Content uploaded by Stephen J. Lepore
Author content
All content in this area was uploaded by Stephen J. Lepore on Nov 06, 2016
Content may be subject to copyright.
EXPRESSIVE WRITING AND HEALTH:
SELF-REGULATION
OF
EMOTION #RELATED EXPERIENCE,
PHYSIOLOGY, AND BEHAVIOR
STEPHEN
J.
LEPORE, MELANIE A. GREENBERG, MICHELLE BRUNO,
AND JOSHUA
M.
SMYTH
.
. .
the brightest
spot
of
all
is
that
at
least
I
can
write
down
all
my
thoughts
and
feelings; otherwise,
I’d
absolutely
suffocate.”
-Anne
Frank
(March
16,
1944)
There is mounting evidence that people who have experienced stress-
ful
life events reap physical and psychological health benefits when
they
engage in expressive writing
(Smyth,
1998).
In
this chapter, we discuss
how self-regulation processes might mediate
the
beneficial effects
of
ex-
pressive writing. Specifically, we suggest that expressive writing can im-
prove regulation
of
emotion-related experience, physiological responses,
and behaviors, which, in turn, can enhance physical and mental health
outcomes (also see
M.
A.
Greenberg
6r
Lepore, in press).
EMOTION
More than a century ago, Darwin
(1872)
and James
(1884)
suggested
that emotions are adaptive behavioral and physiological response tenden-
This work was supported in part by a grant
from
The City University
of
New
York
PSC-CUNY
Research Award
Program
and National Institutes
of
Health Grant CA68354.
99
cies evoked
by
evolutionarily significant situations. For instance, in the
primeval jungle, a sudden noise might have signaled an approaching pred-
ator. The adaptive response in such a situation would be to stop all other
activities, shift attention to the noise source, and mobilize energy for fight
or
flight. Because such responses increase survival odds, biological factors
supporting them were transmitted to future generations. Therefore, humans
express strong negative emotional responses to sudden noises, even though
in a modem context such responses are not necessarily adaptive. In addi-
tion to the ingrained emotional responses, humans leam novel emotional
responses in the course
of
normal development. For instance, shame can
be acquired through social interaction, and disgust can be acquired through
associative learning, as is evident in persons experiencing food poisoning.
For the present discussion, we assume that innate and learned emotional
responses facilitate adaptation
by
engaging and directing responses to sig-
nificant stimuli.
Emotional responses involve at least three systems: subjective-
experiential,
neurophysiological-biochemical,
and behavioral-expressive
(Lang,
1968).
Each system influences a person’s relation
to
significant stim-
uli.
The
experiential component
refers to feeling states, which have a positive
(e.g., pleasure)
or
negative (e.g., pain) valence. These states alert a person
that something significant transpired and signal the need to approach or
avoid a stimulus. The
physiological component
refers to activities in the cen-
tral and autonomic nervous systems, as well as the neuroendocrine system,
which modulate arousal. Arousal levels prevent action
by
conserving en-
ergy
or
support action
by
releasing it. Finally, the
behavioral component
refers
to facial, bodily, and verbal responses. This component serves various hnc-
tions, such as guiding one’s own approach or avoidance to stimuli and
signaling others to approach
or
move away.
Response tendencies in the experiential, physiological, and behavioral
emotion channels are partly independent.
For
instance, in
the
presence
of
a snake, a person could report feeling unafraid but exhibit physiological signs
of fear (Rachman
&
Hodgson,
1974).
Particular response tendencies, such
as a rapid heart rate, accompany diverse emotional states, including fear,
anger, and sadness (Cacioppo, Bemtson, Larsen, Poehlmann,
&
Ito,
2000).
Subjective perceptions
of
stress and arousal during acute stress exposures are
only weakly correlated with physiological changes (Feldman et al.,
1999).
These findings suggest that each emotion component has its
own
determi-
nants, and any approach to regulating emotions might have differential ef-
fects on the components. As we discuss later, this might explain why ex-
pressive writing sometimes has a stronger effect on physical than on mental
health. This might occur if, for instance, expressive writing modulates phys-
iological arousal more than, or prior to, subjective emotional experience.
1
00
LEPORE
ET
AL.
EMOTION REGULATION
Emotion regulation is part
of
the broader construct of self-regulation,
or self-control.
It
refers specifically to control over the quality, frequency,
intensity,
or
duration
of
responses in any
of
the
three emotion channels
-experience, physiology, and behavior
(cf.
Eisenberg, Fabes, Guthrie,
&
Reiser,
2000).
It influences which emotions people have, in what situations
they have them, and how they experience and express them. This defini-
tion emphasizes agency and,
by
inference, implies effortful, conscious pro-
cesses; however, such processes are not always controlled, effortful, and con-
scious.
Emotion regulation can be viewed on a continuum with the anchors
underregulated,
optimally
regulated,
and
overregulated.
People at the extreme
ends of this continuum have dysregulated emotions, which puts them at
increased risk for physical and psychological health problems. People who
are underregulated have little or no control over their responses to
emotion-provoking stimuli. They experience emotions intensely, have ex-
aggerated physiological arousal, and have little control over expressing and
acting on impulse. Frequent or chronic activation of physiologic systems
that respond to stressors can result in cumulative damage
to
these response
systems, which undermines a person’s ability to adapt to future stressors
(McEwen,
1998).
Perhaps as a result of these pathophysiological processes,
chronic, exaggerated arousal during stress is a risk factor for cardiovascular
disorders and infectious illnesses (Lepore, 1998). High leveIs of negative
emotions, such as hostility, anxiety, and depression, constitute risk factors
for asthma, arthritis, and coronary artery disease (Friedman
&
Booth-
Kewley,
1987).
Hostility and impulsiveness also contribute to interpersonal
problems (Smith,
1992).
