Fear is the mind-killer ... I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.  Bene Gesserit "Litany against Fear" from "Dune" by Frank Herbert

You can access a downloadable Word format version of this post by clicking here  .

Last week I wrote "Writing (& speaking) for resilience & wellbeing 1: an introduction" which began this series of posts on different types of therapeutic writing.  It is 25 years since the first expressive writing study (Pennebaker & Beall 1986 - see below for abstracts & links to all research studies mentioned in this post) found that individuals who wrote about a personally traumatic life event for 15 minutes daily over four days had fewer health centre visits during the next six months than control participants who wrote about superficial topics.  Interest in this simple, potentially powerful intervention flourished - there have now been over two hundred research studies exploring the effects of different kinds of therapeutic writing.  Jamie Pennebaker's website lists many of these publications.  Fascinatingly it has been found that writing expressively about important aspects of our lives can strengthen our resilience to stress and boost our wellbeing.  These effects involve improvements in mood, problem-solving, relationships, immune function, wound healing, stress hormones, and vulnerability to illness. 

Over the years, I have lectured and taught many people this "focus on traumas and difficulties" form of therapeutic writing.  The website page "Life review, traumatic memories & therapeutic writing" provides links to a series of downloads that are relevant here.  See, for example, the dozen slides in "Power of words 1" and "Power of words 2", and the printable sets of how-to-do-it instructions "Therapeutic writing by Jamie Pennebaker" and "Therapeutic writing by James Hawkins".

Virtually all of us have "skeletons in our cupboards" - life experiences that we have found upsetting and possibly even traumatising.  As Mol, Arntz et al (2005) found "Life events can generate at least as many PTSD (posttraumatic stress disorder) symptoms as traumatic events".  Holding on to this material excessively can damage us - see for example research listed in "Self-concealment: background information".  The "Self-concealment scale" is an helpful window into this territory.  Try scoring yourself on this questionnaire.  It's been found that "A high tendency to conceal was associated with increased physical and psychological illness, even after allowing for the presence or absence of past trauma".  And past trauma is very common.  Probably most people suffering from anxiety and depression have earlier life traumas and difficulties that contribute to their current distressing symptoms.  See for example the eighteen slides listed in a presentation I gave a while ago - "Importance of traumatic memories 1", "Importance of traumatic memories 2" and "Importance of traumatic memories 3".  This sequence can be printed out as three (6 miniatures to a page) handouts. 

We all are likely to experience emotional reactions to events in our lives.  Ideally these emotions energise and guide us to respond adaptively.  Sadly this isn't always the case.  Our emotions sometimes seem excessive or inappropriate to the situation that triggers them.  This "inappropriateness" may indicate that emotional processing work might be helpful.  See for example the two-slide handout "Emotions, arriving & leaving" or the form "Understanding our reactions: self-monitoring" .  The therapeutic writing handouts already mentioned give suggestions on how to use writing to process such material.  There are also good books on the subject.  See, for example, Jamie Pennebaker's practical "Writing to Heal" or other helpful books listed on his website.

There's so much that I could write about all this.  However, now, I just want to make half a dozen more, brief points.  One is to highlight that, although this type of expressive writing usually focuses on past experiences, it can also be very helpful to write about current difficulties (Barclay & Skarlicki 2009; Graham, Lobel et al. 2008) or even about feared future events that haven't yet happened (Dalton & Glenwick 2009).  A second point is that a tendency to ruminate (Sloan, Marx et al. 2008) or worry (Goldman, Dugas et al. 2007) may well indicate that there is benefit to be had from this type of expressive writing.  Thirdly I'd emphasise that it's likely to be important to dig really deeply into our emotions & thoughts and, at least initially, to try to see the situation from how one actually experienced it at the time (Kuyken & Moulds 2009).  Fourthly - again with this particular form of trauma/difficulty-focused expressive writing - it may be sensible to write on a number of occasions about the same subject rather than chop and change too much (Sloan, Marx et al. 2005).  Fifthly I would take the usual "write continuously for 15 to 20 minutes on 3 to 4 consecutive days" instruction with a pinch of salt.  In fact writing for longer or shorter, less or more continuously, and at varied intervals between the writing sessions have all shown good effects (Smyth & Pennebaker 2008).  The standard instruction just happens to be the one that was used most frequently in research trials.  It's a good basic format to use, but optimal "dose", "frequency", and "number of sessions" in any given situation are all issues that aren't yet properly resolved.  Possibly a better way forward in exploring dose/frequency questions is by monitoring response using measures of continuing emotional upset and helpful/unhelpful beliefs and judgements.  And this is the sixth and final point.  Expressive writing focusing on trauma and difficulties is a great self-help method and stress management tool.  However with difficult traumas and problematic posttraumatic stress reactions it makes sense to see a therapist who is experienced in this kind of work.  Therapeutic writing as normally prescribed typically isn't "enough" in such situations (Smyth, Hockemeyer et al. 2008; Bugg, Turpin et al. 2009).  But as a self-help tool or component of therapy, expressive writing is well worth knowing about and trying out.  

