Write It Out: Assessing the Benefits of Written Emotional Disclosure
In a pioneering 1986 study, researchers Pennebaker and Beall found that recounting traumatic events in writing for 20 minutes across four consecutive days led to general improvements in long-term physical and psychological health among healthy undergraduate participants. When asked to describe how the confrontation of trauma through writing had emotionally affected them, participants noted that it had helped them realize the extent to which they had been affected by said trauma and had allowed a release where they could reach mental resolution and peace and engage in deeper thinking about their lives. “I was finally able to deal with it, work through the pain instead of trying to block it out,” one reported, “and now it doesn't hurt to think about it” (Pennebaker & Beall, 1986).
Research on writing therapy since 1986 has not only tested other healthy samples but has investigated whether results would be replicated amongst individuals struggling with psychological or physical illnesses. But is there enough evidence that this form of therapy- interchangeably referred to as written emotional disclosure or expressive writing-has tangible, positive effects on health? If there is, written disclosure “could potentially be a cheap, simple and easily accessible option” (Mugerwa & Holden, 2012) for populations which often face financial strain, and may “be implemented by non-psychologists, such as nurses and social workers, as long as risk management and clinical referral procedures are well established,” (Wallander, Madan-Swain, Klapow, & Saeed, 2011), hence allowing a greater number of people to reap its benefits. Furthermore, engagement in written disclosure would not require elderly patients to travel to a care center, as writing may take place in the home (Rosenberg et al., 2002), and it may also serve as a substitute for “patients unwilling or unable to engage in counselling or conventional psychotherapy”(Mugerwa & Holden, 2012).
The first study by Pennebaker and Beall (1986) found that healthy undergraduates in trauma-writing conditions reported an increase in negative affect and systolic blood pressure after writing, whether their essays focused specifically on the traumatic event, the emotions associated with it, or both. However, written disclosure appeared to offer long-term benefits, as participants from both experimental and control groups reported a decrease in visits to the hospital for problems in physical or psychological health at follow-up. The study noted that the decrease in health visits could have also been attributed to the fact that subjects continued engaging in written disclosure as a coping mechanism after the experiment was over. King and Miner (2000) found that healthy undergraduates writing about the perceived benefits of a traumatic event produced essays that were less bitter and more insightful. They also reported the least visits to the health center for illness-related issues at the three and five month follow-ups, and even the group that had engaged in written disclosure about their traumas without focusing on beneficial effects reported a decline in health visits. The study noted that “writing about positive aspects of a negative event may spur self-regulatory processes that allow the individual to deal effectively with the emotion caused by the experience […] without having to re-experience it” (King & Miner, 2000). Unlike the previous two studies, Richards, Beal, Seagal, and Pennebaker (2000) tested the benefits of written exposure on a healthy sample of prison inmates rather than students. An increase in negative emotions was reported immediately after writing for those in the written disclosure group, but participants noted fewer trips to the infirmary at follow-ups. Notably, sex offenders showed the most significant improvement in health after writing compared to those who were incarcerated for non-sex crimes. The study “provides qualified support for the efficacy of the writing paradigm beyond the traditional college student samples,” (Richards et al., 2000) and suggests that writing may offer sex offenders an outlet for their emotions, given their lack of confidantes and the social stigma pertaining to the nature of their crimes. As such, while healthy samples may face immediate increases in negative affect following engagement in written disclosure, they unanimously report long-term decreases in trips to health centers for physical or psychological complaints.
