Emotional and physical health benefits

of expressive writing
1. Karen A. Baikie and
2. Kay Wilhelm
-Author Afliations
1. Karen Baikie is a clinical psychologist and postdoctoral research
fellow with the Black Dog Institute and School of Psychiatry, ni!ersity
of "ew South #ales $Black Dog Institute, ni!ersity of "ew South
#ales, %he &illa, Prince of #ales 'ospital, (andwick "S# )*+1,
Australia. ,-.ail/ k.0aikie1unsw.edu.au2. She co.pleted her PhD in
the use of e3pressi!e writing in the Depart.ent of Psychology,
4ac5uarie ni!ersity, Sydney. 'er interests are in the application of
e3pressi!e writing for di6erent clinical populations and in working
therapeutically with sur!i!ors of trau.a, as well as general adult
clinical psychology. Kay #ilhel. is a consultant psychiatrist in
consultation liaison psychiatry at St &incent7s 'ospital, Sydney, and
the 4ood Disorders nit, Black Dog Institute, where she is also pro8ect
leader for the 9eneral Practitioner ,ducation Progra.. She is a clinical
Associate Professor at the ni!ersity of "ew South #ales. She has a
long-standing interest in depression, especially gender issues and
psychosocial risk factors, 0rief psychotherapy for depression and self-
har., as well as pri.ary care and general hospital psychiatry. K.B. is
supported 0y "ational 'ealth and 4edical (esearch :ouncil Progra.
9rant )));*<.

"e3t Section
Abstract
#riting a0out trau.atic, stressful or e.otional e!ents has 0een found to
result in i.pro!e.ents in 0oth physical and psychological health, in non-
clinical and clinical populations. In the e3pressi!e writing paradig.,
participants are asked to write a0out such e!ents for 1=>)* .inutes on +>=
occasions. %hose who do so generally ha!e signi?cantly 0etter physical and
psychological outco.es co.pared with those who write a0out neutral topics.
'ere we present an o!er!iew of the e3pressi!e writing paradig., outline
populations for which it has 0een found to 0e 0ene?cial and discuss possi0le
.echanis.s underlying the o0ser!ed health 0ene?ts. In addition, we suggest
how e3pressi!e writing can 0e used as a therapeutic tool for sur!i!ors of
trau.a and in psychiatric settings.
@!er the past )* years, a growing 0ody of literature has de.onstrated the
0ene?cial e6ects that writing a0out trau.atic or stressful e!ents has on
physical and e.otional health. In the ?rst study on e3pressi!e writing
$Penne0aker A Beall, 1B<C2, college students wrote for 1= .inutes on D
consecuti!e days a0out Ethe .ost trau.atic or upsetting e3periences7 of their
entire li!es, while controls wrote a0out super?cial topics $such as their roo.
or their shoes2. Participants who wrote a0out their deepest thoughts and
feelings reported signi?cant 0ene?ts in 0oth o08ecti!ely assessed and self-
reported physical health D .onths later, with less fre5uent !isits to the health
centre and a trend towards fewer days out of role owing to illness. %he
authors concluded that/
Ewriting a0out earlier trau.atic e3perience was associated with 0oth short-
ter. increases in physiological arousal and long-ter. decreases in health
pro0le.s7 $Penne0aker A Beall, 1B<C/ p. )<*2.
Pre!ious Section "e3t Section
Expressive writing studies
%he 0asic writing paradig. $Penne0aker, 1BBD, 1BB; a, 1BB; bF S.yth A
Penne0aker, 1BBB2 used in .ost of the su0se5uent e3pressi!e writing studies
in!ol!es participants writing a0out trau.atic or e.otional e3periences $Bo3
1G2 for +>= sessions, often o!er consecuti!e days, for 1=>)* .inutes per
session. 4ost studies ha!e 0een conducted in the la0oratory, although .ore
recently writing has 0een done at ho.e or in a clinical setting. Participants
often re!eal a considera0le range and depth of e.otional trau.a in their
writing. Although .any report 0eing upset 0y the writing e3perience, they
also ?nd it !alua0le and .eaningful $Penne0aker, 1BB; b2. :ontrol participants
are asked to write as o08ecti!ely and factually as possi0le a0out neutral topics
such as a particular roo. or their plans for the day, without re!ealing their
e.otions or opinions. "o feed0ack is gi!en on the writing.
