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Written expression and the potential to enhance knowing participation in change.

"Change is continuously innovative." Martha E Rogers

The purpose of this column is to provide opportunities for authors to share new ideas, theories, or research that explores, advances, sheds new light, provides new insight, or renews aspects of the science of unitary human being's postulates, principles, concepts, theories, and/or methods. The science of unitary human beings will only endure, advance, and evolve through the innovative work of its community of scholars. As editor of this column, I invite you to send your manuscripts to Howard K. Butcher, RN, PhD, APRN, BC at the 324NB University of Iowa College of Nursing, Iowa City, Iowa, 52242-1121; work (319-335-7039); email: The feature article in this issue's Column is an explication of an innovative patterning modality, which has the potential to enhance power as knowing participation in change.

Howard Karl Butcher, RN; PhD, APRN; BC Assistant Professor and a John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar

* Everything is held together with stories ... That is all that is holding us together, stories and compassion. Chapter 1. Barry Lopez

* In the process of evolution, man's search for meaning takes on new dimensions and his capacity for understanding grows. Chapter 2. Martha E. Rogers

Human beings are natural storytellers. We conceive our lives as a web of stories and we use stories to construct meaning and to share communicate ourselves with others. Everyone has a story to tell. Stories are often mixtures of pain, suffering, and frustration on one hand, and joy, pride, and satisfaction on the other hand (Rosen, 1996). As people share their stories, they shape the meanings of their unique experiences. Documentation of using the written word spans the history of humankind. There is evidence of expressing meaning in primitive cuneiform signs impressed on clay tablets 5,000 years ago by Sumerians. Records of narratives have been found in many cultures and languages including Sanskrit, Latin, Greek, Chinese, Old German, Icelandic, and Old Slavonic. One of the oldest surviving records is found in the Westcar Papyrus of the Egyptians in which the sons of Cheops entertained their father with stories (Pellowski, 1977).

Writing has always been an avenue for expressing one's feelings and thoughts about traumatic and painful experiences. Shakespeare wrote "Give sorrow words; the grief, that does not speak" (Macbeth, Act IV, Scene lil). More recently, there is increasing interest in the health benefits of writing. This paper examines anecdotal and research evidence on the potential benefits of expressive writing. Hemingway wrote "write hard and clear about what hurts" (Hemingway quoted in Lauber, 2004, p. 37). Expressive writing involves 'writing one's deepest thoughts and feelings of a stressful, traumatic, of difficult experience (Lepore & Smyth, 2002; Pennebaker, 1997a). The paper concludes by conceptualizing expressive writing as an innovative unitary health patterning strategy with the potential to facilitate knowing participation in change.

Narrative and Healing

The process of telling one's story is both an informative and transformational act for both the storyteller and the listener (Butcher & Buckwalter, 2002). Jerome Bruner (1999), one of the creators of narrative psychology, states that telling stories is not just something we do, but rather it is the "very process in which we construct Self ... No story, no self" (p. 8). Central to narrative is the idea that it organizes human meaning. We construct knowledge and meaning by constructing language schemes. These language schemes are organized as narratives. As Polkinghorne (1988) points out, the core argument for the value of narrative is that narratives are "the primary scheme by means of which human existence is rendered meaningful" (p. 11). Robert Coles (1989) has written about the value of storytelling as a humanizing and meaning-giving force for human betterment in a variety of contexts such as education and medicine. As people share their stories, they shape the meanings of their unique experiences. As people share their stories with others, they name and shape the meanings of their unique experiences. Since stories are never told in exactly the same way, stories and story telling permit both continuity and change (Harvey, 1996).

Stories can heal as they endow experience with meaning. The naturalist writer Barry Lopez has written pointedly about the healing power of story. "I felt exhilaration, and a deeper confirmation of the stories ... the stories had renewed in me a sense of purpose of my life ..:. With certain stories, certain individuals may experience a deeper, more profound sense of well-being (Lopez, 2004, pp-4-7). Harvey (1996) poignantly states, "without the pain that comes with significant loss, there can be no story. Without the story telling, there can be no meaning. With out meaning, there can be no healing" (p. 205).

