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Research so far has shown little evidence that written disclosure facilitates recovery from bereavement. There are good reasons to assume that written disclosure may only benefit those bereaved who are at risk for developing problems or who are experiencing significant psychological problems as a result of their loss, and only when appropriate writing instructions are used. Drawing on previous work in the area of post-traumatic stress, a writing intervention was designed to test these assumptions. Bereaved individuals, who were still significantly distressed by their loss, were randomly assigned to the intervention condition (N = 460) or a waiting-list control condition (N = 297). Both groups filled in questionnaires online at baseline, and 3 and 6 months later. The intervention was administered via e-mail immediately after baseline measurement. Results showed that writing decreased feelings of emotional loneliness and increased positive mood, in part through its effect on rumination. However, writing did not affect grief or depressive symptoms. Contrary to expectations, effects did not depend on participants' risk profile or baseline distress level. Implications of these findings are discussed.

Writing has been used as a coping tool by bereaved people through the centuries. On the one hand, this has been undertaken spontaneously by bereaved people, as illustrated in Rosenblatt's (1983) compilation of 19th century diaries, which explores the content of diaries written by people dealing with bereavement or separation. On the other hand, writing has taken place on the instruction of a professional as part of grief therapy (de Keijser, Boelen, & van den Bout, 1998). Systematic research into the effectiveness of writing for the bereaved has only recently begun, and has been greatly influenced by the work of Pennebaker et al. In this article, we first discuss this influential work, from which two principal lines of research into the efficacy of writing as a bereavement intervention have evolved. The first of these focuses on interventions open to all bereaved, the second on those for persons experiencing complications in their grief. Findings from both lines of research are discussed. Against this background, we present the design for a randomized controlled trial to test the efficacy of a newly developed writing intervention specifically for bereaved people. This integrates elements from both lines of research, and addresses the main weaknesses of previous studies. It also explores processes that are postulated to underlie the efficacy of this intervention. The traditional Pennebaker paradigm In 1986 Pennebaker and Beall published a seminal paper reporting an investigation in which they asked individuals to write about their thoughts and feelings concerning a traumatic event for 15 min a day over four consecutive days. The results showed improved health over subsequent months when compared with control participants who wrote about superficial topics. This impressive finding led to an expansion of studies using the expressive writing paradigm. These were undertaken with a wide range of participants, using different instructions, settings, outcome measures, and theoretical frameworks (Smyth & Pennebaker, 2008). In a recent meta-analysis bringing together this body of research, Frattaroli (2006) concluded that experimental disclosure is beneficial for one's psychological health, physical health, and overall functioning, but that its average effect size is small. Use of the Pennebaker paradigm in bereavement Researchers soon recognized the potential of this technique for bereaved people. However, studies that have induced disclosure in bereaved individuals via the traditional Pennebaker paradigm, using a randomized control group design, have generally failed to confirm the disclosure effect (Bower et al., 2003, O'Connor et al., 2005, O'Connor et al., 2003, Kovac and Range, 2000, Range et al., 2000, Segal et al., 1999 and Stroebe et al., 2002; for a review see Stroebe et al., 2002). These investigations have included different samples (e.g. students bereaved by suicide, men and women whose partner had died) and have addressed both psychological and health outcomes. Moreover, all studies have used multiple outcomes, thus increasing the likelihood that a positive result would be obtained. Only in one study was a small improvement in self-reported hopelessness observed (Segal et al., 1999), while in one other (Kovac & Range, 2000), improvement was observed using a measure specific to grief following a suicide (but no effect was found on general grief). Structured writing for treating complications in bereavement Another group of researchers appeared to have more success using writing assignments with bereaved individuals. Lange, Rietdijk, Hudcovicova, van de Ven, Schrieken, and Emmelkamp (2003) were the first to develop and evaluate a treatment for PTSD and complicated grief, in which the central therapeutic procedure also involved writing assignments. This treatment – Interapy – was conducted online and consisted of psycho-education, ten 45-min writing sessions, and personalized feedback. The writing assignments were based on established therapies for post-traumatic stress disorder and research into the effectiveness of social sharing, and consisted of three phases: imaginary exposure, cognitive reappraisal, and social sharing. Findings from a randomized controlled trial showed that participants in the treatment condition improved more than participants in the waiting-list control condition on trauma-related symptoms and general psychopathology (Lange et al., 2003). However, both persons with PTSD and complicated grief were included and results were provided for the entire group and not for the two groups separately. Thus, one cannot be sure that Interapy was effective for bereaved individuals per se. Building on the work of Lange et al. (2003), and Wagner et al., 2006 and Wagner et al., 2007 designed and tested an Internet-based cognitive–behavioural therapy program for bereaved people suffering from complicated grief. The first phase of their intervention was similar to the one used by Lange et al. (2003). The cognitive restructuring and social sharing phases, on the other hand, focused on rather different elements that are more suitable to the bereavement situation. Findings from a randomized controlled trial showed that participants receiving the new treatment improved significantly immediately after treatment relative to participants in the waiting-list control condition on symptoms of intrusion, avoidance, and general psychopathology as well as on post-traumatic growth (Wagner et al., 2006 and Wagner et al., 2007). Unfortunately, no long-term effects were investigated. Also, Wagner et al. did not use a grief-specific outcome measure, but instead relied on a trauma-specific measure that may not have been appropriate for all types of bereavement. Thus, the impact of this type of intervention