16

Written Emotional Expression

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in Schools
Processing Psychological and Emotional Stress
Through Narrative Writing
Kari A. Sassu, Melissa A. Bray, Nicholas Gelbar, and Tiffany P. Kerzner

S chool-based practitioners regularly pursue efficient, effective interventions

that can be readily implemented within the school setting. One such
intervention, written emotional expression, has been applied successfully to
many areas, including health, academic, and social and emotional well-being.
Pennebaker and Smyth (2016) described expressive writing as a simple technique
wherein people typically write about an upsetting experience for a brief period.
This intervention is simple in nature, brief in format, and easy to implement.
Though commonly used to address negative feelings, it has the flexibility to
focus on both negative and positive thoughts and the potential to modify par-
ticipants’ perceptions and facilitate the development of greater coping skills
(Bray et al., 2006). As such, written emotional expression holds considerable
promise for use with a select population of school-age individuals.
Written emotional expression is a form of narrative writing in which the sub-
ject describes his or her feelings, with little regard for writing conventions. As
an intervention, written emotional expression requires few resources and has
proven successful with individuals who possess the requisite skills and have
reached an appropriate developmental level to engage in the writing tasks.
To engage in written emotional expression, individuals typically write their
thoughts on paper or type into a computer in response to a story starter. The
story starter could prompt the individual to write about thoughts that cause
them distress or those that give rise to happy feelings. Outcomes of written
expression as an intervention include decreased feelings of anxiety, reduction

http://dx.doi.org/10.1037/0000157-017
Promoting Mind–Body Health in Schools: Interventions for Mental Health Professionals,
C. Maykel and M. A. Bray (Editors)
Copyright © 2020 by the American Psychological Association. All rights reserved.
Promoting Mind–body Health in Schools: Interventions for Mental Health  245
Professionals, edited by C. Maykel and M. A. Bray
Copyright © 2020 American Psychological Association. All rights reserved.
 246  Sassu et al.

in stress levels, and the heightened ability to focus on tasks at hand (Bray
et al., 2006). Given the ease with which this technique can be implemented,
it remains a feasible option for school-based practitioners to use with select
students.

THEORETICAL AND EMPIRICAL SUPPORT

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Support for the use of written emotional expression as a psychological inter-

vention has grown over the past several decades (Manier & Olivares, 2005).
Benefits derived from the use of written emotional expression include improved
physiological functioning, seemingly validating a common and longstanding
belief among many psychologists in the power of a mind–body connection.
In addition, the use of written emotional expression has effectively led to
changes in social behavior, thereby allowing individuals to access more readily
the scripts they have composed when discussing their thoughts with others
(Manier & Olivares, 2005).
Written emotional expression allows the participant to express feelings,
thoughts, and ideas and to address conflicts without having to engage
with another person. For some, this may be preferable to the traditional
dialogue aspect of cognitive behavioral therapy because they may be more
inclined to articulate their thoughts when they do not feel as though they
are being “judged” by an other. That is, recording one’s thoughts in written
format may allow for an uninterrupted expression of emotion whereby one
can explore one’s thoughts as they occur and revisit those recorded cogni-
tions for further exploration at a later time. For others, written expression
may be a means by which to enhance the dialogue involved in talk therapy,
either serving as an agenda or starting point for a conversation shared with
one’s therapist or counselor. Thus, written expression offers flexibility as an
intervention; it may be used in such a way as to organize one’s thoughts
so that the individual can revisit these thoughts either with a counselor or
independent of one.
Pennebaker and Smyth (2016) suggested that “writing is a natural human
activity . . . [in that] it helps us to integrate and organize our complicated
lives” (p. 72). As such, writing may help us to process complicated ideas,
purge problems, and clear our minds of troubling thoughts. Within the school
setting, if a student is provided the opportunity to briefly write down plaguing
thoughts or ideas as they are occurring in the classroom, he or she may be
able to effectively refocus on the presenting academic task because they have
created a “placeholder” for those thoughts, which then can be revisited at a
more appropriate time within in a counseling session or elsewhere. Conse-
quently, this may allow the student to devote the cognitive energy necessary
to attend to the task at hand, temporarily freeing her or his mind of the
preoccupying thoughts. This may provide students with the assurance that
they have recorded their concerns, which will remain in that repository until
 Written Emotional Expression in Schools 247