Box 1
Typical writing instructions
Hor the ne3t D days, I would like you to write your !ery deepest thoughts and
feelings a0out the .ost trau.atic e3perience of your entire life or an
e3tre.ely i.portant e.otional issue that has a6ected you and your life. In
your writing, I7d like you to really let go and e3plore your deepest e.otions
and thoughts. Iou .ight tie your topic to your relationships with others,
including parents, lo!ers, friends or relati!esF to your past, your present or
your futureF or to who you ha!e 0een, who you would like to 0e or who you
are now. Iou .ay write a0out the sa.e general issues or e3periences on all
days of writing or a0out di6erent topics each day. All of your writing will 0e
co.pletely con?dential.
Don7t worry a0out spelling, gra..ar or sentence structure. %he only rule is
that once you 0egin writing, you continue until the ti.e is up.
@wing to the nature of APT, study results discussed 0elow are not
e3hausti!ely referencedF instead, we ha!e tried to gi!e the .ost
representati!e or co.prehensi!e pu0lications. Hor further reading on
e3pressi!e writing and its i.ple.entation we reco..end Jepore A S.yth
$)**)2, Penne0aker $1BB; a,b2 and Sloan A 4ar3 $)**D b 2.
Pre!ious Section "e3t Section
Immediate and longer-term effects of expressive writing
%he i..ediate i.pact of e3pressi!e writing is usually a short-ter. increase in
distress, negati!e .ood and physical sy.pto.s, and a decrease in positi!e
.ood co.pared with controls. ,3pressi!e writing participants also rate their
writing as signi?cantly .ore personal, .eaningful and e.otional. 'owe!er, at
longer-ter. follow-up, .any studies ha!e continued to ?nd e!idence of health
0ene?ts in ter.s of o08ecti!ely assessed outco.es, self-reported physical
health outco.es and self-reported e.otional health outco.es $Bo3 )G2.
Box 2
Longer-term ene!ts o" expressi#e writing
Health outcomes
Hewer stress-related !isits to the doctor
I.pro!ed i..une syste. functioning
(educed 0lood pressure
I.pro!ed lung function
I.pro!ed li!er function
Hewer days in hospital
I.pro!ed .oodKa6ect
Heeling of greater psychological well-0eing
(educed depressi!e sy.pto.s 0efore e3a.inations
Hewer post-trau.atic intrusion and a!oidance sy.pto.s
Social and behavioural outcomes
(educed a0senteeis. fro. work
Luicker re-e.ploy.ent after 8o0 loss
I.pro!ed working .e.ory
I.pro!ed sporting perfor.ance
'igher students7 grade point a!erage
Altered social and linguistic 0eha!iour
Objectively assessed outcomes
,3pressi!e writing results in signi?cant i.pro!e.ents in longer-ter. physical
health outco.es such as illness-related !isits to the doctor $Penne0aker A
Beall, 1B<CF Penne0aker et al , 1B<<F Penne0aker A Hrancis, 1BBCF King A
4iner, )***2, 0lood pressure $Da!idson et al , )**), citing :row et al2, lung
function $S.yth et al , 1BBB2, li!er function $Hrancis A Penne0aker, 1BB)2 and
nu.0er of days in hospital $"or.an et al , )**D2. ,3pressi!e writing has also
produced signi?cant 0ene?ts in a nu.0er of .easures of i..une syste.
functioning $Penne0aker et al , 1B<<F ,sterling et al , 1BBDF Booth et al ,
1BB;F Petrie et al , 1BB=, )**D2.