Next week, I'll write about "Writing (& speaking) for resilience & wellbeing 3: personal growth" .

Barclay, L. J. and D. P. Skarlicki (2009). "Healing the wounds of organizational injustice: examining the benefits of expressive writing." J Appl Psychol 94(2): 511-23.  [PubMed]
Clinical and health psychology research has shown that expressive writing interventions-expressing one's experience through writing-can have physical and psychological benefits for individuals dealing with traumatic experiences. In the present study, the authors examined whether these benefits generalize to experiences of workplace injustice. Participants (N = 100) were randomly assigned to write on 4 consecutive days about (a) their emotions, (b) their thoughts, (c) both their emotions and their thoughts surrounding an injustice, or (d) a trivial topic (control). Post-intervention, participants in the emotions and thoughts condition reported higher psychological well-being, fewer intentions to retaliate, and higher levels of personal resolution than did participants in the other conditions. Participants in the emotions and thoughts condition also reported less anger than did participants who wrote only about their emotions.

Bugg, A., G. Turpin, et al. (2009). "A randomised controlled trial of the effectiveness of writing as a self-help intervention for traumatic injury patients at risk of developing post-traumatic stress disorder." Behaviour Research and Therapy 47(1): 6-12.  [Abstract/Full Text]
The study investigated the effects of writing and self-help information on severity of psychological symptoms in traumatic injury patients at risk for developing post-traumatic stress disorder (PTSD). Patients attending Accident and Emergency (A & E), were screened for Acute Stress Disorder and randomised to an information control group (n = 36) or a writing and information group (n = 31). Participants in both groups received an information booklet one-month post-injury. Participants in the writing group also wrote about emotional aspects of their trauma during three 20-min sessions, five to six weeks post-injury. Psychological assessments were completed within one month and at three and six months post-injury. There were significant improvements on measures of anxiety, depression and PTSD over time. Differences between groups on these measures were not statistically significant. However, subjective ratings of the usefulness of writing were high. In conclusion, the results do not currently support the use of writing as a targeted early intervention technique for traumatic injury patients at risk of developing PTSD.

Dalton, J. J. and D. S. Glenwick (2009). "Effects of expressive writing on standardized graduate entrance exam performance and physical health functioning." J Psychol 143(3): 279-92.  [PubMed] 
A substantial body of literature has demonstrated that expressive writing about an individual's deepest thoughts and feelings regarding a past or ongoing stressful experience results in a wide range of beneficial effects, including physical health and cognitive functioning. The authors examined the effects of writing about a future stressful experience - an impending graduate entrance exam - by comparing the exam performance and physical health functioning of participants who wrote about their deepest thoughts regarding the exam with those of participants who wrote about neutral and nonemotional topics. The experimental group reported a mean exam score that was significantly (19 percentile points) higher than that of the comparison group (i.e., the control group). The participants in the experimental group who wrote on 3 - compared with fewer - occasions experienced the greatest benefits. The authors propose possible causal mechanisms for the results and suggest future research questions and applications.

