Writing therapy

Expressive writing is a form of writing therapy developed primarily by James W. Pennebaker in the late 1980s. The seminal expressive writing study instructed participants in the experimental group to write about a 'past trauma', expressing their very deepest thoughts and feelings surrounding it.[2] In contrast, control participants were asked to write as objectively and factually as possible about neutral topics (e.g., a particular room or their plans for the day) without revealing their emotions or opinions. Both groups wrote continuously for 15 minutes per day for 4 consecutive days. If participants felt they could not write any more details, they were instructed to return to the begin, potentially repeating what they wrote or writing it in a different manner.

The following text provides an example of writing instructions for expressive writing:

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.

Pennebaker and his team took several measurements before and after, but the most striking finding was that relative to the control group, the experimental group made significantly fewer visits to a physician in the following months. Although many reported being upset by the writing experience, they also found it valuable and meaningful.[3]^: 167

Pennebaker has either written or co-written over 130 articles on expressive writing.[4] One publication suggested expressive writing may boost the immune system, perhaps explaining the reduction in physician visits.[5] This was shown by measuring lymphocyte response to the foreign mitogens phytohaemagglutinin (PHA) and concanavalin A (ConA) just prior to and six weeks after writing.[5] The significantly increased lymphocyte response led to speculation that expressive writing enhances immunocompetence. The results of a preliminary study of 40 people diagnosed with Major Depressive Disorder suggests that routinely engaging in expressive writing may be effective in reducing symptoms of depression.[6]

Pennebaker's experiments have been widely replicated and validated. Following on from Pennebaker's original work, there has been a renewed interest in the therapeutic value of abreaction. This was first discussed by Josef Breuer and Freud in Studies on Hysteria but not much explored since. At the heart of Pennebaker's theory is the idea that actively inhibiting thoughts and feelings about traumatic events requires effort, serves as a cumulative stressor on the body, and is associated with increased physiological activity, obsessive thinking or ruminating about the event, and longer-term disease.[3] However, as Baikie and Wilhelm note, the theory has intuitive appeal but mixed empirical support.

Studies have shown that expressive writing results in significant improvements in various biochemical markers of physical and immune functioning (Pennebaker et al, 1988; Esterling et al, 1994; Petrie et al, 1995; Booth et al, 1997). This suggests that written disclosure may reduce the physiological stress on the body caused by inhibition, although it does not necessarily mean that disinhibition is the causal mechanism underlying these biological effects. On the other hand, participants writing about previously undisclosed traumas showed no differences in health outcomes from those writing about previously disclosed traumas (Greenberg & Stone, 1992) and participants writing about imaginary traumas that they had not actually experienced, and therefore could not have inhibited, also demonstrated significant improvements in physical health (Greenberg et al, 1996). Therefore, although inhibition may play a part, the observed benefits of writing are not entirely due to reductions in inhibition.

In a 2013 article by Nazarian and Smyth, writing instructions for the expressive writing task were manipulated in that 6 conditions were created (i.e., cognitive-processing, exposure, self-regulation, and benefit-finding, standard expressive writing and a control group).[7] While salivary cortisol was measured for each condition, none of the conditions significantly influenced cortisol, but instructions did impact mood differentially depending on the condition.[7] For example, the cognitive-processing as measured post-intervention were influenced not only by the cognitive processing instructions but also by exposure and benefit-finding. These results demonstrate a spillover effect from instructions to outcomes.[7]

In related research, Travagin, Margola, Dennis, and Revenson compared cognitive-processing instructions to standard expressive writing for adolescents with peer problems.[8] This research demonstrated better long-term social adjustment compared to standard expressive writing and greater increased positive affect for those adolescents who reported more peer problems than most.[8]

An additional line of enquiry, which has particular bearing on the difference between talking and writing, derives from Robert Ornstein's studies into the bicameral structure of the brain.[9] While noting that what follows should be considered "wildly hypothetical", L'Abate, quoting Ornstein, postulates that:

One could argue ... that talk, and writing differ in relative cerebral dominance. ... if language is more related to the right hemisphere, then writing may be more related to the left hemisphere. If this is the case, then writing might use or even stimulate parts of the brain that are not stimulated by talking.[10]

Julie Gray, founder of Stories Without Borders notes that "People who have experienced trauma in their lives, whether or not they consider themselves writers, can benefit from creating narratives out of their stories. It is helpful to write it down, in other words, in safety and in non-judgment. Trauma can be quite isolating. Those who have suffered need to understand how they feel and also to try to communicate that to others."[11]

One of the most important aspects of expressive writing used in therapy is the short-term, and long-term effects on the individuals participating. Karen Baikie and Kay Wilhelm[18] go into a brief description of the effects people will have after completing a therapeutic expressive writing session.

The short-term effects after utilizing this form of therapy are usually a quick span of feeling distress or being in a negative mood. However, following up with clients after a longer amount of time to measure those effects finds evidence of many mental and physical health benefits.

These benefits include but are not limited to “reduced blood pressure, improved mood, reduced depressive symptoms, and fewer post-traumatic intrusion/avoidance symptoms.”

This study also showed that these positive long-term emotional outcomes correlated to positive physical outcomes such as improved memory, improved performance at work, quicker re-employment and many more. While the short-term effects of this therapeutic practice may seem daunting, they are just the steppingstones for individuals to begin a cycle of growth.

Illness and disease are experienced on multiple different fronts: biological, psychological, and social. Recent research has explored how narrative medicine and expressive writing, independently, may play a therapeutic role in chronic diseases such as cancer.[19] Comparisons in practice have been made between expressive writing and psychotherapy.[20] Similarly, practices such as integrative, holistic, humanistic or complementary medicine have already been incorporated into the field. Expressive writing is self-administered with minimal prompting. With further research and refinement, it may be used as a more cost effective alternative to psychotherapy.[20]

Recent experiments, systematic reviews, and meta-analyses examining the effects of expressive writing on ameliorating negative cancer symptoms yielded primarily non-significant initial results.[21][16][22][23] However, analysis of sub-groups and moderating variables suggest that particular symptoms, or situations, may benefit some more than others with the implementation of an expressive writing intervention. For example, a review by Antoni and Dhabhar (2019) examined how psychosocial stress negatively impacts the immune response of patients with cancer.[24] Even if an expressive writing intervention cannot directly impact cancer prognosis, it may play an important role in mediating factors such as chronic stress, trauma, depression, and anxiety.

Writing therapy may play a significant role in recovery for individuals with a substance use disorder. Writing exercises have been found to have the potential to improve those in addiction recovery the ability to cope with their conditions, and overall health.[25]