Therapeutic expression

That talking about your problems is good for you is, apparently, an axiom of folk wisdom which exhorts us not to 'bottle things up', to 'get things off our chest, to 'vent our feelings'. The compulsion to express and communicate difficulties and feelings seems to be attested within almost every walk of human life where opportunities for confessional and disclosure abound.

Talking, too, is a mainstay of many therapeutic approaches. Humanistic inspired approaches in which contemporary counselling techniques originated, see talking as the chief means of establishing an atmosphere in which dynamic developmental forces within the individual might come to the fore and effect change within the client’s life (e.g. Rogers, 1951). Psychodynamically inspired practices see dialogue as a vehicle to achieve some degree of insight into hidden material of one's emotional past, as a means of bringing some rational principle to irrationally motivated behaviour (e.g. Freud, 1940). Cognitive therapies (e.g. Beck, 1976) may enable clients to articulate

preconscious or poorly attended beliefs and values driving behaviour in dysfunctional ways. Each approach, even in this extremely cursory synopsis, presents its own

account, and own terminology, and its own psychological model to explain why talking is useful within therapy and how talking helps.

Such views may be counterbalanced by sceptical voices questioning the efficacy of talking therapies. This may have its genesis in Eysenck’s (1952) classic and polemical study that found that psychotherapy had no demonstrable benefits in the treatment of

‘neurotics’. This critique became refined to the claim that psychological training brought no benefits over those not trained in a counselling environment, (Durlak, 1979, 1981; Strupp & Hadley 1979) and the conclusion that the principle benefit of therapy consisted in talking to a sympathetic individual gained some support (e.g. Berman &

Norton, 1985).

Fortunately, this debate does not need here to be pursued. What, for the purposes of this dissertation, is of interest, is that talking appears to bring benefits to psychological distress, and that many of the benefits of counselling or psychotherapy might be attributed to the process of talking alone. This of course leads to the question of why this might be the case.

It is possible, indeed likely, that such benefits are multiply determined. Speculatively, this compulsion to report on experience could be rooted in number of possible causes.

Developmental emphases may suggest that from infancy the act of disclosure may be associated with consolation and assistance a caregiver provides when a child feels distressed. In cognitive terms, the act and effort required in repressing may be cognitively and affectively costly; traumatic and experience may isolate us, and in

communicating its nature we may feel less solitude as a result of being 'understood'.

Communicating emotional experiences may have benefited the communities in which human development was fostered: by pooling knowledge of threats and rewards, and as such the need to disclose might be understood as a phylogenetically prepared remnant of our psychosocial development.

Such speculations could go on. One of the few rigorous empirical attempts to explore this area emerges from a long series of writing studies monitoring affective,

psychological and general performance effects of producing written accounts of

traumatic experience within a normal population. This provides some insight into some of the issues raised above as to why precisely expression might be beneficial.

As a whole these studies provide striking evidence for how verbalising distressing emotional experiences can effect emotional processing. This paradigm was first introduced by Pennebaker and Beall in 1986. In its initial form required a sample of college non clinical students to write whilst comparing outcomes with a control group set the task of writing about trivial subjects over an identical period. No feedback on participants’ accounts was given, offered or implied; participants were instructed to engage with their deepest emotional responses, perhaps connecting their traumatic experience with other experiences in their lives (Pennebaker & Chung, 2007); beyond that no further constraints were set as to how participants should approach the task. At the end of each session participants were instructed to deposit their essays in a black box. Outcome measures comprised self-reported affective ratings, academic

performance, and number of visits to healthcare professionals. The experimental group demonstrated significant improvements in all these areas.

This paradigm has since 1986 been replicated in various forms and has demonstrated robust effects. By 1996 over 150 studies had adopted the basic model (Pennebaker &

Chung, 2007). A 1998 meta-analysis by Smyth, reporting on 14 studies, concluded that writing studies produce reliably positive outcomes with an effect size as great as is seen in many clinical interventions. Strongest outcomes tend to be witnessed in

psychological and physiological measures, compared to health and other measures of general performance. Males typically benefit more than females and a longer interval between writing sessions effects greater responses. Health benefits have comprised blood pressure decrease, increases in t-helper response to Epstein Barr virus, and decreases in resting pulse. Effects have been found in diverse populations, age groups and social classes and professions, including various educational backgrounds and nationalities.

