By David Rakel, MD
The sorrow that hath no vent in tears may make other organs weep. — William Boyd, MD
We all have stories inside us about times in our lives that were fun, sad, and even scary. These stories are associated with emotions that can influence a cascade of physical events that can lead to laughter, tears, and even a reduction in immune function. It seems that nature gave us two ears and one mouth to be used in that proportion because simply listening to someone’s story can be our most valuable therapeutic tool.
When people put their emotional upheavals into words, either through writing or talking, their physical and mental health improves. James Pennebaker, PhD, has spent most of his career researching this process. He has explained how communities come together and open up after a stressful event resulting in an overall improvement in health.1 After 9/11, the people of the city of New York had fewer visits to health care providers. This tragic event opened people up and stimulated communication that fostered relationships and a sense of community. The words they used in their speech and writing switched to include less use of the ego-centered "I" to a more communal use of "we." This event brought the community together and reduced social isolation in part by allowing them to express their emotions.
This process happens naturally in the first 2-3 weeks after a tragic event. This is called the emergency phase—when people and the media open up and discuss the event openly. About three weeks after the event, the amount of discussion significantly declines even though emotions and thoughts remain. (See Figure.) It is at this time, called the inhibition phase, when thoughts remain but no one is talking about it that we may want to encourage continued emotional expression.
It is interesting to see how this process unfolds in communities, but how might this process of disclosure help us facilitate better health for our individual patients?
A Look at the Research
The expression of emotionally upsetting experiences by writing or talking has been found to improve physical health, enhance immune function, and result in fewer medical visits.2 It appears that suppressing the expression of emotions may have negative consequences. For example, there was an increase in the incidence of infectious disease and cancer in gay men who concealed their homosexual identity when compared to those who were open.3
Memory Function. Writing about emotional events may enhance cognitive function and memory. College freshman at North Carolina State University who were assigned to write about their thoughts and feelings about coming to school showed an enhancement of working memory after seven weeks compared to those who wrote about trivial topics. Another group in the same study that wrote about negative emotions not only had improved memory but less intrusive thinking. They were better able to focus on their studies.4 Other research has linked writing to higher grades in college.5,6
Getting a Job. A group of senior-level engineers who wrote about the emotions of being laid off were more likely to find new jobs quicker than those who did not write.7 The writing allowed them to address the anger, deal with it, and move on. The authors concluded that this work allowed them to present a more positive interview when looking for a job.
Asthma and Rheumatoid Arthritis. Writing about past stressful life experiences has been found to result in symptom reduction in patients with asthma and rheumatoid arthritis. One hundred and seven patients with these diseases were assigned to write either about the most stressful event of their lives (study group) or about daily events (control group) for 20 minutes over three consecutive days.8 Four months following journaling the asthma patients in the treatment group showed a 20% improvement in lung function vs. no improvement in the control group. The patients with rheumatoid arthritis who wrote about stressful events showed a 28% reduction in disease severity; the control group showed no change. These are excellent clinical outcomes requiring only paper, pencil, and 60 minutes of the patient’s time.
Wound Healing. A similar study design showed that patients who wrote about emotional events experienced quicker wound healing compared to those who wrote about trivial topics such as time management.9 In the second week after writing for 20 minutes a day for three days, subjects were given a punch biopsy in their upper arm. Those who wrote about traumatic events had significantly smaller wounds 14 days after the puncture.
Writing may not always work by itself, and there are certain situations in which it should be avoided. Those who have difficulty with cognitive processing, such as children, may not benefit. One study evaluated children ages 8-13 to see if writing about negative events, non-emotional events, or not writing at all would have an impact on mental health, school attendance, and performance.10 There was no significant benefit in those who wrote about emotional events in this age group. There also was no benefit found in older adults who were depressed and bereaving the loss of a loved one in a large-scale study in the Netherlands.11 In patients with post-traumatic stress disorder, those who wrote about their traumas did slightly worse than controls. Writing may not benefit patients if they have not received coping-skills training. It would appear that we should not encourage exploration of these events if the patient is not prepared to deal with them when they arise.12
How Does Disclosure Improve Health?
