The Health Benefits of Autobiographical Writing:
An Interdisciplinary Perspective
#The Author(s) 2020
A large body of experimental evidence in the empirical sciences shows that writing about
life experiences can be beneficial for mental and physical health. While empirical data
regarding the health benefits of writing interventions have been collected in numerous
studies in psychology and biomedicine, this literature has remained almost entirely
disconnected from scholarship in the humanities and cognitive neuropsychology. In this
paper, I review the literature from psychological and biomedical writing interventions,
connect these findings to views from philosophy, cognitive neuropsychology and narra-
tology and argue that examining established regularities in how narratives are structured
can shed further light on the psychological processes engaged during writing interven-
tions. In particular, I argue that the narratological concept of conflict can be applied to
resolve patterns of seemingly conflicting empirical findings in psychological studies.
More generally, I propose that an interdisciplinary perspective can provide a broader
theoretical basis for understanding the psychological processes underlying the health
benefits of autobiographical writing and provide directions for future research in psy-
chology and biomedicine.
Keywords Autobiographical writing .Life writing .Expressive writing .Conflict .Narratology .
Department of Psychology, New York University, 6 Washington Place, New York, NY 10003, USA
Theatre Academy, University of the Arts Helsinki, P.O. Box 20, FI-00097 Helsinki, Finland
Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki,
P.O. Box 21, FI-00014 Helsinki, Finland
Published online: 21 May 2020
Journal of Medical Humanities (2021) 42:705–723
“The act of naming is the great and solemn consolation of mankind.”
Elias Canetti, The Agony of Flies
The Nobel-winning author Imre Kertész, who had been imprisoned in Auschwitz and Buchen-
wald when he was young, describes writing as essential in helping him survive. Although he
would carry the experience with him throughout his life, it was writing that enabled Kertész to live
with the emotional and existential repercussions of the "Auschwitz disease," according to literary
scholar Luísa Afonso Soares (2015). "After having written the novel I’ve almost stopped thinking
about my experience in the concentration camp: it became my character’s experience. I’m free and
empty," Kertész describes the writing of his novel, Fatelessness (citedinSoares2015, 176).
A similar motivation was driving Shakespeare, according to philosopher Richard Kearney
(2016). Shakespeare wrote Hamlet to mourn for his son who had died the same year and to
grieve for his father who was also dying. Kearney contends that for Shakespeare, writing was a
way to overcome the psychological impact of these losses to "avoid the madness of
melancholy." More recently, novelist Rakesh Satyal (2018) has described how writing helped
him work through experiences of loneliness, hopelessness, and romantic disappointment.
Many writers, both professional and non-professional, literary and non-literary, report that
they find writing therapeutic. "In terms of cathartic effect, memoir is like therapy, the
difference being that in therapy, you pay them," according to poet and memoirist Mary Karr
(2015, xxii). Rock musician Flea from the Red Hot Chili Peppers, who calls himself
"completely uneducated" as a writer, says "he resorts to the act of journaling 'only when I'm
really miserable,'" implying that writing helps (Pappademas 2019).
But does writing benefit well-being in ways that can be empirically demonstrated using
quantitative methods? Do such benefits extend to physical health? If so, do such therapeutic
benefits require specialized expertise in writing? How exactly does writing help and why?
Perhaps one of the earliest authors to recommend writing as a form of therapy was Robert
Burton in his preface to The Anatomy of Melancholy, 'Democritus to the Reader,' first published
in 1621.1Writing, however, has also been studied extensively in experimental psychology and
biomedicine over the past three decades. In these interventions, participants with no special
training or professional experience are asked to write about their life experiences in a sponta-
neous fashion without revising in short sessions repeated over several consecutive days. The
research on these interventions indicates that writing about life experiences can bring about
impressive health benefits for people who arenot professional novelists or playwrights and who
do not primarily seek to provide aesthetic or artistic value to others in their writing.
How and why writing helps, however, has been difficult to explain through the lens of
psychological and biomedical theories alone. While it is widely accepted in psychology thatit is
"the formation of a narrative" (Pennebaker and Seagal 1999, 1243) and the processing of life
experiences "in a certain structured manner" (Sloan and Marx 2018, 1) that leads to the
observed health benefits, psychologists rarely discuss what this structuring might be, why we
tell stories about our lives, or how the generation of narratives is supported in the human brain.
In this paper, I aim to argue that the quantitative research findings from psychology and
biomedicine are important in demonstrating that writing about life experiences has objectively
demonstrable, quantifiable effects on well-being, but the theoretical perspective through which
706 Journal of Medical Humanities (2021) 42:705–723
these findings have been interpreted in psychology is somewhat restricted. Moreover, empir-
ical findings have called the most prominent psychological hypothesis of writing's health
benefits, the emotional disclosure account, into question. I will argue that these difficulties can
be remedied through an interdisciplinary perspective. A broader and more nuanced under-
standing of the writing process and its psychological value can be achieved if the psycholog-
ical and biomedical findings about health outcomes are complemented by views from
cognitive neuropsychology and philosophy. Moreover, the paradox of seemingly contradictory
empirical findings can be resolved by applying concepts from narratology. Finally, I will
suggest prospects for future research utilizing a hybrid approach combining experimental
methods and narrative theory.
I will first review the evidence from psychological experiments showing that even brief
writing sessions can provide psychological and somatic health benefits for lay participants.
After that, I will turn to how the theoretical basis for understanding these findings can be
complemented by views from cognitive neuropsychology, philosophy, and narratology.
Does it feel like writing helps?
