Expressive Writing for Supporting Care Workers
In 2009 a study on the benefits of Expressive Writing for nurses in the USA was published by a team at Johns Hopkins University in Baltimore, Maryland. The authors of the study argue that Expressive Writing is ‘a new tool to build psychological resilience in nurses by helping them to reduce the negative impact of the primary sources of stress in their jobs.’ Providing care, the study notes, ‘exposes nurses to intense stressors including staffing and workload problems, communication breakdowns, death, bereavement, and medical error,’ and these conditions in turn ‘contribute to job dissatisfaction and burnout which are primary causes of nurse turnover.’ As such, the authors contend, in the healthcare industry there exists ‘an acute need for low cost and simple interventions that enhance nurses’ coping with problems leading up to burnout and turnover.’ ‘Expressive Writing,’ their findings suggest, ‘offers just such a cost-effective and user-friendly tool.’ (307).
As studies like these suggest, for the past two decades, Expressive Writing has been widely used and is well validated in many populations to support people cope more effectively with job-related stress and traumatic events in notably stressful contexts including combat and conflict zones and refugee populations. During that period, as the authors of the Baltimore study note, Expressive Writing has evolved from ‘anecdotal folk wisdom to a large and growing body of scientific research’ that demonstrates improvements in ‘a broad range of physiological, physical and mental states across diverse groups of people’. In addition, Expressive Writing has been linked to ‘non-health related benefits, such as staff turnover, absentee rates, sleep quality, and memory.’ Put simply, expressing thoughts and feelings about stressful and even traumatic events through carefully controlled Expressive Writing exercises has been shown to improve mental and physical health for participants and economic and social benefits to their communities.
The well-being of care workers of all kinds from social workers to front line health care workers to human rights defenders directly affects the quality of care they are able to offer. Expressive writing is a time-efficient and easy-to-use intervention that can support them in reducing job distress, turnover and, ultimately, improving their lives and the lives of all who depend upon them.
HOW DOES EXPRESSIVE WRITING WORK?
Most people have a form of their ‘life story’ that they fall back on when dealing with experiences both good and bad. ‘Nothing good ever happens to me’ is one kind of life story, and ‘I have had a happy life’ is another. Life stories like these provide a space for the reflection upon and the processing life events. Current research suggests that by writing down elements of these ‘life stories’ and even by creating new ‘life stories’ through Expressive Writing, we create what is called a ‘holding space’—a place in which participants can feel free enough and safe enough to explore difficult, painful and even dangerous memories and feelings.
Research over the past twenty years has demonstrated that the Expressive Writing process draws on this life-story-telling holding space to improve health and support mental well-being in three distinct but complementary ways: exposure; improved self-regulation; cognitive restructuring.
Exposure can best be understood as a process by which difficult emotions become less potent and more manageable as they are written about. According to emotional exposure theory, directly confronting difficult emotions over time can help us become used to them to some degree and even extinguish those feelings completely. Through the carefully guided exposure to strong emotions that is part of the Expressive Writing process, daily functioning improves, anxiety is reduced and less time is spent worrying about and/or avoiding negative thoughts and feelings. 
The second way in which Expressive Writing improves health and supports well-being is because it increases the ability to self-regulate thoughts and feelings. According to self-regulation theory, better self-regulation occurs when people are able to understand an upsetting event, label the emotions associated with it, and plan an appropriate reaction. Through the process of Expressive Writing, participants write about various life events, both good and bad, and reflect on the consequences of these. Expressive Writing therefore provides often much-needed practice in understanding and fully appreciating existing coping strategies and developing new, more efficient ones. A further benefit of stronger self-regulation is that it can lead to positive impacts on social integration, improving the social environment of participants and leading to closer social relationships.
Cognition is the process of getting to know something through thought. Cognitive restructuring, therefore, is the process of bringing about new ways of thinking. In the case of mental health, cognitive restructuring can help painful events less upsetting as we learn to think differently about our stress,
Expressive Writing brings about cognitive changes – changes to thought patterns. Through Expressive Writing methods, we are able to change the ways in which upsetting thoughts are ‘labelled’ in our minds, and how our minds structure and organize ideas about distressing and even traumatic events. When this occurs, those events become easier to manage psychologically. Expressive writing can help people make sense of painful past events as well by providing an opportunity to carefully confront and explore those events, and even to find meaning in them. 
THE EXPRESSIVE WRITING METHOD
Through Expressive Writing practice, both negative and positive experiences are expressed through writing (exposure). As they are written down, the emotions those experiences provoke are explored and understood (self-regulation). Finally, through the creative and imaginative processes used in expressive writing, those experiences and the emotions to which they give rise can be reimagined and given meaning through the development of new points of view on the past (cognitive restructuring).
Participants will be carefully guided through stages of writing exercises that invite, rather than force, the expression of emotions and the power of the imagination. These writing exercises encourage participants to recall a wide range of experiences and are open-ended in order to allow for the expression of a range of emotion, positive, negative and neutral. The gradual, gentle progression of these exercises enables participants to express whatever they wish to express.
Participants are encouraged to reflect on their progress through the program by completing a number of self-reflective ‘exercises’ at key points throughout. Such pauses for reflection can build resilience while also supporting the development of coping mechanisms as the participants learn the power of checking in with themselves regularly and reflecting on how the Expressive Writing program is impacting on how they feel. Participants may find that they wish to return to the same exercises more than once, and discover that they respond to them differently each time as they learn to reflect on past events from new, altered points of view.
As a result, participants in Expressive Writing are entirely in control of their exposure to and reflection upon memories and events, and this sense of power over their engagement with the programme also contributes to the process of healing. This gradual, incremental approach helps participants avoid the potential negative ‘triggering’ effects of suddenly intensely recalling a distressing or traumatic event. Our incremental approach enables the steady and progressive expression of both negative and positive emotions, an increasing confidence in one’s ability to engage in, and find interest and relief in Expressive Writing practice and to feel fully supported while doing so.
 Sexton,J.; Pennebaker, J.; Hotzmueller,C.; Wu, A.; Berenholtz,S.; Swoboda, S.; Pronovost, P.; Sexton, B. ‘Care for the caregiver: benefits of expressive writing for nurses in the United States.’ Progress in Palliative Care, 2009 Vol 17 No 6, 307-312
 Sexton, et al, 2009, p. 307.
 American Psychological Association. ‘The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-being.’ Washington, DC: American Psychological Association, 2002.; Liehr P, Meininger JC, Vogler R et al. ‘Adding story-centered care to standard lifestyle intervention for people with stage 1 hypertension.’ Appl Nurs Res 2006; 19: 16–21; Campbell, S.; Jensen, M. ‘Reiterative Practice in Action: The Women In Conflict Expressive Life Writing Project,’ Research Methods in Life Narrative Studies, ed. K. Douglas and A. Barnwell. Routledge, 2019.
 Sexton, et al, 2009, p 307.
 Ibid, p. 309.
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