Healing Through Writing: Insights from Research

Abstract

Over the past two decades, a growing body of research has demonstrated that writing about traumatic or stressful events or experiences has a positive impact on physical and psychological health. This paper reviews the research findings related to expressive writing and health, in clinical as well as non-clinical populations. Research findings comparing the health benefits of vocal and written disclosure of traumatic experiences are addressed. Possible pathways or mechanisms through which expressive writing affects health are discussed. Finally, major issues that need serious attention from researchers in this area for future research are suggested.

Full text

19
International Journal of Mental Health Promotion VOLUME 12 ISSUE 2 - MAY 2010 © The Clifford Beers Foundation
FEATURE
Key words: expressive writing; health; exposure therapy;
traumatic experiences
Introduction
Stressful and traumatic experiences are constant companions
of human beings. To a great extent, the quality of human life
depends on their ability to cope with the various adversities
they encounter. It is natural to human beings to share their
emotions with others, expecting support and relief from
emotional burden. One of the dominant ideas in this direction
endorses the view that confrontation and cognitive processing
of the subjective emotional experience related to trauma are
beneficial for health (Foa & Kozak, 1986; Pennebaker &
Susman, 1988). In contrast, research shows that suppression,
repression and denial of emotional processing have a
negative impact on mental and physical health (Wegner &
Pennebaker, 1993). Exposure therapies, especially talking
with others (talking cure), have been very popular throughout
history. Sigmund Freud introduced the concept of catharsis
(expression of emotions in a socially appropriate ways) as a
form of therapy based on the idea of healing of emotional
blockages by uninhibited talking. Almost all forms of
psychotherapy concur that talking about emotional experi-
ences is an important component of the healing process
(Beck, 1976; Ellis, 1962; Rogers, 1951). It is possible that the
Over the past two decades, a growing body of research
has demonstrated that writing about traumatic or stressful
events or experiences has a positive impact on physical
and psychological health. This paper reviews the research
findings related to expressive writing and health, in clinical
as well as non-clinical populations. Research findings
comparing the health benefits of vocal and written
disclosure of traumatic experiences are addressed.
Possible pathways or mechanisms through which
expressive writing affects health are discussed. Finally,
major issues that need serious attention from researchers
in this area for future research are suggested.
Healing Through Writing:
Insights from Research
Dilwar Hussain
School of Management and Social Sciences,
Thapar University, Patiala, India
A B S T R A C T

20 International Journal of Mental Health Promotion VOLUME 12 ISSUE 2 - MAY 2010 © The Clifford Beers Foundation
FEATURE
act of describing the emotional pain triggers transformation
and even thriving.
The benefits of emotional expression are not limited to
verbal expression. Recent research has shown that encour-
aging individuals to write down their thoughts and feelings
about past traumatic events produces better mental as well as
physical health (Lepore & Smyth, 2002; Smyth & Pennebaker,
2001; Pennebaker, 1990). Expressive writing provides a
secure way of purging one’s emotional experience without
any risk of a negative impact from the other’s inappropriate
response. Expressive writing provides the opportunity for
more cognitive processing and integration of traumatic
experience in memory. It leads to higher emotional awareness
and fosters better regulation of emotion and coping with
distress.
