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Emotional and Physical Health Benefits of Expressive Writing Karen A Baikie & Wilhelm Advances in Psychiatric Treatment (2005), vol. 11, 338–346 Emotional and physical health benefits of expressive writing Karen A. Baikie & Kay Wilhelm Abstract Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations. In the expressive writing paradigm, participants are asked to write about such events for 15–20 minutes on 3–5 occasions. Those who do so generally have significantly better physical and psychological outcomes compared with those who write about neutral topics. Here we present an overview of the expressive writing paradigm, outline populations for which it has been found to be beneficial and discuss possible mechanisms underlying the observed health benefits. In addition, we suggest how expressive writing can be used as a therapeutic tool for survivors of trauma and in psychiatric settings. Over the past 20 years, a growing body of literature emotional experiences (Box 1) for 3–5 sessions, often has demonstrated the beneficial effects that writing over consecutive days, for 15–20 minutes per session. about traumatic or stressful events has on physical Most studies have been conducted in the laboratory, and emotional health. In the first study on expressive writing (Pennebaker & Beall, 1986), college students wrote for 15 minutes on 4 consecutive days about ‘the most traumatic or upsetting experiences’ of their Box 1 Typical writing instructions entire lives, while controls wrote about superficial For the next 4 days, I would like you to write topics (such as their room or their shoes). Parti- your very deepest thoughts and feelings about cipants who wrote about their deepest thoughts and the most traumatic experience of your entire life feelings reported significant benefits in both or an extremely important emotional issue that objectively assessed and self-reported physical has affected you and your life. In your writing, health 4 months later, with less frequent visits to the I’d like you to really let go and explore your health centre and a trend towards fewer days out of deepest emotions and thoughts. You might tie role owing to illness. The authors concluded that: your topic to your relationships with others, ‘writing about earlier traumatic experience was including parents, lovers, friends or relatives; associated with both short-term increases in physio- to your past, your present or your future; or to logical arousal and long-term decreases in health who you have been, who you would like to be or problems’ (Pennebaker & Beall, 1986: p. 280). who you are now. You may write about the same general issues or experiences on all days of Expressive writing studies writing or about different topics each day. All of your writing will be completely confidential. The basic writing paradigm (Pennebaker, 1994, Don’t worry about spelling, grammar or sen- 1997a, 1997b; Smyth & Pennebaker, 1999) used in tence structure. The only rule is that once you most of the subsequent expressive writing studies begin writing, you continue until the time is up. involves participants writing about traumatic or Karen Baikie is a clinical psychologist and postdoctoral research fellow with the Black Dog Institute and School of Psychiatry, University of New South Wales (Black Dog Institute, University of New South Wales, The Villa, Prince of Wales Hospital, Randwick NSW 2031, Australia. E-mail: [email protected]). She completed her PhD in the use of expressive writing in the Department of Psychology, Macquarie University, Sydney. Her interests are in the application of expressive writing for different clinical populations and in working therapeutically with survivors of trauma, as well as general adult clinical psychology. Kay Wilhelm is a consultant psychiatrist in consultation liaison psychiatry at St Vincent’s Hospital, Sydney, and the Mood Disorders Unit, Black Dog Institute, where she is also project leader for the General Practitioner Education Program. She is a clinical Associate Professor at the University of New South Wales. She has a long-standing interest in depression, especially gender issues and psychosocial risk factors, brief psychotherapy for depression and self-harm, as well as primary care and general hospital psychiatry. K.B. is supported by National Health and Medical Research Council Program Grant 222708. 