Family Practice
© Oxford University Press 2002
Vol. 19, No. 2
Printed in Great Britain
Effects of guided written disclosure of stressful
experiences on clinic visits and symptoms in
frequent clinic attenders
Yori Gidrona, Elaine Duncanb, Alon Lazarc, Aya Bidermand,
Howard Tandeterd and Pesach Shvartzmand
Gidron Y, Duncan E, Lazar A, Biderman A, Tandeter H and Shvartzman P. Effects of guided written
disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders.
Family Practice 2002; 19: 161–166.
Background. Psychosocial variables such as major stressful life events/daily stressful events
have been associated with health care utilization.
Objective. Our aim was to examine the effects of a guided disclosure protocol (GDP) of past
traumas on symptoms and clinic visits among frequent clinic attenders.
Methods. Forty-one frequent clinic attenders (>2 visits/3 months) took part. Patients were
randomly assigned individually to either a casual content writing control group (n = 19) or a
trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting
event chronologically (day 1), verbally described their thoughts and feelings and descibed the
event’s impact on life (day 2), and finally wrote about their current perspective on and future
coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms
and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits
again.
Results. Compared with controls, GDP patients reported lower symptom levels at 3 months
(2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month
(5.1 versus 9.7) follow-ups. The percentage of GDP patients making >10 visits during the 15 month
follow-up was smaller (10%) than among controls (33%).
Conclusions. The findings extend previous findings to frequent clinic users, using a new form
of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be
an inexpensive additional intervention in primary care for reducing symptoms and clinic visits
among frequent clinic users.
Keywords. Clinic visits, frequent attenders, memory shift, somatization, written disclosure.
somatization was predictive of clinic visits in several
studies.3,5 Among somatizers, who frequently visit health
clinics, 66–75% did not benefit from medical and surgical
procedures.6 These studies suggest that attempts at reducing utilization of health clinics among frequent users
need to consider and treat problems related to daily or
major stressful events.
People who reported inhibiting the disclosure of past
stressful traumatic events (e.g. sudden death of a spouse)
were found to be more ill in the subsequent year.7 In
contrast, active disinhibition by writing for 3–4 days of
past traumatic events has been found to reduce health
centre visits, to enhance immunocompetence (proliferation of T-helper cells8,9), to enhance the action
of hepatitis B vaccinations10 and, most importantly, to
improve clinically relevant health outcomes of asthmatic
and rheumatoid arthritis patients.11 A meta-analysis
Introduction
An estimated 40–75% of visits to primary care providers
are related to psychosocial problems.1,2 Among the
psychosocial variables known to be associated with
health care utilization are somatization, major stressful
life events, daily stressful events and a psychiatric disorder.3,4 The combination of daily stressful events with
sensitivity to and over-reporting of body sensations or
Received 18 December 2000; Revised 14 August 2001;
Accepted 1 November 2001.
Departments of aSociology of Health, cBehavioral Sciences
and dFamily Medicine, Ben-Gurion University, Be’er-Sheeba,
Israel and bDepartment of Psychology, Glasgow Caledonian
University, Glasgow, UK.
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showed that such brief trauma disclosure has positive
overall health benefits.12
A deeper examination of disclosure studies reveals
that not all patients or students benefit from the usual
unstructured written disclosure. One recent study13
found that disclosure of stressful events had no effect
on clinic visits among frequent attenders. Corroborative
evidence provides important clues as to how to enhance
the effects of brief disclosure, without adding therapist
interventions. Foa et al.14 found that rape victims who
disclosed their traumatic event chronologically had
less psychiatric symptomatology later. Pennebaker and
Francis15 showed that subjects who disclosed their
trauma while writing words indicative of self-reflection
(e.g. “I realize”) had the greatest health benefits. Another
study found that only those who wrote in moderate
cognitive complexity, but not in little or high levels of
cognitive complexity, had positive health benefits from
writing.16 These findings strongly suggest that people
need and may benefit from guidance in the content and
manner of written trauma disclosure.
