Sex Roles (2010) 63:165–172 DOI 10.1007/s11199-010-9771-9

FEMINIST FORUM

Who Benefits from Pennebaker’s Expressive Writing? More Research Recommendations: A Commentary on Range and Jenkins Lisa T. Stickney

Published online: 26 March 2010 # Springer Science+Business Media, LLC 2010

Abstract This manuscript is a commentary on Range and Jenkins’ (2010) exploration of possible gender differences in the outcomes of Pennebaker’s expressive writing paradigm. It too examines possible gender differences, but uses a different perspective and extends Range and Jenkins’ work. She focuses solely on reasons outcomes might be more beneficial for men, while this commentary looks at outcomes that may favor either gender. It employs a communication and emotion framework and explores the effects of previous trauma disclosure, women's tendency to ruminate, and the congruence of written instructions and preferred communication style. Also examined are shame, an emotion associated with some traumas, socially appropriate emotion expression, and the impact of alexithymia on emotional disclosure. Research recommendations are provided. Keywords Gender differences . Emotion . Communication . Expressive writing . Pennebaker

Introduction In 1986, Pennebaker and Beall published a study that examined whether writing about a traumatic event could be beneficial to one’s health. The answer was yes. Students who wrote about how they felt about a traumatic or

L. T. Stickney (*) Department of Management and International Business, The Merrick School of Business, University of Baltimore, 1420 N. Charles St., Baltimore, MD 21201, USA e-mail: [email protected]

stressful experience made fewer subsequent visits to the campus infirmary than students who wrote about a neutral topic. Pennebaker and Beall’s (1986) work spurred a great deal of interest in emotional disclosure, and today, nearly 25 years later, there are well over 200 studies employing what is now referred to as Pennebaker’s expressive writing paradigm. Most of the studies show some sort of benefit from the disclosure. Although, the majority of outcomes observed are health benefits (both physical and psychological), other benefits such as reduced absenteeism, improved college grades, and faster re-employment, have been noted (Range and Jenkins 2010). These benefits have been observed in a wide variety of populations including healthy individuals, those with medical problems, and those with psychiatric or psychological problems (Frattaroli 2006). Also, the writing paradigm has been tested in a variety of settings including clinical and non-clinical settings, and in the United States and several other countries (Range and Jenkins 2010). Yet, after all these studies, we know surprisingly little about emotional disclosure through expressive writing. We do not know how it works, why it works, when it works, or for whom it works. In the words of Smyth and Pennebaker (2008), “After 20 years and hundreds of studies, most of us still acknowledge that expressive writing works—at least some of the time and for some of the people” (2008, p. 6). Range and Jenkins (2010) attempts to identify some of the “for whoms” and “whys” underlying expressive writing. She examines Smyth’s (1998) meta-analysis and writes about one of his findings. Studies with more men had larger effect sizes (i.e. better outcomes) than studies with more women. Using three well known gender theories, Range and Jenkins (2010) explains why Pennebaker’s writing paradigm might show stronger outcomes for men than for women. However, it may be premature to make this claim

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as very few studies examined the role of gender in the expressive writing-improved health relationship. Of the studies that did look at gender, most found no difference in outcomes between men and women, and among the studies that did, there is nearly an equal number supporting the argument that the benefits are stronger for women. Given this and building on Range and Jenkins’ (2010) work, this commentary looks at gender as a potential moderator of the expressive writing-outcome relationship. It begins with a brief review of the paradigm and the state of gender research within it. Then it continues by exploring gender differences in communication and emotions and their effect on a gender-health benefit relationship in expressive writing.

The Writing Paradigm and Gender The general procedure for the expressive writing paradigm begins with participants being randomly assignment to either an experimental (disclosure) or control group. They are asked to write for some length of time, often 15 to 20 min, several times over some period of time (e.g. write once a day for several consecutive days, or once a week for several weeks). The disclosure group is asked to write about a trauma or stressful incident in their lives, and their feelings about that trauma, while the control group is asked to write objectively as possible about some neutral or quotidian topic (e.g. describe in detail, what you did since you woke up this morning). Generally, data are collected pre–and post-writing, and at follow-up several weeks or months later. Results are compared both between and within subjects over time. As Range and Jenkins (2010) notes, the results of expressive writing studies are generally favorable, although not all studies reported positive findings. In 2006, Frattaroli’s performed the largest and most comprehensive metaanalysis to date. It included 146 studies and 10,994 participants. In it, she reported that in 5% of the studies, emotional disclosure had no effect on the outcomes examined. In 25% of the studies, there was a negative effect size, indicating that emotional disclosure through expressive writing was harmful to participants in the experimental group, and in the remaining 70% of the studies, expressive writing was beneficial. Using random effects modeling, she found the overall effect size to be a significant .075, roughly equivalent to a Cohen’s d of .15 from a fixed effect model (Frattaroli 2006). This answers the questions, "Does it work?" and "How well does it work?" It does not answer the "For whom does it work?" question that Range and Jenkins (2010) attempts to answer. Few studies consider gender’s role in expressive writing, and of those that do, most consider it as a potential