Signi?cant 0ene?ts ha!e also 0een found for such o08ecti!e outco.es as
students7 grade point a!erage $Penne0aker A Hrancis, 1BBCF :a.eron A
"icholls, 1BB<2, a0senteeis. fro. work $Hrancis A Penne0aker, 1BB)2, re-
e.ploy.ent after 8o0 loss $Spera et al , 1BBD2, working .e.ory $Klein A
Boals, )**12 and sporting perfor.ance $Scott et al , )**+2. In addition, writing
a0out e.otional topics changed the way that participants interacted with
others, suggesting that writing .ay also ha!e an i.pact on o08ecti!ely
assessed social and linguistic 0eha!iour $Penne0aker A 9ray0eal, )**12.
Self-reported physical health outcomes
,3pressi!e writing also produces longer-ter. 0ene?ts in self-reported health
outco.es such as !isits to the doctor $:a.eron A "icholls, 1BB<2, physical
sy.pto.s $Park A Blu.0erg, )**)2 and nu.0er of days out of role 0ecause
of illness $Penne0aker A Beall, 1B<CF S.yth et al , )**12.
In general, e3pressi!e writing does not a6ect health-related 0eha!iours such
as e3ercise, diet or drugKalcohol use $Penne0aker et al , 1B<<2.
Self-reported emotional health outcomes
So.e studies ha!e also found longer-ter. 0ene?ts of e3pressi!e writing for
e.otional health outco.es, including .oodKa6ect $Penne0aker et al ,
1B<<FPMeN et al , 1BBB2, psychological well-0eing $Park A Blu.0erg, )**)2,
depressi!e sy.pto.s 0efore e3a.inations $Jepore, 1BB;2 and post-trau.atic
intrusion and a!oidance sy.pto.s $Klein A Boals, )**12. 'owe!er, the
?ndings for e.otional health are not as ro0ust or as consistent as those for
physical health.
Meta-analyses
A .eta-analysis of 1+ studies using e3pressi!e writing with healthy
participants $S.yth, 1BB<2 found a signi?cant o!erall 0ene?t $d O
*.D;,PP*.***12 and speci?c 0ene?ts in o08ecti!e or self-reported physical
health, psychological well-0eing, physiological functioning and general
functioning outco.es. S.yth7s re!iew suggests that, for physically and
psychologically healthy indi!iduals, the e6ects produced 0y e3pressi!e writing
are su0stantial and si.ilar in .agnitude to the e6ects of other psychological
inter!entions, .any of which are .ore in!ol!ed, ti.e-consu.ing and
e3pensi!e.
In clinical populations, a .eta-analysis $Hrisina et al , )**D2 of nine e3pressi!e
writing studies also found a signi?cant 0ene?t for health $d O *.1B, PP*.*=2,
although when analysed separately the e6ects for physical health outco.es
in .edically ill populations were signi?cant $d O *.)1, P O *.*12 0ut those for
psychological health outco.es in psychiatric populations were not $d O
*.*;,P O *.1;2. Although the 0ene?ts are .ore .odest than in studies with
healthy participants, this .eta-analysis suggests that e3pressi!e writing
ne!ertheless has positi!e e6ects in clinical populations.
Pre!ious Section "e3t Section
ho can benefit!
Medical conditions
In co.parisons with controls, e3pressi!e writing produced signi?cant 0ene?ts
for indi!iduals with a !ariety of .edical pro0le.s $Bo3 +G2. Study participants
with asth.a or rheu.atoid arthritis showed i.pro!e.ents in lung function
and physician-rated disease se!erity respecti!ely, following a la0oratory-
0ased writing proga..e $S.yth et al , 1BBB2, although people with
rheu.atoid arthritis using a ho.e-0ased !ideotaped progra..e showed no
0ene?t $Broderick et al , )**D2. So.e studies found that patients with cancer
reported 0ene?ts such as 0etter physical health, reduced pain and reduced
need to use healthcare ser!ices $(osen0erg et al , )**)F Stanton A Dano6-
Burg, )**)2, although others failed to ?nd any 0ene?ts $#alker et al , 1BBBF de
4oor et al , )**)2. Patients with 'I& infection showed i.pro!ed i..une
response si.ilar to that seen in .ono-therapy with anti-'I& drugs $Petrie et
al , )**D2 and indi!iduals with cystic ?0rosis showed a signi?cant reduction in
hospital-days o!er a +-.onth period $%aylor et al , )**+2. #o.en with chronic
pel!ic pain reported reductions in pain intensity ratings $"or.an et al , )**D2
and poor sleepers reported shorter sleep-onset latency $'ar!ey A Harrell,
)**+2. Bene?ts ha!e also 0een found for post-operati!e course after
papillo.a resection $Solano et al , )**+2 and for pri.ary care patients
$Klapow et al , )**1F9idron et al , )**)2.