Numerous manipulations of the basic paradigm have attempted to uncover precisely how traumatic disclosure produces such salutary effects. The mode of expression has been altered to include talking into a tape recorder, rather than writing accounts, and found to be effective (Esterling, Antoni, Fletcher, Margulies & Schneiderman, 1994);

oral accounts in a one way interaction have shown comparable effects (Murray, Lamnin

& Carver 1989; Donnelly & Murray, 1991). ‘Finger writing’ (where participants form the shape of words with their fingertips rather than using stationery) has also produced equivalent effects (Pennebaker & Chung, 2007). Similarly, having participants write their accounts on a 'magic pad' where the writing disappears once the page is lifted, produced similar effects to participants writing on actual paper (Czajka, cited in Pennebaker & Chung, 2007).

Pennebaker’s own explanation for these effects has evolved since the publication of his first studies; the simple theory of inhibition (i.e. the removal of inhibition through writing and the subsequent freeing up of cognitive resources it effects) found very mixed support (Greenberg & Stone, 1992). Attempts to account for the effects in terms of habituation were similarly discredited (Pennebaker & Chung, 2007). This evolution has culminated in his more cognitively biased A- to-D (analogue to digital) model. This attempts to describe what is presumed to take place when an experience is translated into linguistic form. In essence, Pennebaker stresses how language enables a reduction from highly detailed experience to a more optimal level of specificity. This level allows memory representations to be reduced to a more manageable and amenable scale within the functional demands of the cognitive system. This he likens to the reduction of the data provided by an analogue signal (such as is provided in a skin conductance study) which is over-detailed and shifts on nanosecond to nanosecond basis to a digital signal which converts data numerically on a sampling basis. The analogue signal here,

presumably, is intended to refer to emotions and emotional experience: the digital signal intended to describe language. If an experience persists in attention until it is

understood or naturally dissipates over time an experience in analogue form cannot be tied to the meaning of the event or conceptually analysed. For this it requires

reformulation in language. Too summary or too detailed a description of experience will not enable to sort of conceptual elaboration and processing it requires.

The research appears to suggest that the efficacy of such traumatic disclosure lies not in the communication of the experience, as these accounts are not produced to be read either by the experimenter or other participants. Feedback is neither offered nor given, so cannot account for any benefits exhibited. Expression per se, has also, to some degree been discounted: Krantz and Pennebaker (1995, cited in Pennebaker, Mayne &

Francis, 1997) explored whether an 'expressive movement' condition whereby participants expressed through some movement or action their representation of a traumatic event and found only short term affective benefits followed compared to a condition where verbal expression was required. Furthermore, studies which have instructed participants to focus exclusively on the emotional response, as opposed to the event which precipitated it report few benefits. Thus expression per se may be

incidental to some more fundamental factor.

Rather, the research suggests that the benefits derive from the formation (rather than communication) of a verbal account. This account need not persist in any tangible form, or be communicated, but rather the act of reviewing and reformulating in language an experience and feelings associated with it appear to produce a range of surprising and unforeseen benefits, psychological, physiological and behavioural, and appear to accelerate the emotional processing of events that persist in memory. It is hard to understand these effects in terms of the removal of repression: in strict

psychoanalytical terms the memories cannot have been repressed as they are at the time of the experiment readily accessible to recall. Furthermore, participants are not selected because they have suffered traumatic experience, but are drawn from a general (often university student) population; although, according to how the experiment is described at recruitment, some degree of self-selection appears wholly possible. Similarly any unnuanced notion of 'expression' as providing a catharsis of pent-up feelings appears, similarly, unlikely to adequately explain the mechanisms at work in producing these effects. Participants are expected to engage with their emotions, but this forms only part of the task requirements. Furthermore, where participants simply express their emotions few benefits are seen. At a broader clinical level, the 'mindless emoting'

Teasdale (1999) discusses is thought to be a symptom of rather than a remedy for many emotional disorders.