Effects of Emotional Disclosure in Caregivers: Moderating Role of Alexithymia

RESEARCH ARTICLE

Effects of Emotional Disclosure in Caregivers:Moderating Role of AlexithymiaLaura Ashley3*†, Daryl B. O’Connor1*† & Fiona Jones2

1Institute of Psychological Sciences, University of Leeds, Leeds, UK2Department of Psychology, University of Bedfordshire, Bedfordshire, UK3Psychosocial Oncology and Clinical Practice Research Group, St James’s Institute of Oncology, Leeds, UK

Abstract

Caregivers have been found to experience high levels of depression and anxiety. This study explored the efficacy oftwo writing interventions aimed at reducing psychological distress in informal caregivers and examined themoderating effects of alexithymia. Caregivers (N= 150) were randomly assigned to (1) write about the stressrelated to being a caregiver, (2) write about positive life experiences or (3) write about a control topic for 20 minon 3 days at home. Depression and anxiety symptoms were assessed at baseline, 2 weeks, 2 months and 6 monthspost‐intervention. Analysis of variance for a mixed design revealed no main effects of writing condition on thefollow‐up measures. However, among caregivers with lower scores on alexithymia, those who wrote about positiveexperiences reported less anxiety and/or depression on follow‐ups at 2 weeks, at 2 months and at 6 months.Moreover, in the control condition, less anxiety was reported by caregivers with lower scores on alexithymia at2 weeks and at 6 months. No effects of stress disclosure were observed; therefore, writing about caregiver stressshould not be encouraged in this vulnerable group. These findings highlight the importance of examiningmoderating factors, such as individual differences variables as well as exploring the efficacy of alternative writinginterventions. Copyright © 2011 John Wiley & Sons, Ltd.

Received 20 July 2010; Accepted 11 December 2010; Revised 7 December 2010

Keywords

intervention; expressive writing; positive writing; distraction; coping; stress

*Correspondence

Laura Ashley, Psychosocial Oncology and Clinical Practice Research Group, St James’s Institute of Oncology, Leeds, UK; Daryl B. O’Connor,

Institute of Psychological Sciences, University of Leeds, Leeds, UK.†Emails: [email protected]; d.b.o’[email protected]

Published online 31 January 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.1388

Introduction

Informal caregivers are people who, without payment,provide care for relatives or friends who, because ofdisability or illness, could not otherwise manage thebasic activities of daily living. There are currentlyestimated 44.4 million carers in the United States, afigure that, because of an ageing population, is likely torise sharply in the near future (NAC, 2004). Informalcaregiving, which is often undertaken for several years,has long been recognized as stressful; carers haveelevated cortisol levels and report high levels of stressrelative to their non‐caring counterparts (Bandeira et al.,2007; Vedhara et al., 1999). It is not surprising,therefore, that many caregivers suffer psychologicalmorbidity. Indeed, numerous studies have foundcaregivers to report higher levels of depression andanxiety symptoms than non‐caregiving controls (e.g.Aschbacher et al., 2008; Bandeira et al., 2007; Dura,Stukenberg, & Kiecolt‐Glaser, 1991; Haley et al., 1995;

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Shaw et al., 1999; see Pinquart & Sörensen, 2003 for areview). Consequently, it is important to identify inter-ventions that may improve carers’ psychological well‐being. Although there are numerous potentially effectiveinterventions, including psycho‐educational and sociallysupportive interventions, cognitive–behavioural therapyand respite care, most are expensive, relatively timeconsuming and/or based outside of the home. Manycarers, however, suffer financial hardship, have littletime to themselves and find it difficult to be away fromtheir homes and care recipients for any length of time(Wiles, 2003; Yantzi, Rosenberg, & McKeever, 2006).Written emotional disclosure is a low‐cost, briefintervention that can be done at home and is thereforepotentially well suited to this vulnerable group.

Written emotional disclosure, healthand well‐beingOver the past 20 years, numerous studies haveinvestigated the health effects of expressive writing

Stress and Health 27: 376–387 (2011) © 2011 John Wiley & Sons, Ltd.

L. Ashley and D. B. O’Connor and F. Jones Emotional Disclosure and Alexithymia

using a paradigm developed by Pennebaker and Beall(1986). In this paradigm, disclosure participants writeabout their deepest thoughts and emotions aboutstressful or traumatic life experiences, typically for 15to 20 min on three or four consecutive days.Beneficial effects of writing expressively about nega-tive life experiences have been found on a variety ofhealth outcomes including depressive and anxioussymptoms (Epstein, Sloan, & Marx, 2005; Radcliffe,Lumley, Kendall, Stevenson, & Beltran, 2007),implicit self‐esteem (O’Connor et al., 2010), physicalwell‐being (Kelley, Lumley, & Leisen, 1997; Smyth,Stone, Hurewitz, & Kaell, 1999), immune function(Pennebaker, Kiecolt‐Glaser, & Glaser, 1988; Petrie,Booth, Pennebaker, Davison, & Thomas, 1995) andhealthcare utilization (Pennebaker & Beall, 1986;Solano, Donati, Pecci, Persichetti, & Colaci, 2003).

To date, only three published studies have examinedexpressive writing with caregivers (Barton & Jackson,2008; Mackenzie, Wiprzycka, Hasher, & Goldstein,2007, 2008; Schwartz & Drotar, 2004). In a study with54 caregivers of youths with chronic illness, Schwartzand Drotar found no effects of disclosure on mood,psychological well‐being or physical symptoms4 months post‐writing. In a study with 40 caregiversof older adults, Mackenzie et al. (2007) also found noeffects of expressive writing, at a 1‐month follow‐up,on caregiver burden, post‐traumatic symptoms orpsychological well‐being. However, in a small follow‐up study, these authors showed that caregivers whoused increasingly positive, optimistic and future‐focused language reported benefits on mental healthoutcomes (Mackenzie et al., 2008). Barton and Jacksonfound limited benefits of disclosure on post‐traumaticsymptoms 2 months post‐writing in a sample of 37carers of people with psychosis, although no effectswere apparent on psychological well‐being, somaticsymptoms or caregiver burden. Thus, prima facie,disclosure appears to have little benefit for carers.However, previous studies examining the healthbenefits of expressive writing in caregivers have beenrestricted to relatively small samples with limitedfollow‐up. Moreover, caregiver disclosure studies haveneglected to examine moderating effects of individualdifferences variables or explore the efficacy of alternativewriting interventions, despite the growing evidence thatwriting about topics other than stress and trauma, suchas positive events, can also have health benefits (Burton& King, 2004, 2008; Wing, Schutte, & Byrne, 2006).

