Taking Pen to Hand: Evaluating Theories ... - Wiley Online Library

Taking Pen to Hand: Evaluating Theories Underlying the Written Disclosure Paradigm Denise M. Sloan and Brian P. Marx, Temple University

In recent years the written disclosure paradigm has been related to improvements in physical health in a number of populations. However, it still remains unclear why this paradigm is effective. In this paper the literature on the written disclosure paradigm is reviewed, and possible explanations for its beneficial effects are explored. It is concluded that, although the paradigm may produce beneficial effects for some individuals, more attention needs to be directed toward understanding why it works and for whom this approach might be best suited. Methodological considerations for future research are also offered.

Key words: written disclosure; underlying mechanisms, psychological health, physical health. [Clin Psychol

Sci Prac 11: 121–137, 2004]

In the mid 1980s Pennebaker and Beall (1986) published a study of the effects of written emotional disclosure on physical health. Their results indicated that participants who expressed their feelings about traumatic or stressful experiences through writing visited the campus infirmary less frequently and reported fewer physical health complaints compared to participants who objectively wrote about how they spent their time. The publication of this study inspired a plethora of similar investigations seeking to replicate and extend these findings (for a review see Smyth, 1998). In these subsequent investigations, participants assigned to the written disclosure condition typically have been asked to Address correspondence to Denise M. Sloan, Department of Psychology, Weiss Hall, Temple University, Philadelphia, PA 19122. E-mail: [email protected].

disclose their deepest thoughts and emotions concerning the most traumatic or stressful event of their lives over several (usually three) sessions conducted across consecutive days. Participants assigned to write about traumatic experiences are usually compared to another group of participants randomly assigned to a control condition in which they have been asked to write about the ways in which they spend their time as objectively as possible. Control-group participants write for the same number of sessions and the same time duration. In 1998, Smyth conducted a meta-analysis of 13 studies of the written disclosure paradigm. Results revealed a weighted mean effect size across all studies and outcomes of d 5 .47 (r 5 .23, p , .0001), indicating that the written disclosure procedure is associated with positive outcome of medium effect size. Smyth additionally found that two variables moderated the overall effect size: (a) length of time between writing sessions (one-week intervals produced a larger overall effect size than one-day intervals) and (b) gender (males tended to have better outcomes that females). All but one of the studies included in the meta-analysis examined randomly selected college undergraduates. It should also be noted that some of the studies included in Smyth’s meta-analysis were not published and have not been published. Since Smyth’s meta-analysis, 14 additional studies of written emotional disclosure have been published. Out of enthusiasm for the potential clinical utility of the paradigm, researchers have used the written disclosure paradigm with a variety of samples. For instance, the paradigm has been studied with individuals who recently lost their jobs (Spera, Buhrfeind, & Pennebaker, 1994), prison inmates (Richards, Beal,

DOI: 10.1093/clipsy/bph062 Clinical Psychology: Science and Practice, V11 N2, Ó American Psychological Association D12 2004; all rights reserved.

121

Seagal, & Pennebaker, 2000), individuals diagnosed with either asthma or rheumatoid arthritis (Smyth, Stone, Hurewitz, & Kaell, 1999), individuals diagnosed with cancer (de Moor et al., 2002; Stanton et al., 2002; Walker, Nail, & Croyle, 1999), bereaved adults (Stroebe, Stroebe, Schut, Zeck, & van den Bout, 2002), individuals taking an upcoming graduate entrance exam (Lepore, 1997), and individuals with a history of traumatic experiences (Batten, Follette, Hall, & Palm, 2002; Gidron, Peri, Connonlly, & Shalev, 1996; Schoutrop, Lange, Hanewald, Duurland, & Bermond, 1997; Schoutrop, Lange, Hanewald, Davidovich, & Salomon, 2002; Sloan & Marx, 2004). In 9 of these 13 studies, participants assigned to the written disclosure condition showed improvements in physical and/or psychological health either relative to those assigned to the control condition or to pre-writing baseline measurement (de Moor et al., 2002; Lepore, 1997; Richards et al., 2000; Spera, Buhrfeind, & Pennebaker, 1994; Smyth et al., 1999; Schoutrop et al., 1997, 2002; Sloan & Marx, 2004; Stanton et al., 2002). Three of these studies found that writing about traumatic experiences did not influence physical or psychological health (Batten et al., 2002; Stroebe et al., 2002; Walker et al., 1999), and one study found that written emotional disclosure actually increased posttraumatic stress disorder symptoms (Gidron et al., 1996). By and large, there is support for the notion that writing about a traumatic or stressful experience with deep emotion produces a positive outcome. Despite the growing attention to and enthusiasm for the paradigm, relatively little attention has been paid to understanding why this procedure appears to result in physical and psychological gains. The purpose of the present paper is to (a) review the published studies that have examined the written disclosure paradigm developed by Pennebaker and Beall (1986), and (b) to explore possible explanations for why the written disclosure procedure may yield physical and psychological benefits. There are a total of 27 studies included in this review, and these studies are listed in Tables 1 and 2. Several theories for understanding the beneficial effects of the written disclosure paradigm have been offered, and each of these theoretical models will be outlined followed by a description of how the models apply to the written disclosure paradigm. In the wake of the supportive findings, other investigators have examined the benefits

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE

of emotional disclosure using alternate methodologies (e.g., Internet-based methods, written disclosure combined with verbal disclosure, verbal disclosure only). Because these efforts substantially deviate from the original written disclosure paradigm, these studies will not be included in this review. In an attempt to better focus our efforts, this paper will concentrate on the results from published studies that have used the written disclosure protocol developed by Pennebaker and his colleagues (1989). Until now, three theoretical models have been offered to explain the beneficial effects associated with written disclosure. The three models— emotion inhibition, cognitive adaptation, and exposure/ emotional processing—will be reviewed briefly next.

THEORETICAL MODELS

Emotional Inhibition

There has been a long tradition in psychology of hypothesizing that emotional inhibition may bring about dysfunction. Freud argued that emotional inhibition resulted in psychological illness, and he subsequently formulated his ‘‘talking cure’’ to release inhibited emotion (Breuer & Freud, 1957/1895). The idea that emotional inhibition may lead to psychological distress remains influential in contemporary psychology. A related literature has further suggested that people who engage in emotional inhibition may be more prone to physical impairments and disease than those who are emotionally expressive (Alexander, 1939; Alexander & French, 1946; Freud, 1961). Indeed, investigators have found empirical evidence linking inhibited anger and hostility with hypertension and coronary heart disease (e.g., Friedman & Booth-Kewley, 1987; Manuck & Krantz, 1986; Smith, 1992; Steptoe, 1993), and others have suggested that emotional inhibition may be linked to a wide variety of minor ailments (Pennebaker, 1990) and to cancer onset and progression (Fawzy et al., 1993; Gross, 1989; Spiegel, Bloom, Kraemer, & Gottheil, 1987). Research on emotion regulation has shown that suppression of emotion increases sympathetic activation (Gross, 1998; Gross & Levenson, 1993, 1997). It may be the case that chronic sympathetic activation may result in adverse physical and psychological outcomes. Pennebaker (1989) originally proposed that disinhibition of emotion was the mechanism of change

V11 N2, SUMMER 2004

122

Table 1.