a point at which they are allowed to return to them and process them. As a
result, this simple intervention may allow the student to develop related skills
including improved self-management and self-awareness. In this way, written
emotional expression might be considered a form of self-help therapy because
it serves to help participants understand and address emotionally challenging
circumstances or events (Pennebaker & Smyth, 2016).
Written emotional expression has demonstrated positive outcomes in both
school-based and clinical applications. It has improved the academic out-
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comes of students across myriad content areas. In particular, written emotional

expression has reduced depression, anxiety, and stress and improved happi-
ness in school-aged students as well as the adult population (Martin, 2007).
Within a school-based setting, written emotional expression has demonstrated
positive outcomes for a variety of behavioral, social–emotional, and academic
outcomes (Pennebaker & Smyth, 2016; Travagin, Margola, & Revenson, 2015).
For example, in a study by Patwa and colleagues (2018), a writing intervention
was applied to externalizing behaviors and successfully resulted in increased
levels of attention and the promotion of appropriate classroom behavior.
In this study, a writing intervention focused on gratitude was used to reduce
off-task behaviors including noncompliant, inattentive, and mildly aggressive
behaviors (see Patwa et al., 2018). Gratitude writing is a simple and effec-
tive type of written emotional expression that been shown to lead to fewer
physical symptoms, heightened optimism, improved life satisfaction, increased
positive emotions, higher levels of attention, and a greater likelihood of offering
help and support (Reivich, 2009). The written expression intervention used
by Patwa and colleagues involved daily 10-minute writing exercises in which
the student was prompted to write a letter expressing gratitude to someone they
had not yet had the chance to thank. The study found that the gratitude writing
intervention was effective in reducing disruptive behavior in students with
off-task, noncompliant, inattentive, and mildly aggressive behaviors, thereby
demonstrating the utility of written emotional expression for externalizing
behaviors in a school-based setting.
Clinical research has demonstrated that written emotional expression applied
to physical health and wellness has proven effective in improving quality of life
indicators across many health areas including cancer, asthma, diabetes, and
cardiovascular disease, among others (Bray et al., 2006; Van Koningsbruggen
& Das, 2009). It also has worked quite reliably to increase coping strategies in
these patients (Pennebaker & Smyth, 2016). Asthma is one disease for which
written emotional expression has improved both small and large airway
functioning (Bray et al., 2006). The hypothesis in these investigations is that
anxiety and/or depression was implicated in the reduced lung values, and
when the written exercise was used, it decreased the internalizing behaviors,
and as a result, lung functioning increased. Standardized spirometry has been
the objective tool used in these studies to measure the dependent variables,
FEV1 (forced expiratory volume in 1 second) and FEF25-75 (forced expiratory
flow at 25%–75% of the pulmonary volume).
 248  Sassu et al.

Beyond this example of improved lung functioning, other health areas have
mainly focused on improving coping strategies among individuals living with
chronic pain and promoting happiness and life satisfaction during difficult
health periods. In particular, cancer patients have used written emotional
expression to mediate the stress of initial diagnosis as well as the effects of
chemotherapy treatment (Root et al., 2016). In these cases, the patients have
written expressively about their negative thought patterns as they relate to
fears about a reduction in their life span and perceived impact on their
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families. Females with breast cancer, who were members of a written emo-
tional expressive group, reported lowered rates of experienced physical
symptoms, less frequent medical appointments, and fewer cancer-related
comorbidities than the control subjects (Stanton et al., 2002).
In all aforementioned cases, the writing exercises increased positive
subjective well-being and decreased negative emotions. Of particular note,
depression and anxiety, with or without health impairments, are uniquely
sensitive to the effects of written emotional expression (Bray et al., 2006).
Writing about fears and sadness has been shown to impact both of these mood
disorders positively. Interestingly, the patients are not asked to write about
anything other than their thoughts regarding current presenting challenges,
and the only directive provided is to write continuously for the full time allot-
ment (typically approximately 20 minutes); no other specific instructions or
guidelines are provided.