Furthermore, a broad range of studies on post-traumatic
stress disorder suggests that traumatic memories are
encoded in a somato-sensoric (e.g. visual cortex) and
affective limbic (e.g. amygdala) memory mode17,18 possibly
with characteristics of implicit and relatively automatic
memory processes.19 In contrast, linguistically labelling
emotionally negative stimuli (‘these are angry faces’) has
been shown to diminish amygdala activity compared
with processing such stimuli in an affective and sensory
manner.20 Guiding individuals in disclosing their trauma
chronologically, in using self-reflection and in linguistically labelling stressful physical and emotional experiences
(rather than simple ventilation and re-experience), may
help shift the encoding of traumatic memories from an
uncontrolled, somato-sensory and affective memory mode
to a relatively more controlled cognitive and explicit
memory mode.21 Such a shift in memory processing
may reduce the extent of uncontrollable intrusions of
traumatic memories and, thus, the need to inhibit them
and the potential ‘health costs’ due to actively inhibiting
them.7 One study which provided direction in writing
found that a self-regulatory disclosure (having subjects
plan future coping strategies) resulted in reductions in
clinic visits similar to the usual non-directed disclosure.22
However, the self-regulatory disclosure did not include
instructions to organize events’ descriptions chronologically, or to reprocess physical/emotional memories more
cognitively. Enhancing the shift in the mode of traumatic
memories seems to be crucial for health benefits.
Given the studies reviewed above, it seems appropriate
to examine the effects of a guided written disclosure on
clinic visits of community patients who visit health clinics
more than the norm. These patients may require
psychological assistance in addition to usual care, and
place a burden on health providers. We developed a new
guided disclosure which aims at helping patients shift
their trauma memory from implicit to explicit memory,
possibly providing them with more control over these
stressful memories. The purpose of this study was to test
the effects of a guided written disclosure on symptoms
associated with somatization and on health care utilization among frequent attenders at an Israeli community
clinic. We hypothesized that frequent attenders describing past traumas/stressful events in a guided manner
would report fewer symptoms associated with somatization and make fewer visits later than controls writing
about casual topics.
Methods
Participants
Fifty Israeli out-patients attending a community clinic
in Be’er Sheeba (south of Israel) were recruited for this
study by their family physician according to the following inclusion criteria: (i) between the ages of 21 and
65 years; (ii) having visited the clinic at least twice during
the past 3 months (above the mean number of visits at
urban clinics in Israel;23 (iii) no known mental illness or
major cognitive difficulties; (iv) no known chronic illness
(e.g. hypertension, diabetes); and (v) judged by their
family physician to be able to write in Hebrew (hence
this was not a randomly selected sample). All patients
provided written informed consent and the study
was approved by the Ethics Committee of the Soroka
University Medical Center. Data of eight chronic patients
who entered the study by mistake were excluded, and
the data of one patient who was a staff member of a community clinic (and, thus, may receive informal medical
care) were also excluded. The final sample included 41
patients. We encountered minimal refusal to participate.
Background and medical data
Background data included patients’ age, gender and
years of education. In addition, the season during which
each subject was first met and asked to write was
registered (coded: 1 = autumn; 2 = winter; 3 = spring;
4 = summer). Medical measures included a simple oneitem assessment of global health24 rated for each patient
by his/her family physician (4 = irreversible illness with
serious disability; 3 = serious chronic illness without
disability; 2 = minor chronic problems; 1 = excellent
health). This parameter was used to verify a similar health
status in experimental and control groups (in addition to
the inclusion criteria). The numbers of clinic visits during
the 3 months prior to the study, during the 3 months after
writing and during a mean of 15 months after the first
follow-up were extracted from patients’ records.
Psychological measures
To assess symptoms associated with somatization,
we used a brief 6-item scale derived from the Hopkins
Symptoms Check List25 which included frequency of
Effects of guided written disclosure in frequent attenders
muscle pains, low back pains, and feelings of heaviness,
weakness, numbness and faintness during the past month.
