>> Hi, welcome back. We are here with Dr. Jamie Pennebaker,
and we're talking about expressive writing and welcome to our second hour.
We talked a lot about the research base and the history of kind of discovering
and figuring out that expressive writing works, especially to help people with
a variety of objective outcomes, including health measures,
job measures, and things related to that, and then we're going to go back
and talk more about how it is that we can think about expressive writing
most productively.
Well, welcome back Jamie. >> It's good to be back.
>> (laughing) Indeed.
So, when we're thinking about expressive writing, you know, one of the things
that I think about a lot here is sort of what's the magic ingredient,
what's the mechanism of treatment effect, do you think, for this process?
>> When the first studies were done, there were all of these hypotheses on
what it must be, and one of them, people were-- felt that
"Well, this must be some kind of catharsis or venting."
And all of our analyses and various studies showed that's not it at all,
it's a much more-- there are many things going on.
And the other thing-- science hates this, science wants a nice simple answer,
but spoilers-- >> What clinicians are (crosstalk)?
>> Spoiler alert! There is not a silver bullet that explains it, that there are
multiple, multiple factors involved.
So for example, with expressive writing, we-- there have now been these
various studies that show first of all just labeling an upsetting experience
is important.
So there have been these studies looking at brain activity,
and if you can just label what happens, or just label your emotions,
that's beneficial.
A second is that writing about an experience helps to give it some
structure and organization.
So that too is really valuable.
Another related one is that expressive writing also helps to provide meaning
for a person.
And then-- and creating a narrative seems to be beneficial.
But another thing that I think is really central is that-- think about what happens
when you don't write, or you don't talk about an upsetting experience.
You're walking down the street, and you've had, just had a terrible interaction
with somebody.
What happens is in your mind, you think about "Ooh, I shouldn't have said that",
"Ooh, I can't believe that they said that" and then you go off in another direction.
Your thought patterns, very often after a trauma, in the days and weeks afterwards,
are random, they're just-- they are-- >> Destroying you.
>> Destroying-- exactly. >> (inaudible).
>> And so what writing does, it forces you to bring together all of these aspects,
so you start to realize "Wow, this upsetting experience is associated
"with why I'm having problems with my spouse, this is associated with
"why I'm having sleep problems, this explains why I don't
"have any money in the bank right now, this..." And so you start putting--
>> Think of those connections we were talking about--
>> You're making connections that's right. >> You want people to be indicating, yeah.
>> So it's all of this. But then there have been all of these other studies
looking at expressive writing, and one was one that I particularly loved
that was looking at essentially working memory or executive function.
And working memory, as you'll remember, is this-- the idea of your ability to
keep multiple ideas in your head at once, it's a frontal lobe phenomenon.
And what this research found was that when people did expressive writing,
that they found enhancements, improved working memory,
in the days and weeks afterwards. >> Oh, yeah.
>> Now, having more working memory does a lot of things, and it's also
associated with... that's one reason I think, by the way, people do better
in school after writing. >> Sure, yeah,
better focus and concentration. >> That's right.
>> They can direct their thinking more effectively.
>> That's right. And there have been some studies showing that people
who are taking the SATs, or college boards of some kind, that if they do expressive
writing beforehand, they do actually better than if they don't.
And again, I think it's the working memory issue.
And there's another thing that's also relevant to working memory,
and a lot of other things, is after people write, they also sleep better.
>> Ah. Good. >> And think about
what we not know about sleep.
We know sleep is associated with reduction in depression, we know
that it's associated with enhanced immune functions, many of the things
that we know expressive writing is beneficial for.
>> Sure, it's the quality and quantity are related to these things, yeah.
>> That's exactly right.
So that's another factor that feeds into this.
But then there's one that I found also quite compelling. Years ago,
we did a study with college students, and what we were interested in was
does expressive writing change your daily behaviors?