In contrast, people who are overregulated constrict, avoid, inhibit, or
suppress emotional response tendencies. Excessive control over emotions
has been implicated in cancer (Gross,
1989)
and cardiovascular disorders
(chapter
2,
this volume). One theory is that inhibition requires physio-
logical work that leads to unhealthy, chronic arousal (Pennebaker,
1989).
For instance, people who avoid conflict might inhibit anger, which could
contribute to chronic increases in autonomic arousal and, eventually,
coronary heart disease. Emotion suppression has been linked to increased
sympathetic activation (Gross
&
Levenson,
1993)
and compromised
immune system functioning (Petrie, Booth,
&
Pennebaker,
1998).
People
who avoid upsetting information might ignore signs and symptoms
of
dis-
ease, delay help seeking, and not work on problematic situations or rela-
tionships.
EXPRESSIVE WRITING
AND
EMOTlON REGULATION
101
EXPRESSIVE
WRITING
AND
EMOTION
REGULATION
MENTAL
&
PHYSICAL
HEALTH
J
When people experience stressful life events, they need to strike a
balance between emotionally overreacting and underreacting.
As
shown in
Figure
6.1,
expressive writing might help people to achieve emotional bal-
ance
by
facilitating emotion regulation processes, such as directing atten-
tion, facilitating habituation, and aiding in cognitive restructuring.
Al-
though we discuss these regulatory mechanisms in separate sections below,
they are interrelated and mutually influential.
Attention
Attention is central to emotion regulation, because people must at-
tend to emotional responses and antecedent stimuli before controlling
1
EXPRESSIVEWRITING
1
r
Regulatorv Processes
Attention
Habituation
Cognitive Restructuring
t
Regiulatorv Outcomes in Emotion Systems
subjective- neurophysiological- behavioral-
experiential biochemical expressive
102
LEPORE
ET
AL.
them. Expressive writing can direct attention
to
sources
of
stress; different
aspects
of
stressors; and subjective, physiological, and behavioral responses.
By
directing attention to these components, expressive writing can facili-
tate other emotion regulation processes.
For
example, directing attention
toward negative stress-related thoughts and feelings can facilitate emotional
habituation (e.g., attenuated physiological and affective responses).
Writing instructions can direct attention
to
different aspects
of
a sit-
uation and one’s emotional response
to
the
situation. Early theorizing
by
Pennebaker
(
1989) emphasized directing attention to negative aspects of
stressors, which tend to
be
avoided.
It
was thought that inhibition of un-
desirable, stress-related thoughts and feelings required physiological work
that resulted in unhealthy levels
of
chronic arousal. The writing manipu-
lation developed
by
Pennebaker instructs people to write about their deep-
est thoughts and feelings about stressful events. Consistent with expecta-
tions, this approach increases people’s expression
of
emotions, particularly
negative emotions; discourages avoidance, or excessive control
of
emotions;
and increases short-term experiences
of
negative emotion
(Smyth,
1998).
This approach may also reduce arousal and improve longer term mood
(Smyth
&
Pennebaker, 2001).
Although Pennebaker’s manipulation reduces physical and emotional
health problems in diverse populations,
the
negative focus
of
attention
might not be necessary. Recent work suggests that directing attention to
positive aspects
of
stressors, or to perceived benefits accrued from experi-
encing stressful events, can enhance health (chapters
3
and
7,
this vol-
ume). This latter approach is more likely than Pennebaker’s approach to
elicit expression of positive affect, which might, in part, explain why it
can produce health benefits. Researchers have shown that positive emotion
can “undo”
or
attenuate residual arousal and long-term distress that may
result from negative emotional responses to stressors (Bonanno, 2001; Fred-
rickson
&
Branigan, 2001). Thus, writing about positive aspects
of
stressors
might evoke positive emotions, which act as a buffer to the negative emo-
tions evoked
by
the stressor. Positive emotions also can facilitate devel-
opment
of
new personal and social resources
to
deal with future stress
(Frederickson
&
Branigan, 2001).
For
example, interest and excitement
can motivate exploratory and skill-building behavior, whereas happiness
can facilitate positive social engagements that strengthen social ties.
Although writing that directs attention to positive aspects
of
stressors
might enhance health, Pennebaker’s approach might produce stronger
health benefits. Stanton and Danoff-Burg (chapter
2,
this volume) ran-
domly assigned women with breast cancer to one
of
three writing groups
in which
they
were to focus on facts related to their cancer experience,
their deepest thoughts and feelings about their cancer experience,
or
the
benefits they perceived in their cancer experience. At 3-month follow-up,
the group writing about their deepest thoughts and feelings reported a
EXPRESSIVE WRITING
AND
EMOTION REGULATZON
1
03
greater decrease
in
physical symptoms than the group that wrote only about
cancer facts; the group writing about benefits fell in between the other
two.
These findings suggest that exploring a broad range of thoughts and feel-
ings, including negative ones, is on average, more beneficial than focusing
on a restricted range
of
positive thoughts and feelings. Nonetheless, the
finding that people might enhance their health
by
writing
on
positive as-
pects
of
stressors and not confronting undesirable thoughts and feelings has
important clinical implications. Some people might prefer the alternative
approach, or some clinical situations might require this alternative because
people cannot bear to confront the stressor directly.
An important goal for future research in this area is to consider why
these vastly different writing approaches
both
result in positive outcomes.
We posit two plausible explanations. First, different people might benefit
from different approaches. For instance, people who are overregulated
might benefit from confronting negative thoughts and emotions, whereas
people who are underregulated might benefit from redirecting attention
from negative to positive aspects
of
situations. Indeed, in a recent study
of
women with
HI'(
Mann (2001) found that writing about a positive future
was associated with better medication adherence and decreased distress
among women who were relatively pessimistic but that it had the opposite
effect among women who were relatively optimistic. Second, attending to
different aspects
of
a stressor (e.g., losses vs. benefits) or
of
one's response
to
a stressor (e.g., sadness vs. relief) might affect different health mediators.
