Journaling Protocol for Mental & Physical Health

Expressive Writing

Expressive Writing is a science backed writing exercise with hundreds of peer reviewed studies exploring its procedure and benefits. It involves writing about a traumatic event that has happened to you in a specific way, to help you remap your relationship to the event over time. It has a wide range of potential benefits with studies showing improvements in student GPAs, memory, arthritis, fibromyalgia, asthma, anxiety, stress, depression, wound healing, blood pressure, and more. These benefits can be long lasting, and come from a relatively short intervention of 4 sessions of 15-30 minutes each over a week or a month.

Last Updated Jan. 18th 2024

Ameer Ayoub

Researched and Written By

This page has not been professionally fact checked.

Protocol: How to implement expressive writing
Potential Benefits: Long term improvements across a wide number of health metrics
Risks: Downsides of self guidance and factors of efficacy
Mechanisms: How does writing affect physical ailments?
Protocol Methodology: Notes on effective interventions
References & Other Resources
Related Research Articles

Protocol: How to implement expressive writing

This protocol is designed to elicit a strong emotional response. It is likely that you will stir strong emotions in you. Should you find the exercise unbearably overwhelming, feel free to stop anytime should you need to.

Requirements

4 sessions over 4 weeks of 25-40 minute of uninterrupted time.
A pen and paper, word processor, or use the Jopro Expressive Writing editor.

Writing Prompt

Write about something that you are thinking about or worrying about way too much. Or, if you're not thinking about or worrying about something way too much, perhaps you've deliberately tried to not think about this series of events or event, something that you've been dreaming about at night, perhaps in disturbing dreams or something that you feel is affecting your life in an unhealthy way either internally or externally. So it could be in your emotional state, your inability to calm down when you want to be calm, maybe you're ruminating maybe even compulsive thought maybe it's leading to addictive or compulsive or habitual behaviors or perhaps you can identify by a specific trauma or set of traumas that you know are really plaguing your body and mind.

I want you to write down your deepest emotions and thoughts as they relate to the most upsetting experience in your life. Really let go and explore your feelings and thoughts about it as you write you might tie this experience to your childhood, your relationship with your parents or siblings, people you have loved or love now, or even your career or schooling. How has this experience related to who you have now become, who you have been in the past, and who you would like to be?

Many people have not had a truly traumatic experience in their lives, but everyone has had major conflicts or stressors and you can write about the most dramatic or stressful experience you've ever had.

Protocol Guidelines

Take your time to consider what you will write about before you start.
This writing is for your eyes only. Don't share it. You should feel uninhibited to write down your deepest thoughts. If you do choose to share it, do so with a trained mental health professional.
Set aside 30 uninterrupted minutes for this exercise, as well as a 10 minute cooldown period after.
Write in complete sentences, but do not pay attention to spelling or grammar.
Write continuously for at least 15 minutes, and at most 30.
Do this exercise 4 times. Use the same topic for all 4 iterations. You can do it for 4 consecutive days or 4 consecutive weeks or something in between. It is not recommended to space it out more any more than that.
As directed by the prompt, write about 3 areas: The details of the event, your thoughts and feelings about it (then and now), and how the event relates to other aspects of your life.

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Potential Benefits: Long term improvements across a wide number of health metrics

Improved immune system function
- Fewer health center visits in the following 6 months after completing the protocol. (Confronting a traumatic event: Toward an understanding of inhibition and disease, 1986)
- Increased immune system efficacy (higher blastogenic response of T-lymphocytes to some mitogens). (Disclosure of traumas and immune function: Health implications for psychotherapy, 1988)
- Decrease in inflammation as marked by C-reactive Proteins (CRP) (related to improved emotional regulation). (Divergent associations of adaptive and maladaptive emotion regulation strategies with inflammation., 2013)
Improved cardiovascular function
- Reduction in systolic and diastolic blood pressure in those with elevated blood pressure. (Autonomic effects of expressive writing in individuals with elevated blood pressure, 2005)
- Reduction in heart rate and increase in heart rate variability in people after marital separation. (Impact of Narrative Expressive Writing on Heart Rate, Heart Rate Variability, and Blood Pressure After Marital Separation, 2017)
Significantly increased rate of wound healing in punch biopsy patients. (The effects of expressive writing before or after punch biopsy on wound healing, 2016)
Improvements in anxiety, stress, and depression
- Reduction of elevated secretory immunoglobulin A (s-IgA) in depressed japanese female students. (Effects of Expression and Inhibition of Negative Emotions on Health, Mood States, and Salivary Secretory Immunoglobulin a in Japanese Mildly Depressed Undergraduates, 2004)
- Self reported decrease in long term subjective distress. (Disclosure of traumas and immune function: Health implications for psychotherapy, 1988)
- Reduction in Major Depressive Disorder (MDD) scores (as measure by the Beck Depression Inventory and Patient Health Questionnaire). (An everyday activity as a treatment for depression: The benefits of expressive writing for people diagnosed with major depressive disorder, 2013)
- May reduce the severity of psychosis in PTSD patients. (Written emotional disclosure following first-episode psychosis: Effects on symptoms of post-traumatic stress disorder, 2010)
- Reduced symptoms of post traumatic stress and depressive symptoms in preterm birth mothers. (Improving Maternal Mental Health Following Preterm Birth Using an Expressive Writing Intervention: A Randomized Controlled Trial, 2015)
Improved lung function in those with moderate asthma over the following 12 months. (The Effects of Expressive Writing on Lung Function, Quality of Life, Medication Use, and Symptoms in Adults With Asthma, 2015)
Improvements in cognition and academic performance
- Increased autobiographical memory specificity. (The Benefits of Expressive Writing on Autobiographical Memory Specificity: A Randomized Controlled Trial, 2011)
- Increased GPAs in college students with physical ailments. (Stress management through written emotional disclosure improves academic performance among college students with physical symptoms., 2003)
Improvements to joint function in Rheumatoid Arthritis (RA) for "high expressors". (Health effects of emotional disclosure in rheumatoid arthritis patients., 1997)
Improved short term physical health for breast cancer patients. (Effect of Expressive Writing Intervention on Health Outcomes in Breast Cancer Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, 2015)
Reduction in pain and fatigue in Fibromyalgia patients (Written emotional expression produces health benefits in fibromyalgia patients, 2005)

