Power of the Pen in Long-Term Care

by James W. Pennebaker, PhD
Professor of Psychology, University of Texas at Austin
Austin, TX

Words can have a powerful healing effect for caregivers as well as patients. When people put their thoughts and feelings into words, there are improvements in physical and mental health. Therefore, I suggest that long-term care teams encourage patients who are able to try recording their thoughts and emotions in a diary or journal.

Evidence confirms both the physical and mental health advantages of such a practical exercise. Although such research is still in its early phases, studies are starting to appear in journals of the American Psychological Association and the American Medical Association, among others.

I revisited this aspect of self-applied psychological care during a recent speaking engagement for the CHEST Foundation (www.chestnet.org/foundation)--the philanthropic arm of the American College of Chest Physicians--and the Cancer Wellness Center, in Northbrook, IL. Writing for health is not just a beneficial exercise for patients who have experienced one-time or short-term traumatic physical or psychological events. Patients facing many months or years of disability, rehabilitation, or declining health can benefit as well.

There are health threats to emotional inhibition, as I explain in my book Opening Up: The Healing Power of Expressing Emotions (Guilford, 1997). The threats to the chronically ill are just as powerful as the threats to children suffering traumatic sexual experiences, adults affected by the untimely death of a spouse, or various other life-altering physical or emotional changes. By expressing themselves in writing, patients tell their stories and free themselves from unwanted thoughts and feelings.

Common results are improved moods and more positive outlooks. These may aid immune function in general, and bolster the will to live, in particular.

Prescription for Emotional Health

The Cancer Wellness Center's Stuart Pinkwater, MD, also a believer in the merits of journaling, works with a 76-year-old woman who lives in a nursing home. After suffering two strokes and now Alzheimer's disease, she has difficulty remembering things that occurred in recent years. Journaling has become a way for her to record and stimulate memories.

Whenever she recalls an important memory, Dr. Pinkwater has her record as many details as possible in her journal. The journal now contains a collection of memories that help supplement her actual memory.

If the resident inquires about her husband, who passed away some time ago, Dr. Pinkwater or other nursing home staff encourage her to refer back to her journal and to the memories she's recorded. Although this woman is initially frustrated and upset that she can't recall an important event, when she reads her journal, her memory of events and people may be stimulated. Thus, journaling has become an empowering self-discovery tool for this woman.

Benefits of Putting Pen to Paper

The implications of journaling for the chronically ill and elderly are clear. Long-term care patients have special psychological needs that are frequently unrecognized, undiagnosed, and untreated. Typically, their minds have not kept pace with processing the devastating physical changes that may result from such conditions as diabetes, stroke, gastrointestinal and neurological problems, and hypertension.

Internalizing thoughts can also have physiological ramifications. And, even though caring for the patients' mental health is expressly mentioned in agencies' home care charters, the truth is that limited funds are earmarked first for physical needs, and some providers do not have the resources to meet psychological needs.

As a result, patients' silent depression has been linked to intensity of self-reported pain and the number of pain complaints. Sleeplessness and weight loss often follow.

Journaling, on the other hand, has the power to change the attitude of the patient to be able to better "roll with the punches." Changes in cognitive and linguistic processes can predict better health. Also, journaling promotes:

• Ownership of the illness.
• A sense of resolution, brought about by understanding the situation and putting meaning to this disruption in their lives.
• Improved coping skills as a part of the grieving process.
• A transformation of thinking patterns from low-level thoughts focusing on, for example, the color of the walls or meaningless inner chatter to higher level thoughts that show perspective, awareness, and emotional stability.

There are other advantages. Keeping a journal is worth a try compared with the alternative of adding mood-altering medications to a drug regimen.

Depression also is a key culprit in cases of immune system suppression. But writing or talking about emotional topics has been found to improve T-helper cell growth, antibody responses to some viruses, and short-term changes to autonomic activity.

Studies of the immune system show that people living silently with upsetting experiences benefited most from writing. This, in turn, reduced the inclination to become obsessed with potential new health problems.

Facing Objections

It's understandable that professional caregivers may be hesitant to suggest journaling. The exercise is often viewed as being too simple to be clinically effective. Plus, some caregivers may feel that they are not trained to promote such a "treatment."

As mentioned, however, there are compelling reasons to consider recommending personal journaling. Issues of appropriateness and timing do arise, however.

Traditional journaling may be inappropriate for individuals with arthritic hands, diminishing sight, or certain incapacitating conditions. However, having people talk into a tape recorder can produce positive benefits as well.

Since many unhealthy thoughts surface after the reality of a long-term situation has set in, an ideal time to begin journaling is shortly after admission to long-term care. But any time you sense unwanted thoughts in your patient is also a good time to mention journaling.

Expect these responses to your suggestion:

• "I don't want to be more of a burden."
• "Rethinking my situation only makes me more depressed."
• "What's the use?"

But also expect at least a gradual psychological improvement as this additional component of quality care begins to take hold.

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