Expressive Writing Among Chinese American Breast Cancer Survivors: A Randomized Controlled Trial

Abstract

Objective:
Despite the significant size of the Asian American population, few studies have been conducted to improve cancer survivorship in this underserved group. Research has demonstrated that expressive writing interventions confer physical and psychological benefits for a variety of populations, including Non-Hispanic White cancer survivors. The study aims to evaluate the health benefits of an expressive writing intervention among Chinese-speaking breast cancer survivors in the U.S. It was hypothesized that expressive writing would increase health-related quality of life (HRQOL).

Method:
Ninety-six Chinese breast cancer survivors were randomly assigned to 1 of 3 writing conditions: a self-regulation group, an emotional disclosure group, or a cancer-fact group. The self-regulation group wrote about one's deepest feelings and coping efforts in addition to finding benefits from their cancer experience. The emotional disclosure group wrote about one's deepest thoughts and feelings. The cancer-fact group wrote about facts relevant to their cancer experience. HRQOL was assessed by FACT-B at baseline, 1, 3, and 6-month follow-ups. Effect sizes and residual zed change models were used to compare group differences in HRQOL.

Results:
Contrary to expectations, the cancer-fact group reported the highest level of overall quality of life at the 6-month follow-up. The self-regulation group had higher emotional well-being compared to the emotional disclosure group.

Conclusions:
The study challenges the implicit assumption that psychosocial interventions validated among Non-Hispanic Whites could be directly generalized to other populations. It suggests that Asians may benefit from writing instructions facilitating more cognitive than emotional processes. (PsycINFO Database Record

Full text

Expressive Writing Among Chinese American Breast Cancer Survivors:
A Randomized Controlled Trial
Qian Lu, Celia Ching Yee Wong,
Matthew W. Gallagher, and Reese Y. W. Tou
University of Houston
Lucy Young and Alice Loh
Herald Cancer Association, San Gabriel, California
Objective: Despite the significant size of the Asian American population, few studies have been
conducted to improve cancer survivorship in this underserved group. Research has demonstrated that
expressive writing interventions confer physical and psychological benefits for a variety of populations,
including Non-Hispanic White cancer survivors. The study aims to evaluate the health benefits of an
expressive writing intervention among Chinese-speaking breast cancer survivors in the U.S. It was
hypothesized that expressive writing would increase health-related quality of life (HRQOL). Method:
Ninety-six Chinese breast cancer survivors were randomly assigned to 1 of 3 writing conditions: a
self-regulation group, an emotional disclosure group, or a cancer-fact group. The self-regulation group
wrote about one’s deepest feelings and coping efforts in addition to finding benefits from their cancer
experience. The emotional disclosure group wrote about one’s deepest thoughts and feelings. The
cancer-fact group wrote about facts relevant to their cancer experience. HRQOL was assessed by
FACT-B at baseline, 1, 3, and 6-month follow-ups. Effect sizes and residual zed change models were
used to compare group differences in HRQOL. Results: Contrary to expectations, the cancer-fact group
reported the highest level of overall quality of life at the 6-month follow-up. The self-regulation group
had higher emotional well-being compared to the emotional disclosure group. Conclusions: The study
challenges the implicit assumption that psychosocial interventions validated among Non-Hispanic
Whites could be directly generalized to other populations. It suggests that Asians may benefit from
writing instructions facilitating more cognitive than emotional processes.
Keywords: expressive writing, Asian/Chinese breast cancer survivors, randomized controlled trial,
quality of life
Breast cancer is the leading cancer among Asian American
women and the incidence of breast cancer among subgroups of
Asian women is rising (Gomez et al., 2010). Despite the increasing
size of the Asian American population in the U.S. (17.3 million;
United States Census Bureau, 2014) and their growing rate of
breast cancer, the quality of life and overall health of Asian
American breast cancer survivors have been overlooked (Lee et
al., 2013). A recent review concluded that Asian Americans ex-
perience disrupted health-related quality of life (HRQOL) follow-
ing breast cancer diagnosis and treatment (Wen, Fang, & Ma,
2014). However, there have been no published randomized con-
trolled trials (RCT) among Asian American cancer survivors. The
current study aimed to fill the gap by investigating the effects of an
expressive writing intervention on HRQOL among Asian Ameri-
can cancer survivors.
Health Benefits of Expressive Writing Among
Cancer Survivors
Over the past decade, the effects of expressive writing have
received considerable empirical attention. A typical paradigm of a
written emotional disclosure experiment is to assign participants
randomly to either an intervention group to write about their
deepest thoughts and feelings related to traumatic experiences, or
a control group to write about a neutral topic unrelated to deep
feelings (Pennebaker & Beall, 1986). A meta-analysis with 146
randomized controlled trials involving predominately Non-
Hispanic Whites revealed that emotional disclosure confers a
variety of benefits, including increased physical and psychological
well-being (Frattaroli, 2006).
Several RCTs of expressive writing among cancer survivors
have shown promising effects, such as improving physical symp-
toms (Stanton et al., 2002), greater perceived social support
(Gellaitry, Peters, Bloomfield, & Home, 2010), better sleep quality
(De Moor et al., 2002), decreased depressive symptoms (Henry,
Schlegel, Talley, Molix, & Bettencourt, 2010), and less pain
(Rosenberg et al., 2002). In a RCT to examine the health effect of
written disclosure, 60 breast cancer patients were assigned to one
of the three conditions: an emotional disclosure condition to write
about their deepest feelings and thoughts, a benefit-finding condi-
tion to write about positive aspects of their cancer experience, and
This article was published Online First December 8, 2016.