Writing and health: research evidence
Over the last two decades, a growing body of scientific
research, mainly by James Pennebaker and his colleagues, has
shown the positive impact of writing on health. Pennebaker
and his colleages proved, using experimental studies, that
disclosing painful memories can lead to better health. They
used the standard experimental design by assigning a group
of participants to an experimental condition and another to a
control condition. Subjects in the experimental condition are
asked to write about the most traumatic experiences of their
life, while subjects in the control condition are asked to write
about a superficial topic. Participants are usually instructed
to write about their assigned topic for 3–5 consecutive days,
for 15–20 minutes each day (Pennebaker & Beall, 1986;
Pennebaker & Seagal, 1999). Pennebaker reported that
through the process of writing one is able to organise the
facts related to overwhelming experiences, which in turn
helps to resolve them. Studies with undergraduate participants
showed that written emotional disclosure resulted in improve-
ment in various health parameters such as improved immune
functioning (Esterling et al, 1994; Pennebaker et al, 1988),
reduced health care visits and fewer physical symptoms
(Pennebaker & Beall, 1986; Pennebaker & Francis, 1996),
increased college grade point average (Cameron & Nichol-
ls, 1998; Lumley & Provenzano, 2003; Pennebaker et al,
1990) and better mood (Greenberg et al, 1996; Lepore, 1997;
Murray & Segal, 1994; Smyth, 1998). Research investigating
the benefits of writing about traumatic experiences has also
been conducted in other samples such as prostate cancer
patients (Rosenberg et al, 2002), unemployed professionals
(Spera et al, 1994), asthma and rheumatoid arthritis patients
(Smyth et al, 1999) and prison inmates (Richards et al,
2000). These beneficial effects of expressive writing were
found across cultures and in diverse samples (Pennbaker &
Graybeal, 2001).
Smyth (1998) conducted a meta-analysis of 13 studies
of expressive writing about trauma by healthy participants
that used the controlled writing method. This meta-analysis
indicated significant long-term health gains in the disclosure
group over the control group (d = 0.47, p<.0001). Effect
size indicated an overall 23% improvement in the long-term
health of the participants who wrote down their traumatic
experiences compared with the control groups. Smyth
(1998) suggested that, for physically and psychologically
healthy individuals, the effects of expressive writing are
similar to those of other psychological, behavioural and
educational treatments. Frisina, Borod and Lepore (2004)
conducted a meta-analysis of nine expressive writing studies
with clinical populations, and also reported a significant
positive effect on health (d = 0.19, p<0.05). However, when
separate analyses were conducted for physical health outcomes
in medically ill populations, and psychological health outcomes
in psychiatric populations, significant effect was found for
physical health outcomes (d = 0.21, p<0.01) but not for
psychological health (d = 0.07, p<0.17). Although the effect
size for the clinical populations was smaller than in studies
with healthy participants, overall the meta-analysis suggests
a positive impact of expressive writing on various health
parameters.
Vocal vs. written expression of emotions
Some studies also compared the health benefits of verbal
and written expression of emotions. Murray, Lamnin and
Carver (1989) assigned undergraduate students randomly to
one of the three conditions: writing about a traumatic event,
writing about a trivial life event, or talking to a therapist about
a traumatic event. The results indicated that the participants
who wrote about their traumatic experience expressed stronger
emotions and increased negative feelings after each session
than participants in the psychotherapy condition. Psycho-
therapy resulted in less negative mood, increased positive
cognitive changes and adaptive behaviour. These results
suggest that the expression of emotion may be necessary
but not sufficient for cognitive re-appraisal and change.
Donnelly and Murray (1991) in a similar study with under-
graduates reported that both writing and psychotherapy
resulted in a decrease in negative mood and increase in
self-esteem. However, this study showed that the writing
group exhibited an increase in negative mood and a decrease
in positive mood immediately after the first session, but
demonstrated greater overall positive mood than the psycho-
therapy group after four sessions. These results suggest that

21
International Journal of Mental Health Promotion VOLUME 12 ISSUE 2 - MAY 2010 © The Clifford Beers Foundation
FEATURE
the benefits of writing depend on the number of sessions of
writing. In another study, Murray and Segal (1994) instructed
one group of undergraduate students to write, and another
group to talk into a tape recorder, about one of the most
traumatic and upsetting experiences of their life for 20 minutes
per day over a four-day period. The results demonstrated that
both groups (vocal and writing) reported significant improve-
ment in their feelings about themselves and an increase in
positive cognitive changes.
These studies reveal that both psychotherapy and written
expression of emotions could be beneficial. However, it
appears that traumatic writing may increase negative mood
immediately, but prove beneficial if pursued for several sessions.
