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Abstract

Researchers and clinicians have begun to search for alternative treatments that are lower in cost and easier to implement than traditional treatment methods. One promising alternative is expressive writing. When people transform their feelings and thoughts about emotional experiences into language, their physical and mental health often improves. An increasing number of studies indicate that having people write about their deeply felt emotions and thoughts can result in healthy improvements in social, psychological, behavioral, and biological measures. Expressive writing offers an alternative to traditional therapies with the advantage of lower cost and greater accessibility. This chapter will begin with an overview of the writing paradigm followed by evidence supporting the efficacy of expressive writing, as well as its potential limitations. The more compelling reasons for why expressive writing works will be presented next. The chapter will conclude with possible real-world applications and future directions.
Expressive Writing 1
Handbook of Low-Cost Interventions to Promote Physical and Mental Health: Theory,
Research and Practice, in press
Expressive Writing:
An Alternative to Traditional Methods
Ewa Kacewicz, Richard B. Slatcher, and James W. Pennebaker,
The University of Texas at Austin
Correspondence should be addressed to James W. Pennebaker, Department of Psychology
A8000, University of Texas, Austin, TX 78712 (e-mail: Pennebaker@psy.utexas.edu).
Preparation of this paper was aided by a grant from the National Institutes of Health (MH52391).
Expressive Writing 2
Researchers and clinicians have begun to search for alternative treatments that are lower
in cost and easier to implement than traditional treatment methods. One promising alternative is
expressive writing. When people transform their feelings and thoughts about emotional
experiences into language, their physical and mental health often improve. An increasing number
of studies indicate that having people write about their deeply felt emotions and thoughts can
result in healthy improvements in social, psychological, behavioral, and biological measures.
Expressive writing offers an alternative to traditional therapies with the advantage of lower cost
and greater accessibility. This chapter will begin with an overview of the writing paradigm
followed by evidence supporting the efficacy of expressive writing as well as its potential
limitations. The more compelling reasons for why expressive writing works will be presented
next. The chapter will conclude with possible real world applications and future directions.
The Expressive Writing Paradigm
In the first expressive writing study, people were asked to write about a trauma or about
superficial topics for four days, 15 minutes per day. We found that confronting the emotions and
thoughts surrounding deeply personal issues promoted physical health, as measured by
reductions in physician visits in the months following the study, fewer reports of aspirin usage,
and overall more positive long-term evaluations of the effect of the experiment (Pennebaker &
Beall, 1986). The results of that initial study led to a number of subsequent investigations, in our
laboratory and by others, with a wide array of intriguing results. We briefly review the writing
paradigm and basic findings below.
The standard laboratory writing technique involves randomly assigning participants to
one of two or more groups. All writing groups are asked to write about assigned topics for one to
five consecutive days, for 15 to 30 minutes each day. Writing is generally done in the laboratory
Expressive Writing 3
with no feedback given. Those assigned to the control conditions are typically asked to write
about superficial topics, such as how they use their time. The standard instructions for those
assigned to the experimental group are a variation on the following:
For the next three days, I would like for you to write about your very deepest
thoughts and feeling about the most traumatic experience of your entire life. In
your writing, I'd like you to really let go and explore your very deepest emotions
and thoughts. You might tie this trauma to your childhood, your relationships with
others, including parents, lovers, friends, or relatives. You may also link this event
to your past, your present, or your future, or to who you have been, who you would
like to be, or who you are now. You may write about the same general issues or
experiences on all days of writing or on different topics each day. Not everyone
has had a single trauma but all of us have had major conflicts or stressors – and
you can write about these as well. All of your writing will be completely
confidential. Don't worry about spelling, sentence structure, or grammar. The only
rule is that once you begin writing, continue to do so until your time is up.
Whereas the original writing studies asked people to write about traumatic experiences,
later studies expanded the scope of writing topics to general emotional events or to specific
experiences shared by other participants (e.g., diagnosis of cancer, losing a job, coming to
college). The amount of time people have been asked to write has also varied tremendously from
10 minutes to 30 minutes for 3, 4, or 5 days – sometimes within the same day to once per week
for up to 4 weeks.
The writing paradigm can be powerful. If nothing else, the technique demonstrates that
when individuals are given the opportunity to disclose deeply personal aspects of their lives, they
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readily do so. Even though a large number of participants report crying or being deeply upset by
the experience, the overwhelming majority report that the writing experience was valuable and
meaningful in their lives. Interest in the method has grown since the original expressive writing
study, and by 2006 well over 150 studies have been published in English language journals.
Below, we briefly summarize some of the more promising findings. For a more detailed and
technical summary, also see a recent paper by Pennebaker and Chung (in press).