Qian Lu, Celia Ching Yee Wong, Matthew W. Gallagher, and Reese
Y.W. Tou, Department of Psychology, University of Houston; Lucy Young
and Alice Loh, Herald Cancer Association, San Gabriel, California.
This research was supported by American Cancer Society MRSGT-10-
011-01-CPPB (PI: Qian Lu).
Correspondence concerning this article should be addressed to Qian Lu,
Department of Psychology, University of Houston, 126 Heyne Building,
Houston, TX 77204. E-mail: qlu.ucla@gmail.com
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2017, Vol. 36, No. 4, 370–379 0278-6133/17/$12.00 http://dx.doi.org/10.1037/hea0000449
370

a control group to write about their cancer facts unrelated to
emotions (Stanton et al., 2002). The results revealed that emotional
disclosure reduced physical symptoms; both emotional disclosure
and benefit-finding reduced medical appointments for cancer-
related morbidities. Despite the growing interest and the large
number of studies using expressive writing paradigm, no studies
investigated the effects of expressive writing using a RCT among
Asian American cancer survivors.
Distress Associated With Cancer Among Asian
American Cancer Survivors
A diagnosis of breast cancer can evoke a wide range of negative
emotions, from denial, guilt, helplessness, and anxiety to fear.
Sharing feelings with others during this traumatic time is important
for breast cancer survivors. However, Asian American breast can-
cer survivors face culturally specific obstacles that prevent them
from seeking emotional support from family and friends. Such
obstacles consist of stigma related to breast cancer (Wong-Kim,
Sun, Merighi, & Chow, 2005), cultural beliefs of bearing burden
alone (Ashing-Giwa, Jinsook, Kagawa-Singer, & Tejero, 2003;
Kagawa-Singer & Wellisch, 2003;Lee et al., 2013), and suppress-
ing emotions to avoid damaging harmony with others (Chen &
Chung, 1994). Asian breast cancer survivors are unlikely to seek
professional assistance for mental health problems (Kagawa-
Singer, Wellisch, & Durvasula, 1997). As revealed in a study with
breast cancer survivors, “a lot of Asian women are very alone
because they’re ashamed to talk about the illness with other
people” (Wong-Kim et al., 2005). A recent study with Chinese
American breast cancer survivors still found that they kept their
cancer a secret, concealed it from others, and avoided interactions
with others (Lu, You, Man, Loh, & Young, 2014). Although all
these studies note the unmet need, few tested strategies to relieve
their distress. It is urged in the “Report of the Surgeon General” to
introduce culturally competent intervention and preventive strate-
gies to promote health in Asian American communities (U.S.
Department of Health & Human Services, 2001).
Expressive Writing—A Potentially Culturally
Sensitive Intervention
Intervention strategies using expressive writing may be espe-
cially suitable to Asian American communities by overcoming the
cultural and linguistic barriers faced by breast cancer survivors.
Expressive writing allows intrapersonal disclosure while assuring
privacy, without damaging harmony or provoking stigma.
Breast cancer is the leading cancer among Chinese, Filipino,
Hawaiian, Japanese, and Korean women. Chinese are the largest
subgroup (22.4%) of Asian Americans (United States Census
Bureau, 2010). We have shown that expressive writing was cul-
turally sensitive and was associated with improvement in health
outcomes in a pilot study with Chinese-speaking breast cancer
survivors (Lu, Zheng, Young, Kagawa-Singer, & Loh, 2012). The
current study aimed to test the efficacy of an expressive writing
intervention among Chinese-speaking breast cancer patients. If
expressive writing was found to be effective at improving physical
and psychological health among Chinese-speaking breast cancer
survivors, it may be an easily disseminated intervention for other
groups of Asian American cancer survivors.
Lu and Stanton (2010) developed a self-regulation moderator
model of expressive writing to emphasize the essential role of
cognitive reappraisal of stressful events and the facilitating role of
emotional disclosure in producing health benefits. The model was
tested and shown to be particularly relevant for Asians in a study
where Asians and Non-Hispanic Whites were randomly assigned
to one of four writing conditions: a neutral control group to write
about a neutral topic, an emotional disclosure group to write about
deepest feelings and thoughts about a stressful event, a cognitive
group to write about positive thoughts of a stressful event and
reappraisal, and a combination of emotional disclosure and cog-
nitive reappraisal group (i.e., self-regulation group) to write about
deepest feelings about a stressful event and then to cognitively
reappraise it. It showed that the self-regulation group had im-
proved positive affect for both Asians and Non-Hispanic Whites.
The self-regulation group and the cognitive reappraisal group
reported reduced physical symptoms compared with the control
group among Asians, but not among Non-Hispanic Whites, sug-
gesting that cognitive reappraisal benefited Asians more. Another
study with Asian and Non-Hispanic White students showed that
emotional disclosure writing reduced physical symptoms in Non-
Hispanic Whites, but not Asians (Knowles, Wearing, & Campos,
2011). These findings were in contrast with previous studies
among Non-Hispanic White samples showing emotional disclo-
sure reduced physical symptoms (Frattaroli, 2006), suggesting that
the cognitive component might be a more important ingredient
than the emotional component for the expressive writing paradigm
to work for Asians.
The current study aimed to investigate the health benefits of
expressive writing among Chinese-speaking breast cancer survi-
vors in the U.S. On the basis of previous findings among Non-
Hispanic White cancer survivors (Stanton et al., 2002), we hypoth-
esized that emotional disclosure would increase quality of life
compared with the fact control group. On the basis of the previous
study among Asian Americans (Lu & Stanton, 2010), we hypoth-
esized that the self-regulation writing (i.e., combining cognitive
reappraisal and emotional disclosure) would improve quality of
life compared with the emotional disclosure and fact control
groups.
