The puzzling way that writing heals the body.

I started working for the Red Cross during the Vietnam war  in 1971 and have seen incredible amounts of extreme suffering. Forty-five years later (late 2016) I was still working for the Red Cross, this time in Bangladesh after major flooding and a cyclone. Having seen so much trauma  and been in the thick of death, injury, exploitation and destruction, the constant exposure to the suffering of people in war and natural disasters took its toll on my mind and body. What I discovered early on in my Red Cross career is how writing a diary about the horrific things I had seen, somehow eased the pain. I have kept diaries for over 40 years and they proved incredibly therapeutic for relieving tension, stress, pain and hurt. I would always pick an inspiring place to write my diary and found it had an amazing healing effect. Today I found this article on the BBC website written by Claudia Hammond which somehow coincided and explained a technique I had been using for over 40 years. Have a read of it. It may be helpful.

In 1986 the psychology professor James Pennebaker discovered something extraordinary, something which would inspire a generation of researchers to conduct several hundred studies. He asked students to spend 15 minutes writing about the biggest trauma of their lives or, if they hadn’t experienced a trauma, their most difficult time. 

They were told to let go and to include their deepest thoughts, even if they had never shared these thoughts before. Four days running they did the same thing. It wasn’t easy. Pennebaker told me that roughly one in 20 students would end up crying, but when asked whether they wanted to continue they always did. Meanwhile a control group spent the same number of sessions writing a description of something neutral such a tree or their dorm room.

Studies have shown expressive writing can reduce the amount of times people visit the doctor (Credit: iStock)

Then he waited for six months while monitoring how often the students visited the health centre. The day he saw the results, he left the lab, walked to his friend who was waiting for him in a car and told him he’d found something big. Remarkably, the students who had written about their secret feelings had made significantly fewer trips to the doctor in the subsequent months.

Ever since, the field psychoneuroimmunology has been exploring the link between what’s now known as expressive writing, and the functioning of the immune system. The studies that followed examined the effect of expressive writing on everything from asthma and arthritis to breast cancer and migraines. In a small study conducted in Kansas, for example, it was found that women with breast cancer experienced fewer troublesome symptoms and went for fewer cancer-related appointments in the months after doing expressive writing.

There is one area where the findings are more consistent and that is in the healing of wounds

The aim of the study wasn’t to look at long-term cancer prognosis, and the authors are not suggesting the cancer would be affected. But in the short-term other aspects of the women’s health did seem better than for those in the control group who wrote about the facts surrounding their cancer rather than their feelings about it.

But it doesn’t always work. A meta-analysis by Joanne Fratarolli from the University of California Riverside does demonstrate an effect overall, but a small one. Nevertheless, for an intervention that is free and beneficial, that’s a benefit worth having. Some studies have had disappointing results, but there is one area where the findings are more consistent and that is in the healing of wounds.

In these studies brave volunteers typically do some expressive writing, then some days later they are given a local anaesthetic and then a punch biopsy at the top of their inner arm. The wound is typically 4mm across and heals within a couple of weeks. This healing is monitored and again and again, and it happens faster if people have spent time beforehand writing down their secret thoughts.

Simply imagining a traumatic event and writing a story about it could have health benefits (Credit: iStock)

What does the act of committing words to paper do? Initially it was assumed this simply happened through catharsis, that people felt better because they’d let out their pent-up feelings. But then Pennebaker began looking in detail at the language people used in their writing.

He found that the types of words people used changed over the course of the four sessions. Those whose wounds healed the fastest began by using the word “I” a lot, but in later sessions moved on to saying “he” or “she” more often, suggesting they were looking at the event from other perspectives. They also used words like “because”, implying they were making sense of the events and putting them into a narrative. So Pennebaker believes that the simple act of labelling your feelings and putting them into a story is somehow affecting the immune system.

But there is a curious finding which suggests something else might be going on. Simply imagining a traumatic event and writing a story about it also makes wounds heal faster, so perhaps it’s less to do with resolving past issues and more to do with finding a way of regulating your own emotions that makes a difference.

Writing about your feelings doesn’t boost your immune system for life

After the first day of writing most people say that churning up the past has made them feel worse. Does the stress cause people to release stress hormones such as cortisol, which are beneficial in the short-term and could enhance the immune system? Or is it the improvement in mood after several days of writing that brings the benefits for immunity? So far, no one knows.

Whatever the mechanism, despite several decades of research showing it works, it’s rarely used clinically. You could imagine a situation where people booked in for surgery are given expressive writing instructions in the preceding weeks, but very few studies have used clinical populations with real, surgical wounds, rather than giving healthy students artificially-induced wounds. Also, it works better for some people than others, all depending on how well they engage with the process. What’s more, the effect is short-lived, so you’d have to get the timing just right. Writing about your feelings doesn’t boost your immune system for life. If the same people are wounded again a few months after an initial study, they don’t heal any faster than anyone else.