For instance, focusing on negative thoughts and emotions associated with
a stressor might reduce negative emotional responses primarily through
habituation processes. In contrast, focusing on positive aspects
of
a stressor
might reduce negative emotional responses primarily through cognitive re-
structuring or, as suggested above,
by
increasing positive affect.
It
is even
possible that increasing positive affect facilitates cognitive restructuring
(e.g., Bonanno,
2001;
Fredrickson
&
Branigan,
2001).
Habituation
Habituation
is defined simply as decreased response
to
repeated stim-
ulation (Groves
&
Thompson,
1970).
Expressive writing interventions
have been likened to forced exposure therapies: Through repeated exposure
to stressful stimuli, expressive writing extinguishes negative emotional as-
sociations (Lepore, 1997). In considering the ways in
which
expressive
writing could influence habituation processes, we draw on work
by
Watson
and Marks
(
1972).
These investigators observed that emotional habituation
could
be
produced in phobic people
by
exposure
to
phobic-specific stimuli
(e.g., exposing people with agoraphobia to scenes
of
crowded places)
or
by
exposure to phobic-irrelevant, but fear-provoking stimuli (e.g., exposing
people with agoraphobia to scenes of a person being eaten
by
a tiger).
1
04
LEPORE
ET
AL
Phobic
clients exposed to either
of
these conditions showed decreases in
anxiety and avoidance. Watson and Marks suggested that exposure to any
fear-arousing stimulus promotes physiological and psychological habitua-
tion, leading to a reduction of the fear response over time. Thus, two
different types
of
habituation were identified: stimulus-related and
response-related.
Stimulus-related
habituation
is decreased emotional reactivity to specific
fear-provoking stimuli that results from prolonged exposure to those stim-
uli.
Response-related
habituation
is decreased emotional reactivity resulting
from prolonged or intense exposure to fear responses provoked
by
any stim-
ulus. While writing about stressful events, people often describe elements
of
the experience-the scenery, actors, and activities-and their responses,
including physical sensations, emotions, and thoughts. In addition, writing
evokes negative emotions,
as
people remember stressful experiences. Thus,
expressive writing should facilitate both stimulus- and response-related ha-
bituation.
Recent writing studies provide data consistent with stimulus-related
habituation. Expressive writing reduced the effects of stress-related intru-
sive thoughts on mental and physical health outcomes, suggesting that
people became desensitized, or habituated, to the intrusive thoughts. In
one study (Lepore,
1997),
expressive writing attenuated the association
between intrusive thoughts about an important impending examination
and depressive symptoms.
As
shown in Figure
6.2,
intrusive thoughts mea-
sured
l
month prior to the exam were positively related to depressive symp-
toms
3
days prior to the exam in the control-writing group but not in the
expressive-writing group.
In
another study (Lepore
&
Greenberg, in press),
expressive writing attenuated the association between a composite measure
of
intrusive-avoidant thoughts about a relationship breakup and upper
respiratory illness
(URI)
symptoms. Specifically, a higher level of intrusive-
avoidant reactions was related to short-term increases in
URI
symptoms in
participants who wrote about a control topic, but it was unrelated to
URI
symptoms in participants who wrote expressively about their breakup.
Investigators also have shown habituation during writing about stress-
ors. Smyth, Stone, Hurewitz, and Kaell
(1999)
examined emotional reac-
tions in patients with asthma or rheumatoid arthritis, who wrote about
their most stressful life experiences on three consecutive days. Participants
rated their level
of
positive and negative mood immediately before and
after each writing session. Mood change scores
(prewriting-postwriting)
were calculated for each writing day. As shown in Figure
6.3,
writing pro-
duced larger increases in negative mood
on
the first day than on subsequent
days
(p
<
-01).
There was a similar trend for positive affect
(i,
<
.08;
Hockemeyer, Smyth, Anderson,
&
Stone,
1999).
Others have examined
how expressive writing relates to physiological arousal, as assessed
by
skin
conductance levels
(SCL).
Pennebaker, Kiecolt-Glaser, and Glaser
(
1988)
EXPRESSWE WRITING
AND
EMOTfON REGULATlON
1
05
0.9
!ii
8
0.8
8
0.7
8
0.6
L
g
L
0.5
0.4
s
0.2
0
m
v)
3
03
3
0.1
a
4
1
LOW
(-1
SD)
High
(t1
SD)
Level
of
Intrusions
(IES)
Time
1
Figure
6.2.
Slope of the relation between intrusive thoughts and changes in
depression from Time
1
to Time
2
(residualized) as a function of writing
condition. The experimental group wrote about an impending entrance
examination, whereas the control group wrote about daily activities. Time
1
measurement occurred
1
month before the examination, and Time
2
measurement occurred
3
days before the examination. The writing
manipulation was administered
10
days before the examination. High
=
+1SD;
low
=
-1SD.
IES
=
Impact of Events Scale (Horowitz, Wilner,
&
Alvarez,
1979).
From “Expressive Writing Moderates the Relation Between
Intrusive Thoughts and Depressive Symptoms,” by
S.
J.
Lepore,
1997,
Journal
of
Personality
and
Social Psychology,
73,
p.
1033.
Copyright
1997
by the
American Psychological Association. Reprinted with permission of the author.
found no effects on
SCL.
In contrast, Petrie, Booth, Pennebaker, Davison,
and Thomas
(1995)
found
SCL
exhibited a steady decline over writing
days
for
participants in a trauma-writing group, whereas
SCL
declined in
the first
2
days of writing but rose again in the last
2
days in a control-
writing group. Overall, these data suggest that participants become emo-
tionally habituated to stress-related stimuli through the repeated exposures
during writing.
Results
from
another study are consistent with response-related ha-
bituation
(M.
A.
Greenberg, Wortman,
&
Stone,
1996).
