WRITING TO HEAL
By Bridget MurrayBy helping people manage and learn from negative experiences, writing strengthens their immune systems as well as their minds.
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.
Autobiography Workshop:
Personal Narrative as a Wellness Tool for the Elderly
By Claudia Collins, Area Aging Issues Specialist
University of Nevada Cooperative Extension
Las Vegas, Nevada
collinsc@unce.unr.edu
Abstract: With the growth of the aging population, Extension is trying to provide meaningful educational programming for seniors. The University of Nevada, Cooperative Extension created the Senior Autobiography Workshop to help older adults write about their lives in a way that can enhance social and family networks and improve seniors' self-esteem, important factors in maintaining physical and mental well-being. Both the process of life review and the autobiographical final product can produce great mental and emotional benefits. Workshop attendees report having gained insight on the value of their life within the context of their family structure.
Introduction
This interactive educational program helps older adults create an autobiographical record of their lives with historical value for them and their families. Sharing their life stories and collaborating with peers in the workshop can enhance their sense of social connection. This writing and sharing process can add meaning to seniors' lives by helping them better understand the past and present (Birren & Cochran, 2001).
Program Design and Delivery
The theoretical basis of the program derives from the body of literature identifying the importance of personal narratives to improve memory and promote self-esteem that can lead to extended independence and more successful aging. This workshop utilizes the social network theoretical model (Heaney & Israel, 1997).
The workshop is offered in collaboration with public and private organizations that provide services for the elderly population, primarily at senior centers and older adult housing. While there is a lot of interest in autobiography-related activities, few of these organizations have staff who feel qualified to conduct life history programs. Extension personnel can either conduct the workshop, or they can provide train-the-trainer instruction for staff or volunteers who provide services to the older adult community. Because Extension is the outreach arm of the university, the workshop gives legitimacy to a project that seems formal and academic but is actually informal and personal.
The program appeals to seniors from a wide variety of cultural and ethnic backgrounds and from varying educational and income levels. As with other Extension wellness programs for older adults, participants tend to be lifelong learners who constantly try new experiences. They are recruited primarily through newsletters or flyers posted in senior centers and older adult housing complexes.
Instructor training basically involves providing an outline for the creative and interactive process, such as outlined here. Taught in a minimum of two sessions, the workshop comprises four incremental action steps: to get seniors thinking, talking, writing, and sharing details of their lives.
First, to get workshop attendees thinking about recounting their lives, the instructor describes different approaches to autobiography and the varied ranges of scope from a single page to book-length manuscripts. Program attendees have told their stories in a variety of traditional written formats as well as in poetry, cookbooks, plays, art, photo albums, and songs. Often someone in the class will question the value of their own life story. In response, the instructor asks them, "How interested would you be to read one paragraph or 100 pages that your parents or grandparents wrote about their lives?"
The next step is to get them talking by asking individualized questions. The process of peer-education usually takes over as they hear others begin reminiscing; this reminds them of incidents from their own lives.
The instructor explains there is no wrong approach and offers suggestions on how to create the document in their own style. Participants are given a three-ring, loose-leaf binder, paper, and pens so that they can start jotting notes throughout the session. It is suggested that they start each topic on a separate page in the loose-leaf binder, making it easier to move ideas around as the work progresses.
Most older adults love to talk; the major challenge is to transition them to writing. At the end of the first session, the assignment for the next class is to write about one topic, event, or life situation. Over the week-long-period, new ideas begin to take shape as they read newspapers, watch television or chat with friends. To help this process, workshop attendees are provided with a written list of questions that include far ranging topics such as:
Q. What were crucial turning points in your life, the decisions you made, the consequences?
Q. Describe an incident you remember from your school days,
Q. How did your family spend vacations or celebrate holidays?
At the second class, the focus is to get them to share their stories by having them read what they've written to the group. They hear what others have created and that all the stories are interesting, and they see the amazing variety of formats. Workshop attendees also begin to realize the value of what they've composed by the praise from their peers.