Before discussing the health benefits of writing, it is first important to note that questions of
aesthetic and therapeutic value are, at least in theory, independent of each other. Arguably,
writing with the aim of creating something of artistic value to others is, or can be, at least in
part, a different process from when the text is written primarily for therapeutic purposes and
not intended for others to read. As Robinson (2000) points out, the difference between craft
and catharsis is often emphasized in literary culture. Although I believe, like Robinson (2000)
andCharon(2006), that there are important aspects in which these processes often overlap
psychologically, for the purposes of this paper it is mostly sufficient to assume that people can
write about their life experiences without an explicit purpose of making art. The empirical
evidence discussed in this paper mostly focuses on this kind of writing.
Second, it should not be taken for granted that writing necessarily confers any health
benefits. Writing about life experiences could, conceivably, have no effects at all, or, especially
when dealing with traumatic experiences, could even be detrimental.
In fact, dwelling on traumatic events mentally is known to be harmful for health. The
tendency to ruminate on negative experiences and emotions is associated with depression
(Lyubomirsky and Tkach 2004), and experimental evidence from psychology shows that
spending time repeatedly thinking about negative life experiences has direct adverse effects
on psychological and physical health. Lyubomirsky, Sousa and Dickerhoof (2006) conducted
an experiment in which they asked twenty college students to think about their worst life
experience for fifteen minutes during three consecutive days. Four weeks later, the participants
reported being less satisfied with life, on average, relative to a control group of thirty-six
students who had not been subjected to an intervention.
If writing has similar effects, it would thus seem better not to write about bad things that
have happened. Is the same true, however, of writing? At least subjectively, many writers seem
Robinson (2000) surveyed thirty-four people who considered themselves writers and who
wrote regularly (albeit not all of them professionally). The vast majority, eighty-four percent,
reported that they felt their writing had therapeutic value for them. Many said they had used
writing to process difficult life experiences such as the loss of a close relative or other stressful
707Journal of Medical Humanities (2021) 42:705–723
periods in their lives. The same also holds for people who do not write regularly: in writing
experiments conducted by psychological researchers, the majority of lay participants –with no
training, experience or commitment to writing regularly –who are asked to write about their
life experiences over a few repeated brief sessions report finding the experience subjectively
valuable, even when instructed to write about the most painful experience in their lives
(Pennebaker and Chung 2011).
Thus, many people find writing psychologically beneficial, at least subjectively, including
people who both write regularly and ones who do not. This would seem to suggest, then, that
something happens during the writing process that is psychologically distinct from the mere
act of thinking about the same experiences. An important caveat, however, regards the
subjectivity of such self-reports. A subjective feeling of psychological benefit, even among
the majority, does not necessarily mean that such benefits are real or objectively demonstrable
in somatic or psychological outcomes. Many interventions that appear helpful to both clini-
cians and patients often in reality are not (Lilienfeld et al. 2014). For this reason, psychologists
have sought to investigate whether writing provides health benefits that can be demonstrated
relative to an experimental control group.
The expressive writing paradigm
To that end, Lyubomirsky et al. (2006)–in the same experiment discussed earlier –assigned
yet a different group of twenty students randomly to a third condition in which they were asked
to write, as opposed to think, about their worst life experience for the same duration on the
same number of sessions as the thinkers.
Their findings show that writing about negative life experiences has strikingly different
psychological effects from merely thinking about them: four weeks later, the writing group
reported higher life satisfaction, better overall and mental health, better social functioning and
fewer physical health symptoms relative to the thinking group. That is, the participants who
had written about their worst experience felt better about their lives four weeks later in
practically every possible way than the ones who had spent the same amount of time thinking
about their experiences. Importantly, as the participants were randomly assigned to the
thinking, writing and control groups, it would be difficult to attribute the differences in mean
outcomes among the groups to chance alone.2
The experiment by Lyubomirsky et al. (2006) is one among more than two hundred
published studies in psychology and biomedicine that have investigated the psychological
and somatic effects of (non-literary) life writing by non-professional participants. In the
experimental paradigm originally developed by Pennebaker (1997) and known in psychology
as expressive writing, participants are randomly assigned to two groups, and both complete a
writing exercise over short sessions (typically fifteen to twenty minutes) across three to five
days. Participants in the expressive-writing group are instructed to write about their emotions
concerning an upsetting or traumatic life event. The control group, in contrast, is given a topic
considered "emotionally neutral" or "superficial" such as how participants plan to use their
time during the following week but for an equal number and duration of sessions.
Researchers using this paradigm have consistently found, through quantitative measures
and focus on group-level effects, that writing about emotionally upsetting life experiences can
have a wide range of beneficial effects on health outcomes. Relative to group averages in the
control condition, the expressive-writing participants have been found to experience a
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multitude of health benefits, such as improved subjective well-being, reduced use of health
care services, reduced absences from work and improvements in immune function (reviews
Arigo and Smyth 2016;Pennebaker1997; Pennebaker and Seagal 1999; Pennebaker and
Chung 2011; Sloan and Marx 2004). Meta-analyses indicate that expressive writing is
consistently associated with positive outcomes and clinically meaningful effect sizes across
studies (Frattaroli 2006; Frisina, Borod and Lepore 2004;Smyth1998; Travagin, Margola and
Revenson 2015). This means that the differences (in group means) between the writing and
control group participants are not only statistically significant but sufficient to be likely to be
meaningful for the participants' real lives.
In addition to outcomes related to psychological well-being (Lyubomirsky, Sousa and
Dickerhoof 2006; Murray and Segal 1994), expressive writing interventions have been found
to benefit physical health. For example, Smyth, Stone, Hurewitz and Kaell (1999) randomly
assigned one hundred twelve patients with asthma and rheumatoid arthritis into two groups,
one instructed to write about the most stressful experience of their lives and a control group
about their plans for the day. Their clinical condition was evaluated with spirometry and in a
rheumatological evaluation in a blinded setting (i.e., the clinical examiners did not know which
one of the two writing assignments an individual patient had completed).
