The Therapeutic Effect of Expressive Writing.

Background:

Body-Compassion

A particular focus of this research is to further contribute towards an understanding of body-compassion. While many studies have explored the concepts of body image and self-compassion with people who have a cancer diagnosis, there is limited research exploring the concept of body compassion with this population. As a construct that has only recently been formally defined, body compassion reflects the aspects of kindness, human connectedness, and mindfulness toward the body. Self-compassion is seen to promote body compassion, which, in turn, acts as a buffer against distressing events that threaten one's body image. The growing interest in this concept has led to the development and validation of body compassion measures. The 'Body Compassion Scale' developed by pioneered the development of a measure of body compassion. This scale was followed by the development and validation of 'The Body Compassion Questionnaire'. The concept of compassion directed towards the body seems highly salient for people with cancer. It would be worth building on current evidence about the role of body compassion in cancer by utilising body-compassion measures to further understand this construct and the experience of having cancer-related body change.

Compassion-based interventions

Over the past two decades, there has been a growing interest in developing evidence-based interventions to support people individually and in groups to foster a sense of compassion (Kirby \& Gilbert, 2017). Compassion-focused Therapy (CFT), developed by Gilbert (2014), and Mindful Self-Compassion by Neff and Germer (2013), are two approaches that apply the importance of facing one's suffering with the motivation to take action to reduce this suffering through self-soothing techniques. These psychological approaches include interventions to support the development of the compassionate self through imagery, breathing exercises, mindfulness, and letter writing. A compassion-focused model applies a compassionate approach to regular psychotherapy, allowing the relatively unrestricted incorporation of compassion-based interventions in clinical practice (Kirby, 2017). Group interventions have built on the CFT framework to reduce self-criticism and foster self-compassion (Kirby et al., 2017). A number of randomised control trial (RCT) studies involving such interventions indicate clinical improvements and a sustained increase in self-compassion (Arimitsu, 2016; Braehler et al., 2013). RCT studies with cancer patients have also yielded promising evidence related to mindfulness and compassion-focused interventions within a clinical setting (O'Gara et al., 2022; Tan et al., 2023)

Expressive Writing

The interest in mindfulness and self-compassion in clinical psychology is also linked with the development of expressive writing (EW) by psychologist Pennebaker in the 1980s (Adams, 2013; Lam, 2024). EW offers a simple, cost-effective means of experiencing the therapeutic effects of writing one's thoughts and feelings (Kupeli et al., 2019). The theories underpinning the effects of EW suggest that the uninhibited confrontation of thoughts surrounding a traumatic life event allows for the reappraisal of the event, reduction in rumination, and an opportunity to gain mastery and control over negative emotions associated with the experience (Lepore et al., 2002; Lowe, 2006). As a result, research has shown that EW can improve physical and psychological health outcomes in clinical populations (Frisina et al., 2004).

Some studies have been interested in understanding how a writing exercise such as EW can be adapted to promote self-compassion and potentially increase the therapeutic benefits of EW (Baum \& Rude, 2013; Kalianivala, 2019). In one study, Compassion-focused EW demonstrated a reduction in negative affect in an experimental study with people writing about stress (Leary et al., 2007). It has also promoted increased self-reported self-esteem and self-soothing in a clinical sample within a hospice setting (Imrie \& Troop, 2012). Such research demonstrates the versatility and the potential benefit of incorporating self-compassionate EW in clinical practice as a supplementary tool with individuals and groups (Lam, 2024). Moreover, evidence indicates that cancer patients can benefit from compassionate EW (Przezdziecki et al., 2013).

The use of Language

The impact of EW can be explored using outcome measures, but it can also be further enhanced by analysing writing scripts. The writing content provides meaningful insight into factors that could contribute to perceptions of the body and the cancer experience (Kaptein et al., 2024). Writing texts can be analysed manually, but such a process would take time and can be subjective. Computerised software such as the Linguistic Inquiry and Word Count (LIWC) provides a more efficient and objective method of analysing linguistic content (McDonnell et al., 2020; Pennebaker et al., 2001). Some word categories within the LIWC include linguistic dimensions such as personal pronouns and prepositions, emotion words, and cognitive words (Boyd et al., 2022). A PubMed search by Kaptein et al. (2024) indicated 17 studies that utilised the LIWC methodology with a cancer population. Most of these studies analysed text to make inferences on the impact of interventions on the number of particular words used and effects on health outcomes (Laccetti, 2007; Martino, 2015). Such aspects provide meaningful insight and are worth exploring further in new research. Moreover, it is important to shed further light on people's experiences of embedded writing tasks such as EW within the context of local support services.

The Clinical Application of this Study

One way of exploring the feasibility of incorporating a compassionate writing intervention into clinical practice is to test whether it could be facilitated within a community cancer clinic. Shifting from clinical trials toward community-based contexts provides an opportunity to test the benefit and applicability of research evidence within clinical care. One example is demonstrated by Morgan et al. (2008), who explored the feasibility of incorporating an EW programme into the existing care provision at a cancer centre in the USA. The Cove Macmillan Cancer Support Centre is a local cancer service that offers a range of physical and psychosocial support for people with cancer and their carers. The Cove also offers psychological therapy and support groups for patients in Cornwall. Piloting an EW intervention within this setting allows a local service to collaborate in research and encourages patients' perspectives on their care and support provision at the Cove. This research explores some relatively novel aspects of cancer patients' experiences and contributes to research that can potentially improve patients' physical and psychological health outcomes.