Writing about positive experiences

A number of recent studies have begun to examine thehealth effects of writing expressively about positive lifeexperiences. Preliminary findings suggest that positivedisclosure can yield benefits on a number of healthoutcomes such as health complaints and health centrevisits as well as on mood and life satisfaction (Burton &King, 2004, 2008; Wing et al., 2006). To our


knowledge, no published studies have examinedpositive disclosure in samples coping with a chronicstressor such as caregiving. This is surprising as theoryand research have highlighted the adaptive functions ofpositive emotions, and the importance of focusing onpositive experiences to foster positive affect, duringchronic stress (see Folkman, 1997 and Fredrickson,1998 for reviews). Folkman, for instance, argued thatpositive emotions provide a psychological ‘breather’from stressors and associated negative emotions andthus may have a restorative effect that helps to sustainthe individuals’ coping efforts. Fredrickson’s ‘broaden‐and‐build’ theory proposes that positive emotionsbroaden the individuals’ thought–action repertoiresand thus serve to ‘undo’ the narrow and fixatedthought and action associated with stress‐inducednegative emotions such as depression and anxiety.Focusing on positive experiences, through infusingordinary events with positive meaning and/or viaremembering past happy events, is one coping strategythat has been found to foster positive emotion duringstressful situations including caregiving. Positive dis-closure, which focuses on happy life experiences andhas immediate positive mood effects, may thus be wellsuited to individuals coping with a chronic stressor likecaregiving (Burton & King, 2004, 2008).

Moderating effects of alexithymia

In an effort to determine for whom disclosure is mostbeneficial, the moderating effects of numerous indi-vidual differences variables have been examined,including sociodemographic characteristics like genderand personality variables such as the ‘Big Five’.Generally, such participant characteristics have notbeen found to moderate disclosure’s effects (Epsteinet al., 2005; Kelley et al., 1997; O’Connor & Ashley,2008; Sheese, Brown, & Graziano, 2004, see Frattaroli,2006, for a review). Consequently, there has been amove away from examining broad, ‘higher‐order’participant characteristics, such as gender and neurot-icism, towards examining more specific personalityfacets explicitly pertinent to the particular task ofwritten emotional disclosure. As the mechanismsunderlying disclosure’s effects are currently unclear(Pennebaker & Chung, 2007; Smyth & Pennebaker,2008), recent focus has been on individual differencesvariables likely to disrupt/prevent engagement indisclosure tasks and thereby presumably the benefitsderived from them. Disclosure tasks require individualsto express their innermost thoughts and emotions andthus demand that individuals can label and interprettheir feelings, that they are able to express them in wordsand that they are willing to do so. Thus, using processmodels of emotional expression (e.g. Kennedy‐Moore &Watson, 1999) as a guide (see Lumley, 2004; Lumley,Tojek, & Macklem, 2002), individual differencesvariables theorized to disrupt/prevent emotional ex-pression at any step in the process are potential

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Emotional Disclosure and Alexithymia L. Ashley and D. B. O’Connor and F. Jones

moderators of written disclosure’s effects. One variablethat has received considerable attention within thiscontext is alexithymia. Alexithymia refers to a deficit inthe processing of emotions, such that, although notcharacterized by an absence of emotional experience,people with alexithymia find it difficult to identify theirfeelings and express them verbally. To engage in writtenemotional disclosure, however, requires identifying andexpressing feelings linguistically.

Several disclosure studies have examined interactionsbetween writing condition and alexithymia, all of whichhave found moderating effects on one or more outcomes(Baikie, 2008; Lumley, 2004; O’Connor & Ashley, 2008;Páez, Velasco, & González, 1999; Solano et al., 2003). Asmight be anticipated, given the difficulties of people withalexithymia in identifying and describing their emotions,the majority of these studies have found individuals lowerin alexithymia to derive greater benefits from expressivewriting (Lumley, 2004; O’Connor & Ashley, 2008).However,findings regarding the direction of alexithymia’seffects are not entirely consistent; some studies havefound higher alexithymia scores to be associated withbetter disclosure outcomes (e.g. Solano et al., 2003). Inaddition, no studies have explored the effects ofalexithymia on positive disclosure. Therefore, althoughtheory and current research indicate that alexithymiaholds promise as a predictor of expressive writingoutcomes, additional studies are required to clarify itsmoderating role.

To summarize, this study had two main aims: (1) toinvestigate the efficacy of two writing interventions(stress/trauma disclosure, positive disclosure) on thepsychological well‐being (depression and anxietysymptoms) of informal caregivers on follow‐ups at2 weeks, at 2 months and at 6 months; and (2) toexamine, in addition to the main effects of writingcondition, the moderating effects of alexithymia.