Each item was answered with a 4-point frequency scale
(0 = never; 1 = hardly; 2 = sometimes; 3 = all the time),
and the sum across all six items yielded the symptoms
score. Life events were assessed with a brief list of nine
events based on a previously validated version of The
Life Events Readjustment Scale.26 This scale included
46 items relevant to Israelis. In order to have a brief and
age-appropriate scale, we selected for this study only
items whose stressfulness was estimated as .60/100 in
the original study26 and which seemed age-appropriate
to our sample (examples of items are death of a spouse,
divorce, being a Holocaust survivor). Items can be provided upon request from the first author. This parameter
served to verify a similar history of life events in the
experimental and control groups.
Writing conditions
We developed a new guided disclosure protocol (GDP;27)
whose rationale is derived from a broad range of findings
from clinical studies and cognitive neuroscience reviewed
above. The GDP aims to provide patients with greater
control over their trauma memories, and hence reduce
their need to inhibit them, and reduce the potential
health cost associated with such inhibition. In the
GDP condition, patients were asked to write about their
most stressful or upsetting experience from the past few
years for 15 minute periods, over three consecutive days.
On day 1, patients were asked to describe the event in its
chronological order, in a ‘journalistic manner’, without
expression of emotions. On day 2, they were asked to
describe their thoughts and feelings at the time of the
event (to enhance cognitive processing and verbal labelling of sensory and affective responses), and whether the
event affected their life (to enhance self-reflection).
Finally, on day 3, they wrote how they currently thought
and felt about the event (to enhance perspective), and
what they would do in the future, should they encounter
similar events (to enhance self-regulation).
Controls were asked to write for three consecutive
days about the following neutral topics: daily activities
(day 1), their house (day 2) and their current or last job
(day 3), without emphasizing any emotionality. This
is similar to previous trials, and mainly controls for
expectations and experimenter contact. All participants
were seen at their homes by a research assistant.
Procedure
A single-blind randomized controlled prospective
design was used. Potential participants were screened by
their physician, who then approached them over the
phone and asked them whether they would be interested
in taking part in a study testing the effects of writing
on health of patients. Consenting patients were then
assigned randomly to either the casual content control
condition (n = 19) or the GDP experimental condition
163
(n = 22). Upon arrival of the researcher at the patient’s
home, the patient completed the informed consent form.
Prior to the first disclosure, and 3 months later, patients’
symptom scores and number of clinic visits were
assessed. Reassessment of symptoms at 3 months postdisclosure was done by a researcher who was blind to
the patients’ group status. Reassessment of clinic visits
was done by the family physician who was blind to the
patients’ group status. The first follow-up of clinic visits
took place 3 months after writing (parallel to reassessment of symptoms), and the second took place in July,
2000, between 10 and 20 months after the first follow-up
(mean = 15.2 months). During the second follow-up,
symptoms were not reassessed.
Data analysis
To test whether patients in the GDP group adhered to
the writing task, a manipulation check compared the
frequency of using negative affect words (e.g. ‘anxious,
sad’) and insight (e.g. “I realize that I was shaken by the
event”) in the GDP and control groups using t-tests. To
control for fluency of writing, these analyses were performed on the number of words in each category divided
by the total number of words a patient wrote, across all
three writing days. The equivalence of both groups at
baseline on all measures was verified with t-tests for
continuous data and chi-square tests for dichotomous
data. A repeated-measures analysis of variance (ANOVA)
was conducted in relation to symptoms and clinic visits,
with time of assessment (time: baseline versus followups) being the within-subjects factor and group (group:
GDP versus control) being the between-subjects factor.
We expected a time by group interaction such that
conditions will differ in relation to symptoms and clinic
visits only at follow-up(s).
Results
Equality of groups at baseline and adherence
to the writing task
No statistically significant differences were found
between the groups in relation to age, gender, years of
education, health status, season of writing sessions,
number of past traumatic events, number of clinic visits
in the 3 months prior to the study and the duration of the
second follow-up in relation to clinic visits. However, the
experimental group (see below) reported significantly
lower levels of symptoms at baseline than controls.
Patients in the GDP group adhered quite well to the
writing instructions in relation to chronological organization (day 1), describing past emotions and impact on
life (day 2) and current perspective (day 3). Supporting this quantitatively, GDP patients wrote proportionally significantly more words reflecting negative affect
and insight (all significant at P , 0.01) than controls.