Now, we had done studies and we gave people questionnaires,
and one thing in my research is I'm very suspicious of questionnaries,
and one of the questionnaire items we asked was, you know,
"To what degree over the last few weeks have you been able to
"connect with others?"
Nobody could answer that question, it's a stupid question.
I wanted, though, to find out can we get at that? So what we devised was a--
it's a method called the electronically activated reporter, the EAR, or the ear.
And it was essentially a glorified tape recorder that would come on for
30 seconds and go off for 12 minutes, and we had people wear this for two days
before they came in to a writing study.
And then we had them wear this again one month later, and what it does is
it just captures how much of the time you're talking with others,
the degree to which you are laughing, the kind of language that you are
using, so forth.
What we found was that people in the experimental conditions, people who
wrote about their deepest thoughts and feelings about something
ended up talking more with others, laughing more with others,
they were more connected with others.
And I think this gets back to executive function, or working memory,
that when you have an upsetting experience, you are thinking about it
all the time.
You are a worse friend, because you're just not paying attention to your friends,
you're not sleeping as well, you're not doing as well at school,
because you're distracted-- >> You're distracted by all your thoughts.
>> That's exactly right.
And then what expressive writing does is it helps to put this upsetting experience
into some kind of context, and you just don't think about it as much.
And if you do think about it, it's not as upsetting.
And you sleep better, and you can connect with others better.
So why does it work?
I think all of those things in this cascade of things, all of those things
help to explain the effect. >> It's basically a form of
cognitive processing, clearly. >> It very much is. It is.
>> And that obviously has been shown in a lot of ways to be
beneficial to people in terms of putting traumating experiences
and other past experiences sort of in their place, right?
>> Yes, that's right. >> It kind of helps to
actually put them in the past, and they don't have to be
thinking about them so actively all the time anymore.
>> That's right, that's right, and a cognitive experience
is also an emotional experience, and this distinction between
cognition and emotion, I think, is somewhat false,
because the two are-- they're all part of the same phenomenon.
>> Yeah, clinically we end up making those distinctions a lot,
I think just mostly as a shorthand way to kind of make life easier
for us as clinicians sometimes, and kind of looking at
someone's emotional functioning and their cognitive functioning.
Obviously those are very intertwined in this way, and especially--
obviously, this is the primary basis of all CBT, cognitive behavioral therapy,
is that those things are very closely linked that way.
So this discussion about working memory kind of makes me wonder about
the timing of these interventions, and whether we have any kind of
indication of boundary conditions, having to do with when we would
recommend that we not use these techniques--
>> This is a critical question. And... so there are interventions,
and I think clinicians worry about this as well, if there is a major
trauma for a person, should you jump right in and start doing some kind of
therapy immediately?
>> Yes, this is very dicey to us. >> It is.
>> Given the evidence base these days. >> That's right, and the data shows
pretty clearly, therapy-- at least deep therapy immediately after trauma's
probably a bad idea.
And I think that includes writing. >> We want much more naturalistic
social support and that kind of thing during that time.
>> Yeah, that's exactly right.
And, you know, if you look at the data, and this is since I started
doing expressive writing, I've since moved into another world
doing analysis of language.
And look-- >> We'll have to have you back
to talk about it. >> Exactly.
But looking at how people write in blogs after, say, 9/11,
or other traumas.
And what you find is that people who are able to distract themselves
actually do much better than people who are really obsessing about
this trauma immediately afterwards. >> Digging into it right away.
>> But the rule I have for expressive writing is you should write when you
find that you're thinking about a trauma too much.
Now, if your spouse died last week and you're thinking about it all the time.
>> How would we define when that's too much?
>> That's not too much, that's completely normal.
If, two years later, you're thinking about the spouse all the time,
that's too much. >> Not so acceptable.
>> So I think you have to weigh when-- at what point do your friends
not want to talk about this anymore?
At what point do you realize that nobody wants to hear this,
or that your friends are avoiding you?
That's a sign you're thinking about it too much, and that's where
expressive writing can be really beneficial.