Method
Overview of Study Design and Rationale
Participants were randomly assigned to one of the three condi-
tions: a cancer-facts writing group to write about facts related to
cancer diagnosis and treatment, an emotional disclosure writing
condition to prompt disclosing one’s deepest thoughts and feelings
regarding their experience with cancer, and a self-regulation writ-
ing condition to facilitate emotional disclosure, coping, and
benefit-finding. The emotional disclosure and cancer facts writing
instructions were adapted from the Stanton et al. study (2002),
which revealed that the emotional disclosure condition decreased
cancer related morbidities among breast cancer patients compared
to the cancer-facts writing. The self-regulation writing instructions
were modified based on the Lu and Stanton (2010) study among a
healthy sample of Asian Americans for whom self-regulation
writing improved positive affect and physical symptoms. The
self-regulation writing aimed to spur stressors and goals into
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371
EXPRESSIVE WRITING

awareness and regulate thoughts and emotions relevant to the
cancer experience through finding benefits and coping efforts thus
ultimately producing health benefits.
Participants
Participants were 96 women who met inclusion criteria: 1)
having a diagnosis of stages 0 –III breast cancer; 2) completing
primary medical treatment (e.g., surgery, radiotherapy, or chemo-
therapy) within four years; 3) self-identified as being comfortable
writing and speaking Chinese (e.g., Mandarin, Cantonese). Power
analysis revealed that 25 participants per group would yield 80%
power to test the hypothesis with an estimated moderate effect size
of 0.5 (Cohen, 1988).
One hundred and twenty-five women with breast cancer indi-
cated interest in the study. They were contacted and screened for
eligibility by the Herald Cancer Association research staff. Among
these women, 1 did not meet the inclusion criteria, 24 did not
respond, and 4 declined to participate for reasons as follows: being
busy, the tasks were too tedious, family issue—participant’s
mother was sick (see Figure 1). The remaining 96 women com-
pleted the baseline questionnaires and were randomly assigned to
the self-regulation condition (n⫽34), the emotional disclosure
condition (n⫽29), or the cancer-facts writing condition (n⫽33).
Among the 96 participants, 74 completed the writing intervention
(25 from the self-regulation group, 26 from the emotional disclo-
sure group, and 23 from the cancer-facts writing group) and 22
dropped out during the writing intervention (see Figure 1). Data
from all 96 participants were retained for analysis, and missing
data were accommodated using maximum likelihood estimation.
Details of their demographic information are shown in Table 1.
Procedure
The study was approved by relevant institutional review boards.
All aspects of the study were carried out in Chinese. Oral instruc-
tions were given in Mandarin or Cantonese and written materials
were in Chinese (note that although Mandarin and Cantonese are
Assessed for eligibility (n=125)
Randomized (n=96)
Excluded (n=29)
Ʉ
Ʉ
Not meeting inclusion criteria (n=1)
ɄDeclined to participate (n=4)
ɄDid not respond (n=24)
Self-Regulation
(n=34)
Emotional
Disclosure (n=29)
Cancer-Fact Writing
(n=33)
Completed 3M follow up (n=24) Completed 3M follow up (n=23)
1M
F
o
ll
o
w-
up
Enrollment
Completed 1M follow up (n=25)
Dropped out (n=1)
- Without reasons (n=1)
Completed 3M follow up (n=24)
Missed (n=1)
3M
F
o
ll
o
w-
up
6M
F
o
ll
o
w-
up
Randomization
Completed writing (n=25)
Dropped out (n=9)
- Without reasons (n=5)
- Not feeling well (n=2)
- Too busy/ no time (n=1)
- Not at home (n=1)
Completed writing (n=26)
Dropped out (n=3)
- Too much work (n=1)
- Too busy/ no time (n=1)
- Not want to write (n=1)
Completed writing (n=23)
Dropped out (n=10)
- Without reasons (n=5)
- Too busy/ no time (n=2)
- Recurrence (n=1)
- Not at home (n=1)
- Famil
y
reason
(
n=1
)
Completed 1M follow up (n=24)
Dropped out (n=1)
- Lost contact (n=1)
Completed 1M follow up (n=23)
Completed 6M follow up (n=24) Completed 6M follow up (n=23)
Completed 6M follow up (n=23)
Dropped out (n=2)
- Without reasons (n=1)
- Too busy/ no time (n=1)
Figure 1. Flow chart of study.
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372 LU, WONG, GALLAGHER, TOU, YOUNG, AND LOH

two different dialects in Chinese, their written Chinese characters
are the same). Participants were recruited from Los Angeles, New
York, and Houston metropolitan areas, in collaboration with the
Herald Cancer Association (HCA), a community-based Chinese
cancer organization. Potential participants were introduced to the
study at cultural events, educational conferences, and support
groups. Breast cancer survivors who indicated interest in the study
were contacted and screened for eligibility by HCA research staff.
Eligible women who agreed to participate received a baseline
questionnaire package, including a self-report of medical condi-
tions, and completed the questionnaire at home. After returning the
baseline questionnaire by mail, participants were randomly as-
signed to one of three conditions: a self-regulation writing condi-
tion, an emotional disclosure condition, or a cancer-fact writing
condition. Participants were told that the study aimed to under-
stand their experience through writing and were not aware of
whether they were assigned to an experimental or a control con-
dition. Researchers who had interaction with participants were
blinded to participants’ condition assignment. Once randomization
was performed, no change in intervention allocation took place.
One week after returning the baseline questionnaire, each par-
ticipant received two copies of a calendar and three sealed enve-
lopes. Participants were asked to schedule three weekly writing
sessions on the calendar, keep one copy of the calendar as a
reminder, and send one copy back so that researchers can remind
them of the next writing session. Each envelope was labeled as
“week 1,” “week 2,” and “week 3” with writing instructions for the
corresponding week. Participants were asked to only open the
corresponding envelope at the scheduled writing time, and to write
continuously for up to 30 min or until they completed one page of
writing.
