Coping with Trauma: The Benefits of Expressive Writing

by James P. David Ph.D. on June 16, 2010

I first learned about the benefits of writing about trauma when I was a graduate student in the 1990s.  I read James Pennebaker’s research which showed that people who had experienced highly stressful events benefitted physically and psychologically simply by writing about the events.  Frankly, I was skeptical, but one thing really stood out.  Pennebaker knew his results would be controversial and scrutinized, so he sent his data to be inspected and analyzed by highly respected researchers at another university.  That’s confidence in your data!

After nearly 25 years of research on the effects of writing about trauma, a sizable literature has emerged.  It is now quite clear that the simple act of writing about trauma can benefit one’s physical health and psychological well-being. In much of the research, writing sessions are about 20 minutes a day over several consecutive days, people write about a highly stressful event and the associated emotions, and the writings remain private.  Writing about trauma does not benefit everyone (e.g., it may be detrimental for adult survivors of childhood abuse), but it has helped people who have experienced events such as medical conditions (e.g., cancer, rheumatoid arthritis, HIV), bereavement, and other major stressors.

So, what are the benefits?  They include physical benefits such as reduced blood pressure, improved immune function, reduced pain, and fewer visits to the doctor.  They also include psychological and behavioral benefits such as improved mood and memory, reduced depression, and even better performance in sports.  We know that “stress makes you stupid” and I previously wrote about this, but the present research on writing goes further by showing it is possible to improve school performance by writing about stressful events (i.e., higher GPA!).  If stress makes you stupid, writing about it makes you smarter!

How does writing help?  This question is still being investigated, but there appear to be some emerging patterns.  Writing about trauma is a form of (mental) exposure to the stressful event, and exposure is known to have benefits in the treatment of trauma.  Writing also may function as a way for one to organize (mentally, cognitively) a major stressful event into something meaningful and integrated with one’s other life experiences; it can help one make sense of the event.  The benefits of writing probably are not based on catharsis, otherwise known as venting or letting off steam.

Who benefits?  It appears that people might benefit from writing about trauma regardless of their age or the severity or their trauma.  One meta-analysis (a procedure whereby multiple studies are examined to determine whether there is an overall pattern across studies) suggests that the benefits of writing about traumatic events may be greater for men than for women.

There remains research to be done, and I hope to see more work that illuminates the mechanisms through which writing is effective.  But I am no longer the skeptic about writing that I was in the 1990s.  For many people, it appears that writing about their traumatic events really helps.

Related References

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.

Petrie, K. J., Fontanilla, I., Thomas, M. G., Booth, R. J., & Pennebaker, J. W. (2004). Effect of written emotional expression on immune function in patients with Human Immunodeficiency Virus infection: A randomized trial. Psychosomatic Medicine, 66, 272–275.

Smyth, J. M. (1998). Written emotional expression. Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.

Coping with Loss: Stages or Not?

by James P. David Ph.D. on May 21, 2010

For decades it has been assumed that people go through stages when confronted with a major loss such as the diagnosis of a terminal illness or the death of a loved-one.  The stage theory proposed by Elizabeth Kübler-Ross, M.D., in 1969 was particularly influential and had widespread appeal.  She proposed that people go through denial, anger, bargaining, depression, and acceptance after being diagnosed with a terminal illness.  Similar stage models have been applied to many other major stressful events such as the death of a loved one or the loss of a limb. 

Even though Kübler-Ross did not believe people necessarily go through all of these stages, or go through them in a particular order, it has become commonly accepted, even among psychotherapists, that a progression through the stages is typical, normal, and reflects adaptive, effective coping.  For example, as psychologists Camille Wortman, Ph.D., and Roxanne Silver, Ph.D., reported, it is often assumed that depression is normal or even inevitable after a major loss such as the death of a loved-one, and that distress and depression are necessary in order to work through the loss successfully.  Clinical lore suggests that that there must be something awry with one’s coping process if one does not show evidence of going through the stages. 