Now, I should also say, there are some people immediately after trauma,
they need to start writing immediately.
Fine!
>> Do we know who these people are-- >> No.
>> I mean from a clinical perspective-- >> No, no.
>> So, you know, if we're doing a crisis intervention kind of a--
an intervention for example, you know, if somebody
runs a practice, for example, who is very centered around crisis intervention,
this might not be the place where we would suggest using this type of technique
as much, I'm not sure we have a way to test who would benefit from it
and who wouldn't.
>> Well, I'll tell you what I have done, and that is when I dealt with
a group like that.
I'll say "look, I don't recommend writing right now, but there might be
"some of you here who feel as though you would benefit from it. Try it."
You know-- but if you're finding that it's not helping, try something else.
>> Yeah, there's that autonomy piece again, and that sort of self-reflective
piece that we want people to be engaging in.
That makes total sense.
So when we think about the ways that this gets implemented, are there
any other sort of really negative effects that can come off of this?
Iatrogenic effects, you know, effects that are actually harmful to people
when we're attempting to help them, other ways in which you would consider
this technique to be dangerous?
>> I've never seen it to be dangerous.
I've seen some people who got quite distressed when they were writing.
Now in the laboratory studies, of the, I don't know, let's say 2,000 people
that I've been involved with, I've probably seen cases of
maybe three cases that were problematic.
One was a project-- we were dealing with people who were self-harmers.
And this was-- actually, this was a pivotal study for me, because
we were not reading people's writings, and I-- but we were vague,
a little bit vague about it, and one person was essentially writing,
you know, "I have my life, I'm going to commit suicide" and so forth.
And weren't reading it-- >> And we didn't see that.
>> They then... she made a half-hearted attempt in the sense that she
took a lot of antidepressants.
And then told somebody immediately.
So that was-- >> A cry for help attempt.
>> That's right, and, you know, I look at that thinking just how stupid I was
not to be much more clear that we weren't reading this, and that if she were
distressed, she should tell us. >> Take to the usual things
that you would need to do to communicate that type of distress.
But we haven't seen this to have any sort of systematic negative effect--
>> Not at all. >> On people's mood,
or to produce suicidal ideation where that isn't already what the person
is expressing or anything along that line certainly.
>> In fact, that's what's been the most intriguing thing about this,
'cause in our early days, this was the big concern for every, you know,
review board, and others, which was "Oh my god, people are--
"You can't let someone talk about their feelings."
And this was the biggest, our biggest problem was in the medical IRBs.
The medical IRBs would-- you could basically submit saying
"I'm doing a project, I want to saw off people's arms,"
and they go "Okay."
And then we would say "We want people to write about that", and they go
"Oh no, that might make people really..." >> Mental health does make people
uncomfortable. >> But I would say
looking across all of the studies that have been done,
there are no major-- I've not seen any particular people who are at risk,
except those people who-- >> Already at high risk.
>> Who are in crisis at the time.
>> Well these are people that obviously from a clinical perspective,
if you have a client who's at high risk of suicial ideation, other kinds of
similar problems, obviously we would expect for that to be being monitored
in other ways that are independent of the expressive writing technique,
since one of the keys I think that Dr. Pennebaker is really
bringing forward to us here is that we really don't want to review this writing.
And in fact, we don't want them to be encouraged, people to be encouraged
to share this writing with others either.
So for example, if we have a group setting in which we're actually doing
group therapy, and we might assign this technique as an individual tool
for people to use, I don't think we would want to encourage them to share
their writing with each other, would we?
>> Probably not. And, you know, it's-- again, I always get nervous about
being too, you know, because-- >> Directive.
>> Too directive. But one of the early studies showed that
expressive writing was bad, and I was so upset
by this experiment, but the project was-- turned out to be an odd one,
what happened was it was done in a situation where they--
these were standing groups, and in one group,
they wrote-- and then afterwards, they got up and had to share--
read what they had written.
