Disclosure and Health

Disclosure is the act of revealing thoughts and emotions, often through language. Disclosure typically occurs in a social setting, with one or more individuals sharing thoughts and feelings with others. Such social sharing is neither recent nor rare; since the development of language, people have shared their stories with one another, across time, many cultures, and different situations. Evidence suggests that people feel a strong desire to share their experiences, and relatively few emotional experiences are kept private. Despite this longstanding and central role of disclosure to our lives, it is only relatively recently that there has been systematic study of the relation between disclosure and health.

Although historically not carefully studied, disclosure processes have long been a component in a variety of symbolic healing rituals. For example, confession and storytelling have been used as a tool to promote health and well-being in both religious and secular settings for thousands of years. A central feature of most contemporary psychotherapeutic interventions is to translate thoughts and emotional experiences into language and to disclose them in a safe and supportive environment. With growing appreciation of the role that thoughts and emotions can have in influencing our physiological states, disclosure is one mechanism whereby psychological and social states might influence health and well-being. The cross-cutting theme addressed here is that disclosure of important and/or powerful thoughts and emotions may constitute an important component of a variety of therapeutic endeavors, and disclosure itself, regardless of the form it takes, may promote health and well-being.

Early investigation into the relation of disclosure to health and well-being provided a more complex picture. When examining the degree to which people disclosed, both in their natural lives and in therapeutic environments, rates of disclosure were often not related to health and well-being. In fact, there was some evidence that high rates of disclosure were associated with distress (e.g., depression, anxiety, fear, etc.), and higher disclosure rates during therapy were not associated with better psychotherapy outcomes. One explanation of this pattern is that people are more likely to disclose when they are psychologically distressed than when they are not distressed. Thus, if we examine people who are currently disclosing at high rates, we will (inadvertently) be observing them at times of high distress. A more important question is what is the relation of disclosure to health under more controlled circumstances, an issue we return to shortly.

There thus exists a bit of a contradiction—disclosure both represents a core and common social experience and perhaps also suggests distress. This view is reflected in common culture and language (the “folk model” of emotion and disclosure). Linguists, for example, have noted that cultural metaphors for strong emotions, such as anger, portray the body as a container for emotions. This metaphor is based largely on a hydraulic model, with contained emotion building up pressure unless it is let out via disclosure (e.g., “blowing off steam”). Overly contained (“bottled up”) emotion can, in this metaphorical model, produce dangerous pressure and cause physiological and psychological damage. Thus, disclosure is often thought of as venting the accumulated build-up of strong (typically negative) emotion. It is important to note, however, that recent evidence suggests that raw emotional expression (lacking self-reflection) may not be very helpful. In fact, a number of studies have linked the persistent tendency to uncritically express negative emotions (e.g., anger) with increased stress, hopelessness, depression, and health problems.

Nondisclosure and Inhibition

Accompanying the notion that disclosure is beneficial is the belief that not disclosing (or inhibiting) ones thoughts and feelings is a bad strategy that can lead to poor psychological and health outcomes. There are, in fact, many reasons why an individual might choose (or feel pressure to) not express his or her emotions. Inhibition may be promoted by limited emotional awareness, personal and cultural values (e.g., a stigma that keeps someone from sharing a problem, a desire to appear strong and independent), a lack of opportunity to disclose one’s emotions (e.g., a lack of supportive listeners), or negative responses from others when disclosure is attempted. Ongoing and dynamic changes in social and cultural contexts also play a role in determining the balance between emotional disclosure and inhibition over time for an individual. In general, however, there is evidence that the persistent tendency to inhibit or conceal one’s thoughts and strong emotions is related to negative outcomes.

Several studies have provided empirical evidence that inhibition may be associated with physiological burden and an increased risk of developing health problems. In the short term, the inhibition or suppression of strong emotions produces a much greater physiological response than not suppressing the emotions. For example, trying to suppress the emotional reaction of anger can produce a much greater increase in heart rate and blood pressure than would be produced without the need for such inhibition. Beyond these short-term effects, the suppression or inhibition of experiences or emotions over time can also be risky. For example, individuals who have experienced traumatic events but not disclosed them to others have more health problems than those who have disclosed more.