While there was no change in the control group's disease state, the asthma patients who had
written about their stressful experiences showed an improvement in lung function relative to a
pre-intervention assessment, as measured in forced expiratory volume four months after the
writing intervention. Similarly, there was no change in the disease state in the group of
rheumatoid arthritis patients who had written about their plans for the day; in contrast, the
rheumatoid arthritis patients who wrote about a stressful life experience showed a clinically
relevant change in their health status four months after the intervention. Of all patients in both
disease groups, 47% of those in the expressive writing condition showed a clinically relevant
improvement in their disease state, as opposed to only 24% of those who completed the control
assignment. That is, while the clinical status of some patients also improved in the control
group, this was true of a significantly fewer number of patients than in the writing group.
Other studies have found expressive writing interventions, for example, to reduce viral load
and increase lymphocyte counts in HIV patients (Petrie et al. 2004); to lower Epstein-Barr
virus antibody titers (Esterling et al. 1994); to increase the level of antibodies against a
hepatitis B vaccine (Petrie et al. 1995); to improve liver function (Francis and Pennebaker
1992); to improve the state of the disease in irritable bowel syndrome (Halpert, Rybin and
Doros 2010); to relieve pain in fibromyalgia patients (Broderick, Junghaenel and Schwartz
2005); to reduce health care utilization among healthy populations (Harris 2006); and to
provide a host of other health benefits in various medical conditions such as cancer, sleep
disorders and chronic pain (Baikie and Wilhelm 2005).
Thus, even brief writing sessions can provide surprisingly substantial changes not only in
the writers' psychological but also their physical well-being, according to the empirical
biomedical evidence. Because of the impressive somatic health effects, an editorial in the
Journal of the American Medical Association (JAMA) contends that were there similar
outcome evidence about a new drug, "it likely would be in widespread use within a short
time" (Spiegel 1999,1329).
While these findings are arguably impressive and important, they of course do not show
that writing benefits everyone or explain why writing helps. What the psychological and
biomedical group studies show is that putting life experiences into words on paper is beneficial
for a sufficient number of lay participants for group-level effects to emerge statistically. The
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quantitative group averages in these data do not tell us who benefits and who doesn't, or why
some people benefit more than others although psychological researchers have made efforts to
disentangle some of these questions (see Pennebaker and Chung 2011). These quantitative
data similarly do not tell us to which extent the participants' writing was shapely, refined, or
coherent, to which extent it may have had aesthetic value, or whether attempts to create art
from the experiences might affect writers differently. They only provide evidence that
something happens during the writing that is psychologically beneficial to a large number of
participants relative to the comparison conditions.
Why, then, does writing help? Despite the mounting empirical evidence, the psychological
processes underlying these health benefits have remained somewhat unclear.
What is it about writing that helps?
Psychological and biomedical researchers have proposed several hypotheses to explain why
writing helps. In psychology, these have included those based on Freudian, cognitive, learning
theory, self-regulation, and social-connections approaches, among others (see Frattaroli 2006;
Pennebaker and Seagal 1999;SloanandMarx2004; Pennebaker and Chung 2011).
Perhaps the most prominent category of psychological explanation is based on the notion that
the disruptive consequences of a stressful life experience come from two sources: first, the
negative experience itself can be detrimental for well-being, and second, any negative effects
will be further exacerbated if the experience is kept a secret. What is assumed to help in the
expressive writing condition, then, relative to the use-of-time writing condition, is the "emotional
disclosure" (or verbal "confrontation") of the traumatic event. Practically all proposed hypotheses
in psychology assume, in the words of Sloan and Marx (2018, 1), that "confronting a previously
avoided stressful or traumatic life event in a certain structured manner" is what helps.
Biomedical authors, in contrast, have focused on proposed biomedical pathways mediating
psychological and somatic effects. Spiegel (1999) suggests that writing may dampen the
effects of stress on the body through the operation of the hypothalamic-pituitary-adrenal axis
(HPA) –a suggestion not incompatible with perhaps any of the psychological hypotheses. In
yet a third perspective, social neuroscientists have proposed that writing may ameliorate
affective distress through activating specialized neural networks in the right ventrolateral
prefrontal cortex in the brain (RVLPFC) (Lieberman 2011).
While these hypotheses are not without merit, they also appear limited. It is widely agreed
that no single theoretical perspective can explain the strikingly wide range of effects (King
2001; Pennebaker 2004; Sloan and Marx 2004). Different benefits have been reported for
bereaved individuals, cancer patients, prison inmates, individuals taking exams, people suf-
fering from migraines, and female caregivers (Frattaroli 2006;Pennebaker1997;Sloanand
Marx 2004;Smyth1998). In one study, unemployed engineers found employment faster after
a writing exercise (Spera, Buhrfeind and Pennebaker 1994); in another, romantic couples were
more likely to stay together (Slatcher and Pennebaker 2006); in yet a third, students preparing
for graduate school exams had higher test scores and lower rates of depressive symptoms than
those in the control group (Frattaroli, Thomas and Lyubomirsky 2011).
For these reasons and others, psychologists have lamented on the lack of theoretical insight
into the writing process and its effects. According to Sloan and Marx, "The entire genre of
expressive writing research has suffered to some extent from its lack of systematic focus and
weak theoretical foundation" (2018, 4). In the words of psychologist Laura King: "Two strong
710 Journal of Medical Humanities (2021) 42:705–723
conclusions can be made with regard to the benefits of writing. First, expressive writing has
health benefits. Second, no one really knows why" (2001, 119).
My proposal is that these problems stem in part from an unnecessarily narrow empirical
perspective in psychology. The experimental approach, centered on collecting quantitative
data sets from large groups of participants, is well suited for answering particular kinds of
questions. Through systematically manipulating experimental settings, this research has fur-
thered our understanding of the significance of individual variables such as the timing of the
writing sessions: one-week intervals between writing sessions are associated with larger effect
sizes, on average, than daily writing sessions (Pennebaker and Chung 2011; Smyth 1998).