Participants in the self-regulation condition were asked to write
about their deepest feelings and thoughts related to their breast
cancer experience at week one, their coping strategies to deal with
stressors caused by breast cancer at week two, and positive
thoughts and feelings regarding their breast cancer experience at
week three. Participants in the emotional disclosure condition were
asked to write about their deepest thoughts and feelings about their
cancer experience for three weeks. Participants in the cancer-fact
group were asked to write about their cancer diagnosis and treat-
ment as objective and detailed as they can for three weeks.
After each writing session, participants mailed their essays to
the research office with a prepaid envelope. After the last writing,
they received manipulation check items described below. At one,
three, and six months after the last writing, participants received
and completed follow-up questionnaires. Semistructured phone
interviews were conducted after the last follow-up at the 6-month
postintervention.
Measures
Functional Assessment of Cancer Therapy (FACT). This is
a 27-item measure of health-related quality of life (Cella & Tulsky,
1993), which assesses perceived life quality in four different
facets, including physical well-being (7 items), social well-being
(7 items), emotional well-being (6 items), and functional well-
being (7 items). The scale possesses adequate psychometric prop-
erties in a Chinese breast cancer sample (Wan et al., 2007).
Participants completed the measure at baseline and follow-up
assessments with regard to their perceptions in the past week. The
items are rated on a 5-point scale from (0) not at all to (4) very
much. Total scores were computed for each of the four subscales
and used to indicate different facets of quality of life. A latent
variable of the four subdimensions indicated the overall quality of
life. In the present study, the Cronbach’s alphas of the four
subscales at all assessments ranged from.72 to .94. The current
study assessed HRQOL and its subdimensions (physical, func-
tional, emotional, and social well-being) as primary health out-
comes of the intervention.
Manipulation check. Participants completed manipulation
check items after the last writing session. They rated how much
emotion they revealed in the writings (i.e., “how much did you
reveal your emotions in what you wrote”), how private the writings
were, and how much writing increased their understanding of their
experience on a 7–point scale ranging from “0⫽not at all”to“6⫽
a great deal.”
Linguistic analysis. Linguistic Inquiry and Word Count
(LIWC2007; Pennebaker, Chung, Ireland, Gonzales, & Booth,
2007) is a text analysis software program to calculate the degree
to which people use different categories of words across a wide
array of texts. LIWC has been commonly used in expressive
writing studies to examine word categories usage such as cog-
nitive and emotion words (Slatcher & Pennebaker, 2006). To
analyze essays written in Chinese, we used LIWC with its
compatible Chinese dictionary developed and validated by
Huang et al. (2012).
Data Analysis Plan
Before conducting the primary analyses, attrition analysis was
conducted to compare potential baseline differences between com-
Table 1
Demographic and Medical Characteristics of Participants
(N ⫽96)
Variable Percentage
a
/(SD)
Age 54.54 (7.91)
Time since diagnosis (months) 19.24 (10.93)
Education
Below high school 14.6%
High school education 33.3%
College education 47.9%
Postgraduate education 3.1%
Marital status
Married 71.9%
Divorced 14.6%
Never married 8.3%
Windowed 2.1%
Separated 3.1%
Annual household income
Less than $15,000 27.1%
$15,000–$ 45,000 27.1%
$45,000$75,000 18.8%
More than $75,000 14.6%
Stage of breast cancer
0 13.5%
I 30.1%
II 41.7%
III 13.5%
a
Percentages may not add up to 100% because of missing data.
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373
EXPRESSIVE WRITING

pleters and noncompleters; baseline equivalence tests were also
conducted to evaluate the success of randomization. Then, the
group means at baseline and the three follow-ups (1-month,
3-month, and 6-month) were compared across conditions.
To examine the proposed hypotheses, all primary analyses with
the longitudinal data were conducted using Mplus 7.2 (Muthén &
Muthén, 1998 –2015) and were conducted as intent-to-treat anal-
yses, in which all randomized participants were included in all
analyses. Direct maximum likelihood estimation procedures were
used to accommodate missing data in all analyses. We began by
calculating effect sizes with 95% confidence intervals to determine
the magnitude of differences in quality of life (total score and four
subscales) between the three conditions at each time point. A series
of regression models were then specified to evaluate the effects of
treatment condition on quality of life at the final assessment when
controlling for baseline levels of quality of life. For these models,
quality of life scores at the final assessment were regressed on
baseline quality of life, with two dummy code variables represent-
ing condition. We first conducted a model in which dummy codes
were specified so that the cancer-facts condition was the reference
condition. We then conducted an additional model in which self-
regulation was specified as the reference condition so as to permit
comparisons between all three conditions. These models were
conducted for the four QOL subscales as well as a QOL latent
variable that was identified by specifying the four QOL subscales
as indicators of a QOL latent construct. The advantage of using a
latent construct as opposed to the total score was to account for
measurement error.
Results
Attrition and Baseline Equivalence Analysis
The completers and noncompleters were compared.
Independent-samples ttests and chi-square test were conducted.
The two groups did not differ on demographic variables (i.e., age,
education level, employment, and marital status), medical vari-
ables (i.e., stage and time since the first diagnosis of breast cancer)
(ps⬎.16), and variables of interest (i.e., quality of life dimen-
sions) at baseline (ps⬎.11). Participants in the three conditions
were compared to determine the success of randomization using
ANOVA. There were no significant group differences in the vari-
ables of interest (quality of life and its domains) at baseline, with
small to medium effect sizes ranging from .01 to .47 (see Table 2).