Anecdotal Evidence of the Benefits of Written Expression

There is both ample anecdotal and scientific evidence that writing heals. Many writers have pointed out the health benefits of writing. Hemingway said to "write hard and clear about what hurts." Alice Walker (1995) sees her writing as "a matter of necessity and that you write to save your life is really true and so far its been a very sturdy ladder out of the pit." In writing the book House of Spirits after her daughter lapsed into a coma, Isabel Allende (1995) stated that writing the book "saved my life." She explained that she began her career as a writer for expressing her grief as a form of self-care. Her book Paula was intended to be a book not for publication but was written as a expression of her profound grief about her daughter's terminal illness and death. Jamaica Kincaid's memoir of her brothers death from AIDS was her effort to understand his dying as to "not to die with him, I would write about it" (Kincaid, 1997). Kincaid believes that writing about unpleasant, painful, and difficult truths about her life and family is the only way she can survive. When the poet Audre Lorde learned she had cancer, she started a writing a diary that later became The Cancer Journal. In the journal, Lorde (1980) wrote about how her writing and her love for women "kept me alive for the last year." Lorde (1980) felt that what is important must be spoken and made verbal and shared. For Lorde, writing is a "a gateway, however cruelly won, into tapping and expansion of [our] own power and knowing.

The shelves of bookstores, libraries, and websites abound with memoirs, novels, poetry collections, testimonies, and illness narratives, which Louise DeSalvo (1999) refers to as "wounded body narratives" (p. 184). DeSalvo (1999) points out that reading the literature on personal disaster gives the audience a sense that "meaning can be found in life's most difficult moments" (p. 185). Narratives provide insight into people's thoughts, feelings, and words as they deal with issues of loss, sometimes failing and sometimes succeeding.

In addition, there have been a number of recent books for the general public offering both a rationale and specific techniques for writing as a way of finding meaning, healing, transformation. Writing to heal the soul. Transforming grief and loss through writing (Zimmermann, 2002); With pen in hand. The healing power of writing (Klauser, 2003); Writing as a way of healing: How telling our stories transforms our lives (DeSalvo); Listen to me: Writing life into meaning (Lauber, 2004); and Writing to save your life: How to honor your story through journaling (Weldon, 2001) are a few of the more recent publications describing the benefits as well as strategies to help people write about their difficult experiences in a way that may be beneficial to one's health.

Review of Research on the Benefits of Written Expression

There is an accumulating mass of scientific literature demonstrating the health benefits of expressive writing. Since 1986, Pennebaker and his colleagues have explored the health benefits to people who write about their deepest thoughts regarding traumatic or stressful experiences. They have reported significant effects using 15 to 30 minute writing sessions for 3 to 5 consecutive days with health benefits lasting as long as 4 to 6 months after writing (Smyth, 1998).

A meta-analysis of 13 randomized experiments from 5 different labs testing the effect of written expression found significant drops in the number of physician visits (d=.42) and changes in physiological functioning, including improved immune functioning, hormonal functioning (d=.68), and better psychological well-being (d=.66) (Smyth, 1998). The dose of the written expression ranged from a single 20 minute session to one such session per week for 4 weeks or writing for 3 to 5 consecutive days in one week. Studies also varied in relation to what participants were asked to write about. In some of the 13 studies, participants were asked to write about the most traumatic event in their life (Greenberg & Stone, 1992), an ongoing traumatic event (Pennebaker, Colder, & Sharp, 1990) or either a past or on-going trauma (Francis, 1992). Participants in the comparison group were typically asked to write for the same amount time as the experimental group about innocuous topics such as what one's plans were for the day. The most common outcome measures in the 13 studies included self-reported symptoms, number of health center visits, and positive or negative affect. Physiological functioning effect sizes were higher in studies that instructed participants to write about either past or current traumas (as opposed to past traumas only).

The longevity of written expression's effect has varied. Some studies have reported positive health outcomes for a duration of 1 or 2 months (Greenberg, & Stone, 1992; Greenberg, Wortman, & Stone, 1996; Pennebaker & Francis, 1996; Pennebaker & Susman, 1988); other studies have demonstrated reductions in the number of health clinic and physician visits lasting 2 months (Cameron & Nicholls, 1998; Krantz, .1994; Pennebaker, & Francis, 1996), 6 months (Francis, 1992; Pennebaker & Beall, 1986; Pennebaker, Colder, & Sharp, 1990) and up to 1.4 years in holocaust survivors (Pennebaker, Barger, & Tiebout, 1989).

