May/June 2007

Writing Wrongs — Putting Pain on Paper
By Bill Asenjo, PhD, CRC
Social Work Today
Vol. 7 No. 3 P. 42

Recording the deepest thoughts and feelings about stressful events can be healing for body and mind.

The Associated Press reported in April 2006 that the number of U.S. soldiers who took their own lives in 2005 was the highest since 1993. Studies reveal a high rate of suicide among war veterans, particularly those with posttraumatic stress disorder (PTSD). A 2003 New England Journal of Medicine study found that one out of six Iraq and Afghanistan veterans were suffering from PTSD, yet more than 60% of them were unlikely to seek help.

One Veteran’s Way Out
In 1991, Vietnam veteran John Mulligan was a homeless “shopping cart soldier” wracked with flashbacks and numbed by PTSD. But his life changed during a veterans’ writing workshop.

Mulligan wrote about a horrific scene from the war—fellow soldiers turning their weapons on a water buffalo for fun and misplaced revenge. He described the blood, noise, senseless loss, and waste.

He later wrote that he left the workshop so elated, he was “whistling and skipping.” Mulligan discovered that putting past horrors into words helped clear his mind and lift his spirits.

More than one hundred studies echo Mulligan’s conclusion: Writing about stressful events can be powerfully therapeutic for the body and mind.

Confronting Dark Memories
Suicide among veterans is not a recent trend. A study published in the American Journal of Psychiatry in 1991 revealed that among the Vietnam veterans with PTSD involved in the study, 20% had attempted suicide, and another 15% had been preoccupied with suicide since the war.

According to the last U.S. Census in 2000, there were 26 million veterans. PTSD remains an ongoing challenge for veterans of all eras and their families. Images from the current war are causing many veterans who served in World War II, Korea, and Vietnam to reexperience PTSD symptoms from their own combat experiences.

The National Center for PTSD has estimated that one out of 20 World War II veterans has suffered symptoms such as bad dreams, irritability, and flashbacks. According to the Department of Veterans Affairs' 2004 statistics, 25,000 World War II veterans were still receiving disability compensation for PTSD-related symptoms.

Researchers estimate that as many as 30% of Korean War veterans have PTSD symptoms. The National Vietnam Veterans Readjustment Survey (1986-1988) found that more than 30% of Vietnam Veterans (more than 1 million) have suffered from symptoms of PTSD. Statistics have risen over the decades for numerous reasons, including the level of guerilla warfare encountered, as well as the attention such conditions have received.
According to the 1999 National Survey of Homeless Assistance Providers and Clients, one in three homeless men in America were veterans, and among homeless veterans, 76% suffered from drug, alcohol, or mental health problems.

Recent news reports of the conditions at Walter Reed Army Hospital spotlight the fact that spending for VA mental health services has declined by 25% during the past decade. Many experts have expressed concern about the system’s capabilities to care for the readjustment needs, including mental health, of the newest generation of U.S. veterans.

Yet researchers have repeatedly found that most people are able to improve their mental and physical health after writing about deeply troubling experiences. James Pennebaker, PhD, a University of Texas professor of psychology, began therapeutic writing research in the 1980s and has led many studies.

According to Pennebaker, those who demonstrated the greatest improvements in health were those who did not feel free to confide their deepest thoughts and feelings to others. Moreover, Pennebaker found that the benefits of therapeutic writing are not strictly emotional.

One of Pennebaker’s earliest studies, which appeared in the April 1988 issue of the Journal of Consulting and Clinical Psychology, revealed that those involved in the study continued to experience enhanced immune function six weeks after writing about stressful events, evidenced by an increase in T-lymphocyte cell activity.

Other studies have reported that people visit doctors less frequently, experience improved ability to function on a daily basis, are rehired more quickly after losing their jobs, and score higher on tests of psychological well-being after therapeutic writing exercises.

Physical Conditions
A study published in the April 14, 1999, issue of The Journal of the American Medical Association (JAMA) revealed that therapeutic writing can ease the symptoms of asthma and rheumatoid arthritis.

The study involved 70 people with asthma or rheumatoid arthritis asked to write about the most stressful event in their lives. Participants wrote about their emotional pain for 20 minutes without interruption on three consecutive days. Another group of 37 patients wrote about their plans for the day.