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moderator. Only, Epstein et al. (2005) performed a direct test comparing outcomes for women and men. They found no differences between genders in stress levels and physical symptoms, but there were differences in word usage. Of the remaining studies examining gender, two were metaanalyses. Smyth's (1998) meta-analysis found a gender difference showing stronger outcomes for men than for women based on the proportion of men in a study, but Frattaroli's (2006) found no such effect. Three other metaanalyses did not examine gender or report the gender distribution of their studies (Frisina et al. 2004; Harris 2006; Meads and Nouwen 2005). Frattaroli (2006) identified nine studies that examined gender as a potential moderator of the expressive writing-outcome relationship, out of which, seven found gender to be insignificant. In the other two (Crow 2000; Pennebaker et al. 1990), women benefited more from treatment than men. In addition, a literature search identified three other studies that included gender in expressive writing. Dierberger (2007) found that gender was not significant, but Manier and Olivares (2005) and Krivoshchekova (2009) found expressive writing to be more beneficial for men. In sum, one meta-analysis and two individual studies found stronger effects for men, while two individual studies found stronger effects for women, a meta-analysis and seven individual studies found no difference between genders in the effects of expressive writing, and no others were located that examined gender in the expressive writing paradigm. Range and Jenkins' (2010) first research recommendation is to test directly for gender effects, and I concur. Epstein and colleagues' (2005) work was the only direct test of gender in expressive writing found. In it, participants were divided into four groups: control and experimental by gender. The groups in their study ranged in size from 21 to 26 participants, a size too small to make any reliable inferences. In addition, they used college students, a group commonly used in expressive writing studies. However, male college students have been shown to and hold more egalitarian gender-role attitudes, ones more similar to women's attitudes (Bryant 2003), and they are psychologically healthier and more emotionally expressive than men in the general population (Graham 2006). Thus, the answer to the question, “Who benefits more, men or women?” appears to be, “it depends.” However, one cannot answer this question without looking at the underlying question of “Why might one gender benefit more than the other?” The “whys” and “hows” of expressive writing are a subject of much debate. Numerous psychological theories have been posited as the mechanism by which expressive writing produces benefits, but no single theory has held consistently (for a brief review, see Sloan and Marx (2004) and Frattaroli (2006)). What we do know about expressive

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writing is that it forces people to acknowledge their emotions, and how it works is complicated. It affects people across multiple dimensions, and it is likely there are interactions across those dimensions (Smyth and Pennebaker 2008). Since the clinical psychology literature has been unable to identify a clear explanation, it may be time to look elsewhere. Using three well-know gender theories (gender schema, social role, and gender socialization), Range and Jenkins (2010) does just that, and so does this commentary which looks at gender differences in communication and emotions, two rarely referenced, domains that represent key features of the expressive writing paradigm.

Gender Differences in Communication Communicating a trauma or stressful event is a key element of the expressive writing paradigm. Most studies did this by asking the participant to handwrite, but some asked participants to type and some used oral disclosure (Frattaroli 2006). Irrespective of the method used, all studies involved communicating emotion by the treatment group. Examining communication within the expressive writing paradigm is important because research has identified distinct differences in communication styles between women and men, and these differences may affect the outcomes of emotional disclosure through expressive writing. In general, men’s communication style can be described as being direct, succinct and instrumental (Mulac et al. 2001) with a greater focus on information (Argamon et al. 2003; Holmes 1998). When communicating, men are more likely than women to discuss factual issues (Bischoping 1993; Colley and Todd 2002; Moore 1922), use more aggressive or adversarial language (Colley and Todd 2002; Colley et al. 2004; Glass 1992; Nicotera and Rancer 1994), and bring up fewer personal topics (Aries and Johnson 1983; Bischoping 1993; Colley et al. 2004; Glass 1992). Overall, men’s communication tends to be outward directed (Glass 1992), and often reflects a desire for power or control (Holmes 1998). By contrast, women’s communication is more interpersonal. Their style can be described as indirect and elaborate (Mulac et al. 2001) with a focus on affective meaning (Holmes 1998). Women are more likely than men to discuss people, appearances (Bischoping 1993; Moore 1922), shopping (Colley et al. 2004), and relationships (Aries and Johnson 1983; Bischoping 1993; Tannen 1990). Stylistically, women are more prone to use linguistic devices that convey affect (Holmes 1998). Compared to men, women use more positive intensifiers (e.g. really, hugely), multiple exclamations (Colley et al. 2004), psychological state verbs such as feel, hope and wish