Goldman, N., M. J. Dugas, et al. (2007). "The impact of written exposure on worry: a preliminary investigation." Behav Modif 31(4): 512-38.  [PubMed]
The main goal of this study was to examine the effect of written exposure on generalized anxiety disorder (GAD)-related symptoms in high worriers. Thirty nonclinical high worriers were randomly assigned to either a written exposure condition or a control writing condition. Self-report measures were used to assess worry, GAD somatic symptoms, depression, and intolerance of uncertainty at four time points during the study. Using hierarchical linear modeling (HLM), the authors found that all symptoms (i.e., worry, GAD somatic symptoms, and depression) significantly decreased over time in the written exposure group (although GAD somatic symptoms also decreased in the control group). Moreover, consistent with previous findings that intolerance of uncertainty preceded changes in worry over the course of treatment, intolerance of uncertainty scores predicted subsequent scores on all symptom measures in the experimental group. In contrast, worry and depression scores predicted subsequent intolerance of uncertainty scores in the control group.

Graham, J. E., M. Lobel, et al. (2008). "Effects of written anger expression in chronic pain patients: making meaning from pain." J Behav Med 31(3): 201-12.  [PubMed]
Based on prior research demonstrating benefits of emotional disclosure for chronically ill individuals and evidence that anger is particularly problematic in chronic pain sufferers, outpatients from a chronic pain center (N=102) were randomly assigned to express their anger constructively or to write about their goals non-emotionally in a letter-writing format on two occasions. Letters were coded for degree of expressed anger and meaning-making (speculation and insight into conditions that precipitated anger). Over a 9 week period, participants in the anger-expression group (n=51) experienced greater improvement in control over pain and depressed mood, and marginally greater improvement in pain severity than the control group (n=51). Degree of expressed anger uniquely accounted for intervention effects and meaning-making mediated effects on depressed mood. These findings suggest that expressing anger may be helpful for chronic pain sufferers, particularly if it leads to meaning-making.

Kuyken, W. and M. L. Moulds (2009). "Remembering as an observer: how is autobiographical memory retrieval vantage perspective linked to depression?" Memory 17(6): 624-34.  [PubMed]
It has long been noted that the emotional impact of an autobiographical memory is associated with the vantage perspective from which it is recalled (Freud, 1950). Memories recalled from a first-person "field" perspective are phenomenologically rich, while third-person "observer" perspective memories contain more descriptive but less affective detail (Nigro & Neisser, 1983). Although there is some evidence that depressed individuals retrieve more observer memories than non-depressed individuals (e.g., Kuyken & Howell, 2006), little is known of the cognitive mechanisms associated with observer memories in depression. At pre- and post-treatment, 123 patients with a history of recurrent depression completed self-report measures and the autobiographical memory task (AMT). Participants also indicated the vantage perspective of the memories recalled on the AMT. Observer memories were less vivid, older, and more frequently rehearsed. The tendency to retrieve observer perspective memories was associated with greater negative self-evaluation, lower dispositional mindfulness, and greater use of avoidance. Furthermore, participants who recalled more field perspective memories at pre-treatment had lower levels of post-treatment depression, controlling for pre-treatment levels of depression and trait rumination. We apply contemporary accounts from social and cognitive psychology, and propose potential mechanisms that link the tendency to retrieve observer perspective memories to depression.

Mol, S. S., A. Arntz, et al. (2005). "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study." Br J Psychiatry 186: 494-9.  [PubMed] 
BACKGROUND: Post-traumatic stress disorder (PTSD) is the only psychiatric condition that requires a specific event to have occurred for its diagnosis. AIMS: To gather evidence from the adult general population on whether life events (e.g. divorce, unemployment) generate as many symptoms of post-traumatic stress as traumatic events (e.g. accidents, abuse). METHOD: Data on demographic characteristics and history of stressful events were collected through a written questionnaire sent to a random sample of 2997 adults. Respondents also filled out a PTSD symptom checklist, keeping in mind their worst event. Mean PTSD scores were compared, controlling for differences between the two groups. Differences in item scores and in the distribution of the total PTSD scores were analysed. RESULTS: Of the 1498 respondents, 832 were eligible for inclusion in our analysis. For events from the past 30 years the PTSD scores were higher after life events than after traumatic events; for earlier events the scores were the same for both types of events. These findings could not be explained by differences in demographics, history of stressful events, individual item scores, or the distribution of the total PTSD scores. CONCLUSIONS: Life events can generate at least as many PTSD symptoms as traumatic events. Our findings call for further studies on the specificity of traumatic events as a cause of PTSD.

