Expressive Writing
November 17, 2010 Written by JP [Font too small?]Expressive writing is a stress management technique that encourages individuals to face emotional and/or traumatic events from their past. This sometimes cathartic experience generally takes place over the course of 3 to 5 sessions which last about 15 to 30 minutes each. In the process, some patients find that they gain greater control over their emotions and develop more confidence in dealing with stress which can result in positive outcomes in a variety of health conditions. Three recent examinations of expressive writing document favorable results in diverse patient populations: men and women with IBS (irritable bowel syndrome); students with eating disorders; and test subjects living with psoriasis.
Researchers from the Boston University School of Medicine are the latest to report success using a modified expressive writing protocol. A total of 103 IBS patients took part in the study. The majority (82) engaged in four, 30 minute writing exercises that described “their deepest thoughts, emotions, and beliefs regarding the disease and their perception of its effects”. The remainder of the participants (21) acted as a comparison group. A battery of IBS symptom severity tests were conducted at baseline, 1 month post therapy and 3 months after the completion of the trial. Those engaging in the writing exercises experienced significant improvements in IBS scores at the 1 and 3 month mark. Benefits in cognitive performance were also noted. (1)
The September-October issue of the European Journal of Dermatology similarly focused on the potential of “emotional writing disclosure” as an adjunct to conventional care. In this trial, researchers evaluated its impact on patients with the skin disease, psoriasis. Forty psoriatic patients were all treated with ultraviolet B (UVB) exposure and one of three add-on therapies: 1) an expressive writing protocol; 2) writing about “major life goals”; 3) no writing/control group. The study volunteers who took part in an expressive writing routine “had a longer period of remission after phototherapy. This provides preliminary evidence that such a simple and inexpensive tool may play a role in enhancing treatment efficacy and QoL (quality of life”. (2)
The previous two examples illustrate the potential of expressive writing in conditions of a physical nature. Some psychological ailments, such as eating disorders, also appear to be responsive to emotional writing. This finding is presented in the May 2010 edition of the journal, European Eating Disorders Review. An 8 week investigation of two experimental writing tasks and a control task revealed that expressive writing addressed “specific features associated with eating disorder presentation” and that “therapeutic writing may be of value to this at-risk population”. The conclusion of the study encourages other mental health professionals to confirm and extend these preliminary results. (3)
| Measure | Baseline | Follow-Up | ||
| Mean | SD | Mean | SD | |
| DASS-21 Depression | 25.4 | 9.0 | 21.0 | 9.9 |
| DASS-21 Anxiety | 22.0 | 8.6 | 17.0 | 11.3 |
| DASS-21 Stress | 25.0 | 7.3 | 21.3 | 9.1 |
| SF-12 Physical | 39.7 | 7.9 | 41.2 | 12.5 |
| SF-12 Mental | 32.3 | 9.8 | 35.2 | 11.3 |
| Mean and standard deviations for DASS-21 and SF-12 subscales at baseline and two-week follow-up (n = 14). | ||||
A scientific summary from the publication Advances in Psychiatric Treatments offers an example of a step-by-step guide to one of the most basic forms of expressive writing. The authors, Drs. Karen A. Balkie and Kay Wilhelm, offered the following general instructions. “For the next 4 days, I would like you to write your very deepest thoughts and feelings about the most traumatic experience of your entire life or an extremely important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore your deepest emotions and thoughts. You might tie your topic to your relationships with others, including parents, lovers, friends or relatives; to your past, your present or your future; or to who you have been, who you would like to be or who you are now. You may write about the same general issues or experiences on all days of writing or about different topics each day. All of your writing will be completely confidential. Don’t worry about spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.” (4)
The common thread that connects the studies I’ve mentioned today is that they’ve employed expressive writing as a supportive therapy to professional care. No one is suggesting that expressing your emotions is some sort of panacea for every physical or psychological challenge faced by mankind. A more accurate and realistic view may be that denying or suppressing experiences and the feelings that accompany them may contribute to a worsening of body-mind health. Since expressive writing is easily accessible to almost all of us, I believe it’s worth considering in the context of a comprehensive treatment protocol. If this interests you, please consult with your health care team to determine whether it’s appropriate in your specific case. You might also seek out the works of the expressive writing pioneer, Dr. James W. Pennebaker. (5)
Note: Please check out the “Comments & Updates” section of this blog – at the bottom of the page. You can find the latest research about this topic there!
Be well!
JP
Tags: Eating Disorders, IBS, Psoriasis
Posted in Alternative Therapies, General Health, Mental Health
November 18th, 2010 at 6:48 am
Expressive Writing –
That includes Blogging?
November 18th, 2010 at 2:18 pm
Anne,
I suppose it would depend on the frequency and type of blogging. I also wonder if blogging allows people to truly purge their deepest feelings and thoughts.