Effects of Expressive Writing
Researchers have relied on a variety of physical and mental health measures to evaluate
the effects of writing. Writing or talking about emotional experiences relative to writing about
superficial control topics has been found to be associated with significant drops in physician
visits from before to after writing among relatively healthy samples. Over the last decade, as the
number of expressive writing studies has increased, several meta-analyses either have been
conducted or are currently being conducted.
Meta-analysis findings. The original expressive writing meta-analysis was published by
Smyth (1998), based on 14 studies using healthy participants. The primary conclusions were that
the writing paradigm is associated with positive outcomes with a weighted mean effect size of d
= .47, noting that this effect size is similar to or larger than those produced by other
psychological interventions. The strongest effect sizes were for psychological (d = .66) and
physiological outcomes (d = .68), which were greater than those for health (d = .42) and general
functioning outcomes (d = .33).
Almost seven years after the Smyth article was published, another meta-analysis by
Meads, Lyons, and Carroll (2003) was released by the Cochran Commission. In an analysis of
dozens of studies, the author concluded that there was not sufficient evidence to warrant
Expressive Writing 5
adopting the writing method as part of clinical practice. One problem that the report underscored
was the lack of any large randomized clinical trials (RCTs) that were based on large, clearly
identified samples. Coming from a medical background, Meads was befuddled by the fact that
most of the experimental studies of expressive writing were more theory-oriented and not aimed
at clinical application. Since the release of the Meads paper, a new wave of RCTs are now being
conducted with a diverse group of patient populations.
Most recently, Frisina, Borod, and Lepore (2004) performed a similar meta-analysis on 9
writing studies using clinical populations. They found that expressive writing significantly
improved health outcomes (d = .19). However, the effect was stronger for physical (d=.21) than
for psychological (d = .07) health outcomes. The authors suggested that a possible reason for
these small effect sizes were due to the heterogeneity of the samples. Writing was less effective
for psychiatric than physically ill populations. Indeed, health improvements were exhibited by
patients with a chronic illness (asthma or rheumatoid arthritis) after writing, relative to
participants with chronic illness writing about neutral topics (Smyth, Stone, Hurewitz, and Kaell,
1999). Health improvements gauged by reduction in physician assessed disease severity provided
evidence for the effectiveness of writing.
Immune system and hormonal effects. Writing and/or talking about emotional topics has
also been found to influence immune functioning in beneficial ways, including t-helper cell
levels as well as growth, antibody response to Epstein-Barr virus, and antibody response to
hepatitis B vaccinations. Other studies are finding effects on wound healing, changes in objective
symptoms associated with arthritis and asthma. Yet other projects report faster healing following
surgery among patients with cystic fibrosis. It is beyond the scope of this paper to summarize
Expressive Writing 6
these many effects. Interested readers are encouraged to read recent reviews by Lepore and
Smyth (2002), Sloan and Marx (2004a), and Pennebaker and Chung (in press).
Autonomic and cardiovascular effects. Activity of the autonomic nervous system is also
influenced by expressive writing. Among those participants who disclose their thoughts and
emotions to a particularly high degree, skin conductance levels are significantly lower during the
trauma disclosures than when describing superficial topics. Systolic blood pressure and heart rate
drops to levels below baseline following the disclosure of traumatic topics but not superficial
ones (Pennebaker, Hughes, & O’Heeron, 1987). In short, when individuals talk or write about
deeply personal topics, their immediate biological responses are congruent with those seen
among people attempting to relax. McGuire, Greenberg, and Gevirtz (2005) have shown that
these effects can carry over to the long-term in participants with elevated blood pressure. One
month after writing, those who participated in the emotional disclosure condition exhibited lower
systolic and diastolic blood pressure (DBP) than before writing. Four months after writing, DBP
remained lower than baseline levels.
Objective behavioral effects. Behavioral changes have also been found. Students who
write about emotional topics evidence improvements in grades in the months following the study
(e.g., Lumley & Provenzano, 2003). Senior professionals who have been laid off from their jobs
get new jobs more quickly after writing (Spera, Buhrfeind & Pennebaker, 1994). Writing about
intimate relationships is associated with the relationships lasting longer (Slatcher & Pennebaker,
in press). Interestingly, relatively few reliable changes emerge using self-reports of health-related
or social behaviors.
Self-reports of depression and distress. Self-reports also suggest that writing about
upsetting experiences, although painful in the days of writing, produces long-term improvements
Expressive Writing 7
in mood and indicators of well-being compared to controls. Although expressive writing is a
decidedly psychological intervention, it rarely has been applied to psychiatric populations. One
reason for the hesitancy was a brief report by Gidron et al. (1996) that indicated that Israeli
PTSD individuals who wrote about traumas reported increases in symptoms five weeks later.