The effects of written disclosure have been measured on samples suffering from symptoms of depression. Koopman et al. (2005) found that female victims of intimate partner violence who engaged in expressive writing reported significant decreases in depression compared to neutral writing controls. However, expressive writing appeared ineffective at alleviating negative psychological symptoms of women who experienced childhood sexual abuse; a study by Batten, Follette, Rasmussenhall, and Palm (2002) found that women in the written disclosure group reported a less significant drop in depression at follow-up compared to women in the neutral writing control condition. Furthermore, the use of words pertaining to negative emotions increased for the expressive writing group across four days. However, the study noted that unusually high levels of traumatization and re-traumatization in their specific sample made it difficult to treat effectively with writing therapy alone, and that longer writing time per day may be required “to allow levels of negative affect to habituate on their own” (Batten et al., 2002). Kovac and Range (2002) assessed the effect of written disclosure on both depression and suicidal ideation and noted that while those in the written disclosure group reported a decrease in automatic negative thoughts at posttest and an increase in positive self-regard and number of health visits at follow-up, there were no significant effects of written disclosure on depression scores and suicidality. Gortner, Rude and Pennebaker (2006) evaluated whether expressive writing would decrease rumination and depressive symptoms among vulnerable college students and found that at six month follow-up, those in the experimental writing group reported significantly lower rumination and depressive symptoms compared to controls, but only if they were used to engaging in the suppression of their emotions. As such, written disclosure appears to alleviate depression among female victims of intimate partner violence and individuals who are both vulnerable to depression and high in emotional suppression, but does not appear to affect depression or suicidality scores amongst females who experienced childhood sexual abuse.
Post-Traumatic Stress Disorder
Written disclosure was also examined as a possible therapy for samples with PTSD symptoms. In a study by Deters and Range (2003), undergraduate students who met subclinical levels of PTSD and had engaged in written disclosure reported an immediate increase in negative affect and PTSD symptoms at posttest, but a substantial decrease in symptoms at the six week follow-up session, so much so that they no longer met criteria for subclinical levels of PTSD. They also reported decreases in dissociation and number of health visits for physical and psychological symptoms, as well as a decrease in the impact that the traumatic event(s) had on their current state. However, these results also applied to the neutral writing control group; a possible reason for this result could be that writing about mundane topics for four consecutive days had actually pushed said participants to focus more on the significant traumas that they had experienced, and hence responded to writing in a similar manner as the experimental group (Deters & Range, 2003). Bragdon and Lombardo’s study (2012) also yielded positive results in their investigation on the effects of expressive writing on individuals who simultaneously met criteria for clinical PTSD and substance use disorder. 53% of the 45 participants who engaged in expressive writing about traumas such as physical or sexual assault, witnessing a sudden death, or motor vehicle accidents, no longer met criteria for PTSD at the two week follow-up, and 47% of the 17 participants that completed the three month follow-up no longer met criteria for either PTSD or subsyndromal PTSD. Blasio, Ionio and Confalonieri (2009) applied expressive writing to postpartum PTSD symptoms in particular, noting that “the experience of childbirth can be traumatic in itself because it often involves fear, pain, impotence and non-expressed negative emotions” (Blasio et al., 2009). At the 48-hour follow-up, women who had engaged in expressive writing alluding to their labor and delivery experiences scored lower on avoidance and hyper-arousal symptoms compared to the neutral writing control group. They also scored lower on scores of irritability, hyper-arousal and sleep disturbances, and higher on scores of concentration and alertness, at the two month follow-up, and reported a decrease in recurrent thoughts and intrusive symptoms at twelve month follow-up. Testing the effects of internet-based expressive writing on a sample of kidney transplant recipients, a pilot study by Possemato, Ouimette and Geller (2010) found that recipients who had engaged in expressive writing reported improved quality-of-life and more significant decreases in PTSD symptoms than did controls at twelve month follow-up. The study also helped confirm that “expressive writing is safe when completed outside the lab for individuals with PTSD symptoms” (Possemato et al., 2010). Comparing the efficacy of structured writing therapy (SWT) to cognitive behavioral therapy (CBT), Van Emmerik, Kamphuis and Emmelkamp (2008) identified SWT as an effective alternative to CBT, as engagement in both therapies led to decreases in intrusion and avoidance symptoms, as well as depression and anxiety scores, for participants with acute stress disorder or acute/chronic PTSD. Notably, SWT differs from standard written disclosure in that it consists of three phases focusing on confrontation, cognitive reappraisal, and a discussion of both trauma and coping mechanisms, respectively. Furthermore, SWT requires 1.5 hours of writing on a weekly basis rather than the standard 20 minutes over 4 days. As such, written disclosure is effective at alleviating both clinical and subclinical PTSD symptoms, both in laboratory settings and over the internet, and is a viable alternative to CBT.