The psychological and biomedical literature on writing interventions has, however,
remained almost completely disconnected from relevant bodies of scholarship in cognitive
neuropsychology, on the one hand, and disciplines in the humanities on the other that work to
understand how narratives are structured. An interdisciplinary perspective can therefore
alleviate these shortcomings.
Narrative and cognition: stories are how humans make sense
Why might writing be helpful for well-being? Although this research is rarely cited in the
context of expressive writing in psychology, established views both in the humanities and in
cognitive neuropsychology propose that constructing stories is a fundamental way in which we
understand our lives.
Literary critics and philosophers have argued for a long time that narratives are psycho-
logically essential for how humans make sense of their experiences. According to bioethicist
Howard Brody, "The primary human mechanism for attaching meaning to particular experi-
ences is to tell stories about them" (2002, 13). The literary critic Frederick Jameson calls
narrative the "central function or instance of the human mind" (cited in Abbott 2008,1).
Sociologist Arthur Frank (1995) contends that stories "are the self's medium of being"; it is a
"rage for order," in the famous words of poet Wallace Stevens. According to literary scholar H.
Porter Abbott, "The gift of narrative is so pervasive and universal that there are those who
strongly suggest that narrative is a 'deep structure,' a human capacity genetically hard-wired
into our minds in the same way as our capacity for grammar (according to some linguists) is
something we are born with" (2008,3).
These views are highly compatible with prominent discoveries in contemporary neuropsy-
chology, showing that the human brain houses a cognitive subsystem specialized for making
sense of unexpected events by generating narratives. Experiments with neurological patients
whose interhemispheric connections have been disconnected suggest that the left hemisphere
of the brain supports a system of specialized cognitive processes that enable the generation of
hypothetical narratives for events and experiences that demand explanation (Gazzaniga 2000).
Interestingly, this line of work has not, to my knowledge, been discussed among psychological
or biomedical researchers seeking to understand the why writing interventions help.
Cognitive neuroscientist Michael Gazzaniga and colleagues have named this left-
hemisphere supported process "the interpreter". The left-brain interpreter is, according to
Gazzaniga, "[a] device with rules for figuring out how one thing relates to another. …Its
job is to interpret our responses—cognitive or emotional—to what we encounter in our
environment. The interpreter sustains a running narrative of our actions, emotions, thoughts,
711Journal of Medical Humanities (2021) 42:705–723
and dreams" (2000, 1320). Gazzaniga argues that the left-hemisphere-enabled process of
crafting narratives is what forms the basis for our subjective unified feeling of being and,
thus, an essential part of the human condition. According to him, "The interpreter is the glue
that keeps our story unified and creates our sense of being a coherent, rational agent." To our
collection "of individual instincts it brings theories about our life. These narratives of our past
behaviour seep into our awareness and give us an autobiography."
Gazzaniga's neuroscientific view of narrative as a unifying glue that underlies our sense of
being is consistent with the concept of narrative identity proposed by the philosopher Paul
Ricoeur. According to Ricoeur, narrative identity is "the kind of identity that human beings
acquire through the mediation of the narrative function" (1991a, 188).
The notion of a cognitive module in the human brain supporting a function centered
primarily on making sense of unexpected events is also congruous with scholarship on
established regularities in how narratives are typically structured. In Gazzaniga's experiments,
the split-brain patients were subjected to conditions in which something violated their as-
sumptions or their experience; their perceptual input typically conflicted with their expecta-
tions or other aspects of their experience. Narratologists argue that this is what a story worth
telling typically requires –an event that violates the expected script of events and disrupts an
initial state of equilibrium. What narrative theorists refer to as the point of attack is what
initiates the action line of a story (Herman, Jahn and Ryan 2005;alsoreferredtoasthe
"precipitating event," Bruner 1991). In Gazzaniga’s studies, the experimenters deliberately
violated the expected script of events for the patients, which prompted them (using only the left
hemisphere of their brain) to generate verbal narratives to make sense of the situation.
Thus, both experimental neuropsychologists and philosophers agree that narrative is an
essentially human medium of existence, one by which we seek to understand unexpected,
untoward and problematic events.
Problems with psychological accounts of writing's health benefits
While integrating views from philosophy and cognitive neuropsychology helps to broaden the
theoretical basis for understanding why writing might benefit well-being, there are also more
specific problems with the psychological emotional disclosure account of the health benefits
of writing. I will argue that these problems also arise from an overly limited empirical
viewpoint in psychology that fails to acknowledge what narratives are and how they typically
The first problem is theoretical. As mentioned earlier, the most prominent psychological
accounts assume that it is the "emotional disclosure" of traumatic experiences that is helpful in
writing. And, indeed, the account seems consistent with Pennebaker's (1997) original expres-
sive writing experiments in which the participants were asked to write about a negative,
traumatic or stressful life event and to focus on the related emotions.
The precise difference between the expressive-writing and control conditions, how-
ever, is important: The health benefits that emerge are always demonstrated relative to
the control writing assignment –such as how the participants organize their use of time
for the week. The evidence about the benefits of writing are demonstrated as a
difference in group averages as compared to writing about this other topic. In the
psychological literature, the control topic is often described as "superficial" or "emo-
tionally neutral." The emotional disclosure account proposes that the traumatic-life-
712 Journal of Medical Humanities (2021) 42:705–723
experiences topic leads participants to a process of written "emotional disclosure,"
whereas the "superficial" topic doesn't. But what is it, exactly, that makes a writing
topic "superficial" and why? The concepts used to define the control condition are
surprisingly vague in the psychological literature, despite their centrality for the inter-
pretation of the findings.