To my mind, expressive writing seems to be a more private therapy.
Be well!
JP
November 18th, 2010 at 5:35 pm
Dr Mark Hyman is an advocate of moving away from just treating the disease with neutricals and pharmaceuticals towards a more holistic approach including as he puts it,” looking at the soil in which the disease is growing instead of just pulling up the weeds.”
I suppose this form of therapy is one aspect of that approach, which has the advantage over psychiatry of being able to bring to the surface, thoughts and experiences which you may not want to share with a therapist.
November 19th, 2010 at 12:41 am
I like Dr. Hyman quite a lot, Liverock. And I agree with his philosophy.
Do you believe in coincidence? The reason I ask is that I received an e-mail from Dr. Hyman this evening from out of the blue. 🙂
Be well!
JP
November 19th, 2010 at 11:49 am
I only check his website occasionally, but with expressions like “looking at the soil in which the disease is growing instead of just pulling up the weeds,” makes him sound a bit like Chauncy Gardner in “Being There.” Remember that film? Those sort of expressions got Chauncy nominated for President!
Now I wonder if Mark Hyman ever considered running!!
November 19th, 2010 at 1:18 pm
Liverock,
It’s one of my favorite films. 🙂 A high point for Hal Ashby, Peter Sellers and virtually all involved, IMO.
Be well!
JP
November 20th, 2012 at 8:10 pm
I’d like to know how to start expressive writing… is it writing about trauma right from the beginning or just writing about general topics? Where to start? Thanks
November 20th, 2012 at 8:34 pm
Hi Akki,
This study (linked to below) provides a basic overview of how expressive writing is frequently carried out.
http://apt.rcpsych.org/content/11/5/338.full
If you’re interested in working with an expressive writing specialist, you might consider contacting Dr. James Pennebaker for a referral.
http://homepage.psy.utexas.edu/homepage/Faculty/Pennebaker/Home2000/JWPhome.htm
Be well!
JP
May 6th, 2015 at 1:14 pm
Update 05/06/15:
http://journals.lww.com/psychosomaticmedicine/pages/articleviewer.aspx?year=9000&issue=00000&article=99090&type=abstract
Psychosom Med. 2015 May 2.
The Effects of Expressive Writing on Lung Function, Quality of Life, Medication Use, and Symptoms in Adults With Asthma: A Randomized Controlled Trial.
OBJECTIVES: Asthma is a chronic condition affecting 300 million people worldwide. Management involves adherence to pharmacological treatments such as corticosteroids and β-agonists, but residual symptoms persist. As asthma symptoms are exacerbated by stress, one possible adjunct to pharmacological treatment is expressive writing (EW). EW involves the disclosure of traumatic experiences which is thought to facilitate cognitive and emotional processing, helping to reduce physiological stress associated with inhibiting emotions. A previous trial reported short-term improvements in lung function. This study aimed to assess whether EW can improve lung function, quality of life, symptoms, and medication use in patients with asthma.
METHODS: Adults (18-45 years) diagnosed as having asthma requiring regular inhaled corticosteroids were recruited from 28 general practices in South East England (n = 146). In this double-blind randomized controlled trial, participants were allocated either EW or nonemotional writing instructions and asked to write for 20 minutes for 3 consecutive days. Lung function (forced expired volume in 1 second [FEV1]% predicted), quality of life (Mark’s Asthma Quality of Life Questionnaire), asthma symptoms (Wasserfallen Symptom Score Questionnaire), and medication use (inhaled corticosteroids and β-agonist) were recorded at baseline, 1, 3, 6, and 12 months.
RESULTS: Hierarchical linear modeling indicated no significant main effects between time and condition on any outcomes. Post hoc analyses revealed that EW improved lung function by 14% for 12 months for participants with less than 80% FEV1% predicted at baseline (β = 0.93, p = .002) whereas no improvement was observed in the control condition (β = 0.10, p = .667).
CONCLUSIONS: EW seems to be beneficial for patients with moderate asthma (<80% FEV1% predicted). Future studies of EW require stratification of patients by asthma severity.
Be well!
JP
October 16th, 2015 at 1:07 pm
Updated 10/16/15:
http://www.ncbi.nlm.nih.gov/pubmed/26467326
J Trauma Stress. 2015 Oct;28(5):381-90.
Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans.
We examined the efficacy of a brief, accessible, nonstigmatizing online intervention-writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self-reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6-months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes. Be well! JP
June 27th, 2016 at 10:07 pm
Updated 06/27/16:
http://www.ncbi.nlm.nih.gov/pubmed/27336216
Psychol Trauma. 2016 Jun 23.
Changes in the Sexual Self-Schema of Women With a History of Childhood Sexual Abuse Following Expressive Writing Treatment.
