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Talking about it: is it worth encouraging emotional disclosure for people with pain?


ResearchBlogging.org
One of the more common coping strategies for people with chronic pain is talking about stressful experiences. It’s thought to be healthy to be open and express feelings, while the very idea of repressing or avoiding emotional content seems almost Victorian. And there are various talk therapies in which emotional disclosure is encouraged – in fact, one popular approach suggests that people risk developing chronic pain if they don’t discuss ‘trauma’ (Sarno). So, does it work?

Some studies of emotional disclosure have found that it has ‘moderate’ effects – people can feel emotionally better, and their general health status can also improve.  Other studies are more equivocal, with less positive outcomes.  Even in meta-analyses, outcomes have been inconclusive.  It has been thought that some of the differences might be whether the participants were encouraged to write or instead, to talk about their situation.

Researchers from Detroit studied the effect of either written or verbal emotional disclosure in people with rheumatoid arthritis.  In a nicely conducted study, people with rheumatoid arthritis were randomised into two groups, one assigned to talking, while the other group was assigned to writing instead.  Within each of these two groups, participants were then randomised into three groups – one group was assigned to disclosing recent stressors, while the other two groups were assigned to either neutral topics or positive topics.  All in all, six different conditions.

What they found was that in the short term, talking or writing about stressful topics made a small difference compared with the two control conditions, but this wasn’t sustained, and it influenced only a few of the outcomes. The authors state “disclosure specifically about negative or stressful experiences – rather than just emotionally relevant experiences – is important”, so it’s not enough to write about positive experiences, they need to be negative experiences to have any effect at all.

The authors suggest that one reason for the weak effect was that the participants talked about the stress of having RA rather than “more powerful, unresolved stressors” such as “shameful experiences including childhood abuse, family of origin problems, and adult victimization” which were rarely disclosed.  They suggest that “such events may simply not have happened to these patients, we think it is likely that patients chose relatively safe, publicly known, and socially validated stressors to disclose”.  It’s my belief that disclosures such as these more serious and shameful ones are more likely to occur in the context of a long-term therapeutic relationship rather than a short-term experimental situation, so this could be an artifact of conducting research in this way.

One interesting finding is that none of the participants viewed either written or verbal disclosure as a particularly credible stress reduction technique.  The approach seems to lack “face validity” as a way for people to manage their stress, so it may mean further work on how to present this approach.

The conclusion in this paper is that although the effects were weak, it’s surprising that there was any effect at all in such a simple and inexpensive technique. They state: “there is modest or limited support for both written and spoken emotional disclosure among people with RA, with effects limited to a few outcomes and generally later rather than earlier time points, such as 6 months after disclosure.” They go on to say “The findings also remind us that stress and negative emotions are potentially important intervention targets for some patients with RA, and encouraging patients to approach rather than avoid such emotions can be beneficial.”

There were some process issues obtained in this research, and it’s nice to see them documented in this paper.  Many men withdrew from the study, and only 1/3 of the people approached actually participated in the study.  It would be helpful to learn why people don’t see disclosure as a useful or helpful approach.

So, is it useful to have people talk about negative experiences in order to manage stress and improve their health?  Well, in people with rheumatoid arthritis, it seems that the overall conclusion from this study is no.  The effects are very small and the authors suggest it’s possibly only helpful for people who can acknowledge that they have unresolved stressors, but who inhibit their feelings and don’t have anyone to talk to.

 

Lumley, M., Leisen, J., Partridge, R., Meyer, T., Radcliffe, A., Macklem, D., Naoum, L., Cohen, J., Lasichak, L., Lubetsky, M., Mosley-Williams, A., & Granda, J. (2011). Does emotional disclosure about stress improve health in rheumatoid arthritis? Randomized, controlled trials of written and spoken disclosure PAIN, 152 (4), 866-877 DOI: 10.1016/j.pain.2011.01.003

5 comments

  1. Interesting and surprising result. I agree with the author’s explanation for the weak effect, but I also wonder whether talking about stressful lie experiences might reduce pain perception through a more general reduction of anxiety.

    1. You make a good point – so if this group of patients were not generally anxious (perhaps because they knew their diagnosis, it was being managed in a specialised clinic, or maybe they had good self efficacy for managing their pain), then the resulting effect may be lower than in other groups. I wonder what the result might be in a group of people with nonspecific low back pain, or fibromyalgia, where the diagnosis and management is less clear-cut.

  2. It wasn’t clear from your summary: how long were the people involved in disclosure? Was it a short session, or something extended over time? I am curious because journalling focused on one’s emotions (particularly negative ones) is considered a powerful stress-reduction technique. Don’t know if there is any research behind it, but just about every guide to coping with stress/anxiety/depression that I have seen, either from NHS or from various charities in the UK, suggest journalling as a coping technique, but also says that you have to commit to keeping a journal over several weeks. The presumption is also that it not just for people “who have no one to talk to”. One of the benefits is supposed to be that you don’t overload the people in your life with your emotions (something I definitely did on occasion).

    I would guess that is why people perceived disclosing emotions as valid – this is common advice from various health professionals, at least in the UK. And of course lots of theories posit connections between stress levels and pain.

    It would be interesting to see if this article relates, or indeed if there is research validating journalling for stress reduction, and corresponding pain reduction.

    1. The paper (I’m quoting directly here) says “Participants were instructed to write in a journal or speak into a cassette tape recorder (which was loaned to them) for 20 minutes daily for 4 days, preferably consecutively, at home in a quiet private place, in the week after their baseline appointment. At home, patients first rated the credibility of their condition and then wrote or spoke on their assigned topic for four 20-minute sessions, on different days, over the next week. Patients rated their mood before and after each session, and rated their writing or speaking on several scales after each session. Patients returned to the clinic for follow-up evaluations 1 month (at which point they returned their writings or recorders and session rating forms), 3 months, and 6 months after the baseline visit, and at each visit, they completed the same battery of health status measures.”

      While emotional disclosure activities like journalling have evidence in generalised stress situations, I think this study shows that it’s not as strongly supported in pain situations. As a result, it could be that the general ‘stress’ levels in this group of participants were too low for this approach to have a strong effect, or it could be that having pain interferes with the way in which disclosure affects wellbeing in the general population.
      I guess it’s another study that suggests ‘more research needed’!!

      1. Ah, that’s a very good point about people in the study perhaps not experiencing too much stress. I think this goes right down to “indiscriminately applying ANY technique to all people with chronic pain, without appropriate pre-screening to determine what is necessary, is not going to work” – whether it is stress reduction, pacing, exercise, physical therapy, or whatever. So if people in that study were not screened for how stressed out they were, then (potential) stress reduction had only a small effect.

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