Emotional expression has been used successfully in a wide range of populations and ethnic groups. Within the United States, written expression has benefited senior professionals with advanced degrees at rates comparable to maximum security prisoners with a sixth grade education (Smyth, 1998; Spera, Buhrfeind, & Pennebaker, 1994). Among college students, no differences have been found as a function of the student's ethnicity or native language (Pennebaker, 1997b). Written expression has consistently produced positive results among French-speaking Belgians (Rime, 1995), Spanishspeaking residents of Mexico City (Dominguez, 1995), and Englishspeaking New Zealanders (Petrie, Booth, Pennebaker, Davison, & Thomas, 1995). Personality and demographic variables, including age, gender, anxiety, inhibition, and constraint, have not been found to be related to the positive health benefits of written expression (Pennebaker, 1997b). However, one study that pre-selected participants on hostility found those high in hostility benefited more from writing than those low in hostility (Christensen et al., 1996).

In addition, other studies using approaches similar to written expression have also found positive health effects. For example, Classen (2001) and associates found supportive-expressive therapy, a non-directive counseling approach that includes finding meaning, leads to greater declines in traumatic stress symptoms in women with breast cancer as compared to patients randomly assigned to a psych oeducational group. Stanton et al. (2000) developed an strategy using six emotion-focused coping sessions with infertile women and found significantly greater improvements in general distress and depression at one month post intervention in women participating in an emotion-focused coping session as compared to women in either the control or problem focused group (McQuenney, Stanton, & Sigmon, 1997). In addition, in a study of women with breast cancer, Stanton and her associates (2000) found that women who coped by expressing emotions surrounding their cancer had fewer medical appointments, improved physical health and vigor, and less distress than those who scored low on expressed emotion.

Harvey's (1996, 2000) extensive research into the role of explaining, describing, and emotionally reacting to major losses in a story-like form, what he calls account-making, has demonstrated the great value in dealing with life's major stressors through the written or verbal expression of one's thoughts and feelings about the event. Research into the processes of accountmaking have demonstrated that telling one's story is associated with successful coping in sexual assault and incest victims (Orbuch, 1994), Vietnam combat veterans (Harvey, Agostinelli, & Weber, 1989), elderly persons' who have lost a loved one from death, divorce, relocation (Weber, Harvey & Stanley, 1987) and persons who retire (Grove, 1998). Harvey (2000) notes Pennebaker's work on written expression is similar to his research on account-making; both demonstrate that for persons who have experienced major trauma and losses recounting their story of the traumatic event leads to health benefits.

Among the most compelling aspects of written expression research is its impact on symptom reduction in persons with asthma and rheumatoid arthritis, and on improved immune function. Most subjects in emotional expression studies have been healthy persons who have experienced a traumatic event. However, research indicates written expression may also enhance health in subjects with health problems. Results from a recent randomized trial published by Smyth, Stone, Hurewitz, & Kaell (1999) in JAMA, demonstrated that asthma patients in an experimental group (N=39) showed improvements in lung function (p < .001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group (N= 32) showed improvements in overall disease activity (p = .0001), whereas control group patients did not change. Smyth and colleagues (1999) note that the gains in the experimental group were beyond those attributable to the standard medical care that all participants were receiving. In this study, participants wrote for 20 minutes on three consecutive days for one week.

A number of studies have found positive effects of written expression on markers of immune function (Christensen, et al., 1996; Esterling, et al., 1994; Futterman, et al., 1992; Knapp, et al., 1992; Lutgendorf, et al., 1994; Pennebaker, KiecoltGlaser, & Glaser, 1988; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995; Petrie, Booth, & Pennebaker, 1998). Written expression has been associated with reliable decreases in autonomic system activity (Pennebaker, 1993), elevations in NK-cell activity (Futterman, et al., 1992), and changes in blood lymphocyte reactivity to mitogens (Knapp, et al., 1992). Experimental studies have also shown immunological changes in persons randomly assigned to either write or talk about emotional issues. Investigations have shown that in comparison to controls, those in emotional disclosure groups have decreased Epstein-Barr Virus (EBV) antibody titers suggestive of better immune control of the latent virus (Esterling, et al., 1994; Lutgendorf, et al., 1994), increased proliferative response capacity of blood T lymphocytes to phytohemagglutinin (Pennebaker & Susman, 1988), increased post inoculation antibody levels against hepatitis B suggestive of a more adaptive antibody response (Petrie, Booth, Pennebaker, Davison, & Thomas, 1995), acute increases in NK cytotoxicity (Christensen, et al., 1996), and increases in total circulating lymphocytes and CD4 (helper) T-lymphocyte levels (Petrie, Booth, & Pennebaker, 1998). These immune effects have lasted as long as 6 months post intervention (Petrie, Booth, Pennebaker, Davison, & Thomas, 1995). Studies have found poorer immunological function after stressful experiences with lower levels of social or spousal support in caregivers who have restricted opportunities to talk to others {Glaser, et al., 1993; Kennedy, Kiecolt-Glaser, & Glaser, 1988; Kiecolt-Glaser, et al., 1991). In addition, studies of survivors of major life events that are difficult to confide to others, such as rape and sexual abuse, suggest that such individuals may be at greater risk for poor health (Golding, et al., 1988; Kimerling, & Calhoun, 1994; Pennebaker & Susman, 1988). The implications of these empirical studies are that written expression xseems to enhance immune function.