ANOVA and chi-square test were also conducted to examine
group differences in the demographic and medical variables, and
no significant group differences were found (ps⬎.22).
Manipulation Check and Essay Ratings
ANOVA was used to compare the three groups on their ratings
of the degree to which their essays were personal, revealing, and
increased their understanding. Statistically significant group dif-
ferences were found in only revealing emotions, with post hoc
analysis showing the cancer-facts writing group reported revealing
less emotions (M⫽1.55, SD ⫽0.91) in the writings than the
self-regulation group (M⫽4.04, SD ⫽1.17) and the emotional
disclosure group (M⫽4.71, SD ⫽1.31), ps⬍.001.
Table 2
Descriptive Statistics and Between Condition Effect Sizes
Cancer-Facts
(n⫽33)
Self-Regulation
(n⫽34)
Emotional Disclosure
(n⫽29) Hedges g (95% confidence interval)
Outcomes Mean (SD) Mean (SD) Mean (SD) CF vs. SR CF vs. ED SR vs. ED
Quality of life (total)
Pre-writing 95.69 (27.15) 90.77 (22.47) 95.88 (25.21) .20 (⫺.29, .68) ⫺.01 (⫺.49, .47) ⫺.21 (⫺.71, .28)
1-month FU 101.48 (27.38) 92.89 (21.67) 97.17 (26.43) .34 (⫺.14, .83) .16 (⫺.32, .64) ⫺.18 (⫺.67, .32)
3-month FU 101.56 (20.63) 94.61 (26.65) 94.14 (27.45) .29 (⫺.19, .77) .30 (⫺.18, .79) .02 (⫺.48, .51)
6-month FU 101.40 (32.43) 90.02 (24.54) 92.73 (25.49) .39 (⫺.09, .88) .29 (⫺.19, .77) ⫺.11 (⫺.60, .39)
Physical well-being
Pre-writing 18.60 (6.60) 18.73 (6.43) 18.43 (8.15) ⫺.02 (⫺.50, .46) .02 (⫺.46, .50) .04 (⫺.45, .54)
1-month FU 20.43 (7.23) 20.03 (5.45) 20.41 (6.43) .06 (⫺.42, .54) .00 (⫺.48, .48) ⫺.06 (⫺.56, .43)
3-month FU 20.63 (7.15) 20.90 (6.19) 20.65 (5.98) ⫺.04 (⫺.52, .44) .00 (⫺.48, .47) .04 (⫺.45, .54)
6-month FU 19.94 (7.31) 20.05 (6.52) 20.15 (7.06) ⫺.01 (⫺.49, .46) ⫺.03 (⫺.51, .45) ⫺.01 (⫺.51, .48)
Social well-being
Pre-writing 19.75 (6.02) 17.86 (6.97) 20.81 (5.14) .29 (⫺.20, .77) ⫺.19 (⫺.67, .29) ⫺.47 (⫺.97, .03)
1-month FU 19.35 (5.12) 17.78 (6.65) 20.95 (5.40) .26 (⫺.22, .74) ⫺.30 (⫺.78, .18) ⴚ.51 (ⴚ1.02, ⴚ.01)
3-month FU 19.69 (6.67) 17.72 (5.68) 18.51 (5.65) .31 (⫺.17, .80) .19 (⫺.29, .67) ⫺.14 (⫺.63, .36)
6-month FU 19.81 (6.08) 16.78 (6.40) 20.49 (3.96) .48 (⫺.01, .96) ⫺.13 (⫺.61, .35) ⴚ.68 (ⴚ1.18, ⴚ.17)
Emotional well-being
Pre-writing 17.46 (4.61) 15.82 (5.09) 17.34 (4.52) .33 (⫺.15, .82) .03 (⫺.45, .51) ⫺.31 (⫺.81, .19)
1-month FU 17.38 (4.27) 16.79 (7.22) 16.47 (5.24) .10 (⫺.38, .58) .19 (⫺.29, .67) .05 (⫺.44, .55)
3-month FU 17.74 (4.71) 17.26 (5.63) 16.15 (5.37) .09 (⫺.39, .57) .31 (⫺.17, .79) .20 (⫺.30, .70)
6-month FU 17.77 (4.93) 16.53 (4.88) 14.27 (5.67) .25 (⫺.23, .73) .65 (.16, 1.14) .42 (⫺.08, .92)
Functional well-being
Pre-writing 17.52 (7.61) 16.17 (6.78) 16.80 (6.35) .18 (⫺.30, .66) .10 (⫺.38, .58) ⫺.09 (⫺.59, .40)
1-month FU 18.53 (9.38) 16.18 (6.16) 17.07 (7.63) .29 (⫺.19, .78) .17 (⫺.31, .65) ⫺.13 (⫺.62, .37)
3-month FU 18.98 (6.57) 15.63 (7.68) 16.18 (7.12) .46 (⫺.02, .95) .41 (⫺.18, .89) ⫺.07 (⫺.57, .42)
6-month FU 19.20 (8.65) 14.06 (5.96) 15.18 (7.24) .69 (.19, 1.18) .49 (.01, .98) ⫺.17 (⫺.67, .33)
Note. Hedges’ g was calculated with correction for small sample size; within-group effect size can be provided upon request. Bolded numbers indicate
medium effect sizes.
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374 LU, WONG, GALLAGHER, TOU, YOUNG, AND LOH

In addition, two independent raters, who were unaware of con-
dition assignment, judged which condition each participant be-
longed to. The sets of essays (three days of writing) were randomly
ordered during the rating. Any discrepancies of rating between the
two raters were reconciled. The percentage of match between rated
condition assignment and actual condition assignment was com-
puted. The majority of essays were judged to belong to the as-
signed writing conditions (91.3% cancer-facts writing, 80% self-
regulation, and 63.0% emotional disclosure). The most common
discrepancies occurred when emotional disclosure essays were
judged to be in the self-regulation condition and vice versa. That
is expected because the two conditions both contain instructions
facilitating emotional disclosure.