And I was thinking "Geez, that's a terrible thing," because what
what writing is doing is you're writing-- think about how we share an upsetting
experience with another person.
So for example, all of us had this experience, you know, you start to
tell a friend about something that was really distressing, and you're starting
to talk, and you're looking at their face, and their face is going "ahh!"
And so what you do is you change the topic and you move it off in some--
>> Make social adjustments in terms of what you're trying to say.
>> But if you're reading your writing, you can't do that, and so therein's
the issue. So I often-- what I have done, some people would call it therapy,
I don't call it therapy, but when I've done work with someone who
wants to write, I say "I want you to write about this, and if you want to
"talk to me about it, that's great, but, you know, I don't need to
"read it, I don't-- and you don't need to read it to me.
"You can just tell me about it."
>> Yeah, there you go. So obviously, I think we're saying that our
patients are welcome to talk to us about their expressive writing,
that it's not that we would say "Ah, I don't want to hear about that,"
obviously we do, and we want to encourage that communicative
relationship, but we also want to make it clear that this writing is private,
so that they are able to fully unload and to, you know, kind of engage
in that process the best way that they can subjectively,
without truncating it for them in some way that would
involve them trying to manage us, really, and our feelings that way.
Fantastic.
So, when we think about the effect that expressive writing has on,
you know, sort of-- sounds very powerful, it sounds like something that I would
be very tempted to start to use and to really encourage,
myself potentially as a practice, and then also with my clients.
But I also know that there's only so much change we can make
for people, and change is often incremental and happens
in small and kind of subtle ways.
What would you say is sort of the powerfulness of this technique
or the effect size, if you will, if we're going to speak
in research terms. >> Right.
So this is a-- I would call this a major question. So it's important to remember
that expressive writing-- it's free.
You know-- so as techniques go, this is a really low-impact
from a clinician's perspective, and also from the client's perspective,
this is something anybody can do in any context.
How effective is it?
I would-- in the grand effect sizes, it's a modest effect size.
It doesn't work for everybody, it's doesn't work for any one person
all the time.
It's something that you can do any way in all-- and in different methods.
But don't think of this as a panacea for everything.
So I guess that would be my-- for those of you out in TV land,
who are into statistics, the average effect size is about 0.16.
And it's also important to appreciate, there have now been, I'm guessing
1,000 studies done on expressive writing. >> Or more. Or more.
>> And they have been-- they've been done all over the world in every-- with every
kind of group you could imagine. >> Interesting.
>> And sometimes it works, sometimes it doesn't.
And sometimes it-- you know, it depends a lot on the kind of measures they have.
But there have been five that I know of, meta analyses, so these are
analyses of large groups of studies.
And still, this effect size of about 0.16, it bounces around a little bit.
But it's generally beneficial. >> Yeah, got it.
And it sounds like there's no systematic group that we would say
"This never works for them, this is not a group that we want to use
"this technique with."
We've talked about the complexities, I think, of using this technique
with children and their developmental status being the main issue there.
Obviously, it looks like literacy would be involved here, can you address that
a little bit for us?
>> You know, it's funny.
One of our early studies looked at the maximum security prisoners.
>> Interesting, yeah.
>> And-- you know, some of these guys couldn't write worth a damn.
>> Yeah, low education level-- >> Low education level.
>> Low (inaudible) or writing ability.
>> But they-- it did work, an even though they couldn't spell or write well,
they wrote incredibly powerful stories that were beneficial.
And we-- occasionally in our research, we come across groups or individuals
who are essentially not literate.
And what we have done with them is have them just talk into
a tape recorder, or we've had them try other kinds of methods.
So they may have had a little bit of training with writing, but they
just can't write.
Or some, they just physically can't write. >> Right.
>> And some of the methods that had been used, one of my colleagues
in Mexico, for example, worked with a Mayan group, and one of their
cultural traditions there are worry dolls, and what he did was have them,
gave them essentially the writing instructions, but instead of
writing, they talked to these little worry dolls, and found beneficial
effects there.
