I’ve made no secret that reading on paper has become harder. Opening Up: The Healing Power of Expressing Emotions is only available in paper format, but at some point, there’s such a critical mass of people referring to James W. Pennebaker’s work that you’ve got to break down and read it. I’m glad I did, because it gave me a way to reconcile the differences around Critical Incident Stress Debriefing (CISD) (also called Critical Incident Stress Management (CISM)) between those that believe it should always be used and those who are critical of its benefits (see Science and Pseudoscience in Clinical Psychology). It also helped me to organize my thinking around post-traumatic stress disorder (PTSD).
Post-Traumatic Stress Disorder
Some people, when confronted with something they can’t process, become caught in the trauma and are unable to escape the feelings of fear and dread. They end up stuck in a state of hyper vigilance either continuously or when provoked into reliving the trauma in the form of a flashback. Tragically, many of those who suffer from PTSD have served their country in war or their community as first responders. However, that doesn’t minimize the PTSD of other people who discover horror arrived at their doorstep through their hands or the hands of another.
The key revelation to Pennebaker’s work is the discovery that the problem with PTSD is that the trauma never gets processed. It’s captured. Our ability to recall things when stressed is heightened, however, they are so overwhelming that the brain can’t integrate them into a coherent story. Because the brain hasn’t integrated them into a coherent story, the fragments keep coming back in the form of flashbacks.
Martin Seligman in his book, Flourish, explains how it is possible to see post-traumatic growth (PTG) – instead of post-traumatic stress disorder (PTSD). He explained that some characteristics, assessed before the trauma occurred, could predict who would suffer PTSD and who would benefit from PTG. In the context of Nassim Taleb’s work in Antifragile, this makes sense. We grow when the break occurs in the right interval and at the right level for our skill. Seligman was effectively identifying those who had greater capacities for dealing with the horrors they’d experience.
Pennebaker’s work centers around the release of emotions through writing, but that writing is more than a release. It’s a framework for creating a story – a narrative of what happened – and in doing so, it can release people from the trauma’s grips.
The Adverse Childhood Experiences (ACE) study is a landmark study that pointed us to the downstream impacts of childhood trauma and the lifelong impact that is has (see How Children Succeed for more). Never before had we known the outcomes that childhood trauma brought upon our society, and never before had we realized the degree to which children had been abused. However, Pennebaker’s work kept tripping over it. He saw that those study participants who were able to open up about past abuse were substantially more healthy than those in the control group who wrote about nothing much at all.
Pennebaker hadn’t believed that people would write down their deepest, darkest secrets, but that’s what they did. Many of them wrote of their abuse – abuse they claim they had never revealed to anyone else.
Pennebaker unintentionally created a nearly ideal situation for the expression of these pent up emotions. The study involved a novel environment where the participant had no preconceived ideas. There was no one watching the participants work, and they were told they could keep or destroy their writing if they would like to.
The result is a new environment with no judgement. It was an environment where they could get things out on paper without worry about what others would think of them. As it turned out, that was important.
When you have a trauma that you can’t get over, you can’t tell the story, because you don’t experience the trauma as a story. It’s experienced as an overwhelming wave of senses and feelings that can’t be separated from the present. These memories intrude on the present like an unwanted guest – and they’re just as difficult to get to leave.
By writing down their traumas, they were momentarily less happy, but in the long term, their self-assessment of their mental state and the objective measure of their health status went up. Despite the initial depression about having revealed the event, the long-term impacts were good.
The therapeutic benefits seemed to be broadly based, including a lower instance of visits to the health center on campus (most of Pennebaker’s participants were students). For the most part, these benefits seemed to last about four months and not longer, as the participants returned to their baseline rate of visiting the health center roughly four months after their writing exercise.
Our ego is an amazing thing. In Change or Die, we learned how well defended our ego is. It will insist that we have control of a situation when we clearly do not. The truth is that we live in a volatile, uncertain, complex, and ambiguous world. However, this truth is carefully hidden from our egos and consciousness. Studies have shown that we believe we have more control than we really have – often by a wide margin.
Sometimes, the trauma we experience is the intrusion of the volatility into the perception of our safe world. For instance, when my brother died in a plane crash, I was instantly and undeniably reminded of the fragility of life and, ultimately, how bad outcomes can happen even when you do everything right. I was forced to confront the world that we live in – rather than the world that I wanted to live in.
For some, these losses are irrecoverable. The idea that the world can change at any time is too much for them to handle. However, for others, it’s a loss that they can learn and grow from – and move on.
The worst problem of losing someone is that people don’t know how to deal with their own pain and emotions, so they pull back from you. The result can be a social isolation that results in a double loss event. It’s been widely reported and validated that social relationships – deep social relationships – are a good insulator from the damages associated with trauma. However, Pennebaker points out that this insulation only happens when people are willing to open up and talk with these close connections – that isn’t always the case.
Sometimes, particularly in the case of sexual abuse, the family relationships closest to a person aren’t able to accept that it happened, because accepting that it has happened would mean that they’ve in some way allowed it to happen. The net result is that the person is doubly harmed. First by the act and then second by the attempts to bury it.
The Only Thoughts to Fear are Those You Deny
It’s not the odd, taboo thoughts that you must worry about. It’s the fact that you’re unwilling or unable to accept their existence. The research shows that parents who are more open with their children about sex have lower incidence of teen pregnancies (see Dialogue). In twelve-step groups, they say that you’re only as sick as your secrets. (See Why and How 12-Step Groups Work for more on the way that the groups function.)