338 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/ Health benefits of expressive writing although more recently writing has been done at Box 2 Longer-term benefits of expressive home or in a clinical setting. Participants often reveal writing a considerable range and depth of emotional trauma in their writing. Although many report being upset Health outcomes by the writing experience, they also find it valuable • Fewer stress-related visits to the doctor and meaningful (Pennebaker, 1997b). Control partici- • Improved immune system functioning pants are asked to write as objectively and factually • Reduced blood pressure as possible about neutral topics such as a particular • Improved lung function room or their plans for the day, without revealing • their emotions or opinions. No feedback is given on Improved liver function the writing. • Fewer days in hospital Owing to the nature of APT, study results dis- • Improved mood/affect cussed below are not exhaustively referenced; • Feeling of greater psychological well-being instead, we have tried to give the most representative • Reduced depressive symptoms before exam- or comprehensive publications. For further reading inations on expressive writing and its implementation we • Fewer post-traumatic intrusion and avoid- recommend Lepore & Smyth (2002), Pennebaker ance symptoms (1997a,b) and Sloan & Marx (2004b). Social and behavioural outcomes • Reduced absenteeism from work Immediate and longer-term • Quicker re-employment after job loss effects of expressive writing • Improved working memory • Improved sporting performance The immediate impact of expressive writing is • Higher students’ grade point average usually a short-term increase in distress, negative • Altered social and linguistic behaviour mood and physical symptoms, and a decrease in positive mood compared with controls. Expressive writing participants also rate their writing as signifi- cantly more personal, meaningful and emotional. about emotional topics changed the way that However, at longer-term follow-up, many studies participants interacted with others, suggesting that have continued to find evidence of health benefits writing may also have an impact on objectively in terms of objectively assessed outcomes, self- assessed social and linguistic behaviour (Pennebaker reported physical health outcomes and self-reported & Graybeal, 2001). emotional health outcomes (Box 2). Self-reported physical health outcomes Objectively assessed outcomes Expressive writing also produces longer-term Expressive writing results in significant improve- benefits in self-reported health outcomes such as ments in longer-term physical health outcomes such visits to the doctor (Cameron & Nicholls, 1998), as illness-related visits to the doctor (Pennebaker & physical symptoms (Park & Blumberg, 2002) and Beall, 1986; Pennebaker et al, 1988; Pennebaker number of days out of role because of illness & Francis, 1996; King & Miner, 2000), blood pressure (Pennebaker & Beall, 1986; Smyth et al, 2001). (Davidson et al, 2002, citing Crow et al), lung function In general, expressive writing does not affect (Smyth et al, 1999), liver function (Francis & health-related behaviours such as exercise, diet or Pennebaker, 1992) and number of days in hospital drug/alcohol use (Pennebaker et al, 1988). (Norman et al, 2004). Expressive writing has also produced significant benefits in a number of measures Self-reported emotional health outcomes of immune system functioning (Pennebaker et al, 1988; Esterling et al, 1994; Booth et al, 1997; Petrie et al, 1995, Some studies have also found longer-term benefits of 2004). expressive writing for emotional health outcomes, Significant benefits have also been found for such including mood/affect (Pennebaker et al, 1988; Páez objective outcomes as students’ grade point average et al, 1999), psychological well-being (Park & Blum- (Pennebaker & Francis, 1996; Cameron & Nicholls, berg, 2002), depressive symptoms before examinations 1998), absenteeism from work (Francis & Pennebaker, (Lepore, 1997) and post-traumatic intrusion and 1992), re-employment after job loss (Spera et al, 1994), avoidance symptoms (Klein & Boals, 2001). How- working memory (Klein & Boals, 2001) and sporting ever, the findings for emotional health are not as performance (Scott et al, 2003). In addition, writing robust or as consistent as those for physical health. Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/ 339 Baikie & Wilhelm Meta-analyses that patients with cancer reported benefits such as better physical health, reduced pain and reduced A meta-analysis of 13 studies using expressive need to use healthcare services (Rosenberg et al, 2002; writing with healthy participants (Smyth, 1998) Stanton & Danoff-Burg, 2002), although others failed found a significant overall benefit (d = 0.47, to find any benefits (Walker et al, 1999; de Moor et al, P<0.0001) and specific benefits in objective or self- 2002). Patients with HIV infection showed improved reported physical health, psychological well-being, immune response similar to that seen
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