Other examples can be found in a variety of research studies. Results from the large Multi-center AIDS Cohort Study found that, among gay HIV+ (but otherwise healthy) men, those who concealed their sexual identity showed faster HIV progression than those who were open about their sexuality. Individuals with a chronic tendency to suppress negative emotions have been shown to have worse outcomes in response to malignant melanoma (skin cancer), whereas expressing emotions was related to positive immunological responses. In another study, holocaust survivors were interviewed about their personal experiences before and after World War II. Survivors who disclosed less during the interview and in the time since the war reported significantly worse health outcomes and more visits to their doctor 1 year later as compared to survivors who disclosed more. Similar findings have been observed in bereaved individuals: The more that surviving spouse talked about the death with others, the fewer the health problems he or she experienced following the loss. This and other accumulating evidence suggests that inhibiting thoughts and feelings about strong emotions or significant personal experiences may pose a risk for developing negative health outcomes.

In spite of this evidence, however, inhibition may be adaptive in some circumstances. There are times where disclosure might prove maladaptive or even harmful, particularly when disclosure would result in negative social or interpersonal consequences. The ability to moderate our emotional expression is an adaptive tool that enables us to determine when, to whom, and under what circumstances we share our personal experiences. There are many negotiations that take place both within and outside of an individual that modulate expression (e.g., how much, when, to whom), and appropriate inhibition is a useful and necessary social strategy. However, persistent and broadly applied inhibition, and a chronic tendency to not disclose, appears to pose a risk for negative psychological and physical health outcomes.

Disclosure, Health, and Well-Being

As aforementioned, an important issue concerns what the effects of disclosure are under more controlled circumstances. Essentially all forms of talk therapy, regardless of theoretical orientation (e.g., psychoanalysis, cognitive—behavioral, etc.), recognize that the labeling of the problem and a discussion of its causes and consequences is an integral part of the therapeutic process. Such talk therapies have been shown to reduce psychological distress and promote both physical and mental well-being across a wide range of theoretical orientations, problems, and clientele. Much of the early work examining the effects of the structured disclosure entailed by talk therapies focused on mental health outcomes (such as reductions in depression). Only relatively recently, however, has disclosure been systematically examined in the context of health and well-being more broadly defined. Several significant clinical trials of psychosocial interventions suggested the important role that disclosure may have in the treatment of medical problems.

Dean Ornish and colleagues found that a healthy heart program that incorporated lifestyle, behavioral, and psychological change for individuals at high risk of heart disease significantly reduced their medical risk profiles. In fact, the Ornish program significantly reversed the severity of the heart disease. One important component of this program is to provide a safe, compassionate, and supportive group setting where patients are encouraged to disclose their thoughts and feelings about the stress and difficulties surrounding their disease and in their lives more broadly. Another pioneering study was conducted by David Spiegel and his colleagues for women with breast cancer. This study examined the effect of providing women diagnosed with breast cancer the opportunity to disclose to other women about their disease, again in a safe and supportive group environment. The women in the experimental group that were provided the opportunity to participate in the support groups lived, on average, about 17 months longer than women in the control group, who received no supportive interventions. Both of these studies suggested the important role disclosure may have in maintaining and promoting good physical health and reducing the mortality risk of certain diseases. Unfortunately, neither of these studies was able to confidently determine whether it was disclosure per se that resulted in the observed improvements or whether some other aspect of the experimental interventions contributed wholly or in part to the benefit received by participants. To better address this question, more careful experimental studies of disclosure and health needed to be conducted. Prior to presenting the effects of disclosure in carefully controlled experimental contexts, some of the forms disclosure can take are first examined.

Modes of Disclosure

Certainly the most typical mode of disclosure is to talk face to face with another person. Such disclosure may take the form of speaking with a friend, a family member, or a professional. However, there are a variety of circumstances that may arise that leave an individual without access to such a supportive listener. For this and a variety of other reasons (e.g., communication and computer technology), many other forms of disclosure have become popular. Interpersonal disclosure now occurs with great regularity from a distance, such as over the phone or by electronic mail. Support groups have grown in popularity, and exist both in traditional settings as well as “virtual” support groups conducted on the Internet via private chat rooms. Although these various modes of disclosure can differ in many ways (duration, content, expertise, etc.), they all share the feature of allowing individuals to disclose thoughts and feelings within an (ostensibly) safe and supportive environment.

A more recent line of enquiry examines whether disclosure can occur, and whether it is helpful, in the absence of an explicit audience. That is, is disclosure helpful if conducted by individuals on their own? In general, research supports the view that disclosure in a private setting, such as talking into a tape recorder, writing (or typing) about one’s thoughts and feelings, or completing workbooks that involve disclosure, can each produce beneficial effects even without an explicit audience or listener. Although more work remains to be conducted in this important area, preliminary findings suggest that disclosure regardless of mode (e.g., interpersonal, verbal private, written private, etc.) can be beneficial, and no one mode shows clear superiority over the others (although there are undoubtedly individual differences in response to disclosure via different modes). One recent line of research that examines the health effects of disclosure conducted in a private setting uses the administration of structured writing exercises that involve expressing thoughts and feelings about important (often stressful) events or topics.