The Gidron procedure, however, required participants to read and openly discuss their writing
with others in the group. Since then, several researchers (including Gidron) have reported
positive effects with people reporting PTSD symptoms without the public reading of stories (e.g.,
Gidron et al., 2001; Nishith, Resick, & Griffin, 2002).
As of this writing, there are virtually no expressive writing studies with clinically
depressed samples. However, several studies have found drops in self-reported depression or
distress among people who have been classified as formerly depressed, who initially reported
elevated depression symptoms among mixed psychiatric, medical and community samples.
Although most bereavement studies have not found expressive writing benefits among people
with uncomplicated grief reactions, writing appears to be potentially beneficial for more
traumatic grief experiences, such as suicide or murder (e.g., Stroebe et al., 2002).
Procedural Differences in Expressive Writing Studies
Writing about emotional experiences clearly influences measures of physical and mental
health. In recent years, several investigators have attempted to define the boundary conditions of
the disclosure effect. Some of the most important findings are as follows:
Topic of disclosure. Although some studies have found that health effects only occur
among individuals who write about particularly traumatic experiences, most have found that
disclosure is more broadly beneficial. Choice of topic, however, may selectively influence
outcomes. Although virtually all studies find that writing about emotional topics has positive
Expressive Writing 8
effects on physical health, only certain assigned topics appear to be related to changes in
behaviors in other domains. For beginning college students, for example, when asked to write
specifically about emotional issues related to coming to college, both health and college grades
improve. However, when other students are asked to write about emotional issues related to
traumatic experiences in general, no improvements in academic performance are found.
Over the last decade, an increasing number of studies have experimented with more
focused writing topics. Individuals diagnosed with breast cancer, lung cancer, or HIV, have been
asked to write specifically about their living with the particular disease. Similarly, people who
have lost their job have been asked to write about that experience. In each case, however,
participants are asked to write about this topic in a very broad way and are encouraged to write
about other topics that may be only remotely related. For example, in the job layoff project,
participants in the experimental conditions were asked to explore their thoughts and feeling
about losing their jobs. Fewer than half of the essays dealt directly with the layoff. Others dealt
with marital problems, issues with children, money, and health.
It has been our experience that emotional upheavals often bring to the fore other
important issues in people’s lives. We recommend that writing researchers and practitioners
provide sufficiently open instructions to allow people to deal with whatever important topics
they want to write about. As described in greater detail below, the more that the topic or writing
assignment is constrained, the less successful it usually is.
Topic orientation: focusing on the good, the bad, or the benefits. There are a number of
theoretical and practical reasons to assume that some strategies for approaching emotional
upheavals might be better than others. With the growth of the field of Positive Psychology,
several researchers have reported on the benefits of having a positive or optimistic approach to
Expressive Writing 9
life. A handful of studies have been conducted examining whether the effects of expressive
writing may differ for optimists vs. pessimists. For example, in one study examining adjustment
to college amongst previously classified optimists and pessimists, Cameron and Nicholls (1998)
demonstrated that overall, only participants in the disclosure condition (writing about thoughts
and feelings only) had higher GPA scores at follow-up. However, they did find that only
participants in the self-regulation condition (writing about thoughts and feelings towards coming
to college and then formulating coping strategies) experienced less negative affect and better
college adjustment to college over controls. Interestingly, optimists visited their doctors less in
the following month if they had participated in either the self-regulation or disclosure condition,
whereas pessimists only reaped these benefits if they had participated in the disclosure condition.
Along similar lines, Laura King and her colleagues have demonstrated that when
instructed to write about intensely positive experiences, participants reported significantly better
mood, and fewer illness-related health center visits than did those who wrote about trivial topics
(Burton & King, 2004). In another study, students were asked to write about traumas in the
standard way, a benefit-finding way, or a mixed condition in which participants were first asked
to write about the trauma, and then switch to the perceived benefits of the trauma (King &
Miner, 2000). Counter to predictions, the trauma only and benefits only participants evidenced
health improvements whereas the mixed group did not. It could be that writing about the
perceived benefits is enough to organize thoughts and feelings about a trauma, and to cope
effectively. However, as evidenced from the mixed condition, if people aren’t able to integrate
their perceived benefits into their trauma story in their own way, writing may be ineffective.
Although several variations on the expressive writing method have been tested, none
have been found to be consistently superior to the original method that encourages participants to
Expressive Writing 10
freely choose their writing topic. Forcing individuals to write about a particular topic or in a
particular way may cause them to focus on the writing itself rather than the topic and the role of
their emotions in the overall story.
Actual or implied social factors. Unlike psychotherapy and everyday discussions about
traumas, the writing paradigm does not employ feedback to the participant. Rather, after
individuals write about their own experiences, they are asked to place their essays into an
anonymous-looking box with the promise that their writing will not be linked to their name. In
one study comparing the effects of having students either write on paper that would be handed in
to the experimenter or on a magic pad (wherein the writing disappears when the person lifts the
plastic writing cover), no autonomic or self-report differences were found. The benefits of
writing, then, occur without explicit social feedback.