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(Glass 1992), and write in a manner that conveys more interpersonal involvement (Argamon et al. 2003). Overall, women’s communication tends to be more communal and socioemotional (Colley and Todd 2002). Men’s tendency to communicate information and avoid personal topics suggests that men would be less likely than women to have disclosed their traumas before participating in expressive writing. Not having previously disclosed a trauma could lead to a greater benefit from emotional disclosure for men. Cognitively based theories on how expressive writing works suggest that repeated writing allows the individual to think about a traumatic event from different perspectives, which changes the way the event is remembered (Manier and Olivares 2005). Also, there is some evidence to suggest the benefits of cognitive processing come from confrontation (Páez et al. 1999). If so, men who have not previously disclosed a trauma may have greater benefit because their lack of pre-writing disclosure forces confrontation. In addition, there may be an added benefit if they process the traumatic event in the factual, information-oriented manner in which men are comfortable communicating. Pennebaker found that as participants' writing became more organized and coherent over time, their improvement increased (Pennebaker 1993; Pennebaker et al. 1997). For women, their affective, relationship-oriented communication style and tendency to discuss people and relationships suggests that they are likely to have previously disclosed the trauma. If they are able to become more organized and focused in their writing, then there would not likely be an observable gender effect. However, this may not occur when the disclosure involves trauma because women tend to ruminate. Rumination is a linguistic representation of cognitive processes (Fresco et al. 2002). It occurs when one repeatedly focuses on a negative event or distressing condition, the symptoms of the distress, and possible causes and consequences of the distress (Nolen-Hoeksema and Jackson 2001). Women are more likely to ruminate than men (Nolen-Hoeksema and Jackson 2001), and more likely to ruminate when distressed, which tautologically, further increases the distress (Nolen-Hoeksema et al. 1999). Among distressed individuals, rumination was found interfere with decision-making (Lyubomirsky et al. 1999), impede concentration and was associated with poorer performance on academic tasks (Lyubomirsky et al. 2003). In a test of the ability of physical activity to dissipate anger, individuals who ruminated became angrier and more aggressive than those who did not ruminate (Bushman 2002). In sum, these studies suggest that rumination is likely to affect a woman’s ability to focus and become organized, thus affecting her ability to confront and cognitively process the trauma. To the extent that expressive writing becomes an outlet for rumination, women would not benefit from

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the writing session and may have negative outcomes. As a result, there should be gender differences in the emotional disclosure-outcome relationship that favor men. Future studies asking subjects to write about traumatic experiences should consider a analyzing the writing to determine the extent the author ruminates. An issue related to preferred communication styles pertains to the wording of the instructions in the disclosure group. Range and Jenkins (2010) proposed including writing instructions that emphasize mastery and control and assess whether this increases benefits for someone with a masculine coping style. This recommendation is congruent with masculine communication styles and as such, these specific instructions may not be necessary for men. A better research question might be “What happens if instructions are congruous with the preferred communication style of the participant?” It is possible that if the writing instructions match the communication style, the communication style might reinforce the instructions and allow for greater focus on the traumatic event. This might occur with men who tend to use a problem-focused coping style (Smyth 1998), and since their tendency to want to solve problems reflects a desire for control (Holmes 1998), it should be evident in their writing and likely to lead to greater benefit. Among women, Epstein and colleagues (2005) found a greater use of causal and insight words reflecting women’s inward-directed communication tendencies. More importantly, is Pennebaker and Francis’ (1996) finding that the use of more casual and insight words were related to improved physical health. Taken together, this suggests that if women write in the inward-focused, introspective style they are most comfortable with, there should be a greater benefit for women than for men. From this perspective, Range and Jenkins’ (2010) proposal to include instructions that emphasize mastery and control would lead to greater benefit for men but not for women. Alternatively, it is possible that incongruous writing instructions and communication styles are beneficial. If the instructions do not match an individual’s preferred communication style, then the individual might be challenged and benefit more by thinking in non-traditional ways. Cognitive theories argue that disclosure is helpful because participants can gain insight (Pennebaker and Francis 1996), then those insights should be improved with different perspectives. Asking someone to write in a manner that is opposite of their preferred communication style is one way to provide a differing perspective. For example, masculine writing instructions, one’s that emphasize mastery and control, may empower women and provide them with greater benefit. Future research should use linguistic content analysis to explore this matter in greater detail.