Participants in
the study were randomly assigned to write about past personal traumas,
imaginary traumas, or nonemotional events. Imaginary trauma participants
were yoked to their real trauma counterparts and wrote about the same
topics,
As
shown in Figure
6.4,
both real and imaginary trauma groups
visited the student health center for illness less often at 1-month follow-
up relative to controls. The authors argued that participants in the imag-
inary group had the opportunity to accommodate themselves to negative
emotions in a safe context, which might have conferred health benefits
by
106
LEPORE
ET
AL.
.9
a
-6
-8
M
V
______________________...________._________.....____..________._______.._____...
._._________._._.___.....________._........
....._....-.
_____._____________.._...___________________...__________._________...____......
__._______.._.___________________.______.___________________________._.___._____
1
I
I
I I
i
1
2
3
Writing
Day
Figure
6.3.
Emotional habituation across writing days as indicated by change
(post-pre)
in
positive and negative mood. Scores represent the mean.
increasing perceived control over and tolerance
of
negative emotion in
other areas
of
their lives.
Emotional engagement is important for habituation. Foa
(1997)
ar-
gued that for successful habituation, people should experience strong neg-
ative emotions initially, followed
by
gradual decreases
in
negative emotion
within and across exposures. Results from some writing studies are consis-
tent with
the
engagement hypothesis. In a secondary analysis
of
data from
one of our studies (Lepore
&
Greenberg, in press), we found a significant
inverse association between the proportion
of
negative emotion words (e.g.,
sad)
expressed in writing and changes in symptoms
of
URI
from baseline
to
follow-up
(r
=
-26,
p
<
.05,
n
=
73).
Expressing more negative emotion
was prospectively associated with improvements in reported health. Unlike
other studies (e.g., Pennebaker, Mayne,
&
Francis,
1997),
we
did
not find
an association between expression
of
positive emotion and health out-
comes. In another study, participants with a higher proportion of emotion-
focused words in their essays had lower levels
of
antibody
to
Epstein-Barr
virus
(EBV),
indicating better immune functioning, than those who ex-
pressed less emotion (Esterling, Antoni, Fletcher,
&
Margulies,
1994).
Fi-
nally, participants who wrote about stressful events that they rated subjec-
tively as more severe had fewer physical symptoms at follow-up than those
who wrote about less severe events
(M.
A.
Greenberg
&
Stone,
1992).
Writing about more severe stressors presumably would increase exposure
to
negative emotions.
EXPRESS
WE WRITING
AND
EMOTION
REGULATiON
107
0.6
0.5
0.4
a
0
d
m
c,
a
m
0.3
+
0.2
z
0.1
a
c,
.d
m
.d
m
n
0
Control
It
Imaginary Trauma
+
Real Trauma
T
I
.
I
8
I
Pretest
Follow-up
figure
6.4.
Group means for illness visits at pretest and follow-up. The real
trauma group wrote about an actual past trauma, the imaginary trauma group
wrote about a hypothetical trauma, the control group wrote about trivial events.
Pretest was 1 month preceding, and follow-up was 1 month following essay
writing. From “Emotional Expression and Physical Health: Revising Traumatic
Memories or Fostering Self-Regulation?”
by
M.
A. Greenberg,
C.
B.
Wortman,
&
A. A. Stone, 1996,
Journal
of
Personality and Social Psychology,
71,
p. 592.
Copyright 1996 by the American Psychological Association. Adapted with
permission from the authors.
Cognitive Restructuring
The third mechanism of emotion regulation is cognitive restructuring.
Several contributors to this volume have argued that expressive writing
can result in changes in stress-related thoughts and appraisals. We propose
that changes in how people view internal (e.g., memory) and external (e.g.,
environmental) stressor-related stimuli, or changes in how
they
view their
emotional reactions to such stimuli, can contribute to
how
well they reg-
ulate their emotions.
As
with habituation, cognitive restructuring is a complex construct
and has been operationalized in various ways. One approach has been to
analyze the content
of
written essays. Pennebaker and colleagues
(1997)
used this approach and found that people writing about stressful life ex-
periences exhibited the greatest improvements in health outcomes when
they
increased their use
of
cognitive terms (e.g.,
understand,
know,
realize)
over writing sessions. However, some investigators have
not
replicated this
finding (e.g., Lepore
&
Greenberg, in press). Donnelly and Murray
(1991)
obtained ratings
of
the extent to which essays showed beneficial cognitive
108
LEPORE
ET
AL.
change (e.g., expressing a better understanding of the problem). Partici-
pants who wrote about stressful events evidenced more beneficial cognitive
change than controls, providing some evidence that writing facilitates cog-
nitive restructuring.
Another way investigators measure cognitive restructuring is through
examining changes in the frequency of intrusive thoughts. This indirect
method rests on the assumption that intrusions reflect incomplete cognitive
processing of stressors (Lepore,
1997).
Cognitive processing theories main-
tain that intrusions are a product of the mental struggle involved in cog-
nitively assimilating information from stressful events that is incongruous
with preexisting schemas.
To
the extent that people can cognitively inte-
grate stressful events, they should experience a reduction and possible erad-
ication
of
intrusive thoughts. Research examining the effects
of
expressive
writing on intrusive thoughts has produced mixed results. Schoutrop re-
ported that undergraduates who wrote about stressful life experiences ex-
hibited declines in intrusive thoughts after the intervention, whereas con-
trol participants did not show improvement (also see chapter
8,
this
volume). In contrast, several investigators found that expressive writing
did not affect the frequency of intrusive thoughts; instead, it attenuated
the negative effects
of
intrusive thoughts on mood and psychological and
physical symptoms (Lepore, 1997; Lepore
&
Greenberg, in press; Smyth,
True,
&
Souto,
2001).
The mixed results with intrusive thoughts may be due to several fac-
tors, including differences in sampling, the type of stressors, and the time
frame
of
measurement. Alternatively,
it
is possible that expressive writing
alters both the frequency and emotional impact of intrusive thoughts (see
Lepore,
1997;
Lepore, Ragan,
&
Jones,
2000).