Typing, handwriting, and finger-writing. Although no studies have compared ways of
writing on health outcomes, a few have explored if mode of writing can influence people’s
ratings of the expressive writing procedure itself. Brewin and Lennard (1999), for example,
reported that writing by hand produced more negative affect, and led to more self-rated
disclosure than did typing. One possibility is that writing by hand is slower and encourages
individuals to process their thoughts and feelings more deeply.
Recently, we have begun to test the idea of finger writing. In finger writing exercises,
people are asked to use their finger and to “write” about a trauma as if they were holding a pen.
Over the last two years, six expressive writing workshops have been given (see Pennebaker &
Chung, in press) in which participants have been asked to write for 5-10 minutes about an
emotional topic on at least two occasions. People are typically asked to write using a pen;
however, one time they are asked to write only with their finger. At the conclusion of each
Expressive Writing 11
workshop, when asked to rate how valuable and meaningful each of the writing exercises was,
individuals rate writing using a pen versus using a finger as equally valuable. Interestingly,
women significantly prefer the finger writing to men because many felt freer to express some of
their most secret thoughts. Indeed, in every workshop, several people reported that they used
more swear words when finger writing compared to writing with a pen.
Timing: How long after a trauma. Is there an optimal time after a trauma that expressive
writing would most likely work? Unfortunately, no parametric studies have been conducted on
this. Over the years, we have been involved in several projects that have attempted to tap
people’s natural disclosure patterns in the days and weeks after upheavals. For example, using a
random digit dialing in the weeks and months after the 1989 Loma Prieta Earthquake in the San
Francisco Bay area, we asked different groups of people the number of times that they had
thought about and talked about the earthquake in the previous 24 hours. We used a similar
method a year later to tap people’s responses to the declaration of war with Iraq during the first
Persian Gulf War. In both cases, we found that people talked with one another at very high rates
in the first 2-3 weeks. By the 4th week, however, talking rates were extremely low. Rates of
thinking about the earthquake and war showed a different pattern: it took considerably longer
(about 8 weeks) before people reported thinking about them at low rates (from Pennebaker &
Harber, 1993).
More recently, we have analyzed the blogs of almost 1,100 frequent users of an internet
site in the two months before and two months after the September 11 attacks. Rates of writing
increased dramatically for about two weeks after the attacks. More striking was the analysis of
word usage. Use of 1st person singular (I, me, and my), dropped almost 15% within 24 hours of
the attacks and remained low for about a week. However, over the next two months, I-word
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usage remained below baseline (Cohn, Mehl, & Pennebaker, 2004). Usage of 1st person singular
is significant because it correlates with depression (see Pennebaker, Mehl, & Niederhoffer, 2003
for review). What was striking was that these bloggers – who expressed an elevated rate of
negative moods in the days after 9/11 – were generally quite healthy. They were psychologically
distancing themselves from the emotional turmoil of the event.
Considering the current evidence, it is likely that defenses such as denial, detachment,
distraction, and distancing may, in fact, be quite healthy in the hours and days after an upheaval.
A technique such as expressive writing may be inappropriate until several weeks or months later.
Indeed, we now encourage clinicians to delay their use of expressive writing until at least 1-2
months after an upheaval or until they think their patient is thinking “too much” about the event.
Obsessing and ruminating about a trauma a few weeks after it has occurred is probably not too
much; thinking about it at the same high rate six months later might in fact signal that expressive
writing may be beneficial.
Timing between writing sessions. Different experiments have variously asked participants
to write for one to five days, ranging from consecutive days to sessions separated by a week,
ranging from 10 to 45 minutes for each writing session, for anywhere from 1 to 7 sessions. In
Smyth’s (1998) meta-analysis, he found a trend suggesting that the more days over which the
experiment takes place, the stronger the impact on outcomes.
Two subsequent studies that actually manipulated the times between writing failed to
support Smyth’s findings. The first, by Sheese, Brown, and Graziano (2004), asked students to
write either once per week for three weeks or for three continuous days about traumatic
experiences or superficial topics. Although the experimental-control difference was significant
for health center differences, no trend emerged concerning the relative benefits of once a week
Expressive Writing 13
versus daily writing. More recently, we had 100 students randomly assigned to write either about
major life transitions or about superficial topics. Participants wrote three times, 15 minutes each
time, either once a day for three days, once an hour for three hours, or three times in a little more
than an hour. Immediately after the last writing session and again at one-month follow-up, no
differences were found between the daily versus 3-times-in-one-hour condition. Indeed, at
follow-up, the three experimental groups evidenced lower symptom reports than the controls
after controlling for the pre-writing symptom levels.