Box $
%edical conditions that might ene!t "rom expressi#e writing programmes
Jung functioning in asth.a
Disease se!erity in rheu.atoid arthritis
Pain and physical health in cancer
I..une response in 'I& infection
'ospitalisations for cystic ?0rosis
Pain intensity in wo.en with chronic pel!ic pain
Sleep-onset latency in poor sleepers
Post-operati!e course
"sychological conditions
@ther studies ha!e in!estigated e3pressi!e writing in preselected groups of
trau.a sur!i!ors and indi!iduals with speci?c psychological difculties, with
.i3ed results. Students with a trau.a history ha!e shown i.pro!e.ents in
physical health $9reen0erg et al , 1BBCF Sloan A 4ar3, )**D a2, post-trau.atic
stress disorder $P%SD2 sy.pto.atology and other aspects of psychological
health $Schoutrop et al , 1BB;, )**)F Sloan A 4ar3, )**D a2, although not all
studies ?nd 0ene?ts $Deters A (ange, )**+2.
Ji.ited 0ene?ts were o0tained for .ale psychiatric prison in.ates
$(ichards et al , )***2, !icti.s of natural disaster $S.yth et al , )**)2 and
indi!iduals who had e3perienced a recent relationship 0reakup $Jepore A
9reen0erg, )**)2.
,3pressi!e writing was 0ene?cial, 0ut not signi?cantly .ore so than control
writing, for fe.ales writing a0out 0ody i.age $,arnhardt et al , )**)2, children
of alcoholics $9allant A Jafreniere, )**+2, caregi!ers of children with chronic
illness $SchwartN A Drotar, )**D2, students screened for suicidality $Ko!ac A
(ange, )**)2 and indi!iduals who had e3perienced a 0erea!e.ent $(ange et
al , )***F @7:onnor et al , )**+2.
:o.pared with controls, e3pressi!e writing was detri.ental for adult
sur!i!ors of childhood a0use $Batten et al , )**)2 and for a s.all sa.ple of
eight &ietna. !eterans with P%SD $9idron et al , 1BBC2.
@ur re!iew of the literature shows that psychological health 0ene?ts tend to
0e .ore often found when participants7 trau.as andKor sy.pto.s are
clinically .ore se!ere, although results are inconsistent. @ne e3planation for
this inconsistency .ay 0e that .any of the studies with null ?ndings
instructed participants to write a0out the speci?c trau.atic e!ent they were
selected for, rather than using the standard instructions $Bo3 1Q2, which allow
the. to write a0out e!ents of their choosing. In studies where e3pressi!e
writing was 0ene?cial, .any participants wrote a0out topics other than their
particular physical illness or psychological pro0le., 0ut still showed
i.pro!e.ents in that area $S.yth A Penne0aker, 1BBB2.
Individual differences
In addition to studying speci?c health populations, researchers ha!e e3plored
!arious indi!idual di6erence indices to identify those su0groups for who.
e3pressi!e writing is .ost 0ene?cial. (esults ha!e 0een inconsistent.
&aria0les generally found to 0e unrelated to outco.e include age, trau.a
se!erity, 0aseline physical and psychological health le!els, negati!e
a6ecti!ity and .easures of inhi0ition and prior disclosure.