One reason the conceptual haziness is problematic is that it makes the emotional-disclosure
explanation somewhat circular. The writing instruction already uses emotional vocabulary
("traumatic" or "negative" life experiences), and writing, by definition, means disclosure. (The
texts in the expressive writing paradigm are typically not written for anyone else to read.) The
emotional disclosure account seems to contend, then, that the disclosure of emotionally
difficult experiences helps because it involves the disclosure of emotionally difficult experi-
ences. To avoid this circularity, it is essential to define the conceptual difference between the
two writing tasks compared.
In addition to this theoretical problem, there is also a specific empirical problem with the
emotional disclosure account. That is, the health benefits of writing are not, according to
research findings, limited to assignments in which participants are asked to write about their
emotions related to negative life events. While the participants were all asked to do so in
Pennebaker's original experiments, psychologist Laura King (2001) later showed that a
(seemingly) completely different writing assignment surprisingly also led to similar group-
averaged health benefits as in the trauma-disclosure experiments, one that does not require
emotional disclosure of any troubling experiences at all.
In King's experiment (2001), one group of participants again wrote about a traumatic
life event, whereas a control group wrote about how they used their time. Critically,
however, King also randomized an additional third group of participants to write about
their life goals. That is, instead of a stressful or traumatic experience, the participants
were asked to imagine almost the opposite: how everything in their life in the future
has gone as well as possible and to write about that. The life-goals assignment does not
seem related to traumatic events or their emotional disclosure at all. Despite the
difference in assignments, however, both the participants assigned to the life-goals
group and to the trauma-writing group made significantly fewer visits to the health
center during the next five months than those in the control group (whose visits tended
to slightly increase). In other words, writing about life goals was equally beneficial to
the writers' health as the disclosure of emotional trauma.
The similar health benefits both groups received, despite the different writing tasks, have
puzzled psychologists because the findings are at odds with the emotional disclosure account.
Analyses further showed that the participants in the trauma and life-goals groups not only
followed different instructions but also wrote differently: groups of independent (lay) raters
judged the texts of the trauma-group participants to be more emotional, more negative, and to
attribute responsibility to others more than texts written about life goals. Thus, both the
instructions and the texts were different in content, yet the health benefits were similar.
Why were both assignments advantageous for the writers' health? And why was writing
about the use of time not? Why is writing about the use of one's time a "superficial" topic but
writing about life goals (presumably) not? How can we avoid the circularity of defining any
task that fails to help as "superficial" and the ones that do as not?
713Journal of Medical Humanities (2021) 42:705–723
A narratological resolution to a psychological paradox
To seek for answers, it is informative to examine a text written by a research participant in the
life-goals group in King's experiment:
I have learned to love as fully and selflessly as possible. I have learned to be humble
without losing and confidence, esteem, or being fake. I have touched the life of at least
one other soul in a significant way and helped them learn to love more greatly. If I have
achieved this then I know that I have also achieved happiness, peace, and worldly
success. By this last I refer to career accomplishment, and enough material wealth to
Narrative theorists have identified a number of narrative universals, elements or
features that tend to recur in stories (Hogan 2005), which can complement the lack
of theoretical perspective in the psychological research literature. Although psycholog-
ical researchers do not discuss their experiments in these terms, King's assignment
directs participants towards a well-identified narrative universal related to character, a
hero striving for a goal.
Strictly speaking, King's participant's text is a non-narrative text, a description of a state,
rather than a narrative. According to Prince's definition, a minimal story consists of three
events that are in temporal succession, causally related and bring about some form of closure,
such as an inversion of the original state: "He was rich, then he lost lots of money, then, as a
result, he was poor" (1973). King's participant's text does not describe such a succession of
events. Importantly, however, the text does not exist in isolation, but in the context of the
Think about your life in the future. Imagine that everything has gone as well as it
possibly could. You have worked hard and succeeded at accomplishing all of your life
goals. Think of this as the realization of all of your life dreams. Now, write about what
Interpreted within the context of the instructions, the participant's text has not only a protag-
onist but also a beginning and an end –that is, events in temporal succession. The temporal
succession and the change in the original state –the requirements of a narrative –are implied
by the combination of a protagonist striving for life goals and the goal states described in the
text that the protagonist reaches. The original state in the story is the protagonist's present
While it is not possible to disambiguate all the text's indeterminacies because most of the
story's constituent events are left out, the narrator does describe the end states of multiple story-
lines in the protagonist's life: the protagonist has learned not only to love but to love in a
certain way, learned to be humble in a specific way, has touched the life of another soul in a
significant way, and so on. We do not know whether or not the multiple story-lines intersect,
nor do we know whether one of them is the main story-line to which the others are subsidiary.
For each of the story-lines, only the resolution is provided.
A hero can only strive for a life goal, however, if the goal is meaningfully different from the
state from which they begin. If the resolution of the first story-line is, "I have learned to love as
fully and selflessly as possible," the initial state is presumably something non-trivially unlike
this state, possibly its inversion: the protagonist has been unable in the beginning, in some
important way, to "love fully and selflessly." Otherwise there would be no striving or goals to
714 Journal of Medical Humanities (2021) 42:705–723
be reached (and hence, no goals to write about). The narrator would similarly not consider
"learning to be humble without…being fake," an important life goal if this state had already
been reached or if this were trivially easy to achieve. According to this interpretation, then, the
protagonist is first unable to love fully and selflessly and then learns to do so.
What could cause such a change in a person’s life? In a paradigmatic story arc, the driving
force propelling a story forward is conflict, "the thwarting of intended actions by unplanned
events, which may or may not be the effect of other characters' intended actions" (Herman
2005b). As Aristotle pointed out, readers and writers tend to expect narratives to begin from an
original state of equilibrium and advance through a phase of conflict to an ending in which a
new equilibrium is achieved (Herman 2005a,2005b; Prince 1973; Rimmon-Kenan 2002).