Workshop attendees are cautioned not to be discouraged by negative people who might undermine their project. It is important for these creative older adults to realize that they are producing this story of their life, primarily as an experience for themselves, secondarily as a legacy for their family. The journey of compiling an autobiography can place their life into new perspective to help them understand how their own personal identity has been shaped by their lives (Birren & Cochran 2001).
Accomplishments and Impacts
Qualitative interviews with workshop attendees reveal the impact of the program, which often includes improved self-esteem and interesting reconnections with social networks. Many describe gaining insight on the value of their life within the context of their family structure. While many claimed at the start of the workshops that their lives "aren't anything important," most report enthusiastic reactions from family, especially grandchildren, and friends to what they write. They also see how they fit, what they contribute, in a process that one participant compared to the holiday classic movie, It's a Wonderful Life.
In April 1999, a group of 15 active older adults at a Las Vegas senior apartment complex participated in two sessions with the Extension instructor. Nine of them decided to continue meeting weekly. Seven months later, each participant had a printed book including pictures, bound with covers, to give their family members as a unique Christmas gift.
The professional quality of their life documents was matched with their stories of reuniting with family members. Bridges were rebuilt as they called, wrote, and visited friends and relatives to obtain pictures and memorabilia or to check facts. Many had not been in contact with these people for decades. One said, " I never thought I could have this much fun." Most of the statements about the impact of the workshop on their lives reflected improved self-esteem and/or reconnections with social networks, program goals directly related to the theoretical model.
References
Birren, J., & Cochran, K. (2001). Telling the stories of life through guided autobiography groups. Baltimore, Maryland the Johns Hopkins University Press.
Heaney, C. A., & Israel, B. A. (1997) Social networks and social support. In Glanz, K. Lewis, F.M. & Rimer, B.K. (eds) Health behavior and health education (pp. 179-205). San Francisco: Jossey-Bass.
This article is online at http://www.joe.org/joe/2005august/iw1.shtml.
Copyright © by Extension Journal, Inc. ISSN 1077-5315. Articles appearing in the Journal become the property of the Journal. Single copies of articles may be reproduced in electronic or print form for use in educational or training activities.
'Share Your Life Story':A New Writing Approach For Elders
By Kate de Medeiros and Thomas R. ColeI want to write, but more than that, I want to bring out all kinds of things that lie buried in my heart. --Anne Frank, The Diary of a Young Girl
What is the purpose of life? To get your story straight. To create a safe and gentle environment for your self, and help create one for other folks, for living what truth you can stand. --Rebecca Hill, All the Big Questions
During the last three years, we have taught writing workshops to roughly 100 men and women ages 60 and older. These workshops, called "Share Your Life Story" or "Spiritual Autobiography," are inspired by three ideas: Participants come with "all kinds of things that lie buried" in their hearts; learning how to write in different genres helps them recover these things; and reading the work aloud to a group enhances personal identity and spiritual growth. The classes are sponsored by the Senior Services Office and the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston, and are held in a variety of places, such as the Rosenberg Public Library in Galveston and the Jewish Community Center in Houston.
We often begin with a Hasidic story about Reb Eizik of Cracow, who dreamed of a great treasure buried beneath a bridge leading to the King's Palace in Prague. He journeyed to Prague and circled for days around the heavily guarded bridge. Finally the captain of the guards asked if he was waiting for someone; Eizik told him the dream. The captain laughed: "As for having faith in dreams, if I had it, I would have gotten going when a dream once told me to go to Cracow and dig for treasure under the stove in the room of a Jew called 'Eizik'!" Rabbi Eizik bowed, returned home, dug up the treasure and built a house of prayer.
RE-STOR(Y)ING LIVES
Unearthing the treasures by re-stor(y)ing lives does not come easily. Sadness, fear, anxiety and resistance impede the creative process of excavation. Vulnerability is inevitable as people searching for their buried pasts through writing have two forces to confront: their own reactions to their pasts and the reactions of perceived readers to their works.