Risks: Downsides of self guidance and factors of efficacy

The protocol will elicit strong emotions, however if those emotions are unbearable then unguided expressive writing may not be for you. Expressive writing is not a replacement for seeking professional help from a psychiatrist, therapist, or doctor. In general the protocol is safe for most people, and there is a wide body of research supporting that is effective. The mechanism by which it works is not completely understood and there are some factors that may decrease the efficacy of the protocol. Many articles note that the protocol increases stress in the short term.

Being an unguided and unassisted exercise may be a weakness of the protocol. One study published in 2000 was unable to replicate results and cautions that "there may be negative consequences of exposing traumatic experiences in the absence of supportive therapy to contain and fully integrate the experiences." Indeed, identity and how this changes, and how you process the traumtic event you're writing about, and how it changes over the four sessions is important. An article from 2001 discusses the ability to work through emotions as important to the effect. It seems reasonable that in some cases this may not be possible without external guidance. Studies which were unable to replicate Pennebaker's results are relatively limited in comparison to research building upon or providing supporting evidence.

There is very little evidence that following the protocol will worsen symptoms. A 2014 study in patients with type 2 diabetes in the UK found that WED (written emotional disclosure) worsened depressive symptoms and diet adherence, however the intervention did not fully encompass the expressive writing protocol and simply focused on emotional disclosure.

There is also a risk of the protocol not working for you. In certain studies benefits varied by certain conditions such as how expressive you were in the writing, such as one study that looked at t-cell response to mitogens showing high expressors as having stronger immune responses. In others, cultural or socioeconomic factors were found to influence efficacy. In a 2004 study in women with chronic pelvic pain, it was found that positive effects were more prominent to subjects who were more ambivalent towards the process.

Mechanisms: How does writing affect physical ailments?

In general expressive writing is thought to work by changing prefrontal cortex activity. Truth telling about traumatic events induces activity in the prefrontal cortex, allowing the brain to create a more coherent narrative about the event leading to sustained function of the prefrontal cortex. The prefrontal cortex, and brain in general, affects the immune system as studies in the field of psychoneuroimmunology have shown.

Expressive writing has been shown to have a biological impact on the immune system. One of the first studies to look at how expressive writing can influence physical biomarkers was a 1988 study which found that expressive writing led to increased immune system efficacy. This was seen as an increased response of T-lymphocytes or T-cells, a type of white blood cell, to certain kinds of mitogens which mimics a bodily infection. We can see the effects of this in decreased health center visits in the following 6 months after completing the protocol.

How does expressive writing have this impact? One leading theory is that traumatic events change our physiology. When we encounter stressful events this reduces the ability of our prefrontal cortex from reasoning well and creating a coherent structural narrative about the event. Recounting traumatic events in a truthful way increases activity in the prefrontal cortex, and neuroplasticity, and essentially a remapping of the traumatic event. When you look at the expressive writing exercise, in general, people tend to get less emotionally expressive over time and go from a more free form expression to a more structured narrative. This in fact increases activity in the prefrontal cortex in a sustained way, and the improved prefrontal cortex function leads to phyical improvements. One supporting piece of evidence can be found in "Frontal brain asymmetry and immune function" which showed that assymetry in the prefrontal cortex was correlated with immune system function.

Protocol Methodology: Notes on effective interventions

Many studies vary in the exact protocol they execute. For example and the number of times the exercise is carried out varies, with some studies only doing it 3 times, and others doing it more. The amount of time and the exact instructions also varies, and whether it was done on a computer or not. In general there does not seem to be a huge difference in the efficacy of these variations.

The protocol we have listed out is a combination of advice and guidance from different articles, and mainly is derived from the advice given by Dr. Andrew Huberman in the related podcast titled "A Science-Supported Journaling Protocol to Improve Mental & Physical Health" [Transcription]. The primary text for the intervention however is taken from the original 1986 paper.

As noted in the risks section, there are some factors which may decrease the efficacy of the protocol. In addition there are some factors that may increase the efficacy. One such factor is your expectation around the results of the protocol. One 2007 paper looked at the role of expectation in expressive writing in 40 female college students and found decreased interpersonal sensitivity and alienation to those who where given the expectation that the expressive writing intervention would help them. Those who expected more from the exercise ended up getting more out of it.

Another interesting and related finding is around the amount of time given to the exercise. While most studies investigate longer writing sessions, this study from 2008 hinted that even a 2-minute writing session could be beneficial. In essence, there may be some benefit from engaging with the protocol regardless of the time spent though we recommend longer sessions of at least 15 minutes.

References & Other Resources

One of the most accessible references for this protocol is the Huberman Lab Podcast episode titled "A Science-Supported Journaling Protocol to Improve Mental & Physical Health" [Transcription]. Much of the information presented in the episode has been captured here.

Expressive writing is sometimes referred to as the "Pennebaker Paradigm" and EWI (for Expressive Writing Intervention) and is aligned with the assimilation model of psychotherapeutic change. Expressive writing is a form of Emotional Disclosure (ED), though not all articles referring to Emotional Disclosure are referring to an intervention that is expressive writing.