Table 1 depicts the means (and standard deviations) of
164
Family Practice—an international journal
TABLE 1 Means (SD) of background, medical and psychological
data for GDP and control patients baseline, 3 month and long-term
follow-up
Variable
GDP
(experimental)
n = 22
Control
n = 19
Background, medical and psychological data
Gender
82% females 68% females
Age
43.9 (9.0)
44.6 (10.0)
Education
13.8 (2.7)
12.9 (2.6)
Health status (1–4)
1.7 (0.5)
1.6 (0.5)
No. of life events (0–9)
0.9 (1.2)
1.6 (1.2)
Outcomes
At baseline symptomsa
3 month follow-up symptomsa
At baseline clinic-visits
3-month follow-up visits
Long-term follow-up visitsb
4.1 (2.7)
2.4 (3.6)
3.1 (1.4)
1.3 (1.4)
5.1 (3.7)
5.9 (2.3)*
4.7 (2.6)*
3.5 (1.9)
3.0 (2.2)**
9.7 (5.6)**
GDP = guided disclosure protocol.
*P , 0.05; **P , 0.01 (differences are between groups at each
assessment period).
a Symptoms were assessed with the somatization subscale of the
Hopkins Symptoms Check List;25 symptoms were not assessed at the
long-term follow-up.
b Long-term follow-up for clinic-visits was a mean of 15 months after
the first follow-up.
background, medical and psychological data of patients
in the GDP (experimental) group and in the casual
writing (control) group.
Effects of writing on health outcomes
The means (SD) of symptoms and clinic visits at baseline
and both follow-ups (for clinic visits only) are shown
in Table 1. Concerning symptom levels, the ANOVA
revealed a significant time effect [F(1,29) = 8.2, P , 0.01]
and a significant group effect [F(1,29) = 4.5, P , 0.05].
Contrary to our hypotheses, the interaction effect of
time by group was not significant [F(1,29) = 0.4, NS]. At
baseline and at the 3 month follow-up, GDP patients
reported significantly less frequent symptom levels than
controls [t(39) = 2.2, P , 0.05; t(29) = 1.9, P , 0.05,
respectively; degrees of freedom differ due to subject
attrition at follow-up]. However, GDP patients appeared
to show (though not significantly) larger reductions
in symptom reporting (41%) than controls (20%; see
Table 1).
Concerning clinic visits, the ANOVA revealed a
significant time effect [F(2,36) = 14.6, P , 0.0001] and a
significant group effect [F(1,36) = 6.1, P , 0.05]. Most
importantly and as hypothesized, we also found a significant time by group interaction [F(2,36) = 3.3, P , 0.05],
such that GDP patients visited their clinic significantly
fewer times than controls at the 3 month follow-up
[t(36) = 2.84, P , 0.01] and also at a mean of 15 months
later [t(28) = 1.98, P , 0.05], but not at baseline (P . 0.05).
These findings are depicted in Figure 1. GDP patients
FIGURE 1
Effects of group status and time on clinic visits
(vertical axis)
showed a reduction of 58% in clinic visits compared with
14% in controls at the 3 month follow-up compared with
3 months prior to writing. Since groups differed significantly on the symptom score at baseline, we repeated
this latter test after controlling statistically for the effects
of baseline symptoms. GDP patients still visited their
clinics significantly less frequently than controls after
controlling for the effects of baseline symptoms at the
3 month follow-up [F(1,35) = 4.9, P , 0.05] and 15 months
later [F(1,35) = 6.2, P , 0.05].
Are the effects of writing on clinic visits clinically
significant?
We then examined whether the statistically significant
effects of the GDP writing condition on clinic visits were
clinically significant. To do this, we compared the percentage of patients in each group at the mean 15 month
follow-up who visited the clinic below versus at or above
10 times during that follow-up period. This cut-off reflected the mean number of urban clinic visits in Israel24
over a mean follow-up of 15 months. During this followup period, 90% of GDP patients versus 67% of controls
visited the clinic fewer than 10 times, while 10% of GDP
patients versus 33% of controls visited the clinic at least
10 times. These differences in percentages between groups
were statistically significant [chi-square (1) = 3.10,
P , 0.05].