Time until benefits are seen. Expressive writing outcomes have been measured up to
about 6 months after the writing sessions are completed. While some psychological and physical
health changes may be immediately apparent, they may be fleeting. On the other hand, some
effects may take days, weeks, months, or even years to emerge as significant changes on various
measures, if at all.
Considering all the other variants on the writing method already mentioned, it would be
difficult to come up with some standard time for follow-up. Instead, knowing the general time-
course of proposed underlying mechanisms, and providing multiple convergent measures to
validate specific outcomes may be a more practical approach in thinking about follow-up
assessments.
Why Does Expressive Writing Work?
Over the last two decades, a daunting number of explanations have been put forward and
many have been found to be partially correct. Ultimately, there may not be a single cause for a
phenomenon as complex as expressive writing. The reason is two-fold. First, any causal
explanation can be dissected at multiple levels of analysis ranging from social explanations to
Expressive Writing 14
changes in neurotransmitter levels. Second, an event that takes weeks or even months to unfold
will necessarily have multiple determinants that can inhibit or facilitate the process over time.
This section will briefly summarize some of the more compelling explanations for the
expressive writing-health relationship. Keep in mind that many of these processes occur
simultaneously or may influence one another.
Individual and social inhibition. The first expressive writing projects were guided by a
general theory of inhibition. These studies showed that people who had experienced one or more
traumas in their lives were more likely to report health problems if they did not confide in others
about their traumas than if they had done so (e.g., Pennebaker & Susman, 1988). The inhibition
idea was that the act of inhibiting or in some way holding back thoughts, emotions, or behaviors
is associated with low level physiological work. Further, people were especially likely to inhibit
their thoughts and feelings about traumatic experiences that were socially threatening. Hence,
individuals who had experienced a sexual trauma would be far less likely to talk about it with
others than if they had experienced the death of a grandparent.
Emotions and emotional expression. Emotional reactions are part of all important
psychological experiences. From the time of Breuer and Freud (1957/1895), most therapists have
explicitly or tacitly believed that the activation of emotion is necessary for therapeutic change.
The very first expressive writing study found that if people just wrote about the facts of a trauma,
they did not evidence any improvement. Consistent with an experiential approach to
psychotherapeutic change, emotional acknowledgement ultimately fosters important cognitive
changes (Ullrich & Lutgendorf, 2002).
A variation on the emotional expression idea is that the benefits of writing accrue because
individuals habituate to the aversive emotions associated with the trauma they are confronting. A
Expressive Writing 15
test of a habituation model would be to see if people who wrote about the same topic in the same
general way from essay to essay would benefit more than people who changed topics. Research
on changes in autonomic reactions to distressing topics over the writing days tends to support
features of this argument (e.g., Sloan & Marx, 2004b).
An alternative approach looks specifically at the topics on which participants write. If
habituation is a strong argument, one would assume that the more your write about the same
thing, the more you would habituate to it. If people wrote about different emotional upheavals,
rather than a single topic, one could argue that they would have less opportunity to habituate.
Empirical tests of this idea are mixed. In earlier studies, judges evaluated the number of different
topics people wrote about across a 3-day writing study. Number of topics was unrelated to health
improvements. Using a more mathematically sophisticated strategy, we attempted to learn if the
content similarity of essays written by people in the experimental conditions in three previous
writing studies was related to health improvements (Campbell & Pennebaker, 2003). The answer
is no. If anything, the more similar the writing content was from day to day, the less likely
people’s health was to improve.
The construction of a story. One of the basic functions of language and conversation is to
communicate coherently and understandably. By extension, writing about an emotional
experience in an organized way is healthier than in a chaotic way. Indeed, growing evidence
from several labs suggest that people are most likely to benefit if they can write a coherent story
(e.g., Smyth, True, & Sotto, 2001). Any technique that disrupts the telling of the story or the
organization of the story is undoubtedly detrimental.
Although talking about the upsetting experience will help to organize and give it
structure, talking about such a monumental experience may not always be possible. Others may
Expressive Writing 16
not want to or even be able to hear about it. Within the discourse literature, particular attention
has been paid to the role of written language in demanding more integration and structure than
spoken language (Redeker, 1984; see also Brewin & Lennard, 1999). It would follow that
writing -- and to a lesser degree talking -- about traumatic experiences would require a structure
that would become apparent in the ways people wrote or talked about the events.
The components of a story: The analysis of cognitive words. The degree to which
individuals are able to cognitively organize the event into a coherent narrative is a marker that
the event has achieved knowledge status and can be determined via the language people use.