Studies examining randomly selected participants and outcome measure and follow-up period employed

Study Esterling, Antoni, Flectcher, Marguiles, & Schneiderman (1994) Francis & Pennebaker (1992) Greenberg & Stone (1992) Greenberg, Wortman, & Stone (1996) King (2001) Klein & Boals (2001) Kloss & Lisman (2002) Park & Blumberg (2002) Pennebaker & Beall (1986) Pennebaker, Kiecolt-Glaser, & Glaser (1988) Pennebaker, Colder, & Sharp (1990) Pennebaker & Francis (1996) Petrie, Booth, Pennebaker, Davidson, & Thomas (1995) Smyth, True, & Souto (2001)

Outcome Measure

Sessions

Duration (min)

Follow-up Period

Sample

3, 5 2, 3, 5 1, 4, 6 2, 5 2, 5 7, 11 1, 2, 4, 8, 9 5, 14 1, 6 2, 3, 4, 1, 3, 4, 6, 12 1, 4, 5, 12

3 4 4 1 4 5 3 4 4 4 3 3

20 20 20 30 20 20 20 20 15 20 20 20

post 6 post, 4, 8 4 3, 20 7 9 16 16, 24 12 4–32 6

college college college college college college college college college college college college

3, 4 1, 4, 7

4 1

20 20

post, 4, 16, 24 1–5

medical students college students

students students students students students students students students students students students students

Note: Outcome type are indicated as 1 5 reported physical health, 2 5 objective physical health 3 5 physiological functioning, 4 5 mood state; 5 5 reported general health; 6 5 health behaviors, 7 5 Impact of Events Scale, 8 5 depression, 9 5 anxiety, 10 5 general psychological functioning, 11 5 working memory, 12 5 grade point average, 13 5 re-employment, 14 5 situational appraisal. Follow-up period indicated as either post (last writing session) or the number of weeks following completion of writing sessions.

associated with the written disclosure paradigm. More specifically, he speculated that disclosing once-inhibited feelings leads to a reduction in stress and, consequently, to improved immune functioning and health. Cognitive Adaptation

Although there is more than one theory of cognitive adaptation to traumatic or stressful experiences, they all share the notion that the processing of a traumatic experience requires changing existing schemas. For example, Janoff-Bulman (1992) suggested that all individuals hold three core assumptions: (a) we are invulnerable, (b) the world is meaningful and comprehensible, and (c) we view ourselves in a positive light. Inherent in these assumptions is additional assumptions that others are trustworthy, moral, and compassionate and that misfortunes occur infrequently. Janoff-Bulman noted that these core assumptions are disrupted by a traumatic event, as such an experience is incompatible with these beliefs. Thus, coping with such an experience requires that the individual come to terms with these shattered assumptions. More specifically, such an individual must work to reestablish a conceptual system in which either the experience is assimilated into the old set of assumptions or the core assumptions are changed so that they can accommodate the traumatic experience. In another cognitive adaptation theory, Horowitz (1986) suggested that people seek to match trauma-

TAKING PEN TO HAND

SLOAN AND MARX

related information with their inner models. Recovery from a traumatic experience then requires that the person work to resolve the incongruence between the information acquired from the traumatic experience and the inner models. Horowitz has referred to this process as ‘‘completion tendency’’ and has suggested that this process results in trauma-related re-experiencing symptoms. Horowitz has further noted that if the trauma information is inconsistent with existing inner models, then the inner models are altered. Pennebaker (1997) and others (e.g., Smyth, True, & Souto, 2001) have suggested that writing about a traumatic event may allow an individual to provide structure, organization, and cohesion to the traumatic memory, which may not have been developed initially. Such changes may, in turn, promote insight into cognitive assimilation of traumatic memories (Pennebaker, 1990; Pennebaker & Beall, 1986). It is further speculated that these changes then result in decreased stress and subsequently improved physical health. Exposure/Emotional Processing

Exposure therapies have their roots in learning theory. The learning theory that has been most influential in the behavioral treatment of anxiety disorders was Mowrer’s two-factor theory (1960). In his theory, Mowrer suggested that an aversive unconditioned stimulus (UCS) elicits an unconditioned response (fear and

123

Table 2.

Studies examining individual differences and outcome measure and follow-up period employed

Study

Outcome Measure

Sessions

Duration (min)

Follow-up Period

Sample

Batten, Follette, Hall, & Palm (2002) de Moor, Sterner, Hall, Warneke, Gilani, & Amato (2002) Gidron, Peri, Connonlly, & Shalev (1996) Lepore (1997) Richards, Beal, Seagal, & Pennebaker (2000) Schoutrop, Lange, Hanewald, Duurland, & Bermond (1997) Schoutrop, Lange, Hanewald, Davidovich, & Salomon (2002) Sloan & Marx (2004) Smyth, Stone, Hurewitz, & Kaell (1999) Spera, Buhrfeind, & Pennebaker (1994) Stanton et al. (2002) Stroebe, Stroebe, Schut, Zech, & van den Bout (2002) Walker, Nail, & Croyle (1999)

1,2,4,8,10 4,6,7 4, 7, 8 7, 8 1, 2, 4 4, 5 4, 5, 7 1, 8, 15 3 13 1, 4, 5 1, 2, 4 4, 7

4 4 3 1 3 5 4 3 3 5 4 7 3

20 15 20 25 20 45 45 20 20 20 20 10–30 20

12 post, 4,6,8,10 post, 5 4, 7, 8 post, 6 post, 8 6 4 2, 8, 16 12–32 4, 12 post, 24 1, 4, 16, 28

CSA survivors cancer patients PTSD patients adults taking entrance exam prison inmates students w/trauma history students w/trauma history students w/trauma history asthma/arthritis patients unemployed adults cancer patients bereaved adults cancer patients

Note: Outcome type are indicated as 1 5 reported physical health, 2 5 objective physical health 3 5 physiological functioning, 4 5 mood state; 5 5 reported general health; 6 5 health behaviors, 7 5 Impact of Events Scale, 8 5 depression, 9 5 anxiety, 10 5 general psychological functioning, 11 5 working memory, 12 5 grade point average, 13 5 re-employment, 14 5 situational appraisal, 15 5 Posttraumatic Stress Diagnostic Scale. CSA 5 childhood sexual abuse; PTSD 5 posttraumatic stress disorder. Follow-up period is indicated as either post (immediately following the last writing session) or the number of weeks following completion of writing sessions.

arousal). Other neutral stimuli become paired (conditioned stimuli [CS]) with the UCS such that the previously neutral stimuli come to elicit fear and arousal (conditioned response). This conditioned response may transfer to other stimuli through the processes of secondary conditioning, higher-order conditioning, and stimulus generalization. This process has been invoked to explain some of the symptoms of posttraumatic stress disorder (PTSD; e.g., Foa, Steketee, & Rothbaum, 1989; Keane, Zimering, & Caddell, 1985; Kilpatrick et al., 1985). According to Mowrer, this conditioned fear is then expected to have motivational and reinforcing properties. In other words, the resulting conditioned fear response sets the stage for other behavior whose function is to avoid or escape the situations or stimuli that produce the conditioned fear response (negative reinforcement). This whole process then serves to maintain fear and arousal, as the avoidance and escape behavior terminates the CS before the individual has the opportunity to realize that the CS may no longer be followed by the aversive UCS. Based on this conceptualization, behavior therapists developed therapeutic techniques designed to expose the fearful individual to the CS in the absence of the UCS, so that the individual might realize that the CS is no longer threatening and that avoidance is no longer needed. More recently, researchers (Foa & Kozak, 1986; Foa & Riggs, 1993; Foa et al., 1989; Foa, Zinbarg, &


Rothbaum, 1992; Rachman, 1980) have formulated an alternative approach that combines learning and cognitive theories of responses to stressful and traumatic experiences. In their discussion of emotional processing theory, Foa and Kozak (1986) stated that cognitive changes mediate the fear reductions observed during exposure. This theory draws from the bioinformational theory of emotion (Lang, 1979), in which pathological fear is construed as a cognitive structure that includes erroneous information about stimuli, responses, and their meanings. Foa and Kozak (1986) suggested that exposure techniques reduce fear by activating the fear structure through exposure to the feared stimuli (indicated by high initial levels of emotional arousal) and providing corrective information about the stimuli, responses, and their meanings (indicated by habituation to stimuli between sessions). Exposure therapy can vary across a number of dimensions, such as medium (in vivo, imaginal), duration of exposure, and elicited arousal level (Meadows & Foa, 1999). A number of investigators have suggested that the written disclosure paradigm may serve as a context that allows an individual to be exposed to aversive stimuli that had been previously avoided. This repeated exposure through several writing sessions may allow for the extinction of UCS-CS associations or, alternatively, it may activate the fear structure and provide corrective information to the individual about the stimuli,