Schoutrop
(2000)
reported
that relative to a wait-list control group, participants writing about negative
experiences exhibited
a
greater decline in intrusive thoughts and depressive
symptoms. In addition, among participants writing about negative experi-
ences, those who had a high level of intrusive thoughts at baseline showed
greater declines in depressive symptoms at follow-up than those who had
a relatively low level
of
intrusive thoughts. This latter finding is consistent
with the hypothesis that expressive writing increases habituation to intru-
sive thoughts. However, the authors
did
not report the relation between
intrusive thoughts and depression in the control group,
so
we cannot be
certain that desensitization is occurring only in the experimental group. In
general, these findings suggest that expressive writing can decrease
both
the frequency and impact of intrusive thoughts. We do not yet know the
parameters or appropriate time frame for obtaining specific effects.
Another approach
to
examining cognitive restructuring is
to
assess
changes in beliefs and attitudes through self-report measures. In one study,
participants rated how much
a
writing intervention had changed their
thoughts and attitudes toward the topic and their self-perceptions (e.g.,
EXPRESSIVE
WRITlNG
AND
EMOTION REGULATION
109
feeling more positive about the topic
or
one’s self; Donnelly
&
Murray,
1991
).
Participants who wrote about stressful events reported more positive
cognitive change relative to participants who wrote about trivial topics. In
the
study
on
romantic breakups, Lepore and Greenberg
(in
press) measured
participants’ feelings and attitudes toward their ex-partner (e.g., resent-
ment)
and themselves (e.g., guilt) before and after writing. Results revealed
changes in attitudes about
the
breakup over time, but not as a function
of
writing. Thus, contrary to expectations, these findings suggest that core
beliefs about
the
self, others, and the situation were unaffected
by
expres-
sive writing.
Investigators also have used experimental approaches to examine
the
role of cognitive organization in mediating expressive writing effects.
For
instance, people were randomly assigned to write about a control topic
(time management), a detailed narrative about their response to a trau-
matic event,
or
a fragmented list describing their response
to
a trauma
(Smyth et al.,
2001).
Participants who formed a narrative account reported
fewer activity restrictions related to illness compared with
both
the
control
and fragment writing groups. This suggests
it
may
be
necessary
to
form a
cohesive story in order to experience health benefits. However, these
find-
ings also could be the result
of
greater exposure and habituation
to
stim-
ulus, response,
or
meaning elements of trauma schemas in the narrative
versus fragmented writing group.
In addition to changing perceptions about a situation, expressive writ-
ing can change people’s perceptions about their responses
to
a situation.
Expressive writing can help people to
feel
more connected with their own
selves and to experience and accept their emotional reactions. Acceptance
of
one’s
own
feelings is sometimes difficult to achieve after a trauma, par-
ticularly if members of one’s social network act distant, critical,
or
uncom-
fortable upon hearing about those feelings (Lepore, Silver, Wortman,
&
Wayment,
1996).
The instructions in writing manipulations typically
encourage writers to explore their deepest thoughts and feelings, imply-
ing that such feelings are valid and potentially beneficial
to
experience.
Delving into one’s own feelings without having to monitor one’s self-
presentation, include the perspectives of others,
or
make the story easier
for others
to
hear may help people
to
see their feelings as an integral part
of
themselves, rather than as something
to
be pushed away. Furthermore,
integrating feelings with thoughts and memories during disclosure may
en-
hance the subjective validity
of
these reactions. People may begin
to
un-
derstand the roots of these feelings in specific past
or
ongoing events. Emo-
tional disclosure manipulations, like certain psychotherapies, may therefore
set the stage for “allowing into awareness an organization
of
one’s experi-
ence previously regarded as unacceptable and accepting it”
(L.
S.
Green-
berg
&
Safran,
1987,
p.
193).
Empirical studies provide some support for these hypotheses.
In
one
110
LEPORE
€3
AL.
study, some participants wrote about doubting their own feelings and trying
to suppress them
(M.
A.
Greenberg
et
al.,
1996).
In another disclosure
study, participants with more alexithymic deficits-that is, those with an
impaired ability to differentiate and describe their feelings-had larger
re-
ductions in negative mood than less alexithymic participants, suggesting
that disclosure may enhance emotional experiencing (Paez, Velasco,
&
Gonzales,
1999).
Swanbon
(1999)
found that gay men who wrote about
their deepest thoughts and feelings about being gay tended to report
in-
creased clarity
of
gay-related feelings at follow-up, relative
to
controls writ-
ing about inconsequential events. The experimental group also reported
decreases in avoidance
of
gay-related feelings, and this was associated with
decreases in psychosomatic symptoms.
In addition to promoting cognitive and emotional clarity, expressive
writing can provide a mastery experience in which people observe them-
selves tolerating and diminishing fear and other negative emotions. As a
result, their self-concept might change in that they now see themselves as
people who can handle negative emotions.
In
other words, their self-
efficacy for emotional regulation should increase.
In
the study
by
Paez and
colleagues
(
1999), people writing expressively about traumas subsequently
perceived these experiences as more controllable. When people feel more
control over their emotional experience, negative moods should dissipate,
resulting in less chronic subjective stress. Indeed, stronger mood regulation
expectancies have been linked to lower distress and physical symptoms in
caregivers
of
Alzheimer’s patients (Brashares
&
Catanzaro, 1994).
CONCLUSIONS
Expressive writing interventions are exciting to clinicians and re-
searchers alike because
of
their relative simplicity and their robust effects
on a wide range of mental and physical health outcomes. In attempting
to
explain the benefits
of
writing, we drew on theory and research
on
emotion
and emotion regulation. Emotional response tendencies and self-regulation
of
emotional responses are plausible mediators
of
both
mental and physical
health outcomes. Furthermore, many
of
the
findings in the literature could
be explained from this perspective.