Discussion
The main findings of this study are that frequent
attenders at primary care clinics who wrote in a guided
manner for three consecutive days about past stressful
events visited their clinic significantly fewer times
and reported less frequent symptoms associated with
somatization than those writing about casual topics. The
effects of group status on clinic visits seen at 3 months
after writing were also maintained a mean of 15 months
Effects of guided written disclosure in frequent attenders
later. These effects were independent of baseline symptoms, which differed between groups despite randomization. Furthermore, the percentage of GDP patients
making at least 10 clinic visits during the mean 15 month
follow-up was significantly lower than among controls, a
clinically significant finding of potential economc value
as well. In fact, many GDP patients would now not meet
the inclusion criteria for the study after taking part in the
experimental condition and reducing their clinic visits.
These findings support those of previous studies9–11
and extend them to a community sample of frequent
clinic atttenders. Unlike the findings of a recent study,13
our disclosure protocol was successful in reducing clinic
visits. Our disclosure protocol differs substantially from
previous unstructured interventions. By building upon
findings of content analyses of previous clinical studies
and upon findings in cognitive neuroscience concerning
the manner in which trauma is encoded in memory, we
attempted to maximize the effects of writing by guiding
patients to write chronologically, with labels and insight.
This guidance attempted to shift trauma processing from
an implicit somato-sensoric and limbic memory mode, to
an explicit cognitive and verbal memory mode. Though
we could not demonstrate these changes in brain processes with the measures used in the present study, we
attempted to achieve this processing shift by asking
patients a series of questions across the three writing
days, rather than inviting them to ventilate without any
guidance. Not guiding patients may even result in insufficient or too much cognitive processing of past traumas,
both of which have been associated with adverse health
outcomes compared with moderate processing.16 The
GDP may bring both extremes to a moderate level of
cognitive complexity.
To the best of our knowledge, these findings are the
first positive findings to be shown with frequent clinic
users. We did not examine the mechanism(s) of these
effects. However, based on previous studies, written
disclosure may reduce overutilization of health clinics by
its positive effects on immunity and/or emotional wellbeing.9,12 Our findings may be particularly relevant to
the medical treatment of frequent clinic users since such
patients are characterized by psychiatric diagnoses, past
daily/major stressors and high somatization levels.3–5
Future studies may wish to identify the mechanism(s)
underlying these findings more closely. The GDP offers
a simple, inexpensive and potentially effective addition
to typical medical treatment for reducing the overuse of
clinic visits as well as possibly reducing symptom levels
among frequent clinic users. This adjunctive form of
intervention may be important particularly since
somatizers do not benefit in most cases from medical/
surgical treatments.6 In addition to improving patients’
well-being, such a finding may have an important
economic value by reducing clinic use.
This study did not include physical outcome measures
such as immune function, measures of organ function,
165
etc. previously shown to be positively affected by written
disclosure.9–11 However, our main aim was to examine
the effects of written disclosure on symptoms and clinic
visits in a sample of frequent clinic users. In addition, the
small and selective sample size reduces the generalizeability of our findings to more general samples of primary care patients. However, the statistically significant
effects obtained with a small sample claim for the
strength of the effect size of the GDP. In addition, we
deliberately aimed at testing the effects of the GDP
with frequent clinic attenders. Another limitation is the
lack of a usual non-guided trauma disclosure condition
to compare with the new GDP. This may have provided
evidence for our contention that the GDP provides a
more controlled, and thus healthier manner of processing trauma than the usual non-guided protocol. Such a
comparison is under way in another study. Should these
findings be replicated with larger samples of patients
visiting primary care clinics, the GDP may constitute an
additional form of intervention for frequent attenders
in primary health care. With minimal physician intervention, GPs may then also serve as confidants for people
with past traumatic life events and frequent clinic visits,
using a structured framework such as the GDP. This may
add a new dimension to the practice of primary care.
Acknowledgements
The authors wish to thank Daniela Arnon, Vivian Torkel,
Racheli Eden, Zehorit Asulin, Hadas Noyman and
Dafna Baruch for their efforts and assistance in
conducting this study.
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