The universe is full of magical things patiently waiting for our wits to grow sharper.   Eden Phillpotts

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Introduction:  This is the first in a series of blog posts that aim to provide a brief, "state of the art" review of where 25 years of research on therapeutic writing has got us to so far.  These posts primarily focus on providing advice on evidence-based ways that individuals can use writing to reduce stress, improve physical health, and increase wellbeing.  The bulk of relevant research has flowered from Jamie Pennebaker's pioneering work on the benefits of expressive writing for emotional processing of difficulties and traumas (Smyth and Pennebaker 2008 - all research studies mentioned have abstracts listed further down this post).  However a series of other research groups have, more recently, developed writing applications that emerge from different understandings of what might also strengthen resilience and nourish wellbeing.  Examples I introduce - in addition to writing about traumas - include personal growth, dissonance theory, affirmation theory, self-transcendence, attachment applications, and positive psychology.  Usually these forms of therapeutic writing are done "privately" but, for some applications, sharing the writing - for example on the internet - can give additional benefits (Chretien, Goldman et al. 2008).

Speaking & writing:  It is also worth pointing out that, in the relatively few research studies comparing writing with talking, it's been shown that these two forms of "outer" expression can be similarly helpful (Esterling, Antoni et al. 1994;; Murray and Segal 1994) - in contrast to the typical unhelpfulness of "inner" rumination and worry.  If you're feeling creative this suggests fascinating ways in which conversations can be made highly beneficial - in therapy (Kelley, Lumley et al. 1997; Greenberg & Malcolm 2002), in couple relationships (Ditzen, Hoppmann et al. 2008; Suls, Green et al. 1997), in families, and between friends (Finkenauer and Rimé 1998).  This writing to speaking "translation" has become easier now we know more about the benefits achieved through focus on diverse topics (see later posts) like "best possible selves", "intense peak experiences", valued areas of our lives, and so on.  No doubt these effects of deeper conversations partly explain why close relationships are so important for health and wellbeing (Dickens, McGowan et al. 2004; Reis, Sheldon et al. 2000).  If you're feeling really creative, it's even possible to adapt some of these ideas into internal exercises as forms of imagery, prayer and meditation.

For more on therapeutic writing, see next week's "Writing (& speaking) for resilience & wellbeing 2: traumas & difficulties" and subsequent posts.

Chretien, K., E. Goldman, et al. (2008). "The reflective writing class blog: using technology to promote reflection and professional development." J Gen Intern Med 23(12): 2066-70.  [PubMed] 
INTRODUCTION: The hidden (informal) curriculum is blamed for its negative effects on students' humanism and professional development. To combat this, educational initiatives employing mentored reflective practice, faculty role-modeling, and feedback have been advocated. AIM: Promote reflection on professional development using collaborative, web-based technology. SETTING: Four-week basic medicine clerkship rotation at an academic institution over a one-year period. PROGRAM DESCRIPTION: Students were asked to contribute two reflective postings to a class web log (blog) during their rotation. They were able to read each other's postings and leave feedback in a comment section. An instructor provided feedback on entries, aimed to stimulate further reflection. Students could choose anonymous names if desired. PROGRAM EVALUATION: Ninety-one students wrote 177 posts. One-third of students left feedback comments. The majority of students enjoyed the activity and found the instructor's feedback helpful. Assessment of the posts revealed reflections on experience, heavily concerned with behavior and affect. A minority were not reflective. In some cases, the instructor's feedback stimulated additional reflection. Certain posts provided insight to the hidden curriculum. DISCUSSION: We have discovered that blogs can promote reflection, uncover elements of the hidden curriculum, and provide opportunities to promote professional development.

Dickens, C. M., L. McGowan, et al. (2004). "Lack of a close confidant, but not depression, predicts further cardiac events after myocardial infarction." Heart 90(5): 518-22.  [PubMed] 
OBJECTIVE: To assess the role of depression and lack of social support before myocardial infarction (MI) in determining outcome in a large representative sample of patients admitted after MI in the UK. DESIGN: Prospective cohort design. PATIENTS: 1034 consecutive patients were screened 3-4 days after MI. MAIN OUTCOME MEASURES: Mortality and further cardiac events over one year after an MI. RESULTS: At 12 months' follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p = 0.022). CONCLUSION: Lack of a close confidant but not depression before MI was associated with adverse outcome after MI in this sample. This association may be mediated by unhealthy behaviours and lack of compliance with medical recommendations, but it is also compatible with difficulties in early life leading to heart disease.

