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Harvard Medical School HEALTH BEAT, October 11, 2011

Writing about emotions may ease stress and trauma

Stress, trauma, and unexpected life developments — such as a cancer diagnosis, a car accident, or a layoff — can throw people off stride emotionally and mentally. Writing about thoughts and feelings that arise from a traumatic or stressful life experience — called expressive writing — may help some people cope with the emotional fallout of such events. But its not a cure-all, and it wont work for everyone. Expressive writing appears to be more effective for people who are not also struggling with ongoing or severe mental health challenges, such as major depression or post-traumatic stress disorder.

Testing the theory

Dr. James W. Pennebaker, currently chair of the psychology department at the University of Texas, Austin, has conducted much of the research on the health benefits of expressive writing. In one early study, Dr. Pennebaker asked 46 healthy college students to write about either personally traumatic life events or trivial topics for 15 minutes on four consecutive days. For six months following the experiment, students who wrote about traumatic events visited the campus health center less often, and used a pain reliever less frequently, than those who wrote about inconsequential matters.

Most studies have evaluated the impact of expressive writing on people with physical health conditions such as sleep apnea, asthma, migraine headaches, rheumatoid arthritis, HIV, and cancer. Likewise, most of the outcomes measured are physical, and the findings — such as blood pressure and heart rate — suggest that expressive writing initially may upset people but eventually helps them to relax.

More recently, researchers have evaluated whether expressive writing helps reduce stress and anxiety. One study found that this technique reduced stigma-related stress in gay men. Another found that it benefited chronically stressed caregivers of older adults. And a study by researchers at the University of Chicago found that anxious test-takers who wrote briefly about their thoughts and feelings before taking an important exam earned better grades than those who did not.

The standard format involves writing for a specified period each day about a particularly stressful or traumatic experience.

Participants usually write nonstop while exploring their innermost thoughts and feelings without inhibition (and the writing samples remain confidential for that reason). They may also use the exercise to understand how the traumatic event may revive memories of other stressful events.

Why writing may help

When Dr. Pennebaker and other researchers first started studying expressive writing, the prevailing theory was that it might help people overcome emotional inhibition. According to this theory, people who had suppressed a traumatic memory might learn to move beyond the experience once they expressed their emotions about it. But its not quite that simple. Instead, multiple mechanisms may underlie the benefits of expressive writing.

The act of thinking about an experience, as well as expressing emotions, seems to be important. In this way, writing helps people to organize thoughts and give meaning to a traumatic experience.

Or the process of writing may enable them to learn to better regulate their emotions. Its also possible that writing about something fosters an intellectual process — the act of constructing a story about a traumatic event — that helps someone break free of the endless mental cycling more typical of brooding or rumination.

Finally, when people open up privately about a traumatic event, they are more likely to talk with others about it — suggesting that writing leads indirectly to reaching out for social support that can aid healing.

Timing also matters. A few studies have found that people who write about a traumatic event immediately after it occurs may actually feel worse after expressive writing, possibly because they are not yet ready to face it. As such, Dr. Pennebaker advises clinicians and patients to wait at least one or two months after a traumatic event before trying this technique.

Even with these caveats, however, expressive writing is such an easy, low-cost technique — much like taking a good brisk walk — that it may be worth trying.

COPING WITH CANCER

Our Writing - It's Good For You

By Nancy Pierce Morgan, MA

I can handle the physical side of cancer, says a woman at a support group. Its the emotional side – worrying about my young daughters future – that is so hard. Feelings like this are frequently expressed by survivors, and for good reason. A cancer diagnosis presents unknowns in all aspects of life. Health, work, relationships, appearance, and identity are all called into question. The emotional burden of cancer can be overwhelming. Knowing how and when to express emotions and the benefits of self expression may help.

Habits of expression are shaped by family, culture, and circumstance. Many of us are taught to keep a stiff upper lip, to not dwell on problems. In the case of cancer, concerned family and friends may also be reluctant to discuss it. Yet people with cancer want to address all aspects of healing to ensure the best treatment outcome, and studies continually show that expressing feelings may contribute to good health.

How can cultural norms and family expectations be respected while finding relief from the emotional impact of cancer? Writing is one particularly accessible and tested method. Writing can be private, yet highly effective in helping people articulate thoughts and feelings about cancer find relief in communicating those feelings. Research suggests this relief may come in the form of improved sleep quality, reduced pain and symptom awareness, improved communication, and fewer doctor visits.

As an example of how many cancer centers incorporate therapeutic writing, at the Lombardi Comprehensive Cancer Center where I work, writing is introduced in several ways:

•weekly writing workshops

•the distribution of writing prompts

•research on writing and health

•the annual publication of Lombardi Voices, an anthology of writing by people with cancer and caregivers

•scheduled readings

•offering blank journals and information about writing benefits at the new-patient orientation

The expression of thoughts and feelings is encouraged as part of good health. Universal themes related to nature, family, and identity are introduced as catalysts for writing. Expressive writing is free of academic rules, competition, or critique. Writing a story from life experience, whether shared or kept private, can be cathartic and life-affirming. Positive feedback about the benefits of weekly writing from participants in writing programs at Lombardi was so consistent we decided to contribute to the growing body of evidence with our own study, published in The Oncologist.

Twenty years of research in controlled laboratory settings indicates writing may contribute to improved physical and emotional health. Our study moved research from the lab to the waiting room of a busy cancer clinic. We invited people with leukemia and lymphoma in our hospital waiting room to participate in the study. Participants completed surveys and responded to the question, How has cancer changed you, and how do you feel about those changes?

Study results suggest there may be a link between those who felt writing changed the way they thought about their cancer and an improved physical quality of life (reported weeks later in a followup interview). Most participants described a pattern of emotional change during their cancer experience, starting with the shock of diagnosis, then moving to acceptance, gratitude, and descriptions of life improvements in the areas of family, self-care, spirituality, and work. As one participant wrote, I dont like to talk about the cancer even though I feel like I should. Writing helps to get the feelings out of me.

Whether you use writing to take a break from cancer or to confront cancer directly, writing becomes a surprisingly effective tool for self expression and simply feeling better.

Try It!

•Write for a respite from cancer: Trees often figure prominently in childhood memories as a source of strength, beauty, shade, protection, or games. Write about a tree that was a part of your childhood and why it was important to you.

•Write to confront cancer: Answer the question, How has cancer changed you, and how do you feel about those changes?

•Reflect: After completing your writing exercise, reflect on how the writing makes you feel during, immediately after, and later that day.

Your thoughts and feelings about writing can help you decide if writing is a useful coping tool for you.

Nancy Morgan is a writing clinician and director of the Arts and Humanities program at Lombardi Comprehensive Cancer Center at Georgetown University in Washington, D.C.

This article was originally published in Coping® with Cancer magazine, March/April 2009.

THE ONCOLOGIST REFLECTIONS

Implementing an Expressive Writing Study in a Cancer Clinic

NANCY P. MORGAN, KRISTI D. GRAVES, ELIZABETH A. POGGI, BRUCE D. CHESON

Lombardi Comprehensive Cancer Center, Georgetown University and Georgetown University Hospital, Washington, DC, USA

Key Words. Expressive writing • Cancer clinic • Emotional disclosure • Feasibility • Leukemia • Lymphoma

Disclosure: No potential conflicts of interest were reported by the authors, planners, reviewers, or staff managers of this article.