V11 N2, SUMMER 2004

124

responses, and meanings (Bootzin, 1997; Kloss & Lisman, 2002; Lepore, Greenberg, Bruno, & Smyth, 2002; Pennebaker, 1997; Sloan & Marx, 2004). The notion that exposure to feared stimuli can lead to the proper processing of emotional material appears relevant to the written disclosure paradigm, as it may help attenuate distress by overcoming a person’s tendency to avoid or suppress distressing memories, emotions, thoughts, or physiological sensations (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Marx & Sloan, 2002). Conceptualizing the written disclosure paradigm as a context for exposure to aversive stimuli would also explain associated cognitive changes observed in some writing studies. Interestingly, Resick and colleagues (Nishith, Resick, & Griffen, 2002; Resick & Schnicke, 1992) have employed a written exposure procedure in their cognitive processing therapy (CPT) for sexual assault survivors. They instruct clients to write about the details of their traumatic experiences at a time and place when they feel as if they can be as emotionally expressive as possible. Clients are asked to include all sensory memories, thoughts, and feelings during the event in their writings. Following this, clients are asked to read their accounts aloud during two therapy sessions. The writing instructions given to clients in this therapy are quite similar to those employed in the emotional disclosure task used by Pennebaker and others. It is unclear if writing about traumatic events alone produces beneficial outcomes or if it is the writing in combination with the other components of the treatment that results in positive outcome. Each of these models appears to serve as a possible explanation for the beneficial effects associated with the written disclosure paradigm. Although few studies have directly examined underlying mechanisms of the paradigm, findings have emerged that may support or disconfirm each of these models. The evidence for each model will be reviewed next.

A P PL I CA T IO N O F T H EO R I ES T O T H E W R IT T EN D IS C L O S U R E P A R A D I G M

Emotional Inhibition

Some research findings have provided support for the emotional inhibition theory. For example, it has been

TAKING PEN TO HAND

SLOAN AND MARX

shown that increased stress results in health problems, particularly infectious illness (e.g., Cohen & Williamson, 1991), and studies examining the written disclosure paradigm have shown that writing leads to improvement in immune functioning, namely the growth of t-helper cells; antibody response to Epstein-Barr virus; and hepatitis B vaccinations (Esterling, Antoni, Fletcher, Margulies, & Schneiderman, 1994; Pennebaker, KiecoltGlaser, & Glaser, 1988; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995). Other findings for the emotional inhibition theory have been more equivocal. For instance, there is no evidence to support the notion that decreases in inhibition mediates the relationship between writing about stressful/traumatic events and improved health. In fact, there is evidence to the contrary; writing about stressful/traumatic events that one has discussed with others is as likely to produce beneficial health outcomes as writing about stressful/ traumatic events that have not been previously discussed (Greenberg & Stone, 1992; Pennebaker, 1989). A possible explanation for these findings is that there is an important distinction between superficially discussing or describing traumatic experiences with others and disclosing deep emotions and thoughts related to these experiences. Highlighting this point is the finding that writing about deep emotions related to imaginary traumas produces the same effects as writing about deep emotions related to experienced traumas (Greenberg, Wortman, & Stone, 1996). Overall, the emotional inhibition theory has not received much support as an underlying mechanism of the written disclosure paradigm, and this has led researchers to shift their attention away from the emotional inhibition theory and towards other theories. Cognitive Adaptation

The cognitive adaptation explanation for the writing paradigm has typically been tested by examining the relative percentages of words used in the written essays that fall into various categories (e.g., insight-related words, causation-related words, negative emotion words, and positive emotion words). For example, Pennebaker and colleagues have found that increases in the use of causal- and insight-related words across the writing sessions are related to improved physical health at follow-up (Pennebaker & Francis, 1996).

125

Further, there is some evidence that writing about a trauma produces a decrease in intrusive thoughts (Klein & Boals, 2001; Schoutrop et al., 2002), and this decrease is related to increases in working memory (Klein & Boals, 2001). Despite these encouraging findings, the cognitive theory has proven difficult to evaluate empirically. The evidence supporting the cognitive theory (i.e., changes in linguistic indicators) is correlational in nature, and it is possible that the changes observed in the language used to describe and discuss traumatic and stressful events may be associated with some other mechanism of change. Further, much of the correlational evidence supporting a cognitive model has been equivocal. For instance, cognitive or linguistic changes have been observed in the absence of any physical or psychological improvements (Batten et al., 2002; Park & Blumberg, 2002; Walker et al., 1999). There have been two published studies that directly examined the hypothesis that cognitive changes account for the beneficial outcome of the written disclosure paradigm. In the first study, Smyth and colleagues (2001) examined one group of participants who wrote about stressful/traumatic events in a narrative fashion, as is typical in these writing studies, a second group of participants who wrote about stressful/traumatic experiences in a fragmented manner (e.g., lists of their thoughts, feelings, and sensations related to the experience), and a third group who wrote about a trivial topic (control condition). Results indicated that the participants who wrote about traumatic events in a narrative manner reported less illness-related restriction of activity at follow-up compared to the other two groups. There were also group differences at follow-up on PTSDrelated avoidance symptoms, with participants in the narrative writing group reporting more avoidance symptoms compared to the other fragmented writing and control groups. Further, participants in the fragmented writing group did not differ from those in the control group on any of the measures at follow-up. Although this study provides some support for the cognitive model, the beneficial effects observed may be the result of some other process, such as exposure, in that elicitation of negative emotional associations may not have occurred when writing about traumatic events in a fragmented manner.


More recently, Park and Blumberg (2002) tested the cognitive model hypothesis by examining cognitive appraisals of the traumatic/distressing event prior to the writing sessions, on the last day of writing, and 4 months following the writing sessions. The authors proposed that the cognitive model would be supported if findings indicated that positive outcome was associated with changes in the appraisal of the traumatic event. Findings indicated that appraisal of the traumatic/distressing event (uncontrollability, threat, stressfulness, intrusions, avoidance) improved from pre-writing to follow-up for the disclosure participants. Unfortunately, the cognitive variables were examined for the disclosure participants only; thus, it is unclear if the appraisal changes occurred as a result of experimental condition. Further, analyses of the outcome measures indicated that the disclosure group did not differ in self-reported emotional and physical health from pre-writing to follow-up, while the control group was significantly worse at follow-up relative to pre-writing scores. The authors interpreted these findings as indicating that the written disclosure exerted a protective effect for well-being; however, the results indicated that positive changes in appraisals of the traumatic/stressful event occurred in the absence of beneficial outcome. In general, there has not been consistent support for a cognitive model of the written disclosure paradigm. Part of the reason for the lack of support may be the difficulty in measuring cognitive changes. Some investigators have used linguistic indices to measure cognitive change across the writing sessions. Although linguistic indices may be informative for some processes, it is unclear if linguistic change indices are able to capture the nuances of cognitive restructuring thought to be important for positive change (Lang, 1979). Another issue is that cognitive changes may be an outcome of successful exposure (Foa & Kozak, 1986); thus, any changes in cognitive process may also be explained by an exposure model. Emotional Processing/Exposure

If exposure underlies the written disclosure paradigm, then changes in posttraumatic symptoms should be observed (e.g., changes in intrusive thoughts and avoidance behaviors). Several studies have examined changes in intrusive thoughts and avoidance as outcome