Rationale

Cancer and its treatment can profoundly impact people's lives, especially if they result in permanent changes to the body. Changes to the body's appearance, function, and internal composition affect a person's day-to-day life and cognitive and emotional perceptions of the self (Melissant et al., 2020). Current evidence indicates that compassionate skills can mitigate the adverse emotional effects of events like cancer (Oliveira et al., 2018). Compassion towards the self involves recognising suffering as part of the human condition while seeking to improve this and heal. Research indicates that mindfulness practices, such as expressive writing, can encourage compassionate thinking towards oneself. It is noted that current evidence tends to focus on the role of self-compassion in the context of cancer-related changes in appearance. Alternatively, research exploring the impact of internal body changes on compassion towards the self and the body is limited (Arambasic et al., 2019; Przezdziecki et al., 2013; Todorov et al., 2019). This gap in research has prompted me to explore compassionate thinking in those who have experienced cancer-related changes to their appearance, as well as bodily changes that are less visible but impact functionality and quality of life. This study also aims to conduct a randomised controlled trial to test whether there is a difference in compassion and well-being outcomes between those who complete regular expressive writing and those who complete an expressive writing task that includes a compassionate writing prompt.

Study Design

This project will utilise a quantitative methodology by collecting and analysing questionnaires, standardised outcome measures, and writing scripts. This study will follow a randomised control trial (RCT) design within a heterogeneous cancer patient population. Participants will be randomly allocated either to a writing group with a compassionate writing prompt or to a control writing group with no compassionate prompt. This project will be designed as a pragmatic RCT as it aims to provide information on the feasibility and acceptability of such an intervention at one cancer support site.

Study Procedure

At least 46 participants will be recruited using volunteer and opportunity sampling methods with the support of the staff team at the Cove Macmillan Support Centre. The field supervisor of this project, who is the Clinical Lead of the Psychology Service at the Cove, together with members of the multi-disciplinary team at the Cove (support workers, counsellors, occupational therapists) will support recruitment by directing those who express interest to the Chief Investigator (CI) for more information and study materials (Informed Consent Form (ICF) \& Participant Information Sheet (PIS).

Consent will be gained in person at the Cove or recorded over the phone with those who make contact to volunteer. Once a sufficient sample size is recruited and written consent is acquired, participants will be asked to complete the screening questionnaire (Impact of Events Scale) to confirm their eligibility. Using a computerised random number generator, participants will then be randomly assigned to a compassionate or control writing group.

Prior to commencing the first writing task, participants will complete the pre-writing task questionnaire to gather demographic and medical information and information on previous writing experience. Participants will also be asked to complete standardised measures of body compassion, self-compassion, quality of life and psychological well-being before their first writing task.

Following service user feedback shared with the CI, participants will be given the choice to either attend an in-person group writing task at the Cove Macmillan Centre or they can participate remotely via an online communication platform (e.g., Microsoft Teams or Zoom). Participants will be blinded to the study conditions and invited to attend only one of the two weekly writing groups at the Cove or online for four consecutive weeks, according to their allocated writing conditions. As the primary researcher cannot be blinded to the study conditions, a script will be followed to minimise researcher bias when introducing the study and stating writing instructions.

The writing task will be introduced to participants attending each writing session, advising them to limit distractions and to write freely without focusing on structure, grammar, or spelling (Elbow, 1998). Participants attending the Cove will be provided with the necessary writing materials. A topic will be selected by the researcher for each writing session. Such topics may include reflections on participants' past, present, and future selves, their feelings about their bodies, the impact of their treatment journey on their relationships, and their values. Participants in both writing groups will be asked to write about a topic for 15-20 minutes. In the compassionate writing group, participants will be encouraged to maintain compassion towards themselves and their experiences while writing. Participants in the control writing condition will be given the same instructions, but with no reminder about being compassionate.

Upon completion of each writing task, participants will be asked to hand in their writing scripts and complete the post-writing task questionnaire to gather subjective information about their writing task experience. This process will be repeated after each of the four writing sessions. Participants will only be asked to repeat the standardised measures following their final writing task.

At one-month follow-up after study completion, participants will be contacted to complete the follow-up questionnaire and repeat the standardised outcome measures. Participants will be provided with various options for completing the questionnaires and outcome measures, from the screening stage through to follow-up. These include completing paper versions in person at the Cove, remotely over the phone or through online access using the University of Plymouth-approved platform Jisc. A debrief sheet will also be provided once the study is completed, to clarify the study conditions and the rationale for the procedure and provide signposting for further support if needed. Participants will be provided with this sheet via email and offered the opportunity to discuss or ask further questions to the CI. Participants will also be asked whether they wish to receive study results and will be directed to the Cove team for any further support needed as a result of their participation in the study.