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Writing Therapy
"...writing or talking about your experiences may improve both your physical and mental health. I am not selling a miracle cure. Rather, recent studies from around the world are uncovering some exciting findings that may help you in your coping." (Pennebaker, 1990)
Contents:
1. Introduction2. Variety of Responses
2.1 Psychological/emotional health gains
2.2 Physical health gains
2.3 Behavioural changes
3. Focusing on the Good or Bad? Expressive and Positive Writing
4. Comparative Research
4.1 Positive vs. Negative Writing
4.2 Writing vs. Speaking
4.2.1 The difference between writing and Speaking in expressing emotions
4.3 Expressive Writing vs. Psychotherapy
5. Everyday writing cures
5.1 Blogging
5.2 Poetry Therapy
5.3 Journal Writing
6. Mechanisms
7. Exciting and Interesting finds
8. Practical Writing Exercise
9. Conclusions: Is it Insight that matters?
10. See Also
11. Recommended Reading
Introduction
Writing therapy is a form of expressive therapy that employs the act of writing and processing the written word. It comes in many different forms and has a wide range of effects, including psychological, physical and behavioural benefits.
The earliest and most important work was carried out by Pennebaker & Beall in 1986 in their study on expressive writing and trauma. Results of the study indicated that writing about one's trauma for just 15 minutes a day across a 4 days period yielded significant benefits.Those who have written about their traumatic experiences showed marked strengthening of their immune system, increases in psychological well-being, reduction in physician visits in the months following the study and less self-reported aspirin usage.
Although a large number of participants reported crying or being deeply upset by the experience, it is thought that the long term benefits far outweigh the possible short term negative effects. Most participants taking part in the study reported that the writing experience was a valuable and a meaningful addition to their lives (Pennebaker & Chung, in press).
Since then the paradigm has been altered to apply to a variety of populations including students, patients who are physically as well as mentally ill etc. Furthermore, a range of everyday uses is now available, such as: journaling, poetry or blogging.
A number of mechanisms behind the therapeutic effects of writing cures have been proposed however, there is still no comprehensive explanation proposed or conclusive evidence for a single mediator available. Pennebaker believes that this is due to the fact that simply no single mediator exists, and that expressive writing ultimately sets off a cascade of effects (Pennebaker & Chung, in press).
Even though a growing research in support of the beneficial effects of writing cures exist, it cannot be described as a panacea. The overall positive effects are modest at best, and many individual, cultural or gender differences can influence therapy outcomes as well as 'decide' for whom the writing cure works for.
It is worth noting that not all studies have been so favourable, for example, Earnhardt et al. (2002) found that the paradigm failed to surpass the effect of a placebo whereas Wetherell et al. (2005) found that the small positive effects seen in the experimental group were due to the deteriorations in the control group. And so the research on writing cures continues…
http://www.youtube.com/watch?v=XsHIV9PxAV4&feature=related
Massive reference list of all writing cure studies since mid-2011
http://homepage.psy.utexas.edu/HomePage/Faculty/Pennebaker/Reprints/writingrefs.htm
D.I.Y. personality writing therapy
http://www.utpsyc.org/personality/
Variety of Responses
Writing therapies have been a focus of research for over 25 years, and various forms of response have been studied in that time. Not only are there psychological benefits to writing, but there are also physical benefits, changes in immune system function, behavioural changes and even social improvements. The list of possible gains is extensive and so there are a number of meta-analyses attempting to get an overview of the research out there. Smyth’s review (1998) concluded that effect sizes were higher for psychological and physical outcomes as opposed to health and general functioning outcomes, and Frisina et al.’s review (2004) found the effect was stronger for physical than psychological health outcomes. Frattaroli’s 2006 paper breaks each domain into subcategories and looks at the effect sizes of each of the suggested components. She found that, overall, 102 of 146 studies (70%) had a positive effect size.
Psychological/emotional health gains
Most people are said to find the experience valuable and meaningful in their lives (Pennebaker & Chung), which could be attributed to Lyubomisky et al.’s finding of improved life satisfaction (2006), or that found by Palmer & Braud (2002), that disclosure was positively associated with purpose in life, positive psychological attitudes and well-being. Donnelly & Murray (1991) found that, over the days, positive emotion, cognitive changes and self esteem changes increased as negative emotion decreased. Furthermore, long term changes have been seen in mood/affect (Pennebaker et al., 1988), depressive symptoms (Lepore, 1997) and self esteem (O’Connor et al., 2011). However, Baikie & Wilhelm (2005) report that the findings are not as robust and consistent for emotional health as they are for physical health.