Method

Participants

Participants were informal caregivers recruited pri-marily through charitable carers’ centres across theUnited Kingdom. Caregivers were those who identifiedthemselves as someone who, without payment, provideshelp to a partner, child, relative, friend or neighbourwho could not otherwise manage day‐to‐day activities.This could be due to age, physical or mental illness,addiction or disability. The exclusion criteria were thefollowing: (1) being under 18 years of age; (2) notbeing a resident in the United Kingdom; (3) inability toread and write in English; and (4) self‐reportedpsychiatric problems (information materials instructedthe caregivers not to participate if they were currentlydiagnosed with, or felt themselves to be experiencing, apsychological illness, for example, obsessive compulsivedisorder, depression or schizophrenia). The final

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exclusion criterion was selected to protect vulnerableparticipants, particularly as the study was home‐based,and is consistent with numerous previous disclosuretrials (e.g. Smyth et al., 1999; Zakowski, Ramati,Morton, Johnson, & Flanigan, 2004). All eligiblecaregivers who agreed to participate in the study wererecruited. This resulted in a final sample of 150,adequate to detect between‐group differences ofmedium effect with power of 0.80 using two‐tailedtests at α= 0.05 (Cohen, 1988). Indeed, the finalsample size per condition (i.e. stress disclosure, n= 51;positive disclosure, n= 51; control, n= 48) is largerthan in most disclosure trials, including those that havepreviously found significant between‐group differences(e.g. Epstein et al., 2005; Petrie et al., 1995; Solanoet al., 2003).

Of the 332 caregivers who enquired about the studyin response to adverts, 222 were eligible and agreed toparticipate, although 40 carers withdrew after baselineassessment (12 stress, 19 positive, 9 control), five didnot complete the writing tasks as requested (one stress,four positive), one set of essays was lost in the mail(control) and 26 participants withdrew during thefollow‐up period or provided incomplete outcome data(10 stress, 3 positive, 13 control). Carers were notrequired to provide a reason for withdrawal from thestudy, but those that did generally cited a lack of timeor deterioration in the health of their care recipient.There were no differences between completers andnon‐completers on sociodemographic or caregivingvariables, baseline psychological distress or alexithymia.Table I shows the sociodemographic characteristics ofthe final sample (N= 150) by experimental condition.The final sample was predominantly white (90%) andcomprised 23 men and 127 women. The majority of thesample (93%) were middle‐aged and older (i.e. 40 yearsplus) with a mean age of 55.73 years [standarddeviation (SD) = 11.61; range = 31–85]. The majorityof the sample cared for one person (74.7%), notably apartner (38.4%), child (31.3%) or parent (25%), andhad been doing so for an average of 10.45 years(SD= 8.56). Health problems suffered by care recipientsincluded Down’s syndrome, autism, dementia, arthritis,cancer and schizophrenia.

Writing interventions

Participants were randomly assigned using computer‐generated random numbers to one of three experi-mental conditions: stress disclosure, positive disclosureor control. Randomization was performed by the firstauthor who generated the allocation sequence, enrolledthe participants in the study and assigned them to theconditions. The participants were unaware that theyhad been assigned to one of three possible conditionsand that other participants were writing about differenttopics. All the participants wrote on their assignedtopic at home and were asked to do so continuouslyfor 20 min, on three consecutive days, without regard


Table I. Sociodemographic information by condition

Stress disclosure (n= 51) Positive disclosure (n= 51) Control (n= 48)

Gender (male, female) 9 m, 42 f 5 m, 46 f 9 m, 39 f

Age, years, M (SD) 57.16 (11.55) 54.14 (12.32) 55.91 (10.90)

Ethnicity White people (%) 96 92 81

Asian (%) 2 4 15

Afro‐Caribbean (%) 0 0 2

Prefer not to say (%) 2 4 2

Marital status Married (%) 55 72 71

In a relationship (%) 10 4 8

Single (%) 12 6 8

Separated/divorced (%) 17 14 11

Other (%) 6 4 2

Education School (%) 20 22 33

College (%) 25 25 21

University (%) 43 37 29

Other (%) 12 16 17

Number of care recipients, M (SD) 1.37 (.72) 1.45 (.97) 1.40 (.76)

Years caring, M (SD) 11.79 (10.25) 9.36 (8.25) 10.21 (6.67)


for spelling, sentence structure or grammar. Instruc-tions requested that the participants try to conducttheir writing in a quiet place where they could be alone(‘maybe a bedroom for example’). Participants wereasked to date their essays and submit them but wereassured of their confidentiality and told that theywould not receive feedback on them.

Stress disclosure

The instructions for the stress disclosure task werebased on those developed by Pennebaker and colleagues(e.g. Pennebaker et al., 1988; Petrie et al., 1995) but weremodified for caregiving. The participants were urged to‘really let go’ and explore their ‘very deepest emotionsand thoughts’ about their ‘role as a carer’. It wassuggested that they might write about difficulties theyencounter in their role as a carer and how it affects theirwell‐being, performance at work, home life andrelationships. However, the instructions emphasizedthat the participants were free to write about anythingconcerning their caregiving role.

Positive disclosure

The instructions for the positive disclosure task werebased on those used in previous studies with a positivewriting condition (e.g. Burton & King, 2004, 2008). Theparticipants were urged to ‘really let go’ and exploretheir ‘very deepest emotions and thoughts’ about the‘positive and happy experiences’ in their life. It wassuggested that they might write about being in love,becoming a parent, personal achievements at work ormusic or literature that had ‘touched’ them. However,the instructions emphasized that the participants werefree to write about any type and number of positiveexperiences.


Control

Disclosure studies often ask the control participantsto write objectively about their day‐to‐day activities(e.g. Epstein et al., 2005; Vedhara et al., 2007). Thisso‐called ‘time management’ task was not used in thepresent study; however, as for most carers, day‐to‐dayactivities are not a neutral topic as they involvecaregiving. Further, it was believed that it would bedifficult for the participants to write neutrally, withoutreference to their thoughts and feelings, about activitiesthat were caregiving duties. The control participantswere therefore asked to describe three neutral‐colourlandscape pictures, a task previously used in a disclosurestudy with arthritis patients (Kelley et al., 1997). Theparticipants were asked to describe one picture each day,in a specified order, and to do so ‘accurately and in asmuch detail as possible’ without adding personalinformation or opinions.