Words or phrases such as, “I now realize that...” or “I understand why...” suggest that people are
able to identify when they have achieved a knowing state about an event. Consistent with this,
linguistic analyses find promising effects for changes in insight and causal words over the course
of emotional writing (see also Klein & Boals, 2001; Petrie et al., 1998). Specifically, people
whose health improves, who get higher grades, and who find jobs after writing go from using
relatively few causal and insight words to using a high rate of them by the last day of writing. In
reading the essays of people who show this pattern of language use, judges often perceive the
construction of a story over time. Building a narrative, then, may be critical in reaching
understanding or knowledge. Interestingly, those people who start the study with a coherent story
that explained some past experience generally do not benefit from writing.
Writing as a way to change perspective. A central tenet of all insight-oriented therapies is
that through psychotherapy people are able to develop a better understanding of their problems
and reactions to them. Inherent in this understanding is the ability to stand back and look at
oneself from different perspectives.
Expressive Writing 17
Using a variety of computerized text analysis methods, we are discovering that peoples’
linguistic styles can predict who benefits from writing. Linguistic style is reflected in function
words, which include pronouns, prepositions, conjunctions, articles, and auxiliary verbs
(Pennebaker, Mehl, & Niederhoffer, 2003). Analyzing three previous expressive writing studies,
we found that the more that people oscillated in their use 1st person singular pronouns (I, me,
my) and all other personal pronouns (e.g., we, you, she, they) from day to day in their writing,
the more their health improved (Campbell & Pennebaker, 2003). If individuals wrote about
emotional upheavals across the 3-4 days of writing but they approached the topic in a consistent
way – as measured by pronoun use, they were least likely to show health improvements. The
findings suggest that the switching of pronouns reflect a change in perspective from one writing
day to the next. Interestingly, it doesn’t matter if people oscillate between an I-focus to a we- or
them-focus or vice versa. Rather, health improvements merely reflect a change in the orientation
and personal attention of the writer.
Implications for Treatment
The purpose of this chapter has been to present expressive writing as an alternate low
cost intervention strategy for improving mental health. Evidence for the efficacy of expressive
writing, its boundary conditions, as well as possible reasons for why it works were offered in an
effort to gain a better idea of practical limitations in the real world. For this chapter and certainly
for this book, the most important aspects of expressive writing include low cost, ease of
implementation, and its proven efficaciousness in improving mental health.
Writing forces people to stop and reevaluate their life circumstance, which is especially
relevant for people suffering from mental illness. The mere act of writing also demands a certain
degree of structure as well as the basic labeling or acknowledging of their emotions. All of these
Expressive Writing 18
cognitive changes have the potential for people to come to a different understanding of their
circumstances without the restrictions of expensive therapy. This provides compelling evidence
for the potential use of expressive writing as a low-cost alternative to traditional methods.
Despite the large number of promising studies, expressive writing is not a panacea. The
overall effect size of writing is modest at best. It is still uncertain for whom it works best, when it
should be used, or when other techniques should be used in its place. Despite these
shortcomings, it is reasonable to assume that expressive writing methods have potential to be
used on a large-scale basis. Given the current status of the discipline, some recommendations for
treatment may be of value.
Anonymity and confidentiality. In the treatment world, there is often a sense that the
therapist always knows best. Many therapists, then, feel as though they need to read whatever
writing samples that their clients produce. Our research suggests otherwise. If finger writing is
potentially beneficial, there may not be a need for clients to read their writings to others or to
give them to a therapist.
Diaries, journaling, and number of writing sessions. In some quarters, there is a belief
that the more that people write, the better their health. Again, expressive writing research does
not support this idea. It may be that a fixed number of writing sessions – perhaps only 3-5 may
be sufficient to optimize improvement. Too much writing, in fact, may simply begin to reflect
the processes of rumination or obsession.
Flexibility in topic, timing, and genre. It is often helpful for clients and therapists to
have a structured treatment method. Although structure and organization may be manna to
practitioners of CBT, all evidence suggests that too much structure in the writing world is not
beneficial. Some people may not want to write about something. This may be a healthy defense
Expressive Writing 19
for them at the time. Others may want to write in verse rather than prose. Encourage it. Some
may want to write for an hour a day; others for 5 minute sessions at different times of the day.
Why not? There is no good evidence that one type of writing is necessarily better than others.
Flipping out, cracking up, and going insane. Some ethics or IRB committees
(especially in medical schools – ironically) have raised concerns that if people confront upsetting
issues, they may regress into serious mental decline. This “flip out” hypothesis has never been
observed in our lab. To bypass this remote possibility, however, we often tell our participants
about the Flip Out Rule. Prior to participation, we simply explain the flip out issue. We then note
that if they feel as though they might flip out to simply stop writing or to write about another
topic. The Flip Out Rule has been effective for many years (Pennebaker, 2004).