Physical health gains
Pennebaker found in numerous studies that participating in writing therapy resulted in reduced illness-related visits to the doctor (1986, 1988, 1990, 1996). However, further researchers went on to find writing therapy results in improvements in blood pressure (Davidson et al., 2002), lung function (Smyth et al., 1999), liver function (Francis & Pennebaker, 1992), number of days in hospital (Norman et al., 2004), respiratory problems (Greenberg et al., 1996), and so on. Smyth et al. (2008) found enhanced recovery of patients with p osttraumaticstress disorder (PTSD) and suggested it was the physiological changes and decreased dysphoric mood caused by writing what caused it.
The benefits can also be seen in the short term: Pennebaker, Hughes & O’Heeron (1987) found that the activity of the autonomic nervous system responses is congruent with those seen among people attempting to relax during the writing.
Behavioural changes
These changes may be due to the psychological or physical benefits from writing therapy, but among those behavioural changes found are:
- increases in students’ grade point averages (Pennebaker & Francis, 1996)
- getting a new job more quickly after being made unemployed (Spera et al., 1994)
- less absenteeism from work (Francis & Pennebaker, 1992)
- improved sporting performance (Scott et al., 2003).
Focusing on the Good or Bad? Expressive and Positive Writing
The expression of deep, powerful, and often intensely painful feelings has been linked with psychotherapy and are traceable to Sigmund Freud’s work. Based on Pennebaker’s influential program of research over the past 2 decades on the effects of emotional disclosure, a large body of literature has indicated that the written expression of one’s deepest emotions and thoughts about diverse types of stressful and traumatic experiences can lead to improvements in physical and mental health across a range of populations. Research has shown that writing about traumatic life events is associated with enhanced immune functioning, reduced health problems, lowering rumination and depressive symptoms, and lower skin conductance levels and symptom reduction for those with asthma.
Meta-analytic work by Smyth (1998) supports the idea that these effects are robust and similar to those found in other psychological interventions. For many years research on therapeutic writing focused almost exclusively on negative expressive writing however, the emergence of the positive psychology movement, with its focus on positive emotions, individual well-being and strengths-based approaches to treatment, led to the emergence of the positive writing paradigm, in which participants write about an intensely joyful experiences instead of a trauma. Results from a few studies using variations of this approach suggest that participants show similar health improvements to those observed in expressive writing studies.
Burton and King (2004) found that, compared to controls, writing about intensely positive experiences was associated with enhanced positive mood and significantly fewer health center visits for illness. Similarly, King (2001) found that individuals who wrote about their ‘best possible future selves’ showed physical health benefits and enhanced psychological wellbeing after writing, suggesting that writing may not necessarily have to be expressive and trauma-focused in order to be effective. These findings have been interpreted as challenging the previously considered mechanisms by which expressive writing confers benefit.
Comparative Research
Positive vs. Negative Writing
Additionally, two studies comparing expressive, positive and control writing on physical and psychological health outcomes reported no significant differences between the three groups on any physical health measures. For psychological health, one study found an improvement following positive writing (Marlo and Wagner, 1999) and the other found no change for any of the three groups (Kloss and Lisman, 2002).
King et al. (2001) asked their participants to write about intensely positive experiences (IPE) or control topics. Participants who wrote about IPEs reported significantly better mood, and fewer illness‐related health center visits than did those who wrote about trivial topics. In another study,
- students were asked to write about traumas in the standard way.
- or in a benefit-finding way, where participants were encouraged to focus on the benefits that have come from the trauma.
- or in the mixed condition, where participants were first asked to write about the trauma, and then to switch to the perceived benefits arising from the trauma experience.
Counter to predictions, the trauma only and benefits only participants showed health improvements whereas the mixed group did not. Researchers concluded that writing about the perceived benefits is enough to organize thoughts and feelings about a trauma, and to cope effectively. However, as seen in the outcome for the mixed condition, if people aren’t able to integrate their perceived benefits into their trauma story in their own way, writing may be ineffective (King & Miner, 2000).
Writing vs. Speaking
Before the use of expressive writing in psychology, many therapies were verbally-based; with a patient discussing with and expressing their feelings to a therapist. However, research on the benefits of written expression supported writing as a new way for people to express their feelings. Many psychologists still prefer the verbal, face-to-face relationship-based method but have found that expressive writing can aid as a secondary component to therapy sessions.
In practical use, writing is a low-cost way for people to reflect on events and their feelings. Writing allows for a different mode of expression that patients can use to help in personal reflection and to verbalize their feelings. Writing can vary in structure and content from open-ended, guided, focused and programmed.