V11 N2, SUMMER 2004

126

measures of the written disclosure paradigm. The findings from these studies have been mixed, with some studies indicating reductions in intrusive thoughts and images (Klein & Boals, 2001; Schoutrop et al., 2002), and some studies finding no effect for intrusions (de Moor et al., 2002; Lepore,1997; Stroebe et al., 2002; Walker et al., 1999). Interestingly, the findings for avoidancerelated symptoms have been even more mixed, with two studies reporting beneficial outcome (Klein & Boals, 2001; Schoutrop et al., 2002), two studies reporting null effects (de Moor et al., 2002; Stroebe et al., 2002), and three studies finding significantly greater avoidance symptoms following the written disclosure sessions (Gidron et al., 1996; Greenberg et al., 1996; Smyth et al., 2001). Several explanations might account for these mixed findings. First, some of these studies have used small sample sizes, which likely resulted in insufficient power to adequately examine outcome effects (Gidron et al., 1996; Walker et al., 1999). Second, two studies used a single writing session only (Lepore, 1997; Smyth et al., 2001), which may have been inadequate to extinguish negative emotional associations. Third, studies have varied widely on the follow-up period employed to assess outcome (see Tables 1 and 2). Length of follow-up period may account for the noted differences in efficacy. Highlighting this point, Nishith and colleagues (2002) found that during the course of treatment female rape victims increased in trauma-related avoidance symptoms before they improved. Lastly, there is great variability in the samples used to examine these hypotheses. Some studies have examined treatment-seeking individuals (Gidron et al., 1996), while others have used college students who were either randomly selected or preselected based on a trauma history (Klein & Boals, 2001; Schoutrop et al., 2002), and others used a medical illness sample (Walker et al., 1999). Given the variability in these samples, the presence and severity of psychological symptomatology may have also varied considerably. This sample variability could be important because it is feasible that the paradigm works best for those with low to moderate levels of symptomatology and may only serve to increase negative emotional associations for those with more severe levels of psychopathology. In such cases, more sessions may be needed in order properly to extinguish negative emotional associations.

TAKING PEN TO HAND

SLOAN AND MARX

To further address this question, future studies should collect information regarding the presence and severity of PTSD-related symptomatology and self-reported ratings of emotion after each writing session. Noting that observed changes in the activation and habituation of negative emotion would support the exposure/emotional processing model, researchers in one recent study investigated the emotional reactions of participants after each writing session. Kloss and Lisman (2002) randomly assigned college undergraduates to one of three experimental conditions: (a) a traumatic/stressful experience written disclosure group, (b) a positive experience written disclosure group, and (c) a trivial topic, control writing group. Participants completed measures of psychological and physical health both prior to and 9 weeks following the writing sessions. They also completed a measure of state anxiety both immediately before and after the writing session in order to investigate whether activation associated with written disclosure initially increased and then gradually decreased over the course of the sessions. The findings of this study did not support an exposure/emotional processing hypothesis as state anxiety, contrary to expectations, increased from pre- to post-writing. Further, the level of state anxiety did not decrease across the writing sessions, and no significant changes from baseline to follow-up in symptomatology for any of the participants were found. These findings indicated that decreases in emotional reactivity across the sessions may not have been observed because the written disclosure procedure was not beneficial for the participants. In addition, the investigators relied solely on a self-report method to assess emotional activation and extinction, and the measure employed (state anxiety scale) was not developed or intended for assessing fear activation. Consequently, the researchers’ hypotheses may not have been supported as a result of a measurement issue. A more appropriate self-report measure to test fear elicitation during the disclosure sessions would be a measure that is more analogous to the subjective units of distress (SUDs) metric commonly used in exposure procedures. Further, as Lang (1979, 1985) has argued, various methods (e.g., self-report, physiological, behavioral) should be employed when assessing emotional reactions because self-report can be imprecise, particularly at high levels of emotional response.

127

Another approach that could be used to examine the exposure/emotional processing hypothesis would be to examine the utility of the disclosure procedure with individuals who have actually experienced a traumatic event, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria for PTSD. Indeed, several researchers have examined the efficacy of the disclosure task with individuals who have experienced such traumatic events (Batten et al., 2002; Gidron et al., 1996; Schoutrop et al., 1997; Schoutrop et al., 2002; Sloan & Marx, 2004). However, the findings of these investigations also have been equivocal. The first researchers who examined the potential usefulness of the writing paradigm with trauma survivors were Gidron and colleagues (1996). In their study, 14 individuals diagnosed with PTSD were assigned to either a written disclosure writing condition (n 5 8) or a trivial, nondisclosure writing condition (n 5 6). Both groups wrote for 20 min on each of three consecutive days; on the last day both groups verbally disclosed details of their written essays. Results indicated that those participants assigned to the written disclosure condition reported greater PTSD-related avoidance symptoms and greater physical symptom complaints at follow-up compared to participants assigned to the control condition. Although this study had a number of strengths, such as the use of a clinical sample, the study also had a number of limitations. First, the two conditions differed at baseline on a number of variables, including severity of PTSD symptomatology. Another methodological concern is that some of the participants were taking psychotropic medication during the study, raising the possibility that the findings at outcome were not due solely to experimental manipulation of the independent variable (writing group assignment), an issue that could not be addressed because of the small sample size. The final concern arises because of the addition to the procedure of a single verbal disclosure session, a significant variation on the written disclosure paradigm. Schoutrop and colleagues (1997, 2002) conducted two studies examining the efficacy of written disclosure with individuals who had experienced a traumatic event. In the first study, 32 college students who reported a traumatic event were asked to write expressively about these experiences. Results indicated that, compared to


baseline scores, participants reported less depression, anxiety, fatigue and tension immediately following and 8 weeks after the written disclosure sessions. No control or other comparison group was used in this study. In the second study, college students who endorsed a trauma history and reported distress associated with such events were randomly assigned to a written disclosure or a waitlist control condition. Participants assigned to the disclosure condition wrote on five separate occasions for 45 min each session over a 2-week period. Results indicated that individuals who wrote about traumatic experiences reported fewer intrusions, showed less avoidance-related behaviors, and decreased depressive symptoms at follow-up compared to participants assigned to the control condition. General mood state was also examined in this study, though no significant condition differences were observed. Batten et al. (2002) studied individuals with a history of childhood sexual abuse (CSA). Participants were randomly assigned to either a written disclosure condition or a trivial writing condition. Participants were examined 3 months later using the same measures that were collected prior to the writing sessions. In contrast to expected results, no significant condition differences were found. One possible explanation for these findings is that the written disclosure writing instructions were altered, such that participants were instructed specifically to write about a particular experience (their child sexual abuse) during each writing session, rather than being allowed to choose their own writing topic (consistent with the standard protocol). Such a change in procedure is likely to be of critical concern, as not all CSA survivors subsequently develop psychological difficulties as a result of their CSA experiences (Rind, Tromovitch, & Bauserman, 1998). In fact, the individuals in the Batten et al. (2002) investigation generally did not report experiencing significant levels of psychopathology upon entry into the study. Additionally, participants were informed prior to their participation that they might be asked to write about their CSA history. Only participants who agreed to this condition were entered into the study. Given that only 64% of the eligible participants agreed to participate, there may have been a sample bias. More recently, Sloan and Marx (in press) conducted a study on the written emotional disclosure paradigm

V11 N2, SUMMER 2004

128

with trauma survivors who reported high levels of psychological distress. In keeping with the standard writing protocol (Pennebaker, 1997), participants were able to select the topic of their writing. In support of the exposure/emotional processing hypothesis, participants assigned to the written disclosure condition showed significantly greater emotional reactivity (via self-report and salivary cortisol, a biomarker of stress) to the first writing session compared to the control participants, and the heightened reactivity was no longer observed at the last writing session. Results for outcome variables indicated that, compared to control participants, participants assigned to the disclosure condition showed significant reductions in PTSD and depressive symptomatology and reported significantly fewer physical health complaints at follow-up. Although these findings provide some support for the exposure hypothesis of the written disclosure paradigm, it should be noted that the sample examined was not a treatment-seeking sample, and PTSD diagnosis was not considered. Even though the written disclosure procedure is similar to other well-acknowledged exposure techniques, the procedure differs from exposure techniques in some critical ways. First, the standard instructions for the writing procedure do not require that the person write about the same topic at each session. Some have argued that exposure to the same traumatic experience/memory is critical for extinction/habituation to occur and, as a result, critical for successful outcome (e.g., Foa & Rothbaum, 1998). This may explain the mixed findings obtained across studies—some individuals may choose to write about the same topic at each session, while other individuals may elect to write about different topics. It is feasible that the individuals who write about different topics each day are engaging in avoidance behavior by not focusing on any single event. However, it could also be the case that individuals who write about the same topic each day may be avoiding their most upsetting/ traumatic experience. It is also feasible that extinction of negative associations may be achieved through the consistent elicitation of intense negative affect, regardless of the eliciting stimulus. Once tolerance of negative affect is achieved, it is possible that any stimulus that previously elicited high levels of negative affect will no longer do so. There is some empirical support for this speculation.