Written Expression as a Unitary Patterning Modality

Psychoneuroimmunologic, cognitive, constructivist theories explaining the processing of traumatic memories offer theoretical explanations on how writing can facilitate psychological and physiological changes (Booth & Petrie, 2002; Mahoney, 2003; Pennebaker, 1997b; Lutgendorf & Ullrich, 2002). Pennebaker (1997b) postulates the act of constructing stories is a natural process that can be accelerated through written expression by helping one to organize and to integrate thoughts and feeling into a coherent fashion. Pennebaker and Seagal (1999) explain that writing about a traumatic experience is an act of converting emotions and images into words changes the way the person organizes and thinks about the trauma. Writing about or expressing feelings "accelerates" or facilitates the coping processing by enhancing meaning-making. The labeling of emotions through written disclosure allows individuals to reduce the perceived affective intensity of stressful events while simultaneously affording them an increased sense of control over affective experiences.

While these theoretical explanations shed some understanding on the "psychological and physiological mechanisms" associated with expressive writing, Rogers science of unitary human beings presents an alternative understanding. Rogers (1988, 1992, 1994) placed great emphasis on modalities that are traditionally viewed as holistic and noninvasive. In particular, therapeutic touch, guided imagery, and the use of humor, sound, dialogue, affirmations, music, massage, journaling, expressive emotional writing, exercise, nutrition, reminiscence, aroma, light, color, artwork, meditation, storytelling, literature, poetry, movement, and dance are just a few of the voluntary mutually patterning modalities consistent with a unitary perspective.

The use of expressive writing as a patterning modality is an extension of Butcher's (1998) Unitary Field Pattern Portrait research methodology (UFPP). In the UFFP research method, the researcher constructs a "unitary field pattern profile" for each participant by synthesizing together all the information collected for each participant into a narrative statement revealing the essence of the participant's description of the phenomenon of concern. The field pattern profile is in the language of the participant, and is then shared with the participant for validation and revision.

In addition to sharing the profile with research participants, creating and sharing unitary pattern profiles are also part of the "unitary pattern-based nursing practice method" (Butcher, 2000, in press). When initial pattern manifestation knowing and appreciation is complete, the nurse synthesizes all the pattern information into a meaningful pattern profile. Voluntary mutual patterning may begin by sharing the pattern profile with the client. Sharing the pattern profile with the client is a means of validating the interpretation of pattern information and may spark further dialogue, revealing new and more in-depth information. Sharing the unitary field pattern profile with the participant is postulated to enhance knowing participation in change.

Reading a reflection of one's own experiences, perceptions, and expressions (unitary field pattern portrait) provides a means for one see new insights and understandings into one's life pattern. Cowling (1990) explained that many "health problems and issues" rest on the notion that there is an underlying and enduring process that accounts for the experience and that awareness techniques" offer a way to "get in touch with this underlying process" (p. 61). The recognition of new patterns has the potential to facilitate transformations in patterning. With a new sense of awareness, participants are free to choose if and how they want to participate in their own change process (Barrett. 1998). An increased awareness of one's own pattern may offer new insight and increase one's desire to participate in the change process (Butcher, 2001, in press).

Writing one's own "portrait," written expression, may offer a powerful means to enhance knowing participation in change. Lauber (2004) explains that "it has been my experience that personal writing can go a long way in fulfilling this function [making meaning]; as an instrument of self-awareness and reflection, it often serves to illuminate life"(p. 15). Lauber (2004) goes on to describe expressive writing is "an act of power" (p. 16). Barrett (1990) explains that modalities designed to enhance power as knowing participation -in change "allow the client's health patterns to develop, evolve, or change in ways that foster healing" (p. 36). Barrett has described the notion of power from the perspective of Rogerian nursing science.