Written and spoken language differs in many ways (L’Abate, 1991):
Spoken language | Writing |
learned earlier in life | learned later in life |
learned automatically | It must be taught |
It requires less effort | Takes more effort (because it must be taught) |
less time for planning and encoding | More time spent on planning and forming sentences |
It allows for more ideas to be expressed in a certain amount of time and thus can be more productive. | less productive |
It is abstract | Ideas are expressed in permanent form and is more structured if recalling an event |
The difference between writing and Speaking in expressing emotions
psychotherapy involves interpersonal interactions and vocal emotional expression. Responses by the therapist, verbal or nonverbal, can still affect a person’s different mood effect, which can affect a person’s emotional processing of the event or memory. The voice is another way through which emotion can be expressed by different subtleties in intensity, frequency, tone and rate of speech. Some of these differences have been correlated to physiological arousal and may also correlate to emotional arousal which causes changes in emotional processing (Murray and Segal, 1994). Despite these factors and the differences between speaking and writing, research has found that both can be beneficial as ways of emotional disclosure and have provided similar results.
Expressive Writing vs. Psychotherapy
Research on the differences of written versus oral emotional disclosure has mainly focused on negative (traumatic) events. In trying to eliminate confounding factors, most procedures compare writing alone in a room for a given amount of time against speaking into a tape recorder.
Murray and Segal (1994) found that written and vocal expressions of traumatic events have a similar overall therapeutic effect when compared to subjects writing or speaking about trivial conditions. However, the two methods of expression did not differ in effectiveness. When compared to the trivial groups, both the written and oral expression traumatic groups had a more positive therapeutic effects and felt more positive about their topics but there was no difference between writing and speaking.
Participants in another study who were placed in one of four groups of disclosure methods (talking to a facilitator, talking to a passive listener, speaking alone and writing). All four disclosure methods were equally effective and no difference was found between the four groups. The cognitive, psychological and physical symptoms of the participants decreased but were not more significant than the changes that occurred in the control groups (Slavin-Spenny et al, 2011).
Harrist, Carlozzi, McGovern and Harrist (2006) looked at the differences between oral and written expression of life goals as opposed to trivial topics. They found that those who discussed life goals rated their positive mood higher and negative mood lower than those in the trivial topic condition. Those who talked about their life goals had a lower post-intervention negative mood than those who wrote about their life goals.
These findings have been suggested that written and oral emotional expression can produce similar therapeutic effects in the processing in interpersonal traumatic experiences and were equally effective. Further research is looking into mechanisms of these two expressive mediums.
Everyday Writing Cures
Blogging
Blogs provide a space for catharsis, venting about stress and emotions in daily living (Nardi et. Al., 2004). Blogs also potentially open up the possibilities of social support, friendship, and positive interactions that are otherwise unavailable with diaries because blogs have a “readership”(Miura & Yamashita, 2007).
A recent trial examined the psychosocial changes in bloggers and non-bloggers after using Myspace for 2 months. They found that bloggers felt a greater sense of belonging. In other words, they were more likely to feel that they could relate to a group of like-minded people who share the same interest as their own. Similarly, reliable alliance, the tendency to count on others for assistance, is also increased for bloggers; thus, blogging has been shown to enhance one's well being (Baker & Moore, 2008).
A study by Boniel-Nissim & Barak (2011) examined the therapeutic benefit of blogging for adolescents who experience social and emotional difficulties; they found that blogging showed a significant positive change in their initial distressful condition. This finding reflects the power of expressing oneself in the social environment of Internet, an environment accepted and commonly inhabited by adolescents.
Poetry Therapy
Poetry therapy is a form of expressive arts therapy that has been increasingly used by mental health professionals because of its emphasis on emotional expressiveness (Rickett, Greive & Gordon, 2011). It allows individuals to express emotions, define ideas, validate feelings, put experiences in context, scrutinize assumptions and become aware of personal choices (Hynes &Hynes-Berry, 1994). According to the National Association of Poetry Therapy (NAPT), poetry therapy involves poetic and narrative techniques as well as bibliotherapy.
Most of the research in poetry and wellbeing has been in the context of psychotherapy and Holmes has drawn attention to the similarities between poetry therapy and psychotherapy. They both involve the use of metaphors and mentalization, defined as the capacity to think about one’s feelings. The practitioners provide an opportunity to create a ‘second story’ that may help patients make sense of their experience (Holmes, 2008).