Written disclosure may yield benefits among individuals struggling with negative body-image. Women who engaged in written disclosure about body-image in Earnhardt, Martz, Ballard and Curtin’s study (2008) showed improvements in body-image, dieting and eating behavior at posttest and follow-up. Possible explanations of results are that written disclosure caused cognitive restructuring pertaining to body image, in that participants reconsidered negative ideas about their bodies and changed them into more rational or positive ones. Positive results were also shown among participants in the control condition who described objects in their rooms, and it was suggested that they learned to rate their bodies as objectively as they would the objects they were describing, or that such a neutral topic may have steered attention away from negative body rumination (Earnhardt et al., 2008). While Lafont and Oberle’s study (2014) deemed written disclosure ineffective at changing women’s views towards their ideal figures and the body-types that they believed men would more strongly desire, it found that disclosure about either trauma or body-image improved ratings towards one’s current figure in high-symptomology participants at posttest and even more so at one month follow-up. In the asymptomatic group, ratings also decreased at posttest for those in the written disclosure groups, but did not decrease further at follow-up. A possible explanation of the results is that written disclosure allowed participants to “label and acknowledge emotional experiences” (Lafont & Oberle, 2014) which in turn “may change the way a person views herself, especially if she already has a distorted body image” (Lafont & Oberle, 2014). Furthermore, because the study revealed the benefits of written disclosure for “women with higher levels of eating disorder symptomology […] then perhaps this paradigm can be used with women with eating disorders,” (Lafont & Oberle, 2014) or could be used as a preventive measure for symptomatic women before they develop a full-blown eating disorder. Contrastingly, Gamber, Lane-Loney and Levine (2013) found that written disclosure about trauma among women diagnosed with eating disorders did not lead to reductions in eating-disordered behavior despite the increased usage of words pertaining to cognitive restructuring in their essays. As such, written disclosure among female participants with negative body-image may lead to a positive reassessment of their bodies, but yields mixed results in terms of improved subsequent eating habits.
Written disclosure was implemented on samples who had experienced the termination of meaningful relationships, which is “among life’s most stressful experiences and confer risk for poor outcomes in mental […] health outcomes,” (Sbarra, Boals, Mason, Larson & Mehl, 2013). Sbarra et al. (2013) found that expressive writing actually disrupted emotional recovery among individuals who had recently experienced marital separation. Those in the expressive writing condition, who scored higher in levels of rumination and an active search for meaning following their divorce, reported worse emotional outcomes than controls, who reported “significantly lower levels of separation-related emotional disturbance” (Sbarra et al., 2013). The study brings attention to the fact that the effects of expressive writing may vary according to how people react to and interpret significant events. It also suggested that recounting traumas so soon after marital termination may exacerbate emotional distress due to lack of adequate time for psychological closure, although writing about neutral topics may be beneficial. Directly contrasting Sbarra et al. (2013), Lepore and Greenberg (2002) found that those who engaged in expressive writing after the termination of non-marital romantic relationships reported decreases in emotional attachment pertaining to their ex-partner and no increase in levels of avoidance or intrusive thoughts, whereas controls asked to objectively discuss controversial topics relating to sex and relationships showed the opposite. Furthermore, the control group reported greater tension and fatigue compared to the experimental group, who reported no such negative effects and were also ironically more likely to reunite with their ex-partner. As such, while expressive writing may potentially alleviate the pain of a breakup, it also may be risky to engage in due to results suggesting that it may actually impede emotional recovery.