Wortman and Silver challenged these assumptions back in the 1980s.  They completed an extensive review of the published literature that was related to coping with loss, although back then there had been no published studies that tested stage models explicitly (in spite of, or perhaps as a result of, the widespread acceptance of stage models).  Among their many compelling revelations, they found that depression is not inevitable after loss, some people do not even experience major distress, and failure to experience depression or significant distress is not particularly indicative of a failure to work through the loss.  Their review, in short, challenged the stage models as well as some of the more general and widely accepted assumptions about coping with loss noted above. 

A recent study published in JAMA by Paul Maciejewski, Ph.D., and his colleagues appears to be the first empirical investigation designed explicitly to assess whether there is a normal progression through stages after a major loss.  They examined whether bereaved individuals progress through disbelief, yearning, anger, depression, and acceptance.  They studied 233 individuals who had lost a loved one to natural causes.  The authors assert that their results support a stage model, and base their interpretation on the fact that the five emotional responses they examined “peaked” in the order predicted by the theory.  Specifically, disbelief peaked soon after the death (within two months), followed by a peak in yearning, then anger, depression, and finally acceptance (at 20-24 months after the loss).   

But the JAMA study yielded data that are also inconsistent with stage models of coping with loss.  For example, although disbelief peaked soon after the death of a loved-one as stage theory would suggest, the most frequent response to the death of a loved one was, by far, acceptance.  Even though acceptance peaked later on in the coping process, and disbelief peaked early on, people reported experiencing acceptance early in the coping process (soon after their loss) much more frequently than any of the other emotions (stages) assessed.  Participants reported a greater frequency of acceptance than all other responses, including disbelief, at all of the time points assessed in this study.  In short, most people accepted the death, and did so fairly quickly.  This directly contradicts stage theories and the common assumption that acceptance emerges as the final stage of coping with loss, after one experiences feelings such as disbelief, anger, and depression. 

So, what about the other stages?  The second most frequently occurring response was yearning (we miss our loved ones after they die).  Beyond that, the bereaved participants in the JAMA study reported feeling disbelief, anger, and depression pretty infrequently (e.g. once per month).  This does not mean that people are not sad or upset when their loved ones die; rather, it means that most people are able to accept their loss without frequently feeling (or even going through a significant period of) disbelief, anger, and depression.  Perhaps people would feel more of these emotions (i.e., go through these “stages”) if their loved ones died from unexpected, non-natural causes (e.g. auto accidents), but this remains speculation as there are no published data akin to the JAMA study. 

Overall the data are inconclusive at best with respect to stage models, and even incompatible with models that suggest denial, anger, and depression are typical, normal responses to loss.  In fact, the study suggests that these responses are atypical in response to natural loss and perhaps indicative of less effective coping.

Most people yearn for their deceased loved ones and apparently are able to accept the loss fairly quickly.  But it seems there are probably as many ways to cope effectively with major loss as there are people.  There are many adaptive, effective ways of coping that may or may not fit neatly within a stage model.  Some people even have positive emotional experiences as part of their grieving process (think reminiscence).  Some people use humor.  Others get angry, but apparently not everyone.  In short, this clinician is not ready to endorse stage models of coping with loss.   

Related References

Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.

Maciejewski, P. K., Zhang, B., Block, S. D., & Prigerson, H. G. (2007). An empirical examination of the stage theory of grief. Journal of the American Medical Association, 297, 716-723.

Wortman, C. B. & Silver, R.C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57, 349-357.

Stress Makes Us Sick and Stupid

The impact of stress on physical health is well known.  For example, we now know that stress is a risk factor for illnesses such as heart disease, and it is associated with increased susceptibility to infectious diseases such as the common cold. Stress has other effects that may be less obvious but still important. In fact, stress […]

Read the full article →

Psychotherapy Helps

Hello and welcome to my blog. In the coming weeks and months I plan to comment on issues that I believe might be of interest to you and others who find themselves on psychology-related websites. I will choose topics from popular culture and media (like the Newsweek article noted below) as well as topics I […]

Read the full article →