The links between emotion regulation and mental health outcomes
are most obvious. Internalizing disorders, such as depression, and extemal-
izing problems, such as anxiety, are practically defined as problems in reg-
ulating emotions. Behavioral problems, too, such as aggression, risk taking,
and withdrawal, have also been conceptualized as problems in emotion
regulation (Eisenberg et al.,
2000).
Links between emotion regulation and
physical health are
not
as obvious; but here, too, we find evidence that
the undercontrol
or
overcontrol
of
negative moods, behaviors, and physi-
EXPRESSIVE WRITING
AND
EMOTION REGULATION
111
ological arousal can undermine physical health.
In
addition
to
highlighting
the
relation between emotion regulation and
both
physical and mental
health outcomes, we sought in this chapter to outline the links between
expressive writing and emotion regulation processes. We focused on three
regulatory processes-attention, habituation, and cognitive restructuring
-that are prominently featured
in
different models
of
emotion regulation
and have been identified as mediators in the literature on emotional dis-
closure.
Attention is clearly a central regulator of emotion. It can mediate
emotion responses in a rudimentary manner
by
controlling the probability
and duration
of
exposure to stressful stimuli.
By
directing attention toward
or
away from different aspects of a stressor and one’s responses, attention
can directly dampen or activate responses in all three of the emotional
systems-experience, physiology, and behavior. Furthermore, attention can
influence activity in these emotional systems indirectly
by
influencing other
emotion regulation processes, such
as
habituation and cognitive restruc-
turing.
It is clear that expressive writing influences attention deployment,
but there are still areas in need of further investigation. First,
it
is not yet
clear why attending to either negative or positive aspects
of
stressors pro-
duces benefits. We have suggested that different writing approaches might
be more or less beneficial depending on the writer’s attention style (e.g.,
approach, avoid). This is an important area for future research, because it
could inform clinicians about how to tailor writing interventions to max-
imize benefits in people with different personalities or coping styles. In
addition, we need more studies on
the
effects of positive writing. The few
studies that have been conducted are innovative, but they do not con-
vincingly show that participants benefit from writing exclusively about pos-
itive aspects of stressors. Even when instructed to emphasize positive as-
pects, people inevitably write and think about negative aspects of stressful
experiences.
It
is important
to
pursue this line of research, because positive
writing might be more beneficial than negative writing
to
some people,
and because it might confer health benefits without the short-term negative
emotional effects that sometimes result from writing with a negative em-
phasis. Second, we need research on
the
long-term effects
of
writing
on
attention. Manipulation checks of expressive writing tasks indicate that
attention is altered during writing, but we know virtually nothing about
attention in the period after writing. It is possible that brief writing inter-
ventions have robust effects on adjustment because they trigger long-term
changes in attention, which affect emotion systems that mediate health out-
comes.
Evidence from several studies suggests that expressive writing facili-
tates
both
stimulus and response habituation. Most
of
the data support a
model of habituation in the experiential emotion system. During writing,
112
LEPORE
ET
AL.
more frequent writing reduces the intensity of negative emotions and, to
a lesser extent, positive emotions (Hockemeyer et al.,
1999).
After writing,
there is a reduction in the positive association between intrusive thoughts
about a stressor and depressive symptoms (Lepore,
1997).
Moreover, after
writing about imaginary trauma, people may have greater tolerance for
negative emotions
(M.
A.
Greenberg et al.,
1996).
We found mixed evi-
dence of habituation in the physiological emotion system (Pennebaker et
al., 1988; Petrie et al., 1995),
as
well as some indirect evidence: Lepore
and Greenberg (in press) observed that expressive writing reduced tension
and
fatigue, which can
be
caused
by
sustained arousal. Overall, the evi-
dence suggests that this is a promising area for additional research.
It
is especially important to examine the relation between habituation
in the experiential and physiological emotion systems. There is evidence
that expressive writing has beneficial effects on physical health even in the
absence of strong effects on mood (e.g., Lepore
ti
Greenberg, in press;
chapter
3,
this volume). We speculate that physiological habituation may
occur independently of and possibly prior to subjective habituation. One
could argue that physiological responses precede subjective experience in
emotion (James,
1884).
Therefore, health-promoting physiological changes
could occur prior to changes in mood.
If
a person’s physiological responses
to a stressor become habituated, it could result in health benefits despite
ongoing feelings of distress.
Investigators have looked for evidence of cognitive restructuring dur-
ing and after expressive writing using various methods, including content
analysis, global ratings, self-reports about the frequency of stress-related
intrusive thoughts, and self-reports about changes in thoughts and attitudes
about stressful events. The results of these investigations have been mixed,
with positive, null, or contradictory findings. Although there is some evi-
dence of short-term cognitive changes related to writing, there are no com-
pelling data that writing can produce enduring and profound changes in
fundamental schemas about the world, self, and relations with others. In
addition,
it
is not clear whether cognitive changes result in changes in the
emotion systems that could mediate the health effects of writing. The study
of cognitive restructuring
is
more complex than the study of attention and
habituation processes.
It
is possible that the measures used to date have
been too crude (e.g., word counts), unreliable (e.g., global ratings), or in-
direct (e.g., frequency
of
intrusive thoughts). It is also possible that the
frequency and duration of experimental writing (generally
60-80
minutes
over 1-4 weeks) has been too brief
to
achieve such lasting changes. Larger
doses of writing intervention may be necessary to change schematic beliefs
(see Lange et aI., chapter
12,
this volume). Until these issues are resolved,
we should not rule out cognitive restructuring as a mechanism.
It
may be
time to borrow methods from other areas, such as cognitive psychology
(see Klein, chapter
8,
this volume), or to apply more qualitative ap-
EXPRESSIVE WRITING
AND
EMOTION REGULATION
I13
proaches,
to
get more sensitive assessments of changes in cognitive repre-
sentations.