Pennebaker, J. W. and S. K. Beall (1986). "Confronting a traumatic event: toward an understanding of inhibition and disease." Journal of Abnormal Psychology 95(3): 274-81.  [PubMed]
According to previous work, failure to confide in others about traumatic events is associated with increased incidence of stress-related disease.  The present study served as a preliminary investigation to learn if writing about traumatic events would influence long-term measures of health as well as short-term indicators of physiological arousal and reports of negative moods.  In addition, we examined the aspects of writing about traumatic events (i.e., cognitive, affective or both) that are most related to physiological and self-report variables.  Forty-six healthy undergraduates wrote about either personally traumatic life events or trivial topics on 4 consecutive days.  In addition to health center records, physiological measures and self-reported moods and physical symptoms were collected throughout the experiment.  Overall, writing about both the emotions and facts surrounding a traumatic event was associated with relatively higher blood pressure and negative moods following the essays, but fewer health center visits in the 6 months following the experiment.  Although the findings and underlying theory should be considered preliminary, they bear directly on issues surrounding catharsis, self-disclosure, and a general theory of psychosomatics based on behavioural inhibition.

Sloan, D. M., B. P. Marx, et al. (2005). "Further examination of the exposure model underlying the efficacy of written emotional disclosure." J Consult Clin Psychol 73(3): 549-54.  [PubMed] 
In the current study, the authors examined the effects of systematically varying the writing instructions for the written emotional disclosure procedure. College undergraduates with a trauma history and at least moderate posttraumatic stress symptoms were asked to write about (a) the same traumatic experience, (b) different traumatic experiences, or (c) nontraumatic everyday events across 3 written disclosure sessions. Results show that participants who wrote about the same traumatic experience reported significant reductions in psychological and physical symptoms at follow-up assessments compared with other participants. These findings suggest that written emotional disclosure may be most effective when individuals are instructed to write about the same traumatic or stressful event at each writing session, a finding consistent with exposure-based treatments.

Sloan, D. M., B. P. Marx, et al. (2008). "Expressive writing buffers against maladaptive rumination." Emotion 8(2): 302-6.  [PubMed]
This study examined whether ruminative style moderated the effects of expressive writing. Sixty-nine participants were assessed for ruminative style and depression symptoms at the beginning of their 1st college semester. Participants were then randomized to either an expressive writing or a control writing condition. Changes in depression symptoms were assessed 2, 4, and 6 months later. Results showed that a brooding ruminative style moderated the effects of expressive writing such that among those assigned to the expressive writing condition, individuals with greater brooding scores reported significantly fewer depression symptoms at all of the follow-up assessments relative to individuals with lower brooding scores. In contrast, reflective pondering ruminative style did not moderate the effects of expressive writing on depression symptoms. These findings suggest that expressive writing could be used as a means of reducing depression symptoms among those with a maladaptive ruminative tendency to brood.

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.

Smyth, J. M., J. R. Hockemeyer, et al. (2008). "Expressive writing and post-traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity." British Journal of Health Psychology 13: 85-93.  [Abstract/Full Article] 
Objectives: This study investigates the boundary conditions (feasibility, safety, and efficacy) of an expressive writing intervention for individuals with post-traumatic stress disorder [PTSD].  Design: Randomized trial with baseline and 3-month follow-up measures of PTSD severity and symptoms, mood states, post-traumatic growth, and (post-only) cortisol reactivity to trauma-related stress.  Methods: Volunteers with a verified diagnosis of PTSD (N=25) were randomly assigned to an experimental group (writing about their traumatic experience) or control group (writing about time management).  Results: Expressive writing was acceptable to patients with PTSD and appeared safe to utilize. No changes in PTSD diagnosis or symptoms were observed, but significant improvements in mood and post-traumatic growth were observed in the expressive writing group. Finally, expressive writing greatly attenuated neuroendocrine (cortisol) responses to trauma-related memories.  Conclusions: The present study provides insight into several boundary conditions of expressive writing. Writing did not decrease PTSD-related symptom severity. Although patients continue to exhibit the core features of PTSD, their capacity to regulate those responses appears improved following expressive writing. Dysphoric mood decreased after writing and when exposed to traumatic memories, participants' physiological response is reduced and their recovery enhanced.