While the gappiness of the text allows for numerous possibilities, it is clear that the conflict in
this story-line will, in any interpretation, revolve around the inability "to love fully and
selflessly," which apparently has proven more challenging than the protagonist initially
The possibilities for how this conflict occurs and what the constituent events may be are, of
course, innumerable, but choosing this as a central life goal clearly suggests that the protag-
onist is conscious of at least some shortcomings in this area –something has violated the
protagonist’s initial state of equilibrium and led to conflict in one way or another. Perhaps the
protagonist has countered a relationship that forced him or her to recognize that loving fully
and selflessly can be complicated and demanding; perhaps the protagonist has struggled to
reconcile his or her own desires with societal expectations; perhaps he or she has experienced
failed attempts at balancing another person's values, needs and desires with one’s own.
Whatever the details may be, the struggle for a new equilibrium is based on the recognition
that loving fully is a skill the protagonist does not currently possess but needs to acquire.
Thus, the struggle for "learning to love as fully and selflessly as possible" is a critical theme
in the protagonist's life, in any interpretation of this text. The same is naturally true of all the
other story-lines in the text: each of them individuates a goal state that has not yet been reached
and involves a meaningful struggle ("you have worked hard") related to a theme that is
important. The protagonist in King's participant's text would not be striving for the realization
of these life dreams unless they were both important and difficult –that is, if they did not
involve conflict and have exceptional personal value. It is pointless to dream of life goals that
are meaningless, trivially easy to achieve or have already been accomplished.
Thus, considered from the viewpoint of narrative, the life-goals text is not only a descrip-
tion of ideal states but also contains implications of story-lines that all involve conflict centered
on important life challenges. Psychologically, the life-goals writing assignment likely guides
participants to explore and mentally simulate ideal resolutions to important conflicts in their
lives –to put into written words their imagined ideal states of denouement for conflicts in life
they consider most important.
A paradox resolved: narrative and conflict
This simple application of a narratological perspective to a participant's text from King's
experiment provides important implications for the interpretation of the results. The main
insight is this: although the participants were neither instructed to explore sources of psycho-
logical conflict nor asked to explain which conflicts they considered important in their lives,
this may very well be what they did.
715Journal of Medical Humanities (2021) 42:705–723
Experimental psychological studies that focus on intervention outcomes reveal little about
what goes on in the minds of individual writers. Stories, however, are highly structured entities
governed by established regularities (e.g., Rimmon-Kenan, 2002), and there are shared
elements among humans in the ways we (typically) relate to narratives. These shared elements
guide readers in making sense of texts, regardless of our other views and beliefs about the
world (Abbott 2008). The above examination of one participant's text can therefore shed light
into what may have occurred during its writing psychologically.
While this analysis may not sound groundbreakingly insightful or innovative from a
narratological point view, it may help to explain why the life-goals writing assignment led
to similar health outcomes as writing about traumatic events in psychological experiments.
Conflict is a narrative universal that participants (including those without a literary back-
ground) will have encountered in countless stories regardless of genre, both as readers and as
writers, and it is therefore not surprising that it can emerge also in narratives constructed during
instructed interventions, including ones about life goals when the assignment allows.
Literary authors often describe writing as a process of discovery. The novelist Margaret
Atwood describes writing as a desire to enter a kind of darkness, "and, with luck, to illuminate
it, and to bring something back out into the light" (2003, xxii). Gillie Bolton uses a similar
simile, comparing writing to "dropping a bucket into the well of oneself, pulling it up dripping
to see what is there" (1999, 120); or, Seamus Heaney in his poem, "Personal Helicon": "I
rhyme / To see myself, to set the darkness echoing" (1966,57).
A possible hypothesis, then, emerging in combination from these two perspectives, is that
writing is a method that can allow a writer to discover and explore important sources of
conflict in their lives and to reflect on their meaning. Perhaps the participants in King's
experiments were not fully aware of the central sources of conflict in their lives or their
significance before beginning writing. From this viewpoint, both Pennebaker's (1997)and
King's writing assignments may function in this profoundly similar way: both involve mentally
identifying sources of conflict in the writer's life that are subjectively important and exploring
their ramifications and possible resolutions. From this perspective, it is perhaps not surprising
that the associated health benefits are similar, as different as the traumatic-event and the life-
goals writing assignments superficially appear.
An important additional point psychologically is that the text a participant writes during
such an intervention is not nearly as ambiguous to the author as to the reader. Although an
outside reader cannot disambiguate the innumerous possibilities, the author will mentally fill in
the gaps and process the implied conflicts in ways that are far richer. It is therefore reasonable
to assume that during the writing process, the writer will mentally process the challenges
related to what they value in life in complex and intricate ways and continue to do so in the
aftermath of the writing.
The suggestion that conflict is central for the health effects of expressive writing is further
corroborated by other studies. Positive health outcomes have been reported also when
unemployed engineers wrote about the experience of losing their jobs –another way of guiding
participants to craft written narratives centered on conflict central in the writers' lives. In yet
another writing assignment, similar health benefits were found when participants were asked to
write about an imagined trauma (Pennebaker and Seagal 1999). Again, the writers were
directed toward sources of conflict that they have either experienced or can imagine could
threaten things important in their lives. Although some assignments ask that the participants
remember the past (past trauma, past lost job) and others that they imagine the future (life-
goals, imagined trauma), they all require the writer to identify and explore, from the distance of
716 Journal of Medical Humanities (2021) 42:705–723
a written narrative, conflicts that feel subjectively both important and challenging in the
This may be the essential reason that the using-your-time assignment is different from the
negative-experiences, imagined-trauma and life-goals assignments: writing about how to use
your time this week is not as likely to lead to an examination of subjectively meaningful
sources of important conflict in life. Psychologists are thus correct in describing it as
"superficial" topic, but grounding the comparison in the narratological concept of conflict
and established regularities in how narratives function provides a theoretical basis for under-
standing why that is.