>> Fascinating, so obviously the writing in and of itself may not be the sort of
crucial mechanism that we were talking about, but instead
is something that prompts the thinking-- >> It's the translation into words.
>> And relates what's happening. >> In fact, another study that
I'm really proud of, this was done by Anne Krantz, she's a dance therapist
in San Francisco who was getting her PhD, and came-- and worked
with me for her PhD.
And we had people do expressive movement in a room by themselves, you know,
express your most traumatic experience, or they would do this, and then
they would write afterwards.
And then there was a control group.
And what we found was with the expressive movement, people found this
to be wonderful, and on their questionnaires, they say
"It was valuable, meaningful, it changed my life."
But it had no effect on their physical health, nor on their grades.
The group that changed were the ones who did the expressive movement
and they also wrote.
And if you think of how dance therapy works, or art therapy,
what happens is the person does this expressive movement, or they
draw or whatever, but then afterwards, the clinician says
"Tell me about that." >> "Let's talk about this."
>> That's right. And I think what happens is that therapy works--
that the expression is valuable, it makes you think, but it's the words
that cement the changes.
>> That verbalizing, and whatever mechanism of verbalizing
we're talking about, but the verbalizing is sort of the key in this way.
>> That's right. And another issue that I think is also important,
is when we put things into words, there are different ways that
we can do it.
So talking is a good one, but there's also-- there's the feedback.
And one of the things that's always is a high risk for a person is
"I'm going to tell you something so profoundly personal,
"and you're not going to validate me." >> Right.
>> And I think people are nervous even in therapy.
>> Oh, I know they're nervous even in therapy of that,
and I think they even have the experience in therapy,
>> That's right. >> Sometimes, of being invalidated.
>> That's right. And I think all of us have had that experience sometimes.
And this is where writing is good.
But speaking also fast, you know, words just explode out of our mouths.
>> It is, it's very quick, yeah.
>> So you can compare, say, typing with writing by hand.
Or another method that I call finger writing.
And all of these-- these are kind of different types. Expressive writing
with typing, so there have been several studies comparing
expressive writing to typing versus with handwriting.
>> Versus handwriting, yeah.
>> And by and large the studies don't show much difference,
but if you stand back and kind of squint at the data,
this is called the squint method.
And you kind of look and you see some slight benefit for handwriting
over typing, but it's not pretty big.
And if you're more comfortable just typing...
>> Just do it, yeah.
>> I think handwriting might work a little bit better, because it's slower.
And I think how quickly you write makes a big difference.
>> I wonder if people slow down over time in the process,
with themselves, even, as they go.
>> It could be.
I've often wondered, actually, if you had a typewriter,
you had people come in, they write either on their computer,
on a typewriter, you know, the old manuals where you have to push--
>> Boom, boom, boom, yeah, it's more efffort, slower there.
>> That that might be more beneficial.
>> What is finger writing, define this for our audience.
>> I'm the inventor of finger writing.
>> (laughing) Congratulations.
>> No, no. So many years ago, my wife and I were travelling in another country,
we were in some hotel, and I can't remember even what the issue was,
but I was tossing and turning about some issue that I was dealing with.
And I didn't want to get up and turn on the light and so forth, so I just
got up and sat in the chair, and just started writing in the air.
>> Like as though you were writing and your finger was the pen?
>> That's right, that's right.
And I, you know, I'd go like this, and...
And then I started noticing that "Wow, this works really well."
And then I tried writing in much bigger letters, which I did--
>> Big, loopy letters.
>> And when you do that, you're slowing it down even more.
>> Yes you are, that's the connection here between that verbal and movement
and all. That's interesting. >> That's right.
And so I then started doing this in workshop, so I would have people
write by hand, versus they would have one period for you to just
write by fingers.
And what I find is a lot of people actually prefer finger writing
to writing by hand.