A study was carried out by Christina Bracegirdle (2011) to evaluate the use of a group poetry therapy intervention with cancer patients. It was found that there was a significant decrease in suppression of emotions and a reduction of anxiety in those who experienced the poetry intervention. Poetry therapy encouraged:
- The expression of emotions
- Reduced emotional control
- Improved adjustment to having cancer
- Improved emotional resilience
- Increased psychological growth
In other words, poetry therapy sessions are non-invasive, enjoyable and have been shown to be therapeutic (Tegner, Fox, Philipp & Thorne, 2009).
The use of poetry to work through traumatic life events offers people a sense of meaning and community. Moreover, in a supportive group atmosphere participants are provided with a means of creatively expressing their feelings, which they can incorporate into their daily lives to work through traumatic life experiences.
Researchers who explored the effect of a poetry writing program for people who had experienced a serious illness found:
- patients responded enthusiastically.
- each group demonstrated an increase in wellbeing over the course of their workshop.
- It was found that participants enjoyed the challenge of writing and the companionship of other group members (Rickett, Greive, and Gordon,1997).
Used alongside biomedical treatments, reflecting on life experiences through writing therapy has found to increase the wellbeing of patients suffering from a chronic illness. Psychiatrists, especially those in liaison psychiatry, are in a position to encourage patients who have experienced a serious adverse life event to test the potential of expressive writing in coming to terms with the experience. Psychiatrists are also in a position to pass on this knowledge to students and junior doctors to understand the benefits that running writing treatments alongside other treatments can help patients with serious illnesses.
Journal Writing
Journal writing is about seeking happiness and functioning better in the world, whilst being able to understand one's own feelings and emotions. Nevertheless, the field of journal writing is one which lacks much research, and future research is needed to investigate this area further. All therapy aims to develop the clients capacity for self-therapy (Duncan, Miller & Sparks, 2004). It has been suggested that through journal writing, the positive therapeutic benefits are more attributed to the person themselves, than it would be in, for example, group therapy. (Wright, 2003).
A case study which followed one woman’s experience of dialogical journal writing provides a “compassionate image” for self-therapy. Journal writing has helped Jane to use her creativity and imagination to achieve a compassionate change and increase in wellbeing. By writing the journal, she manages to attribute compassion to herself and avoids negative emotions by working through them. Through writing dialogues, she is able to attribute compassion to herself and the writing enables her to work through the problems she is faced with (Wright, 2009).
Mechanisms
Research in the area of writing cures has consistently shown the positive benefits. In particular, expressive writing has been shown to promote health and wellbeing. There are a variety of explanations for the positive effects of expressive writing, including those derived from a traditional Freudian explanation, which includes the notion that through expressive writing, the writer is able to go through a cleansing process, and it allows the writer to express their feelings, thus giving them more insight into understanding themselves and their own feelings through their writing (Lepore & Smyth, 2002).
In a review of the history of therapeutic writing, focusing on the role of narrative competence and the use of writing therapy for stress, trauma and coping with chronic illness, Peterkin and Prettyman (2009) explain that through expressive writing, the writer is able to construct and understand their own goals through connecting the situated events. The writer is able to attach meaning to their feelings, as they are given the ability to communicate the context of the writing and their own experiences into meaningful storylines (Peterkin & Prettyman, 2009).
In a study which investigated whether the mechanism of narrative writing enhances the benefits of expressive writing, Burg, Mosher, Seawell and Agee (2009) found results which suggested that the health benefits associated with expressive writing, including mental health and wellbeing, are connected to the extent to which the writer expresses their true feelings and emotions in their writing, this was also suggested for the structure in which the writer put forward their narrative.
Exciting & Interesting Finds
- Participants writing about "imaginary" traumas also showed improvements in physical health(Greenberg et al., 1996).
- Writing about the "worries" relating to an exam before it takes place significantly improves test scores, especially for those who are normally anxious about exams( Ramirez & Beilock, 2011).
- Participants who wrote about their relationship were significantly more likely to still be dating their romantic partners 3 months later (Slatcher & Pennebaker, 2006).
- Spending 2 minutes writing for 2 consecutive days caused people to have fewer physical symptoms at 4 to 6 weeks follow up than did controls (Burton & King, 2008).
- A decreases in male's aggressive behavior was evident in relationships when the male was assigned to the expressive writing condition, however, when the female had been assigned to the expressive writing condition, there was a strong decrease in marital satisfaction within the couple(Baddeley & Pennebaker, 2009).
Practical Writing Exercise
Writing about emotional traumas has been shown to improve our health and mental wellbeing. The scientific research surrounding this form of expressive therapy is still in its early phase, yet there are some approaches to writing that have been shown to be helpful. Below is a rough guide to a practical writing exercise.
Getting ready to write
1. You have the option to hand write or type on your computer and if you can’t write you can record. In any case, make sure you have all the tools needed for this exercise. This may include, pen and paper or a computer or a voice recorder.