Why does writing help? Conflict and psychological resolution
The previous analysis suggests that there is something psychologically particularly relevant
about conflict in narrative. Why is conflict so central to what we spontaneously write about?
Why is it such an essential component in stories we generally prefer to read? Without conflict,
events either predictably follow an expected path or feel unimportant (Bruner 1991;Herman
2005b). Some screenwriters go as far as to insist that conflict is required in every single scene
for a story to remain interesting to the audience (Ackerman 2003).
Novelist Nellie Hermann notes that people often end up writing about conflict regardless of
assignment type. Even when she uses very general prompts with clinicians, it is almost as if
they are waiting for an opportunity to write about the important conflicts in their lives:
…this same work is valuable for all of us, even with all of our daily disruptions, the
traumas that are not so great that they disrupt the flow of our lives. …And it is not
uncommon for traumatic events to come to the surface very quickly in response to a
writing prompt—I have never done a workshop with medical professionals where at
least one vivid traumatic event has not poured onto the page in the 3-minute window
they have to write. I am always amazed at the memories that are called back in response
to a writing prompt, decades-old memories leaping to mind and to the page in less than a
Conflict has consistently been in the heart of all human narratives throughout history. Abbott
contends that it probably performs important social and cultural functions:
One very plausible possibility is that the representation of conflict in narrative provides a
way for a culture to talk to itself about, and possibly resolve, conflicts that threaten to
fracture it (or at least make living difficult). In this view of narrative, its conflicts are not
solely about particular characters (or entities). Also in conflict, and riding on top of the
conflict of narrative entities, are conflicts regarding values, ideas, feelings, and ways of
seeing the world. There is, of course, no culture without many such conflicts. Narrative
may, then, play an important social role as a vehicle for making the case for one side or
another in a conflict, or for negotiating the claims of the opposing sides, or simply for
providing a way for people to live with a conflict that is irreconcilable (as, for example,
the conflict between the desire to live and the knowledge that we have to die). (2008,55)
These social and cultural functions are fundamentally connected to individual psychological
reality. Narrative structures support human thinking by performing several important cognitive
717Journal of Medical Humanities (2021) 42:705–723
functions, such as assisting problem solving (Herman 2013). Telling stories centered around
conflict would likely not play such important societal functions if they were not also a
meaningful psychological tool for human thinking at the individual level.
Because of the way narratives are centered around conflict, Abbott calls narratives "a form
of passionate thought" (2008, 195): readers make sense of conflict in narratives by relating
them to ones they have experienced, observed or imagined in their own lives. This makes the
reader concerned for, and engaged in, how the psychological, social, and cultural aspects of
conflict are resolved that are at play in a narrative, and makes our emotional responses closely
tied to our interpretations of the narrative. According to Abbott:
[I]nsofar as we share in our own lives the larger conflicts of which these narrative
conflicts are particular examples, we are moved by the narrative, drawn into it, and
become alert to how these conflicts play out. And this, I am arguing, is an important
form of thinking, whether or not the negotiation of conflicts is seen to be successful.
Moreover, in contrast to more abstract modes of thought, this is passionate thinking.
That is, in narrative our thinking is intimately tied to the emotions aroused during our
narrative journey. (2008, 198-199)
Perhaps, then, constructing a written narrative about stressful life experiences –or about how
life goals might be accomplished in the future –provides a mode of thought, of passionate
thinking, that is psychologically powerful in the face of important life conflicts, in a way that
the mere act of thinking is not.
Why does writing about life experiences help? An interdisciplinary
We can now return to the essential question posed in the beginning: why is writing about life
experiences and goals helpful for well-being whereas merely thinking about them is not?
Although both literary scholars (Ricoeur 1991a;Abbott2008) and cognitive neuropsycholo-
gists (Gazzaniga 2000) agree that constructing narratives is an essential mental process through
which human beings make sense of their experiences, constructing written or spoken narra-
tives seems to provide a powerful tool for processing conflict, whereas constructing mental
narratives does not. Why might this be? Several possibilities offer themselves in light the prior
analyses, several of which can be simultaneously true.
One suggestion is that the construction of a narrative that is written down or spoken out
loud provides distance to the depicted experiences in a way that the construction of a mental
narrative for some reason does not. According to Brody, we not only have a need to tell stories
about our experiences, but the act of telling these stories also provides us with a source of self-
knowledge because of the combination of distance and intimacy that personal narratives offer.
"Distance exists because the narrator is separated from the narrated events in time and thus can
assume a reflective, observant posture toward those events in a way that was impossible when
the events were in progress. Intimacy exists, especially in autobiographical narrative, because
the narrator is the individual mentioned in the narrative, is responsible for the events disclosed,
and thus has a personal stake in how others react to the telling of the story" (2002, 25).
Pioneer of narrative medicine, Rita Charon, uses the term autobiographical gap to con-
ceptualize this distance created when writing. "Any time a person writes about himself or
herself, a space is created between the person doing the writing and the person doing the
718 Journal of Medical Humanities (2021) 42:705–723
living, even though, of course, these two people are identical. Called the “autobiographical
gap,”this space between the narrator-who-writes and the protagonist-who-acts confers the
very powerful distance of reflection, without which no one can consider his or her own actions,
thoughts, or life. Within this reflective space, one beholds and considers the self in a
heightened way, revealing fresh knowledge about its coherent existence" (2006, 70).
Sociologist Arthur Frank (1995) notes that when abrupt, traumatic changes happen in life,
people are in particular need of telling stories about their life. Gazzaniga's (2000) experiments
suggest that the left-brain interpreter is typically activated when we are confronted with events
that are unexpected, problematic or difficult to understand. Conceivably, the more important
and the more complex the conflict one seeks to make sense of, the more helpful the
construction of a narrative may be. In writing about one's life, one does not "set out to report
on the self but rather to eavesdrop on oneself, writing about it so as to learn what it might have
become," according to Charon (2006,72).
