THERAPEUTIC JOURNALING

WHAT IS THERAPEUTIC JOURNALING?

Therapeutic journaling is the process of writing down our thoughts and feelings about our
personal experiences. This kind of private reflection allows us to sort through events that
have occurred and problems that we may be struggling with. It allows us to come to a
deeper understanding about ourselves, with a different perspective on these difficulties.
Therapeutic journaling differs from more traditional diary writing, which involves
recording the details of daily events. In contrast, therapeutic journaling is an internal
process of using the written word to express the full range of emotions, reactions and
perceptions we have related to difficult, upsetting, or traumatic life events. Along the way,
this process can mean writing ourselves to better emotional and physical health and a
greater sense of well-being.

THERAPEUTIC WRITING PROTOCOLS

Therapeutic journaling can be done by keeping a regular journal to write about events that
bring up anger, grief, anxiety, or joy that occur in daily life. It can also be used more
therapeutically to deal with specific upsetting, stressful, or traumatic life events. An
expressive writing protocol developed by Dr. James Pennebaker is the most widely used
and researched method utilized in clinical practice. This writing protocol has been linked
to improvements in both physical and psychological health. It has been used in non-clinical
and clinical populations. The expressive writing protocol consists of asking someone to
write about a stressful, traumatic or emotional experience for three to five sessions, over
four consecutive days, for 15-20 minutes per session. Research has found it to be useful as
a stand-alone tool or as an adjunct to traditional psychotherapies.

Other forms of expressive writing include autobiographical writing where a person reflects
on important life events to give meaning to them and build a sense of personal identity.[1]
This type of writing assists a person in recognizing themselves as the authors of their
experiences with a feeling of personal agency and allows reflection on their life path to
better understand the present situation.[2] McAdams developed a therapeutic writing
technique, the “Guided Autobiography,” aimed at exploring, in the span of ten weekly two-
hour sessions, the most important events of a person’s life around a specific life theme (i.e.
family, money, work, health, spirituality, death, aspirations)[3]. This Guided
Autobiography exercise has been found to be an effective method to enable participants to
understand and appreciate their life stories to increase optimism and self-esteem.[4]

One additional form of therapeutic writing is gratitude expression exercises, including a

Gratitude Letter where a person writes a letter to a person they have never sincerely
thanked and Gratitude Journaling, where a person identifies at least three good things that
happened that day and reflects on their causes and impact. (Refer to the “Creating a
Gratitude Practice” tool.)

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Gratitude journal interventions have been proven to increase well-being, positive affect,
social relationships, optimism, life satisfaction, and to lower negative affect and depressive
symptoms.[5] A gratitude journal intervention was also found to improve veterans'
gratitude over time, and to have positive effects on their psychological well-being.[6]

HOW IT WORKS
Emotional expression has been found to be good for our health. It enhances our immune
system functioning. When upsetting or traumatic events occur, we often are not able to
fully process what happened, and the event and the emotions around what occurred
become stuck in our memory. The simple act of expressing thoughts and feelings on paper
about challenging and upsetting events can allow us to move forward by openly
acknowledging, accepting, expressing and letting go of the feelings involved. Expressive
writing also provides an opportunity to construct a meaningful personal narrative about
what happened. It brings clarity and enables us to place our experience into the context of
our larger place in the world. Expressive writing helps to make cause and effect links
between life events and increases our capacity for self-reflection, awareness and resilience.

The benefits of writing also include self-regulation, clarifying life goals, gaining insight,
finding meaning and exploring different points of view.[7] Writing can foster positive
emotions as putting feelings and thoughts into words widens our scope of attention, sparks
the search for solutions and allows the mind to be more flexible.[8]

Writing about traumatic or particularly painful situations, may also generate forgiveness in
interpersonal conflict and can promote feelings of wisdom and hope in difficult situations
as it assists us in going beyond our suffering to reaching more positive perspectives.[9,10]
(Refer to the “Forgiveness” tool.)

In expressive writing, an important element consists of feeling completely honest and free
to write anything, in a safe and private context without necessarily sharing the content
with another person. Conversely, the outcome of talking about difficult or traumatic life
experiences depends on the listener’s capability to comprehend and accept the patient’s
narrative.[11] As a result, the interactions with a therapist could be particularly stressful
for individuals discussing particularly painful topics or sensitive experiences or for those
who have social anxiety and feel anxious sharing vulnerable things with another
person.[12]

According to Pennebaker, who first investigated therapeutic journaling for traumatic

events, but later expanded the focus to general emotional events or specific experiences,
what makes writing therapeutic is that the writer openly acknowledges and accepts their
emotions and becomes able to give voice to his/her blocked feelings and to construct a
meaningful story in a safe environment.[11]