Ditzen, B., C. Hoppmann, et al. (2008). "Positive Couple Interactions and Daily Cortisol: On the Stress-Protecting Role of Intimacy." Psychosom Med 70(8): 883-889.  [Abstract/Full Text]  
Objective: To determine whether intimacy might be associated with reduced daily salivary cortisol levels in couples, thereby adding to the epidemiologic literature on reduced health burden in happy couples. Methods: A total of 51 dual-earner couples reported time spent on intimacy, stated their current affect quality, and provided saliva samples for cortisol estimation approximately every 3 hours in a 1-week time-sampling assessment. In addition, participants provided data on chronic problems of work organization. Results: Multilevel analyses revealed that intimacy was significantly associated with reduced daily salivary cortisol levels. There was an interaction effect of intimacy with chronic problems of work organization in terms of their relationship with cortisol levels, suggesting a buffering effect of intimacy on work-related elevated cortisol levels. Above this, the association between intimacy and cortisol was mediated by positive affect. Intimacy and affect together explained 7% of daily salivary cortisol variance. Conclusions: Our results are in line with previous studies on the effect of intimacy on cortisol stress responses in the laboratory as well as with epidemiologic data on health beneficial effects of happy marital relationships.

Esterling, B. A., M. H. Antoni, et al. (1994). "Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus antibody titers." Journal of Consulting and Clinical Psychology 62(1): 130-40.   [PubMed] 
Healthy Epstein-Barr virus (EBV) seropositive undergraduates (N = 57) completed a personality inventory, provided blood samples, and were randomly assigned to write or talk about stressful events, or to write about trivial events, during three weekly 20-min sessions, after which they provided a final blood sample. Individuals assigned to the verbal/stressful condition had significantly lower EBV antibody titers (suggesting better cellular immune control over the latent virus) after the intervention than those in the written/stressful group, who had significantly lower values than those in the written/trivial control group. Subjects assigned to the written/stressful condition expressed more negative emotional words than the verbal/stressful and control groups and more positive emotional words than the verbal/stressful group at each time point. The verbal/stressful group expressed more negative emotional words compared with the control group at baseline. Content analysis indicated that the verbal/stressful group achieved the greatest improvements in cognitive change, self-esteem, and adaptive coping strategies.

Finkenauer, C. and B. Rimé (1998). "Keeping Emotional Memories Secret : Health and Subjective Well-being when Emotions are not Shared." Journal of Health Psychology 3(1): 47-58.  [Abstract/Full Text]
The present study investigated two predictions derived from inhibition theory. It was hypothesized that emotional secrecy has a negative impact on (1) physical and (2) subjective well-being. Also, the study examined whether the relation holds when controlling for negative affectivity (NA), a variable that can be assumed to mediate the relation between emotional secrecy and physical and subjective well-being. Consistent with the hypothesis, emotional secrecy negatively affected physical health. This finding was not explained by NA, which contributed independently to physical health. Contrary to the prediction, emotional secrecy affected life satisfaction but indirectly through the mediating influence of physical health. The implications of these results for future research on emotional secrecy and physical and subjective well-being are discussed

Greenberg, L. S. and W. Malcolm (2002). "Resolving unfinished business: relating process to outcome." J Consult Clin Psychol 70(2): 406-16.  [PubMed]
This study related the process of the resolution of unfinished business with a significant other to therapeutic outcome in a population of 26 clients who suffered from various forms of interpersonal problems and childhood maltreatment. Clients were treated in emotion-focused, experiential therapy with gestalt empty-chair dialogues. Those clients who expressed previously unmet interpersonal needs to the significant other, and manifested a shift in their view of the other, had significantly better treatment outcomes. The presence of the specific process of resolution in the clients' empty-chair dialogues was also found to be a better predictor of outcome than the working alliance. Degree of emotional arousal was found to discriminate between resolvers and nonresolvers.