S.yth7s $1BB<2 .eta-analysis found that the e6ects were greater for .ales
than for fe.ales. ,3pressi!e writing is .ore 0ene?cial for those high in
ale3ithy.ia $PMeN et al , 1BBBF Baikie, )**+F Solano et al , )**+2 and high in
splitting $Baikie, )**+2, characteristics often seen in patients with
psychoso.atic disorders and 0orderline personality disorder respecti!ely,
suggesting potential for the use of e3pressi!e writing in these populations.
#onclusion
@!erall, studies e3a.ining e3pressi!e writing de.onstrate so.e 0ene?cial
e6ects in physical andKor psychological health. Although the e.pirical
?ndings are at ti.es e5ui!ocal and further research is re5uired to clarify
populations for who. writing is clearly e6ecti!e, there is sufcient e!idence
for clinicians to 0egin applying e3pressi!e writing in therapeutic settings with
caution. Indeed, Spiegel $1BBB2 noted that a drug inter!ention reporting
.ediu. e6ect siNes si.ilar to those found for e3pressi!e writing $S.yth,
1BB<2 would 0e regarded as a .a8or .edical ad!ance.
Pre!ious Section "e3t Section
$ow does it wor%!
Although the e3act .echanis. 0y which e3pressi!e writing confers health
0ene?ts is still unclear, there ha!e 0een a nu.0er of potential e3planations
$Bo3 DG2 $see also Sloan A 4ar3, )**D b2.
Box &
%echanisms y which expressi#e writing might work
,.otional catharsis/ nlikely
:onfronting pre!iously inhi0ited e.otions/ 4ay reduce physiological
stress resulting fro. inhi0ition, 0ut unlikely to 0e the only
e3planation
:ogniti!e processing/ It is likely that the de!elop.ent of a coherent
narrati!e helps to reorganise and structure trau.atic .e.ories,
resulting in .ore adapti!e internal sche.as
(epeated e3posure/ 4ay in!ol!e e3tinction of negati!e e.otional
responses to trau.atic .e.ories, 0ut so.e e5ui!ocal ?ndings
Emotional catharsis
%here is little support for the initial hypothesis that e3pressi!e writing
operates through a process of e.otional catharsis or !enting of negati!e
feelings. #riting only a0out the e.otions associated with a trau.a is not as
0ene?cial as writing a0out 0oth the e!ent and the e.otions $Penne0aker A
Beall, 1B<C2. Hurther.ore, e3pressi!e writing results in i..ediate increase in
negati!e a6ect rather than i..ediate relief of e.otional tension, and the
o0tained health 0ene?ts are unrelated to the a.ount of negati!e e.otion or
distress either e3pressed or reported 8ust after writing $S.yth, 1BB<2.
Emotional inhibition and confrontation
Penne0aker7s $1B<=2 theory proposed that acti!ely inhi0iting thoughts and
feelings a0out trau.atic e!ents re5uires e6ort, ser!es as a cu.ulati!e
stressor on the 0ody and is associated with increased physiological acti!ity,
o0sessi!e thinking or ru.inating a0out the e!ent, and longer-ter. disease.
:onfronting a trau.a through talking or writing a0out it and acknowledging
the associated e.otions is thought to reduce the physiological work of
inhi0ition, gradually lowering the o!erall stress on the 0ody. Such
confrontation in!ol!es translating the e!ent into words, ena0ling cogniti!e
integration and understanding of it, which further contri0ute to the reduction
in physiological acti!ity associated with inhi0ition and ru.inations
$Penne0aker, 1B<=2.
%his theory has intuiti!e appeal 0ut .i3ed e.pirical support. Studies ha!e
shown that e3pressi!e writing results in signi?cant i.pro!e.ents in !arious
0ioche.ical .arkers of physical and i..une functioning $Penne0aker et al ,
1B<<F ,sterling et al , 1BBDF Petrie et al , 1BB=F Booth et al , 1BB;2. %his
suggests that written disclosure .ay reduce the physiological stress on the
0ody caused 0y inhi0ition, although it does not necessarily .ean that
disinhi0ition is the causal .echanis. underlying these 0iological e6ects. @n
the other hand, participants writing a0out pre!iously undisclosed trau.as
showed no di6erences in health outco.es fro. those writing a0out pre!iously
disclosed trau.as $9reen0erg A Stone, 1BB)2 and participants writing a0out
i.aginary trau.as that they had not actually e3perienced, and therefore
could not ha!e inhi0ited, also de.onstrated signi?cant i.pro!e.ents in
physical health $9reen0erg et al , 1BBC2. %herefore, although inhi0ition .ay
play a part, the o0ser!ed 0ene?ts of writing are not entirely due to reductions
in inhi0ition.