Linguistic Analysis
To determine group differences in words used in the written
essays, we used LIWC2007 to examine word counts in two emo-
tion categories (positive and negative emotions) and two catego-
ries that reflect cognitive processes including insight (e.g., think,
know, consider) and causation (e.g., because, effect, hence). As
expected and consistent with the manipulation check results, the
emotional disclosure and self-regulation groups used more positive
and negative emotion words compared to the cancer-fact group (all
ps⬍0.001); there was no difference between the emotional dis-
closure and the self-regulation groups. However, the cancer-fact
group used significantly more insight words and causation words
compared to the emotional disclosure group, t(47) ⫽2.12, p⬍.05,
d⫽0.61, 95% CI [0.03, 1.18] and t(47) ⫽2.39, p⬍.05, d⫽0.68,
95% CI [0.11, 1.26], respectively. There was no difference be-
tween the cancer-fact group and the self-regulation group.
Given the unexpected findings of more insight and causation
words usage in the fact writing group, we reviewed the original
essays to further examine the pattern of cognitive mechanisms
word use in this group. Many participants wrote about insight and
causation in their essays. Example quotes that illustrated insights
were “I will never forget everything that I went through. It had
changed my life” and “Now I become positive and diligent, be-
cause I have learned that life is precious, valuable, and limited.”
Sample quotes that illustrated causation were “I couldn’t imagine
it was me when I was diagnosed a malignant tumor. I had always
been cautious about my diet. How could this be possible?” and “I
was curious why I had cancer.” These quotes converged with the
LIWC results.
Descriptive Statistics and Preliminary Group
Comparison at Each Assessment
We began by examining the group means at baseline and the
three follow-ups across conditions. The means, standard devia-
tions, between-condition effect sizes (with 95% confidence inter-
val) for each facet of HRQOL are presented in Table 2. Statisti-
cally significant group differences in social well-being, emotional
well-being, and functional well-being were found at the 6-month
follow-up, with medium effect sizes (Hedge’s gs greater than or
equal to .49, see Table 2). Specifically, the cancer-facts group
reported a significantly higher level of functional well-being
(Hedges’ g⫽.49; 95% CI ⫽0.01, 0.98) and emotional well-being
(Hedges’ g⫽.65; 95% CI ⫽0.16, 1.14) than the emotional
disclosure group. The cancer-facts group also reported a signifi-
cantly higher level of functioning well-being than the self-
regulation group (Hedges’ g⫽.69; 95% CI ⫽0.19, 1.18). The
emotional disclosure group reported a significantly higher level of
social well-being than the self-regulation group (Hedges’ g ⫽.68;
95% CI ⫽0.17, 1.18).
The group differences were less salient at the 1-month and
3-month follow-ups. There were minimal effects of group differ-
ence in physical well-being, with Hedges’ granging from .02 to
.06, and small effect of group differences for overall quality of life
and other domains (i.e., social well-being, emotional well-being,
and functional well-being) at the 1-month and 3-month follow-up
assessment with Hedges’ granging from .02 to .34. The only group
differences that reached medium effect size magnitude were higher
social well-being in the emotional disclosure group compared to
the self-regulation group at the 1-month follow-up (Hedges’ g⫽
.51; 95% CI ⫽0.01, 1.02), and this difference became small at the
3-month follow-up.
Longitudinal Modeling of Effects of Writing at the
6-Month Follow-Up
As statistically significant group differences were predomi-
nately observed at 6-month follow-up assessment but not 1-month
and 3-month follow-up assessments, later longitudinal (residual
change) models were only examined with the 6-month follow-up
data. Because three conditions are included in the present study,
two regression models were conducted for a latent variable of
quality of life and each dimension of quality of life (physical
well-being, social well-being, emotional well-being, functional
well-being) as outcomes, with the first regression model testing the
effects of self-regulation and emotional disclosure in comparison
to cancer-facts writing, and the second model testing the effects of
emotional disclosure and cancer-facts in comparison to self-
regulation writing.
In the first regression model, the cancer-facts writing condition
was treated as the reference group. Outcomes at the 6-month
follow-up were regressed onto the corresponding baseline score
and two dummy code variables representing self-regulation con-
dition and emotional disclosure condition. In the second regression
model, the self-regulation condition was treated as the reference
group. Outcomes at the 6-month follow-up were regressed onto the
corresponding baseline score and two dummy code variables rep-
resenting emotional disclosure condition and cancer-facts writing
condition.
Results from these residualized change regression analyses are
presented in Table 3. Unstandardized regression coefficients rep-
resenting the direct effect of the conditions and the results of their
corresponding significance tests are presented. Results show that
the cancer-facts group reported higher levels of overall quality of
life (b⫽1.99, p⬍.05), emotional well-being (b⫽2.87, p⬍.01),
and functioning well-being (b⫽3.52, p⬍.05) than the emotional
disclosure group. The cancer-facts group also reported higher
levels of overall quality of life (b⫽2.18, p⬍.05), social
well-being (b⫽2.71, p⬍.05), and functioning well-being (b⫽
4.75, p⬍.001) than the self-regulation group. The self-regulation
group had a higher level of emotional well-being (b⫽2.35, p⬍
.05) than the emotional disclosure group.