Four months later, 47% of the group who wrote about past traumas showed significant improvement—less pain and greater range of motion for the arthritis patients; increased lung capacity for the asthmatics—while only 24% of the group that wrote about their daily activities showed any progress.

Stress
According to Pennebaker, the reason writing about stressful experiences works is the connection between stress and disease. Drawing from the pioneering effort of Hans Selye, The Stress of Life, Pennebaker also cites more recent research about the stress response in Robert Sapolsky’s Why Zebras Don’t Get Ulcers.

Numerous studies have found that prolonged emotional stress weakens the immune system, promotes heart disease, and worsens diseases such as arthritis and asthma. The December 16, 1998, issue of the Journal of the National Cancer Institute featured a study indicating that older adults who were depressed had nearly double the risk of developing cancer.

Putting traumatic memories into words can help ease emotional turmoil and defuse anger. According to Pennebaker, writing enables someone to gain a sense of control and understanding. Writing about a stressful event helps someone break down overwhelming and troubling memories, thereby enabling the writer to make better sense of them and rendering them more manageable.

Job Loss
Spera et al (1994) conducted one of the first studies focusing on writing and job loss, which took place at Texas Instruments in Dallas after their first massive layoff in 1990. Participants included 63 Texas Instruments professionals who had been laid off at the same time. All held engineering or other professional positions. Those participating in the study wrote about one of the two following topics:

• their deepest thoughts and feelings surrounding the layoff and how their personal and professional lives had been affected; or

• their plans for the day and their job search activities.

The results revealed that participants who wrote about the trauma of losing their jobs were much more likely to find employment in the months following the study than the participants who wrote about their general plans. After writing about their anger and fear, participants were able to handle themselves better during interviews.

Home Remedy for PTSD
In one study, veterans with PTSD who wrote about their traumatic memories carried beepers for 24-hour access to counselors. Yet Mulligan never had a beeper, counselor, or even a home when he confronted his past. He frequented cafeterias and sat on park benches while filling his notebook with horrific images, taking breaks when the memories grew too upsetting. For Mulligan, writing was often a struggle, but it was also a matter of survival.

Pennebaker encourages people to try writing therapy on their own, as long as they follow one rule: If you can’t handle it, quit. In his book Opening Up, Pennebaker recommends writing about life’s stresses whenever one feels down.

Like Mulligan, people can face their demons, which always seem more manageable on paper.

More About Mulligan
Born in Scotland in 1950, Mulligan immigrated with his family to Indianapolis in the late 1960s. At the age of 17, he joined the Air Force.

He soon found himself on the front lines in Vietnam as a weather observer, watching as his buddies were shot or blown up beside him. After six years of service, he was changed forever.

Returning home, Mulligan married, had a daughter, and worked as a machinist. But when PTSD kicked in, he began drinking and drugging heavily. He walked out on his family in 1980 and spent the next decade on the streets, pushing shopping carts piled with his belongings and sleeping anywhere he could.

Mulligan struggled with alcoholism, drug addiction, homelessness, and nightmares like so many other Vietnam veterans haunted by combat experience demons.

In 1991, Mulligan attended a writing workshop held at a VA hospital that changed his life and led to his novel Shopping Cart Soldiers. Literary fame brought stability for a couple years, but he stumbled to the streets again.

With the help of friends and fellow writers, Mulligan struggled back to stability to write parts of four more novels, short stories, and a book offering advice to other vets about PTSD. He was also about to get married.

That all ended on the evening of October 12, 2005, as Mulligan crossed a busy street to his Mountain View, CA, home. A car hit him, and he died instantly.

Mulligan’s fiancée, poet Kristen Jensen, said, “He fought hard against his pain, right up to the end, and he turned it into something useful for other people through his writing. No matter how far he fell, he never gave up.

“He was completely normal most of the time” Jensen added. “But he was always walking with the ghosts of his Vietnam buddies.”

Those ghosts came to life in his novel—which won the PEN Award for outstanding writing—as he wove the tale of soldier Finn MacDonald, set in the battlefields of Vietnam and the homeless haunts of San Francisco.

In an interview, Gerald Nicosia, author of Home to War: A History of the Vietnam Veterans’ Movement, said he thought Shopping Cart Soldiers was one of the preeminent novels showing the aftereffects of the Vietnam War on the psyche. Nicosia said that many vets had told him Mulligan’s work helped them understand their own experience.