on grief remains unknown. Notwithstanding these limitations, the research of Wagner et al. suggests that structured writing assignments can help improve bereaved individuals' mental health, at least in the short term. Toward explanation of the differences in findings So how is it that the two lines of research described above could lead to apparently conflicting conclusions? Four major features distinguish them from each other, each of which could contribute to the discrepancy: (1) the targeted population (unselected bereaved versus bereaved experiencing significant difficulties in coping with their loss); (2) the (non) employment of cognitive–behavioural principles; (3) inclusion of psycho-education and therapeutic feedback; (4) number of essays and duration of writing. While all four factors could be critical, in our view there are good reasons initially to focus further empirical evaluation on the first two. With regard to the targeted population, we posit that bereaved people in general do not benefit from the disclosure manipulation, because they can talk about their loss naturally, that is, within the context of their daily interactions. Despite the intensity of the emotions it arouses, bereavement is not usually an experience that is out of the ordinary, in the sense that it is a normal human experience for people to die and for their survivors to grieve for them. The above argument is in agreement with general research on the efficacy of intervention for bereaved people (for a review see Currier, Neimeyer, & Berman, 2008). Interventions that are open to all bereaved people generally fail to produce better outcomes than would be expected by the passage of time. Only in cases of high risk and complicated grief are beneficial effects of intervention to be found. Given these findings, we would expect that only a subsample of bereaved individuals would profit from expressive writing: those who are at high risk for developing problems and those who have already developed problems. This could explain – in part – why Wagner et al., 2006 and Wagner et al., 2007 who focused on persons suffering from complicated grief, did find effects, whereas studies that used the traditional Pennebaker paradigm and included all bereaved did not. With regard to the second factor: another important reason why effects were found by Wagner et al., 2006 and Wagner et al., 2007 could be that more powerful writing instructions, better fitted to the bereavement situation, were used. The instructions were highly specific, clearly indicating what should be the focus of the assignment, whereas the traditional Pennebaker instructions were far less structured, merely indicating a need to write about deepest feelings and thoughts regarding a certain topic. The instructions used by Pennebaker would be more likely to invite ruminative accounts. Nolen-Hoeksema (2001) has consistently found associations between rumination, negative affect and poor adjustment in bereavement, and has identified ruminative coping as detrimental to positive outcomes. In addition, there are theoretical reasons why an exclusive focus on the loss (as encouraged in the Pennebaker paradigm) might not be beneficial. The Dual-Process Model (DPM; Stroebe & Schut, 1999) postulates two coping strategies, loss- and restoration-orientation, attention to both of which is needed for favourable psychological adjustment in bereavement. The protocol by Wagner et al., 2006 and Wagner et al., 2007 is in line with the DPM, in so far that it emphasizes loss-orientated coping in the first phase, and restoration and integration in phases two and three. Finally, the writing assignments that Wagner et al., 2006 and Wagner et al., 2007 developed were heavily influenced by cognitive–behavioural principles. A substantial number of randomized controlled trials and several meta-analyses have demonstrated cognitive–behavioural therapy to be efficacious in the treatment of many mental disorders (for a review, see Leichsenring, Hiller, Weissberg, & Leibing, 2006). Recently it has also been shown to have superior effects in the treatment of complicated grief, compared to interpersonal psychotherapy (Shear, Franck, Houck, & Reynolds, 2005) and supportive counselling (Boelen, de Keijser, van den Hout, & van den Bout, 2007). Overview of the current study In summary then, we contend that writing can benefit the bereaved, but only those bereaved who are at risk for developing problems and those who are experiencing complications in their grief, and only when appropriate instructions are used that are tailored to the bereavement situation. The aim of this study was to test these assumptions. For this purpose, we developed and evaluated a writing intervention that draws from both lines of research described earlier. Similar to research that has used the traditional Pennebaker paradigm, this intervention consists of a limited number of assignments and no personalized feedback is provided. The content of the assignments, on the other hand, is heavily influenced by the work done by Lange et al. (2003) and van Emmerik (2005). Should this intervention prove effective, it could offer a cost-effective alternative to the treatment offered by Wagner et al. (2006), because it eliminates the need for trained personnel to provide feedback. In testing this intervention, a number of methodological improvements were implemented. Grief-specific as well as generic measures of adjustment were included; the immediate as well as the long-term effects of the intervention were investigated; and appropriate analyses to handle attrition were used. Moreover, attention was paid to processes that might mediate the effect of the intervention. Over the years, researchers have attempted to explain the mechanisms underlying the benefits of experimental disclosure (for an overview, see Frattaroli, 2006). However, to our knowledge, no such attempts to establish underlying mechanisms have yet been made in the bereavement area. Given the particular nature of this intervention, which includes exposure and cognitive restructuring as its central components, we identify three potential mediating processes, all of which have been linked to detrimental outcomes in bereavement: deliberate grief avoidance (e.g. Bonanno, Papa, Lalande, Zhang, & Noll, 2005), rumination (e.g. Nolen-Hoeksema, 2001) and threatening grief interpretations (Boelen, van den Bout, & van den Hout, 2006). We expect the intervention to have a positive effect on the mental health of those bereaved who are at risk for developing problems or who are experiencing significant psychological problems as a result of their loss. Clearly, there may be overlap between these groups (i.e. most people who are at risk will probably be experiencing problems). However, we feel that it is important for conceptual reasons to make this distinction. We also expect the impact of the intervention on mental health to be mediated by its effect on deliberate grief avoidance, rumination, and threatening grief interpretations.