Writing as therapy: possible mechanisms
Although the exact mechanism by which expressive writing
affects health is not yet clear, many possible explanations
have been propounded. Pennebaker (1985) posited that the
inhibition of emotions related to negative or traumatic
experiences may cause heightened autonomic arousal and
obsessive thinking about the event. In the long run, such
inhibition may cause various psycho-somatic illnesses due
to the cumulative effect of stress or emotional burden. On
the other hand, disclosure (talking or writing) reduces the stress
of inhibition and increases overall well-being. Pennebaker
(1985) suggests that we want to share our traumatic experi-
ences with others, expecting social support. However, sharing
experiences with others could be detrimental to self-esteem
in the case of negative or inappropriate responses from
others. In contrast, expression or disclosure through writing
does not carry the risk of social rejection and so should
gradually lower the stress, emotional burden and risk of
psycho-somatic illnesses (Pennebaker, 1993).
The benefits of expressive writing were also explained
in terms of cognitive processing. Expressive writing converts
emotions and images into words and consequently changes
the thinking about and perception of emotional experience.
Ehlers, Hackmann and Michael (2004) in their cognitive
theory of trauma processing suggested that re-experiencing
and verbalising thoughts and memories related to trauma
may lead to elaboration and integration of traumatic experience
into the conscious autobiographical memory. Inhibitions and
unpleasant intrusions may decrease or cease as a result.
Expressive writing helps in the organisation of traumatic
memory and the development of integrated schemas about
the self, other and the world (Harber & Pennebaker, 1992). It
helps in the development of coherent narratives of emotional
experience over time. Coherent narrative is an indicator of
increased cognitive processing and better integration of the
upsetting experience. Several empirical investigations are
finding support for this idea. Smyth and colleagues (1999)
in an indirect test instructed the participants to write about a
traumatic experience in either an organised or an unstructured
way. The results showed that only organised writing resulted
in improvement in health and mood. Several investigations
have consistently shown that use of more positive emotion
words, a moderate number of negative emotion words, and
words indicating increased cognitive processing (such as
‘understand’ and ‘realise’) are associated with improvements
in health (Pennebaker, 1997; Campbell & Pennebaker, 2003;
Klein & Boals, 2001).
So it seems that expressive writing has a positive impact
on health by alleviating emotional inhibitions and stress
from the psychosomatic system. It also provides opportunities
for better integration of emotional experience into the memory,
and consequently assists in the development of adaptive
schemas related to self, others and the world.
Conclusions and future directions
As reviewed above, expressive writing about traumatic
experiences shows potential benefits for physical as well as
psychological health. Although the mechanisms through
which expressive writing affects health are complex and
still far from clear, the evidence suggests that it decreases
emotional inhibitions and cumulative stress. It also helps in
the integration of upsetting experience into the memory,
and consequently in development of adaptive schemas
related to self, others and the world. The implication of this
research is that expressive writing could provide a simple
and cost-effective therapeutic intervention method for general
as well as clinical populations. It could also be used as an
adjunct to other psychotherapy, especially for clinical popu-
lations (Pennebaker & Susman, 1988). Expressive writing
provides opportunities to express emotions without the risk
of negative responses from others, which offers added
advantage over speaking about deeper emotional experiences
to others. Writing provides a medium through which one
can honestly purge emotions without distortions. Most of
the research found that writing about traumatic or upsetting
events for a minimum of 15 minutes a day for at least three
or four consecutive days shows beneficial effects. Some
studies also suggest that traumatic writing may increase
negative mood immediately, but does not appear to pose
any long-term risk and proves beneficial if pursued for a
few sessions. Empirical evidences also indicates that more
structured approaches to expressive writing and use of more
cognitive and emotional aspects of experience are helpful
(Smyth & Pennebaker, 1999).