Measures

Intervention fidelity

Several manipulation checks were conducted todetermine intervention fidelity. One, all essays werecounted and read by the first author, and the date oneach inspected, to ensure that each participant hadadhered to protocol and written three essays onconsecutive days on their assigned topic. Two, essayswere analysed using the Linguistic Inquiry and WordCount text analysis programme (Pennebaker, Chung,Ireland, Gonzales, & Booth, 2007), and the experi-mental conditions were compared on positive emotion(e.g. ‘happy’, ‘love’), negative emotion (e.g. ‘sad’,‘angry’) and cognitive/insight (e.g. ‘think’, ‘realize’)words. Consistent with task instructions, the disclosure

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essays (stress and positive) ought to contain a greaterproportion of emotion and cognitive/insight wordsthan control essays. Three, after each writing session,the participants rated the extent to which they hadexpressed their deepest thoughts and feelings in theiressay and how meaningful it was to them (1 = not at allto 7 = a great deal). Congruent with the nature of theirwriting tasks, the disclosure participants (stress andpositive) ought to rate their essays as more expressiveand meaningful than the control participants.

Sociodemographic and caregiving variables

A questionnaire assessing gender, age and ethnicitywas completed at baseline. Carers were also asked howmany people they cared for, their relationship to theperson(s) they cared for, the health problem(s)suffered by their care recipient(s) and the number ofyears that they had been a carer.

Psychological distress

The depression and anxiety subscales of the BriefSymptom Inventory (BSI; Derogatis, 1993) werecompleted at baseline, at 2 weeks, at 2 months and at6 months post‐writing. Higher scores indicated greaterpsychological distress. The BSI has well‐establishedpsychometric properties (Derogatis, 1993), and thedepression and anxiety subscales had good internalconsistency in the current sample at baseline and allfollow‐ups (all Cronbach’s alphas were 0.80–0.88).

Alexithymia

The 20‐item Toronto Alexithymia Scale (TAS‐20;Bagby, Parker, & Taylor, 1994; Bagby, Taylor & Parker,1994) was completed at baseline. This measure is wellestablished and widely used, possesses good psycho-metric properties (Bagby, Parker, & Taylor, 1994,Bagby, Taylor & Parker, 1994) and has been employedin all previous disclosure studies that have examinedalexithymia (e.g. Lumley, 2004; O’Connor & Ashley,2008; Solano et al., 2003). The TAS‐20 has threesubscales: difficulty identifying feelings (DIF), difficultydescribing feelings (DDF) and external orientedthinking (EOT). Coefficient alpha for the presentsample was 0.82 for the total scale and 0.87 and 0.74for the DIF and DDF subscales, respectively. The EOTsubscale, however, as other studies have found (e.g.Lumley et al., 2005; Mehling & Krause, 2007), had lowinternal reliability (α= 0.43) and was not analysed.

Procedures

The study received ethical approval from the UniversityDepartment of Psychology Ethics Committee. As innumerous previous disclosure studies (e.g. Lepore &Greenberg, 2002; Wing et al., 2006; Zakowski et al.,2004), all the writing materials and questionnaires weremailed to the participants, completed at home andreturned in pre‐paid addressed envelopes. Advertsinviting caregivers to take part in a study examining the

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‘effects of writing on health’were placed in carers’ centresacross the United Kingdom and on websites relatedto caregiving. Interested carers who contacted theresearcher were randomized into one of the experimentalconditions and sent a baseline pack. The pack containedan information booklet, identical for all conditions save asentence describing the writing topic, a consent form andbaseline questionnaires. Eligible carers who wished toparticipate completed and returned the consent form andquestionnaires. The carers were then sent materials forthe writing intervention: an instruction sheet, threewriting booklets containing lined paper and manipula-tion check questions, and three envelopes. After eachwriting session, the participants sealed their essays inenvelopes and returned all three at the end of theintervention.Follow‐upquestionnaireswere sent2weeks,2 months and 6months after the date on the final writingbooklet. On completion of the study, the participantswere debriefed. No adverse events were reportedthroughout the duration of the study.

Results

Baseline psychological distress andequivalence of conditions

The carers’ mean baseline levels of depressive andanxious symptoms, shown in Table II, were higher thanthose found in normative female adult non‐patientsamples (Derogatis, 1993), although comparablewith those found in other caregiver studies that haveused the BSI (e.g. Aschbacher et al., 2008; Shaw et al.,1999). One‐way analysis of variance (ANOVAs) andchi‐square tests revealed no significant differencesbetween the experimental conditions on gender, age,ethnicity, marital status, education, number of carerecipients, length of time caring, alexithymia (total scoreand subscales), depressive symptoms or anxioussymptoms (all p> 0.23; see Tables I and II). Therandom assignment of participants thus resulted inequivalent conditions at baseline.

Intervention fidelity

Essay dates

Of the 144 participants who dated their essays(96%), 131 wrote on three consecutive days (91%). Ofthe 13 participants who did not write on consecutivedays (seven stress, five positive, one control), 11completed the essays within a week, although twowrote over longer periods. As exclusion of theseparticipants (and those who omitted to date theiressays) did not substantively alter the results of themain (effects) analyses, they were retained.