How to Start Writing
According to Pennebaker, it may not be necessary to write about the most traumatic experience of your life. It can be more important to focus on issues that occupy too much of your present thinking or dreaming. If there is something that you’d like to tell others but can’t for fear of embarrassment or punishment, express it on paper.

Although many people write in diaries every day, most entries do not grapple with fundamental existential and psychological issues. Pennebaker points out that while writing is therapeutic, it is not a substitute for action.

Pennebaker suggests that in many cases, it may be wise to keep what you’ve written to yourself or perhaps destroy it when finished (though many people find this difficult to do). The rationale is that if you plan to show what you’ve written to someone else, that will likely affect your mindset while writing.

Guidelines
• Write only for yourself; there’s no need to share what you’ve written with anyone.

• Spelling, grammar, and punctuation are not important.

• Choose a quiet, undisturbed environment, if possible.

• If you find yourself getting too upset, stop.

• Write about a different topic each day or continue the same topic.

• If you’re unable to write, use a recorder.

Suggestions
• Focus on thoughts and feelings.

• Use all your senses—describe colors, sounds, odors.

• Explore whether there have been any changes since the experience.

• Write about what you have learned.

• Ask yourself: What matters more now? Less? Why?

Final Note
Bear in mind that it may be uncomfortable, even painful, at first. But studies repeatedly show that almost everyone’s discomfort diminishes as they continue to write. Lastly, this bears repeating: If you find yourself getting too upset, stop.

— Bill Asenjo, PhD, CRC, is a board certified rehabilitation counselor and a consultant. He began writing during his recovery from multiple brain tumor surgeries. He conducts writing workshops and presentations for a variety of audiences.

Books About Personal Struggles

• Cousins, N. Anatomy of an Illness as Perceived by the Patient. Bantam. (life threatening illness)

• Drescher, F. Cancer Schmancer. Warner Books. (cancer)

• Frank, A. Anne Frank: The Diary of a Young Girl. Bantam. (Holocaust)

• Frankl, V.E. Man’s Search for Meaning. Pocket. (Holocaust)

• McCourt, F. Angela’s Ashes. Scribner. (alcoholism, poverty, abuse)

• Powell, D. My Tour in Hell: A Marine’s Battle with Combat Trauma. Loving Healing Press. (posttraumatic stress disorder, alcoholism, divorce, unemployment)

• Radner, G. It’s Always Something. Harper. (cancer)

• Stringer, L. Grand Central Winter. Washington Square Press. (addiction, trauma, homelessness)

• Styron, W. Darkness Visible: A Memoir of Madness. Vintage. (suicidal depression)

Popular Books About Therapeutic Writing and Journaling

Abercrombie, B. (2002). Writing Out the Storm: Reading and Writing Your Way Through Serious Illness and Injury. St. Martin’s Griffin.

Adams, K. (1998). The Way of the Journal: A Journal Therapy Workbook for Healing. Sidran Press.
Baldwin, C. (1991). One to One: Self-Understanding Through Journal Writing. Evans Publisher

DeSalvo, L.A. (2000). Writing As a Way of Healing: How Telling Our Stories Transforms Our Lives. Beacon Press.

Doane, S. (1996). New Beginnings: A Creative Writing Guide for Women Who Have Left Abusive Partners. Seal Press.

Fox, J. (1997). Poetic Medicine: The Healing Art of Poem-Making. Tarcher Press.
Goldberg, N. (1986). Writing Down the Bones: Freeing the Writer Within. Shambala Press.

Lepore, S. and Smyth, J. (Eds.) (2002). The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being. American Psychological Association.

Myers, L. (2003). Becoming Whole: Writing Your Healing Story. Silver Threads.

Pennebaker, J.W. (1997). Opening Up: The Healing Power of Expressing Emotions. Guilford Press.

Pennebaker, J.W. (2004). Writing to Heal: A Guided Journal for Recovering from Trauma and Emotional Upheaval. New Harbinger Press.

Rainer, T. (1979). The New Diary: How to Use a Journal for Self-Guidance and Expanded Creativity. Tarcher Press.

Zimmerman, S. (2002). Writing to Heal the Soul: Transforming Grief and Loss Through Writing. Three Rivers Press.