In summary, expressive writing can facilitate adjustment to stressors
through emotion regulation mechanisms. Research in psychiatry, as well as
clinical, health, and social psychology, supports the proposition that emo-
tion dysregulation-either excessive or inadequate control over emotional
experience, physiology, and behavior-has inimical effects on mental and
physical health. Findings presented in this chapter suggest that expressive
writing influences attention and habituation to stressful stimuli and
to
neg-
ative emotions and that it may influence restructuring
of
cognitions related
to stressors and stress responses. Our approach extends others presented in
this volume
by
integrating cognitive, emotional, and physiological mech-
anisms under the single rubric
of
emotion regulation. One implication of
our approach is that future investigations should use multiple methods and
measures to capture effects in the different emotion systems. Additionally,
research designs should be developed
to
determine the relative importance
of
the different systems for mental versus physical health outcomes. Re-
search that further delineates the relations between specific emotion reg-
ulation mechanisms (e.g., attention, habituation, cognitive restructuring)
and specific emotional responses (e-g., subjective, physiological, behav-
ioral), as well as the patterning
of
these relations over time, can enhance
understanding of why expressive writing has robust effects on diverse men-
tal and physical health outcomes.
REFERENCES
Bonanno,
G.
A.
(2001).
Emotion self-regulation. In
T.
J.
Mayne
&
G. A.
Bonanno
(Eds.),
Emotions: Cuwent issues
and
future
directions
(pp.
251
-285).
New York:
Guilford Press.
Brashares,
H.
J.,
&
Catanzaro,
S.
J.
(1994).
Mood regulation expectancies, coping
responses, depression, and sense
of
burden in female caregivers of Alzheimer’s
patients.
Journal
of
Nervous
and
Mental
Disease,
182,
437-442.
Cacioppo,
J.
T.,
Bemtson,
G.
G.,
Larsen,
J.
T.,
Poehlmann,
K.
M.,
&
Ito,
T.
A.
(2000).
The psychophysiology of emotion. In
M.
Lewis
&
J.
M.
Haviland-
Jones (Eds.),
Handbook
of
emotions
(2nd ed., pp. 173-191). New York: Guil-
ford Press.
Darwin,
C.
(1872).
The
expression
of
the
emotions in man
and
animals.
New York:
Appleton.
Donnelly,
D.
A.,
&
Murray,
E.
J.
(1991). Cognitive and emotional changes in
written essays and therapy interviews.
Journal
of
Social
and
Clinical Psychology,
Eisenberg,
N.,
Fabes,
R.
A., Guthrie,
I.
K.,
&
Reiser,
M.
(2000).
Dispositional
10,
334-350.
114
LEPORE
ET
AL.
emotionality and regulation: Their role in predicting quality
of
social func-
tioning.
Journal
of
Personality and Social Psycf~bgy,
78, 136-157.
Esterling, B. A., Antoni, M. H., Fletcher, M.
A.,
&
Margulies,
S.
(1994). Emo-
tional disclosure through writing or speaking modulates latent Epstein-Ban
virus antibody titers.
Journal
of
Consulting
and
Clinical Psychology,
62, 130-
140.
Feldman,
P.,
Cohen,
S.,
Lepore,
S.
J.,
Matthews, K., Kamarck,
T.,
6r
Marsland,
A.
(1999).
The
impact
of
negative
emotions on
acute
physiological responses
to
stress. Annals
of
Behawimal Medicine,
21,
211-215.
Foa, E. B. (1997). Psychological
processes
related
to
recovery from
a
trauma and
an
effective treatment for
PTSD.
Annals
of
the
New
York
Academy
of
Sciences,
Frank,
A.,
&
Pressler, M. (Eds.). (1997).
The
diary
of
a
young
girl:
The
definitive
edition.
Bantam Books: New York.
Fredrickson, B.
L.,
&
Branigan, C. (2001). Positive emotions.
In
T.
J.
Mayne
&
G. A. Bonanno (Eds.),
Emotions:
Current issues
and
future directions
(pp.
251
-
285). New York: Guilford Press.
Friedman, H.
S.,
&
Booth-Kewley,
S.
(1987).
The
“disease-prone” personality:
A
meta-analytic view
of
the
construct.
American Psychologist,
42, 539-555.
Greenberg, L.
S.,
&
Safran,
J.
D.
(1987).
Emotion in psychotherapy.
New York:
Guilford Press.
Greenberg, M. A.,
&
Lepore,
S.
J.
(in press). Theoretical mechanisms involved
in
disclosure: From inhibition
to
self regulation. In
I.
Nyklicek
&
A.
J.
J.
M.
Vingerhoets (Eds.),
The
expression
and
non-expression
of
emotions in
health
and
disease.
Amsterdam: Harwood Academic.
Greenberg,
M.
A.,
&
Stone, A.
A.
(1992). Emotional disclosure about traumas
and
its
relation
to
health: Effects
of
previous disclosure and trauma severity.
Joud
of
Personality and Social Psychology,
63, 75-84.
Greenberg, M. A., Wortman,
C.
B.,
&
Stone, A.
A.
(1996). Emotional expression
and physical health: Revising traumatic memories or fostering self-regulation.
3oud
of
Personality
and
Social Psychobgy,
71,
588-602.
Gross,
J.
J.
(1989). Emotional expression
in
cancer
onset
and progression.
Social
Sciences and Medicine,
28, 1239- 1248.
Gross,
J.
J.,
&
Levenson,
R.
W. (1993). Emotional suppression: Physiology, self-
report, and expressive behavior.
Journal
of
Personality
and
Social Psychology,
64,
Groves, P. M.,
&
Thompson,
R.
F. (1970). Habituation: A dual-process theory.
Psychological Rewiew,
77, 419-450.
Hockemeyer,
J.,
Smyth,
J.,
Anderson,
C.,
&
Stone,
A.
(1999).
Is
it
safe
to
write?