TAKING PEN TO HAND

SLOAN AND MARX

Watson and Marks (1971) examined the importance of relevant versus irrelevant fear cues in the flooding of phobic clients. These researchers treated a group of specific phobics and agoraphobics with imaginal flooding that involved exposure to either stimulus-specific cues or response-specific (i.e. fear) cues. Individuals in the former group were exposed to a description of their phobic stimulus (e.g., ‘‘you are ten feet outside of your house and begin to vomit and convulse as a crowd gathers around you’’) while individuals assigned to the latter group were exposed to a description of being trapped in a cage and attacked by a lion. Watson and Marks found that exposure to both stimulus-specific and response-specific cues were effective at reducing anxiety when the clients were subsequently confronted with stimuli related to their phobia or agoraphobia. These findings suggest that what is critical in exposure therapy is exposure to the response (i.e., fear), rather than exposure to a particular feared stimulus. The study by Greenberg, Wortman, and Stone (1996), in which writing about deep emotions related to imaginary traumas produced the same effects as writing about deep emotions related to experienced traumas, also corroborates the notion that intense negative affect, elicited by any stimulus, followed by habituation of the response may be the most significant feature of exposure-based interventions. Other factors related to the exposure hypothesis that may have resulted in the equivocal findings reported here include the number of sessions employed and the duration of sessions. In therapeutic exposure, clients typically engage in multiple exposure sessions that typically last for approximately 45–90 min (e.g., Foa & Rothbaum, 1998; Nishith et al., 2002). Investigators examining the written disclosure paradigm have unsystematically varied the number of sessions from 1 to 7 and the length of the writing session from 10 min to 45 min (see Tables 1 and 2). Such procedural variations likely may affect the outcome and make it difficult to draw any definitive conclusions regarding the efficacy of the paradigm. Overall, it is important to collect data on emotional reactions to the writing sessions in order to evaluate whether negative emotional responses are being elicited adequately and to further examine the exposure hypothesis. The findings obtained, thus far, have not

129

provided consistent support for the exposure hypothesis, though it is also the case that the data necessary to appropriately examine this model have not been consistently gathered. CONCLUSIONS AND FUTURE DIRECTIONS

Findings from studies examining the written disclosure paradigm indicate that the paradigm has some promise for clinical utility. However, the underlying mechanism of the paradigm has received far less attention and, consequently, is not well understood. Several theories have been proposed and, although there are some data to support each of the theories, there is also contradictory evidence for each theory. It should be noted, however, that the theories offered to date have not be investigated adequately. It is also possible that an alternative theory not yet explored underlies the effects of the written disclosure paradigm. For instance, Pennebaker and Graybeal (2001) have suggested that written emotional disclosure may be beneficial because it results in changes in social and linguistic behaviors that, in turn, result in increased social connections. However, this explanation has not been tested. One possibility that has not yet been entertained fully is that a single theory may not fully account for the effects of written emotional disclosure. Instead, it may be the case that a combination of these previously theorized mechanisms underlies the beneficial effects observed. For example, it is possible that one mechanism accounts for the initial changes in health and psychological status while another mechanism accounts for the maintenance of these changes. Stated another way, it is likely that the mechanism of action that accounts for the benefits of the written disclosure paradigm may be quite complex and not accounted for by any single theory. Efforts aimed at integrating theories of psychotherapy have been attempted by several others (e.g., Dollard & Miller, 1950; Kohlenberg & Tsai, 1991; Safran & Greenberg, 1991; Wachtel, 1977) with varying success. Whether or not two or more theoretical approaches can be appropriately integrated to explain sufficiently the success of the written emotional disclosure paradigm is ultimately an empirical question. In recent years there have been several studies (Kloss & Lisman, 2002; Park & Blumberg, 2002; Smyth et al., 2001; Sloan & Marx, 2004) that have attempted to


address the underlying mechanism of the paradigm and these studies should represent the beginning stages of a long line of work applying basic research to understand the mechanism underlying the writing paradigm. These studies have examined either the cognitive model or the exposure model as an underlying mechanism, though there are certainly other mechanisms that may account for beneficial effects observed. Additionally, no study has simultaneously investigated more than one model. Given the possibility that more than one model may account for positive changes observed, examining multiple models simultaneously would be ideal. As briefly mentioned earlier, part of the reason that support for each of the purported theories has been so equivocal relates to the varying methodologies across the studies. To adequately evaluate possible underlying mechanisms of the written disclosure paradigm, and to further explore the efficacy of the procedure, a number of methodological considerations should be considered. Outcome Variables

Studies have included different outcome variables (and different measures for the same outcome variable), making comparisons across studies difficult. A number of studies have primarily relied on physician visits or visits to the campus infirmary as the dependent variable (i.e., outcome measure). This outcome variable may be problematic because many individuals do not visit a physician, even when they are sick. For instance, Pennebaker and Francis (1996) reported that 50% of participants in their study reported never visiting the campus infirmary in the month prior to the writing sessions. Similarly, other investigators have found only a small percentage of participants report health care visits, despite a majority of the participants reporting physical symptom complaints and multiple days sick during the same time period (e.g., Sloan & Marx, 2004). These findings raise questions about the sensitivity of visits to a physician or campus infirmary as an outcome measure. The findings also raise the possibility that a subset of participants who exhibit help-seeking behavior may be producing the significant betweengroup differences for health care visits. The exclusion of additional outcome measures limits investigators’ ability to determine whether physical health complaints and

V11 N2, SUMMER 2004

130

visits to a physician may be indicative of some process other than physical illness, such as trauma history or depressive symptomatology (Litz, Keane, Fisher, Marx, & Monaco, 1992). To elucidate an answer to this question, future studies should include psychometrically sound self-report measures of psychological functioning as well as a measure of physical functioning. When employing self-report measures of psychological functioning, investigators have varied greatly on the measures used. Some investigators have examined mood state using a single-item measure, while other investigators have used an unpublished mood measure. In general, these studies have found no beneficial outcome on mood state (see Table 3). The null effects may be a result of the insensitivity of the mood measure employed. The inclusion of psychometrically sound measures of depression, anxiety, and PTSD symptoms likely would be better able to assess changes in psychological functioning in response to the writing paradigm. Sample

Some studies have examined the efficacy of the written disclosure paradigm using samples of randomly selected healthy college students, whereas other studies have examined individual differences such as PTSD diagnosis, history of traumatic experiences, and medical illness (see Tables 1 and 2 for the samples examined). The wide variation in these study samples may also explain the equivocal findings that have emerged. As noted earlier, individuals with more severe psychological symptomatology (e.g., PTSD) may require more writing sessions of longer duration, consistent with the practice of prolonged exposure. The degree to which avoidance is used as a coping strategy may also affect outcome. For instance, Stanton and colleagues (2002) noted that, for a group of women diagnosed with breast cancer, writing about the positive aspects of breast cancer was associated with significant symptom improvements for high avoiders, while writing about the negative aspects of breast cancer was associated with significant symptom improvements for low avoiders. These findings are intriguing as they suggest a potentially important moderator variable for the written disclosure paradigm and may also explain why the paradigm was not efficacious in the Gidron et al. study (1996). In the

TAKING PEN TO HAND

SLOAN AND MARX

Table 3.