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375
EXPRESSIVE WRITING

Discussion
Expressive writing has been shown to improve psychological
and physical outcomes in both healthy and clinical populations
(Frattaroli, 2006;Frisina, Borod, & Lepore, 2004). However, it is
unclear whether the findings could be generalized to other popu-
lations as very few expressive studies have been conducted among
ethnic minorities. The present study is the first attempt to examine
the health benefits of expressive writing among Chinese American
breast cancer survivors using a randomized controlled trial. We
found that self-regulation writing increased emotional well-being
compared with emotional disclosure writing, partially supporting
our hypothesis. However, contrary to expectations, the cancer-fact
group reported the highest level of overall quality of life at the
6-month follow-up, and the increase in quality of life from baseline
to the 6-month follow-up reached both statistical significance and
clinical significance set forth by Cella et al. (2002). The unex-
pected findings challenge the implicit assumption that psychoso-
cial interventions validated among Non-Hispanic Whites could be
directly generalized to other populations. These stimulating find-
ings shed light on the importance of developing culturally targeted
interventions for minority breast cancer survivors.
At the 6-month follow-up, it was found that the cancer-facts
writing group reported higher levels of overall quality of life and
functional well-being compared to both the emotional disclosure
and the self-regulation groups. In addition, cancer-facts writing
had higher emotional well-being compared to the emotional dis-
closure group and higher social well-being compared to the self-
regulation group. There are several plausible explanations for these
unexpected findings.
The first one concerns potential cultural differences in the
benefits of expressive writing. A previous study showed that
Asians benefited from writing conditions promoting cognitive
reappraisal and not emotional disclosure in reducing physical
symptoms (Lu & Stanton, 2010). Another study showed that
written emotional disclosure benefited European Americans but
not Asian Americans (Knowles et al., 2011). These studies, to-
gether with the current one, suggest that Asians tend to benefit
from writing instructions that prompt cognitive reappraisal of
stressful events rather than emotional processing. In these studies,
cognitive reappraisal includes evaluating stressful events, coping
strategies, and challenges and opportunities arising from the event.
For this underserved population, diving deeply into their emotions
alone may not be beneficial, because Asian culture values emo-
tional control and restraint over emotional expression (Gross &
John, 2003;Wei, Su, Carrera, Lin, & Yi, 2013) and because
Chinese and Asian Americans tend to suppress emotions more
often than other cultural groups (Gross & John, 2003;Soto, Perez,
Kim, Lee, & Minnick, 2011). As such, Asian cancer survivors may
need further training to effectively cope with negative emotions. A
recent intervention that provided social support and education,
including strategies managing emotions, decreased depressive
symptoms among Chinese-speaking cancer survivors (Lu et al.,
2014). In addition, we have observed that in support groups,
Chinese speaking breast cancer survivors mostly talk about actual
facts of their cancer experience, rather than sharing emotional
aspects. So they might not be used to diving into emotional aspects
of cancer experience directly.
Second, the cancer-facts condition was conceptualized as a
control condition in the Stanton et al. (2002)study, but there are
good reasons to believe that it may have therapeutic effects for
Chinese cancer survivors. Chinese Americans tend to not openly
talk about their cancer diagnosis and experience (Papadopoulos,
Guo, Lees, & Ridge, 2007), and therefore their thoughts related to
cancer might have been suppressed. The cancer-facts writing task
was to write about the details of one’s cancer experience. The
opportunity to describe cancer could be therapeutic as it presents
the opportunity to process suppressed thoughts. This speculation is
supported by data in the present study. Results of linguistic anal-
ysis indicated that the cancer-facts writing group wrote about the
attribution to the causes of their cancer, and the insights they
Table 3
Residual Change Models at 6-Month Follow-Up
Model 1 Model 2
Outcome Predictor bSEPredictor bSE
Quality of Life (Qol)
a
Baseline Qol .74
ⴱⴱⴱ
.17 Baseline Qol .74
ⴱⴱⴱ
.17
SR (vs. CF) ⫺2.18
ⴱ
.89 ED (vs. SR) .20 .79
ED (vs. CF) ⫺1.99
ⴱ
.90 CF (vs. SR) 2.18
ⴱ
.89
Physical Well-Being (PWB) Baseline PWB .56
ⴱⴱⴱ
.14 Baseline PWB .56
ⴱⴱⴱ
.14
SR (vs. CF) ⫺.93 1.63 ED (vs. SR) .24 1.54
ED (vs. CF) ⫺.68 1.61 CF (vs. SR) .93 1.63
Social Well-Being (SWB) Baseline SWB .71
ⴱⴱⴱ
.08 Baseline SWB .71
ⴱⴱⴱ
.08
SR (vs. CF) ⫺2.71
ⴱ
1.09 ED (vs. SR) 1.75 .97
ED (vs. CF) ⫺.96 1.03 CF (vs. SR) 2.71
ⴱ
1.09
Emotional Well-Being (EWB) Baseline EWB .70
ⴱⴱⴱ
.11 Baseline EWB .70
ⴱⴱⴱ
.11
SR (vs. CF) ⫺.52 1.07 ED (vs. SR) ⫺2.35
ⴱ
1.09
ED (vs. CF) ⫺2.87
ⴱⴱ
.98 CF (vs. SR) .52 1.07
Functional Well-Being (FWB) Baseline FWB .73
ⴱⴱⴱ
.10 Baseline FWB .73
ⴱⴱⴱ
.10
SR (vs. CF) ⫺4.75
ⴱⴱⴱ
1.25 ED (vs. SR) 1.23 1.38
ED (vs. CF) ⫺3.52
ⴱ
1.45 CF (vs. SR) 4.75
ⴱⴱⴱ
1.25
Note. SR represents self-regulation group, ED represents emotional disclosure group, and CF represents cancer-facts writing group. Model 1: CF was the
reference group; model 2: SR was the reference group.
a
Quality of life is a latent variable.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.01.