&evelopment of a coherent narrative
A co.puterised te3t analysis syste., Jinguistic In5uiry and #ord :ount
$JI#:FPenne0aker et al , )**12, was speci?cally designed to deter.ine
whether certain linguistic .arkers .ight 0e associated with i.pro!e.ents in
health. %he JI#: progra. analyses the writing tasks 0y calculating the
percentage of words in the te3t .atching each of <) prede?ned language
categories. %he .ost consistent ?nding has 0een that, o!er the course of
writing, participants whose health i.pro!ed used .ore positi!e-e.otion
words, a .oderate nu.0er of negati!e-e.otion words and an increased
nu.0er of Ecogniti!e .echanis.7 words $the latter include insight words such
as understand,realise and causal words such as because, reason2
$Penne0aker, 1BB; b2.
%he su0se5uent suggestion that the 0ene?cial e6ect of e3pressi!e writing is
the de!elop.ent of a coherent narrati!e o!er ti.e, reRecting increasing
cogniti!e processing of the e3perience, is consistent with the literature on
trau.atic .e.ory and trau.a treat.ent $e.g. !an der Kolk et al , 1BBC2. In
addition, recent linguistic studies ha!e shown that session-to-session
!ariations in pronoun use are related to health i.pro!e.ents, which .ay
reRect a transfor.ation in the way people think a0out the.sel!es in relation
to others and the world $Penne0aker, )**)2.
#ognitive processing
4ore direct in!estigations of cogniti!e processing as a potential .echanis.
suggest that writing .ay help the writer to organise and structure the
trau.atic .e.ory, resulting in .ore adapti!e, integrated sche.as a0out self,
others and the world $'ar0er A Penne0aker, 1BB)2.
Although the cogniti!e processing hypothesis has 0een difcult to e!aluate
e.pirically owing to the difculty of .easuring cogniti!e changes, there is
e!idence that narrati!e for.ation and coherence are necessary for e3pressi!e
writing to 0e 0ene?cial $S.yth et al , )**12 and that e3pressi!e writing
increases working .e.ory capacity, which .ay reRect i.pro!ed cogniti!e
processing $Klein A Boals, )**12.
Exposure
%he e6ecti!eness of prolonged e3posure as a treat.ent for post-trau.atic
stress $Hoa A (oth0au., 1BB<2 led to the suggestion that the writing
paradig. .ay produce e3tinction of negati!e e.otional responses through
repeated writing a0out trau.atic .e.ories $Jepore et al , )**)2. %his
hypothesis has .et with .i3ed support. %here is so.e e!idence that
e3posure .ay underlie the e.otional health 0ene?ts of e3pressi!e writing
$Sloan A 4ar3, )**D aFSloan et al , )**=2. 'owe!er, .any participants 0ene?t
fro. writing regardless of whether they write a0out the sa.e trau.atic
e3perience or di6erent e3periences at each writing session. Hurther.ore,
writing sessions are usually considera0ly shorter than the D=>B* .inutes
dee.ed necessary to facilitate e.otional ha0ituation. So.e of the 0ene?ts of
e3pressi!e writing .ay 0e a result of repeated e3posure to negati!e
e.otional e3periences.
#onclusion
As can 0e seen, each of the proposed theories has supporting and
contradictory e!idence $Sloan A 4ar3, )**D b2. %he .echanis. of action
appears to 0e co.ple3, with the de.onstrated 0ene?ts potentially resulting
fro. so.e co.0ination of i..ediate cogniti!e andKor e.otional changes,
longer-ter. cogniti!e andKor e.otional changes, social processes and
0iological e6ects, rather than 0eing accounted for 0y any single factor
$Penne0aker, )**D2.