Meta-Analytic Outcomes

The initial meta-analysis of written emotional expression (see Smyth, 1998)

indicated that the early studies demonstrated robust effect sizes (mean Cohen’s
d = 0.47). However, the variability in the observed effect sizes across studies
was considerable, and most of the studies up to that point were conducted
using convenience samples of college students. As the intervention has been
studied with different populations, by different research teams, and/or with
different outcomes measured, the effect sizes have been medium or higher
(Frattaroli, 2006; Frisina, Borod, & Lepore, 2004). It should be noted that
a curvilinear relationship has been found with respect to the level of dis-
tress and the derived benefit of written emotional expression. That is, those
experiencing either high or low levels of distress are less likely to derive
benefit from written emotional expression, whereas those experiencing
moderate levels of distress are likely to derive the greatest benefit (Manier
& Olivares, 2005).
Frisina and colleagues (2004) noted that written emotional expression
may be more effective in clinical populations; they observed a greater effect
size in their meta-analysis (mean d for physical health outcomes = 0.21) than
found in meta-analyses that included samples drawn from the general popu-
lation (Frattaroli, 2006; Travagin et al., 2015). Individuals from the general
population may experience a ceiling effect, at which point it is not possible
 Written Emotional Expression in Schools 249

for them to improve on the outcome measures. Germane to this chapter,

Travagin and colleagues (2015) conducted a meta-analysis of expressive
writing interventions for adolescents that found an average small, positive
effect across studies. A systematic review conducted by Holder-Spriggs (2015)
concurred with the results from the Travagin et al. study but also included
studies using samples of children. Holder-Spriggs indicated that there is a
paucity of research in this area; however, what has been found is promising.
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Special Considerations

Overall, written emotional expression is an intervention that requires little

in the way of resources or time to implement. Further, written emotional
expression can be easily added to traditional cognitive–behavioral approaches
as a homework assignment. However, the efficacy of written emotional
expression has varied over time and across research teams, outcomes, and
dosages (Holder-Spriggs, 2015), which means that school-based professionals
hoping to adopt this intervention should exercise caution when choosing
students who could potentially benefit, and these practitioners should be
certain to monitor the derived benefits effectively.
Taken together, the results of the meta-analyses discussed earlier indicate
that adolescents and adults experiencing moderate or greater levels of psycho-
logical distress may be the most likely to profit from this intervention (Manier
& Olivares, 2005). It is a task that students and adults with the requisite skills
can complete independently with little direction. Adolescent and adult popu-
lations are more likely to have the abstract reasoning and emotional devel-
opment necessary to be able to access the therapeutic benefits of written
emotional expression. When considering who would benefit most from this
intervention, it is important for practitioners to consider an individual’s ability
to engage in abstract reasoning as well as their ability to explore their emo-
tions. Modifications to assist a wider range of individuals with varying levels
of abstract reasoning in accessing this intervention are offered subsequently.
It is suggested that clinicians focus on building the prerequisite skills of emo-
tional awareness before using this intervention with individuals who may
not have the emotional development necessary to access the intervention.
To fully access this intervention, individuals must also have the writing
skills necessary to be able to complete the required tasks. That is, they have to
be able to write fluently about their feelings and thoughts, without the need
to expend cognitive energy on the conventions of writing (e.g., spelling,
formatting, phrasing), which are of little import to the technique.
Younger children and those without these requisite skills will not likely
gain from an open-ended approach to written emotional expression. In par-
ticular, this approach may be less efficacious for individuals with disabilities
who, because of the nature of their disability, may not possess these skills.
For example, students who struggle with writing would not likely benefit
from this intervention approach because their cognitive resources would be
 250  Sassu et al.