In attempting to understand the pathophysiology behind the positive clinical effects of disclosure we can return to Pennebaker’s research. He interviewed polygraphers (operators of lie detectors) who worked for the FBI and CIA. In doing these tests the polygraphers would look for changes in parameters of the autonomic nervous system (ANS), such as heart rate, blood pressure, respiratory rate, and skin conductance, for clues of validity. He described what was called the polygraph confession effect where readings in these areas significantly dropped after a person confessed. These changes were consistent with those seen with relaxation. It is thought that to actively inhibit one’s thoughts, feelings, and behaviors requires physical work—work that can result in a chronic low-grade stress to the autonomic nervous system and may result in disease.13 This inhibition also can lead to dysregulation of the hypothalamic-pituitary-adrenal axis (HPA) that results in hypercortisolemia and immune suppression.14
Disclosing stressful events transfers repressed thoughts from the unconscious to the conscious level where they can be organized and controlled. This removes the need for chronic low-grade stress to stimulate the ANS and the HPA that can lead to disease and somatic symptoms. When our mind stores a stressful event, it is not organized and stored as a concrete thought, but a chaotic accumulation of a multitude of images, sensations, and emotions. Disclosing allows our mind to interpret this new information from the subconscious, unlocking emotions that can stimulate positive physical results. It is the process of organizing chaotic thoughts, allowing us to interpret and evaluate the stressor. In doing so, the chronic somatic stress improves.15
Simply making the connection between how our mind’s stressors can influence our physical health may be the main ingredient to the healing effects of disclosure. A quote by Lord Chesterfield describes this well: "I find, by experience, that the mind and the body are more than married, for they are most intimately united; and when one suffers, the other sympathizes."
John Sarno, MD, professor of clinical rehabilitation medicine at New York University School of Medicine, has found success in helping people overcome chronic myofascial pain by educating them about this mind-body connection. Once they develop the insight into how the stress in their lives can influence their physical pain, their symptoms improve because the body no longer needs to sympathize.16
Analyzing the Writing
James Pennebaker and colleagues are now focusing their research on the stories that people write and how the words they use are related to health. Through the use of a computer program they were able to analyze writing and come to important conclusions.
Those who had the greatest health benefits had the following characteristics in their writing.17,18
• The person constructed an evolving story. Those who created a story with a beginning, middle, and an end did better than those who wrote the same story day after day. Creating a story where the writing related a transition in insight to a greater understanding of what the event meant for them resulted in better health than those who simply told the same event without change or transformation.
• The person developed insight and used more causal words (e.g., realize, understand).
• The person developed more optimism (greater use of positive words and moderate use of negative words).
• As the story evolved, pronouns changed from first person singular (I, me, my) to second person pleural (we, us), suggesting that with writing they became less isolated and more connected to their community.
How to Do It
Providing an avenue for expressing repressed emotions can take many forms. It appears that writing and talking about stressful events have similar benefits.19 Using journaling can be an inexpensive way to have a positive influence on health if the patient is ready to do so. No one has to read what is written, and what is written need not be kept. The therapeutic process comes from the writing itself (see Table).
Table: How to journal
Source: Rakel DP, Shapiro D. Mind Body Medicine, Textbook of Family Practice. 6th ed. Philadelphia, PA: W.B Saunders; 2002:56.
Dose and Duration of Effect
The reason many of the studies have used 15-20 minutes of writing daily for three days is because this is the amount of time the researchers were able to reserve a room to conduct the earlier studies. It is nice to see that this small investment in time results in significant health benefits, but this therapeutic tool certainly can be used more often if needed.
If journaling is done once daily for 3-4 consecutive days, the positive effects appear to last for 4-8 months.
Risks and Precautions
It is important to keep in mind that the process of disclosure may improve physical but not always mental health.17 Our minds suppress these traumatic events for a reason and uncovering them can be difficult for the conscious mind to handle, especially in children. In many cases, it is important to work closely with a licensed therapist so the patient can continue to heal from this expression if needed.
Timing of disclosure also is important. When the body-mind is ready to deal with repressed emotions, it generally has a way of letting us know. Danger comes in encouraging someone to write or express emotions when they are not ready to do so.