Essay content

Table II shows the percentage of emotion andcognitive/insight words, on average over the three


Table II. Descriptive statistics for main study variables by condition

Variable Stress disclosure (n= 51) Positive disclosure (n= 51) Control (n= 48)

M SD M SD M SD

Depression (baseline) 0.94 0.84 0.80 0.77 0.96 0.85

Depression (2 weeks) 0.95 0.75 0.76 0.89 0.92 0.87

Depression (2 months) 0.99 0.87 0.79 0.90 0.80 0.83

Depression (6 months) 1.03 0.84 0.77 0.88 0.98 0.90

Anxiety (baseline) 0.80 0.66 0.92 0.88 0.85 0.83

Anxiety (2 weeks) 0.83 0.62 0.87 0.91 0.86 0.77

Anxiety (2 months) 0.91 0.77 0.82 0.87 0.78 0.75

Anxiety (6 months) 0.91 0.70 0.88 0.82 0.79 0.72

Alexithymia (total) 47.92 11.85 46.67 9.35 49.42 10.99

Alexithymia (DIF) 17.39 6.37 16.47 5.89 17.04 5.40

Alexithymia (DDF) 12.43 4.17 11.55 3.61 12.90 4.22

Positive emotion words 3.49 0.90 5.39 1.80 0.90 0.83

Negative emotion words 2.60 0.67 1.29 0.49 0.48 0.30

Cognitive/insight words 4.46 1.03 3.90 1.27 0.66 0.44

Expressiveness ratings 6.10 0.89 5.91 0.86 3.97 1.99

Meaningfulness ratings 6.08 1.13 6.40 0.82 4.30 1.65

Note. DIF: difficulty identifying feelings; DDF: difficulty describing feelings.


essays, by experimental condition. The proportions ofemotion and cognitive/insight words in the disclosureessays are consistent with those generally found indisclosure studies (Pennebaker et al., 2007). One‐wayANOVAs, followed by post hoc Games–Howellcomparisons, revealed that the disclosure essays (stressand positive) contained more positive emotion,negative emotion and cognitive/insight words thanthe control essays (all p< 0.001). Positive essays alsocontained more positive emotion words, and fewernegative emotion words, than stress essays (bothp< 0.001).

Participants’ ratings

Themean expressiveness andmeaningfulness ratings,shown in Table II, were analysed using one‐wayANOVAs and post hoc Games–Howell comparisons.The carers in the stress and positive conditions gavecomparable ratings (both p> 0.26), but the participantsin both disclosure conditions rated their essays as moreexpressive and meaningful than the control participants(all p< 0.001). Essay content and participants’ ratingsthus indicated that the three writing tasks weregenerally well adhered to and delivered as intended.

Effects of the writing interventions ondepressive and anxious symptoms

Two‐way (3 × 4) mixed ANOVAs were conducted toexamine the relative effects of the two writinginterventions. The between‐group factor was conditionwith three levels: stress disclosure, positive disclosureand control, and the repeated‐measures factor was timewith four levels: baseline, 2 weeks, 2 months and6 months post‐writing. As Table II shows, the threeexperimental conditions reported similar levels of


depressive and anxious symptoms at all time points,and these were fairly consistent across time. TheANOVA revealed no effect of condition, F(2,147) < 1,or time, F(3,441) < 1, and, moreover, no interactionbetween condition and time, F(6,441) < 1, on depressivesymptoms. Similarly, there was no effect of condition,F(2,147) < 1, or time, F(3,441) < 1, and no condition × timeinteraction, F(6,441) < 1, on anxious symptoms. Therewas thus no effect of writing condition on psychologicaldistress.

Moderating effects of alexithymia

To examine the moderating effects of alexithymia,hierarchical multiple regressions were conducted,following procedures outlined by Baron and Kenny(1986) and Aiken and West (1991, pp. 116–138), topredict depressive and anxious symptoms at eachfollow‐up. Baseline outcome values were entered inthe first step. Alexithymia was mean‐centred to reducemulticollinearity and entered in the second step.Consistent with previous disclosure studies that haveexamined alexithymia (e.g. Lumley, 2004; O’Connor &Ashley, 2008; Solano et al., 2003), in addition to totalscale score, the TAS‐20 subscales (DIF and DDF) werealso examined. The experimental condition wasrepresented by two dummy variables (D1: stress = 1,positive = 0, control = 0 and D2: stress = 0, positive = 1,control = 0) and entered in the third step. Two cross‐product terms, created by multiplying the mean‐centred alexithymia variables by each of the twodummy variables comprising condition, were enteredin the fourth step to represent the alexithymia ×condition interaction. Significant moderation effectswere decomposed by conducting simple slopes analyses.Note that given the absence of main effects of writing

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condition and for purposes of brevity, only the resultsfor the alexithymia by writing condition interactions arereported below.

Depressive symptoms

The 20‐item Toronto Alexithymia Scale total

There was a significant interaction between TAS‐20total score and writing condition on depressivesymptoms at the 2‐week follow‐up, F(2,143) = 3.93,p= 0.02, ΔR2 = 0.03, total R2 = 0.47. The relationshipbetween alexithymia and post‐writing depression inthe positive condition differed significantly fromthat in the stress [t(143) = 2.65, p= 0.01] and control[t(143) = 2.29, p= 0.02] conditions, which did notdiffer from each other [t(143) < 1]. Among theparticipants who wrote about positive events, loweralexithymia predicted a reduction in depressivesymptoms [t(143) = 3.33, p= 0.001]. In the stress andcontrol conditions, however, alexithymia was notpredictive of post‐intervention depression scores[both t(143) < 1]. TAS‐20 score did not interact withexperimental condition to predict depression at the2‐month, F(2,143) < 1, or 6‐month, F(2,143) = 2.62, ns,follow‐ups.

Difficulty identifying feelings subscale

There was a significant DIF × condition interactionon depressive symptoms 2 weeks post‐writing,F(2,143) = 4.49, p= 0.01, ΔR2 = 0.03, total R2 = 0.47.Consistent with the effects of TAS‐20 total score,the positive condition, in which lower DIF wasassociated with lower post‐writing depression scores[t(143) = 3.30, p= 0.001], differed from the stress andcontrol conditions (both p= 0.01), in which DIF wasunrelated to post‐writing depression [both t(143) < 1].There was also a significant moderating effect ofDIF 2 months post‐writing, F(2,143) = 3.32, p= 0.04,ΔR2 = 0.02, total R2 = 0.49. Consistent with the 2‐weekfollow‐up, lower DIF predicted a reduction indepressive symptoms in the positive condition[t(143) = 2.53, p= 0.01] but was unrelated to post‐writing depression in the stress and control conditions[both t(143) < 1]. DIF also interacted with writingcondition to predict depressive symptoms at the6‐month follow‐up, F(2,143) = 3.94, p= 0.02,ΔR2 = 0.03,

Table III. Summary of the main significant moderating effects of alex

Depressive symptoms

2 weeks 2 months 6 month

Total alex Pos — —

DIF Pos Pos Pos*/co

DDF Pos — —

Note. Total alex: total alexithymia; DIF: difficulty identifying feelings; DDF:

*p< 0.07; **p< 0.08.

