Emotional expression

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262 HEALTH PSYCHOLOGY
sclerosis/motor neurone disease. The study used a prospective design with 38 consecutive patients completing measures of mood (anxiety and depression), self-esteem, wellbeing and disability at time of diagnosis and after six weeks. Survival and disability were
also measured after six months. Ten patients had died by six months. Controlling for
disease severity, the results showed that those who died reported lower mood at the six
week interview and that low mood at six weeks was also predictive of greater disability in
the survivors.
Beliefs
It has also been suggested that beliefs may themselves have a direct effect on the
immune system. Kamen and Seligman (1987) reported that an internal, stable, global
attributional style (i.e. a pessimist approach to life whereby the individual blames themselves when things go wrong) predicted poor health in later life. This was supported by
Seligman et al. (1988) who argued that pessimism may be related to health through a
decrease in T-cells and immunosuppression. The authors argued that this was not
mediated through behavioural change but was indicative of a direct effect of
attributional style and beliefs on physiology. In a further study, Greer et al. (1979)
suggested that denial and a fighting spirit, not hopelessness, predicted survival for breast
cancer, suggesting again that beliefs might have a direct effect on illness and recovery.
Similarly, Gidron et al. (2001) measured hopelessness (defined as pessimism and helplessness) at baseline and assessed change in a serological marker for breast cancer in
women with breast cancer after four months. The results showed that helplessness
but not pessimism was related to poorer outcome (see Chapter 14 for a discussion
of cancer).
Emotional expression
There is evidence that certain coping styles linked to emotional expression may relate
to illness onset and progression. For example, some studies have studied suppression
and denial and have reported associations with poorer health outcomes (e.g. Kune et
al. 1991; Gross and Levenson 1997). Other studies have focused on emotional (non)
expression and an emotionally inexpressive coping style known as ‘type C’ and have
described a link with illness (e.g. Solano et al. 2001, 2002; Nykliček et al. 2002).
Whilst other researchers have highlighted the importance a repressive coping style
(e.g. Myers 2000). This research consistently indicates that non-expression of emotions, particularly negative emotions in stressful situations can be harmful for health.
There is also evidence that encouraging emotional expression through writing or disclosure groups may be beneficial. This work has been particularly pioneered by Pennebaker (e.g. Pennebaker 1993, 1997) using his basic writing paradigm. This has
involved randomly allocating participants to either the experimental or control group
with both groups being asked to write for three to five consecutive days for 15 to 30
minutes each day. The experimental group are asked to ‘write about your very deepest
thoughts and feelings about an extremely emotional issue that has affected you and
your life. In your writing I’d really like you to let go and explore your very deepest
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emotions and thoughts . . .’. The control group is asked to write about more superficial
topics such as how they spend their time. This intervention has been used with a
range of people including adults, children, students, patients and maximum security
prisoners and survivors of the holocaust who disclose a range of traumatic experiences including relationship break-ups, deaths and abuse. The writing paradigm has
been shown to impact upon a range of outcome measures. Some research has shown
a reduction in subsequent visits to the doctor (e.g. Greenberg and Stone 1992; Pennebaker and Beall 1986), re-employment following job loss (e.g. Spera et al. 1994),
absenteeism from work (Francis and Pennebaker 1992), self reported physical symptoms (Greenberg and Stone 1992; Petrie et al. 1995) and changes in negative mood
(Petrie et al. 1995). In terms of PNI, emotional expression through writing has also
been shown to effect the immune system. For example, it has resulted in changes in T
helper cell responses (Pennebaker et al. 1988; Petrie et al. 1998), Natural Killer cell
activity (Futterman et al. 1992; Christensen et al. 1996) and CD4 (T lymphocyte)
levels (Booth et al. 1997). Therefore this simple intervention provides support for the
PNI model suggesting a link between an individual’s psychological state and their
immune system. However, as with all associations research indicates that the impact
of emotional expression might vary according to aspects of the task and aspects of the
individual.
Aspects of the task
Writing versus talking:
Some research has compared the effectiveness of writing
versus talking either into a tape recorder or to a therapist (e.g. Donnelly and Murray
1991; Esterling et al. 1994). The results showed that both writing and talking about
emotional topics were more effective than writing about superficial topics.
Type of topic: Some research has shown that changes in outcome only occur after
writing about particularly traumatic experiences (e.g. Greenberg and Stone 1992).
Others have found that it is the relevance of the topic to the outcome variable which
is important. For example, Pennebaker and Beall (1986) found that writing about the
experience of coming to college had a greater impact upon college grades than writing
about ‘irrelevant’ traumatic experiences.
Amount of writing:
Research using the writing paradigm has varied the stipulated
time of writing both in terms of the length of sessions (from 15 to 30 minutes) and the
spread of sessions (over a few days to over a month). Smyth (1996) carried out a meta
analysis and concluded that writing over a longer period might be the most effective
approach.
Aspects of the individual
Demographics: Pennebaker (1997) concludes that the effectiveness of emotional
expression does not seem to vary according to age, level of education, language or culture.
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