Barrett's (1989) Theory of Power as Knowing Participation in Change was derived directly from Rogers' postulates and principles and interweaves awareness, choices, freedom to act intentionally, and involvement in creating changes. Power is a natural continuous theme in the flow of life experiences and dynamically describes how human beings participate with the environment to actualize their potential. Barrett's power enhancement nursing model also emphasizes increasing awareness as a means to facilitate change. The nurse does not simply provide information to increase awareness, but rather focuses on eliciting client descriptions, incorporating information concerned with the client's current health situation, and helping the person work through the complexities (Barrett, 1989). Written expression as a voluntary mutual patterning modality potentially enables the client's efforts to actualize health potentials from their own perspective.

Written expression is pattern work and has the potential to enhance meaning making. Pattern work involves the reflective exploring of experiences, perceptions, expressions, and their meanings and connections. Like Frankl (1963), Rogers (1970) recognized the importance of making meaning when she stated: "In the process of evolution, man's search for meaning takes on new dimensions and his capacity for understanding grows" (p. 93). Written expression, like journaling and bibliotherapy, can transform life patterns (Mahoney, 2003). In a ways consistent with Rogerian Science, Mahoney (2003) describes in detail how transformations or changes in life patterns: a) occur in waves or oscillations of perceived expansion and contraction, progress and regress, success and failure; b) are nonlinear, reflecting mixtures of mostly slow, small steps; frequent return to repeating similar yet different patterns with occasional large and sudden leaps of change; c) are unpredictable; d) are holistic or unitary in nature; and e) can be amplified or accelerated into large and enduring changes through patterning modalities (Mahoney, 2003). Lauber (2004) explains that writing is a means for catharsis, rinsing pain, facilitating integration, navigating one deep self, and providing perspective. As new understanding and meaning unfolds from the reflective writing process, a new shift in perception may emerge as one meaning pattern is transformed into another (Carlsen, 1996; Mahoney, 2003). Thus, expressive writing is a unitary energetic patterning modality with the potential to transform humanenvironmental pattern manifestations by enhancing knowing participation in change and accelerating meaning making.

Processes of Written Expression

There are multiple guidelines describing the processes of written expression. The research described in this article is based on Pennebaker's (1997b) protocol for emotional written expression. In general, writing need only be for 20 minutes over a period of three to four days. Ask participants or clients to use a space to write that is comfortable, private, and where they can write for the 20 minutes without interruption. Participants write about issues that they are currently dealing with, traumas not disclosed, or resolved, or something that they happen to dream about constantly. Participants typically asked to write about what happened and express their deepest thoughts and feeling about the event/experience. Encourage participants to express both "positive" and "negative" emotions. Pennebaker's (1997a) research shows that narratives that are both very high and very low in the expression negative emotions correlate with poorer health. Those narratives that correlated with health improvements were those that contained a moderate number of negative emotions. Also, the research indicates that those who benefit most from writing constructed coherent meaningful "stories" (Pennebaker, 1997b). Typically, participants are asked not to be concerned with grammar, spelling, or punctuation. Rather, the idea is write without fear of judgment and to spend the time writing and not editing. Writing, however, should not be a substitute for action or involvement in the change process.

While it is natural for human to tell stories and seek meaning, expressive writing is an innovative modality that demonstrates much promise toward accelerating health, healing, and knowing participation in change. As a patterning innovation, one of the most remarkable features written expression is its simplicity. To write about one's deepest thoughts and feelings an experience for 20 minutes takes little time and is inexpensive since all that is needed is a writing instrument and a pad. Writing is portable since one can actually write most anywhere and is flexible because one can choose what to write about and when to write. Yet, there is strong evidence that writing enhances health, wellbeing, and human betterment.

Acknowledgement: This paper was made possible through funding from the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholars Program; NINR (1R15N0821301), H. Butcher(PI); and the Geriatric Nursing Intervention Research Center at the University of Iowa College of Nursing.


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Howard Karl Butcher, RN; PhD, APRN; BC Assistant Professor and a John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar
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Author:Butcher, Howard Karl
Publication:Visions: The Journal of Rogerian Nursing Science
Article Type:Column
Date:Jan 1, 2004
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