https:/.../2018-10-12_Expressive_Writing_pt2_edited_1.mp4

>> 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.