Individuals psychologically affected by the traumatic experiences of loved ones may also benefit from written emotional disclosure. Gallant and Lafreniere (2003) investigated how written emotional disclosure affected functioning in the children of alcoholics, “a population among which emotional expressivity is often suppressed” (Gallant & Lafreniere, 2003). Improvements in affect and internalizing symptoms were observed at posttest, as was an increase in prosocial behavior and conduct, suggesting that individuals “characterized by emotional restraint could reap benefits from participating in an experiment that involves emotional content in its measures and methods” (Gallant & Lafreniere, 2003). However, results were not specific to the experimental group, a possible explanation being that all participants fell into an age-group still developing in the exploration of the inner self, and hence written expression of emotions did not yield more significant results than writing about neutral topics. Martino, Freda & Camera (2012) found that the parents of children diagnosed with acute lymphoblastic leukemia showed reduced symptoms of psychological distress, such as anxiety, depression, hostility, tension, and fatigue, as well as somatic symptoms, after completing written disclosure exercises, whereas the control group worsened over time. It also emphasized that poor emotional expression hindered the effectiveness of written disclosure. In a similar study, Duncan et al. (2007) found that written disclosure alleviated PTSD symptoms in parents of children with unspecified cancers, but did not alleviate depression. However, Schwartz and Drotar (2004), who asked participants to engage in written disclosure in the hospital setting, revealed that caregivers of children and adolescents struggling with severe and chronic illnesses reported no alleviation of mood, depression and anxiety in long-term follow-up. The study suggests that “in an applied setting with a distressed population” (Schwartz & Drotar, 2004) the beneficial effects of written disclosure do not apply, possibly due to impediments of habituation and cognitive restructuring, and may thus be optimal in a controlled environment without a plethora of stressors. As such, written disclosure may be implemented as a therapy for the children of alcoholics and parents of children with cancer, but may be ineffective when administered in a high-stress environment such as a hospital setting.
Expressive writing has the potential to affect memory capacity, as psychological stress and “thoughts associated with stressful […] life situations compete with ongoing task requirements for attentional resources” (Klein & Boals, 2001) and thus impairs memory performance. Klein and Boals (2001) investigated the effect of expressive writing on working memory capacity among students and found that those who engaged in written disclosure showed less intrusive and avoidant thinking and hence improved working memory capacity, whereas those who engaged in positive written disclosure demonstrated no decreases in intrusive and avoidant thoughts and thus decreased working memory capacity. Ahmadi, Abdollahi, Ramezani and Heshmati (2010) yielded similar results, noting that at posttest, written emotional expression simultaneously led to significant decreases in depressive symptoms and increases in working memory capacity, and that results remained stable at six month follow-up. As such, by alleviating symptoms of stress and depression, expressive writing allows for an increase in working memory capacity.
In a study by Danoff-Burg, Agee, Romanoff, Kremer and Strosberg (2006), participants suffering from either rheumatoid arthritis or systemic lupus erythematosus engaged in either perceived benefit-finding writing or standard expressive writing. At the one month follow-up, participants in the control group had reportedly been experiencing more physical pain compared to those who had participated in benefit-finding or standard expressive writing, the latter which reportedly experienced the least amount of physical pain. Furthermore, at the three month follow-up, both benefit-finding and expressive writing groups had reportedly experienced lower levels of fatigue compared to controls. The study noted that benefit-finding writing was the most useful for participants who scored highest in trait anxiety, whereas expressive writing helped those with low trait anxiety the most significantly. Testing the benefits of written disclosure even further, Lumley et al. (2011) compared its efficacy to spoken emotional disclosure among patients with rheumatoid arthritis. Participants in the experimental written disclosure group addressed their arthritis, as well as divorce, drug-use and physical or sexual abuse, and reported an increase in negative emotions such as guilt and anger at posttest compared to the experimental spoken disclosure group, which only addressed traumas related to their arthritis and reported only feeling an increase in sadness. The written disclosure participants revealed a decrease in sensory pain at one month follow-up, an increase in grip strength at three month follow-up, and a decrease in affective pain and increase in walking speed at six month follow-up. In comparison, spoken disclosure participants reported decreases in sensory and affective pain as well as increases in walking time at three month follow-up, and a decrease in number of swollen joints and improvements in physician assessment of disease at six month follow-up. However, the study concluded that effects were too limited to categorize written or spoken emotional disclosure as anything other than a supplementary treatment of rheumatoid arthritis. As such, standard written disclosure has limited benefits for those suffering from rheumatoid arthritis, the most notable being the alleviation of physical pain, but may only help those with low trait anxiety and does not appear to have significantly better effects than spoken emotional disclosure.