RESEARCH
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Over the past 35 years, a growing body of research has demonstrated the beneficial effects
that writing about traumatic or stressful events has on physical and emotional health. Dr.
Pennebaker, one of the first researchers in this area, found that writing about emotionally
difficult events or feelings for just 20 minutes at a time over four consecutive days was
associated with both short-term increases in physiological arousal, higher blood pressure
and negative moods following the writing but long-term decreases in health problems, such
as immune system functioning and fewer visits to a health center in the six months
following the study.[13,14] Smyth conducted a meta-analysis of 13 studies of written
emotional expression with healthy participants and found specific benefits in objective or
self-reported physical health, psychological well-being, physiological functioning, and
general functioning outcomes.[15] This finding suggests that the effects of written
emotional expression are substantial and similar in magnitude to the effects of other
psychological interventions, many of which can be time-consuming and expensive.[15]

Frisina et al. conducted a meta-analysis of nine studies on written emotional disclosure on

clinical populations and found significant benefit for health outcomes in medically ill
populations but did not find any psychological health outcomes in psychiatric
populations.[16]

More recently, Sohan et al. conducted a meta-analysis of 20 journaling intervention studies

and their findings support the wide use of journaling in many forms of psychotherapy for a
broad range of mental illnesses. They found an average statistically significant 5%
reduction in patient scores on mental health measures compared with control groups, with
a greater benefit in anxiety and PTSD symptoms, and a lesser benefit in depression.[17]

Several meta-analyses have been conducted over the last 30 years on the Pennebaker
expressive writing protocol that showed small to moderately sized beneficial effects in
improving PTSD symptoms.[16,18-20] For example, in 2012 Emmerik, Reijntyes and
Kamphuis conducted a meta-analysis investigating the efficacy of expressive writing for
treatment of posttraumatic stress conditions (e.g., acute stress disorder and PTSD) and
comorbid depressive symptoms. It resulted in significant and substantial short-term
reductions in posttraumatic stress and depressive symptoms. There was no difference in
efficacy between writing therapy and trauma-focused cognitive behavioral therapy.
Another meta-analysis by Pavlacic et al., provided additional insight that expressive writing
produced a small overall effect size for posttraumatic stress but negligible to small effect
sizes for posttraumatic growth and quality of life.[21]

In another study, enhanced expressive writing (i.e., writing with scheduled contacts with a
therapist) was found to be as effective as traditional psychotherapy for the treatment of
trauma in patients. Expressive writing without additional talking with a therapist was
found to be only slightly inferior. The researchers concluded that expressive writing could
provide a useful tool to promote mental health with only minimal contact with a
therapist.[22]

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Another meta-analysis explored 39 randomized controlled trials of expressive writing with

64 intervention‐control group comparisons in a physically healthy adult population with
varying degrees of stress but without PTSD. Expressive writing did not yield significant
long‐term effects on depressive symptoms. However, effects were larger when the number
of sessions was higher and when the writing topic was more specific. The results of this
meta‐analysis did not support the effectiveness of brief, self‐directed expressive writing as
an intervention that decreases depressive symptoms in physically healthy adults with
varying degrees of psychological stress.[23]

Expressive writing may also hold promise as a nonstigmatizing, accessible, resource-

efficient intervention for some veterans. One study found that the Veterans experiencing
reintegration difficulties most likely to benefit from expressive writing and experiencing a
significant reduction in distress were those without probable PTSD, with higher social
support, and with less combat exposure.[24] In this study, most veterans reported
moderate reductions in distress while a very small percentage reported very large
decreases in distress. However, some veterans did not change at all and a small percentage
reported increases in distress.

Two studies evaluated the effectiveness of expressive writing for solders about the feelings
associated with challenges of reintegrating back into civilian life and relationships. In the
first study Sayer et al. found that solders in the expressive writing group experienced some
significant reductions in anger, physical symptoms, distress, PTSD symptoms and
reintegration difficulties.[25] In the second randomized clinical trial by Baddeley and
Pennebaker, the effectiveness of expressive writing(on paper during three fifteen minute
sessions) about emotions surrounding the transition home by soldiers returning from Iraq
or Afghanistan and reuniting with their spouse was evaluated.[26] Couples reported
greater marital satisfaction one month later if the soldier engaged in expressive compared
to non-emotional writing, Effects were greatest for those couples with a soldier reporting
higher combat exposure.

Importantly, adding writing techniques to talk therapies was found to reduce the length of
treatment and improve access to psychological therapies.[22,27] The integration of writing
techniques within traditional talk therapies or other therapeutic interventions could be
easily done through using app, emails, online journals or social networks which could be
more appealing for younger patients.[28]

WHO CAN BENEFIT

Expressive writing has been found to produce significant benefits for individuals with a
variety of medical conditions including:[29]

• Lung functioning in asthma

• Disease severity in rheumatoid arthritis
• Pain and physical health in cancer
• Immune response in HIV infection
• Hospitalizations for cystic fibrosis
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• Pain intensity in women with chronic pelvic pain

• Sleep-onset latency in poor sleepers
• Post-operative course

In addition, it can be helpful for assistance with specific life circumstances, including:

• Break-up with life partner[30]

• Death of loved one[31]
• Unemployment[32]
• Natural disaster[33]
• General stressful events[34]