A further degree of complexity comes from the observation that life experiences can be, in
turn, shaped and sometimes also distorted by the act of arranging them into a written narrative.
An interesting question –that psychological and biomedical researchers have so far not
attempted to address –concerns whether the health benefits of writing may be related to the
degree to which the writer is or isn't telling the truth about their experiences. Some writers,
however, like poet and memoirist Mary Karr (2015), argue vehemently that there is particular
psychological (and artistic) value in confronting one's false beliefs and forms of self-deception
through the writing process.
The act of constructing a narrative can also be more consequential than it may seem: As
Charon points out, "Telling our story does not merely document who we are; it helps to make
us who we are" (2006, 69). It is a constructive act which, according to the poet Dannie Abse
(1998), profoundly affects, or perhaps even redirects, the trajectory of the writer's life itself.
Following Aristotle, Paul Ricoeur (1991b,23)talksaboutphronetic or narrative understand-
ing, a form of knowledge stories can provide that is closer to "the practical wisdom of moral
judgment" than to scientific knowledge or theoretical reasoning. Arthur Frank (2004)similarly
argues that stories can help us develop phronesis, wisdom about life that can only come
through a combination of experience and reflection. While writing about life experiences may
reduce the number of visits to the doctor's office (Pennebaker and Chung 2011), the process
can be even more valuable in providing a deeper view of the meaning of one's experiences,
one's values and possible future selves.
James W. Pennebaker, the pioneer of the expressive writing paradigm in psychology, contends
that writing affects people on multiple levels, including (at least) the cognitive, emotional,
social, and the biological, and over both the short and the long term; writing "touches all parts
of [writers'] lives" (2004,140).
In this paper, I have aimed to argue that the positive health outcomes of expressive writing
interventions in psychology and biomedicine can be best understood from an interdisciplinary
perspective, broadened by views from philosophy, cognitive neuropsychology and narrative
theory and grounded in an understanding of the established regularities in how narratives
719Journal of Medical Humanities (2021) 42:705–723
The concept of conflict and the central role it plays in narrative is merely an example of the
kinds of conceptual tools experimental psychologists and biomedical researchers could have at
their disposal utilizing perspectives from the humanities. The application of other narratolog-
ical concepts and methods to psychological writing interventions could potentially also shed
similar light into other ways in which writers make meaning of their experiences during the
For example, psychological experiments suggest that the participants who are able to construct
coherent stories from their experiences during the writing process are more likely to benefit from it
than those who are not. Pennebaker and Chung (2011) note that participants who begin a
psychological writing intervention with a coherent story explaining their past experience "generally
do not benefit from writing," unlike participants who generate such a story during the process.
Coherence in writing, however, has proven difficult for psychologists to assess and investigate:
"Unfortunately, we are not yet at the point of being able to precisely define what is meant
by coherent, understandable, or meaningful when it comes to writing about emotional
upheavals," Pennebaker and Chung confess (23). "One person’s meaning may be another’s
rumination. Many times in our own research we have been struck by how a person appears to
be writing in a way that avoids dealing with what we see as a central issue. Nevertheless, the
person’s health improves and he or she exclaims how beneficial the study was. Meaning, then,
may ultimately be in the eyes of the writer."
How meaning emerges from texts through interpretation, however, is an area extensively
studied by narratologists and other narrative theorists. While meaning is, in some ways, in the
eyes of the writer, in other important ways it is not (e.g., Rimmon-Kenan 2002; Bruner 1991).
Scholarship from the humanities could importantly complement the experimental methods
used by psychologists to provide insights into the interpretation of the participants' texts –
material research psychologists rarely examine (aside from isolated linguistic components
detached from their context) –and into the underlying psychological processes.
For example, several authors have pointed out that metaphor is an important tool by which
humans organize their thought processes (e.g., Hesse 2000; Ricoeur 1977,1991b). The roles
that narrative phenomena such as metaphor play in writing have not, to my knowledge, been
examined in psychology –perhaps because they depend on context and are not easily
quantified mechanically across large groups of participants, as opposed to, for example, the
frequencies of first-person pronouns in texts. Such phenomena may be difficult or even
impossible to isolate experimentally, but it would be possible to take an interdisciplinary
perspective and look for generalizable patterns across participants in the ways such literary
devices and others are (or are not) used in autobiographical writing.
A combined approach informed by both narratological and experimental methods would
enable interdisciplinary scholars to probe questions about psychological processes at a deeper
level and ask questions such as (but not limited to): Are the ways in which writers represent
conflict in their writing related to identifiable patterns of health outcomes? Is the presence of a
particular narrative device in autobiographical texts associated with superior (or inferior) health
outcomes? Does the subjective discovery of particular types of unresolved psychological
conflict have relevance for health outcomes? Is the ability to generate psychological resolu-
tions during the writing process associated with well-being? Is coherence in writing associated
with superior health outcomes? These are merely a few examples of unexplored directions
future studies could pursue utilizing a hybrid approach.
720 Journal of Medical Humanities (2021) 42:705–723
Acknowledgements I am grateful to Mathilde Walter Clark, Josh Connor, Nellie Hermann, Tuomas Juntunen,
Bradley Lewis, Ethan Ludwin-Peery, Mari Sophia Ōtsu and an anonymous reviewer for helpful comments on
Funding I nformation Open access funding provided by University of Helsinki including Helsinki University
1I thank an anonymous reviewer for this point.
2While the basic rationale of such quantitative comparisons sounds straightforward, in practice this reasoning
depends on a host of methodological and statistical assumptions, some of which are currently under scrutiny in
psychology and biomedicine (e.g., Munafó et al. 2017). The details are beyond the scope of this paper, however.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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