And I would ask people, "Well, what was the difference?" And many people would say
"Well, I swear more when I'm writing with my fingers," 'cause you know,
they don't want to leave-- >> More open, they're
leaving no trace. >> There's no trace, exactly.
>> Interesting. It's like another level of privacy, almost,
on the product that you're creating. >> That's exactly right.
>> That's really neat (laughing).
>> So-- but all of these, the ultimate goal is translating an emotional
experience into words.
And I think that is really a critical dimension. Well in many ways,
I'm sure that that's a commonality that underlies a lot of
effective therapies, actually. >> Effective therapies,
social support. >> Anything that helps us.
>> Just like religion and prayers, all of these are is that translation process.
>> Often many I think meditative, and contemplative practices
also involve that same type of process, that's why it's interesting to
see that it's there.
So I wonder-- you know, we talked a lot about sort of the, a bit of the
symptomatology that people might find is eased through this process,
sleep problems, for example.
Obviously frontal lobe-related things, if you're having a cluttered
working memory, that kind of thing.
And in my experience of this, those symptoms overlap
through a lot of different kinds of disorders that we might see
in clinical practice.
I don't think that this-- this hasn't really been done, experimenting,
looking at specific diagnostic groups so much.
>> Well it kind of has. >> Yeah, so I've talked (inaudible).
>> In a sense-- and this is so intersting looking at expressive writing
versus other methods like kind of the official ones, CVT, ACT,
you know, they all have three letters. (laughter)
>> Yes, DBT, we've got lots of them. >> Expressive writing is just EW,
just for... >> 'Cause you're a rebel,
through and through, there it is. >> (laughing) That's right.
But expressive writing, because it's, you know, because it's, there's no
license for it, you don't need a certificate, you just do it.
And there's no money that changes hands, there haven't been these
giant RCTs of 10,000 people. >> Yes, indeed.
Sort of safety and efficacy studies in that way.
>> That's right. And my approach is, well, why would you want to do it?
I certainly-- I'm not going to do it. >> Sure.
>> So what this means is it's been a-- it's kind of been a ground swell of
small researchers in clinical psychology, social psychology, cognitive psychology,
and frankly, in anthropology, sociology, and other areas.
And so you have this giant community that has done this expressive writing,
and so now we have to look, so this person-- so it's been done with
people awaiting surgery.
This is chronic pain, this one has been done on this kind of cancer,
this one's been done on-- you name a disorder,
there are studies that have been done.
Does it work better for some diseases, some people more than others?
You know, if you stand back and look at it, there's just not a clear answer.
It seems to be generally beneficial.
>> Yeah. But it's not so much that we would say this is an empirically
supported treatment for depression, or for anxiety, or anything
along that line, but instead that this is much more of a general technique
that would expect to be potentially beneficial to anyone that's
carrying something around, really.
>> That's right. That's right, and so depression would be the obvious one.
And-- >> But PTSD also,
and other kinds of anxiety experiences. >> And PTSD is another one.
And what you see when you look at this is it seems to work, but it's not,
they're not huge effect sizes, it's very modest,
and I think people right in the midst of it, so if one of these PTSD studies
was done right after trauma, which means its really not PTSD,
it's probably not going to work. >> You know, that's acute stress disorder.
>> And I think also a person in the-- right in the depths of a
depressive episode, I would not recommend that.
>> I doubt they'd be willing to engage in it or able to engage in it.
>> You know, and I wouldn't even recommend it.
>> Yeah, yeah. And so this is also something that we would think of
as being kind of relevant to the therapists as well, right?
I mean it sounds to me like it's probably, you know, appropriate
for a general population that would also include the worriers among us,
the clinicians who are carrying client data around potentially.
I know you and I had talked about this separately, that there are
some ways that we might think about this as a tool, possibly, also
for sort of processing information as a therapist, case conceptualization,
thinking about how it is that a particular patient is managing things,
perhaps you would write your deepest thoughts and feelings about a patient.
>> I think something like that can be really beneficial.