devoted to the task of writing itself versus being focused on the emotional dis-
closure aspect of the task. As noted previously, this aspect has been theorized to
be one of the potential key ingredients of written emotional expression. In
addition, those individuals who are incapable of introspecting or considerably
limited in their abilities to introspect also are unlikely to derive much benefit
from this intervention. Ultimately, the decision to implement this intervention
with students of varying abilities should include consideration of whether the
activity will likely result in greater benefit than frustration. For some students,
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the task of writing itself may increase frustration or anxiety due to individual
challenges; others without the inherent skills still may derive the intended
benefit if accommodations are provided.
Modifications to the technique could be considered for individuals who
lack certain skills but for whom it is anticipated that emotional benefit could
be derived using this technique. For example, individuals for whom the motor
component of writing is difficult could be encouraged to use a form of tech-
nology such as voice-to-text. Others for whom the process of writing is difficult
due to executive functioning challenges might be provided with not only the
questions to prompt thought but also sentence starters to guide writing. This
second accommodation may also be beneficial for individuals whose abstract
reasoning ability might have precluded the use of this intervention strategy.
Though these accommodations do not represent the typical implementation
of this technique, they may allow for more effective and widespread use in
a tiered system within the school setting.

School-Based Application of Written Expression

Within a Tiered System

Within a school-based setting, written emotional expression interventions

typically involve engaging a student with a writing prompt for 10 to 20 min-
utes each day. The specific prompts can take many forms; some, such as
gratitude writing, use a positive psychology approach, whereas others focus
on expressing current feelings, fears, or challenges through writing. As with
all school-based interventions, monitoring the progress of the student’s target
behaviors should continue to determine intervention effectiveness.
Because evidence indicates that clinical populations seem to reap greater
benefits from written emotional expression (Frisina et al., 2004), this inter-
vention is best conceptualized as a Tier 2 or Tier 3 intervention within the
school setting. However, this does not preclude its use as a Tier 1 intervention.
Because it requires few resources to implement, it can be completed by
students independently, and it is largely innocuous (i.e., it is not likely to
cause harm). Thus, when adapting and using this intervention for nonclinical
samples, interventionists must use clinical judgment to determine the appro-
priateness and potential benefits of Tier 1 use. For example, written emotional
expression might be beneficial as a Tier 1 intervention when used class wide
to alleviate test anxiety or as a method of stress reduction for all students.
 Written Emotional Expression in Schools 251

This would likely be presented differently in the lower grades than the
upper grades. For example, elementary teachers might provide students
with a sentence starter and guidance such as, “The upcoming test makes me
feel ____ because ____. Write one to two additional sentences about how you
are feeling.” High school teachers might ask students to use a blank piece of
paper and write a brief (e.g., 5–10 minutes) response to the question of how
they are feeling about an upcoming test or a recent stressful event.
As a school-based intervention, written emotional expression may be par-
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ticularly suited for use as a Tier 2 intervention for students who are at risk of
psychological and/or behavioral difficulties because it can easily be delivered
as a group intervention. As a Tier 2 intervention, it may even be beneficial
for adolescents who have experienced adverse childhood events or trauma;
it has been implemented successfully with adolescents who were refugees
(Kalantari, Yule, Dyregrov, Neshatdoost, & Ahmadi, 2012; Neuner, Schauer,
Klaschik, Karunakara, & Elbert, 2004). At the Tier 2 level, integrating written
emotional expression into small group interventions could easily be done
using a homework format, allowing for further reflection and emotional
processing outside of group intervention sessions. Depending on age and
abilities, students might be provided with specific questions to ponder or
sentence starters to guide writing.
Finally, the research supports the use of written emotional expression with
clinical samples (Frisina et al., 2004). Thus, it certainly could be used either as
a stand-alone Tier 3 intervention or in combination with other intervention
approaches such as cognitive behavior therapy. Again, it should be emphasized
that adolescents experiencing significant physical or psychological distress
may be ideal targets for this intervention at the Tier 3 level because they are
most likely to possess the abstract reasoning, emotional development, and
writing skills necessary to access the therapeutic benefits of written emotional
expression. In a Tier 3 context, it is imperative that clinicians monitor the
writing samples produced by the students because students may indicate higher
levels of emotional distress and/or thoughts of self-harm than they would
when talking directly with the clinician or within a group. It should be noted
that the intervention may initially increase negative feelings because it may
bring difficult experiences to the surface to be processed (Pennebaker & Smyth,
2016). This underscores the importance of actively monitoring students’
writing such that an appropriate response to these potential consequences
can be efficiently delivered.