ⴱⴱⴱ
p⬍.001.
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376 LU, WONG, GALLAGHER, TOU, YOUNG, AND LOH

gained from their cancer experience. Participants may thus expe-
rience health benefits through having cognitive reappraisal of their
cancer experience. It is possible that the cognitive reappraisal
experienced by the cancer-fact writing group may promote partic-
ipants’ quality of life by reducing intrusive thoughts related to their
cancer experience. Indeed, a study found that reduced intrusive
thoughts were associated with higher quality of life among Chi-
nese breast cancer survivors (You & Lu, 2014).
The cancer-facts condition in the present study is different
from the typical expressive writing control condition among
healthy adults, in which writing instructions focus on neutral
topics, such as objectively describing furniture in a room. The
utility of cancer-facts writing can be further informed by future
studies comparing writings focusing on objective description of
facts related to stressful events with writings describing a
neutral event. It is possible that objective description of stress-
ful events could facilitate cognitive processing and increase
acceptance of one’s breast cancer diagnosis, which in turn
promotes adjustment. Indeed, a previous longitudinal study
showed that acceptance predicted quality of life 3 months later
(Stanton et al., 2000).
It is also possible that the fact writing may match well with
thinking styles that Asians prefer. Cultural research shows that in
contrast to European Americans who prefer analytic and verbal
thinking, Asians tend to engage in holistic thinking, an orientation
and a preference to explain events in relation to the context (see
Nisbett, Peng, Choi, & Norenzayan, 2001 for a review). Such
thought processes are relatively complex and involve efforts to
convert nonverbal thoughts to words (Kim & Ko, 2007). By giving
participants a protected time and place to convert their thoughts
into words at their own pace, writing about facts could provide an
opportunity for holistic thinking, bringing context into their
thought process, which may in turn help to gain new understanding
of a stressful event.
The study also showed that the self-regulation group reported
a significantly higher level of emotional well-being than the
emotional disclosure group at the 6-month follow-up. This is
consistent with our expectation and a previous study that Asians
tend to benefit more from self-regulation writing than emotional
disclosure (Lu & Stanton, 2010). In both studies, self-regulation
writing combined emotional disclosure and cognitive reap-
praisal writing instructions. Participants in the self-regulation
writing group were also asked to write about cognitive tasks
such as their coping strategies, positive thoughts, and feelings
related to their cancer experience, in addition to disclosing their
deepest thoughts and feelings related to their cancer experi-
ences, as participants in the emotional disclosure condition did.
Our finding suggests that writing tasks facilitating cognitive
aspects may fare better for the Chinese than emotional disclo-
sure alone.
These combined writing instructions were designed to facilitate
cancer survivors’ self-regulatory processes and development of a
coherent representation of their experiences (Cameron & Nicholls,
1998), which in turn may lead to meaning-making (King & Miner,
2000) and psychological benefits (Ullrich & Lutgendorf, 2002).
With preliminary evidence that suggests differential impacts of
cognitive and emotional processing of stressful events among
Chinese American breast cancer survivors, future studies should
explore the effectiveness of alternative writing paradigms that aim
to promote cognitive processing, such as meaning-making, post-
traumatic growth, or even focus on the recounting of events, and so
forth.
The present study is subject to several limitations. The study
was conducted with a sample of female Chinese American breast
cancer survivors. Whether our findings could be generalized to
other cultural groups needs to be tested in future research. Another
limitation is the lack of an immediate postintervention assessment
of major outcomes. The decision to not include a postintervention
assessment was a result of a conscious attempt to reduce partici-
pant burden. Although it is possible that one or more conditions
had more robust effects immediately after the intervention, the
literature suggests that the most robust effects for healthy popula-
tions happened around 1 month follow-up (Frattaroli, 2006). In the
current study, the most robust effects were at the 6-month follow-
up, suggesting the importance of a long-term follow-up among
patient populations. Third, there is a lack of a “neutral” control
condition because the cancer-facts writing seems to deliver bene-
fits. It is unclear whether self-regulation would confer health
benefits against a neutral condition. We have previously found that
self-regulation improved quality of life in a pilot study among
Chinese breast cancer survivors (Lu et al., 2012). With a neutral or
assessment-only control condition, we may be able to detect ben-
eficial effects of the self-regulation condition. This possibility
could be tested in the future by adding a nonwriting group. In fact,
previous expressive writing studies with cancer survivors suggest
that the studies with a nonwriting control group were more likely
to find benefits of writing (Gellaitry et al., 2010;Henry et al.,
2010). Fourth, about one third of the participants in the emotional
disclosure group had writings similar to the fact or the self-
regulation group. This may have weakened the ability to test group
differences. Furthermore, the goals of the self-regulation condition
were not assessed in this study, which may limit us from making
attribution to the effect found in the self-regulation group. Future
studies should examine these goals and its effect in the self-
regulation group.
Despite the limitations, this study has several strengths, includ-
ing an experimental method, long-term follow-ups, and shedding
light onto the expressive writing literature by extending a validated
paradigm to an underserved patient population. As the first RCT
expressive writing study conducted among Asian American breast
cancer survivors, our findings suggest that Asian American breast
cancer survivors tend to benefit more from writing instructions that
emphasize cognitive processing rather than emotional disclosure.
Thus, people from different cultures may benefit from different
writing instructions.
The study challenges the implicit assumption that psychosocial
interventions validated among Non-Hispanic Whites could be di-
rectly generalized to other populations. Cultural adaptation and
evaluation is critical for applying validated psychosocial interven-
tions to a new population.
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Received April 5, 2016
Revision received September 16, 2016
Accepted September 30, 2016 䡲
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