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Writing is no stranger to therapy. For years, practitioners have used logs, questionnaires, journals and other writing forms to help people heal from stresses and traumas.

Now, new research suggests expressive writing may also offer physical benefits to people battling terminal or life-threatening diseases. Studies by those in the forefront of this research--psychologists James Pennebaker, PhD, of the University of Texas at Austin, and Joshua Smyth, PhD, of Syracuse University--suggest that writing about emotions and stress can boost immune functioning in patients with such illnesses as HIV/AIDS, asthma and arthritis.

Skeptics argue that other factors, such as changes in social support, or simply time, could instead be the real health aids. But an intensive research review by Smyth, published in 1998 in the Journal of Consulting and Clinical Psychology (Vol. 66, No. 1), suggests that writing does make a difference, though the degree of difference depends on the population being studied and the form that writing takes.

Researchers are only beginning to get at how and why writing may benefit the immune system, and why some people appear to benefit more than others. There is emerging agreement, however, that the key to writing's effectiveness is in the way people use it to interpret their experiences, right down to the words they choose. Venting emotions alone--whether through writing or talking--is not enough to relieve stress, and thereby improve health, Smyth emphasizes. To tap writing's healing power, people must use it to better understand and learn from their emotions, he says.

In all likelihood, the enlightenment that can occur through such writing compares with the benefits of verbal guided exploration in psychodynamic psychotherapies, notes Pennebaker. He notes, for example, that talking into a tape recorder has also shown positive health effects. The curative mechanism appears to be relief of the stress that exacerbates disease, researchers believe.

Health benefits

A groundbreaking study of writing's physical effects appeared in the Journal of the American Medical Association (Vol. 281, No. 14) three years ago. In the study, led by Smyth, 107 asthma and rheumatoid arthritis patients wrote for 20 minutes on each of three consecutive days--71 of them about the most stressful event of their lives and the rest about the emotionally neutral subject of their daily plans.

Four months after the writing exercise, 70 patients in the stressful-writing group showed improvement on objective, clinical evaluations compared with 37 of the control patients. In addition, those who wrote about stress improved more, and deteriorated less, than controls for both diseases. "So writing helped patients get better, and also kept them from getting worse," says Smyth.

In a more recent study, presented in a conference paper and submitted for publication, Pennebaker, Keith Petrie, PhD, and others at the University of Auckland in New Zealand found a similar pattern among HIV/AIDS patients. The researchers asked 37 patients in four 30-minute sessions to write about negative life experiences or about their daily schedules. Afterward, patients who wrote about life experiences measured higher on CD4 lymphocyte counts--a gauge of immune functioning--than did controls, though the boost to CD4 lymphocytes had disappeared three months later.

Regardless, the fact that they at first showed improved immune functioning suggests that it reduced their stress through a release of HIV-related anxiety, says Pennebaker. "By writing, you put some structure and organization to those anxious feelings," he explains. "It helps you to get past them."

Other research by Pennebaker indicates that suppressing negative, trauma-related thoughts compromises immune functioning, and that those who write visit the doctor less often. Also, Petrie's colleague Roger Booth, PhD, has linked writing with a stronger antibody response to the Hepatitis B vaccine.

Writing right

Not everyone agrees, though, that the mere act of writing is necessarily beneficial. In fact, initial writing about trauma triggers distress and physical and emotional arousal, researchers have found. And not all people will work through that distress therapeutically or through continued writing, says psychologist Helen Marlo, PhD, of Notre Dame de Namur University and a private practitioner in Burlingame, Calif. In past research, she found that, contrary to Pennebaker's results, writing about negative and positive life events produced no physical health benefits in undergraduate students.

"I get concerned that if people just write about traumatic events, they get raw and opened up and aren't able to work through it on their own," says Marlo. Her study did not, however, provide evidence that writing poses any long-term risk to people.

But there is evidence that the nature of a person's writing is key to its health effects, notes health psychology researcher Susan Lutgendorf, PhD, of the University of Iowa. An intensive journaling study (in press, Annals of Behavioral Medicine) she conducted recently with her doctoral student Phil Ullrich suggests that people who relive upsetting events without focusing on meaning report poorer health than those who derive meaning from the writing. They even fare worse than people who write about neutral events. Also, those who focus on meaning develop greater awareness of positive aspects of a stressful event.

"You need focused thought as well as emotions," says Lutgendorf. "An individual needs to find meaning in a traumatic memory as well as to feel the related emotions to reap positive benefits from the writing exercise."

In explaining this phenomenon, Pennebaker draws a parallel with therapy. "People who talk about things over and over in the same ways aren't getting any better," he says. "There has to be growth or change in the way they view their experiences."

Evidence of a changed perspective can be found in the language people use, Pennebaker has found. For example, the more they use such cause-and-effect words as "because," "realize" and "understand," the more they appear to benefit.

Pennebaker also acknowledges that some personality types likely respond better to writing than others. Tentative evidence suggests that more reticent people benefit most. A host of other individual differences--including handling of stress, ability to self-regulate and interpersonal relations--also mediate writing's effectiveness.

A place in practice?

After all, writing's power to heal lies not in pen and paper, but in the mind of the writer, say a number of psychologists who use it with their patients. That's where clinicians come in, helping clients tap that healing power, they say. Private practitioner Marlo, for example, employs writing cautiously--using it only with patients who take to it, and closely integrating it into the therapeutic process.

"The cornerstone of therapy is engagement in the therapeutic relationship that addresses the individual's process--especially the intrapersonal, interpersonal, affective and symbolic dimensions of experience," says Marlo.

Another practitioner, Judith Ruskay Rabinor, PhD, author of "A Starving Madness: Tales of Hunger, Hope and Healing in Psychotherapy" (Gurze Books, 2002), has her patients explore their anxieties in writings between sessions, e-mailing her as the anxiety strikes them. Rabinor offers feedback on their writing and helps them track progress in their thinking.

Though more studies are needed, many behavioral researchers believe such approaches could also work with treating chronically ill people. "Writing is another potential tool in the armatorium of the clinical professional," says Smyth.

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