Written disclosure may be therapeutic during or following cancer treatment. Stanton et al. (2002) found that women who engaged in written disclosure about their breast cancer reported a reduction in somatic symptoms at three month follow-up, and both they and participants in the benefit-finding group reported less cancer-related physician visits. However, written disclosure was found to be the most effective in patients with low avoidance coping mechanisms, while benefit-finding helped those high in avoidance. Working with former breast cancer patients, Craft, Davis and Paulson (2013) reported that breast cancer survivors who engaged in expressive writing specifically about the traumas of their cancer experience or about facts related to breast cancer experienced enhanced quality-of-life at follow-up compared to controls. The first to test written disclosure effects on male cancer patients, Rosenberg et al. (2002) found that men with prostate cancer who engaged in written disclosure reported lower levels of pain and reduced usage of medication, although they reported no immunological benefits. As such, written disclosure may decrease physical pain and number of health visits, and may enhance quality of life, for both male and female cancer patients.
A number of other studies have examined written disclosure on a variety of other physical illnesses. Wallander et al. (2011) examined the use of written disclosure in a pediatric population suffering from recurrent abdominal pain. Participants who had engaged in standard medical care along with written disclosure showed significant decreases in gastrointestinal (GI) pain frequency compared to youth who had only received standard medical care. Furthermore, those who participated in written disclosure reported “about 50% fewer days with activity-limiting GI pain in the past 2 weeks than did the standard medical care group” (Wallander et al., 2011), a significant increase in physical quality of life, fewer visits to the hospital and fewer phone-calls to the clinic for GI-related problems. Examining physiological effects of expressive writing on individuals with elevated blood pressure, McGuire, Greenberg and Gevirtz (2005) found that those in the expressive writing condition had no changes in very-low frequency heart rates from posttest to one and four month follow-ups, indicating lower arousal, worry and rumination, whereas those in the control condition reported an increase in very-low frequency rates. Furthermore, both systolic and diastolic blood pressure was shown to have decreased at one month follow-ups for both groups. The study also noted that the effects of expressive writing were moderated by high “Anger-In” scores among participants, as those who were “prone to anger or who demonstrated excessive levels of anger inhibition, anger expression or both” (McGuire et al., 2005) exhibited lower diastolic blood pressure levels at four month follow-up. D’Souza, Lumley, Kraft and Dooley’s (2008) pilot study was the first study to compare the efficacies between relaxation training and written emotional disclosure on a sample of undergraduate participants who suffered from either tension or migraine headaches. At one and three month follow-ups, the effects of written emotional disclosure on headache frequency, severity and disability were insignificant and did not differ between the experimental and control groups. However, relaxation training resulted in significant decreases in tension headache frequency and disability for participants in the experimental group, and decreases in migraine pain severity. The study “used methods designed to increase the effectiveness of written disclosure therapy” (D’Souza et al., 2008) such as a greater number of writing sessions, supervised conditions and strong adherence among participants, but written disclosure still appeared to have only limited effectiveness at alleviating tension and migraine headaches. However, none of the participants disclosed significant traumas, instead writing about trivial relationship or academic difficulties, “in which case written disclosure would not be expected to lead to much health change” (D’Souza et al., 2008). Furthermore, the relaxation training group engaged in extra at-home sessions whereas written disclosure occurred strictly in the laboratory, which may also explain why relaxation training was more effective. As such, written disclosure appears beneficial to pediatric populations suffering from chronic abdominal pain and participants with elevated blood pressure and high Anger-In scores, but appears to be inefficient at alleviating tension and migraine headaches when compared to relaxation training.
Written emotional disclosure has been tested as a therapeutic tool across both healthy samples and those dealing with a variety of psychological and physical health issues. Results concerning its efficacy are mixed: while some suggest that participants engaging in written disclosure reap psychological and physical benefits in the short-term, long-term or both, others suggest limited or no beneficial effects or note that other forms of therapy, such as CBT and relaxation training, may be as or more beneficial. A noteworthy observation, however, is that a majority of participants who engaged in expressive writing about a traumatic event described their essays as more personal and replete with meaning and emotion, allowing for ample self-expression regardless of whether participants psychologically or physically benefited from it. Furthermore, control groups have often benefited from written disclosure, even if they addressed neutral rather than traumatic events; this suggests that the very act of writing may be therapeutic for some individuals, regardless of the topic of disclosure. Future research should further investigate the moderating roles of emotional expressivity, anxiety and anger suppression on the efficacy of expressive writing, so that different writing exercises may be developed to target specific samples possessing different levels of such traits. Furthermore, future research should include larger sample-sizes and explore the effects of written disclosure on a greater number of male and non-Caucasian participants.
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