Number of studies finding significant beneficial effects, null

effects, and detrimental effects for outcome measures. All studies are listed in Tables 1 and 2

Outcome Variable

Beneficial Effect

Null Effect

Detrimental Effect

Self-reported physical health Objective physical health Physiological functioning Mood state Self-reported health behaviors IES—overall score IES—Intrusions IES—Avoidance PDS Depression Anxiety General psychological functioning Working memory Grade point average Re-employment

3 4 4 1 1 1 1 1 1 3 0 0 1 1 1

5 3 0 5 3 2 1 1 0 1 2 1 0 1 0

2 1 0 0 0 0 0 3 0 0 0 0 0 0 0

Note: IES 5 Impact of Events Scale; PDS 5 Posttraumatic Stress Diagnostic Scale. Beneficial effects 5 experimental group showed significant reduction in symptom at outcome; Detrimental effect 5 experimental group showed significant increase in symptom at outcome.

Gidron et al. study, emotional disclosure was studied using a sample of participants diagnosed with PTSD, a disorder characterized in part by severe avoidance behaviors. However, as mentioned previously there were a number of other factors that may have accounted for the detrimental effects observed in the Gidron et al. study. There has also been some indication that the outcome associated with the writing paradigm may be affected by gender differences, with males showing greater benefit from written disclosure compared to females (Smyth, 1998). In general, gender is not examined specifically in the written disclosure studies, and it will be important for future studies to further explore if gender does in fact influence outcome and, if so, why gender contributes to outcome. Ethnicity may also affect the efficacy of the paradigm, though no studies included in Tables 1 and 2 have addressed ethnic differences. Investigating gender and ethnicity effects may provide further insight into the underlying mechanism of the paradigm. Writing Instructions

An important aspect of the paradigm that may alter outcome is the instructional set employed. The instructions developed by Pennebaker and Beall (1986) allow the participant to choose the writing topic. However,

131

some studies have directed the participant to write about particular topics, such as adjusting to college (Pennebaker & Francis, 1996; Pennebaker et al., 1990), an upcoming graduate entrance exam (Lepore, 1997), past childhood sexual abuse (Batten et al., 2002), recent death of a spouse (Stroebe et al., 2002), or a current physical illness (Smyth et al., 1999; Stanton et al., 2002; Walker et al., 1999). All of the studies that directed participants to write about an ongoing stressor, such as transitioning to college, have reported beneficial outcome. In contrast, the study by Batten and colleagues (2002), in which participants were asked to write about a past traumatic event, resulted in null effects. Smyth’s (1998) metaanalysis of the available literature indicated that instructions to write about current traumas resulted in a higher mean effect size for outcome than instructions to write about past traumas. These findings might have been obtained because, for randomly selected college students (who comprised the majority of samples examined in the meta-analysis), current stressors may have been more distressing than previous stressors. Interestingly, Schoutrop and colleagues (1997, 2002) and Sloan and Marx (2004) allowed participants who endorsed a trauma history to write about either current or past traumas/distressing events. Findings indicated beneficial effects for written disclosure regardless of the type of trauma disclosed. It is unclear if the meta-analysis findings reported by Smyth would be similar for individuals with a trauma history. In general, though, it is probably best not to make decisions about which experience might have been the most traumatic for the participant , but rather to allow participants to select the most traumatic/distressing topic. Several investigators have also varied the original writing instructions in another important way. A few studies have instructed a group of participants to write about the positive aspects of a traumatic/stressful event (King, 2001; Klein & Boals, 2001; Kloss & Lisman, 2002; Stanton et al., 2002). The inclusion of such an experimental manipulation in future studies may help to delineate if observed beneficial effects are due to cognitive reframing of a traumatic event or to exposure/ emotional processing. The findings from the four studies that have included a positive writing disclosure group have been mixed, with one study finding evidence indicating greater benefits for negative trauma disclosure


(Klein & Boals, 2001), two finding beneficial effects for both negative disclosure and positive disclosure relative to a control group (King, 2001; Stanton et al., 2002), and one study finding no beneficial effects for either disclosure group (Kloss & Lisman, 2002). Additional research is needed to examine further the potential benefits of writing about positive aspects of a traumatic event. Number of Writing Sessions

As outlined in Tables 1 and 2, the number of writing sessions and duration of the sessions has varied across studies. Typically, studies include three writing sessions (Batten et al., 2002; Esterling et al., 1994; Richards et al., 2000; Smyth et al., 1999; Sloan & Marx, 2004), though some studies have used one session (Greenberg et al., 1996; Lepore, 1997), four sessions (Pennebaker & Beall, 1986; Greenberg & Stone, 1992; Park & Blumberg, 2002; Pennebaker et al., 1988; Petrie et al., 1995), five sessions (Klein & Boals, 2001; Schoutrop et al., 2002; Spera et al., 1994), and seven sessions (Stroebe et al., 2002). The duration of the writing sessions has also varied, though to a smaller extent than the number of session employed. Most studies have used 20-min sessions (Batten et al., 2002; Esterling et al., 1994; Greenberg & Stone, 1992; Park & Blumberg, 2002; Pennebaker et al., 1988; Pennebaker, Colder, & Sharp, 1990; Richards et al., 2000; Smyth et al., 1999; Smyth et al., 2001; Sloan & Marx, 2004; Stanton et al., 2002), though the original study by Pennebaker and Beall (1986) used 15-min sessions, and some studies have used 30-min sessions (Greenberg et al., 1996) and 45-min sessions (Schoutrop et al., 1997; Schoutrop et al., 2002). Finally, Stroebe and colleagues (2002) directed participants to write between 10 to 30 min during each session. Smyth’s (1998) meta-analysis of the available literature indicated that number of sessions and duration of sessions did not affect the overall effect size. However, the meta-analysis was conducted using studies that employed physically and psychologically healthy participants. Consistent with both the cognitive and exposure models, the number and duration of the sessions may be important for individuals with PTSD-related symptoms, as only a few sessions short in duration may not be adequate for cognitive reframing and/or extinction of negative emotional associations.

V11 N2, SUMMER 2004

132

Time Between Sessions

The time period between writing sessions has also varied. The majority of studies have conducted the writing sessions on consecutive days (Batten et al., 2002; de Moor, 2002; Esterling et al., 1994; Park & Blumberg, 2002; Pennebaker & Beall, 1986; Pennebaker et al., 1988; Pennebaker et al., 1990; Petrie et al., 1995; Richards et al., 2000; Smyth et al., 1999; Smyth et al., 2001; Sloan & Marx, 2004). Although a few studies have spaced out the sessions over a 1-week period (Esterling et al., 1994; de Moor et al., 2002), two studies have spaced five sessions out over a 2-week period (Schoutrop et al., 1997; Schoutrop et al., 2002), and one study spaced out four sessions over 3-week period (Stanton et al., 2002). Interestingly, Smyth’s (1998) meta-analysis indicated that studies that used a longer period of time between sessions were associated with a higher effect size. However, this finding was based on a limited number of studies, making interpretations of these data tentative. Based on the available literature, there does not appear to be a clear indication that a longer time period between the writing sessions is associated with greater benefits than writing sessions conducted on consecutive days. Follow-up Visit

The final variable that would seem important to outcome, yet that varies widely across studies, is the time until follow-up assessment. As indicated in Tables 1 and 2, investigators have varied the follow-up period such that they range from immediately following the last writing session to 6 months after the writing sessions. Most investigators have not provided a rationale for the follow-up period employed. The variation of the follow-up period may also explain some null findings (Batten et al., 2002; Stroebe et al., 2002) as it may be the case that any beneficial effects obtained through written disclosure may dissipate after several weeks. Ideally it would be useful for studies to include multiple followup periods and several studies have already done this. However, all of these studies collapsed the multiple follow-up visits in order to compute a single follow-up visit score used in subsequent analyses (de Moor et al., 2002; Smyth et al., 2001; Walker et al., 1999). Such an approach does not allow for an examination of whether the beneficial effects of the paradigm are fleeting. The

TAKING PEN TO HAND

SLOAN AND MARX

literature on exposure therapy for assault victims has indicated that individuals usually experience an initial increase in psychological symptoms followed by a decrease in the symptoms compared to pretreatment (e.g., Nishith et al., 2002). Thus, a systematic investigation of symptom changes over time related to written disclosure would be informative. Although a meta-analysis of the literature examining the efficacy of the written disclosure paradigm would be informative, such an analysis of the available literature seems inappropriate given the substantial degree of methodological variation across studies. Statistical Significance Versus Clinical Significance

