The Effects of Expressive Writing on Adjustment to HIV

Inna D. Rivkin; Julie Gustafson; Ilene Weingarten; Dorothy Chin

Disclosures

AIDS and Behavior. 2006;10(1):13-26. 

In This Article

Abstract and Introduction

Abstract

Previous research suggests that writing about stressful experiences results in better health and psychological well-being. In the present study, a multi-ethnic sample of 79 HIV-positive women and men participated in a structured interview, and wrote about either their deepest thoughts and feelings about living with HIV (expressive writing) or their activities in the last 24 hr (control). Sixty-two participants returned for the 2-month follow-up and 50 returned for the 6-month follow-up interview. Oral fluid samples of beta2-microglobulin were taken at the baseline and follow-up assessments to examine the immunological effects of writing. No effects of writing condition were found, but expressive writing participants who included increasing insight/causation and social words in their writing had better immune function and reported more positive changes at follow-up. Results suggest that cognitive processing and changes in social interactions may be critical to the benefits of writing.

Introduction

HIV is a persisting life-threatening illness that can contribute to adverse psychological adjustment (Kelly et al., 1998; Simoni and Ng, 2000). Persons diagnosed with HIV infection may develop post-traumatic stress disorder in response and develop a comorbid disorder following the onset of PTSD (Kelly et al., 1998). Not only can HIV diagnosis itself be a traumatic incident, but persons living with HIV are additionally confronted by the continuing trauma of stressful life experiences associated with the disease and its progression. HIV related stressors can include confronting one's own mortality, death of a loved one (Kemeny and Dean, 1995), physical limitation, disability (Griffin et al., 1998), stigma, fear of disclosure (Herek and Capitanio, 1999; Lee et al., 2002), and decline in social support (Moneyham et al., 1996). The stress of living with HIV can affect immune function and HIV disease progression (Ironson et al., 1994; Leserman et al., 2002). HIV progression has been linked to higher levels of depression (Ickovics et al., 2001), lower social support, and heightened stress (Leserman et al., 2002).

Among women and men living with HIV and AIDS, women report increased likelihood of poverty and an overall lower quality of life, lower levels of education and income (CDC, 2002), greater burdens of caretaking roles (Ingram and Hutchinson, 1999), and higher anxiety, depression, and traumatic stress (Sikkema et al., 2003). Yet, despite these increased vulnerabilities, both women and men report many positive changes from dealing with HIV and AIDS, including positive changes in health behaviors, greater empathy, increased spirituality and self-understanding, connection to community, and greater appreciation for life and loved ones (Bower et al., 1998; Folkman et al., 1997; Siegel and Schrimshaw, 2000; Updegraff et al., 2002). The benefits and growth that women and men experience can buffer them from psychological distress (Stein et al., 1997; Updegraff et al., 2002) and have positive effects on immune function (Bower et al., 1998). An intervention that helps individuals cope with HIV-related stress and facilitates stress-related growth can not only influence psychological adjustment but health outcomes as well.

Research has shown that the expression of the emotions associated with stressful experiences, by writing or talking about them, results in better health and psychological well-being (Lepore, 1997; Park and Blumberg, 2002; Pennebaker, 1993; Pennebaker et al., 1988; Smyth, 1998). These effects have been found for a variety of stressful and traumatic events and for a variety of outcomes, including psychological well-being, rumination, cognitive reappraisal, immune function, self-reported symptoms, and health center visits. Pennebaker (1993) suggests that the benefits of writing and talking about stressful experiences result from cognitive processing, as well as from the expression of emotions. It allows people to confront and work through their experience, and helps them to understand it more thoroughly. It may also influence people's interactions with others, and affect their social lives (Pennebaker, 2004; Pennebaker and Graybeal, 2001).

Internal analyses of participants' writing have examined how individual differences in the way people write influences the benefits of the writing intervention. For example, those whose essays depicted increasing cognitive processing, as operationalized by words implying insight and causation, and those whose essays included moderate expression of negative emotions and high expression of positive emotions, experienced more health benefits from the writing intervention (Pennebaker et al., 1997). In another study within an expressive writing paradigm, depth processing of trauma (as operationalized by cognitive appraisal change, experiential involvement, self-esteem enhancement, and adaptive coping) mediated the relationship between emotional expression and long-term survival of AIDS (O'Cleirigh et al., 2003). For women, depth processing and emotional expression was also related to better immune function. Cognitive processing assessed in verbal interviews has also predicted benefits, such as reduced rumination (Pennebaker et al., 1997), slower CD4 decline, and lower mortality (Bower et al., 1998), suggesting that both verbal and written processing can confer benefits.

Few studies have examined the effects of written expression on health and adjustment for people living with HIV, although one recent study found that expressive writing resulted in increased CD4+ lymphocytes for HIV-infected patients (Petrie et al., 2004). Support for the benefits of expressive writing has come mostly from studies with healthy participants (Park and Blumberg, 2002; Pennebaker, 1993; Pennebaker et al., 1988). However, writing has also been found to have health benefits for people dealing with chronic illnesses, such as asthma and rheumatoid arthritis (Smyth et al., 1999), for women with breast cancer (Stanton et al., 2002), men with prostate cancer (Rosenberg et al., 2002), and patients with metastatic renal cell carcinoma (de Moor et al., 2002). It is important to investigate the benefits of this potentially valuable intervention for people living with HIV. The cognitive processing that occurs in expressive writing can facilitate finding meaning in the struggle with HIV, and have positive effects on emotional adjustment and health for people living with HIV.

There is some evidence that expressive writing may be especially effective in improving adjustment for those who have difficulties in talking about their stressful experiences (Norman et al., 2004; Paez et al., 1999; Rivkin, 2000). Talking about HIV may be difficult because of the stigma associated with HIV, and the rejection and shame that could result from disclosure (Herek and Capitanio, 1999). The decision to disclose one's positive serostatus is often accompanied by worry about burdening family members, about disrupting relationships, about the stigma of HIV, and about discrimination (Chin and Kroesen, 1999; Mason et al., 1995; Simoni et al., 1995). HIV-related stigma and rejection can interfere with coping and result in greater distress (Heckman et al., 2004; Lee et al., 2002). Thus, expressive writing interventions may be especially valuable for people dealing with a stigmatizing experience such as HIV, which is often difficult to discuss with others.

The purpose of the current study was to examine the effects of an expressive writing intervention on the adjustment of women and men living with HIV, and to examine whether men and women respond to the writing intervention in different ways. We hypothesized that writing about one's thoughts and feelings about being HIV-positive would improve people's emotional adjustment to HIV and result in better immune function. In addition, the intervention was expected to result in greater stress-related growth, or positive changes from dealing with HIV. Expressive writing was expected to be most effective for those whose writing indicated increased cognitive processing and high expression of positive emotion. Because writing may prompt changes in social relationships (Pennebaker, 2004; Pennebaker and Graybeal, 2001), we also examined whether increases in use of social words in the expressive writing exercise predicted benefits. The current study also examined differences in the social environment for HIV-positive women and men, their strengths and vulnerabilities, and the positive and negative changes in their lives from dealing with HIV.

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