22 International Journal of Mental Health Promotion VOLUME 12 ISSUE 2 - MAY 2010 © The Clifford Beers Foundation
FEATURE
Although research in expressive writing is growing very
fast, many questions are still far from clear. The underlying
mechanisms between expressive writing and health are still
elusive and needs attention. Although several explanations of
the health benefits of expressive writing have been propound-
ed, they are based mainly on theoretical understanding rather
than empirical data. The effects of expressive writing on
social life and the role of individual differences (such as
personality traits) on health outcomes could be other pertinent
areas for future investigations. The possibility of post-
traumatic growth or thriving as a result of expressive writ-
ing could be an interesting area for future investigation. A
growing body of research suggest that, as well as experiencing
negative symptoms of post-traumatic stress, many victims
report positive changes after facing the trauma. These positive
psychological changes, experienced as a result of the struggle
with highly challenging life circumstances, are termed post-
traumatic growth (PTG) (Tedeschi & Calhoun, 1995). For
most trauma survivors, post-traumatic growth and distress
co-exist, and the growth emerges from the struggle with
coping, not from the trauma itself. This growth is reflected
in personality development and psychological well-being. It
is possible that expressive writing can facilitate the post-
traumatic growth or thriving process.
Address for correspondence
Dilwar Hussain, School of Management and Social Sciences,
Thapar University, Patiala, Punjab-147004, India. Email:
dhussain81@gmail.com
References
Beck AT (1976) Cognitive Therapy and Emotional Disorders
New York: International Universities Press.
Cameron LD & Nicholls G (1998) Expression of stressful
experiences through writing: effects of a self-regulation manipu-
lation for pessimists and optimists. Health Psychology 17 84–92.
Campbell RS & Pennebaker JW (2003) The secret life of
pronouns: flexibility in writing style and physical health.
Psychological Science 14 60–5.
Donnelly DA & Murray EJ (1991) Cognitive and emotional
changes in written essays and therapy interviews. Journal
of Social and Clinical Psychology 10 334–50.
Ehlers A, Hackmann A & Michael T (2004) Intrusive re-
experiencing in post-traumatic stress disorder: phenomenology,
theory, and therapy. Memory 12 403–15.
Ellis A (1962) Reason and Emotion in Psychotherapy. New
York: Stewart.
Esterling BA, Antoni MH, Fletcher MA, Margulies S &
Schneiderman N (1994) Emotional disclosure through writing
or speaking modulates latent Epstein-barr virus antibody
titers Journal of Consulting and Clinical Psychology 62
130–40.
Foa E & Kozak M (1986) Emotional processing of fear:
exposure to corrective information. Psychological Bulletin
99 20–35.
Frisina PG, Borod JC & Lepore SJ (2004) A meta-analysis
of the effects of written emotional disclosure on the health
outcomes of clinical populations Journal of Nervous and
Mental Disease 192 629–34.
Greenberg MA, Wortman CB & Stone AA (1996) Emotional
expression and physical health: revising traumatic memories
or fostering self-regulation. Journal of Personality and
Social Psychology 71 588–602.
Harber KD & Pennebaker JW (1992) Overcoming traumat-
ic memories. In: SA Christianson (Ed) The Handbook of
Emotion and Memory: Research and Theory. Hillsdale, NJ:
Lawrence Erlbaum Associates.
Klein K & Boals A (2001) Expressive writing can increase
working memory capacity. Journal of Experimental Psychology:
General 130 520–33.
Lepore SJ (1997) Expressive writing moderates the relation
between intrusive thoughts and depressive symptoms.
Journal of Personality and Social Psychology 73 1030–7.
Lepore SJ & Smyth JM (Eds) (2002) The Writing Cure:
How expressive writing promotes health and emotional
well-being Washington, DC: American Psychological
Association.
Lumley MA & Provenzano KM (2003) Stress management
through written emotional disclosure improves academic
performance among college students with physical symptoms.
Journal of Educational Psychology 95 641–9.
