Positive expressive writing as a self-help intervention for improving perceived stress, anxiety and physical symptoms following the Covid-19 pandemic

Background and rationale
The Covid-19 pandemic has had a profound impact on public health and wellbeing, and a global mental health pandemic is anticipated for many years to come (as evidenced following previous pandemics [1]). Factors such as financial uncertainty, caring responsibilities, social distancing and isolation, and quarantine have led to heightened psychological distress and anxiety (2-4), and these adverse effects have not only been observed in those with pre-existing mental health conditions (5), but those with no previous diagnoses have also shown worsened psychological health and increases in symptoms (6). To limit the strain on mental health services (7) it is essential that interventions are developed and targeted for populations with sub-clinical symptoms that are widely accessible, easily administered and cost-effective. Evidence shows that self-help activities were one of the most popular methods of mental health support during lockdown (8), which suggests that there is a demand for this type of intervention and serves as an avenue for current research.

One potential self-help technique is positive expressive writing, which involves writing expressively and in detail about positive qualities or experiences in life. Positive expressive writing is developed from the traditional written emotional disclosure (WED) paradigm, which involves writing about traumatic experiences for 15 to 20 minutes per day over three consecutive days (9). Considerable evidence shows that WED conveys a range long-term physical and psychological health benefits (10-11), however, the immediate psychological distress often reported following WED (12) means that it would likely need delivering with additional support and would be less appropriate served as a self-help intervention. Preliminary findings suggest that positive writing engenders similar health benefits as WED (10), including improvements in anxiety, perceived stress and depression (13-14). Although, there is less of an evidence-base for the positive writing paradigm, particularly concerning the potential long-term health benefits, therefore further research is needed before this technique can be recommended for use in the general population.

The aim of this study is to investigate the effects of a positive expressive writing intervention, delivered online for 20 minutes per day over three consecutive days, on self-reported perceived stress, anxiety and physical symptoms when compared to a neutral control writing activity and a guided imagery activity. The use of a subjective physical symptoms measure in this study is based upon previous findings showing the benefits of expressive writing on physical health (15), as well as the relationship between psychological distress and physical symptoms (16). In addition, the use of a guided imagery activity as a comparison group is to observe whether positive writing engenders similar beneficial effects to a well-established technique for alleviating psychological distress and anxiety (17-18).

Primary Aim

  • Assess the immediate, mid-term (2-week follow-up) and long-term (3-month follow-up) effects of a three day online positive expressive writing intervention on self-reported perceived stress, anxiety and physical symptoms, when compared to a neutral writing control activity and a guided imagery activity

Exploratory Aim

  • Assess whether there is a difference between the positive expressive writing and guided imagery conditions with respect to immediate changes in state anxiety from pre- to post-writing, as well as changes in perceived stress, trait anxiety and physical symptoms from baseline to the two follow-up points

The study will use an experimental, independent groups design and will take part entirely online using the survey platform Qualtrics. Participants will be asked to take part in a 20-minute online activity with writing for once a day over three consecutive days and complete measures on physical and psychological wellbeing at baseline, immediately pre- and post-writing, and at two follow up points (2 weeks and 3 months following the final writing day). Participants will be randomly allocated to one of three conditions: 1) positive expressive writing, 2) neutral control writing and 3) guided imagery.

Following informed consent, participants will complete baseline measures on trait anxiety, perceived stress and physical symptoms using the State-Trait Anxiety Inventory (STAI; 19) trait anxiety subscale, the Perceived Stress Scale (PSS; 20) and the Cohen Hoberman Inventory of Physical Symptoms (CHIPS; 21), retrospectively.

Participants will be randomised to one of the three conditions and will be asked to complete measures of state anxiety immediately pre- and post-writing using the STAI state anxiety subscale.

1) Positive writing
Participants will write for 20 minutes about the most intensely positive experience or experiences of their lives (22). Participants will be allowed to write about the same experience or different experiences each of day of writing.

2) Neutral control writing
Participants will write for 20 minutes about what they did the previous day, from the time they woke up to the time they went to bed, in an objective and factual manner (22).

3) Guided imagery
Participants will listen to a 10-minute audio clip involving external instructional guidance of a walk through a forest whilst imagining all of the sensory experiences. Participants will then write for 10 minutes about their guided imagery experience.

Participants will again complete the STAI trait anxiety subscale, PSS and CHIPS two weeks following, and three months following the final writing session.

Sample size
Participants will be recruited via Prolific. A priori power analysis using G*Power (3 x 3 mixed ANOVA, alpha = 0.05, power = 0.8) indicted that a sample size of 204 participants (68 per condition) is required to observe a small effect (f = 0.10).

Study costs
Participants will be paid £30 for their time, which equates to £5 for each stage of the study (baseline, three writing sessions, two follow-up points). Therefore, we are asking for £8,568 to fund participant payments (including service fee and VAT).

Open science commitment
Key aspects of the study protocol have been preregistered on the Open Science Framework (OSF) at: OSF. Ongoing pilot work for the proposed study is preregistered at: OSF. All findings, study materials, analysis code and data will be made openly available on the OSF once the study is complete.


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