OBJECTIVE: Sexual self-schemas are cognitive generalizations about the sexual self that influence the processing of sexually pertinent information and guide sexual behavior. Until recently sexual self-schemas were exclusively assessed with self-report instruments. Recent research using the meaning extraction method, an inductive method of topic modeling, identified 7 unique themes of sexual self-schemas: family and development, virginity, abuse, relationship, sexual activity, attraction, and existentialism from essays of 239 women (Stanton, Boyd, Pulverman, & Meston, 2015). In the current study, these themes were used to examine changes in theme prominence after an expressive writing treatment.
METHOD: Women (n = 138) with a history of childhood sexual abuse completed a 5-session expressive writing treatment, and essays on sexual self-schemas written at pretreatment and posttreatment were examined for changes in themes.
RESULTS: Women showed a reduction in the prominence of the abuse, family and development, virginity, and attraction themes, and an increase in the existentialism theme.
CONCLUSIONS: This study supports the validity of the 7 themes identified by Stanton and colleagues (2015) and suggests that expressive writing may aid women with a history of sexual abuse to process their abuse history such that it becomes a less salient aspect of their sexual self-schemas.
Be well!
JP
November 30th, 2016 at 2:42 pm
Updated 11/30/16:
http://www.sciencedirect.com/science/article/pii/S088915911630527X
Brain Behav Immun. 2016 Nov 24.
The effects of expressive writing before or after punch biopsy on wound healing.
OBJECTIVE: Recent studies have shown that written emotional disclosure (expressive writing) performed in the two weeks prior to wounding improves healing of punch biopsy wounds. In many clinical settings, it would be more practical for patients to perform this intervention after wounding. The aim of this study was to investigate whether expressive writing could speed the healing of punch biopsy wounds if writing was performed after wounds were made.
METHODS: One hundred and twenty-two healthy participants aged between 18 and 55 years were randomly allocated to one of four groups in a 2 (intervention) by 2 (timing) design. Participants performed either expressive writing or neutral writing, either before or after receiving a 4mm punch biopsy wound. Wounds were photographed on day 10 (primary endpoint) and day 14 after the biopsy to measure epithelisation. Participants also completed questionnaires on stress and affect two weeks prior to the biopsy, on the day of biopsy and two weeks after biopsy.
RESULTS: There was a significant difference in healing at day 10 between groups, χ2(3, N = 97) = 8.84, p = .032. A significantly greater proportion of participants who performed expressive writing before the biopsy had fully reepithelialised wounds on day 10 compared to participants who performed neutral writing either before or after wounding, with no other significant differences between groups. Amongst people who wrote expressively after wounding, those who finished writing over the first 6 days were significantly more likely to be healed at 14 days than those who finished writing later. There were significant differences in positive and negative affect over the healing period between the pre and post expressive writing groups.
CONCLUSIONS: Expressive writing can improve healing if it is performed prior to wounding. Performing expressive writing after wounding may be able to improve healing depending on the timing of writing and wound assessment. Expressive writing causes worsening affect followed by a subsequent improvement in affect and it is important to consider this in the timing of intervention delivery. Further research with patient groups is required to determine the clinical relevance of these findings.
Be well!
JP
October 23rd, 2018 at 2:05 pm
Updated 10/23/18:
https://www.ncbi.nlm.nih.gov/pubmed/30346497
Ann Behav Med. 2018 Oct 22;52(11):952-962.
Expressive Writing Intervention Improves Quality of Life Among Chinese-American Breast Cancer Survivors: A Randomized Controlled Trial.
Background: Expressive writing interventions are shown to confer health benefits for Caucasian cancer survivors. However, few studies reported improved quality of life or studied ethnic minorities.
Purpose: The study evaluated whether a culturally sensitive expressive writing intervention improved quality of life.
Methods: Chinese-speaking breast cancer survivors (n = 136) in the USA were randomly assigned to one of three conditions to write three 30-min weekly essays: a cancer-fact condition to write about facts relevant to the cancer experience for three weeks; a self-regulation condition to write about deepest feelings at week 1, stress and coping at week 2, and finding benefits at week 3; or an enhanced self-regulation condition to write about stress and coping at week 1, deepest feelings at week 2, and finding benefits at week 3. Quality of life was assessed by Functional Assessment of Cancer Therapy at baseline, 1-, 3-, and 6-month follow-ups.
Results: Growth curve models showed that quality of life was increased in the sample from baseline to the 6-month follow-up. The enhanced self-regulation condition had a large and statistically significant effect (d = 0.90, 95% CI [0.02, 1.687]), and the self-regulation condition had a small effect (d = 0.22, 95% CI [-0.79, 1.07]) on quality of life improvement compared with the cancer-fact group.
Conclusion: Expressive writing is shown to be an effective intervention to improve quality of life for Chinese-American cancer survivors. Future efforts are warranted to disseminate and implement this low-dose and brief intervention in community and clinical settings.
Be well!
JP