During the first week of the workshop, a retired electrician summed up his discomfort by writing, "I was taught that the written word was an expression of truth. Perhaps not all the truth is the real truth, but a least a truth. Consequently, I've hesitated writing about anything that may expose me to ridicule or censure. If I write it, it must be a truth about me, and I may not want to share it." Having a safe place to challenge and explore whatever these "truths" may be becomes critical to the success of the workshops.
As teachers wishing to model our willingness to share vulnerability, we read from our own autobiographical works. Through this gesture, participants view us more like guides than authority figures. We also ask group members to sign an agreement that formally recognizes the workshop as a place of mutual trust and respect, where stories can be told and discussed in a nonjudgmental, emotionally safe and confidential environment. This includes accepting the boundaries of those who do not want to actively participate but who keep their views and works to themselves.
Once we establish a safe atmosphere for exploration, we work on broadening the participants' literary concept of a life story. When we ask students to write a first-person memoir about turning points, they turn to experiences such as forced immigration and exile, family deaths or lost loves, difficult or joyful marriages. It has never occurred to most of them that their lives might have more than one linear story line or that a single experience can be written in the form of a letter, a poem, a first-person memoir or a third-person story. As the eight weeks of the course pass, we introduce participants to different literary genres, discuss the narrative concepts shaping each one, look at examples of well-known and unpublished authors, and listen and react to written assignments.
MOST DOUBT THEIR POTENTIAL
Participants have ranged from 63 to 95 years old, with educational backgrounds from completion of only the seventh grade to PhDs or MDs. A few have been writers in their spare time. Most doubt their own potential but have come at the urging of friends and family members. They have given little thought to how their story will be told, but gradually develop the confidence to test their self-imposed boundaries. They often find that what was ineffable in one literary form is easily articulated in another.
For example, a 79-year-old woman first wrote of her long, idyllic marriage in stale, uneventful terms: "This particular story began many years ago, when my main man and I were united in marriage. We were both fairly young. I was 20, and he was 22. As the years passed, our love and respect for each other grew." The story continues to describe a happy 40-year marriage, free of conflict, which ended at her husband's death. It is a story written for a family about their parents.
When the same author turned from a first-person to a third-person narrative, though, her focus also shifted: "She looked at him pleadingly and said, 'My birthday is next week, and the only present I want and ask for is for you to go to the marriage encounter weekend with me.' After seeing the melancholy look on her face, he reluctantly said, 'Okay.'" In this version she transformed herself into a woman who feels forgotten or taken for granted, and who wants to do something to fix it. The narrative distance built into the third-person narrative gave her the space she needed to re-story this part of her life.
As the students begin to discover their own voices as writers, they also discover themselves as listeners, as individuals able to react to another's experiences through their reactions to the writing. We spend the majority of each 90-minute meeting listening to volunteers from the group read their work aloud. Afterward, we invite the group to comment on what literary qualities of the piece helped to enhance or inhibit the story. Was it descriptive enough? Was there an underlying metaphor? Did the writing evoke an emotion or a particularly strong image? What are some of the unanswered questions in the piece? We address questions on the technical aspects of the writing that cannot be answered during the class time by carefully reading each piece and providing written feedback and suggestions for revisions.
Approximately 40 people have formed two new writing groups composed of past participants, so they may continue to explore the stories of their past. Members meet twice a month, sometimes bringing a new piece to share, and other times simply listening to others in the group read their work. Most importantly, they continue challenging themselves and one another to keep looking for what lies buried in their hearts.
Thomas R. Cole directs the graduate program at the Institute for the Medical Humanities, University of Texas Medical Branch (UTMB), Galveston. He is an editor of the newsletter Aging and the Human Spirit, and he recently edited the second edition of Handbook of the Humanities and Aging, to be issued by Springer Publishing Company, New York City.
Kate de Medeiros is the community education specialist for the UTMB Senior Services Office and is associate editor of Aging and the Human Spirit, which can be downloaded at http://sagesite.utmb.edu/spirit.
American Society on Aging
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