How Expressive Writing Works
What we know (and don't know).
Posted Nov 08, 2020
A recent New York Times article with the provocative title ‘How to be happy’ listed a number of steps to increase this elusive state (1). They were divided into categories of improving the home environment, relationships, and one’s internal life. Among the suggestions were to minimize negative thinking, exercise, use controlled breathing, practice optimism, and ‘rewrite your story’. I was struck by this latter thought, given the increasing number of reports indicating that expressive writing may improve performance during stress (2), reduce a sense of trauma and improve ‘general psychological health’ in caregivers (3), as well as benefit depressive symptoms in childhood PTSD and persons with maladaptive rumination, or affective pain in rheumatoid arthritis (4). Though clearly not a panacea (it has shown little benefit in depression among breast cancer survivors, quality of life in COPD patients, or migraine symptoms), it raises the possibility that in some situations writing about one’s experience can be helpful. In this post let’s explore therapeutic writing and mood.
How is it done? In expressive writing, the emphasis is not so much on what has happened, but rather on what it felt like. There have been various formulations of expressive writing, but typically a person sets aside 20 minutes a day for perhaps four days. The goal is to express feelings as spontaneously as possible, without regard to the need for a storyline or worrying about punctuation, and to write for oneself, not others (5). Narrative writing, in contrast, emphasizes the events which actually happened. This can take the form of a kind of written exposure therapy for trauma patients, or just trying to develop a consistent narrative which seems to make sense of a person’s unhappy experiences. It can then involve re-writing the experience in a way which produces a more favorable outcome.
How effective is it? In general, the reports of therapists using writing therapies have been very positive. There are some data that writing about past negative experiences can reduce the stress response and inattention from a subsequent stressful experience (2). Looking at systematic studies with various control groups, both strengths and some limitations should probably be recognized, though. In college students with ‘both elevated prior depressive symptoms and low current depressive symptoms’, those with higher scores on the suppression scale of the emotion regulation questionnaire had a reduction in rumination and depressive symptoms after expressive writing (6).
Most studies have not looked at persons with major depressive disorders. Rather, the emphasis has been on trauma, chronic stress, or medical illness. Interestingly, the benefit is often independent of the symptom of depressed mood per se. In the study of caregivers mentioned earlier, for instance, written expressive therapy reduced symptoms of trauma and improved general psychological health without specifically reducing measures of depression or anxiety (3). Similarly, in a study of patients with renal cell carcinoma, expressive writing reduced overall reports of cancer symptoms without altering measures of fatigue, sleep, or depression (7). In patients in a palliative care setting, there were no benefits found (8), which could reflect both the limited data available as well as the possibility that at some point the overwhelming nature of an illness may challenge self-expression.
How does it work? There is no shortage of theoretical ways by which expressive writing might be therapeutic, and it seems likely that more than one may be involved, or that different ones may apply to different individuals. The most obvious is catharsis, the relief thought to come from releasing internalized negative feelings (9). It has been speculated that writing about past unhappy events makes more cognitive resources available for new challenges. Another possibility is that writing something down takes a degree of focus which is incompatible with ruminations. Yet another is that the act of writing involves a kind of cognitive activity that re-formulates traumatic memories in a manner more susceptible to making connections with past experiences and putting them into context. To the degree that the writing forms a narrative out of the troubling experience, it also opens the door to re-writing the narrative with a more positive outcome.
In summary, writing therapy has been found beneficial in a number of conditions, particularly in the setting of chronic stress, trauma, and some medical conditions. One of its intriguing qualities is that in some situations it improves overall well-being or medical symptoms without specific changes in measures of depression. Studies have not always distinguished the relative roles of writing about feelings and the development of a narrative and their relative roles in the therapeutic process.
There is much to be learned, then, about the promise as well as limitations of therapeutic writing. There has been remarkable persistence in interest in it since its modern formulation in the late 1880s and 1990s (9), perhaps because it makes intuitive sense and appeals to the more general theme in much of psychotherapy suggesting that the importance of expressing inner feelings. There is much to be said for the ease with which it can be administered, leading to the possibility that it might be a useful tool in primary care as well (4). There are also many things we need to learn. One is the relative importance of bringing out emotional content and the development of a narrative, and whether this varies with the individual. Another is whether expressive writing has benefits similar to airing these thoughts orally, or whether there is something additionally gained from the cognitive processes involved in putting down the written word.
1. Tara Parker-Pope: How to be happy. New York Times, October 8, 2020. https://www.nytimes.com/interactive/2017/well/mind/well-happiness-guide.html?referringSource=articleShare
2. Dimenichi, B.C. et al.: Writing about past failures attenuates cortisol responses and sustained attention deficits following psychosocial stress. Front. Behav. Neurosci. 23;12:45, 2018. https://pubmed.ncbi.nlm.nih.gov/29628878/
3. Riddle, J.P.; Smith, H.E.; and Jones, C.J.: Does written emotional disclosure improve the psychological and physical health of caregivers? A systematic review and meta-analysis. Behavior Research and Therapy 80:23-32, 2016.
4. Mugerwa, S. and Holden, J.D.: Writing therapy: a new tool for general practice? Brit. J. General Practice. 62: 661-663, 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505408/
5. Evans, J.F.: Expressive Writing. Psychology Today. August 15, 2012. https://www.psychologytoday.com/us/blog/write-yourself-well/201208/expressive-writing
6. Gortner, E-M, Rude, S.S. and Pennebaker, J.W.: Benefits of expressive writing in lowering rumination and depressive symptoms. Behavior Therapy 37: 292-303, 2006. https://www.sciencedirect.com/science/article/abs/pii/S0005789406000487
7. Milbury, K. et al.: Randomized controlled trial of expressive writing for patients with renal cell carcinoma. J. Clin. Oncology 32: 663-670, 2014. https://ascopubs.org/doi/full/10.1200/JCO.2013.50.3532
8. Kupeli, N. et al.: Expressive writing as a therapeutic intervention for people with advanced disease: a systematic review. BMC Palliative Care 18: 65, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676535/.
9. Pennebaker, J.W.: Writing about emotional experiences as a therapeutic process. Psychol. Sci. 18:62, 1997. https://scholar.google.com/scholar_lookup?journal=Psychol+Sci&title=Writing+about+emotional+experiences+as+a+therapeutic+process&author=JW+Pennebaker&volume=18&issue=3&publication_year=1997&pages=62-166&