SCHOOL-BASED CASE EXAMPLE

Sienna is a sixth-grade student exhibiting high levels of off-task behaviors in

the classroom. Her teacher reported that Sienna was often verbally disruptive
during classroom instruction or was simply passively disengaged in the class
activities. The school psychologist conducted a series of classroom observations
 252  Sassu et al.

using the Behavioral Observation of Students in Schools (BOSS; Shapiro,

2003). After three observations, it was found that Sienna was academically
engaged, on average, only 59% of the time. In addition, she engaged in off-task
behaviors 58% of the time. On reviewing this data, the team decided to begin
the response to intervention process by implementing a written emotional
expression intervention. Gratitude writing, specifically, was chosen because
evidence has supported its efficacy in decreasing off-task behavior. Further,
Sienna has demonstrated that she possesses the skills required to engage in
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writing tasks, and her teacher reported that, when engaged, she was often able
to convey her thoughts effectively.
Each day during language arts, the teacher sent Sienna to the school
psychologist’s office at a time when she would not be missing direct instruc-
tion. When Sienna arrived in the school psychologist’s office, she was given a
prompt to write a letter expressing gratitude to someone she had not yet had
the chance to thank. She was given 10 minutes to complete the task, she
reviewed the letter with the school psychologist to ensure task engagement,
and then she returned to class with her letter. She was told she may give the
letter to the person she wrote about, but it was not required that she do so.
During intervention implementation, the school psychologist completed
biweekly classroom observations using the BOSS to measure academic engage-
ment and off-task behaviors. Sienna’s classroom engagement increased steadily,
and after 4 weeks of the intervention, Sienna’s academic engagement reached
95% or higher for four consecutive observations. Further, Sienna’s off-task
behaviors remained below 5% for four consecutive observations. The inter-
vention was then discontinued, though follow-up observations occurred three
times the following week to ensure maintenance. Sienna’s academic engage-
ment and off-task behaviors remained consistent with intervention values,
demonstrating a positive response to the gratitude writing intervention.

CONCLUSION

Written emotional expression is an intervention that requires minimal

resources and can be adapted for use across tiers. It can be combined with other
forms of intervention and used in combination with a variety of behavioral
measurement tools. However, the effectiveness of this intervention is likely
to vary according to the skill levels of participants as they relate to writing,
expression, introspection, and reflection. Further, the level of participants’
distress also is likely to impact the degree of this intervention’s effectiveness,
with moderately distressed individuals reporting the greatest improvements.
Research has suggested that, within the school setting, written emotional
expression may be best suited for adolescents and preadolescents experienc-
ing moderate levels of psychological or emotional distress, supporting its use
at Tiers 2 and 3. This population is likely to be the most suitable for the use
 Written Emotional Expression in Schools 253

of written emotional expression as an intervention because they are likely to

possess the requisite skills required for effective implementation. Further, the
adaptability and feasibility of this intervention as a part of a treatment plan
makes it an appealing choice for use within the school setting.

REFERENCES
Bray, M. A., Kehle, T. J., Peck, H. L., Margiano, S. G., Dobson, R., Peczynski, K., . . .
Copyright American Psychological Association. Not for further distribution.