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total R2 = 0.48. Consistent with the earlier follow‐ups,DIF was not a significant predictor of post‐interventiondepression scores among the participants in the stresscondition [t(143) < 1]. Unlike the earlier follow‐ups,however, the positive condition did not differ fromthe control condition [t(143) < 1]. At the 6‐monthfollow‐up, there was a significant positive relationshipbetween DIF and depressive symptoms in the controlcondition [t(143) = 2.65, p= 0.01], whereas DIF wasnot predictive of post‐writing depression scores amongthe control participants at the earlier follow‐ups.Among the participants in the positive condition,consistent with the 2‐week and 2‐month follow‐ups,lower DIF continued to predict lower depression scores[t(143) = 1.82, p= 0.07], although only marginally so.

Difficulty describing feelings subscale

There was a significant DDF× condition interactionat the 2‐week follow‐up, F(2,143) = 5.11, p= 0.01,ΔR2 = 0.04, total R2 = 0.49. Consistent with the TAS‐20and DIF effects at 2 weeks, the positive conditiondiffered from the stress [t(143) = 2.84, p= 0.01] andcontrol [t(143) = 2.83, p= 0.01] conditions, which didnot differ from each other [t(143) < 1]. Lower DDF wasassociated with lower depression scores in the positivecondition [t(143) = 4.13, p< 0.001] but was unrelated topost‐writing depression in the stress and controlconditions [both t(143) < 1]. As with the TAS‐20 totalscore, there was no DDF × condition interaction2 months, F(2,143) < 1, or 6 months, F(2,143) = 1.65, ns,post‐writing. A summary of the main findings fordepressive symptoms is shown in Table III.

Anxious symptoms

The 20‐item Toronto Alexithymia Scale total

There was a significant moderating effect of theTAS‐20 total score on anxious symptoms at the 2‐weekfollow‐up, F(2,143) = 4.43, p= 0.01, ΔR2 = 0.03, totalR2 = 0.50. Consistent with alexithymia effects ondepressive symptoms, the positive condition differedfrom the stress [t(143) = 2.97, p= 0.003] and control[t(143) = 1.90, p= 0.06] conditions, which did notdiffer from each other [t(143) = 1.09, p= 0.28]. Loweralexithymia predicted a reduction in anxious symptomsin the positive condition [t(143) = 3.97, p< 0.001] and

ithymia

Anxiety symptoms

s 2 weeks 2 months 6 months

Pos/con** — Pos/con

n Pos/con — Pos/con

Pos — —

difficulty describing feelings; Pos: positive writing; con: control writing.


1The authors would like to acknowledge Dr Mark A. Lumley for his

very helpful comments in terms of this line of argument.


in the control condition (marginally) [t(143) = 1.79,p= 0.08], whereas the TAS‐20 score was not sig-nificantly related to anxiety in the stress condition[t(143) < 1]. There was no interaction between theTAS‐20 score and condition on anxious symptomsat the 2‐month follow‐up, F(2,143) < 1. There was,however, a significant TAS‐20 × condition interactionat the 6‐month follow‐up, F(2,143) = 3.70, p= 0.03,ΔR2 = 0.03, total R2 = 0.48, consistent with alexithymiaeffects on depressive symptoms at the final follow‐up.Lower alexithymia was associated with lower anxietyscores in the positive condition [t(143) = 2.72,p= 0.01], but this did not differ from the controlcondition [t(143) < 1] in which there was also a positivealexithymia–anxiety relationship [t(143) = 1.95,p= 0.05]. The TAS‐20 score was unrelated to post‐intervention anxiety in the stress condition [t(143) < 1].

Difficulty identifying feelings subscale

There was a significant DIF × condition interactionon anxious symptoms at the 2‐week follow‐up,F(2,143) = 3.42, p= 0.04, ΔR2 = 0.02, total R2 = 0.52.Consistent with the effects of the TAS‐20 total score,there was a significant positive relationship betweenDIF and 2‐week anxiety in the positive condition[t(143) = 4.42, p< 0.001], which differed from thatin the stress condition [t(143) = 2.62, p= 0.01], inwhich DIF was unrelated to post‐intervention anxiety[t(143) = 1.20, p= 0.23]. However, unlike the inter-action with the TAS‐20 total score, the DIF–anxietyrelationship in the positive condition did not differsignificantly from that in the control condition[t(143) = 1.19, p= 0.24], in which there was also apositive relationship between DIF and post‐writinganxiety [t(143) = 2.45, p= 0.02]. There was no mod-erating effect of DIF at the 2‐month follow‐up,F(2,143) = 1.00, ns. There was, however, a significantDIF × condition interaction at the 6‐month follow‐up,F(2,143) = 4.64, p= 0.01, ΔR2 = 0.03, total R2 = 0.51.Consistent with the moderating effects of the TAS‐20total score, in the stress condition, DIF was unrelatedto post‐intervention anxiety [t(143) < 1], whereas inthe positive condition [t(143) = 3.80, p< 0.001] andthe control condition [t(143) = 2.41, p= 0.02], therewas a significant positive relationship between DIF and6‐month anxiety.