2. Find a quiet place to write where you won’t be disturbed. Ideally, before you go to bed.
3. Promise yourself that you will write for 15 minutes a day, for the next 3-4 days.
4. You can write about the same thing every time or you could write about something different. It’s entirely up to you.
5. Once you start writing, write continuously without stopping and do not worry about spelling or grammar. If you run out of things to write about you can repeat what you have already written.
What should you write about?
Write about something that worries you, something you have been dreaming of and/or have been avoiding for the past week. Write about anything that comes to your mind good or bad.
In Pennebaker’s research the following instructions are given:
“Over the next four days, I want you to write about your deepest emotions and thoughts about the most upsetting experience in your life. Really let go and explore your feelings and thoughts about it. In your writing, you might tie this experience to your childhood, your relationship with your parents, people you have loved or love now, or even your career. How is this experience related to who you would like to become, who you have been in the past, or who you are now? Many people have not had a single traumatic experience but all of us have had major conflicts or stressors in our lives and you can write about them as well. You can write about the same issue every day or a series of different issues. Whatever you choose to write about, however, it is critical that you really let go and explore your very deepest emotions and thoughts . ”
Conclusions: Is it Insight that Matters?
See Also
Recommended Reading
Key Article
Pennebaker, J.W. (1993). Putting stress into words: Health, linguistic, and therapeutic implications. Behaviour Research and Therapy. 31, 539-548.
Other interesting papers
Burton, C. M., & King, L. A. (2008). Effects of (very) brief writing on health; The two-minute miracle. British Journal of Health Psychology, 13, 9-14.
Pennebaker, J.W. (1997). Writing About Emotional Experiences as a Therapeutic Process. Psychological Science, 8, 162-166
Smyth, J.M. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting & Clinical Psychology, 66, 174-184.
References
Baddeley, J. L.,, & Pennebaker, J. W. (2009). An expressive writing intervention for military couples. Manuscript in preparation.
Baikie, K. A., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11, 338-346.
Baikie, K., Geerligs L Wilhelm K. (2011). Expressive writing and positive writing for participants with mood disorders: An online randomized controlled trial. J.Affect. Disorders, doi:10.1016/j.jad.2011.11.032
Baker, J. & Moore, S. (2008). Blogging as a Social Tool:A Psychosocial Examination of the Effects of Blogging, Cyberpsychology & Behavior , 11, 747-749.
Boniel-Nissim, M., & Barak, A. (2011, December 12). The Therapeutic Value of Adolescents' Blogging About Social–Emotional Difficulties. Psychological Services,11, 1541-1559.
Boone, B. & Castillo, L. ( 2008). The use of poetry therapy with domestic violence counselors experiencing secondary posttraumatic stress disorder symptoms. Journal of Poetry Therapy , 21, 3-14.
Bracegirdle, C. (2011). Writing poetry: Recovery and growth following trauma. Journal of Poetry therapy, 24, 79-91.
Burg, D.S., Mosher, C.E., Seawell, A. H., & Agee, D.E. (2009). Does narrative writing instruction enhance the benefits of expressive writing? Anxiety, Stress & Coping: An International Journal. 341-352.
Burton, C.M., & King, L.A. (2004). The health benefits of writing about intensely positive experiences. Journal of Research in Personality, 38, 150-163.
Burton, C. M., & King, L. A. (2008). Effects of (very) brief writing on health; The two-minute miracle. British Journal of Health Psychology, 13, 9-14.
Davidson, K., Schwartz, A. R., Sheffield, D., et al (2002) Expressive writing and blood pressure. In The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-being (eds S. J. Lepore & J. M. Smyth), pp.17–30. Washington, DC: American Psychological Association.
Donnelly, D. A., & Murray, E. J. (1991). Cognitive and emotional changes in written essays and therapy interviews. Journal of Social and Clinical Psychology, 10, 334-350.
Earnhardt, J. L., Martz, D. M., Ballard, M. E., & Curtin, L. (2002). A writing intervention for negative body image: Pennebaker fails to surpass the placebo. Journal of College Student Psychotherapy, 17, 19-35.
Francis , M.E. & Pennebaker, J.W. (1992). Putting stress into words: Writing about personal upheavals and health. American Journal of Health Promotion, 6, 280-287.
Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin, 132, 823-865.
Frisina, P.G., Borod, J.C., & Lepore, S.J. (2004). A meta-analysis of the effects of written emotional disclosure on the health outcomes of clinical populations. Journal of Nervous and Mental Disease, 192, 629-634.
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