The writing could work after you're wounded - such as when you're healing after surgery (Credit: iStock)

But now new research from New Zealand suggests it’s not essential to do the writing before you are wounded. It can work just as well if you do the writing afterwards. This opens up the possibility of using expressive writing not just when surgery is planned, but for real-life injuries which of course we can’t predict. Kavita Vedhara from the University of Nottingham and her team in New Zealand took 120 healthy volunteers, and made them write about either a distressing event or how they spent the previous day. They did this either before or after a punch biopsy on their upper arm. The people from the expressive writing group were six times more likely to have a wound that had healed within 10 days than the people in the control group.

We’d need to have more studies conducted with real life patients, but maybe one day when we’ve had an operation, we might be told to go home with instructions on expressive writing. As Kavita Vedhara told me in the BBC’s Health Check, the effect is “short-lived, but powerful”.

What might the tsunami have looked like on social media?

By BBC Trending What's popular and why

Aerial views of Banda Aceh, Indonesia, after the 2004 tsunami (top) and today

Continue reading the main story

How has social media transformed our understanding - and our ability to respond to - major disasters?

The Indian Ocean Tsunami was one of the worst natural disasters on record. But it also occupies an unusual place in history. Although it occurred in a globalised world, and was covered by every major media source on earth, it took place just before the modern age of social media.
Facebook was founded in early 2004 - the year the tsunami hit - but it wasn't open to the general public at the time. Twitter didn't come into existence until 2006. And part of the inspiration for YouTube came when a founder was looking for online videos of the tsunami - and couldn't find them.
So what might the reaction to the tsunami have looked like on today's social media? We asked the audience of the BBC's Indonesian Service to tweet messages as if they had gone back in time to 26 Dec 2004.

Translation: "Aceh in emergency. Need your help to help them."

Translation: "God forgive us - and save our brothers and sisters. Will the world come to an end?"

Translation: "Go climb a coconut tree and hang tight."

The internet was of course well-established in late 2004, and blogs captured the devastation of the tsunami and the human impact of the wave. Online news outlets, including the BBC, covered the disaster with a full range of online video and audio.
But without the immediacy and intimacy of social media, many internet users turned to blogs for personal accounts of the disaster. Mark Oberle, a doctor and professor emeritus at University of Washington School of Public Health in Seattle, was on a family holiday in Thailand when the wave struck. He immediately started treating victims. And a few days in, he started a a gripping account online from Bangkok - a blog post which continues to get traffic today.

A screen grab of Mark Oberle's post about the tsunami.

"I knew that there were a lot of people who were trying to make sense of the situation," he says. "[Online], I pretty much only found news stories that were posted by reporters and news services ... I felt that writing was my own personal catharsis but also a service to other people. I got a tremendous number of queries and I still, a decade later, get a note every few months from someone saying 'Thank you for posting this.'"
There were social media stirrings in 2004, even if widespread adoption of those technologies was some years off, according to Leysia Palen, an associate professor who researches the use of social media during disasters at the University of Colorado Boulder.
"We had been getting these indications that some major changes were underfoot," during the tsunami, and even earlier, during the 11 Sept attacks in New York and Washington, she says, pointing to activity on the photo-sharing site Flickr.
These days social networking can translate into practical help for people on the ground.
"Those people who are onlookers to the event, sometimes get involved in helping activity. Not a huge number, but more than one might expect," Palen says.
Twitter and other platforms are also now used to provide early disaster warnings - such as this account run by the US National Weather Service.
Social networking can help in the search for missing people, Oberle says, pointing out that a relatively low-tech system was used in this way after the 2010 Haiti earthquake, in which he lost a family member.
"That technology wasn't available at the time of the tsunami," he says. "People used paper and boards as people wandered from hospital to relief camps to find people who were missing."
But the importance of networks isn't limited to immediate practical concerns like guiding people to safe havens and coordinating emergency response - it has also profoundly affected our our overall understanding of history.
"Usually when we think of social media we think of that immediate instant response," Palen says. "But social media accounts are going to be very important in the future, we will see them as part of a rich way in which we document what has happened."
Even the stories of historical, pre-social media disasters are being retold online today, often - like the tsunami now (being marked on Twitter at @BBCNewsAsia and elsewhere), or this year's World War I commemorations - at the point of key anniversaries. Seemingly ephemeral messages are becoming key to the way we will tell stories far into the future, Palen says.
"Those significant disasters even in the 'before social media' age are being revived and commemorated anew in the social media world," she says.

Reporting by Mike Wendlin