Pre!ious Section "e3t Section
$ow to use expressive writing as a therapeutic tool
,3pressi!e writing has pri.arily 0een in!estigated in carefully controlled
research settings, with results generalising well across la0oratories. 'owe!er,
gi!en its si.plicity, e3pressi!e writing appears to ha!e great potential as a
therapeutic tool in di!erse clinical settings or as a .eans of self-help, either
alone or as an ad8unct to traditional therapies $see also S.yth A 'el.,
)**+FPenne0aker, )**D2. Hor e3a.ple, pro.ising results ha!e 0een found
using e-.ail-0ased writing assign.ents $Sheese et al , )**D2, an internet-
0ased writing inter!ention for post-trau.atic stress $Jange et al , )***2 and
writing tasks for couples reco!ering fro. an e3tra.arital a6air $Snyder et al ,
)**D2.
In e3tending the paradig. to clinical settings, following as .uch of the
traditional protocol as possi0le will .ake it .ore likely that health 0ene?ts will
0e achie!ed $see also Batten, )**)2. Although there is no direct e!idence, it
has 0een suggested that the .ore structured approach of the e3pressi!e
writing paradig. is .ore 0ene?cial than si.ple diary-keeping $S.yth A
Penne0aker, 1BBB2. In addition, it see.s that incorporating 0oth the cogniti!e
and the e.otional co.ponents of the e3perience $i.e. thoughts and feelings2
is helpful $Penne0aker A Beall, 1B<CF S.yth A Penne0aker, 1BBB2.
Suggestions for using e3pressi!e writing in clinical or self-help settings are
gi!en in Bo3 =G.
Box '
(uggestions "or the clinical use o" expressi#e writing
,3pressi!e writing tasks can 0e set as ho.ework, or can 0e carried
out 0efore, during or after a session
#riting should 0e carried out in a pri!ate, personalised place, free
fro. distractions
#rite on three or four occasions, usually on consecuti!e days or
weeks
Set aside +* .inutes, with )* .inutes for writing and 1* .inutes
for patients to co.pose the.sel!es afterwards
se the writing instructions shown in Bo3 1Q
Jet the patient select a trau.aticKstressful e3perience/ do not
specify a particular trau.a or e!ent
Allow the patient to structure the writing rather than i.posing
structure
If possi0le, gi!e the patient the option to write 0y hand or on a
co.puter
,3plain to the patients that their writing is pri!ate, for the.sel!es
not for you and that con?dentiality and anony.ity are assuredF
e3plain that you will not read their writing unless they want you to
Do not gi!e feed0ack
#riting should 0e kept 0y the patient or separate fro. the clinical
?le
As the application of e3pressi!e writing outside of research settings is
relati!ely recent, it is reco..ended that clinicians collect so.e data to
assess its e6ecti!eness in their particular setting, including appropriate pre-
and post-writing .easures of physical health, psychological health or general
functioning $see Bo3 CG2.
Box )
*otes on expressi#e writing
As a clinical psychiatrist working in a pu0lic teaching hospital, I $K.#.2 ha!e
found e3pressi!e writing to 0e a useful addition to .y repertoire of short-ter.
psychological inter!entions for people who har. the.sel!es, in the .edical
wards and for out-patients with stress-related sy.pto.s, an3iety and
depression. I use it together with daily .ood charts, pro0le.-sol!ing, goal-
setting, rela3ation, .indfulness, e3ercise prescription and other inter!entions
that for. part of the Black Dog Institute7s general practitioner education
progra..e $for related screening .easures and infor.ation sheets follow the
pro.pt for :linician aids on the Institute7s we0site
at http/KKwww.0lackdoginstitute.org.au2.
I keep a series of e.pty 8ournals of di6erent colours $to o6er a choice2 and
ask patients to write on four occasions, following the instructions in Bo3 1Q.
