursing

Experimental disclosure and its moderators: a meta-analysis

American Psychological Association

Cochrane handbook for systematic reviews of interventions, Version 5.1.0

Is it safe to write? Evaluating the short-term distress produced by writing about emotionally traumatic experiences

Psychosomatic Medicine

Feasibility and participant experiences of a written emotional disclosure intervention for parental caregivers of people with psychosis

Stress and Health

Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors

Journal of Pediatric Psychology

Chronic stress alters the immune response to influenza virus vaccine in older adults

Proceedings of the National Acadamy of Sciences of the United States of America

Does writing about suicidal thoughts and feelings reduce them?

Suicide and Life-Threatening Behavior

Does expressive writing reduce stress and improve health for family caregivers of older adults?

Gerontologist

Seeing the glass half full: optimistic expressive writing improves mental health among chronically stressed caregivers

British Journal of Health Psychology

Effects of Guided Written Disclosure Protocol on mood states and psychological symptoms among parents of off-therapy acute lymphoblastic leukemia children

Journal of Health Psychology

Informal caregivers of clients with neurological conditions: profiles, patterns and risk factors for distress from a home care prevalence study

BMC Health Services Research

Preferred reporting Items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Medicine

The parental experience of having an infant in the newborn intensive care unit

The Journal of Perinatal Education