Difficulty describing feelings subscale

Difficulty describing feelings interacted with con-dition to predict anxious symptoms at the 2‐weekfollow‐up, F(2,143) = 5.15, p= 0.01, ΔR2 = 0.04, totalR2 = 0.51. Consistent with the moderating effects ofthe TAS‐20 total score and DIF on 2‐week anxiety,the positive condition, in which lower DDF predicteda reduction in anxious symptoms [t(143) = 4.40,p< 0.001], differed from the stress [t(143) = 3.15,p= 0.002] and control [t(143) = 2.31, p= 0.02] condi-tions, in which DDF was not predictive of anxiety


2 weeks post‐intervention (both p> 0.10). There was nointeraction between DDF and condition on anxiety atthe 2‐month, F(2,143) < 1, or 6‐month, F(2,143) = 2.14, ns,follow‐ups. A summary of the main findings for anxietysymptoms is shown in Table III.

DiscussionTwo key findings emerged from this study. Firstly, therewere no main effects of the writing interventions ondepressive or anxious symptoms indicating that theinterventions did not benefit all caregivers in the study.Secondly, aspredicted, alexithymiamoderated theefficacyof the writing interventions such that lower scores onalexithymiawereassociatedwith improveddepressive andanxiety symptoms at follow‐up in the positive and controlwriting conditions but not in the stress writing condition.

The absence of main effects of the emotionaldisclosure interventions is not new and is consistentwith numerous other studies that have found limited orno benefits of disclosure writing in caregiver (e.g. Barton& Jackson, 2008; Mackenzie et al., 2007; Schwartz &Drotar, 2004) and non‐caregiver samples (e.g. Harris,Thoresen, Humphreys, & Faul, 2005; Vedhara et al.,2007; Zakowski et al., 2004). These findings highlightthe importance of examining moderating factors, suchas individual differences variables, as well as exploringthe efficacy of alternative writing interventions.

The central finding of the current study was thatlower alexithymia scores predicted reduced depressiveand anxiety symptoms at follow‐up in the positive andcontrol writing conditions but not in the stresscondition. Moreover, there was evidence that positivewriting, compared to control, had a stronger and moreconsistent impact during the follow‐up period. Theseare intriguing findings. There are a number of possibleexplanations for this pattern of results. One interpre-tation might be that individuals lower in alexithymia getbetter over time as a matter of course and that thisnaturalistic improvement is enhanced to some extentby positive writing (and control writing does notinterfere with this process).1 Evidence of significantimprovements in both the positive and control writingconditions over time are consistent with this explana-tion. In terms of the favourable outcome in the positivewriting condition, the beneficial effects of writing aboutpositive events have been observed in a number ofrecent studies (Burton & King, 2004, 2008; Wing et al.,2006). Positive emotions have been proposed to havenumerous adaptive functions in the context of chronicstress, one of which is to provide a psychological‘breather’ (Folkman, 1997). For many carers, caregivingforms a large part of their past, dominates their day‐to‐day life and is likely to extend into their future. Positivedisclosure may therefore aid and/or facilitate natural-

383


istic improvement in individuals low in alexithymia byproviding psychological respite from an unremittingstressor and the associated negative emotions. Indeed,many caregivers spontaneously noted in their disclo-sures that writing about positive events was a welcomemental and physical break from their caregivingconcerns and duties.

Alternatively, the current findings may indicate thatboth the positive writing and the control writingconditions contain active ingredients that may facilitateimproved depressive and anxiety symptoms overtime inindividuals low in alexithymia. The improvementsobserved in the control writing condition may pointto the possibility that individuals low in alexithymiamaybenefit from writing about topics that are not personal,traumatic/stressful or upsetting. If this is the case, it ispossible that in the current control task, writingobjectively and descriptively about colour landscapesdistracted the caregivers’ attention away from thecurrent stressors in their environment. Moreover,distraction has been shown to be a successful copingstrategy in numerous studies (e.g. Nolen‐Hoeksema &Morrow, 1993; Penley, Tomaka & Wiebe, 2002;Shimazu & Schaufeli, 2007). Nolen‐Hoeksema andMorrow (1993) showed that mildly‐to‐moderatelydepressed participants who engaged in distraction byfocusing on descriptions of geographic locations andobjects experienced less depressedmood.More recently,Shimazu and Schaufeli (2007) showed that distraction islikely to be beneficial for individuals facing highlystressful work situations. It has also been suggested thatdistractionmay provide individuals with an opportunityto rest, detach from their stressful work environmentand replenish depleted resources (e.g. Shimazu &Schaufeli, 2007). Nevertheless, we acknowledge thatthe current study does not provide definitive evidencein support of either explanation, and therefore, itis incumbent on future research to explore thesepossibilities further. A useful next step would be todesign a study that, in addition to positive writing,includes a formal distraction condition alongside ano‐writing control group.

Another important finding that requires furtherdiscussion relates to the absence of any associationbetween alexithymia and our measures of psychologicaloutcome in the stress writing condition. If we assumethat individuals lower in alexithymia potentially getbetter over time as a matter of course and that thisnaturalistic improvement is further aided by positivewriting, then this result suggests that writing about thestress of their caregiving role interrupts this process andmay even damage emotional regulation. Moreover,given that the stress associated with caregiving is largelyuncontrollable, unrelenting and ongoing, it is possiblethat stress disclosure, in this context, brings to mindnegative beliefs and cognitions, which are not easilyassimilated into the caregivers’ own self‐schema. Theprimary mechanisms proposed to account for the

384

beneficial effects of emotional disclosure are exposureand cognitive processing (see O’Connor & Ashley, 2008;Sloan &Marx, 2004). Central to this model is the notionthat through restructuring, the individual assimilatesthe stressor into his or her own beliefs system, becomesaware of the associated feelings and considers methodsof coping with the stressful or traumatic encounter.However, in the current case, it is feasible that such‘consciousness raising’ may provide a setback for thecaregivers’ (low in alexithymia) ability to regulate theiremotions such that they perceive their situation asuncontrollable, and thus they are not motivated toengage in coping efforts. The absence of the beneficialeffects of stress disclosure is also broadly consistent withthe only three other studies in caregivers (Barton &Jackson, 2008; Mackenzie et al., 2007; Schwartz &Drotar, 2004). None of these investigations reportedsalutary effects of written disclosure of stressful ortraumatic events on measures of general psychologicaldistress such as depression or anxiety. These possibilitiesnotwithstanding, future research ought to explorefurther, using qualitative methods, whether writingabout stressful events in caregivers elicits uncontrollableand unmanageable beliefs and cognitions.