Murray EJ, Lamnin A & Carver C (1989) Emotional expression
in written essays and psychotherapy. Journal of Clinical
and Social Psychology 8 414–29.
Murray EJ & Segal DL (1994) Emotional processing in
vocal and written expression of feelings about traumatic
experiences. Journal of Traumatic Stress 7 391-405.
Pennebaker JW (1985) Traumatic experience and psychoso-
matic disease. Exploring the roles of behavioural inhibition,
obsession, and confiding. Canadian Psychology 26 82–95.
Pennebaker JW (1990) Opening Up: The healing power of
confiding in others New York, NY: William Morrow.
Pennebaker JW (1993) Putting stress into words: health,
linguistic, and therapeutic implications. Behaviour
Research and Therapy 31 539–48.

23
International Journal of Mental Health Promotion VOLUME 12 ISSUE 2 - MAY 2010 © The Clifford Beers Foundation
FEATURE
Pennebaker JW (1997) Writing about emotional experi-
ences as a therapeutic process. Psychological Science 8
162–6.
Pennebaker JW & Beall SK (1986) Confronting a traumatic
event: toward an understanding of inhibition and disease.
Journal of Abnormal Psychology 95 274–81.
Pennebaker JW, Colder M & Sharp LK (1990) Accelerating
the coping process. Journal of Personality and Social
Psychology 58 528–37.
Pennebaker JW & Francis ME (1996) Cognitive, emotional,
and language processes in disclosure. Cognition and
Emotion 10 601–26.
Pennebaker JW & Graybeal A (2001) Patterns of natural
language use. Disclosure, personality, and social integration.
Current Directions 10 90–3.
Pennebaker JW, Kiecolt-Glaser JK & Glaser R (1988)
Disclosure of traumas and immune function: health impli-
cations for psychotherapy. Journal of Consulting and Clinical
Psychology 56 239–45.
Pennebaker JW & Seagal JD (1999) Forming a story: the
health benefits of narrative. Journal of Clinical Psychology
55 1243–54.
Pennebaker JW & Susman JR (1988) Disclosure of traumas
and psychosomatic processes. Social Science and Medicine
26 327–32.
Richards JM, Beal WE, Seagal JD & Pennebaker JW
(2000) Effects of disclosure of traumatic events on illness
and behavior among psychiatric prison inmates. Journal of
Abnormal Psychology 109 156–60.
Rogers CR (1951) Client-Centered Therapy Boston, MA:
Houghton Mifflin.
Rosenberg HJ, Rosenberg SD, Ernstoff MS et al (2002)
Expressive disclosure and health outcomes in a prostate
cancer population. International Journal of Psychiatry in
Medicine 32 37–53.
Smyth JM (1998) Written emotional expression: effect
sizes, outcome types, and moderating variables. Journal of
Consulting and Clinical Psychology 66 174–84.
Smyth JM & Pennebaker JW (1999) Sharing one’s story:
translating emotional experiences into words as a coping
tool. In: CR Snyder (Ed) Coping: The Psychology of What
Works. New York: Oxford University Press.
Smyth JM & Pennebaker JW (2001) What are the health
effects of disclosure? In: A Baum, TA Revenson & JE Singer
(Eds) Handbook of Health Psychology. Mahwah, NJ:
Lawrence Erlbaum.
Smyth JM, Stone AA, Hurewitz A & Kaell A (1999) Effects
of writing about stressful experiences on symptom reduction
in patients with asthma or rheumatoid arthritis: a randomized
trial. Journal of the American Medical Association 281 1304–9.
Spera SP, Buhrfeind ED & Pennebaker JW (1994) Expressive
writing and coping with job loss. Academy of Management
Journal 37 722–33.
Tedeschi RG & Calhoun LG (1995) Trauma and Transfor-
mation: Growing in the aftermath of suffering. Thousand
Oaks, CA: Sage.
Wegner DM & Pennebaker JW (Eds) (1993) Handbook
of Mental Control Upper Saddle River, NJ, US: Prentice Hall.