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Gender Differences in Emotion Like communication, emotion is an important feature of the expressive writing paradigm. Regardless of study variations, participants in the disclosure group are asked to write in a way that evokes emotion, while control participants are specifically asked to write in a nonemotional style about a neutral topic. Also like communication, there are distinct gender differences in emotion. Some of those differences can be traced to gendered socialization practices and normative pressures in society (Brody and Hall 2008; Grossman and Wood 1993), but cross-cultural research indicates there may be biological differences too (Fischer et al. 2004). In general, women are more emotionally expressive than men. When communicating, women use more emotion laden words, particularly for negative emotions (Glass 1992). In studies of emotion, women report feeling emotions more often and more intensely than men (Grossman and Wood 1993), particularly negative emotions such as sadness, fear, anxiety, hurt, shame, embarrassment (Brody and Hall 2008), and disgust (Nolen-Hoeksema and Jackson 2001). Also, they have longer and more robust responses to negative emotional stimuli than men (Gard and Kring 2007). Examining gender differences in negative emotions is particularly salient when examining the expressive writing paradigm because these are the emotions likely to be associated with trauma. This commentary will explore one particular negative emotion, shame, as well as culturally appropriate emotional expression, and the role of alexithymia in the emotional disclosure-outcome relationship. Some traumas (e.g. rape) carry a stigma, and as such are more likely to be associated with shame. Range and Jenkins (2010) maintains that those writing about “shaming trauma” are more likely to improve. However, she does not say why this might be or when this might occur, and it may not. Shame is a particularly difficult emotion to ameliorate. It is classified as a treatment resistant anxiety disorder (Sookman and Leahy 2009). Individuals with profound levels of shame often feel guilty and do not believe they deserve help. More importantly, they have limited capacity to soothe themselves through a self-talk process. Thus, they cannot access feelings of kindness and care vital to the healing process (Lee 2010), and they seem less able to cognitively sort out their actions (Parker and Thomas 2009). If these feelings are extremely strong, these individuals are likely to need assistance from a clinician and may not be aided by expressive writing. However, at lower levels expressive writing may help individuals with shame. Although, that is a matter for future research, the remainder of this discussion will focus on lower levels of shame, those that may be responsive to expressive writing.

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From a cognitive processing perspective, a shaming trauma should not be any different than any other trauma (Young 2009). If an individual can process the trauma, change his or her perspective about it, and integrate it into his or her own schema, then the trauma ceases to be a trauma (Pennebaker and Francis 1996). Shame would just be another part of that trauma that needs to be processed cognitively. However, difficulties are often encountered when treated shame exclusively from a cognitive basis and other perspectives are recommended (Lee 2009, 2010; Parker and Thomas 2009). One such perspective is a social integration theory, and from it, shame could pose a problem. Social integration theory examines the interaction between what occurs in an experiment and in society. It posits that emotional disclosure in a laboratory affects the manner in which individuals interact in society and that interaction produces health benefits (Pennebaker and Graybeal 2001). That perspective is more likely to be true in supportive societies, but shame traumas often carry a social stigma, particularly for females in some cultures such as Asian cultures where shame can lead to social ostracization (Kim 1995; Zane and Yeh 2002). In shame-avoidant cultures and among individuals with shame-avoidant ethnicities, disclosing shame traumas would likely have a negative effect on health outcomes. To test this, future research would need to examine the relationship between trauma type and ethnicity or culture by gender. Related research questions might include, What is the role of privacy of emotional disclosure among shame-avoidant participants? Does it attenuate the social implications of shame disclosure? If so, to what extent, and is the effect greater for women who are more likely to feel shame and experience the negative side effects of shame? For men, the situation differs. Their emotional stoicism is likely to have implications in outcomes of expressive writing. In addition to men displaying less emotion than women (Kring and Gordon 1998), they are more likely to suppress their emotions (Nolen-Hoeksema and Jackson 2001). As boys, they are socialized to be less expressive and more in control of their emotions, particularly those reflecting vulnerability such as fear, anxiety, hurt, shame and embarrassment (Brody and Hall 2008). These emotions are the ones likely to accompany trauma. If men fully suppress these emotions, they would not be likely to benefit from expressive writing, as chronic suppression of emotion is associated with negative health effects (NolenHoeksema and Jackson 2001). However, emotional disclosure through expressive writing should abate the negative health effects and benefit participants. To the extent that emotional disclosure through expressive writing can release those feelings in a socially acceptable manner, then expressive writing is likely to benefit males.