Our finding that alexithymia moderated the effectsof writing interventions on depressive and anxietysymptoms is an important observation such thatcaregivers higher in this individual differences variabledid not improve in any of the writing conditions. Thisis congruent with theorizing that the salutary effects ofemotional disclosure may not extend to individualshigher in alexithymia because their difficulties inter-preting and expressing emotions impede them from(fully) engaging in expressive writing tasks (Lumley,2004; Lumley et al., 2002). Indeed, the term‘alexithymia’, which literally means ‘lacking wordsfor feelings’, was coined in the clinical setting todescribe those patients who have difficulty engaging inintrospective psychotherapy and who appear to derivelittle benefit from it (Lumley, Neely, & Burger, 2007).Moreover, as suggested earlier, if some of the benefitsobserved in the current study are accounted for bynaturalistic improvement (in the control and/orpositive writing condition), the current findingsindicate that caregivers high in alexithymia are notequipped to cope with the natural course of stressfulencounters in their lives. Therefore, researchers oughtto investigate the efficacy of alternative psychologicaland non‐psychological interventions within thisvulnerable group.

We acknowledge some limitations of the currentstudy. It must be noted that the sample waspredominantly female (85%), and therefore it cannotbe assumed that the findings are generalizable to malecaregivers. However, the gender make‐up of the sampleis representative of the caregiver population andconsistent with previous caregiver research (Pinquart& Sörensen, 2003). Furthermore, previous disclosure



research robustly indicates that the effects of expressivewriting do not vary as a function of gender (e.g. Kelleyet al., 1997; O’Connor & Ashley, 2008; Sheese et al.,2004; see Frattaroli, 2006, for a review). We alsorecognize that, although relatively large, the finalsample comprised just over two‐thirds (68%) of thoserandomized into the study. However, this rate ofattrition is comparable with other disclosure studiesemploying non‐student samples (e.g. Hamilton‐West &Quine, 2007; Norman, Lumley, Dooley, & Diamond,2004), and there is no indication that attritionwas systematic; completers were equivalent to non‐completers and the experimental conditions wereequivalent at baseline on all study variables.

We are also mindful that the experimental conditionsmay have differed in terms of temporal frame (inaddition to emotional valence): the stress conditionbeing, prima facie, more current focused and the positivecondition more past focused. There is little to suggest,however, that the time frame is a crucial differencebetween the two tasks. Inspection of the essays revealedlittle evidence that the tasks were distinct in theirtemporal focus; many carers in the stress conditionwrote about experiences and feelings stretching backmany years, and many of the positive experiencesdisclosed were relatively recent. Furthermore, althoughno studies appear to have experimentally manipulatedthe time reference of writing instructions, a recent meta‐analysis of disclosure trials did not find this aspect ofinstructional set to moderate effects (Frattaroli, 2006).

We employed the TAS‐20 to assess alexithymia. TheTAS‐20 is currently the most commonly used andpsychometrically sound measure of alexithymia, and ithas been used exclusively in the disclosure literature.Use of the TAS‐20 in the current study was thereforecrucial to enable integration of our findings with thoseof the extant literature. However, some researchershave questioned the validity of assessing alexithymia,which by definition involves limited introspectivecapacities, via a self‐report measure. Consequently,interview‐based, observer‐rated measures of alexithymiahave been developed (Haviland & Reise, 1996;Sifneos, 1973), which circumvent the problem ofreliance on individuals’ self‐knowledge. However, theinter‐rater reliability of observer measures has yet tobe established (Lumley et al., 2007; Taylor, Bagby, &Luminet, 2000), and they are impractical for use in


large, geographically disparate research samples, suchas in this study.

The current study did not focus on exploring thepossible mechanisms underlying the beneficial effectsof the experimental conditions. Therefore, it isimportant for future research to investigate thepotential intervening processes, such as increasedcaregiver self‐efficacy and improved social connec-tivity, in order to elucidate how positive disclosuremight confer health benefits in particular groups(e.g. caregivers low in alexithymia) or whetherparticipants build psychological ‘breathers’ into theircoping repertoire. Moreover, our examination ofdisclosure’s effects was restricted to self‐reportedindicators of psychological health. Although depressiveand anxious symptoms are important outcomes giventhe high prevalence of psychological morbidityamong carers, further research should examinewhether the salutary effects observed here extend tomultidimensional quality of life outcomes, includingphysical, social and spiritual functioning, implicitoutcome measures (cf. O’Connor et al., 2010) andphysiological outcomes. As many carers suffer frompoor cardiovascular and immune function (Vedharaet al., 1999; Vitaliano, Zhang, & Scanlan, 2003), futurecaregiver studies might usefully examine disclosure’seffects on blood pressure indices and markers ofimmunity and incorporate innovative daily diarytechniques (cf. O’Connor, Conner, Jones, McMillan,& Ferguson, 2009; O’Connor, Jones, Conner, McMillan,& Ferguson, 2008).

To conclude, the current study found no maineffects of writing condition on depressive or anxioussymptoms indicating that the interventions did notbenefit all caregivers. However, as predicted, alexithy-mia moderated the efficacy of the writing interventionssuch that lower scores on alexithymia were associatedwith improved depressive and anxiety symptoms atfollow‐up in the positive and control writing condi-tions but not in the stress writing condition. Writingabout caregiver stress should not be encouraged in thisvulnerable group.

AcknowledgmentWe would like to thank Dr Jeremy Miles for his helpfuladvice in terms of our statistical analyses.

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Effects of Emotional Disclosure in Caregivers: Moderating Role of Alexithymia