Thursday, March 12, 2009

Therapeutic Writing

There have been a few studies (two published quite recently) which have shown patients who completed writing homework exercises exhibited fewer anxiety and depression symptoms as well as greater therapeutic progress than patients in the writing control groups. One of these studies also showed an efficacy of structured writing comparable to that of CBT alone.

There have also been studies investigating the physiological effect of expressive writing and some of those findings include a lower heart rate and lower blood pressure in the emotionally expressive groups.

Writing can help identify thematic stressors as well as give insight into thought processes and problem solving strategies, which may be impaired in the presence of a psychiatric disorder but can be remedied once they are recognised. Writing can also be a way of divulging secrets while still keeping them safe.

Writing is common in CBT, but it is usually highly structured. The reason for this format is that it forces the patient to spend only a certain amount of page space in their usual thinking patterns and then using the rest of the space to analyse and restructure their thought patterns.

A very simple exercise is to divide a page in half by drawing a line down the middle; on the left side of the page one can record a negative thought, but this thought must be challenged on the right hand side of the page. For example, on the left side there might be a comment such as, “I am always late for work,” and on the right side this might be balanced with, “I have only been late for work twice this year and both times were due to unusually high traffic.” This kind of task might be very difficult in the beginning. IF someone has suffered a chronic depression, even the positive side might come out sounding negative or cynical, but it will get easier the more the exercise is done. It is important for the therapist to be supportive during this learning phase and acknowledge the patient’s effort. It is also important for the patient to listen to criticism on how their homework can be improved.

I certainly do not argue against the benefits of structured CBT writing, but I also know that thoughts don’t come in discrete units. Sure it’s nice to put things neatly into columns, but there is always that possibility of a something-is-missing feeling.

As a balance to other therapies where the patient may feel disconnected from their work and therefore abandon it, journal or creative writing can be helpful. While writing can be a healthy, cathartic process giving the person a sense of control, I still think there needs to be some structure to the writing, at least in terms of content. The patient should spend an equal amount of time on positive writing, but they can be placed anywhere in the piece. As well, I do not believe it to be particularly healthy for someone to write about the same issue repetitively or at length.

I have my reservations regarding the Pennebaker protocol, simple because of the intensity of negative emotions that will likely be experienced, and there is no balance during those four days of analytic catharsis. For those in psychiatiric treatment, I would recommend only one day of writing before their next session and do not tackle events that are too traumatic to deal with now (you can come back to these situations later if you decide to). And, as I have said, any negative writing should be balanced with something positive, even if it’s fiction.

References: 1, 2, 3, 4, 5, 6


  1. "simple because of the intensity of negative emotions that will likely be experienced,"

    why do folks seem to think the experiencing negative emotions intensely should be avoided?

    That's why CBT and psychotherapy is so slow. Walking on eggshells around the patient. Let's not get too intense now or it's time to back off.

    I will share a real story with you Jenn.

    I grew up with religious abuse and mentally ill parents. Low self esteem led to being targeting at school too. Eventually the two places I spent the most time, home and school, became a daily nightmare of assault or threat of assault.

    If that wasn't enough I ended up in biopsych care, hospitalized for my first teen suicide attempt. There I was forced to take drugs against my will and restrained by being ganged up on by staff. I went to get help and became even more traumatized.

    Eventually I ended up either suicidally depressed all the time or I ended up stalking people and sleeping with weapons. I took ten different martial arts to train myself for anything at any time. Surviving assault and battery and human cruelty was the only thing I was operating on. No college or kids for me. Just fights and ODs, fights and more ODs. Never ending war.

    At some point I learned real meditation from a genuine master of it. I learned to go in and face each and every traumatic memory and process and get rid of it.

    To do that I had to go inside and revive memories. Play them back in full color and sound. Relive the entire trauma again and feel the indignant rage, the helplessness, the sadness, the victimness of it.

    In the process I relived these events which in reality I never had forgotten. They were all there waiting for a trigger. The easiest way to revive a PTSD trigger is to think about it intensely.

    In less than five years I completely recovered from ptsd. Utterly. As though I had not spent years being abused and years in institutions watching more abuse or experiencing it.

    I did this by climbing into the dragon's mouth. By pushing my envelope and 'comfort zone'. By triggering myself I had immediate access to the memory and it's resulting effects on my mind, emotions and physical body. (shaking, adrenaline, sweating etc)

    Once I learned how to process triggers getting over them was really fast. I spent hours and hours alone by myself in the privacy of my apartment with no one holding my hand just disarming trigger after trigger after trigger.

    Trauma is a conversation on the other line that you have to finish. The longer you delay and walk around it or avoid it the longer it takes to get over it. After I learned mindfulness meditation and the inner dissolving technique I gained a tool far superior to CBT, DBT, EMDR or any other therapies going on right now. The major difference lies in how you go after memories. No neat columns on a journal page. You conjure your memories, your trigger yourself, your ride the lightning and you dissolve. Then you are over it and the trigger has no more power over you. None. Zilch. It's like it happened to someone else.

    As a survivor you have to have courage to face that stuff intensely and prepare for it. If you do you will end your suffering sooner rather than later.

  2. I completely agree with you on the benefits of mindfulness meditation. I have only written one post dedicated to the method, but I do mention it frequently.

    Also, my post was more about how to work outside the confines of columns and categories of CBT, so I agree with you there as well. Actually, I agree with you on just about everything. I don't think feelings should be avoided, but I do believe that the intensity of the emotions can, for some people, cause an upheaval leaving them confused, suicidal, afraid...And for some people the trigger might not ever completely go away, but it becomes easier to control it without being overwhelmed by stress symptoms.

    What you went through, and how you recovered, is a tremendous story.