Kelley, J. E., M. A. Lumley, et al. (1997). "Health effects of emotional disclosure in rheumatoid arthritis patients." Health Psychology 16(4): 331-40.  [PubMed]
This study examined the effects of emotional disclosure of stressful events on the pain, physical and affective dysfunction, and joint condition of patients with rheumatoid arthritis (RA). Patients were randomly assigned to talk privately about stressful events (disclosure group, n = 36) or about trivial topics (control group, n = 36) for 4 consecutive days. Disclosure resulted in immediate increases in negative mood. At 2 weeks the 2 groups did not differ on any health measure, but at 3 months disclosure patients had less affective disturbance and better physical functioning in daily activities. There was no main effect of disclosure on pain or joint condition, but among the disclosure patients, those who experienced larger increases in negative mood after talking demonstrated improvements in the condition of their joints. This study concludes that, among RA patients, verbal disclosure and emotional processing of stressful life events induces an immediate negative mood followed by improved psychological functioning.

Murray, E. J. and D. L. Segal (1994). "Emotional processing in vocal and written expression of feelings about traumatic experiences." Journal of Traumatic Stress 7(3): 391-405.  [PubMed]
The purpose of this study was to compare vocal and written expression of feeling about interpersonal traumatic and trivial events in 20-min sessions over a 4-day period. Similar emotional processing was produced by vocal and written expression of feeling about traumatic events. The painfulness of the topic decreased steadily over the 4 days. At the end, both groups felt better about their topics and themselves and also reported positive cognitive changes. A content analysis of the sessions suggested greater overt expression of emotion and related changes in the vocal condition. Finally, there was an upsurge in negative emotion after each session of either vocal or written expression. These results suggest that previous findings that psychotherapy ameliorated this negative mood upsurge could not be attributed to the vocal character of psychotherapy.

Reis, H. T., K. M. Sheldon, et al. (2000). "Daily well-being: the role of autonomy, competence, and relatedness." Pers Soc Psychol Bull 26(4): 419-435.  [Abstract/Full Text] 
Emotional well-being is most typically studied in trait or trait-like terms, yet a growing literature indicates that daily (within-person) fluctuations in emotional well-being may be equally important. The present research explored the hypothesis that daily variations may be understood in terms of the degree to which three basic needs - autonomy, competence, and relatedness - are satisfied in daily activity. Hierarchical linear models were used to examine this hypothesis across 2 weeks of daily activity and well-being reports controlling for trait-level individual differences. Results strongly supported the hypothesis. The authors also examined the social activities that contribute to satisfaction of relatedness needs. The best predictors were meaningful talk and feeling understood and appreciated by interaction partners. Finally, the authors found systematic day-of-the-week variations in emotional well-being and need satisfaction. These results are discussed in terms of the importance of daily activities and the need to consider both trait and day-level determinants of well-being.

Smyth, J. M. and J. W. Pennebaker (2008). "Exploring the boundary conditions of expressive writing: In search of the right recipe." Br J Health Psychol 13(Pt 1): 1-7.  [PubMed]
This is a great introduction to the journals special section on "Boundary conditions of expressive writing" and its 19 associated articles.  What once appeared to be a straightforward intervention is turning out to be much more complex than initially thought.

Suls, J., P. Green, et al. (1997). "Hiding worries from one's spouse: associations between coping via protective buffering and distress in male post-myocardial infarction patients and their wives." J Behav Med 20(4): 333-49.  [PubMed] 
The relationship between protective buffering, a style of coping in which the individual hides his/her concerns from spouse, and level of distress was studied among post-myocardial infarction (MI) patients and their spouses. Forty-three male married MI survivors and their wives completed measures of psychological distress and protective buffering at 4 weeks and 6 months post-hospital discharge. At both time periods, a greater propensity for protective buffering by the patient was related to higher levels of patient distress. Protective buffering by wife was also associated with higher levels of wife distress. In addition, patient buffering at 4 weeks predicted increased patient distress at 6 months. The results suggest that male MI patients who conceal their worries from their spouses adjust more poorly over time.