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To examine this, future research should include measures of individual attitudes and beliefs regarding socially appropriate emotional expression, particularly for vulnerable emotions. The idea that socially acceptable forms of emotion expression may be beneficial to men is consistent with Range and Jenkins’ (2010) idea that expressive writing may help those with masculine socializations by mitigating their stoicism and providing support. However, if men’s emotional stoicism cannot be mitigated, then they would not be likely to benefit from expressive writing. Range and Jenkins (2010) continues by suggesting this might be the case in individuals with alexithymia, and states that if expressive writing decreases alexithymia, then the benefits return. However, she does not explain why or how the alexithymia might decrease with expressive writing. Since current research indicates that alexithymia might be more prevalent among men than originally though, this is an area worthy of further discussion. Alexithymia is a recognized psychological disorder that impedes emotion processing. It is characterized by difficulty identifying feelings, describing feelings and verbally communicating feelings (Lumley 2004). In addition, individuals with alexithymia engage in externallyoriented thought. They have impoverished dream states, lack fantasy, make little use of symbolism, and have difficulty displaying empathy in interpersonal relationships (Levant et al. 2009; Lumley 2004). In severe cases, individuals with alexithymia are totally nonemotional. In 1992, Levant theorized that mild to moderate alexithymia was likely to occur among men who were socialized as boys using traditional masculine ideology. As boys, these men were discouraged from expressing or talking about their emotions, and some were punished for doing so. Subsequently, they did not develop an awareness of or a vocabulary for their emotions and developed alexithymia. Later, Levant dubbed this condition Normative Male Alexithymia and found empirical support for his theory (Levant et al. 2003, 2009). This disorder is important to examine within the expressive writing paradigm because neurobiological research shows that contrary to conventional wisdom, emotions are not the antithesis of rational thought. In fact, they may be critical to it. The limbic system is the portion of the brain that controls emotion, sensory perception, and long-term memory. Individuals with serious injury to their limbic system lost their ability to feel emotion and make even the simplest of decisions (Damasio 2005). This suggests that emotions and the ability to reason are biologically intertwined. If an individual is deficient in emotional processing (e.g. someone with alexithymia) and emotions are needed for rational thought, then that individual would not be able to reap the benefits of

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emotional disclosure. Empirically, a few studies examined alexithymia in the expressive writing paradigm, and the majority found limited benefit for individuals with alexithymia (Lumley 2004; O’Connor and Ashley 2008; Páez et al. 1999; Solano et al. 2003). Only one study that included alexithymia in expressive writing found that it had no effect on the outcomes, but in that study only five patients were reported to have alexithymia (van Middendorp and Geenen 2008). Irrespective of sample size, a more important issue is that none of these studies examined alexithymia by gender. Since men are more likely to have alexithymia than women, their participation in emotional disclosure through expressive writing should result in worse outcomes than for them than for women. Future research should continue to include measures of alexithymia and examine alexithymia results by gender.

Conclusion Range and Jenkins (2010) identifies conditions under which men may benefit more from emotional disclosure using Pennebaker’s expressive writing paradigm than women. She grounds her work in gender socialization, social role and gender schema theories and offers numerous research recommendations. However, gender differences favoring men have not been clearly established in the expressive writing literature. They are suggestive at best. I begin by taking another look at the few expressive writing studies which included a test of gender differences, then expand her work and offer other research recommendations. If there is one thing that is clear about Pennebaker’s expressive writing paradigm, it is that its effects are not clear. Most of the time it works, sometimes it doesn’t. For most people there seems to be a positive effect, but for others, there isn’t. Sometimes there is a gender effect favoring men, and other times it favors women. This area of research is particularly complex and seems to generate more questions than answers. Nearly all of the literature on expressive writing adopts a purely psychological view, but it has not provided clear answers, only more questions. This commentary adopts a different perspective and looks at possible gender differentiated outcomes in expressive writing using a communication and emotion framework. Both communication and emotion are key features of the expressive writing paradigm, and yet they have been rarely studied. Much has been written about gender differences in both domains. In communication, this commentary explores possible gender differences based on whether a traumatic event was previously disclosed, women’s tendency to ruminate, and the effect of congruence between written

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instructions and communication style. In the emotion domain, it looks at the role of a particular negative emotion, shame, socially appropriate emotion expression, and the potential for alexithymia to impede the emotional disclosure-health benefit relationship in men. On the whole, research on emotional disclosure is extremely complicated because emotions are affected by sociocultural, cognitive, biological, and behavioral factors (Brody and Hall 2008). The research recommendations put forth in this commentary were designed to provide a different perspective and hopefully will help to advance our understanding of these complex relationships.

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