Alric, J. M. (2006). Written emotional expression as an intervention for asthma:

A replication. Journal of Applied School Psychology, 22, 141–165. http://dx.doi.org/
10.1300/J370v22n01_08
Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis.
Psychological Bulletin, 132, 823–865. http://dx.doi.org/10.1037/0033-2909.132.6.823
Frisina, P. G., Borod, J. C., & Lepore, S. J. (2004). A meta-analysis of the effects of
written emotional disclosure on the health outcomes of clinical populations.
Journal of Nervous and Mental Disease, 192, 629–634. http://dx.doi.org/10.1097/
01.nmd.0000138317.30764.63
Holder-Spriggs, J. (2015). Expressive writing interventions for children and young people:
A systematic review and exploration of the literature (Doctoral dissertation). Retrieved
from https://eprints.soton.ac.uk/389518/1/JHS%25201.1%2520Thesis%2520with
%2520amendments%2520without%2520signature.pdf
Kalantari, M., Yule, W., Dyregrov, A., Neshatdoost, H., & Ahmadi, S. J. (2012). Efficacy
of writing for recovery on traumatic grief symptoms of Afghani refugee bereaved
adolescents: A randomized control trial. Omega: Journal of Death and Dying, 65,
139–150. http://dx.doi.org/10.2190/OM.65.2.d
Manier, D., & Olivares, A. (2005). Who benefits from expressive writing? Moderator
variables affecting outcomes of emotional disclosure interventions. Counseling and
Clinical Psychology Journal, 2, 15–28.
Martin, M. W. (2007). Happiness and virtue in positive psychology. Journal for the
Theory of Social Behaviour, 37, 89–103. http://dx.doi.org/10.1111/j.1468-5914.
2007.00322.x
Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004). A comparison
of narrative exposure therapy, supportive counseling, and psychoeducation for
treating posttraumatic stress disorder in an African refugee settlement. Journal
of Consulting and Clinical Psychology, 72, 579–587. http://dx.doi.org/10.1037/
0022-006X.72.4.579
Patwa, S., Cross, K., Bray, M. A., D’Orio, R., Kim, S., & Bryne, D. (2018). Gratitude
writing as an intervention for off-task behavior. Manuscript submitted for publication.
Pennebaker, J. W., & Smyth, J. M. (2016). Opening up by writing it down. New York, NY:
Guilford Press.
Reivich, K. (2009). Fishful thinking: Cultivating gratitude in youth. Communique,
38(3), 1–20.
Root, M., Bray, M. A., Maykel, C., Cross, K., Shankar, N., & Theodore, L. A. (2016).
Students with cancer: Presenting issues and effective solutions. The International
Journal of School and Educational Psychology, 4, 25–33. http://dx.doi.org/10.1080/
21683603.2016.1130549
Shapiro, E. S. (2003). Behavioral Observation of Students in Schools (BOSS) [Computer
software]. San Antonio, TX: Psychological Corporation.
Smyth, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and
moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.
http://dx.doi.org/10.1037/0022-006X.66.1.174
 254  Sassu et al.

Stanton, A. L., Danoff-Burg, S., Sworowski, L. A., Collins, C. A., Branstetter, A. D.,
Rodriguez-Hanley, A., . . . Austenfeld, J. L. (2002). Randomized, controlled trial of
written emotional expression and benefit finding in breast cancer patients. Journal
of Oncology, 20, 4160–4168. http://dx.doi.org/10.1200/JCO.2002.08.521
Travagin, G., Margola, D., & Revenson, T. A. (2015). How effective are expressive
writing interventions for adolescents? A meta-analytic review. Clinical Psychology
Review, 36, 42–55. http://dx.doi.org/10.1016/j.cpr.2015.01.003
Van Koningsbruggen, G. M., & Das, E. (2009). Don’t derogate this message! Self-
affirmation promotes online type 2 diabetes risk test taking. Psychology & Health,
Copyright American Psychological Association. Not for further distribution.

24, 635–649. http://dx.doi.org/10.1080/08870440802340156