When people are taught meditation, they’re taught that their thoughts will wander. They’ll stray from their focused task. That’s normal. The trick is to gently accept the thought and then return to the place thinking about the focal point. This gentle acceptance of the thought and moving on doesn’t trigger shame or reinforce the thought. It’s just a thought, and it will pass. (See Happiness for more.) This perspective doesn’t give power to the thought as is done when it’s banished. This fits into David Richo’s concept of acceptance from How to Be an Adult in Relationships. We accept the thought and move on.
Ultimately, if you deny your feelings – like your thoughts – you’ll create a great deal of damage to your psyche as well as your body, as I summarized in my post, I’ll Have Some Emotional Stuffing With That.
Of Two Minds
In addition to the benefits of creating a story or narrative from trauma, writing may have another powerful mechanism in its ability to help synchronize the thinking between our emotions and our rational thought. Daniel Kahneman, in Thinking, Fast and Slow, explains a two-system model of the brain, and Jonathan Haidt explains his model for how our thinking works in The Happiness Hypothesis with the Elephant-Rider-Path model. Emotion and Adaptation and How Emotions Are Made both explain how emotions are created – and how they’re separate from rational thought. When you pull this work together, it becomes clear that we are of two minds – our rational mind and our emotional mind – and we work best when the two are in harmony.
Writing happens from Broca’s area and others in the brain that are a part of the logical or rational processing. Broca’s area is specifically used for syntax construction of speech – both written and verbal. (See The Tell-Tale Brain for more on the various areas of the brain and their known functions.) Those with PTSD – and those who are struggling to move past traumatic events – are often unable to coordinate the activity between their emotional responses and their rational riders. Writing, it seems, brings these two together and causes them to reach more harmonious states.
Having harmony in your brain’s functioning has rather obvious positive impact on affect (or feelings) even if the explanation of it borders on tautology. In simple terms, even though the rational rider is sometimes capable of commanding the elephant, the elephant sometimes has to show the rider who the real boss is.
Ziegarnik Effect and Trauma
In simple terms, the Ziegarnik effect says that you’ll remember something that is incomplete more clearly than something that is complete. It seems that there’s some sort of a boost to memory that happens for the incomplete that is removed when it’s completed. Trauma is one place where you don’t want to have anything incomplete – like incomplete processing of it.
By writing it out, bringing the parts of the brain in harmony, and converting it from individual fragments into a coherent story, we “complete” the event and we are able to move on – instead of being stuck in the endless cycle.
The Physiological Impacts of Psychology
Many people would prefer to say that our thinking doesn’t impact our physiology, but it clearly does in a statistical sense. Consider the city of Dallas, where John F. Kennedy was shot – a city that felt some collective shame from the event. If psychology has no impact on our physiology, then I beg you to explain why overall heart attacks dropped 3% over the five years following Kennedy’s assassination – except for Dallas, where they rose by 4%. Memphis, where Dr. Martin Luther King, Jr. was assassinated, saw a similar condition of a 3% rise of heart attacks while the rest of the country – including Dallas – saw a 4% drop.
In short, our individual psychology – and our collective psychology – has an impact on our health. As such, we must consider how we take care of our minds as much as how we take care of our bodies.
Safety isn’t an absolute thing. It’s a perception. We’ll confess our secrets into a recorder with greater ease than telling one other person even if we don’t know what will happen with the recording. Objectively telling one person without a recorder is safer – but it doesn’t feel safe.
When it comes to using writing to overcome trauma, you have to create enough safety that the person trying to process their memories can remain feeling relatively safe – so that they can get through the process of processing them. If you can’t create a safe feeling in the present, you have no business potentially opening old wounds in the past.
Writing as a tool for helping people learn how to process their trauma is powerful – but only when it’s used in a way that leaves the person feeling safe. This is the heart of the challenge with CISD/CISM.
If you don’t have family members who are first responders, then you don’t know how unwilling to talk they are in general – and more specifically about their work. Separating HIPAA laws and professional ethics, they’ll likely not talk about the things that don’t even approach these boundaries. They know they see things that other people can’t understand and can’t process, so they’ve stopped talking about it – consciously or unconsciously.
The problem with CISD/CISM done incorrectly is that it tries to force people to speak in situations where they don’t feel safe. They believe what they say will end up on a fitness evaluation and can prevent them from returning to work. The result is that they feel less safe in the room talking to someone than they may have felt in a shooting or other objectively more dangerous situation.
This is the core problem. CISD/CISM isn’t inherently bad. It’s not that creating a safe space for people to be able to talk about a trauma. Similarly, initiating the creation of the space isn’t bad. It’s good to create a safe space for the conversation – the critical piece is creating the safe space.
It occurs to me that, without this safe space, you can do more damage than good. The self-reinforcing delusions will kick in. Like, “I knew that counselor had it in for me,” when they report back that the person wasn’t forthcoming in sharing their perspectives on the situation.
They may not accept that some people will really roll with the punches and be okay while others may clam up, suppress their emotions, and fail to feel. There’s nothing inherently wrong with taking a pause from overwhelming emotions – however, those emotions shouldn’t be bottled up forever. They’ll do too much damage.
So, I remain skeptical of the CISD/CISM in so much as I’m unsure that proper emphasis is placed on creating a safe space and therapeutic alliance. (See The Heart of Change for more about how to make psychotherapy work better.)
I am, however, sure you’ll find that Opening Up is a great way to live a more healthy psychological life.