%hey are told to write for the.sel!es and it is up to the. whether they want
to share the writing with anyone else. Jater, I gi!e so.e feed0ack on the
changes in writing $after linguistic analysis2, if re5uested.
#riting has helped people to resol!e longstanding issues a0out relationships
at ho.e and work, and to put into words feelings that ha!e 0een too sensiti!e
to descri0e face to face. So.e patients ha!e shown their writing to signi?cant
others and found this helpful.
(esearch suggests that writing .ay 0e .ore 0ene?cial for .en and, in .y
e3perience, .en ha!e certainly found it an accepta0le inter!ention.
%he writing is intended for patients to use as a short-ter. inter!ention to start
a process of dialogue with the.sel!es or to Eun0lock7 a difcult issue. It is not
intended to replace face-to-face interaction and is 0est done with a follow-up
appoint.ent for de0rie?ng.
As the whole point is to 0ring up issues that are e.otionally charged, it is
i.portant to work out the 0est ti.ing for the writing and to ha!e a
contingency plan if the patient 0eco.es distressed.
Hor so.e people the e3perience has 0een e3tre.ely helpful and has 5uickly
resol!ed issues that ha!e 0een .ulled o!er > so.eti.es for years > with no
resolution.
I encourage people to continue to use their 8ournals in whate!er way they
think 0est, and .ost do so.
Pre!ious Section "e3t Section
#autions and limitations
,3pressi!e writing is generally associated with an i..ediate increase in
negati!e a6ect, 0ut this short-ter. distress does not appear to 0e detri.ental
or to pose a longer-ter. risk to participants $'ocke.eyer et al , 1BBB2. 9i!en
the large nu.0er of studies conducted to date, with only a few ?nding any
worsening of sy.pto.s for those writing a0out trau.atic e3periences, the
e3pressi!e writing paradig. appears to 0e reasona0ly safe for participants,
e!en if no speci?c 0ene?ts are o0tained. 'owe!er, it is reco..ended that
patients 0e told that they can stop writing at any ti.e, should they wish, and
appropriate contact nu.0ers should 0e .ade a!aila0le in case of distress.
Patients should 0e encouraged to write for a .a3i.u. of )* .in at each
session, so that the task does not see. too o!erwhel.ing, although they .ay
choose to continue writing once the ti.e is up if they wish and if this is
feasi0le.
(egardless of the de.onstrated 0ene?ts of e3pressi!e writing, it should not
replace appropriate .edical or psychological treat.ent in clinical populationsF
it should 0e used as an ad8unct to standard treat.ent while further research
is 0eing conducted.
Pre!ious Section "e3t Section
M#'s
1.(uccess"ul outcome in expressi#e writing re+uires,
a. a correct state.ent of the facts
0. re!ealing su0conscious thought processes
c. 0eing a0le to discuss the writing with a signi?cant other
d. 0eing a0le to write freely for one7s self
e. !er0al e3pression of e.otion while writing.
2.-xpressi#e writing has een shown to lead to,
a. signi?cant i.pro!e.ent in lung function in asth.a
su6erers
0. i.pro!ed i..une response in 'I& patients
c. decreased ad.ission rates in cystic ?0rosis
d. i.pro!e.ents in 8oint sti6ness in rheu.atoid arthritis
e. i.pro!ed i..une response in glandular fe!er.
$..eople engaging in expressi#e writing are instructed to,
a. write 0y hand or on a co.puter
0. always play soft .usic while writing
c. answer a set of 5uestions pro!ided
d. write freely without worrying a0out gra..ar
e. think a0out a topic prior to the session.
&.-xpressi#e writing results in,
a. higher college grades for students
0. .ore e3ercise taken per week
c. higher rates of re-e.ploy.ent after redundancy
d. fewer !isits to the general practitioner or health centre
e. 0etter diet.
'.The instruction "or an expressi#e writing task should
include,
a. no.inating a particular ti.e of day
0. writing a0out Edeepest thoughts and feelings7
c. writing a0out the sa.e topic on each occasion
d. writing a0out a !ery trau.atic e3perience
e. speci?c instruction not to write at 0edti.e.