In reporting the efficacy of the written disclosure paradigm, investigators use a statistical significance approach, typically comparing participants in the written disclosure condition to participants assigned to a control condition. In addition to using statistical significance tests, investigators should also employ tests of clinical significance (see Jacobson, Roberts, Berns, & McGlinchey, 1999; Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999). Clinical significance analyses would allow for an examination of the clinical relevance of any reductions in physical and psychological health, and these tests also take into account the test-retest reliability of the outcome measures (see Kazdin, 1999). Further, some statistically significant differences have emerged as a result of participants in the control group increasing in symptomatology, while disclosure participants remain unchanged (e.g., Park & Blumberg, 2002). If the paradigm were efficacious, then one would expect clinically meaningful reductions in symptoms for the disclosure participants. At this point, only Sloan and Marx (2004) have examined clinical significance, and the findings indicated clinical significance for only one out of three outcome variables included in the study. Overall, the work conducted with the written disclosure paradigm has demonstrated some beneficial effects, though the reason for these positive outcomes remains unclear. Out of enthusiasm for the initial findings, there have been some suggestions to use the written disclosure paradigm as a therapeutic modality (e.g., MacCurdy, 2001), and this notion has been further promoted by a number of recent publications (e.g., Anderson & MacCurdy, 2001; DeSalvo, 2000).

133

However, as outlined in this paper, the empirical findings have been equivocal, and there is insufficient evidence to support the use of the writing paradigm as a therapeutic modality at this time. There seem to be some benefits that are derived from written emotional disclosure, although caution is warranted. Indeed, the medium effects sizes obtained for a sample of healthy young adults is striking (Smyth, 1998), and the effect size was even larger in the Smyth and colleagues (1999) study of individuals diagnosed with a chronic medical condition. In an editorial, Spiegel (1999) noted that if a drug intervention had the same effect sizes as the writing paradigm it would be regarded as a major medical advance. Although still in the beginning stages, research examining the written disclosure paradigm with psychologically compromised individuals also appears promising. What is needed now is attention towards understanding the mechanism(s) underlying the paradigm. In focusing on this question, we would better understand the crucial components of the paradigm as well as the types of individuals who would be best served by its use. AC KN OWLEDGM ENTS

The paper was supported by a Temple University Faculty Summer Fellowship awarded to Denise M. Sloan. We thank the anonymous reviewers and Philip Kendall for helpful comments on an earlier version of this paper. REFERENCES

Alexander, F. (1939). Psychological aspects of medicine. Psychosomatic Medicine, 1, 7–18. Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and applications. New York: Ronald Press. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, C. M., & MacCurdy, M. M. (Eds.). (2000). Writing and healing: Toward an informed practice. Urbana, IL: National Council of Teachers of English. Batten, S. V., Follette, V. M., Hall, M. L. R., & Palm, K. M. (2002). Physical and psychological effects of written disclosure among sexual abuse survivors. Behavior Therapy, 33, 107–122. Bootzin, R. R. (1997). Examining the theory and clinical utility of writing about emotional experiences. Psychological Science, 8, 167–169.


Breuer, J., & Freud, S. (1957). Studies on hysteria (J. Strachey, Trans.). New York: Basic Books. (Original work published 1895) Cameron, L. D., & Nicholls, G. (1998). Expression of stressful experiences through writing: Effects of a self-regulation manipulation for pessimists and optimists. Health Psychology, 17, 84–92. Cohen, S., & Williamson, G. M. (1991). Stress and infectious disease in humans. Psychological Bulletin, 109, 5–24. de Moor, C., Sterner, J., Hall, M., Warneke, C., Gilani, Z., Amato, R., et al. (2002). A pilot study of the effects of expressive writing on psychological and behavioral adjustment in patients enrolled in a Phase II trial of vaccine therapy for metastatic renal cell carcinoma. Health Psychology, 21, 615–619. DeSalvo, L. (2000). Writing as a way of healing: How telling our stories transforms our lives. Boston: Beacon Press. Dollard, J., & Miller, N. E. (1950). Personality and psychotherapy: An analysis in terms of learning, thinking, and culture. New York: McGraw Hill. Esterling, B., Antoni, M., Fletcher, M., Marguiles, S., & Schneiderman, N. (1994). Emotional disclosure through writing or speaking modulates Epstein-Barr virus antibody titers. Journal of Consulting and Clinical Psychology, 10, 334–350. Fawzy, F. I., Fawzy, N. W., Hyun, C. S., Elashoff, R., Guthrie, D., Fahey, J. L., et al. (1993). Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Archives of General Psychiatry, 50, 681–689. Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). The efficacy of exposure therapy, stress inoculation training and their combination in ameliorating PTSD for female victims of assault. Journal of Consulting and Clinical Psychology, 67, 194–200. Foa, E. B., & Kozak, M. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35. Foa, E. B., & Riggs, D. S. (1993). Post-traumatic stress disorder in rape victims. In J. Oldham, M. B. Riba, & A. Tasman (Eds.), American Psychiatric Press review of psychiatry (Vol. 12, pp. 273–303). Washington, DC: American Psychiatric Press. Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26, 487–499.

V11 N2, SUMMER 2004

134

Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press. Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualization of post-traumatic stress disorder. Behavior Therapy, 20, 155–176. Foa, E. B., Zinbarg, R., & Rothbaum, B. O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112, 218–238. Francis, M. E., & Pennebaker, J. W. (1992). Putting stress into words: The impact of writing on physiological, absentee, and self-reported emotional well-being measures. American Journal of Health Promotion, 6, 280–287. Freud, S. (1961). The ego and the id. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 3–66). London: Hogarth Press. (Original work published 1923) Friedman, H. S., & Booth-Kewley, S. (1987). Personality, Type A behavior, and coronary heart disease: The role of emotional expression. Journal of Personality and Social Psychology, 53, 783–792. Gidron, Y., Peri, T., Connonlly, J. F., & Shalev, A. Y. (1996). Written disclosure in posttraumatic stress disorder: Is it beneficial for the patient? Journal of Nervous and Mental Disease, 184, 505–507. Greenberg, M. A., & Stone, A. A. (1992). Emotional disclosure about traumas and its relation to health: Effects of previous disclosure and trauma severity. Journal of Personality and Social Psychology, 63, 75–84. Greenberg, M. A., Wortman, C. B., & Stone, A. A. (1996). Emotional expression and physical health: Revisiting traumatic memories or fostering self-regulation? Journal of Personality and Social Psychology, 71, 588–602. Gross, J. J. (1989). Emotional expression in cancer onset and progression. Social Science and Medicine, 28, 1239–1248. Gross, J. J. (1998). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74, 224–237. Gross, J. J., & Levenson, R. W. (1993). Emotional suppression: Physiology, self-report, and expressive behavior. Journal of Personality and Social Psychology, 64, 970–986. Gross, J. J., & Levenson, R. W. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106, 95–103. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis

TAKING PEN TO HAND

SLOAN AND MARX

and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168. Horowitz, M. J. (1986). Stress response syndromes (2nd ed.). Northvale, NJ: Jason Aronson. Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, J. B. (1999). Methods for defining and determining the clinical significance of treatment effects: Description, application, alternatives. Journal of Consulting & Clinical Psychology 67, 300–307. Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press. Kazdin, A. E. (1999). The meaning and measurement of clinical significance. Journal of Consulting and Clinical Psychology, 67, 332–339. Keane, T. M., Zimering, R. T., & Caddell, J. M. (1985). A behavioral formulation of posttraumatic stress disorder in Vietnam veterans. The Behavior Therapist, 8, 9–12. Kendall, P. K., Marrs-Garcia, A., Nath, S. R., & Sheldrick, R. C. (1999). Normative comparisons for the evaluation of clinical significance. Journal of Consulting & Clinical Psychology 67, 285–299. Kilpatrick, D. G., Best, C. L., Veronen, L. J., Amick, A. E., Villeponteaux, L. A., & Ruff, G. A. (1985). Mental health correlates of victimization: A random community survey. Journal of Consulting and Clinical Psychology, 53, 866–873. King, L. A. (2001). The health benefits of writing about life goals. Personality and Social Psychology Bulletin, 27, 798–807. Klein, K., & Boals, A. (2001). Expressive writing can increase working memory capacity. Journal of Experimental Psychology: General, 130, 520–533. Kloss, J. D., & Lisman, S. A. (2002). An exposure-based examination of the effects of written emotional disclosure. British Journal of Health Psychology, 7, 31–46. Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum. Lang, P. J. (1979). A bioinformational theory of emotional imagery. Psychophysiology, 16, 495–512. Lang, P. J. (1985). The cognitive psychophysiology of emotion: Fear and anxiety. In A. H. Turner & J. Maser (Eds.), Anxiety and anxiety disorders (pp. 131–170). Hillsdale, NJ: Lawrence Erlbaum. Lepore, S. J. (1997). Expressive writing moderates the relation between intrusive thoughts and depressive symptoms. Journal of Personality and Social Psychology, 73, 1030–1037. Lepore, S. J., Greenberg, M. A., Bruno, M., & Smyth, J. M. (2002). Expressive writing and health: Self-regulation of emotion-related experience, physiology, and behavior. In S. J. Lepore and J. M. Smyth (Eds.), The writing cure. How

135

expressive writing promotes health and emotional well-being (pp. 99–117). Washington, DC: American Psychological Press. Litz, B. T., Keane, T. M., Fisher, L., Marx, B., & Monaco, V. (1992). Physical health complaints in combat-related posttraumatic stress disorder. A preliminary report. Journal of Traumatic Stress, 5, 131–141. MacCurdy, M.M. (2001). From trauma to writing: A theoretical model for practical use. In C. M. Anderson & M. M. MacCurdy (Eds.), Writing and Healing: Toward and informed practice (pp. 158–200). Urbana, IL: National Council of Teachers of English. Manuck, S. B., & Krantz, D. S. (1986). Psychophysiologic reactivity in coronary heart disease and essential hypertension. In K. A. Matthews, S. M. Weiss, T. Detre, T. M. Dembrowski, B. Falkner, S. B. Manuck, et al. (Eds.), Handbook of stress, reactivity, and cardiovascular disease (pp. 11–34). New York: Wiley. Marx, B. P., & Sloan, D. M. (2002). The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse. Behavior Therapy, 33, 563–577. Meadows, E. A., & Foa, E. B. (1999). Cognitive-behavioral treatment of traumatized adults. In P. A. Saigh & D. J. Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (pp. 376–390). Needham Heights, MA: Allyn & Bacon. Mowrer, O. H. (1960). Learning theory and behavior. New York: Wiley. Nishith, P., Resick, P. A., & Griffin, M. (2002). Pattern of change in prolonged exposure and cognitive-processing therapy for female rape victims with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 70, 880–886. Park, C. L., & Blumberg, C. J. (2002). Disclosing trauma through writing: Testing the meaning-making hypothesis. Cognitive Therapy and Research, 26, 597–616. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer-Verlag. Pennebaker, J. W. (1989). Cognition, inhibition, and disease. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 22, pp. 211–244). New York: Academic Press. Pennebaker, J. W. (1990). Opening up: The healing powers of confiding in others. New York: Morrow. Pennebaker, J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162– 166. Pennebaker, J. W., & Beall, S. K. (1986). Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281.


Pennebaker, J. W., Colder, M., & Sharp, L. K. (1990). Accelerating the coping process. Journal of Personality and Social Psychology, 58, 528–537. Pennebaker, J. W., & Francis, M. (1996). Cognitive, emotional, and language processes in disclosure. Cognition and Emotion, 10, 601–626. Pennebaker, J. W., & Graybeal, A. (2001). Patterns of natural language use: Disclosure, personality, and social integration. Current Directions in Psychological Science, 10, 90–93. Pennebaker, J. W., Kiecolt-Glaser, J., & Glaser, R. (1988). Disclosure of traumas and immune functioning: Health implications for psychotherapy. Journal of Consulting and Clinical Psychology, 56, 239–245. Petrie, K., Booth, R., Pennebaker, J. W., Davison, K. P., & Thomas, M. G. (1995). Disclosure of trauma and immune response to a hepatitis B vaccination program. Journal of Consulting and Clinical Psychology, 63, 787–792. Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy, 18, 51–60. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748–756. Richards, J. M., Beal, W. E., Seagal, J., & Pennebaker, J. W. (2000). Effects of disclosure of traumatic events on illness behavior among psychiatric prison inmates. Journal of Abnormal Psychology, 109, 156–160. Rind, B., Tromovitch, P., & Bauserman, R. (1998). A metaanalytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22–53. Safran, J., & Greenberg, L. (Eds.). (1991). Emotion, psychotherapy & change. New York: Guilford. Schoutrop, M. J. A., Lange, A., Hanewald, G., Davidovich, U., & Salomon, H. (2002). Structured writing and processing major stressful events: A controlled trial. Psychotherapy and Psychosomatics, 71, 151–157. Schoutrop, M. J. A., Lange, A., Hanewald, G., Duurland, C., & Bermond, B. (1997). The effects of structured writing assignments on overcoming major stressful events: An uncontrolled study. Clinical Psychology Psychotherapy, 4, 179–185. Sloan, D. M., & Marx, B. P. (2004). A closer examination of the written disclosure paradigm. Journal of Consulting and Clinical Psychology, 72, 165–175. Smith, T. W. (1992). Hostility and health: Current status of a psychosomatic hypothesis. Health Psychology, 11, 139–150. Smyth, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.

V11 N2, SUMMER 2004

136

Smyth, J. M., Stone, A., Hurewitz, A., & Kaell, A. (1999). Writing about stressful events produces symptom reduction in asthmatics and rheumatoid arthritics: A randomized trial. Journal of American Medical Association, 281, 1304– 1309. Smyth, J. M., True, N., & Souto, J. (2001). Effects of writing about traumatic experiences: The necessity for narrative structuring. Journal of Social and Clinical Psychology, 20, 161–172. Spera, S., Buhrfeind, E., & Pennebaker, J. W. (1994). Expressive writing and coping with job loss. Academy of Management Journal, 3, 722–733. Spiegel, D. (1999). Healing words: Emotional expression and disease outcome. Journal of the American Medical Association, 281, 1328–1329. Spiegel, D., Bloom, J. R., Kraemer, H. C., & Gottheil, E. (1989). Effect of psychosocial treatment on survival of patients with metatastic breast cancer. Lancet, 2, 888–891. Stanton, A. L., Danoff-Burg, S., Sworowski, L. A., Collins, C. A., Branstetter, A. D., Rodriguez-Hanley, A., et al. (2002). Randomized, controlled trial of written emotional expres-

TAKING PEN TO HAND

SLOAN AND MARX

sion and benefit finding in breast cancer patients. Journal of Clinical Oncology, 20, 4160–4168. Steptoe, A. (1993). Stress and the cardiovascular system: A psychosocial perspective. In S. C. Stanford & P. Salmon (Eds.), Stress: From synapse to syndrome (pp. 119–141). San Diego, CA: Academic Press. Stroebe, M., Stroebe, W., Schut, H., Zech, E., & van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. Journal of Consulting and Clinical Psychology, 70, 169–178. Wachtel, P. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books. Walker, B. L., Nail, L. M., & Croyle, R. T. (1999). Does emotional expression make a difference in reactions to breast cancer? Oncology Nursing Forum, 26, 1025–1032. Watson, J. P., & Marks, I. M. (1971). Relevant and irrelevant fear in flooding: A crossover study of phobic patients. Behavior Therapy, 2, 275–293. Received August 23, 2002; revised January 27, 2003; accepted March 25, 2003.

137