Disclosure through Writing

Expressive writing has increasingly been used as an intervention to foster emotional disclosure while avoiding the potentially negative social interactions that might accompany interpersonal disclosure. The procedure, initially pioneered by James Pennebaker and colleagues (Pennebaker, 1995; Pennebaker & Beall, 1986), generally involves having participants come into a safe and private environment to write about their deepest thoughts and emotions about a stressful experience for 2030 min, which they repeat for three to five sessions. In experimental settings, this writing is contrasted with writing about emotionally neutral topics. Such randomized designs for exploring the effects of disclosure are very important because they allow much clearer demonstration that any observed differences between the groups are due to disclosure. That is, such designs allow us to examine the effects of disclosure specifically and not confuse them with effects produced by a broader intervention, the context, or other uncontrolled factors. Early work utilizing this writing intervention found that individuals provided the opportunity to disclose in this manner showed reliable improvements in a wide array of health outcomes, including reports of physical health, psychological well-being, physiology (e.g., immune function), and measures of performance (e.g., academic performance) when compared to those individuals writing about emotionally neutral topics. Also important was that the benefits of written disclosure did not appear limited by age, race or ethnicity, education, gender, or language.

With the demonstration that disclosure via writing could promote health and well-being, researchers began to explore new domains in which to apply this novel intervention. A number of empirical studies have now demonstrated that such expressive writing can be a useful supplement to standard medical care for individuals with a range of physical illnesses. For example, individuals receiving medical care for chronic asthma or arthritis who completed a series of written disclosure exercises demonstrated clinically significant improvements in their disease (e.g., improved lung function, reduced pain) relative to patients who wrote about emotionally neutral topics. Related, although less dramatic, benefits have been observed in the context of cancer care and primary care settings. These studies, along with those discussed earlier, suggest that if patients with a physical illness are provided the opportunity to disclose in a safe and supportive way (whether interpersonally or via writing), they can experience health benefits beyond those attributable to their ongoing medical care.

How Might Disclosure Improve Health?

The accumulation of evidence that the disclosure of thoughts and feelings can make us feel better, both psychologically and physically, naturally leads to the question, “How does disclosure work?” Numerous theories have been proposed to explain the health benefits of disclosure. The theories vary in accordance with factors such as the theoretical orientation of a researcher or clinician (e.g., behavioral vs. psychodynamic), type of disclosure (interpersonal vs. written), and nature of the people under study (e.g., healthy vs. ill). A popular early explanation for the health effects of disclosure was that it removed the harmful effects of inhibiting, or not disclosing, thoughts and emotions surrounding an important event. More recently, however, other explanations have been offered, including exposure-based models, the acquisition of skills related to the recognition and regulation of emotion, increases in insight and processing of past experiences, and changes in the cognitive and/or linguistic representation of thoughts and emotions. Although some evidence consistent with each of these theories exists, continued research must examine the relative contribution of each of them to the health benefits of disclosure. Furthermore, it is likely the case that disclosure under different circumstances and for different individuals may operate through a variety of different pathways.

Conclusion

We are social beings, and appear to have strong tendencies to share our thoughts and feelings with others. Such disclosure has long been part of a variety of healing rituals, and scientific enquiry suggests that, under safe and supportive circumstances, disclosure may promote greater health and well-being. Examination of disclosure suggests it is most beneficial when it involves the expression of emotion along with self-reflection, rather than mere catharsis. Additionally, recent empirical evidence supports the view that disclosure can occur, and produce health benefit, even in the absence of an explicit audience (such as through writing). Disclosure interventions are useful tools for promoting both psychological and physical good health, and may represent a promising line of supplemental treatments for individuals with physical illness. A number of important questions about the health effects of disclosure, however, are open to further investigation. For example, what is the effect of the growing number of possible modes of disclosure, such as the telephone, the World Wide Web, or email? For whom will disclosure provide benefit, and under what circumstances? Through what mechanisms does disclosure improve health? Ongoing and future research into these and related questions will shed further light on the health effects of disclosure as well as aid in the design and implementation of disclosure as a therapeutic tool.