When writing fails. Expressive writing is much like every other intervention: it works
for some people and not for others. Despite a great deal of research, we still can’t predict exactly
who will benefit. We have had people who have been in psychotherapy for years who
immediately benefited from writing. We’ve had many people who found the expressive writing
boring and irrelevant. Others have fallen into a trap of writing more and more without ever
getting any sort of closure. Our recommendation is to encourage people to try the method for
perhaps 4 days, 20 minutes a day. If they find the method unhelpful or aversive, then try
something else. If it is beneficial, it might be wise to try something else as well.
Workbooks, manuals, workshops, retreats, and therapy. Effective therapy often
requires a therapist who is a strong believer in the methods he or she is using. There is also an
occasional feeling of territoriality among believers in different treatment methods. “My treatment
is better than yours because I have had the certified training and am using the certified materials
from the Certified Institute.” As should be apparent, the expressive writing method is not
Expressive Writing 20
certified, licensed, trademarked, or copyrighted. A feature that may work well with one therapist
may not be effective for another. At the end of the day, we encourage practitioners to experiment
with expressive writing. See what works and reject what doesn’t.
Our understanding of expressive writing and, indeed, all psychotherapy is in the very
early stages of knowledge. When expressive writing works, it is probably due to a variety of
causes and contexts. In the years to come, we welcome comments and suggestions of therapists
and clients about expressive writing. Together, we can begin to build a better understanding of
the power of writing among people in the real world.
Expressive Writing 21
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... Across the years researchers have proposed several hypotheses to explain the mechanisms underlying expressive writing, however it is still unclear how expressive writing works. For example, it has been proposed that expressive writing helps create a coherent, well-structured story, that wasn't organized before it was put into writing (Kacewicz et al., 2006), eventually re-thinking the experience (Lumley & Provenzano, 2003). One author has proposed that short-term negative affect following the task, reflects the meaning-making process that happens during expressive writing, interpreting it as a positive outcome (Pascual-Leone et al., 2016). ...
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Expressive writing helps the disclosure of an emotionally charged event, in a safe and nonthreatening environment, while focusing on the feelings and emotions associated with a traumatic experience. Studies have proposed that expressive writing improves both mental and physical health, and that writing perspective might influence expressive writing outcomes. However, no studies have compared both emotion regulation outcomes and Heart-Rate Variability between self-immersed (I) and self-distancing expressive writing (She/He). Two hundred and one college students at a university were randomly assigned to either an expressive group, writing about their most upsetting life experience (using either a self-immersed or distanced perspective), or a control group (using either a self-immersed or distanced perspective), writing about their daily routine. Positive and negative affect, emotion regulation, anxiety and alexithymia were measured before and after writing. Heart-rate variability was recorded during the experiment to examine the effects of the writing exercise on the autonomous nervous system. We found that suppression decreased at follow-up (η²p = .023) and LF/HF ratio increased after writing (η²p = .031) in the self-immersed expressive group, in comparison to the self-immersed control group. These are promising results as they suggest that self-immersed expressive writing might be used to foster emotion regulation.
... Avoiding traumatic memories and pretending trauma did not happen keeps the individual in a cycle of victimhood (Medley, 2012;Yoder, 2005). No empirical research has been published on the extent and effects of exposure and disclosure in the ESOL classroom (Carello & Butler, 2014), yet several studies (Barak & Leichtentritt, 2017;Pennebaker, 1997;Kacewicz et al., 2007;Thatcher, 2020) suggest elements of poetry, and creative and expressive writing increase self-awareness and help the traumatised make sense and meaning of their loss. Again, in line with Hayward (2017), we do not advocate for teachers to facilitate the disclosure of traumatic experiences in the classroom. ...
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Forced migrants join the ESOL classes to learn a language. The process of acquiring a new language can be negatively affected by psychological trauma intensified by forced migration stressors. To deepen the understanding of the reality, via semi-structured interviews and online surveys, this mixed-methods study attempts to provide an insight into the experiences of ESOL teachers working with traumatised forced migrants in Wales, and strategies employed to tackle these challenges. The study reveals that teaching ESOL is inextricable from Mental Health. However, the majority of the respondents are not trauma-trained and prioritise creating safety in the classroom by investing in good relationships and applying moral values. There is a space for trauma healing in the ESOL classroom whilst the evidence-based practices that could have facilitated it are not widely applied. The study recommends redesigning ESOL courses to be trauma-responsive using a co-production approach by involving those with lived experience.
... Of the mentioned treatments, NET appears to be the less often used; however, a meta-analysis has found that NET may be fairly effective with populations with trauma (Lely et al., 2019). Among the NET therapies, an expressive writing (EW) intervention could be a useful alternative to traditional therapies with the advantage of lower cost and greater accessibility (Kacewicz et al., 2007). The EW paradigm comprises to write for a minimum of 15 minutes a day for 3 to 5 consecutive days about stressful events. ...