Evaluating the short-term distress produced by writing about emotionally
trau-
matic experiences.
Psychosomatic Medicine,
61
[Abstractl.
Horowitz,
M.
J.,
Wilner, N.,
&
Alvarez, W. (1979). Impact
of
Events
Scale:
A
measure of subjective stress.
Psychosomatic Medicine,
41, 209-218.
James, W. (1884). What
is
an emotion?
Mind,
9, 188-205.
821, 410-424.
970-986.
EXPRESSNE
WRITING
AND
EMOTION REGULATZON
115
Lang, P.
J.
(1968). Fear reduction and fear behavior: Problems in treating a con-
struct. In
J.
M. Schlien (Ed.),
Research in psychology
(Vol. 3, pp. 90-103).
Washington,
DC:
American Psychological Association.
Lepore,
S.
J. (1997). Expressive writing moderates the relation between intrusive
thoughts and depressive symptoms.
Journal
of
Personality and Soclal Psychology,
7,
1030- 1037.
Lepore,
S.
J. (1998). Problems and prospects for the social support-reactivity hy-
pothesis.
Annals
of
Behavioral Medicine,
20,
257-260.
Lepore,
S.
J.,
&
Greenberg, M. A. (in press). Mending broken hearts: Effects
of
expressive writing on mood, cognitive processing, social adjustment, and
health following a relationship breakup.
Psychology
and
Health.
Lepore,
S.
J.,
Ragan,
J.,
&Jones,
S.
(2000). Talking facilitates cognitive-emotional
processes of adaptation to an acute stressor.
Journal
of
Personality and Socd
Psychology,
78,
499-508.
Lepore,
S.
J.,
Silver, R.
C.,
Wortman, C. B.,
&
Wayment, H. A. (1996). Social
constraints, intrusive thoughts, and depressive symptoms among bereaved
mothers.
Joud
of
Personality
and
Social Psychology,
70,
271-282.
Mann,
T.
(2001). Effects of future writing and optimism on health behaviors in
HIV-infected women.
Annals
of
Behavioral Medicine,
23,
33.
McEwen, B.
S.
(1998). Protective and damaging effects of stress mediators.
New
England
Journal
of
Medicine,
338,
17
1
-
179.
Paez,
D.,
Velasco,
C.!
&
Gonzalez,
J.
L.
(1999). Expressive writing and the role of
alexithymia
as
a dispositional deficit in self-disclosure and psychological
health.
Journal
of
Personality
and
Social Psychobgy,
77,
630-641.
Pennebaker,
J.
W. (1989). Confession, inhibition, and disease. In L. Berkowitz
(Ed.),
Advances in experimental and social psychology
(Vol. 22, pp. 211-244).
Orlando,
FL:
Academic Press.
Pennebaker,
J.
W., Kiecolt-Glaser,
J.
K.,
6r
Glaser, R. (1988). Disclosure of traumas
and immune function: Health implications for psychotherapy.
Journal
of
Con-
sulting
and
Clinical Psychology,
56,
239-245.
Pennebaker, J. W., Mayne,
T.
J.,
&
Francis,
N.
E.
(1997). Linguistic predictors of
adaptive bereavement.
Journal
of
Personality
and
Social Psychology,
72,
863-
871.
Petrie, K. J., Booth, R.
J.,
&
Pennebaker, J. W. (1998). The immunological effects
of thought suppression.
Journal
of
Personality and Social Psychology,
75,
1264-
1272.
Petrie,
K.
J.,
Booth, R. J.,
6r
Pennebaker,
J.
W., Davison,
K.
P.,
6r
Thomas,
M.
G. (1995). Disclosure of trauma and immune response to a hepatitis
B
vaccination program.
Journal
of
Consulting
and
Clinical Psychology,
63(5),
787-
792.
Rachman,
S.,
&
Hodgson,
R.
(1974). Synchrony and desynchrony in fear and
avoidance.
Behavior Research
and
Therapy,
12,
3 1 1-3 18.
Schoutrop, M. (2000).
Structured writing and processing traumatic events.
Unpub-
lished doctoral dissertation, University
of
Amsterdam.
116
LEPORE
ET
AL.
Smith,
T.
W. (1992). Hostility and health: Current
status
of
a
psychosomatic
hy-
pothesis.
Health
Psychology,
J
1,
139-150.
Smyth,
J.
M. (1998). Written emotional expression: Effect
sizes,
outcome types,
and moderating variables.
Journal
of
Consulting and Clinical Psychology,
66,
174- 178.
Smyth,
J.
M.,
&
Pennebaker,
J.
W.
(2001). What
are
the health
effects
of
disclo-
sure?
In
A.
Baum,
T.
A.
Revenson,
&
J.
E.
Singer (Eds.),
Handbook
of
health
psychology
(pp. 339-348). Hillsdale, NJ: Erlbaum.
Smyth, J.
M.,
Stone,
A. A.,
Hurewitz,
A.,
&
KaelI,
A.
(1999).
Effects
of
writing
about stressful experiences on
symptom
reduction
in
patients
with
asthma or
rheumatoid arthritis.
Journal
of
the
American Medical Association,
281,
1304-
1329.
Smyth,
1.
M.,
True, N.,
&
Souto,
J.
(2001). Effects
of
writing about traumatic
experiences:
The
necessity
of
narrative structuring.
]ournal
of
Sod
and
Clin-
Swanbon,
T.
(1999).
The
physical and psychobgical health effects
of
self-disclosure in
homosexual
males.
Unpublished doctoral dissertation, California School
of
Pro-
fessional Psychology,
San
Diego.
Watson,
J.
I?,
&
Marks,
I.
M. (1972). Relevant and irrelevant fear
in
flooding:
A
crossover study
of
phobic patients.
Behavior Therapy,
2,
275-293.
ical
psycho log^,
20,
161-172.
EXPRESSWE
WRlTlNG
AND
EMOTlON
REGULATlON
117