These benefits were found across individuals with different educational levels or writing
skills.[35]

Expressive writing has been concluded to be beneficial also as a “stand alone” technique for
the treatment of anxiety and post-traumatic stress disorder symptoms and to a lesser
extent for depression and anxiety.[36,37] In one study, enhanced expressive writing (i.e.,
writing with scheduled contacts with a therapist) was found to be as effective as traditional
psychotherapy for the treatment of trauma in patients. Expressive writing without
additional talking with a therapist was found to be only slightly inferior. The researchers
concluded that expressive writing could provide a useful tool to promote mental health
with only minimal contact with a therapist.[22]

Therapeutic journaling constitutes a useful treatment alternative for patients who do not
respond to other evidence-based therapies. It may be especially useful for reaching trauma
survivors in need of evidence-based mental health care who live in remote areas.
Therapeutic journaling can also be a way to reach people who are unwilling or unable to
engage in psychotherapy.

Expressive writing may be contraindicated for individuals who do not typically express
emotions or who have severe trauma histories or psychiatric disorders.[38-40] When
therapeutic journaling causes very intense levels of distress or cognitive rumination, it is
not advisable to continue the writing exercise.[11]

It is important to note that expressive writing can trigger a sense of shame and
embarrassment when someone else reads the writing and can cause resistance to writing
down negative thoughts and feelings.[11] In these cases and often in general, it is
recommended that the writing remain confidential but to still provide psychological
support so that the negative emotions can be discussed with a trusted clinician.

THERAPEUTIC JOURNALING INSTRUCTIONS

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This writing exercise is useful for dealing with emotional upheavals or traumas. It is a four-
day writing program that has proven effective for improving mental and physical health. It
is best to do your writing in a meaningful place, time, and atmosphere, so think about
finding a location where you will be undisturbed by others, your phone, e-mail, etc.

It is important to think about what your writing topic will be. You might pick an
emotionally upsetting event that is bothering you. If you have faced a massive trauma, it is
best not to write about it for several weeks afterwards, as it may be too difficult to deal
with some of the emotions that arise around what happened. Trust where your writing
takes you. You might start writing about a traumatic experience and then find yourself
writing about something entirely different.

For the next four days, please write about an emotionally upsetting or traumatic event that
has had a strong impact on you. During your writing, you are encouraged to explore your
deepest emotions and thoughts about this difficult life experience. As you write about this
topic, you might tie it to your relationships with others. You may relate it to your past,
present, or future, or you may connect it with who you may have been, who you would like
to be, or who you are now. You may write about the same general issues or experiences on
all days of writing, or you may choose to write about different topics each day.

Keep in mind these few simple guidelines recommended by Pennebaker:[41]

Writing topic. You can write about the same event all four days or different events each
day. What you choose to write about should be something that is extremely personal and
important for you.

Length and frequency. Write for 15-20 minutes each day for four consecutive days if you
can. It is a bit more effective than writing four days over the course of several weeks.

Write continuously. Once you begin writing, write continuously without stopping. Don’t
worry about spelling or grammar. If you run out of things to say, simply repeat what you
have already written. Keep writing about the topic until the time is up.

Write only for yourself. You are writing for yourself and no one else. After you complete
the expressive writing exercise, you may want to destroy or hide what you have written.
Remember this writing can be for your eyes only.

What to avoid. If you feel that you cannot write about a particular event because it would
be too upsetting, then don’t write about it. Just write about events or situations that you
can handle now.

What to expect. It is common for people to feel somewhat saddened or depressed after
writing, especially on the first day or two. Know that this is completely normal if this
happens to you. Typically, the feeling usually lasts just a few minutes or a few hours. It is a
good idea to plan some time to yourself after your writing session to reflect on the issues
you have been writing about and support yourself in any emotions that come up.

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Considerations. Writing about the same topic day after day for too many days is not
helpful. If, after several sessions, you feel you are not making progress, then you might
need to stop and contact a health care practitioner.

When to discontinue the journaling exercise. Writing exercises aren’t for everyone. If
the writing exercise evokes strong feelings that you cannot cope with, stop immediately
and do something soothing for yourself. Experiencing symptoms of hypervigilance, stress
or distress are signals to discontinue this journaling exercise immediately. Take care of
yourself by doing something like practicing diaphragmatic breathing, reaching out to a
friend or loved one, or going for a walk to center and calm yourself. If you experience
lingering negative feelings, you might benefit from some additional help. It is
recommended to seek the professional advice of a psychologist, counselor, or physician to
discuss these feelings and experiences.

AUTHOR(S)
“Therapeutic Journaling” was written by Shilagh A. Mirgain, PhD and by Janice Singles,
PsyD (2016, updated 2023).

This Whole Health tool was made possible through a collaborative effort between the
University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and
Cultural Transformation, and Pacific Institute for Research and Evaluation.

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39. Batten SV, Follette VM, Hall MLR, Palm KM. Physical and psychological effects of
written disclosure among sexual abuse survivors. Behav Ther. 2003;33(1):107-122.
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