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A renaissance is underway as research studies are substantiating psychotherapeutic and physiological benefits of psychedelic medicines, along with advancements towards legalization, expansion of professional training programs and a renewed cultural recognition of the healing qualities of the medicines. Pending legislation, a cadre of trained psychotherapists are poised to apply their expertise for those who might benefit however, they are currently largely blocked from doing so. There are also ranks of competent psychedelically informed psychotherapists who might provide support to clients engaging with the medicines but are lacking guidelines to do so. ‘Psychedelic-Supportive Psychotherapy’ is a proposed model which might be immediately implemented by qualified practitioners for working with clients adjacent to but not during a medicine experience without compromising ethical or legal risk. This model aimed at psychotherapists who are increasingly challenged to help clients already engaging with or considering psychedelics, draws from the current field of knowledge to respond to a moral imperative for practitioners to act in the service of client's best interests and expand access for diverse communities. It balances psychedelic harm reduction perspectives with support for the emotional, psychological, and spiritual gains to be had when clients use psychedelics outside of therapy and can process the experience within their therapy. The model of psychedelic-supportive psychotherapy,’ is transtheoretical, its core premise being centrality of the therapeutic relationship as a change agent even as the therapist is not physically present in the client's medicine journey. Here a foundational structure is presented along with criteria, parameters, and recommendations for practitioners in its application.
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A theory of inhibition and psychosomatic disease suggests that the failure to confide traumatic events is stressful and associated with long-term health problems. We investigated the short-term autonomic correlates of disclosing personal and traumatic experiences among two samples of healthy undergraduates. In Experiment 1, subjects talked into a tape recorder about extremely stressful events that had occurred in their lives, as well as what they planned to do following the experiment. Skin conductance, blood pressure, and heart rate were continuously measured. Based on judges' ratings of subjects' depth of disclosure, subjects were classified as high or low disclosers. Talking about traumatic events was associated with decreased behavioral inhibition, as measured by lower skin conductance levels among high disclosers. Disclosing traumatic material was also associated with increased cardiovascular activity. In Experiment 2, subjects both talked aloud and thought about a traumatic event and about plans for the day. Half of the subjects were alone in an experimental cubicle and talked into a tape recorder; the remaining subjects talked to a silent “confessor” who sat behind a curtain. Among high disclosers, both talking and thinking about traumatic events produced lower skin conductance levels than did thinking or talking about plans for the day. The presence of a confessor inhibited subjects' talking. Implications for understanding the nature of confession and the development of an inhibitory model for psychosomatic processes are discussed.
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Research by Pennebaker and his colleagues supports the healing power of writing about traumatic events. This study explored the importance of writing about the perceived benefits of traumatic events as a factor in this process. The study included 118 participants who were randomly assigned to write about one of four topics in a 2 (writing about perceived benefits vs. not writing about perceived benefits)×2 (writing about trauma vs. not writing about trauma) factorial design. Participants also completed questionnaire measures of subjective well-being and released health center information for the year. Participants who wrote only about trauma or perceived benefits showed significantly fewer health center visits for illness 3 months after writing. In addition, 5 months after writing, the trauma-only and perceived-benefits-only groups maintained a difference from the control group. These results suggest that writing about perceived benefits from traumatic events may provide a less upsetting but effective way to benefit from writing.
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Although writing about traumatic events has been shown to produce a variety of health benefits, little is known about how writing produces benefits. The degree to which individuals form narrative structure when writing may predict health improvements. This study manipulated narrative formation during writing to test if narrative structure is necessary for writing to be beneficial. A total of 116 healthy students were randomly assigned to write about control topics or about their thoughts and feelings regarding the most traumatic event of their life in one of two ways: list in an fragmented format or construct a narrative. Individuals asked to form a narrative reported less restriction of activity because of illness and showed higher avoidant thinking than the other groups. The fragmented writing group did not differ from controls on any measure. These data (a) demonstrate that instructions to form a narrative produce a different response to writing than instructions to form fragmented and control writing and (b) suggest narrative formation may be required to achieve health benefits.
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In a variation on Pennebaker’s writing paradigm, a sample of 90 undergraduates were randomly assigned to write about either an intensely positive experience (IPE) (n=48) or a control topic (n=42) for 20min each day for three consecutive days. Mood measures were taken before and after writing. Three months later, measures of health center visits for illness were obtained. Writing about IPEs was associated with enhanced positive mood. Writing about IPEs was also associated with significantly fewer health center visits for illness, compared to controls. Results are interpreted as challenging previously considered mechanisms of the positive benefits of writing.