In helping others explore emotions of past events, it is important to avoid the process of creating guilt. There is little evidence to show that traumatic events in our lives, or repressing them, can increase the risk of a disease such as cancer. It is important that we don’t create this association but simply learn how these events can help us improve our future health.
The primary care provider is in an ideal position to help patients heal through disclosure since people are more likely to discuss these stressful events with someone who is accepting and whom they trust.20 The most important aspect of relationship-centered care is that we provide an environment where the patient feels comfortable exploring issues that allow us to get at the root of what can influence long-term health. In doing this, whatever tool we use, be it journaling or counseling, will work better because our patients will have a connection with someone they feel comfortable telling their deepest and most meaningful stories. In listening, we may heal just as much as they do.
Creating a space where patients feel comfortable telling their story, can be one of the most important therapeutic tools we offer. Bringing these emotions into the consciousness through writing, talking, or the expression of art often can result in significant symptomatic relief. This is one of the most powerful examples of self-healing we see in the practice of medicine. When our patients are ready for this to take place, we should be prepared to help them through this challenging process of disclosure so it can result in improved health.
Dr. Rakel is Director, Integrative Medicine, Department of Family Medicine, University of Wisconsin Medical School, Madison, WI.
1. 2003 Integrative Health-Care Conference. Green Lake, WI; Sept. 11-13, 2003.
2. Berry DS, Pennebaker JW. Nonverbal and verbal emotional expression and health. Psychother Psychosom 1993;59:11-19.
3. Cole SW, et al. Elevated physical health risk among gay men who conceal their homosexual identity. Health Psychol 1996;15:243-251.
4. Klein K, Boals A. Expressive writing can increase working memory capacity. J Exp Psychol Gen 2001;130:520-533.
5. Pennebaker JW, Francis M. Cognitive, emotional and language processes in disclosure. Cognition Emotion 1996;10:601-626.
6. Cameron LD, Nicholls G. Expression of stressful experiences through writing: Effects of a self-regulation manipulation for pessimists and optimists. Health Psychol 1998;17:84-92.
7. Spera SP, et al. Expressive writing and coping with job loss. Acad Management J 1994;37:722-733.
8. Smyth JM, et al. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. JAMA 1999;281: 1304-1309.
9. Banburey CL. Wounds heal more quickly if patients are relieved of stress: A review of research by Susanne Scott and colleagues from King’s College, London. Presented at the Annual Conference of the British Psychological Society. BMJ 2003;327:522.
10. Reynolds M, et al. Emotional disclosure in school children. J Child Psychol Psychiatry 2000;41:151-159.
11. Stroebe M, Stoebe W. Writing Assignments and Grief. Paper presented at The (Non) Expression of Emotions and Health Disease Conference; Tilburg, The Netherlands; 1996.
12. Gidron Y, et al. Written disclosure in posttraumatic stress disorder: Is it beneficial for the patient? J Nervous Mental Dis 1996;184:505-507.
13. Pennebaker JW. Opening Up: The Healing Power of Expressing Emotions. New York: The Guilford Press; 1997.
14. Kiecolt-Glaser JK, et al. Marital stress: Immunologic, neuroendocrine, and autonomic correlates. Ann N Y Acad Sci 1998;840:656-663.
15. Rakel DP. Integrative Medicine. Philadelphia, PA: W.B. Saunders; 2003:723-726.
16. Sarno JE. Healing Back Pain: The Mind-Body Connection. New York: Warner Books; 1991.
17. Pennebaker JW, et al. Linguistic predictors of adapt-ive bereavement. J Personal Soc Psychol 1997;72: 863-871.
18. Pennebaker JW. Pain, Language, and Healing. Biofeedback Society of Wisconsin 2003 Integrative Health-Care Conference. Green Lake, WI; Sept. 11-13, 2003.
19. Donnelly DA, Murray EJ. Cognitive and emotional changes in written essays and therapy interviews. J Soc Clin Psychol 1991;10:334-350.
20. Fox SG, et al. Perceptions of therapist disclosure of previous experience as a client. J Clin Psychol 1984; 40:496-498.